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The worldwide incidence of placenta accrete spectrum (PAS) is increasing day by day, mostly due to the increasing trends in caesarean section (CS) rates. PAS is accountable for high maternal morbidity and mortality as it is associated with extensive haemorrhage, which often requires hysterectomy, multiple blood and blood product transfusions, ureteric and bladder injuries and prolonged ICU stay. The aim of this case series is to highlight the importance of early diagnosis and high degree of suspicion of PAS for a planned management in decreasing maternal morbidity and mortality. Antenatal patients who were associated with PAS and managed in obstetrics and gynaecology department, Kalinga institute of medical sciences, Bhubaneswar during the time period of 2 years were critically reviewed and are being presented as case series. High degree of suspicion, pre operative radiological diagnosis, well preparedness and multidisciplinary approach help us in reducing the maternal mortality and morbidity significantly. Conservative management of PAS can preserve future fertility but should only be done in hospitals with 24 hour emergency care and enough expertise as it carries high chances of maternal complications.

To assess the hospitalized sick children admitted to the pediatric emergency department (ED) and to find new patterns of clinical and laboratory attributes using association rule mining (ARM).In this observational study, 158 children with median (IQR) age 11 months and a PRISM III score of 5 (2-9) were enrolled. Hotspot data mining method was applied to assess clinical attributes, lab investigations and pre-defined outcome parameters of children and their association in sick hospitalized children aged 1 month to 12 years.We obtained 30 rules with value for outcome as discharge is given attributes as follows: duration of hospitalization4 days, lactate1.2 mmol/L, platelet = 3.67/μL, dur_ventil = 0 h, serumARM is an effective data analysis technique to find meaningful patterns using clinical features with actual numbers in pediatric critical illness. It can prove to be important while analysing the association of clinical attributes with disease pattern, its features, and therapeutic or intervention success patterns.

Internet offers an immense opportunity as a resource for education, training, and health promotion. This narrative review summarizes the opportunities for health promotion among adolescents through use of the Internet and technology (defined as eHealth). The details of technology and use of Internet for adolescent-health related topics such as nutrition, fitness, sexual health, adventure, and violence were searched through PubMed. The review reports few digital solutions to address key challenges during adolescence like promotion of nutrition and sexual reproductive health, prevention of noncommunicable diseases, substance abuse, and mental health issues. eHealth was concluded as a potential solution for preventive and promotional health practices during adolescence. However, concerns of Internet addiction, safety, privacy, mental health disorders, and misinformation need to be addressed and monitored during adolescence.

To compare the efficacy of sunlight exposure and oral vitamin D3 supplementation to achieve vitamin D sufficiency in infants at 6 months of age.Open-label randomized controlled trial.Public hospital in Northern India (28.7°N).Breastfed infants at 6-8 weeks of age.Randomized to receive sunlight exposure (40% body surface area for a minimum of 30 minutes/week) or oral vitamin D3 supplementation (400 IU/day) till 6 months of age.Primary - proportion of infants having vitamin D sufficiency (20 ng/mL). Secondary - proportion of infants developing vitamin D deficiency (12ng/mL) and rickets in both the groups at 6 months of age.Eighty (40 in each group) infants with mean (SD) age 47.8 (4.5) days were enrolled. The proportion of infants with vitamin D sufficiency increased after intervention in the vitamin D group from 10.8% to 35.1% (P=0.01) but remained the same in sunlight group (13.9%) and was significant on comparison between both groups (P=0.037). The mean (SD) compliance rate was 72.9 (3.4) % and 59.7 (23.6) % in the vitamin D and sunlight group, respectively (P=0.01). The geometric mean (95% CI) serum 25(OH) D levels in the vitamin D and sunlight group were 16.23 (13.58-19.40) and 11.89 (9.93-14.23) ng/mL, respectively; (P=0.02), after adjusting baseline serum 25(OH)D with a geometric mean ratio of 1.36 (1.06-1.76). Two infants in sunlight group developed rickets.Oral vitamin D3 supplementation is more efficacious than sunlight in achieving vitamin D sufficiency in breastfed infants during the first 6 months of life due to better compliance.

Class IV homeodomain leucine-zipper transcription factors (HD-Zip IV TFs) are key regulators of epidermal differentiation that are characterized by a DNA-binding HD in conjunction with a lipid-binding domain termed steroidogenic acute regulatory-related lipid transfer (START). Previous work established that the START domain of GLABRA2 (GL2), a HD-Zip IV member from Arabidopsis (Arabidopsis thaliana), is required for TF activity. Here, we addressed the functions and possible interactions of START and the HD in DNA binding, dimerization, and protein turnover. Deletion analysis of the HD and missense mutations of a conserved lysine (K146) resulted in phenotypic defects in leaf trichomes, root hairs, and seed mucilage, similar to those observed for START domain mutants, despite nuclear localization of the respective proteins. In vitro and in vivo experiments demonstrated that while HD mutations impair binding to target DNA, the START domain is dispensable for DNA binding. Vice versa, protein interaction assays revealed impaired GL2 dimerization for multiple alleles of START mutants, but not HD mutants. Using in vivo cycloheximide chase experiments, we provided evidence for the role of START, but not HD, in maintaining protein stability. This work advances our mechanistic understanding of HD-Zip TFs as multidomain regulators of epidermal development in plants.

Micro Insurance in India is beginning from the financial institutions’ activities i.e., they hedge their own risks while lending to the poor under the requirements of direct lending. In India, Micro Insurance is guaranteed through poverty alleviation programs by the Government. These programs are built into the credit package as compulsory elements to the development of the unorganized sector. Both the life and General insurance companies have issued various Micro Insurance products for those who are not financially strong enough to buy the premium products. For comparing the Micro Insurance products, total top three companies form life insurance sector (inclusive of public and private sector companies) have been selected on the basis of annual premium being received. Out of top three companies one (i.e. Life Insurance Company) from consists of three companies related to life insurance such as Life Insurance Corporation of India Public sector and two private (i.e. DHFL Pramerica Life Insurance Company Limited and Shriram Life Insurance Company) have been selected in life insurance business. All of these businesses were chosen based on the amount of annual premium they collected (2015-16).

Introduction Classically IgA in the gut prevents the invasion of microorganisms to systemic organs through the process of neutralization and immune exclusion. Interestingly, recent reports suggest that IgA might help in biofilm formation and promote bacterial growth inside the intestine. Methods In this study, we used flow cytometry, ELISA and chemical models of colitis to test whether the quality and quantity of IgA can select for bacterial persistence in the gut. Results We found that members of Proteobacteria such as γ-Proteobacteria and SFB are preferentially coated by IgA in WT mice. In partial absence of either T-dependent or T-independent IgA responses, there are no significant differences in the frequency of bacteria coated with IgA in mice. However, in, Rag-/- mice that lack all antibodies, had a severe reduction in Proteobacteria and were resistant to DSS induced colitis, suggesting that secretory IgA might be essential for differential retention of these taxa in the mouse gut. Rag-/- littermates in the F2 generation generated from (B6 x Rag-/-) F1 mice acquired the underrepresented bacteria taxa such as γ-Proteobacteria through vertical transmission of flora and died soon after weaning possibly due to the acquired flora. Additionally, continued exposure of Rag-/- mice to B6 flora by cohousing mice led to the acquisition of γ-Proteobacteria and to mortality. Conclusion Together, our results indicate that host survival in the complete absence of an IgA response necessitates the exclusion of certain bacterial taxa from the gut microbiome.

Chronic kidney disease (CKD) is a global public health issue, with Asia accounting for one of the highest CKD prevalence worldwide. This study examines the burden of CKD in Asian continent in the last three decades.The estimates of age, sex and year wise burden of CKD for 49 countries in Asia for 1990 to 2019 were procured from the Global Burden of Disease 2019 study.In 2019, there were 9.8 million [9.0-10.6 million] new cases and 763 024 [696 050-823 829] deaths due to CKD in Asia. Between 1990 and 2019, CKD prevalence doubled from 202.4 million [186.5-219.1 million] to 431.2 [400.3-462.0 million]. Although age-standardized incidence rate (ASIR) of CKD increased from 170.6 [156.7-186.2] in 1990 to 206.3 [190.4-223.4] per 100 000 person-years in 2019, the age-standardized mortality rate (ASMR) witnessed a modest reduction from 18.4/100 000 [17.0-20.1] to 17.3/100 000 [15.7-18.7]. In 2019, the ASIR spanned from 141.9/100 000 [126.2-159.2] in Tajikistan to 561.4/100 000 [524.6-598.6] in Saudi Arabia, and ASMR varied from 8.9/100 000 [7.2-9.8] in Japan to Saudi Arabia (52.9 [42.8-63.1]). Between 1990 and 2019, absolute count of CKD incident cases, deaths, prevalent cases and disability-adjusted life years (DALYs) increased 100% or more in 48/49, 32/49, 43/49 and 23/49 countries, respectively.CKD is widespread in the Asian region, with an alarming burden in resource-constrained countries. Strategies such as promoting awareness, screening among high-risk individuals, provision of cost-effective therapies, and increased healthcare coverage could help deal with the CKD epidemic in Asia.

The aim of the study was to compare the efficacy of daily v. weekly oral vitamin D3 therapy in radiological healing of nutritional rickets. Children 6 months to 12 years (n 132) diagnosed with nutritional rickets were randomised into three groups (n 44): group A – 2000 IU daily vitamin D3 for 12 weeks, B – 60 000 IU weekly for 3 weeks, C – 60 000 IU weekly for 6 weeks. Serum calcium, phosphorus, 25-hydroxyvitamin D (25(OH)D), parathyroid hormone and X-ray score were estimated at baseline and 12 weeks (endline). The proportion of children who achieved complete radiological healing at endline was compared between three groups by χ2 and delta change in laboratory parameters by ANOVA (parametric data) or Kruskal Wallis test (non-parametric data), respectively. Baseline 25(OH)D ≤ 20 ng/ml was seen in 119 (90·2 %), hyperparathyroidism in 90 (68·8 %) and hypocalcaemia in 96 (72·7 %). A total of 120/132 children completed the study. Complete radiological healing seen in 30 (75 %) in group A, 23 (60·5 %) in group B and 26 (61·9 %) in group C; P = 0·15, with comparable endline X-ray scores; P = 0·31. The median (interquartile range (IQR)) delta X-ray score (baseline–endline) was 7 (4,9), 5 (2·25, 6) and 6 (4,7) in groups A, B and C, respectively; P = 0·019. Median (IQR) 25(OH)D endline levels in groups A, B and C were 50·0 (26·5, 66·5), 42·1 (28·4, 54·4) and 53·5 (33·7, 71·2) ng/ml, respectively; P = 0·045. Radiological scores were comparable at endline among daily and weekly vitamin D groups with greater change from baseline in daily supplemented group.

Background: Flipped classroom is an interactive teaching-learning method which has reported good acceptability in medical education. The effectiveness of this technique in teaching a non-mainstream subject is less explored. Objective: This study was planned to assess the understanding among the homoeopathic students of a clinical subject taught via flipped class methodology. Method: The flipped classroom approach was used for conducting online teaching sessions in paediatrics for the undergraduate students of homoeopathy. The students were provided with lecture material and learning aids before each of the two sessions on newborn health. Two separate online sessions were conducted in flipped class style. Students were asked to respond to a post-test questionnaire for knowledge assessment and a feedback questionnaire regarding learning satisfaction. A five-point Likert scale was used to assess the satisfaction experiences. Results: A total of 64 responses were received after both classes where the mean (SD) knowledge score was 6.3 (1.2). Majority (79.6%) did not find the preparation for the lecture to be difficult and 63 (98.4%) agreed that this lecture style is helpful for learning. 53 (82.8%) participants agreed that it is useful for the preparation of examinations. Majority (90.6%) rated the satisfaction after the class as 4 or 5. Few topics were suggested for further learning by the students after the class. Conclusion: Flipped classroom was used as a novel approach for teaching a clinical subject to the students of homoeopathy. High student satisfaction in terms of learning motivation and usefulness in preparation for examinations was recorded.

One of the major challenges that the world is facing currently is the inadequate amount of food production with high nutrient content in accordance with the increase in population size. Moreover, availability of cultivable area with fertile soil is reducing day by day owing to ever increasing population. Further, water scarcity and expensive agricultural equipment have led to the use of agrochemicals and untreated water. Excessive use of chemical fertilizers to increase crop yield have resulted in deleterious effects on the environment, health and economy, which can be overcome to a great extent by employing biological fertilizers. There are various microbes that grows in the rhizospheric region of plants known as plant growth-promoting rhizobacteria (PGPR). PGPR act by direct and indirect modes to stimulate plant growth and improve stress reduction in plants. PGPRs are used for potential agriculture practices having a wide range of benefits like increase in nutrients content, healthy growth of crops, production of phytohormones, prevention from heavy metal stress conditions and increase in crop yield. This review reports recent studies in crop improvement strategies using PGPR and describes the mechanisms involved. The potential mechanisms of PGPR and its allies pave the way for sustainable development towards agriculture and commercialization of potential bacteria.

The reference cut-offs for overweight and obesity have evolved from the use of International obesity task force (IOTF) to extended IOTF and revised Indian Academy of Pediatrics (IAP) growth charts.Secondary analysis of anthropometric data of school-going children from Delhi in the year 2008, 2013 and 2015 was performed. The proportions of children with overweight, obesity, and undernutrition were checked for agreement using different diagnostic cutoffs, and compared at three-time points.Among 8417 adolescents, weighted Kappa statistics showed good agreement between extended IOTF and IAP cutoffs (k=0.933; 95% CI 0.93-0.94), between eIOTF and IOTF (k=0.624; 95% CI 0.619 - 0.629) and between IAP and IOTF (k=0.654; 95% CI 0.645-0.662). A higher proportion of adolescents were diagnosed with obesity with extended IOTF and IAP charts than IOTF charts (P0.001 for both genders). The mean (SD) BMI showed a rising trend for adolescents overall from 19.61 (3.89) kg/m2 in 2008, 20.44 (4.37) kg/m2 in 2013 and 20.88 (4.60) kg/m2 in 2015 (P0.001). 158 adolescent (97 girls) were undernourished using combined IAP and extended IOTF criteria.Both extended IOTF and IAP charts showed good agreement for diagnosing overweight and obesity in adolescents. A secular trend in malnutrition was observed in adolescent girls.

Sphingolipid is an 18-carbon amino-alcohol-containing lipid with a sphingosine backbone, which when phosphorylated by sphingosine kinase 1 (SphK-1), generates sphingosine-1-phosphate (S1P), an essential lipid signaling molecule. Dysregulation of S1P function has been observed in a variety of pathologies, including severe malaria.

Supplementary Information from Sperm-Associated Antigen 9 Is Associated With Tumor Growth, Migration, and Invasion in Renal Cell Carcinoma

BACKGROUND: There are limited data on large-scale, multi-level implementation research studies to improve hypertension diagnosis, treatment, and control rates at the primary health care (PHC) level in Africa. We describe the characteristics, treatment, and control rates of patients with hypertension in public PHC centers in the Hypertension Treatment in Nigeria Program. METHODS: Data were collected from adults ≥18 years at 60 public PHC centers between January 2020 and November 2020. Hypertension treatment rates were calculated at registration and upon completion of the initial visit. Hypertension control rates were calculated based on systolic and diastolic blood pressures

The emerging literature on prevalence of vitamin D deficiency in India, prevention and treatment strategies of rickets, and extra-skeletal benefits of vitamin D suggest the need for revising the existing guidelines for prevention and treatment of vitamin D deficiency in India.To review the emerging literature on vitamin D prevalence and need for universal vitamin D supplementation. To suggest optimum vitamin D therapy for treatment of asymptomatic and symptomatic vitamin D deficiency, and rickets. To evaluate the extra-skeletal health benefits of vitamin D in children.A National consultative committee was formed that comprised of clinicians, epidemiologists, endocrinologists, and nutritionists. The Committee conducted deliberations on different aspects of vitamin D deficiency and rickets through ten online meetings between March and September, 2021. A draft guideline was formulated, which was reviewed and approved by all Committee members.The group reiterates the serum 25-hydroxy vitamin D cutoffs proposed for vitamin D deficiency, insufficiency, and sufficiency as12 ng/mL, 12-20 ng/mL and20 ng/mL, respectively. Vitamin D toxicity is defined as serum 25OHD100 ng/mL with hypercalcemia and/or hypercalciuria. Vitamin D supplementation in doses of 400 IU/day is recommended during infancy; however, the estimated average requirement in older children and adolescents (400-600 IU/day, respectively) should be met from diet and natural sources like sunlight. Rickets and vitamin D deficiency should be treated with oral cholecalciferol, preferably in a daily dosing schedule (2000 IU below 1 year of age and 3000 IU in older children) for 12 weeks. If compliance to daily dosing cannot be ensured, intermittent regimens may be prescribed for children above 6 months of age. Universal vitamin D supplementation is not recommended in childhood pneumonia, diarrhea, tuberculosis, HIV and non-infectious conditions like asthma, atopic dermatitis, and developmental disorders. Serum 25-hydroxy vitamin D level of20 ng/mL should be maintained in children with conditions at high-risk for vitamin deficiency, like nephrotic syndrome, chronic liver disease, chronic renal failure, and intake of anticonvulsants or glucocorticoids.

Purpose Haemorrhage, preeclampsia and sepsis are the leading causes of renal dysfunction in women with a maternal nearmiss(MNM) complication. The study aimed to assess the prevalence, pattern and follow up of these women. Methods This was a hospital based prospective observational study, conducted over one year. All women with a MNM leading to acute kidney injury (AKI) were analysed for fetomaternal outcomes and renal function at 1 year of followup. Results The incidence of MNM was 43.04 per 1000 livebirths. 18.2% women developed AKI. 51.1% women developed AKI in the puerperal period. Most common cause of AKI was haemorrhage seen in 38.3% women. The majority of women had s.creatinine between 2.1 to 5 mg/dl and 44.68% required dialysis. 80.8% women recovered fully when the treatment was initiated within 24 h. One patient underwent renal transplant. Conclusion Early diagnosis and treatment of AKI results in full recovery.

This paper analyses the networks, experiences and aspirations of Nepalese workers in Southern Portugal's farms and greenhouses. The main research objective is to analyse how recruitment networks, which supported the move of Nepalese to Portugal, were established and have rapidly consolidated. These networks impacted not only the increase of irregular migration flows but also the migration experience and vulnerability in the country of destination, including the passive acceptance of a certain degree of exploitation. By highlighting the perspective of the migrants themselves, we examine the impact on their lives, both of the migration experience and of paying large sums to smugglers, usually obtained through indebtment, to enter Portugal. We relate this impact to a context of immigration where the existence of a large informal labour market facilitates these workers being hired as irregular migrants. The study employed secondary data, in-depth interviews and participant observation. As well as migrants, greenhouse owners and recruiters were also interviewed for the study. The main finding is that the disposition of Nepalese to migrate, in which the pressure of the family plays a key role, tends to be reinforced by the action of the networks of recruiting agents. Secondly, the costs of migration and labour exploitation tend to be accepted by the migrants as a way to fulfil their social aspirations and economic necessities. info:eu-repo/semantics/acceptedVersion

The emergence of resistance to conventional antimalarial treatments remains a major cause for concern. New drugs that target the distinct development stages of Plasmodium parasites are required to address this risk. Herein, water-soluble aggregation-induced emission active cyclometalated iridium(III) polypyridyl complexes (Ir1-Ir12) are developed for the elimination of malaria parasites. Remarkably, these complexes show potent antimalarial activity in low nanomolar range against 3D7 (chloroquine and artemisinin sensitive strain), RKL9 (chloroquine resistant strain), and R539T (artemisinin resistant strains) strains of Plasmodium falciparum with faster killing rate of malaria parasites. Concomitantly, these complexes exhibit efficient in vivo antimalarial activity against both the asexual and gametocyte stages of Plasmodium berghei malaria parasite, suggesting promising transmission-blocking potential. The complexes tend to localize into mitochondria of P. falciparum determined by image and cell-based assay. The mechanistic studies reveal that these complexes exert their antimalarial activity by increasing reactive oxygen species levels and disrupting its mitochondrial membrane potential. Furthermore, the mitochondrial-dependent antimalarial activity of these complexes is confirmed in yeast model. Thus, this study for the first time highlights the potential role of targeting P. falciparum mitochondria by iridium complexes in discovering and developing the next-generation antimalarial agents for treating multidrug resistant malaria parasites.

In recent years electrochemical energy storage solutions such as supercapacitors have emerged as an attractive option. Supercapacitor electrode materials which are carbon-based composites with meta...

SummaryThe intraerythrocytic growth of malaria parasite is challenged by the presence of proteotoxic stress and intrinsically unstructured proteins in the cytoplasm due to formation of toxic heme during haemoglobin digestion. To overcome the unavoidable stress and maintain the cellular protein homeostasis, parasite encodes for a number of chaperones and co-chaperones. Here, we functionally characterize the Plasmodium falciparum prefoldins (PfPFD1-6), a hexameric co-chaperone complex, for their role in protein homeostasis. We demonstrate that PfPFD1-6 localise to cytosol of the parasite and the subunits perform an orchestrated interaction (-PFD3-PFD2-PFD1-PFD5-PFD6-PFD4-) to form an active jelly-fish like complex. Biperiden, an N-propylpiperidine analogue identified by chemotype search from FDA, strongly binds and restricts the formation of prefoldin complex and inhibited its interaction with the substrates, PfMSP-1 and α-tubulin-I. Biperiden treatment potently inhibited the in vitro (IC50: 1μM) and in vivo growth of malaria parasite. Thus, this study provides novel virtues towards understanding the role of PfPFDs in regulating protein homeostasis and opens new avenues for drug discovery against malaria.

Poor complementary feeding (CF) challenges early childhood growth. We examined the trends and influencing factors of CF practices among children aged 6-23 months in Côte d'Ivoire. Using data from Demographic and Health Surveys (DHS, 1994-2011) and Multiple Indicator Cluster Surveys (MICS, 2000-2016), the trends and predictors of World Health Organization-United Nations International Children's Emergency Fund CF indicators including the timely introduction of complementary foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD) and minimum acceptable diet (MAD) were determined. Using 2016 MICS data, we applied multivariate logistic regression models to identify factors associated with CF indicators. Between 1994 and 2016, the mean proportion of children aged 6-8 months achieving INTRO was 56.9% and increased by about 25% points since 2006. Over 2011-2016, the proportion of children aged 6-23 months meeting MMF, MDD and MAD increased from 40.2% to 47.7%, 11.3% to 26.0% and 4.6% to 12.5%, respectively. Older children and those from urban households had higher odds of meeting MDD and MAD. Maternal TV watching was associated with higher odds of meeting MDD. The secondary or higher education levels of mothers significantly predicted higher odds of meeting INTRO and MDD. Currently, breastfeeding was also positively associated with odds of meeting MMF and MAD. Children from poorer households had lower odds of meeting MMF, MDD and MAD. Despite the improvements, CF practices remain suboptimal in Côte d'Ivoire. Influencing factors associated with CF were distributed across individual, household and community levels, calling for future programmes and policies to implement multi-level strategies to improve young children's diet in Côte d'Ivoire.

More than 1.2 billion adults worldwide have hypertension. High retention in clinical care is essential for long-term management of hypertension, but 1-year retention rates are less than 50% in many resource-limited settings.To evaluate short-term retention rates and associated factors among patients with hypertension in primary health care centers in the Federal Capital Territory of Nigeria.In this cohort study, data were collected by trained study staff from adults aged 18 years or older at 60 public, primary health care centers in Nigeria between January 2020 and July 2021 as part of the Hypertension Treatment in Nigeria (HTN) Program. Patients with hypertension were registered.Follow-up visit for hypertension care within 37 days of the registration visit.The main outcome was the 3-month rolling average 37-day retention rate in hypertension care, calculated by dividing the number of patients who had a follow-up visit within 37 days of their first (ie, registration) visit in the program by the total number of registered patients with hypertension during multiple consecutive 3-month periods. Interrupted time series analyses evaluated trends in retention rates before and after the intervention phase of the HTN Program. Mixed-effects, multivariable regression models evaluated associations between patient-, site-, and area council-level factors, hypertension treatment and control status, and 37-day retention rate.In total, 10 686 patients (68.3% female; mean [SD] age, 48.8 [12.7] years) were included in the analysis. During the study period, the 3-month rolling average 37-day retention rate was 41% (95% CI, 37%-46%), with wide variability among sites. The retention rate was higher among patients who were older (adjusted odds ratio [aOR], 1.01 per year; 95% CI, 1.01-1.02 per year), were female (aOR, 1.11; 95% CI, 1.01-1.23), had a higher body mass index (aOR, 1.01; 95% CI, 1.00-1.02), were in the Kuje vs the Abaji area council (aOR, 2.25; 95% CI, 1.25-4.04), received hypertension treatment at the registration visit (aOR, 1.27; 95% CI, 1.07-1.50), and were registered during the postintervention period (aOR, 1.16; 95% CI, 1.06-1.26).The findings suggest that retention in hypertension care is suboptimal in primary health care centers in Nigeria, although large variability among sites was found. Potentially modifiable and nonmodifiable factors associated with retention were identified and may inform multilevel, contextualized implementation strategies to improve retention.

Background Hypertension is the most common cardiovascular disease in Nigeria and contributes to a large non-communicable disease burden. Our aim was to implement and evaluate a large-scale hypertension treatment and control program, adapted from the Kaiser Permanent Northern California and World Health Organization HEARTS models, within public primary healthcare centers in the Federal Capital Territory, Nigeria. Methods A type 2 hybrid, interrupted time series design was used to generate novel information on large-scale implementation and effectiveness of a multi-level hypertension control program within 60 primary healthcare centers in the Federal Capital Territory, Nigeria. During the formative phase, baseline qualitative assessments were held with patients, health workers, and administrators to inform implementation package adaptation. The package includes a hypertension patient registry with empanelment, performance and quality reporting, simplified treatment guideline emphasizing fixed-dose combination therapy, reliable access to quality essential medicines and technology, team-based care, and health coaching and home blood pressure monitoring. Strategies to implement and adapt the package were identified based on barriers and facilitators mapped in the formative phase, previous implementation experience, mid-term qualitative evaluation, and ongoing stakeholder and site feedback. The control phase included 11 months of sequential registration of hypertensive patients at participating primary healthcare centers, followed by implementation of the remainder of the package components and evaluation over 37 subsequent, consecutive months of the intervention phase. The formative phase was completed between April 2019 and August 2019, followed by initiation of the control phase in January 2020. The control phase included 11 months (January 2020 to November 2020) of sequential registration and empanelment of hypertensive patients at participating primary healthcare centers. After completion of the control phase in November 2020, the intervention phase commenced in December 2020 and will be completed in December 2023. Discussion This trial will provide robust evidence for implementation and effectiveness of a multi-level implementation package more broadly throughout the Federal Capital Territory, which may inform hypertension systems of care throughout Nigeria and in other low- and middle-income countries. Implementation outcome results will be important to understand what system-, site-, personnel-, and patient-level factors are necessary for successful implementation of this intervention. Trial registration ClinicalTrials.gov NCT04158154. The trial was prospectively registered on November 8, 2019.