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Several international studies have stratified people with diabetes into phenotypical clusters. However, there has not been a systematic examination of the variation in these clusters across ethnic groups. For example, some clusters appear more frequent among Asians and may have lower weight, age at diagnosis and poorer beta cell function.

Introduction: In addition to established risk factors for cardiovascular disease, women have unique biological characteristics related to reproduction that may further contribute to their CV risk. Among South Asian Indians, this aspect has been understudied. This study addresses this gap by evaluating the relationship between reproductive characteristics and cardiometabolic risk factors (CMRF) among women in India. Methods: We analyzed data from a community-based nationally representative sample of women aged 15-49 in the National Family Health Survey-5 (N= 724,115). Primary exposures (self-reported) included age at union and first delivery, use of contraception and history of pregnancy loss. Study outcomes (self-reported, objectively measured) were prevalent hypertension (HTN), diabetes mellitus (DM) and obesity. We estimated the association between each exposure and outcome using survey-weighted multivariable Poisson regression models adjusted for age, religion, caste, location, education and employment. Results: Prevalence (95% CI) of HTN (measured blood pressure of >=140/90 mm Hg), DM (self-reported or on medications to lower blood glucose levels) and obesity (body mass index > 25kg/m 2 ) was 25.8 (25.5, 26.2)%, 1.9 (1.8, 1.9)% and 24 (23.8, 24.2)%, respectively. Younger age at union and first delivery and, use of contraception [PR (95% CI): 1.13 (1.11, 1.16)] were associated with higher obesity. Pregnancy loss (due to miscarriage or abortion) was associated with higher prevalent DM [PR (95% CI): 1.21 (1.03, 1.41)] and obesity [PR (95% CI): 1.26 (1.22, 1.31)] ( Table ). Conclusion: Reproductive characteristics (age at union and first delivery, and pregnancy loss) are linked to higher prevalence of CMRF. These results provide impetus for screening for reproductive history and its inclusion in risk prediction algorithms for cardiovascular risk among Indian women. Table: Cross-sectional associations between reproductive characteristics with cardiometabolic risk factors, in the NFHS-5 (N= 724,115)

ImportanceDiabetes mellitus (DM) is widespread and treatable. Little is known about the diabetes care continuum (diagnosis, treatment, and control) in India, and whether it varies by socio-demographic characteristics and vary at the national, state, and district levels.ObjectiveTo estimate the diabetes care continuum among individuals aged 18-98 years old at national, state, and district-levels, and by socio-demographic group.DesignCross-sectional, nationally representative surveySetting28 states, 8 union territories, and 707 districts of IndiaParticipants1,895,287 approached in the Fifth National Family Health Survey (NFHS-5), 2019-2021ExposuresDistrict, state, urban vs rural residence, age (18-39, 40-64, ≥65 years), sex, household wealth quintileMain Outcomes and MeasuresDiabetes was defined by self-report or high capillary blood glucose (≥126mg/dL [fasting] or ≥220mg/dL [non-fasting]). Of those with diabetes, we estimated proportions that were diagnosed (self-reported). Among those diagnosed, we reported the proportions treated (self-reported medication use) and proportion controlled (blood glucose ResultsAmong 1,651,176 adult respondents (52.6% female; mean age: 41.6 years) with blood glucose measures, the proportion with diabetes was 6.5% (95%CI: 6.4, 6.6). Among adults with diabetes, 74.2% [73.3, 75.0] were diagnosed. Among those diagnosed, 59.4% [58.1, 60.6] reported taking medication and 65.5% [64.5, 66.4] achieved control. Diagnosis and treatment were higher in urban areas, older age groups, and wealthier households. Of the 707 districts, 34.8% districts met diagnosis target, while 10.7% districts met the control target among those diagnosed. Most of the variability in diabetes diagnosis (VPC:69.9%), treatment (VPC:51.8%), and control (VPC:66.8%) were between districts in a state, and not between states.Conclusions and RelevanceNationally, the diabetes care continuum masks considerable state- and district-level variation, as well as age- and rural-urban disparities. Surveillance at the district-level can guide state health administrators to prioritize interventions and monitor achievement of global targets.KEY POINTSQuestionHow does the diabetes care continuum (diagnosis, treatment, and control) vary by state, district, and sociodemographic groups in India?FindingsNationally, among 1.65 million respondents in the National Family Health Survey of 2019-2021, 74.2% were diagnosed. Among those diagnosed, 59.4% reported taking medication and 65.5% achieved control. Most of the variability in care continuum was within-state, between districts (% variance explained: 51.8-69.9) and not between-states. Higher diagnosis and treatment, but lower control was observed in urban compared to rural areas and older compared to younger and middle age groups.MeaningConsiderable differences between states, between districts in a state, for rural adults, and by age imply the need for targeted, decentralized solutions to improve the diabetes care continuum in India.

Synodality represents the main road for the Church, called to renew herself under the action of the Spirit and by listening to the Word. Alone we can do so little; Together, we can do so much. Holy Father Pope Francis invites each of us to think, suggest, and work together to achieve or fulfill the synodal nature of the Church. Synodality is not a new concept; instead, it’s an invitation to re-discover the practice of the early Church.

Background: Diabetes detection and treatment in married couples presents opportunities for designing dyadic interventions to improve screening and management. Methods: Using data from 59237 heterosexual married couples (women: 18-49y, men: 21-54y) assessed in India’s National Family Health Survey (2015-16) , we estimated the diabetes care cascade as the percent diagnosed, treated, and controlled with measured high blood glucose (BG) by spouse’s diabetes status. Results: The prevalence of high BG was 8.8% (men) and 14.2% (women) . In adults with high BG, the percent diagnosed, treated, and controlled was 22.6%, 18.7%, and 9.2% (men) and 22.5%, 18.0%, and 8.5% (women) , respectively. Of adults with high BG, the prevalence of diabetes diagnosis was higher in men (prevalence ratio [PR]: 1.85 [1.37, 2.49]) and women (PR: 2.03 [1.47, 2.8]) whose spouse was diagnosed (ref=spouse undiagnosed) . Among the diagnosed, the prevalence of being treated for diabetes did not differ by their spouse’s diagnosis status in men or women. Among the treated, the prevalence of blood glucose control was higher in women (PR: 1.45, [0.93, 2.25]) , but not men (PR: 0.96 [0.66, 1.40]) , whose spouse was diagnosed (ref=spouse undiagnosed) . Conclusions: Spouse’s diabetes was associated with higher probability of detection of diabetes but not with treatment. Outreach among couples may improve medical management of diabetes in India. Disclosure J.Varghese: None. S.A.Patel: Research Support; Johnson & Johnson.

Background Parity has been associated with both short- and long-term weight gain in women. However, it is not clear if timing of parity across the reproductive age has different associations with BMI. Methods To prospectively assess the association between age at childbirth and maternal change in BMI, we analyzed data from the ongoing INCAP Longitudinal Study, which started in 1969 in four villages in Guatemala. Cohort women (n=778) provided information on reproductive history and anthropometric measures were measured in 1988-89 (adolescence, 15 to 25y), 2002-04 (early adulthood, 26 to 36y) and 2015-17 (mid adulthood, 37 to 55y). We evaluated the associations of number of live births in the period preceding each study wave (1969-77 to 1988-89, 1988-89 to 2002-04 and 2002-04 to 2015-17) with BMI change in the same period using multivariable linear regression models. Results Number of live births between 1988 and 89 and 2002-04 was positively associated with increased BMI, while there was not an association between number of live births and BMI in the other intervals. Women who had one, two, or three or more children between 1988 and 89 and 2002-04 had 0.90 (kg/m2, 95% CI: -0.55, 2.35), 2.39 (kg/m2, 95% CI: 1.09, 3.70) and 2.54 (kg/m2, 95% CI: 1.26, 3.82) higher BMI, respectively, than women who did not give birth in the same period. Conclusions Our findings suggest that women who had three or more children during early adulthood gained more weight compared to women who had no children in the same period. In contrast, women who had children earlier or later in their reproductive lives did not gain additional weight compared to those who did not have children during that period. Childbirth may have different associations with BMI based on the mother’s age.

OBJECTIVES With the expansion of transcatheter aortic valve replacement (TAVR) into intermediate and low risk, the number of TAVR procedures is bound to rise and along with it the number of cases of infective endocarditis following TAVR (TIE). The aim of this study was to review a multicentre experience of patients undergoing surgical intervention for TIE and to analyse the underlying indications and operative results. METHODS We retrospectively identified and analysed 69 patients who underwent cardiac surgery due to TIE at 9 cardiac surgical departments across Germany. The primary outcome was operative mortality, 6-month and 1-year survival. RESULTS Median age was 78 years (72–81) and 48(69.6%) were male. The median time to surgical aortic valve replacement was 14 months (5–24) after TAVR, with 32 patients (46.4%) being diagnosed with early TIE. Cardiac reoperations were performed in 17% of patients and 33% underwent concomitant mitral valve surgery. The main causative organisms were: Enterococcus faecalis (31.9%), coagulase-negative Staphylococcus spp. (26.1%), Methicillin-sensitive Staphylococcus aureus (15.9%) and viridians group streptococci (14.5%). Extracorporeal life support was required in 2 patients (2.9%) for a median duration of 3 days. Postoperative adverse cerebrovascular events were observed in 13 patients (18.9%). Postoperatively, 9 patients (13.0%) required a pacemaker and 33 patients (47.8%) needed temporary renal replacement therapy. Survival to discharge was 88.4% and survival at 6 months and 1 year was found to be 68% and 53%, respectively. CONCLUSIONS Our results suggest that TIE can be treated according to the guidelines for prosthetic valve endocarditis, namely with early surgery. Surgery for TIE is associated with acceptable morbidity and mortality rates. Surgery should be discussed liberally as a treatment option in patients with TIE by the ‘endocarditis team’ in referral centres.

In December 2019, the global outbreak of coronavirus disease-2019 (COVID-19) was announced. The pandemic has cast a spotlight like never before on health-care professionals in general, and nurses in particular. Nurses have been dubbed "warriors" by the general public for their determination to provide frontline care to patients with the disease, despite the risk of exposure and a lack of professional resources. The goal of the study was to assess the obstacles and consequences faced by Kerala nurses during the COVID-19 pandemic.A cross-sectional study was conducted from January to June 2021 among Kerala nurses. A total of 1630 nurses were chosen using a randomized sampling technique. The data were gathered using a semi-structured self-reported questionnaire. The information was entered into a database and analyzed using SPSS program version 16.0.After analyzing the data, seven themes emerged: (a) love for the profession; (b) frustration for being labeled as "COVID Nurses"; (c) fear of infection and transmission; (d) personal protective equipment uncertainty; (e) workplace safety especially against hospital violence; (f) burnout in nurses; and (g) job stress.Nurses undertook a hazardous rescue mission and played an essential contribution in COVID-19 pandemic. Over the course of intensive work, they underwent significant psychological changes. Nurses burnout and occupational stress must be addressed with effective interventions. In order to mitigate the pandemic, the administration should also promote a healthy workplace and have a positive attitude and harmonious connection with the frontline personnel.

BackgroundOverweight/obesity increased dramatically among Indian women since 2000. We evaluated the independent contributions of economic and nutrition context to the changing distribution of overweight/obesity among women from 1998 to 2016 across India.MethodsIndividual-level data from 473 912 ever married Indian women aged 18–49 in the National Family Health Surveys (1998–1999, 2005–2006, 2015–2016) were merged with year-matched state-level economic and nutrition context indicators. Cross-classified generalised linear mixed models were estimated to quantify associations of contextual characteristics with overweight/obesity (body mass index ≥25 kg/m2) across survey rounds.ResultsBetween 1998 and 2016, age-standardised prevalence of overweight/obesity increased from 13.9% to 27.5% nationally at an annual growth rate of 0.8%. After accounting for a woman’s age, parity and social class, the adjusted OR (aOR) for overweight/obesity was 2.02 times higher for every unit of state log per capita gross domestic product (GDP) (95% credible interval (CrI) 2.00 to 2.03). Yet, the association of state GDP with overweight/obesity generally decreased over survey round. Women in states with higher per capita daily oil (aOR 1.02 per gram; 95% CrI 1.01 to 1.03) and sugar (aOR 1.05 per gram; 95% CrI 1.04 to 1.05) consumption were more likely to be overweight/obese, while women in states with higher cereal consumption were less likely to be overweight/obese (aOR 0.93 per 10 gram; 95% CrI 0.93 to 0.93).ConclusionsIndicators of state economic development and nutrition transition were independently associated with a woman’s likelihood of being overweight/obese. The impact of state wealth waned over survey round, suggesting that risks for overweight/obesity may be increasingly shaped by individual factors as economic development expands in India.

Background Though laser guided extractions of cardiac implantable electronic devices leads have become a routine procedure, the severe complications are associated with a high mortality. Here, we report our single center experience using uniportal video-assisted thoracoscopy for laser lead extraction and compare it to stand-alone laser lead extraction. Methods The intraoperative data and postoperative clinical outcomes of patients undergoing laser lead extraction with concomitant thoracoscopy ( N = 28) or without ( N = 43) in our institution were analyzed retrospectively. Results Neither the median x-ray time (612.0 s for the thoracoscopy group vs. 495.5 s for the non-thoracoscopy group, p = 0.962), length of the operation (112.5 vs. 100.0 min, p = 0.676) or the median length of hospital stay (9.0 vs. 10.0 days, p = 0.990) differed significantly. The mean intensive care unit stay was longer for patients in the non-thoracoscopy group (0.8 vs. 2.5 days, p = 0.005). The 30-day-mortality in the thoracoscopy group was zero, whereas five patients died in the non-thoracoscopy group. Furthermore, four patients in the non-thoracoscopy group had encountered haemothorax, while none were observed in the thoracoscopy group ( p = 0.148). Conclusions The adoption of uniportal video-assisted thoracoscopy during laser-guided lead extraction of cardiac implantable electronic devices can be considered safe and does not lengthen the operating time or hospital stay. It might be useful in the detection of severe complications and, in experienced hands, possibly allow direct bleeding control.

We evaluated changes in priority indicators of child growth from 2006 to 2021 and examined the role of human development measures in these changes.We estimated cumulative and annualized changes in state- and district-level child growth indicators using 3 rounds of National Family Health Surveys (2005-2006, 2015-2016, 2019-2021) in 36 states. Outcomes included stunting, underweight, wasting, and overweight. Human development was measured using a principal components analysis of 9 ecological indicators. We contrasted expected versus observed changes in district-level growth outcomes between 2016 and 2021 based on changes in development indicators using 2-way Blinder Oaxaca decomposition.From 2006 to 2021, the prevalence of stunting, underweight, and wasting decreased by 12.3, 10.3, and 0.7 percentage points, respectively, while the prevalence of overweight increased by 1.9 percentage points. The annualized rate of within-state change for stunting was lower from 2016 to 2021 compared with the 2006 to 2016 period, while the rate of change in overweight was higher. Simultaneously, all 9 human development indicators improved between 2006 and 2021. A unit increase between 2016 and 2021 in the human development score predicted a -5.1 percentage point (95% confidence interval=-5.8, -4.4) change in stunting, yet observed stunting declined by just -2.5 percentage points.From 2016 to 2021, population-level reduction in child stunting has slowed and the rise in child overweight has accelerated, relative to the 10 years preceding this period.

Background Temporally-harmonized asset-based measures of wealth can be used to study the association of life-course wealth exposures in the same scale with health outcomes in low- and middle-income countries (LMICs). The within-individual longitudinal stability of asset-based indices of wealth in LMICs is poorly understood. Methods Using data from five birth cohorts from three continents, we developed temporally-harmonized asset indices over the life course through polychoric principal component analysis of a common set of assets collected consistently over time (18 years in Brazil to 50 years in Guatemala). For each cohort, we compared the harmonized index to cross-sectional indices created using more comprehensive asset measures using rank correlations. We evaluated the rank correlation of the harmonized index in early life and adulthood with maternal schooling and own attained schooling, respectively. Results Temporally-harmonized asset indices developed from a consistently-collected set of assets (range: 10 in South Africa to 30 in Philippines) suggested that mean wealth improved over time for all birth cohorts. Cross-sectional indices created separately for each study wave were correlated with the harmonized index for all cohorts (Brazil: r = 0.78 to 0.96; Guatemala: r = 0.81 to 0.95; India: 0.75 to 0.93; Philippines: r = 0.92 to 0.99; South Africa: r = 0.84 to 0.96). Maternal schooling (r = 0.15 to 0.56) and attained schooling (r = 0.23 to 0.53) were positively correlated with the harmonized asset index in childhood and adulthood respectively. Conclusions Temporally-harmonized asset indices displayed coherence with cross-sectional indices as well as construct validity with schooling., Highlights • Temporally-harmonized asset indices are useful to assess relative importance of wealth at different life stages with health on the same scale. • Harmonized indices using a subset of assets were correlated with cross-sectional asset indices using all available assets in five LMIC birth cohorts. • Harmonized indices displayed construct validity, as demonstrated by its correlation with schooling. • Harmonized indices were robust to alternate specifications such as shorter lists of assets, study years, and factor extraction procedures.