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Nationa Medical Commission (NMC) had recently undertook the revision of Undergraduate CBME curriculum. the Authors were involved in Psychiatry curriculum revision. In this paper,authors explain the process of revision, the rationale behind the changes made and make specific suggestions for the better implementation of the revised curriculum. [ABSTRACT FROM AUTHOR]

Background and Aims: This study aims to investigate the clinicopathological profile of cervical lymphadenopathy in a tertiary referral centre. The findings will contribute to a deeper understanding of the disease spectrum, aid in accurate diagnosis, and help in improving patient treatment and outcomes. Methodology: This is a prospective study conducted in the Department of ENT, Head and Neck Surgery, Apollo Hospital, Chennai, between June 2022 and May 2023. The clinicopathological profile of all patients was analysed. The final histological diagnosis and the preoperative Fine Needle Aspiration Cytology (FNAC) were correlated. The primary tumour was identified in cases with metastatic secondary tumours in the neck. Results: Among the 80 patients in our study, 67% had a benign aetiology (most common was tuberculosis), and 33% had a malignant aetiology (most common was Hodgkin's Lymphoma). Gender distribution was equal, with those between the ages of 35 and 60 more frequently affected. The nasopharynx (30%) was the most likely location of the occult primary, followed by the thyroid (20%) and larynx (20%). In detecting TB, FNAC had a sensitivity of 75.5% and a specificity of 98%; in detecting lymphomas, it was 64% and 100%; in detecting metastatic secondaries, it was 80% and 100%; and in detecting reactive lymphadenitis, it was 79% and 86%. Conclusion: Cervical lymphadenopathy is a common entity requiring careful evaluation and treatment. PET scans prove invaluable in detecting occult primary tumours. FNAC is an initial, cost-effective diagnostic tool. However, biopsy is indicated in specific conditions to obtain accurate diagnosis to enable prompt treatment. [ABSTRACT FROM AUTHOR]

This paper examines a digital platform used in the primary health sector in a state in Eastern India. Within a 'regime of tactility,' it is supposed to redefine the state's presence in rural areas, not only by attending to patients but also by screening the population and establishing health databases. While the health workers who operate the digital platform represent the state in 'the peripheries,' the state itself exhibits mistrust towards them and monitors their performance through the platform. Based on long-term ethnographic research, the manuscript analyses the use of digital health technologies as technologies of accountability. The competitive nature of monitoring techniques leads to an ever-higher number of digital consultations, which projects the image of a caring and efficient state. However, the paper also explores the unintended consequences of this politics by display on the provision of healthcare. Even though digital technologies and the managerial form of governance they engender promise to touch people's lives, they lead to intangible forms of care while leaving untouched pressing structural issues that India's health sector has been facing for decades. [ABSTRACT FROM AUTHOR]

Background: Non-adherence to medication leading to a break in continuity of care poses significant challenges in severe mental illness (SMI), leading to poor outcomes. In India, proxy consultation, wherein caregivers consult on behalf of patients, is a commonly adopted but insufficiently researched area to address these challenges. Aims: To explore the extent of proxy consultation in outpatient care of persons with SMI and investigate its sociodemographic and clinical correlates. Methodology: In a tertiary care psychiatry outpatient setting, we conducted a cross-sectional study involving 374 caregivers of persons with SMI (Schizophrenia, Bipolar and related disorders). Descriptive statistics and univariate logistic regression were performed to examine correlates' relationships with proxy consultation. Results: Proxy consultation prevalence was 43% in the past 1 year. Compared with 18 to 30 years, middle-aged patients aged 31 to 40, 41 to 50 and 51 to 60 years had twofold, threefold and sixfold increased chances of proxy consultation, respectively. Being illiterate had six times higher odds than graduates, three times and two times if they studied till primary and secondary education. Early age of onset was associated with three times higher chances of proxy consultation compared to the onset of illness in adulthood. On the contrary, male gender and upper and middle socioeconomic status decreased the chances of proxy consultation by 40%. Financial difficulties (n = 72, 45%) and patients' unwillingness to visit outpatients (n = 44, 27.5%) were the most commonly cited reasons for proxy consultation. Conclusion: Proxy consultations are relatively common, driven by many social, economic, patient-related, pragmatic and practical factors. In formulating community care policies for persons with SMI, the primary imperative should be to conduct additional research, deepening our understanding of proxy consultations. Additionally, it is essential to be mindful of the diverse issues associated with proxy consultations during the formulation process. [ABSTRACT FROM AUTHOR]

Postiodization era has experienced a change in pediatric thyroid disorders with autoimmune disorders and subclinical hypothyroidism (SCH) now more frequently diagnosed. The aims of this study were to evaluate the clinical spectrum of thyroid disorders among children referred to us, to ascertain characteristics that influence treatment, and to follow them for various outcome measures. An observational longitudinal study where all treatment-naïve children (<18 years) with suspected thyroid disorders were recruited. Data collected were anthropometry, serum TSH, TT4, TT3, antithyroid autoantibodies, family history, and clinical symptoms. The management was based on the clinical judgment of the endocrinologist with the first follow-up at six weeks and subsequent visits three monthly for one year. A total of 241 subjects aged 28 days to 17 years were included. Overall, SCH was the most common abnormality (39%) detected among subjects, followed by overt hypothyroidism (OH) (33%), congenital hypothyroidism (CH) (18%), and overt thyrotoxicosis (5%). A total of 85.5% (n = 204) of subjects were treated and in follow-up, 81% of them were found to be adequately managed. Comparative analysis of OH and SCH revealed pubertal age, female predominance, and the presence of autoimmunity (positive anti-TPO and anti-TG Ab) statically significant variables in the OH group. A major independent predictor of treatment in treated SCH (72/96) in comparison with nontreated SCH (24/96) was anti-TPO positivity (P = 0.029). Eight of 24 nontreated SCH were eventually treated in follow-up and positive family history was observed as a significant variable among them (P < 0.05). Subjects with CH presented at a mean age of 6 months (28 days to 2 years). However, guidelines for the management of SCH are still evolving, autoimmunity and positive family history should be considered as decisive factors while initializing treatment. Delayed presentation of CH in our study warrants active surveillance of children at birth for thyroid disorders for their mental well-being. [ABSTRACT FROM AUTHOR]

Background: In resource-limited facilities, the greatest number of unfavorable maternal-fetal outcomes at referral hospitals is chronicled from emergency obstetric referrals of critically ill patients from lower health facilities. An efficient obstetric referral system is thus necessitated for improving maternal health. Referral practices have not been optimized effectively till date, owing to paucity of a detailed profile of referred women and indigenous barriers encountered during implementation process. Materials and methods: This five-year retrospective audit was conducted in the Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital, New Delhi from September 2018 to 2023, in which records of all critically ill obstetric women referred were reviewed. The primary outcomes included were proportion and pattern of patients being referred, while secondary outcomes included demographic variables, referring hospital, reason and number of steps in referral, duration of hospital stay and fetomaternal outcome. The data were recorded on a predesigned case proforma and analyzed using the SPSSv23 version of software, after application of appropriate statistical tests. Results: The referral rate to obstetric intensive care unit (ICU) ranged from 39 to 47% in last 5 years; hypertensive disorder of pregnancy (31%) being the foremost cause of the referrals. Around 2/3rd women were transferred without escort (70%) or prior communication (90.6%) and referral slips were incomplete in half the admissions. Conclusion: Ensuring emergency obstetric care (EmOC) at various levels by up-gradation of health infrastructure would go a long way in improving fetomaternal health outcomes. There is need of standardized referral slips tailor-made to each state and contextualized protocols for early recognition of complications and effective communication between referral centers. [ABSTRACT FROM AUTHOR]

"Eliminate rheumatic fever (RF) and minimize the burden of rheumatic heart disease by 2025" is the goal of World Heart Federation (WHF). The most important step to achieve the goal of WHF is the implementation of the prevention and control of RF in India. The program can be implemented with minimal fund allocation from government making use of the existing manpower in the government and private health sector and schools with the concurrence of National Health Mission, Ministry of Health and Family Welfare, Ministry of Public Education and under the guidance of Cardiological Society of India, National Rheumatic Heart Consortium, Rheumatic Heart Club India, Association of Physicians of India, Indian Academy of Pediatrics, and Association of Otolaryngologists of India. By the successful implementation of this program, the children of 5--15 years in India can be protected from RF. India eradicated smallpox in 1980 and Polio 2012. With this program, we can start our efforts to eliminate RF by 2025. [ABSTRACT FROM AUTHOR]

Background: Substance use disorders (SUDs) are among the leading causes of morbidity in the population. In low- and medium-income countries like India, there is a wide treatment gap for SUD. A multicentric study on the care pathways for SUD in India can help to understand service provision, service utilization, and challenges to improve existing SUD care in India. Aim: We aimed to map pathways to care in SUD. We compared the clinical and demographic characteristics of patients who first consulted specialized services versus other medical services. Methods: This was a cross-sectional study of consecutive, consenting adults (18-65 years) with SUD registered to each of the nine participating addiction treatment services distributed across five Indian regions. We adapted the World Health Organization's pathway encounter form. Results: Of the 998 participants, 98% were males, 49.4% were rural, and 20% were indigenous population. Addiction services dominated initial (50%) and subsequent (60%) healthcare contacts. One in five contacted private for-profit healthcare. Primary care contact was rare (5/998). Diverse approaches included traditional healers (4-6%) and self-medication (2-8%). There was a 3-year delay in first contact; younger, educated individuals with opioid dependence preferred specialized services. Conclusion: There is a need to strengthen public healthcare infrastructure and delivery systems and integrate SUD treatment into public healthcare. [ABSTRACT FROM AUTHOR]

Pain management constitutes a pivotal aspect of palliative care. Certain instances of distressing pain are significantly relieved through interventional pain methodologies, demanding the expertise of pain specialists. Our perspective revolves around the integration of these 2 facets, envisaging a symbiotic relationship that could enhance patient outcomes. A prospective assessment was carried out within a collaborative clinic, uniting the realms of pain management and palliative medicine. Anonymized patient information was scrutinized to grasp the advantages of this amalgamation and identify strategies to address any inherent deficiencies. Furthermore, an illustrative case study was delineated, spotlighting the collaborative dynamics at a systemic level. During the period spanning from November 2020 to June 2021, a total of 43 patients received consultations at this collaborative clinic. Each patient was exposed to a comprehensive pain management regimen, with the most frequently conducted procedure being an intercostal nerve block, which was administered in 9.30% of cases. For the provision of effective pain relief within the palliative care context, the confluence of joint consultations from cancer pain specialists emerges as a requisite measure. This approach carries the promise of optimizing pain control and augmenting the quality of palliative care. [ABSTRACT FROM AUTHOR]

The new 2023 update of the International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer incorporates the advances made in the understanding of the pathology and molecular classifications into the staging system. While the new staging system aids in precision medicine and may lead to better documentation of prognostic risk categories of endometrial cancer, it is complex and calls for an integrated approach and better communication between multiple disciplines involved in the management of endometrial cancer. In this review article, we address how the referral patterns to imaging services might change considering the updated staging system for endometrial cancer. We also discuss the practical aspects and nuances involved in the radiology service delivery and reporting practices as we adopt the new FIGO staging system for managing endometrial cancer patients. [ABSTRACT FROM AUTHOR]

Introduction: Chemotherapy, postchemotherapy retroperitoneal lymph node dissection (pcRPLND), and metastasectomy remain the standard of care for the management of advanced nonseminomatous germ cell tumor (NSGCT). Methods: We retrospectively studied 73 patients who had pcRPLND at a single tertiary-care center (2003-2022). Surgical and clinicopathological features and oncological outcomes are presented. Results: The mean age was 28.27 years (15-48). Three-fourths had Stage III disease at diagnosis. International Germ Cell Cancer Collaborative Group risk stratification was 54.54% and 21.21% in intermediate risk, and poor risk, respectively. Sixty-two patients had Standard, 7 had Salvage and 4 underwent Desperation pcRPLND. Eleven patients (15.06%) required adjunctive procedures. Thirteen patients (17.8%) had ≥ class 3 Clavien--Dindo complications and postoperative mortality occurred in 5 (6.8%) patients. The histopathologies (HPE) of the pcRPLNDs were necrosis, teratoma, and viable tumor in 39.7%, 45.2%, and 15.1%, respectively. Seven patients underwent metastasectomy. An 85% size reduction in the size of RPLN predicted necrosis. There was 71.4% concordance between pcRPLND and metastasectomy HPEs. The median follow-up was 26.72 months (inter-quartile range -- 13.25-47.84). The 2-year recurrence-free survival (RFS) rate was 93% (95% confidence interval [CI]-83%-97%) and the overall survival (OS) rate was 90% (95% CI-80%-95%). This is the largest series of pcRPLND for NSGCT in India to our knowledge. Conclusion: Although most of the cohort belonged to stage III, an RFS and OS rate of >90% at 2 years was achieved. We believe that successful management of postchemotherapy residual masses in NSGCT is contingent on the availability of multidisciplinary expertise and is therefore best done at tertiary-care referral centers. [ABSTRACT FROM AUTHOR]

Background: Musculoskeletal disorders are the leading cause of disability worldwide and occur across all age groups. The treatment of choice for this remains nonsteroidal anti-inflammatory drugs despite evidence showing exercises reduce pain and also improve quality of life. In India, the majority of the population belongs to rural areas where access to physiotherapy can be difficult. Greater dependence on traditional medicine is also seen in these areas. This research aims to identify obstacles faced by the rural communities in Goa in obtaining physiotherapy services. Objectives: The objective of this study was to identify barriers to physiotherapy services for musculoskeletal problems in rural sectors and reliance on traditional medicine for movement-related problems. Materials and Methods: This was a descriptive study involving 200 participants and 27 health workers. The questionnaire was administered by the investigator. Data were analyzed manually as well as using SPSS (version 26). Results: Movement-/function-related pain in daily life was reported by 63.5%. Awareness of physiotherapy was present in 74% and 12% had a clinic in their community. Only 18% relied on traditional medicine. Out of the health workers/professionals interviewed, 96% were aware of physiotherapy. The most common reason was the lack of resources for the absence of physiotherapy services. Conclusion: The obstacles identified were lack of clinics, poor referrals, and lack of resources for physiotherapy equipment. Clinical Implications: Identification of barriers to physiotherapy in rural sectors will help to improve services in the area. [ABSTRACT FROM AUTHOR]

Background and Aim: There is high prevalence of mental disorders in specialist treatment seekers across specialties. Still, psychiatry referral rates have been found to be very low. A physician refers a patient to psychiatric services for reasons like known case of mental disorder, physical symptoms without adequate explanation, or if the physician feels inadequate in dealing with psychological symptoms. A multi disciplinary approach should be encouraged for the management of such patients, facilitating early recognition and management of psychiatric problems. The aim is to study the sociodemographic variables of psychiatric referrals, reasons and diagnostic categories of psychiatric referrals, and the distribution of psychiatric diagnoses according to reasons and sources of referrals. Materials and Methods: A retrospective hospital based study was conducted in the Department of Psychiatry, Hamdard Institute of Medical Sciences and Research, New Delhi, by analyzing the recorded data of referrals to the Psychiatry Department from various other specialties from January 2019 to March 2020. All referred patients were evaluated by a Psychiatrist (MD Psychiatry) and the diagnosis was made as per the International Statistical Classification of Diseases 10 criteria. The data obtained were analyzed using descriptive statistical methods. Results: This study included 315 psychiatric referrals. The mean age and standard deviation of the entire sample were 37.75 ± 17.63. The referral rate was minimum from January to March 2020. The highest number of referrals was from Medicine Department (66.3%). Among those, the most common diagnoses were that of alcohol dependence (27%). The most common overall reason for referral was substance use (26.2%). The most common psychiatric diagnosis was alcohol dependence (24%). Hypertension was the most common physical comorbidity. The most common diagnosis for known case of psychiatric illness and follow ups were psychotic disorders (27.3% and 26.3%). Conclusion: The findings of this study give us insight that consultation liaison psychiatry should focus on early recognition and wholesome management of psychiatric disorders in patients with physical illness through consultation psychiatry services in general hospital settings. [ABSTRACT FROM AUTHOR]

Background and Aim: Adolescent pregnancy has become an important health and social issue in both developing and developed countries. According to the National Family Health Survey-5, the prevalence of adolescent pregnancy in India is 6.8%. Adolescent pregnancy has shown association with preterm birth, low birth weight, perinatal death, miscarriage, puerperal sepsis, mental illness, and maternal death. With this background, this study was taken up with the objective to delineate the maternal and neonatal complications seen in teenage pregnant women. Materials and Methods: This study was a retrospective case record analysis with descriptive study design of all adolescent pregnancies delivered between October 2021 and September 2022 with mother's age being ≥19 years, at a first referral hospital in Bengaluru were included in the study. Participants who could not be contacted were excluded from the study. Results: Out of the 1005 deliveries during the study period, 55 were adolescent pregnancy with a proportion of 5.47%. The most common maternal complication is pregnancy-induced hypertension (8.5%) and the most common neonatal complication is low birth weight (21.2%). Conclusions: Despite continuous and consistent efforts by the health-care administration and health-care personnel under maternal and child national health program, the expected outcomes in terms of usage of contraception and delaying first pregnancy have not been attained. [ABSTRACT FROM AUTHOR]

Introduction: Pediatric dentists play a role in the prevention of the communicable diseases such as COVID-19 and in the identification and referral of those children. There are concerns about the identification, referral, diagnosis, and treatment of oral manifestations of COVID-19 in children. Aim: To assess the knowledge, attitude, and practice (KAP) among pediatric dentists regarding oral manifestations of COVID-19 in children. Materials and Methods: This questionnaire-based cross-sectional survey included 255 registered pediatric dentists at Indian Society of Pedodontics and Preventive Dentistry. They were E-mailed an E-questionnaire with the help of Google Forms portal including informed consent and 16 formulated questions assessing the KAP among pediatric dentists regarding oral manifestations of COVID-19 in children. Incomplete forms were not accepted. The response was awaited for a period of 3 months. The collected data were subjected to descriptive and Chi-square analysis. Results: Sixty-three percent of the population had knowledge about all the oral manifestations of COVID-19 seen in children. Sixty percent were unsure about scheduling the next dental appointment for such patients. 48.3% of pediatric dentists could not prescribe medications for oral manifestations of COVID-19. Conclusion: Pediatric dentist could identify and diagnose the oral manifestations of COVID-19 and its associated complications however were unsure of treatment modalities as there is limited evidence for definitive treatment regarding the same. Clinical protocols concerning treatment for oral manifestations due to COVID-19 should be well established and practiced. [ABSTRACT FROM AUTHOR]

Introduction: Silicosis is the most common and oldest occupational lung disease. The disease has been an ancient one and has been recognized in India for the past around 100 years. However, despite its ubiquitous presence among various mine and quarry workers, there is no uniformly available referral system in India in general for workers having occupational dust exposure and respiratory symptoms. The current study involved the clinical assessment of those working in mines and quarries in Jodhpur, Rajasthan, Western India and explore the possibility of development of a referral system for symptomatic mine workers. Materials and Methods: Workers working in mines and quarries in Jodhpur district were clinically screened for symptoms related to silicosis after choosing the quarries randomly. Demographic information and detailed occupational history were recorded using a predesigned questionnaire. Duration of exposure and morbidity/ mortality details related to silicosis in the family were noted in detail. Respiratory symptom score was evaluated using a numeric score. The study was a cross-sectional one, and a 12-point respiratory symptom score based on predesigned questionnaire was constructed using the literature survey of silicosis symptoms. Results: A total of 435 mine/quarries workers (M: F = 432:3) working in sandstone belt of Jodhpur, Rajasthan, Western India were assessed clinically, and details of their symptoms were noted. Demographic information was as followed mean age = 36.44 ± 11.23 years and mean duration of dust exposure = 13.4 ± 9.6 years. A total of 96/435 workers were symptomatic (22%), and salient hypoxia was present in 113/435 (26%). Both groups of these workers were referred to nearby community health centers for further evaluation. Awareness levels among the workers were poor, as only 119/435 (27%) workers had some ideas about the silicosis prevention while working in mines and quarries. Regular wearing of masks while being on the field was observed in only 8% (35/435). Mine Worker Screening Camp approach was used for symptomatic workers and evaluation by a three-member clinical board was done in community health center in the vicinity of mining areas. Those suspected of having silicosis were referred to pneumoconiosis board for further evaluation. Conclusions: High frequency of symptomatic mine workers (22%) exposed chronically to occupational dust was found in sandstone mines and quarries of Jodhpur region. Awareness levels about silicosis prevention were poor. A referral system for those needing further evaluation has been demonstrated. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to identify the knowledge of and perceived barriers to providing low vision services among eye care practitioners in Goa. Methods: A pretested and predesigned questionnaire was sent to 72 eye care practitioners, which included the optometrists and ophthalmologists working in Goa, through offline and online (social media like WhatsApp, Instagram, etc.) platforms. Information was collected to understand the barriers that restrict eye care practitioners from providing low vision services. Results: Seventy-two participants took part in this study, of which 26.39% (n=19) were ophthalmologists and 73.61% (n=53) were optometrists. From the practitioner's point of view, lack of awareness (70.83%, n=51) and training (68.06%, n=49) were the major barriers to providing low vision services. Conclusion: A lack of awareness and training facilities among eye care practitioners acts as a barrier to providing low vision services. [ABSTRACT FROM AUTHOR]

This paper reports findings from a qualitative study conducted on the Need for Social work interventions in the Emergency Department (ED) at a large tertiary care center in India. The emergency department is an important social work intervention point for individuals with various psychiatric, medical, and social needs who have little or no additional interaction with social services. Social workers are specially trained to understand the impact of social factors on health outcomes and provide interventions that address social barriers to improving health and accessing community resources; social workers are well prepared to provide services in the emergency department. However, limited research is available to understand the impact of psychosocial services in the emergency department. We aimed to identify areas which require integrated social work services and coordination to address the psychosocial issues within the ED. Interviews with 10 healthcare workers are analyzed thematically. Recurring themes throughout the interviews confirm the need for providing social work interventions to ensure the medical, psychological, and social care needs in the emergency department. [ABSTRACT FROM AUTHOR]

Objectives: Critically ill cancer patients in the intensive care unit (ICU) did not have any palliative care (PC) intervention as there was no PC referral from the ICU. The project aimed to initiate PC referral for at least 50% of progressive palliative intent cancer patients in intensive care to enhance communication with patients and caregivers. We included PC physicians, oncologists, and psychologists in the team for this project. Material and Methods: We used the A3 problem-solving method of quality improvement (QI) and also used the Plan Do Check Act process. The first baseline assessment over 6 months of ICU deaths of patients who could have benefited from PC referral was collected; this made us realise that PC could have been initiated for some patients. Process maps of patient admission into the ICU and the process of their discharge were constructed. Analysis of root causes that were barriers to referral was examined. We made a PC trigger tool after team consultations and consensus and started using it to initiate PC referrals. PC discharge protocol was also initiated. Educational discussions were held with residents and nurses to ensure the continued use of the trigger tool. Results: PC referral from intensive care slowly went up from 0% to beyond 50% by November 2019 and reached over 70% by March 2020; patients getting discharged had details of PC centres near their homes. Conclusion: Structured QI process and introducing the PC trigger tool led to the outcome of 50% PC referral for critically ill patients in ICU. [ABSTRACT FROM AUTHOR]

Therapy process research focuses on understanding how therapy is conducted by professionals in the field. It is a nascent field of psychotherapy enquiry in India. This paper explores how novice therapists in India perceive their clients, and how this influences the process of therapy. In depth interviews were conducted with ten novice therapists, with less than six years of practice experience, from Mumbai, India. The data was thematically analysed. The data revealed that therapists' perceptions of their clients were defined by socio‐demographic features of age and gender, along with presenting complaints and personal attributes. Participants had defined beliefs about good clients as contrasted with difficult ones. Distinct preferences for particular client types were identified. The antecedents to these beliefs were attributed to the therapist's worldview, their training and the supervision received. These views, and the conceptualisation of the client, influenced the choice of client, the process of therapy and how they proceeded with sessions, and their methods of referral. The data from the study has implications for therapist training, supervision and further research. [ABSTRACT FROM AUTHOR]

Background: In 2019, the World Health Organization, set a target to halve the burden of snakebite, by 2030, and identified 'health systems strengthening' as a key pillar of action. In India, the country with most snakebite deaths, the Union Government identified (in September 2022) training of health workers as a priority action area. In this policy context, we provide empirical evidence by analysing the most recent nationwide survey data (District Level Household and Facility Survey − 4), to assess structural capacity and continuum of snakebite care in primary health care system in India. Methodology: We evaluated structural capacity for snakebite care under six domains: medicines, equipment, infrastructure, human resources, governance and finance, and health management information systems (HMIS). We categorised states (aspirant, performer, front-runner, achiever) based on the proportion of primary health centres (PHC) and community health centres (CHC), attaining highest possible domain score. We assessed continuum of snakebite care, district-wise, under five domains (connectivity to PHC, structural capacity of PHC, referral from PHC to higher facility, structural capacity of CHC, referral from CHC to higher facility) as adequate or not. Results: No state excelled (front-runner or achiever) in all six domains of structural capacity in PHCs or CHCs. The broader domains (physical infrastructure, human resources for health, HMIS) were weaker compared to snakebite care medicines in most states/UTs, at both PHC and CHC levels. CHCs faced greater concerns regarding human resources and equipment availability than PHCs in many states. Among PHCs, physical infrastructure and HMIS were aspirational in all 29 assessed states, while medicines, equipment, human resources, and governance and finance were aspirational in 8 (27.6%), 2 (6.9%), 17 (58.6%), and 12 (41.4%) states respectively. For CHCs, physical infrastructure was aspirational in all 30 assessed states/UTs, whereas HMIS, medicines, equipment, human resources, and governance and finance were aspirational in 29 (96.7%), 11 (36.7%), 27 (90%), 26 (86.7%), and 3 (10%) states respectively. No district had adequate continuum of snakebite care in all domains. Except for transport availability from CHC to higher facilities (48% of districts adequate) and transport availability from PHC to higher facilities (11% of districts adequate), fewer than 2% of districts were adequate in all other domains. Conclusion: Comprehensive strengthening of primary health care, across all domains, and throughout the continuum of care, instead of a piece-meal approach towards health systems strengthening, is necessitated to reduce snakebite burden in India, and possibly other high-burden nations with weak health systems. Health facility surveys are necessitated for this purpose. [ABSTRACT FROM AUTHOR]

Background: Expressed emotion (EE) being a part of the family environment could adversely affect the course and prognosis of schizophrenia. Aim: This study aimed to assess the effects of family intervention among the caregivers of persons with schizophrenia. Methods and Materials: The experimental research design was used for 80 caregivers of persons with schizophrenia. Sociodemographic interview schedule of caregivers, family emotional involvement and criticism scale, and mini international neuropsychiatric interview (MINI 6.0) were used for data collection. A standardized family intervention program involving 10 sessions was provided to caregivers. The intervention included six sessions of family psychoeducation, two sessions of communication training, one session of stress management, and one session on recap and referral services over a period of 2-3 months. The intervention used methods of social case and group work, social work principles, and therapeutic activities. The methodologies adopted a brainstorming technique, case vignettes, role plays, and video clippings concerning the topics of the day. Brief handout on intervention was given. Results: The RMANOVA score (F = 35.892; P =0.001) revealed that there was a significant reduction in EE of the caregivers of the intervention group who underwent the family intervention program in comparison with the control group. Conclusion: Family-based intervention was found to be effective for reducing EE in schizophrenia. [ABSTRACT FROM AUTHOR]

Objective: Pediatric burns pose difficult healthcare issues in underdeveloped nations. Due to the scarcity of pediatric burn care facilities and qualified burn-care staff, patients are frequently referred from a rural hospital. This study explores the burn-treatment approach that could be used in rural hospitals in the absence of a dedicated pediatric burn care facility. Materials and Methods: A retrospective analysis of clinical data of 199 children who received treatment for burn-injury in an isolated general surgical ward. Wound debridement under anesthesia at the earliest was the cornerstone of the treatment plan for this cohort. Until the wounds healed, the treatment was repeated every alternate day. The patient's demographic data, number of surgical dressings, length of hospital stay, and outcome were analyzed. Results: The mean age of the patients was 51.68 ± 23.79 months. The male-female ratio was 1.45:1. The survival rate was 99.00%. The disability rate was 4.52%. Univariate logistic regression identified the age group, total body surface area affected, depth of the wound, and time of intervention as statistically significant variables (P < 0.05) predicting the disfigurement. Multivariate logistic regression identified the time intervals between surgical intervention and injury as an important predictor of morbidity. In addition, delayed presentation and delayed intervention led to a longer hospital stay, and more interventions than the early intervention cohort. Conclusions: Early debridement accelerates recovery and lessens the need for future skin grafts or contracture procedures. This approach can be used in rural hospitals as well because pediatric burns can be manageable in an isolated general ward. [ABSTRACT FROM AUTHOR]

Low rates of caesarean delivery (CD) (<10%) hinder access to a lifesaving procedure for the most vulnerable populations in low-resource settings, but there is a paucity of data regarding which factors contribute most to CD rates. We aimed to determine caesarean delivery rates at Bihar's first referral units (FRUs) stratified by facility level (regional, sub-district, district). The secondary aim was to identify facility-level factors associated with caesarean delivery rates. This cross-sectional study used open-source national datasets from government FRUs in Bihar, India, from April 2018–March 2019. Multivariate Poisson regression analysed association of infrastructure and workforce factors with CD rates. Of 546,444 deliveries conducted at 149 FRUs, 16961 were CDs, yielding a state-wide FRU CD of 3.1%. There were 67 (45%) regional hospitals, 45 (30%) sub-district hospitals, and 37 (25%) district hospitals. Sixty-one percent of FRUs qualified as having intact infrastructure, 84% had a functioning operating room, but only 7% were LaQshya (Labour Room Quality Improvement Initiative) certified. Considering workforce, 58% had an obstetrician-gynaecologist (range 0–10), 39% had an anaesthetist (range 0–5), and 35% had a provider trained in Emergency Obstetric Care (EmOC) (range 0–4) through a task-sharing initiative. The majority of regional hospitals lack the essential workforce and infrastructure to perform CDs. Multivariate regression including all FRUs performing deliveries demonstrated that presence of a functioning operating room (IRR = 21.0, 95%CI 7.9–55.8, p < 0.001) and the number of obstetrician-gynaecologists (IRR = 1.3, 95%CI 1.1–1.4, p = 0.001) and EmOCs (IRR = 1.6, 95%CI 1.3–1.9, p < 0.001) were associated with facility-level CD rates. Only 3.1% of the institutional childbirths in Bihar's FRUs were by CD. The presence of a functional operating room, obstetrician, and task-sharing provider (EmOC) was strongly associated with CD. These factors may represent initial investment priorities for scaling up CD rates in Bihar. [ABSTRACT FROM AUTHOR]

High burden of acute malnutrition among children less than 5 years is a major public health problem in India. A "Two-days National Consultation on Addressing Acute Malnutrition" was organized to gather experiences and evidence from 13 states of India on prevention and management of acute malnutrition among children and documenting viewpoints from experts and government counterparts on the same. The consultation centered around five key themes of addressing acute malnutrition: 1) capacity building, 2) strengthening screening, 3) nutritional care of wasting, 4) tracking progress, and 5) scale-up. The paper highlights the experiences and key recommendations around the above key themes. It emerged that there is a need to further accelerate the efforts toward strengthening existing platforms and services to address acute malnutrition among children. Regular trainings of the frontline workers, increased convergence, regular monitoring, and continued service delivery during the pandemic should be undertaken for better outcomes. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the study was to survey keratoconus management by optometrists in India. Methods: A validated online survey questionnaire was circulated to all optometrists from India who had completed 4 years of optometry programs. Practitioners were asked general contact lens practice questions and keratoconus management-related questions. For analysis, data were imported into SPSS (IBM Corp. 2011). Results: A total of 159 optometrists responded to the questionnaire, of whom 10.7% of practitioners had >10 years of experience and the remaining 89.3% had <10 years. Only 45.3% of respondents had corneal topography in their practice. Approximately 55% of practitioners prescribed gas permeable (GP) lenses. Around 77.4% of practitioners considered that a combination of multiple factors is necessary for keratoconus investigations. In addition, 91.8% of practitioners used the keratoconus severity classification. Also, 73% of practitioners consider that GP contact lens (CL) fitting is more difficult in keratoconic eyes than in healthy eyes. The average number of GP diagnostic lenses used in keratoconus CL fittings was 3.93 ± 1.92. A majority of practitioners calculate back optic zone radius (BOZR) using the manufacturer's guidelines (based on manual keratometry [39.6%] or based on corneal topography [40.3%]). Around 40.3% of respondents prefer to refer patients to another optometrist for CL fitting before consulting an ophthalmologist for surgical intervention. Finally, half of the respondents participate in co-management with ophthalmologists after surgical treatment (54.1%). Conclusion: This study provides details about the management of keratoconus by optometrists in India. Keratoconus patient care could be improved with new evidence-based guidelines for the management and referral of these patients that would provide guidance on GP CL fitting procedures. Furthermore, it determines referral criteria and enhances co-management between optometrists and ophthalmologists. [ABSTRACT FROM AUTHOR]

Background: Speech–language pathologists are often involved in the assessment and management of communication, cognition and swallowing deficits in people with Parkinson's. However, speech–language pathologists' self‐perceived competency levels in serving people with Parkinson's remain elusive, especially in the Indian context where there is an increasing disability burden due to Parkinson's disease. Additionally, the challenges faced by speech–language pathologists in India to provide efficient services to this population are unidentified. Aims: To determine speech–language pathologists' self‐perceived competence and challenges faced when providing services to people with Parkinson's in India. Methods & Procedures: A survey questionnaire was sent to speech–language pathologists through emails and social media asking them questions to evaluate self‐perceived competency in serving people with Parkinson's and to identify the challenges to their service delivery. A total of 69 speech–language pathologists responded to the survey. Outcomes & Results: The majority of respondents reported to be competent in dealing with various domains of assessment and management of people with Parkinson's. Although competent, they reportedly faced a few challenges during their service delivery. Conclusions & Implications: This study provides an insight into the speech–language pathologists' self‐perceived competency in serving people with Parkinson's in India, and also identifies the challenges related to interprofessional service delivery. The findings of the study have educational and clinical implications. What this paper adds: The study delineates speech–language pathologists' self‐perceived competency in working with people with Parkinson's in India, a nation that is seeing a constant rise in the incidence of Parkinson's disease.The study the unique challenges within India to speech–language pathologists' service delivery for people with Parkinson's, thus having educational and clinical implications in Parkinson's disease care. [ABSTRACT FROM AUTHOR]

Background: Telepsychiatry has grown exponentially during the COVID-19 pandemic. As regular outpatient services were shut down, we initiated a telephonic follow-up consultation for geropsychiatry patients who have had their first face-to-face consultation up to 2 months before the pandemic-induced lockdown with the intent to maintain the continuity of care. Methods: In this background, we are reporting our experience of this unique initiative, in terms of acceptance of service, status of patients, adherence to treatment, and barriers to care. Results: We could contact 120 patients, among whom 8 patients had died at the time of the call. Consent for tele follow-up was given by 108 patients, whose mean age was 68.76 ± 7.22 years. Sixteen patients needed urgent referrals for face-to-face consultation. Medical comorbidities were present in 56.48% of the patients. Adherence was good in 60.78% and 93.44% for psychotropic and nonpsychotropic medications, respectively. Unavailability of psychiatric consultation as well as psychotropic medicines in the locality along with lack of awareness were the major reasons for poor adherence. Clinician-initiated teleconsultation was opted as the preferred mode for the next consultation by 70.37% of patients. Conclusion: Clinician-initiated telephonic follow-up was well received. This initiative has uncovered hurdles to care and unmet needs of geropsychiatry patients in such unprecedented situation and would help in improving the preparedness in future. [ABSTRACT FROM AUTHOR]

Introduction: In mid-March 2020, the Kerala government implemented additional preventive measures to the steps already taken to reduce the transmission of COVID-19. Strategies were taken by a non-governmental palliative care organisation (Pallium India) with Coastal Students Cultural Forum -- a coastal area-based collective of young educated people in the coastal region to address the medical needs of people living in this community. The facilitated partnership lasted 6 months (July--December 2020) and addressed the palliative care needs of the community in the selected coastal regions during the first wave of the pandemic. Volunteers sensitised by the NGO identified more than 209 patients. The current article highlights the reflective narratives of key players in this facilitated community partnership. Materials and Method:The current article is dedicated to highlighting the reflective narratives of key players in this facilitate community partnership to the readers of this journal. The palliative care team's overall experience was collected from selected key participants to understand the program's impact, identify areas of improvement, and discuss possible solutions if there were any challenges. The contents below are their statements on the experience of the entire program. Conclusion: Palliative care delivery programmes must be configured to respond to local needs and customs, be community-based and integrated with local health and social care and have accessible referral pathways between and across services. They must also be responsive to changing individual and population needs and shifts in local and national health structures. [ABSTRACT FROM AUTHOR]

Introduction: Newborn hearing screening is essential for the early identification of hearing loss, which can lead to timely intervention and improved outcomes for affected infants. Two commonly used screening methods are distortion product otoacoustic emissions (DPOAEs) and automated auditory brainstem response (AABR). While both methods are effective, there is still ongoing research to determine which method is more efficient and accurate. The aim is to compare the referral rates of DPOAE and AABR in neonatal hearing screening and to evaluate the efficacy of the two technologies in identifying hearing loss in high-risk and well-born neonates by adhering to the new 1-3-month timeline (Joint Committee on Infant Hearing, 2019). Methods: This was a prospective cross-sectional study conducted on 404 neonates (808 ears) in a multispecialty hospital in Tamil Nadu, India. Neonates with referral criteria for either DPOAE or AABR in the first step were rescreened immediately with the preferred technology. Obtained data were subjected to statistical analysis. Results: Among 404 (100%) neonates screened, 364 (90.14%) were well-born and 40 (9.90%) were high-risk babies. The total referral rate for DPOAE was 70 (8.6%) among which 54 (7.5%) were well-born babies and 16 (20%) were high-risk infants. The total referral rate in AABR was 68 (8.4%) among which 52 (7.2%) were well-born and 16 (20%) were high-risk infants. All the infants enrolled were screened by 1 month and no referrals were obtained for a detailed audiological diagnostic for reaching the 2-month benchmark and intervention by 3 months. Statistical analysis revealed no significant difference between the groups (P > .01). Conclusion: AABR had similar referral rates with DPOAE in neonatal hearing screening. The two-technology screening protocol was effective in identifying hearing loss in high-risk and well-born neonates. The inclusion of AABR in the screening protocol proves utility in detecting retrocochlear pathologies such as auditory neuropathy spectrum disorder (ANSD). [ABSTRACT FROM AUTHOR]

World is suffering from a pandemic situation due to coronavirus disease (COVID-19) since December 2019. In this emergency, everyone at individual/country/global level is trying to contribute at their best with their available knowledge and resources. However, more and more research and developmental activities are going on but, the reality is far away for a grass-root level health professional. They rely on the indirect sources, that is, published or unpublished literature, social media, internet etc. Many a time, these sources may share an unrealistic or false positive/negative information. Our study was intended to assess the knowledge, attitude and practices related to COVID-19 among the healthcare professionals of different levels. We conducted an online survey after the initiation of the first lockdown in India. Our research team in consultation with the subject experts designed a mix method-based study tool and shared it by sending emails to 1,200 participants. A total of 180 respondents participated in the online survey of which 34% were government health professionals and 24% were working with a research/academic institution. All participants were between 23 and 74 years age group (mean 39 years). Participants shared their views on first, knowledge about symptoms, preventive measures and treatment options for COVID-19. Second, on attitude towards handling COVID-19 pandemic using social distancing, following lockdown and travel advisory, etc. Third, on the practice of non-pharmaceutical measures to prevent COVID-19. We found that the social media platform acted as one of the most important platforms for awareness generation regarding COVID-19 but it was also generating stigma among people. Till the time of the survey, there is still a dearth of knowledge about social distancing and what it means, especially physical distance of 1–3 metres and correct usage of mask in different situations. Various important issues pertaining to infant feeding practices, mother and childcare and disposal of dead bodies of COVID infected persons require deliberations and awareness. [ABSTRACT FROM AUTHOR]

Patient referral management is an integral part of clinical practice. However, in low-resource settings, referrals are often delayed. The World Health Organization categorizes three types of referral delays; delay in seeking care, in reaching care and in receiving care. Using two case studies of maternal referrals (from a low-resource state in India), this article shows how a culture of downstream blaming permeates referral practice in India. With no referral guidelines to follow, providers in higher-facilities evaluate the clinical decision-making of their peers in lower-facilities based on patient outcome, not on objective measures. The fear of punitive action for an unfavorable maternal outcome is a larger driving factor than patient safety. The article argues for the need to formulate an ecosystem where patient responsibility is shared across the health system. In conclusion, it discusses possible solutions which can bridge communication and information gap between referring facilities. [ABSTRACT FROM AUTHOR]

Objectives: Advanced cancer patients attending tertiary cancer centres from rural places are referred back to local physicians for symptom management. Due to lack of networking with palliative care centres (PCCs), the referred patients do not receive appropriate palliative care (PC) services. Hence, an attempt was made to map the PCCs in Tamil Nadu to make the referral system efficient. Material and Methods: PCCs in Tamil Nadu were identified from the National Health Mission directory, online sources and from morphine license annexure of drug control department. The details regarding nature of facility, PC model, service type, procedures, cost, morphine availability and type of personnel involved in their PCCs were collected from government and private centres. The data were analysed using descriptive statistics and geomapping of all the centres identified was created. Results: A total of 371 PCCs were identified, of which 32 were government headquarter hospitals (GHQH), 281 were government community centres and 58 were private. Eighty-three of the 90 centres (including GHQH and private) were active and 60 responded to the survey. More than half of the centres were hospital-based (61.7%) and 28.3% were community-based. The majority of the PCCs had in-patient (75%) and out-patient (63.3%) facilities and 63.3% had regular home visits. Forty-six centres provide PC service free of cost. Nearly 80% provide morphine for pain management, wherein 41 have obtained a license. In total, ten centres had a social worker and four had a psychologist. Conclusion: The number of PCCs is disproportionate, in which majority of the centres are clustered in urban areas. Integrating PC services into the existing health system is the way forward. [ABSTRACT FROM AUTHOR]

Background: Sepsis and Septic shock contributes to significant morbidity and mortality in hospitalized patients. Early detection and initiation of early and appropriate antibiotic therapy determines the outcome in septic shock. The objective of this research was to describe clinical profile of septic shock patients and to determine various predictors of inhospital mortality in septic shock patients which could be assessed from simple hematological parameters. Methods: This was a prospective observational study done over a period of one year in which a total of 145 adult patients with septic shock diagnosed as per American College of Chest Physicians (ACCP) and the Society for Critical Care Medicine (SCCM) criteria (2016) admitted in medicine ward in a tertiary care hospital were included. Detailed history and clinical examination was done and various routine investigations such as Complete hemogram, Neutrophil to lymphocyte ratio(NLR), Platelet to lymphocyte ratio(PLR), Liver function tests, Renal function tests, C-reactive protein and Blood gases including lactate levels at admission were determined and compared among survivors and non-survivors to assess in hospital mortality predictors. Results: A total of 145 patients with septic shock were studied. Most of the patients were males (55.2%). Majority were from rural areas (59.31%). Major co-morbidities included diabetes mellitus (24.8%), COPD (13.1%) and hypertension (11%). Fever was the most common presentation (34.5%). Mortality in septic shock was 30.3%. The most common source of infection leading to septic shock was scrub typhus (33.8%) followed by respiratory infections and skin infections. The highest mortality was seen in the age group of 60-69 years. Patients who were given primary care and stabilized in a primary or secondary health centre and then referred had a better survival (77.2%) as compared to those who directly visited the tertiary care centre in a sick state. Out of various mortality predictors studied, a strong positive correlation of mortality was seen among patients with thrombocytopenia i.e. platelet count (86.4%), hypoalbuminemia (78.6%), high neutrophil to lymphocyte ratio, high C-reactive protein values(74%) and high mean platelet volume. Conclusion: There is high prevalence of tropical infections such as Scrub typhus in Himachal and even simple investigations like Complete haemogram, Serum albumin levels, C-reactive protein and Total serum bilirubin levels which are routinely done in health care centers correlate significantly with mortality in septic shock. These investigations can guide appropriate antibiotic therapy and appropriate timing of referral of patients to higher centers, hence can improve the outcome among septic shock patients. [ABSTRACT FROM AUTHOR]

Background: This study is a low-cost community mental health task-sharing model driven by university students to strengthen the mental health workforce in poor resource settings. This article presents the feasibility of a stepped referral model using the community health workforce and university students. The primary feasibility objective is to detect and refer people with mental illness from the community using a task-sharing approach. Methods: We tested the model using a cross-sectional, one-phase door-knock survey in three geographically defined locations in Kerala, India, between May and July 2019. Students surveyed 549 residents above 18 years of age who consented to participate in the study to detect depressive symptoms and suicidality. The feasibility of the current model was evaluated based on four criteria: (a) identification and deployment of untapped human resources, (b) coordination of community health resources, (c) the acceptability of stepped referral pathways, and (d) identification of implementation challenges. Results: The mean age of the participants was 38.8, and more than 62% of the respondents were women. The results showed that 11.29%, 8.38%, and 4.91% of people reported mild, moderate, and severe levels of depression, respectively, and suicidal thoughts were found in 6.9% and suicidal ideation in 1.8%. The odds of depression were higher among females compared to males (OR: 1.64 (0.75–2.52), poor people (OR: 2.01 (1.14–2.88), and people with chronic illnesses (OR: 2.03 (1.24–2.81). The agreement of the findings with professional-administered research validated the strategy's efficiency. Twenty-seven patients with severe/extreme degrees of depression were sent for high-intensity interventions led by the mental health team, whereas 135 individuals with mild and above depression were referred for low-intensity interventions. Conclusions: The newly recruited mental health workforce-driven screenings were acceptable and effective in detecting mental illness in the community population. We tested the care coordination systems and processes in creating referral pathways for the detected patients. Further, task-sharing stepped referral model will be tested in five panchayats (the lowest tier of local self-government) before replicating the model across India through Unnat Bharat Abhiyan (UBA) scheme. [ABSTRACT FROM AUTHOR]

Objective To implement a community-based screening and awareness-raising project for gestational diabetes in Ahmedabad, India. Methods The project took place between April 2016 and August 2019 in Ahmedabad. Medical college faculty members and medical officers trained 3582 paramedical staff on screening for gestational diabetes. These paramedical staff tested all pregnant women 24-28 weeks gestation, who were attending village health and nutrition days -- also called mamta days -- in urban and rural health centres for routine antenatal care, for gestational diabetes. An oral glucose tolerance test was used and blood sugar ≥ 7.8 mmol/L was the cut-off for gestational diabetes. Women with gestational diabetes were referred for counselling and treatment and all women were followed until 6 weeks after delivery. Findings Of 53 522 pregnant women screened, 6786 (12.7%) had gestational diabetes and were referred for nutritional therapy or medication; 836 (12.3%) of these women started medication. There was no significant difference in the prevalence of stillbirths between women with gestational diabetes (0.8%; 54/6786) and women without (0.7%; 338/46 736; P-value: 0.51). Of the women on treatment, 38 had abnormal blood glucose after delivery and continued with the medication. Two women with gestational diabetes died; they had other associated co-morbidities -- pre-eclampsia and anaemia. Conclusion We found a high prevalence of gestational diabetes, indicating the need for gestational diabetes screening and implementation of this project on a larger scale. Gestational diabetes screening at the community level is operationally feasible using the existing human resources and infrastructure of the reproductive health programmes. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the effectiveness of tele-ophthalmology (TO) versus face-to-face screening for diabetic retinopathy (DR) in diabetes care centers (DCC) across India. Methods: This is an observational, multicenter, retrospective, cross-sectional study of DR screening in individuals with diabetes performed across 35 branches of a chain of DCC in 20 cities in India over 1 year. In 30 DCC, DR screening was performed by TO, where retinal images obtained using Fundus on Phone camera were uploaded through the telemedicine network for centralized DR grading by eight retina specialists. In five DCC, DR screening was performed by fundus examination (FE) by the same retina specialists. The rate of detection of sight-threatening DR (STDR) (defined as the presence of proliferative DR and/or diabetic macular edema) through the two modes was compared. Results: A total of 58,612 individuals were screened for DR from January 1, 2018 to December 31, 2018: 25,316 by TO and 33,296 by FE. The mean age and mean duration of diabetes of the individuals with diabetes screened by TO was 55.8 ± 11.2 years and 9.5 ± 7.3 years; and in individuals screened by FE, it was 57.5 ± 11.6 years and 11.5 ± 8.0 years respectively. The mean glycated hemoglobin was 8.8% ± 2.1% and 8.5% ± 1.9% in the two groups, respectively. Any DR was detected in 31.7% (95% confidence interval [CI]: 31.0-32.3) by tele-screening and in 38.5% (95% CI: 37.9-39.0) by FE, whereas STDR was detected in 7.3% (95% CI: 7.0-7.7) by TO and in 10.5% (95% CI: 10.2-10.9) by FE. Overall, 11.4% individuals with diabetes in the TO group, including 4.1% with ungradable images, were advised referral to retina specialists for further management. Conclusion: Screening for DR at DCC using TO is feasible and effective for STDR detection in India and may be adopted throughout India. [ABSTRACT FROM AUTHOR]

Healthcare professionals, both in India and in the rest of the world, have been coming under increasing attack - both physical and verbal - from patients, their relatives, and attendants. This has led to physical and emotional stress on healthcare workers, which is creating difficulties in performing their duties. Not only the safety of healthcare workers is threatened but the quality of healthcare delivery to patients is also impacted. By understanding the underlying reasons and implementing proactive strategies, healthcare organizations can foster a safer environment for patients and providers alike. By addressing this issue head-on, we can preserve the integrity of healthcare systems, maintain quality care, and ensure the well-being of all involved parties. [ABSTRACT FROM AUTHOR]

Background: Global health care is moving toward function, quality of life, and occupation. Occupational therapy (OT) has been the only profession using "occupation" as core intervention since inception. With advancements in intervention techniques, occupational therapists (OTs) need to ensure the continued use of "occupation" as core intervention type. Previous surveys were conducted to analyze the use of specific intervention types: occupation-based interventions (OBIs), creative activities, acute-hospital-based rehabilitation, and different interventions used in pediatric OT practice. However, information on OT practices and types of interventions used by Indian OTs versus global OTs is unavailable. Objectives: The objective of this study was to analyze differences, if any, in the OT practices and types of interventions frequently used in daily practice by Indian versus global OTs. Study Design: This was an online, survey-based, cross-sectional study. Methods: The Google Forms questionnaire link was sent to OTs on E-mail with electronic written informed consent from May 2020 to March 2021 using convenient sampling. The questionnaire included participant's demographics, 17 clinical practice areas, and 9 intervention types and factors influencing OT practice. Total 201 (84 Indian OTs and 117 global OTs) fulfilled the selection criteria: OTs with at least bachelor's degree and minimum 3 years of work experience. Results: Indian OT workforce showed significantly more male OTs than global OTs (31 [36.9%] vs. 11 [9.4%]; 95% confidence interval [CI]: [0.0236-0.2964]; P = 0.0001) and OTs with master's degree (56 [66.7%] vs. 41 [35.04%]; 95% CI: [0.1852-0.4480]; P = 0.0001). Global OTs have more OTs with additional qualifications in non-OT fields (58 [49.57%] vs. 27 [32.10%]; 95% CI: [-0.3088--0.0406]; P = 0.013) and more OTDs (13 [11.11%] vs. 1 [1.23%]; 95% CI: [-0.1641--0.0335]; P = 0.006) than Indian OTs. Indian OTs practiced significantly more in the private sector: clinic and hospital (52 [61.90%] vs. 40 [35.80%]; 95% CI: [0.1273-0.3947]; P = 0.0001), whereas global OTs practiced significantly more in the government sector (46 [39.31%] vs. 19 [22.61%]; 95% CI: [-0.2930--0.0410); P = 0.0124). Among the organizational roles, Indian OTs work significantly more as consultants (50 [50.95%] vs. 35 [29.91%]; 95% CI: [0.0751-0.3457]; P = 0.0001) while global OTs work significantly more as managers (36 [30.76%] vs. 12 [14.28%]; 95% CI: [-0.2770--0.0526]; P = 0.0069). Among patient population treated, Indian OTs majorly (54.76%) treat children (up to 15 years) but significantly more in "all age groups" (35 [41.67%] vs. 18 [15.38%]; 95% CI: [0.1388-0.3870]; P = 0.0001) while global OTs treat significantly more adults (21-65 years) (61 [52.13%] vs. 25 [29.76%]; 95% CI: [-0.3569--0.0905]; P = 0.0015) and geriatric (>65 years) (50 [42.73%] vs. 17 [20.23%]; 95% CI: [-0.3492-0.1008]; P = 0.0008). Indian OTs practice significantly more in developmental disability rehabilitation (78 [92.85%] vs. 68 [58.11%]; 95% CI: [0.2424-0.4524]; P = 0.0001), ante- and postnatal women's care (15 [17.85%] vs. 3 [2.56%]; 95% CI: [0.0662-0.2396]; P = 0.00018), and hemophiliac rehabilitation (14 [16.67%] vs. 2 [1.70%]; 95% CI: [0.0666-0.2328]; P = 0.00012) areas of practice than global OTs. Indian OTs practice significantly more in clinic outpatient department (OPD) (62 [73.80%] vs. 55 [47%]; 95% CI: [0.1375-03985]; P = 0.0001), hospital OPD (40 [47.61%] vs. 27 [23.07%]; 95% CI: [0.1141-0.3767]; P = 0.0002), and inpatient (37 [44.04%] vs. 30 [25.64%]; 95% CI: [0.0516-0.3164]; P = 0.0006) while global OTs practice significantly more in natural environment settings (53 [45.29%] vs. 24 [28.57%]; 95% CI: [-0.2994--0.0350]; P = 0.016). Most preferred types of interventions among both groups are relatively the same: client education, counseling, and consultation and interview; therapeutic relationships; and therapeutic use of self. Besides these, Indian OTs prefer performance skills training and adaptive interventions, while global OTs prefer activities as therapeutic media and OBIs over other types. Preventive interventions and advocacy were the least preferred types of intervention among each group. Despite these relative preferences, significant differences were found between groups with regard to number of OTs practicing these 5 types of interventions: client education, counseling, and consultation (46 [54.76%] vs. 47 [40.17%]; 95% CI: [0.0073-0.2845]; P = 0.04]; performance skills training (41 [48.80%] vs. 34 [29.05%]; 95% CI: [0.0626-0.3324]; P = 0.004); preventive intervention and health promotion (29 [34.5%] vs. 24 [20.51%]; 95% CI: [0.0148-0.308]; P = 0.026]; adaptive interventions (39 [46.42%] vs. 23 [19.65%]; 95% CI: [0.1390-0.3964]; P = 0.001]; and preparatory interventions: (35 [41.67%] vs. 28 [23.93%]; 95% CI: [0.0467-0.3081]; P = 0.0075). Conclusion: The study provides the current stand for preferences and practices of therapeutic interventions by OTs in India versus globally, thus aiding in repositioning of OT practice, focusing on core OT domains as well as providing a baseline for monitoring practice trends over time. [ABSTRACT FROM AUTHOR]

Objective To compare the incidence of maternal near miss using the World Health Organization (WHO) near-miss tool and six other criteria sets, including criteria designed for low-resource settings or specifically for India. Methods In a cohort study we used WHO severity indicators to identify women with potentially life-threatening conditions during pregnancy or childbirth admitted to a referral hospital in Puducherry, India, from May 2018 to April 2021. We analysed sociodemographic, clinical and laboratory data for each woman and calculated the incidence of maternal near miss and other process indicators for each set of criteria. Findings We analysed data on 37 590 live births; 1833 (4.9%) women were identified with potentially life-threatening conditions, 380 women had severe maternal outcomes and 57 died. Applying the different sets of criteria to the same data, we found the incidence of maternal near miss ranged from 7.6 to 15.6 per 1000 live births. Only the Global Network criteria (which exclude laboratory data that may not be available in low-resource settings) and the WHO criteria could identify all women who died. Applying the criterion of any number of units of blood transfusion increased the overall number of women identified with near miss. Conclusion The WHO and Global Network criteria may be used to detect maternal near miss in low-resource settings. Future studies could assess the usefulness of blood transfusion as an indicator for maternal near miss, especially in low- to middle-income countries where the indicator may not reflect severe maternal morbidity if the number of units received is not specified. [ABSTRACT FROM AUTHOR]

India has the highest number of stillbirths in the world in 2019, with an estimated stillbirth rate of 13.9 per 1,000 births. Towards better identification and documentation, a stillbirth surveillance pilot was initiated with the World Health Organization Southeast Asia collaboration in Northern India in 2014. This study aimed to assess whether stillbirth surveillance is feasible and whether this approach provides sufficient information to develop strategies for prevention. This study followed the framework provided in "WHO Making Every Baby Count" in which mortality audit is conducted in six steps; (1) identifying cases; (2) collecting information; (3) analysis; (4) recommending solutions; (5) implementing solutions; and (6) evaluation. A total of 5,284 births were examined between December 2018 and November 2019; 266 stillbirths were identified, giving a stillbirth rate of 50.6 per 1,000 births in a tertiary care referral hospital of northern India. Out of 266 stillbirths, 223 cases were reviewed and recommendations were formulated to strengthen obstetric triage, implementing fetal growth charts, strengthen the existing referral system and improve the communication skills of health care providers for better compliance with clinical practice guidelines. Conducting stillbirth surveillance review and the response of cases in low-middle income countries setting is feasible. As countries progress towards ending preventable mortality, this has the potential to serve as a key process in improving evidence-based and context-specific planning and preventive strategies towards improving the quality of care. [ABSTRACT FROM AUTHOR]

Objectives  Treatment for mental health problems is determined by cultural, health infrastructure, and illness-related factors. Literature is sparse from India, particularly from the mental health resources-deficient regions of the country such as central India. Therefore, the current study is aimed at assessing the profile of the patients visiting the psychiatry outpatient facility (OPF) of a tertiary-care general hospital setting (GHS), their referral patterns, and their determinants. Materials and Methods  A retrospective chart review of the newly registered individuals (October 2019 to March 2020) in the psychiatry OPF of the GHS from Central India was used in the study. Data (sociodemographic profiles, illness characteristics, and referral patterns) were extracted as per the standard guidelines. Statistical Analysis  Descriptive statistics were used to represent sociodemographic, illness-, and past treatment-related characteristics of the participants. Chi-squared test was used to compare the referral characteristics of the two groups (self-referred patients vs. those referred by others, dependent variable) with regard to characteristics of the patients (independent variables). Results  A total of 418 individuals were registered in the clinic. Most individuals suffered from the neurotic, stress-related, and somatoform group of disorders (n  = 231, 39.5%). More than halves were self-referred; most were referred from the internal medicine and allied departments. Being male, having at least graduate degree (χ 2 df(1) = 4.25 to 6.79, p  < 0.05), suffering from organic mental-, psychotic-, and recurrent affective-disorders, and positive family history (χ 2 df(1) = 4.91 to 21.76, p  < 0.05 to <0.001) along with first treatment attempt or previous treatment from the traditional healers, and absence of co-occurring medical illness were associated with self-referral (vs. referred by others) (χ 2 df(1) = 4.64 to 17.6, p  < 0.05 to <0.001). Conclusions  GHS has a characteristic referral pattern. The referral patterns of the patients for various psychiatric problems are determined by their sociodemographic, illness, and cultural characteristics; particularly, poor mental health literacy (among the patients-caregivers), stigma related to mental disorders, and unavailability of the mental health services act as major determinants. Sensitizing the patients-caregivers and health-care professionals concerning this could facilitate an early engagement with the psychiatric treatment. Future research needs to explore this phenomenon in greater detail, maybe by qualitative methods. [ABSTRACT FROM AUTHOR]

Timely HIV testing and diagnosis are necessary to prevent the development of AIDS and interrupt its transmission in society. We collected the data on HIV testing and diagnosis in 2020 and compared it with preceding years to examine how COVID-19 pandemic-related restrictions impacted HIV services. The number of people who underwent HIV testing at the apex tertiary referral hospital of India in 2020 reduced by 57% compared to 2019 or the average/year during 2019-2016. Hence, the diagnosis of new HIV infections decreased by 52% compared to 2019 and 54% compared to the average/year during 2019-2016. Provider-initiated testing and diagnosis were more affected than client-initiated. There was a non-significant change in the rate of HIV detection among tested individuals. The male testing saw a more notable drop than female testing. HIV testing between ≥50 years and ≤14 years was more affected than other age groups. The transmission via regular partner/spouse increased, whereas it decreased via heterosexual commercial sex workers. [ABSTRACT FROM AUTHOR]

Background: Treatment gap causes significant loss to individuals, families, societies and the nation. Treatment adherence enhancement is a major challenge in psychiatric disorders. Globally, the community mental health services are obligated to minimize the treatment and adherence gap. In recent years' retrospective studies are gaining importance to measure the trend of mental health service utilization, cost effectiveness, resources allocation and similar aspects. Aim: To explore the treatment adherence pattern of persons with neuropsychiatric illness from a rural community mental health centre. Method: Five hundred and ninety-six medical records of persons with neuropsychiatric disorders who registered for outpatient treatment between 2015 and 2017 at Sakalawara Rural mental health centre of National Institute of Mental Health and Neuro Sciences, Bangalore, India, were reviewed to understand their adherence pattern Results: Out of 596 patients, 68 (11.4%) were referred to tertiary care mental health and District Mental Health Programme (DMHP) services. Out of the remaining 528 patients, 29.7% were regular to mental health services over a period of 12 months and above; majority of the patients (36.2%) dropped out of their treatment after their first contact and 34.1% discontinued their follow up visits over a period of first week to 12 months. Conclusion: Community based mental health centres too face challenges of and problems related to treatment non-adherence. Persons with neuropsychiatric disorders require continuity of care through regular home visits, out-reach services and innovative methods which will enhance treatment adherence. [ABSTRACT FROM AUTHOR]

Background. CKD patients are often asymptomatic in the early stages and referred late to nephrologists. Late referred patients carry a poor prognosis. There is a lack of data on outcomes associated with referral patterns in CKD patients from northern India. Methods. In this observational cohort study, all CKD patients who visited the nephrology OPD of the institute between Nov 1, 2018, and Dec 31, 2020, were classified as early referral (ER) if their first encounter with a nephrologist occurred more than one year before initiation of dialysis and education about dialysis (from a nurse or nephrologist). The remaining others were considered late referrals (LRs). The outcomes impact of early and late referrals was analyzed. Results. A total of 992 (male 656) CKD patients (ER, n = 475 and LR, n = 517) were enrolled. Patients referred early were older and diabetic and had higher BMI, better education, occupation, and socioeconomic status as compared to those referred late. The mean eGFR at first contact with the nephrologist was (25.4 ± 11.5 ml/min) in ER and 9.6 ± 5.7 ml/min in the LR group and had a higher comorbidity score. The CKD-MBD parameters, hemoglobin, and nutritional parameters were worse in LR. Only a few patients had AVF, and the majority required emergency dialysis in the LR group. A total of 91 (9.2%) patients died, 17 (1.7% ER and 74 (7.5%) patients in the LR group patients. There was significantly lower survival at 6 months (ER 97.1% vs. LR 89.7%), 12 months (ER 96.4% vs. LR 85.7%), 18 months (ER 96.4% vs. LR 85.7%), and 24 months (ER 96.4% vs. LR 85.7%) in late referral group as compared to early referral group P = 0.005 . Conclusions. LR to nephrologists has the risk of the emergency start of dialysis with temporary vascular access and had a higher risk of mortality. The timely referral to the nephrologist in the predialysis stage is associated with better survival and reduced mortality. [ABSTRACT FROM AUTHOR]

Antinuclear antibody (ANA) pattern and autoantibody (autoAb) profiling of 150 adult systemic sclerosis (SSc) patients concerning their clinical association and diagnostic significance were analyzed by indirect immunofluorescence (IIF), immunoblot, and fluorescence enzyme immunoassay. One hundred and forty‐three (95.3%) patients had positive ANA: DNA topoisomerase I (topo I)‐like pattern‐84(56%); speckled pattern‐44(29.3%);centromere pattern‐7(4.6%); and nucleolar pattern‐4(2.6%). Three distinct topo I‐like immunofluorescence patterns were detected at 1:40 dilution. Topo I‐like pattern (32/75–limited cutaneous systemic sclerosis (lcSSc) vs. 52/75‐diffuse cutaneous systemic sclerosis (dcSSc); p < 0.001) was found to be associated with dcSSc subset and speckled pattern (lcSSc 28/75 vs. dcSSc 16/75; p < 0.03) with lcSSc subset. One hundred and thirty‐eight (92%) patients were positive for SSc‐associated autoAbs. The frequency distribution of autoAbs to topo I, centromere A (CENP A) and centromereB (CENP B), RNA polymerase III (RP11, RP155), fibrillarin (U3RNP), nucleolus organizer region (NOR)‐90, Th/To, PM‐Scl75, PM‐Scl100, Ku, platelet‐derived growth factor receptor (PDGFR) and Ro‐52, were 87(58%), 9(6%), 8(5.3%), 6(4%), 9(6%), 0, 6(4%), 6(4%), 8(5.3%), 5(3.3%), 11(7.3%),0 and 46(30.6%), respectively. Topo I autoAb was strongly associated with dcSSc (35/75 lcSSc vs. 52/75 dcSSc; p < 0.004), Raynaud's (p < 0.003), interstitial lung disease (ILD) (p < 0.001) and pulmonary arterial hypertension (PAH) (p < 0.04). This study helps in defining SSc clinical subset, prognostic markers of disease severity, characterization of the topo I‐like ANA pattern, and provides a definite association between the ANA patterns and corresponding autoAb. [ABSTRACT FROM AUTHOR]

Background: This study was planned to study the existing status of neonatal transport in North India after the introduction of National Ambulance Service (NAS). We evaluated the quality of referral, admission status, and outcome of referred neonates. Materials and Methods: We enrolled neonates admitted between March 2016 and October 2016, excluding neonates referred from the outpatient department. Information was collected from referral slips, interviewing accompanying persons and observation. Results: Sixty-one percent were referred from government hospitals with "sick newborn care units" contributing to maximum. The main mode of transport was ambulance in 80% and referral notes were available in the majority but incomplete in majority. Sepsis (39%), jaundice (16%), and birth asphyxia (13%) were the most common diagnoses. Half of the neonates were hemodynamically unstable. Twenty-seven percent had poor circulation, 15% were hypoxic, 9% hypoglycemic, and 8% hypothermic. Twenty-two percent either died or "left against medical advice" with a high probability of death. Conclusion: NAS is utilized for transporting neonates. However, there are quality gaps which need attention to develop it into efficient referral system. [ABSTRACT FROM AUTHOR]

Background: Mental health is one of the critical health requirements that society needs to address in the present century. Accredited Social Health Activist (ASHA) can play an important role in identifying mental health problems at the earliest and help in improving community health status. Objectives: The objective of this study was to evaluate the effectiveness of a mental health education program on knowledge, attitude, and practices (KAP) of ASHAs. Materials and Methods: An intervention study was conducted to empower ASHAs for providing mental health services at a district located in Western India during 2016 and 2017. A semi-structured questionnaire was administered to assess KAP regarding mental health in intervention and control groups before and post intervention. An educational program was imparted in two batches. Hybrid methods for imparting teaching/training were utilized. "Paired t-test" was applied to compare pre- and post-results in intervention group and "unpaired t-test" for baseline comparison. Results: There was a statistically significant improvement in KAP of ASHAs after intervention. Majority of ASHAs referred cases of mental health problems to government tertiary care hospitals. Conclusions: The study indicates that it is possible to empower ASHAs with a short course related to mental health to achieve effective outcomes in terms of improved knowledge, attitudes, and practices. [ABSTRACT FROM AUTHOR]

The article examines the various issues related to the practice of consultation-liaison (CL) psychiatry, which can be considered as a barrier to the practice of CL Psychiatry and resultant lower referral rates. Topics discussed include psychiatry morbidity in medically ill patients, barriers in accepting psychiatric referrals by the psychiatrists, and what psychiatrists can do to improve psychiatric referrals.