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Aim of this study was to determine predictors of failure of non-invasive oxygenation methods like high-flow nasal cannula (HFNC) and non-invasive (NIV) in COVID-19 ARDS patients.

Introduction Tobacco is one of the biggest public health problems and a major risk factor for various non-communicable diseases (NCDs). An important aspect of tobacco control strategy could include modifications in the tobacco-related built environment. This study investigated the association between tobacco shop density and tobacco use prevalence in the urban slums of Bhopal city, India. Methods We conducted a cross-sectional survey to obtain the distribution of tobacco-related built environment (tobacco shops) in the neighbourhood (400-m service area) of 32 urban slum clusters of Bhopal. We plotted this distribution using the 'network service area analysis' in ArcMap 10.7.1 software. Then, we used an ecological design to determine the association between tobacco shop density and tobacco use prevalence in these 32 clusters (N = 6214 adult inhabitants). We used multiple linear regression analysis to estimate the regression coefficient (adjusted for socio-demographic variables) between tobacco use and tobacco shop density at the cluster level. Results The prevalence of tobacco use among all 32 slum clusters ranged from 22.1 to 59.6% (median 40.9% with IQR 31.8–44.2). There were 194 tobacco shops situated in the neighbourhood of all clusters. The median density of tobacco shops was 59.40/km2 (IQR 39.9–108.1/km2) in the neighbourhoods of slum clusters. Tobacco use prevalence was significantly associated with tobacco shop density (estimate or B = 0.071, p value = 0.002) after adjusting for age, literacy, wealth index, and gender ratio. Conclusions Tobacco use prevalence is significantly associated with tobacco shop density in the slums of Bhopal city in central India. We need to develop appropriate built environment interventions to control rampant tobacco use.

Objectives Etiology of thrombocytopenia is multifactorial and its pathogenesis should be distinguished for appropriate management. Newly formed immature platelets are called reticulated platelets (RPs) and can be estimated in peripheral blood using automated hematology analyzers, which express them as immature platelet fraction (IPF). In the present study we intend to assess and establish the clinical utility of IPF in differentiating the two major causes of thrombocytopenia—decreased production and increased destruction of platelets—along with determining its significance in monitoring patients with thrombocytopenia. Materials and Methods Sixty-one cases of thrombocytopenia and 101 healthy controls with normal platelet count were included in the study. IPF and all the other usual blood cell parameters were measured using a fully automated hematology analyzer. Based on the pathogenesis of thrombocytopenia, the cases were divided into groups and the difference in IPF value between the groups was evaluated. Results The reference range of IPF among healthy controls was estimated to be 0.7 to 5.7%. The mean IPF was significantly higher in patients with increased peripheral destruction of platelets (13.4%) as compared to patients with decreased production of platelets (4.6%). The optimal cutoff value of IPF for differentiating patients with increased peripheral destruction of platelets from patients with decreased production of platelets was 5.95% with a sensitivity of 88% and specificity of 75.9%. Conclusion Measurement of IPF is useful for detecting evidence of increased platelet production and helps in the initial evaluation of thrombocytopenia patients. It is a novel diagnostic method which can be used to differentiate patients with thrombocytopenia due to increased destruction of platelets from patients with thrombocytopenia due to bone marrow failure/suppression.

Multidrug-resistant (MDR)-TB has emerged as a major challenge to eliminate TB as envisioned at policy level. Distinctive traits associated with the disease such as physical, psychosocial and environmental dimensions may influence the treatment outcome in both directions. Quality of life (QoL) indicators may capture these traits distinctively.To quantify the differential effect of MDR-TB on specific QoL domains, their distributions across the strata and to check for possible interactions. This community-based cross-sectional study was conducted on 98 MDR-TB patients registered in the calendar year 2017 under National Tuberculosis Elimination Programme (NTEP) in a central Indian district using the WHO-QoL BREF Scale by patients in their vicinity. The transformed domain scores were descriptively summarized, stratified and exploratory visualised. Likert mapping for each item was done. A two-way ANOVA test was applied to check differences across strata and interaction effects were calculated.Participants perceived a higher QoL in the social domain (median score 69, IQR 56-75) while the psychological health domain (median 31 IQR 20.5-44) was professed as most negotiated by disease. More than 50% of participants were found to be dissatisfied with their assumed physical status in item-wise analysis. A statistically significant interaction (p=0.008) was detected with education strata to income tertile most evident in the physical domain while psychological domain alone (p=0.017) without significant interaction with treatment duration (p=0.316) was associated with the type of TB. Overall QoL scores were tilted in favour of an urban setting, male gender and towards a relatively younger population. The overall deficits in QoL are evident in the study, per se in the psychological and physical domains. Moreover there is an inequitable distribution of these scores as revealed in the study. Inclusion of an additional parameter of periodical QoL assessment may thus predict the outcome at individual level and may address this inequity at policy level.

Background The outcome of acute kidney injury (AKI) in patients with COVID-19 and the factors associated with its outcome, including mortality, are understudied among the Indian population. Objective The objective of this study is to determine the outcome of AKI in a cohort of patients with COVID-19 admitted to medical wards and associated intensive care unit (ICU) and the factors associated with its outcome, including mortality. Method This is a retrospective study of patients with COVID-19 and AKI admitted to a tertiary care hospital. A total of 1765 patients were admitted to a hospital with COVID-19 between March 23, 2021, and June 30, 2021, during the second wave of the pandemic chiefly attributed to SARS-Co-V-2 lineage B.1.617. Patients with AKI for whom a nephrology call was sought for management (N=60) were included. Measurements carried out were the stage of AKI, co-morbidities, ICU admission, mechanical ventilation, lab parameters, and mortality. We classified AKI by comparing the highest to lowest recorded serum creatinine in hospital and staged AKI based on the Kidney Disease: Improving Global Outcomes (KDIGO) system. We further developed stepwise logistic regression models to find independent factors associated with mortality. Results Out of the 1765 patients hospitalized with COVID-19, a total of 60 (3.4%) patients with AKI were referred to nephrology for management. The observed mortality in this cohort was 41/60 (68.3%). AKI stage 3 was observed to be the most common (78.3%). Based on a univariate analysis of association, age, chronic kidney disease, admission to ICU, the requirement for vasopressor and ventilation, lactate dehydrogenase (LDH) DH, liver function tests (LFT), hypernatremia, and leucocytosis were associated with the mortality of patients (p0.05) with AKI and COVID-19 infection. Multivariate analysis using logistic regression led to the identification of hypernatremia (OR 5.24 {0.95-42.31}) and multiple co-morbidities (OR 2.59 {1.03-8.75}, p0.07) as potential factors independently associated with mortality. Conclusion The study indicates the potential association of hypernatremia with mortality in AKI, along with the simultaneous presence of multiple co-morbidities with COVID-19. As the statistical power of the association is weak, we are claiming the association as potential only. It needs to be confirmed in other larger studies.

Background. Mental illness affects over one-third of the Indian population, and only a little is known about the exact situation of health systems in Madhya Pradesh, India. Therefore, the present research work provides an assessment of state mental health systems in Madhya Pradesh. Methods. The present cross-sectional study was conducted as a part of National Mental Health Survey 2015-16 in 48 districts of Madhya Pradesh, to provide an overview of the status of mental health systems. Secondary data was also retrieved from the state office so as to present the situational analysis in a more comprehensive and inferential way. The proforma for the study was developed based on the experience gained from studies conducted earlier with World Health Organization’s Assessment Instrument for Mental Health Systems (WHO-AIMS) and with WHO’s Mental Health Atlas as the base for thematic analysis. Results. Out of 51 districts, 13.7% of the districts of the state have been covered under District Mental Health Program (DMHP) in 2015-16. Around 11.8% of district/general hospitals were involved in providing mental health services. The availability of psychiatrist was 0.05 per Lakh population. Around 0.2% of the total health budget was allocated by the state for the last financial year for mental health. The overall average score of Madhya Pradesh in the assessment of qualitative indicators was 31 out of 100 in the year 2015-16. Conclusion. There is huge scope and an urgent need to increase mental healthcare facilities (with upgradation of existing one) along the availability of mental healthcare staff.

There is sparsity of studies evaluating blood pressure in children with sickle cell disease (SCD), which have shown inconsistent results. Few of the studies have documented lower office blood pressure (BP) in SCD patients, whereas, others have shown presence of masked hypertension and abnormal ambulatory blood BP monitoring (ABPM). Thus, the present study was conducted to examine 24 h ABPM parameters and renal dysfunction in children with SCD and compare them with healthy controls. A cross-sectional study was conducted on 56 children (30 children having SCD and 26 controls). ABPM and evaluation of renal functions including serum creatinine, serum urea, urinary creatinine, urinary protein and specific gravity was performed. Spot urinary protein to creatinine ratio was found to be higher in patients with SCD (63.3%) as compared to controls (p

Introduction The management of septic shock and refractory septic shock is essential in preventing sepsis-related death. The handheld vital microscope is a new modality of investigation for sepsis for microcirculatory assessment. This study aimed to identify predictors of inotrope requirements among patients with early sepsis and impending septic shock with particular reference to sublingual microcirculation assessment parameters. Methodology We conducted an observational cross-sectional hospital-based study in central India. The formal sample size was calculated to be 52 patients using a convenient sampling technique. The study was initiated with ethics approval (IHEC-LOP/2019/ MD0090) with consent from the patients. We used the MicroScan (MicroVision Medical, Netherlands) Video Microscope System (No.16A00102) to obtain sidestream dark-field imaging along with the AVA 4.3C software (MicroVision Medical). Results Of 51 cases, 60.8% were women, and 39.2% were men, and the study population had a mean age of 41.0 ± 14.9 years. Patients were recruited from medical wards (64.7%) and emergency departments (35.3%). The most common site of infection was gastrointestinal (33.3%), followed by respiratory infections (25.5%) and genitourinary infections (11.8%). The quick sequential organ failure assessment score was 2.0 ± 0.1. Eight patients required inotropes, and six patients died. High respiratory rates and lactate levels were important predictors of inotrope requirements in patients with early sepsis. Sublingual microcirculatory parameters at baseline did not significantly affect the requirement of inotropes consequently. Conclusions Sublingual microscopy is a suggested tool for the management of sepsis. However, without clearly defined cut-off values, handheld vital microscopy could not predict fluid responsiveness among patients with early sepsis. Also, it would be difficult to incorporate this technology into regular practice without equipment upgrades and image acquisition software.

Despite the rising prevalence of liver fibrosis and its potentially life-threatening complications, there are currently no recommendations or guidelines to screen individuals with diabetes mellitus (DM) or high body mass index (BMI) for non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH). This is mainly due to the uncertain performance and feasibility of presently available screening tools. This research was carried out to assess the diagnostic accuracy of non-invasive screening tools in predicting liver fibrosis in individuals with DM and metabolic syndrome.For this study, 140 patients with DM and metabolic syndrome were identified between March 2020 and October 2021. Liver stiffness measurement by point shear wave elastography was considered the gold standard in our study. Five non-invasive scores such as aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio, aspartate aminotransferase to platelet ratio index (APRI) score, fibrosis-4 (FIB-4) index, BARD score, and NAFLD fibrosis score were determined in all of the participants. Using receiver operator characteristic (ROC) curve analysis, sensitivity, specificity, both negative predictive value (NPV) and positive predictive value (PPV) were calculated for each of these scores. The area under the ROC curve (AUROC) was used to calculate the diagnostic accuracy of these scores.Of the 507 individuals screened, 140 were enrolled for the study. Among the 140 participants, 83 were male (59.29%), 30 (21.43%) had liver fibrosis as per liver stiffness measurement by point shear wave elastography, and 110 (78.57%) did not have fibrosis. The mean age and mean BMI were 54.53±12.42 and 27.37±2.73 respectively in the 'Fibrosis' group and 56.20 ±11.76 and 27.10±4.22 in the 'No fibrosis' group. The major finding of our study was that all these scores had relatively high NPV (85 %) for predicting liver fibrosis in our cohort. The AST/ALT ratio had the highest NPV (90.28%) followed by APRI Score (88.94%). The AUROC for FIB-4 Score, NAFLD-fibrosis score, APRI score, AST/ALT ratio, and BARDd score were 0.6669, 0.657, 0.655, 0.637 and 0.599, respectively. The FIB-4 index (p=0.005) had the highest AUROC, followed by the NAFLD-fibrosis score (p =0.009). But all the scores had relatively low specificity (60 %), PPV (35 %), and accuracy (63 %).The FIB-4 index and NAFLD-fibrosis score can be used reliably to exclude liver fibrosis in individuals with DM and metabolic syndrome in the Indian population, but may not be useful in accurately diagnosing liver fibrosis. Utilization of these non-invasive and cost-effective screening tools in routine practice may have promising results in predicting liver fibrosis in 'at risk' populations.

Background: Human resources for health (HRH) include a range of occupations that aim to promote or improve human health. The UN Sustainable Development Goals (SDGs) and the WHO Health Workforce 2030 strategy have drawn attention to the importance of HRH for achieving policy priorities such as universal health coverage (UHC). Although previous research has found substantial global disparities in HRH, the absence of comparable cross-national estimates of existing workforces has hindered efforts to quantify workforce requirements to meet health system goals. We aimed to use comparable and standardised data sources to estimate HRH densities globally, and to examine the relationship between a subset of HRH cadres and UHC effective coverage performance. Methods: Through the International Labour Organization and Global Health Data Exchange databases, we identified 1404 country-years of data from labour force surveys and 69 country-years of census data, with detailed microdata on health-related employment. From the WHO National Health Workforce Accounts, we identified 2950 country-years of data. We mapped data from all occupational coding systems to the International Standard Classification of Occupations 1988 (ISCO-88), allowing for standardised estimation of densities for 16 categories of health workers across the full time series. Using data from 1990 to 2019 for 196 of 204 countries and territories, covering seven Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) super-regions and 21 regions, we applied spatiotemporal Gaussian process regression (ST-GPR) to model HRH densities from 1990 to 2019 for all countries and territories. We used stochastic frontier meta-regression to model the relationship between the UHC effective coverage index and densities for the four categories of health workers enumerated in SDG indicator 3.c.1 pertaining to HRH: physicians, nurses and midwives, dentistry personnel, and pharmaceutical personnel. We identified minimum workforce density thresholds required to meet a specified target of 80 out of 100 on the UHC effective coverage index, and quantified national shortages with respect to those minimum thresholds. Findings: We estimated that, in 2019, the world had 104·0 million (95% uncertainty interval 83·5-128·0) health workers, including 12·8 million (9·7-16·6) physicians, 29·8 million (23·3-37·7) nurses and midwives, 4·6 million (3·6-6·0) dentistry personnel, and 5·2 million (4·0-6·7) pharmaceutical personnel. We calculated a global physician density of 16·7 (12·6-21·6) per 10 000 population, and a nurse and midwife density of 38·6 (30·1-48·8) per 10 000 population. We found the GBD super-regions of sub-Saharan Africa, south Asia, and north Africa and the Middle East had the lowest HRH densities. To reach 80 out of 100 on the UHC effective coverage index, we estimated that, per 10 000 population, at least 20·7 physicians, 70·6 nurses and midwives, 8·2 dentistry personnel, and 9·4 pharmaceutical personnel would be needed. In total, the 2019 national health workforces fell short of these minimum thresholds by 6·4 million physicians, 30·6 million nurses and midwives, 3·3 million dentistry personnel, and 2·9 million pharmaceutical personnel. Interpretation: Considerable expansion of the world's health workforce is needed to achieve high levels of UHC effective coverage. The largest shortages are in low-income settings, highlighting the need for increased financing and coordination to train, employ, and retain human resources in the health sector. Actual HRH shortages might be larger than estimated because minimum thresholds for each cadre of health workers are benchmarked on health systems that most efficiently translate human resources into UHC attainment. Anders O. Larsson ingår i gruppen GBD 2019 Human Resources for Health Collaborators

Background: Supportive supervision has lately been gaining traction in various national health systems as an effective way of boosting the performance of community health workers in a constructive and sustainable way. However, not much is known about the basis/mandate of supportive supervision and its approach in maternal and child health programs in India. The current analysis contributes to a clearer understanding of the paradigms within which supportive supervision is envisioned to operate within India and identifies potential strengths and areas requiring attention. Method: Document analysis of implementation documents such as guidelines/ operational manuals/operationalization modules/ training modules of nationally implemented maternal and child health programs, with data extraction according to a pre-determined domain-based template. Results: Many of the documents reviewed do not mention supportive supervision at all. In the few documents where supportive supervision is mentioned, the paradigms within which it is supposed to operate (who will do it, when will it be done, how to do it, training and logistic support, reporting formats, etc.) have not been clearly identified in most programs. Conclusion: Even though supportive supervision is being increasingly identified as an effective way of performative improvement in national health programs in India, more effort needs to be put into identifying and enforcing the tenets of supportive supervision in practice, in order to bring about the desired change.

To meet the unprecedented requirement of diagnostic testing for SARS-CoV-2, a large number of diagnostic kits were authorized by concerned authorities for diagnostic use within a short period of time during the initial phases of the ongoing pandemic. We undertook this study to evaluate the inter-test agreement and other key operational features of 5 such commercial kits that have been extensively used in India for routine diagnostic testing for COVID-19. The five commercial kits were evaluated, using a panel of positive and negative respiratory samples, considering the kit provided by National Institute of Virology, Indian Council of Medical Research (2019-nCoV Kit) as the reference. The positive panel comprised of individuals who fulfilled the 3 criteria of being clinically symptomatic, having history of contact with diagnosed cases and testing positive in the reference kit. The negative panel included both healthy and disease controls, the latter being drawn from individuals diagnosed with other respiratory viral infections. The same protocol of sample collection, same RNA extraction kit and same RT-PCR instrument were used for all the kits. Clinical samples were collected from a panel of 92 cases and 60 control patients, who fulfilled our inclusion criteria. The control group included equal number of healthy individuals and patients infected with other respiratory viruses (n = 30, in each group). We observed varying sensitivity and specificity among the evaluated kits, with LabGun COVID-19 RT-PCR kit showing the highest sensitivity and specificity (94% and 100% respectively), followed by TaqPath COVID-19 Combo and Allplex 2019-nCoV assays. The extent of inter-test agreement was not associated with viral loads of the samples. Poor correlation was observed between Ct values of the same genes amplified using different kits. Our findings reveal the presence of wide heterogeneity and sub-optimal inter-test agreement in the diagnostic performance of the evaluated kits and hint at the need of adopting stringent standards for fulfilling the quality assurance requirements of the COVID-19 diagnostic process.

Background Individuals with chronic pain have been reported to have an increased incidence of psychological morbidities. We aimed to examine the prevalence of anxiety, depression, disability, alexithymia, insomnia, and sleep quality in patients having chronic low back pain (LBP) and study their association with the severity of pain and any disability arising from it. Methods This descriptive study was conducted in a tertiary care teaching hospital setting. Fifty adults with nonspecific LBP of > 6-week duration were included. Study instruments employed were patient health questionnaire-9 for depression, generalized anxiety disorder-7 for anxiety, visual analogue scale (VAS) score for pain, Oswestry disability index (ODI) to assess disability, Toronto alexithymia scale-20 for alexithymia, and insomnia severity index and Pittsburgh sleep quality index for insomnia. Descriptive results were expressed as numbers, means, and proportions. Association study between variables was performed using Fisher’s exact test. Results Mean ODI score was 31.54% (95% CI, 26.09–36.99); mean VAS score was 6.08 (95% CI, 5.35–6.81). Insomnia of varying severity was found in 29 patients. Sleep quality was reported as good by 23 patients. One patient had alexithymia. There was significant association between the level of disability and depression, anxiety, insomnia, and sleep quality. The severity of pain had significant association with insomnia but the association with anxiety, depression, alexithymia, and sleep quality was not significant. Conclusions Patients with chronic LBP do have associated psychological comorbidities of varying extent. A “patient-centric” approach when treating patients with chronic LBP is necessary, so that appropriate evaluation of psychiatric and psychosocial comorbidities, sleep problems, and quality of life is done as part of their routine management to ensure the desired outcomes.

Background The success of the Community Based Management of Severe Malnutrition (CSAM) programme largely depends on the knowledge and skills of Front-Line Workers (FLWs). A robust supportive supervision system in CSAM should be tailored to individualistic learning needs by distinguishing the FLWs as per their ability and simultaneously identifying the task domains to be emphasized more in supervisory visits. This paper details the ability assessment strategy developed and employed in the selected geographical locations in Madhya Pradesh (Central India) among the 197 Anganwadi workers (FLWs involved in CSAM implementation). Methodology A 25 items tool was developed based on an analytical construct for ability estimation through Rasch Analysis (RA). RA models the probability of right/wrong answers as a function of a person (participants) and item (questions) parameters and calculates the item difficulty in relation to personability on the same unidimensional linear scale. Suitable visualization like item characteristic curve (ICC), person item map (PIM) and quadratic allocation were plotted in RA. The data fitting to the Rasch model (Rasch diagnostic) was tested by numeric (Anderson LR and Wald test) and graphical methods. Results The item easiness parameter (β) value related to Diarrhoeal assessment was lowest (-2.32, -2.91 to -1.73) and related to peer assessment meaningful action (2.009, 1.669- 2.348)) was highest (most difficult). Anderson LR test (LR=31.32, df=24, p=0.079) showed the absence of global outliers. Quadrant analysis using the permutations of ability score and adjusted burden of malnutrition further mapped 41/197 (20.8%) FLWs to low ability -high burden quadrant and 44/197(25%) as low ability low burden quadrant. Conclusion Rasch assessment may address the innate challenges to maintain homogeneity, discrimination capacity and linearity in a raw score-based measurement construct. The monitoring strategy developed on this thus may offer a judicious, pragmatic and thematic approach to supportive supervision in the CSAM program.

Critically ill patients with COVID-19 are at an increased thrombotic risk, hence thromboprophylaxis with heparin is considered mandatory. Antithrombin III (ATIII) is the most potent endogenous anticoagulant and is required for the clinical efficacy of heparin. Profound hypercoagulable and inflammatory state associated with COVID-19 can result in decreased ATIII levels and ineffective heparin treatment resulting in increased mortality. The present study evaluated ATIII levels in critically ill patients of COVID-19 and correlated them with other coagulation parameters and disease outcomes. A retrospective review of those critically ill COVID-19 patients was performed who were on a therapeutic dose of low molecular weight heparin (LMWH) and had serial measurements of ATIII, anti-factor Xa (antiFXa) assay and other routine coagulation parameters. A total of 27 critically ill COVID-19 patients were identified, out of these, 12 survived and 15 had disease-induced mortality. ATIII levels were found to be significantly lower in non-survivors on the third day of serial measurement along with worsening of other coagulation parameters. AntiFXa levels were found to be higher in non-survivors as compared to survivors. Further studies are required to establish ATIII as a prognostic marker and to determine the utility of monitoring antiFXa levels in COVID-19 patients on LMWH therapy.

Background: Social media like WhatsApp is known to affect relationships of an individual, and busy professionals like doctors appear no bar. The objectives of this study were to analyze the pattern of WhatsApp use in specialist-doctors and to study its effect on their relationships. Materials and Methods: This was a cross-sectional pilot study. Consecutively selected hundred married specialist doctors were assessed using self-reported validated questionnaire including questions related to demographics, WhatsApp use, and effects on relationships in a tertiary care center. Statistical analysis was performed using mean, standard deviation, t-test, and Chi-square test. A value of P < 0.05 was considered statistically significant. Results: Participants of various specialties, with a mean age of 41.5 years reported regular WhatsApp-use (89%) of mean duration 2.5 years with 19% spending> 2 h/day. About 62% reported using WhatsApp during personal time, leading to reduction in time spent with spouse (37%), impairment in household responsibilities (24%), disturbances in social-activities (26%) and craving. About 36% reported negative effects on married life. 21% reported inability to spend quality-time with spouse, 24% had concern about spouse's WhatsApp-use, 25% reported reduced cohesion between them and 22% felt that excessive use can create doubts in spouse's mind. Those aged

Objectives This study was performed to estimate diagnostic accuracy of the two commercially available point-of-care tests to identify poor glycemic control defined by HbA1c levels, with high-performance liquid chromatography (HPLC) as a reference. Settings The study was carried at two locations, general medical outpatient department of a teaching medical college in Bhopal (urban), and a primary health care centre in a rural area in the state of Madhya Pradesh, India. Participants All individuals with diabetes mellitus who presented to the health care facility for assessment of glycemic control. We compared HbA1c estimated from two index tests (Hemocue Hb 501, Sweden; SD Biosensor, South Korea) from capillary blood samples with HPLC performed from venous blood, as a reference standard. Primary and secondary outcome measures Diagnostic properties of index tests such as sensitivity, specificity, positive and negative predictive value and diagnostic accuracy for identifying poor glycemic control were primary outcome measures. Lin's concordance correlation coefficient (CCC) was secondary outcome measure. Results Out of 114 patients, all received reference standard - 103 patients received Hemocue A1C test and 110 patients received SD Biosensor test. Overall both the index tests had similar diagnostic accuracy estimates. The area under the Receiver Operating Curve for SDA1c device was 0.935 (95% CI 0.886-0.983), and for Hemocue device was 0.938 (95% CI 0.893-0.984). The Hemocue device HbA1c value of above 7.0 (positive) correctly predicted poor glycemic control 92% times (81.58% for SD device). There were 4 vs. 11 device failures and 14 vs. 12 failures with SD and Hemocue, respectively. Ambient air temperatures were no different for the device test failures. Conclusions Commercially available point-of-care tests evaluated in this study are comparable and an acceptable alternative to HPLC-based measurements for the assessment of glycemic control. Tests and device failure rates of both the index tests are similar.

Purpose The accuracy of the diagnosis of hypertension increases by obtaining repeated blood pressure values. This can be achieved by obtaining multiple office blood pressure measurements (OBPM) or by home blood pressure measurements (HBPM) or using ambulatory blood pressure measurement (ABPM). A 24-hour ABPM is recommended as the preferred modality to diagnose hypertension by the latest guidelines. In this study, we evaluated the diagnostic accuracy achieved by four short-duration-ABPM (sABPM) protocols, i.e., two-hour, four-hour, six-hour, eight-hour compared to standard 24-hour ABPM. Materials and methods We performed a prospective diagnostic accuracy study in individuals attending the medicine outpatient department. Participants were >18 years, had systolic BP between 130 and 150 mmHg, and were not previously diagnosed as hypertensive. Initially, two OBPM values were taken, and then the ABPM apparatus was applied for 24 hours, which recorded BP at every 30 minutes while awake and at every 60 minutes while asleep. We used four sABPM values (2-hour, 4-hour, 6-hour, and 8-hour sABPM) and OBPM values as index tests, with awake ABPM cut-off of greater than or equal to 135/85 as the definition of hypertension. Analyses were conducted using the R Statistical language (version 4.0.3; R Core Team, 2020) on macOS Catalina 10.15.6. Result Based on the 24-hour ABPM based reference standard definition, 76 (48.7%) individuals out of 156 were classified as hypertensive. The positive predictive value (PPV) of sABPM at two-hour, four-hour, six-hour, and eight-hour above the cut-off of 135/85 was 80.0%, 83.8%, 93.4%, and 94.8%, respectively. PPV increased from 83.8% to 93.4%, and the positive likelihood ratio (LR+) increased from 5.4 to 15.0 with an increase in the sABPM duration from four to six hours. Conclusion We conclude that short-duration ABPM for six hours has a good diagnostic accuracy amongst hospital attendees. It can act as an intermediary approach between multiple OBPM and standard 24-hour ABPM in this population.

Background The monitoring framework for evaluating health system response to noncommunicable diseases (NCDs) include indicators to assess availability of affordable basic technologies and essential medicines to treat them in both public and private primary care facilities. The Government of India launched the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) in 2010 to strengthen health systems. We assessed availability of trained human resources, essential medicines and technologies for diabetes, cardiovascular and chronic respiratory diseases as one of the components of the National Noncommunicable Disease Monitoring Survey (NNMS - 2017-18). Methods NNMS was a cross-sectional survey. Health facility survey component covered three public [Primary health centre (PHC), Community health centre (CHC) and District hospital (DH)] and one private primary in each of the 600 primary sampling units (PSUs) selected by stratified multistage random sampling to be nationally representative. Survey teams interviewed medical officers, laboratory technicians, and pharmacists using an adapted World Health Organization (WHO) – Service Availability and Readiness Assessment (SARA) tool on handhelds with Open Data Kit (ODK) technology. List of essential medicines and technology was according to WHO - Package of Essential Medicines and Technologies for NCDs (PEN) and NPCDCS guidelines for primary and secondary facilities, respectively. Availability was defined as reported to be generally available within facility premises. Results Total of 537 public and 512 private primary facilities, 386 CHCs and 334 DHs across India were covered. NPCDCS was being implemented in 72.8% of CHCs and 86.8% of DHs. All essential technologies and medicines available to manage three NCDs in primary care varied between 1.1% (95% CI; 0.3–3.3) in rural public to 9.0% (95% CI; 6.2–13.0) in urban private facilities. In NPCDCS implementing districts, 0.4% of CHCs and 14.5% of the DHs were fully equipped. DHs were well staffed, CHCs had deficits in physiotherapist and specialist positions, whereas PHCs reported shortage of nurse-midwives and health assistants. Training under NPCDCS was uniformly poor across all facilities. Conclusion Both private and public primary care facilities and public secondary facilities are currently not adequately prepared to comprehensively address the burden of NCDs in India.

BackgroundHypertension (HTN) is a key risk-factor for cardiovascular diseases (CVDs). Blood-pressure (BP) categorizations between systolic blood pressure (SBP) of 120 and 140 remain debatable. In the current study we aim to evaluate if individuals with a baseline SBP between 130-140 mm Hg (hypertension as per AHA 2017 guidelines) have a significantly higher proportion of incident hypertension on follow-up, as compared to those with SBP between 120-130 mm Hg.MethodsSecondary data analysis was performed in a community-based cohort, instituted, and followed since 2017. Participants were aged ≥30 years, residents of urban slums in Bhopal. BP was measured at or near home by Community Health Workers (CHWs). Two-year follow up was completed in 2019. We excluded participants who were on BP reduction therapy, had fewer than two out-of-office BP measurements and who could not be followed. Eligible participants were re-classified based on baseline BP in four categories: Normal (Category-A), Elevated-BP (Category-B), Variable-BP (Category-C) and reclassified HTN based on AHA-2017 (Category-D). Proportion of individuals who developed incident hypertension on follow up was primary outcome.ResultOut of 2649 records, 768 (28.9%), 647 (24.4%), 586 (22.1%), 648 (24.4%) belonged to Categories A, B, C and D respectively. Incident HTN with cut-off of 140/90 mm Hg was, 1.6%, 2.6%, 6.7%, 12% in categories A, B, C and D respectively. Incidence of incident hypertension in individuals with a baseline SBP between 130-140 mm Hg (Category D) was significantly higher as compared to those with SBP between 120-130 mm Hg (Category B).ConclusionWe conclude that biological basis for AHA-2017 definition of hypertension is relatively robust also for low income and resource-limited settings. Evidence from our longitudinal study will be useful for policy makers for harmonizing national guidelines with AHA-2017.

In the wake of rising number of SARS-CoV-2 cases, the Government of India had placed mass-quarantine measures, termed as “lockdown” measures from end-March 2020. The subsequent phase-wise relaxation from July 2020 led to a surge in the number of cases. This necessitated an understanding of the true burden of SARS-CoV-2 in the community. Consequently, a sero-epidemiological survey was carried out in the central Indian city of Ujjain, Madhya Pradesh. This article details the processes of data acquisition, compilation, handling, and information derivation from the survey. Information on socio-demographic and serological variables were collected from 4,883 participants using a multi-stage stratified random sampling method. Appropriate weightage was calculated for each participant as sampling fraction derived from Primary Sampling Unit (PSU), Secondary Sampling Unit (SSU) and Tertiary Sampling Unit (TSU). The weightage was then applied to the data to adjust the findings at population level. The comprehensive and robust methodology employed here may act as a model for similar future endeavours. At the same time, the dataset can also be relevant for researchers in fields such as data science, epidemiology, virology and earth modelling.

Background. Community-based health insurance (CBHI) is a health-financing mechanism based on voluntary membership, risk pooling, with a non-profit objective and relies on social capital as a driving force. It aims to improve equity in healthcare utilization in the community. We did this study to understand if CBHI schemes reach the poor, improve healthcare utilization and protect them from catastrophic health events. Methods. Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sevagram, located in Wardha district of Maharashtra, India, runs a variety of CBHI schemes in surrounding villages. Many households (HHs) have opted for these schemes. We conducted a cross-sectional survey of all HHs of 35 villages and collected information about sociodemographics, inpatient healthcare utilization (in previous 5 years), outpatient healthcare utilization (in previous 1 year) and insurance status of the HHs. We derived wealth index based on 33 sociodemographic variables and classified HHs in quintiles of wealth index. We compared the distribution of healthcare utilization variables by insurance status and wealth index and used logistic regression to evaluate if health insurance independently improves healthcare utilization, after adjusting for confounders. Results. Of a total of 7261 HHs surveyed, 2210 (30.4%) were uninsured, 4153 (57.2%) were insured under MGIMS CBHI schemes, and 898 (12.4%) had family insurance either from MGIMS or other providers. Insured HHs had a higher wealth index compared to uninsured. Mean (SD) hospitalization episodes in an HH were 0.82 (1.75) among uninsured, 1.13 (1.56) in CBHI insured and 1.21 (1.55) in those with family insurance. Within each category, healthcare utilization was lower for poor HHs (lowest quintile of wealth index) and higher for affluent HHs (higher quintiles of wealth index). Among those who were hospitalized, catastrophic health events were less in CBHI insured (7.9%) compared to uninsured (12.3%). After adjusting for socioeconomic status and other confounders, our data suggest that participating in a CBHI scheme increased odds of utilization of inpatient services (OR 1.18; 95% CI 1.04–1.33) and protected from catastrophic health events (OR 0.52; 95% CI 0.43–0.64). Conclusion. CBHI schemes improve healthcare utilization and protect against catastrophic health expenditure among those who get hospitalized. However, there also exists a socioeconomic gradient both in membership and in utilization of healthcare services favouring those who are more affluent.

Human anatomy instruction is mostly focused on cadaver dissection and prosected specimen examination. Exposure to cadaver dissection can be a stressful experience that may cause a wide variety of symptoms among students of health sciences. To compare and evaluate the effect ofAn open-label randomized trial (matched-control experimental design) was conducted among 127 1The study showed that there was a statistically significant difference in state anxiety related to cadaver dissection in the experimental group (The findings provided evidence that video-demonstration of cadaver dissection reduced anxiety, although it did not have any effect on disgust and attitudes of death. The dissection hall experience may evoke feelings of anxiety and disgust that need to be addressed through advanced preparedness and coping strategies, especially among medical and nursing students.

OBJECTIVE To evaluate medication adherence, the effect of recall periods on self-reported adherence and factors influencing medication adherence among patients of chronic diseases, such as hypertension and diabetes, particularly in the community. METHODS A cross-sectional cohort study was conducted among individuals with hypertension and/or diabetes coming as outpatients in community camps organised in a cluster of urban slums. Responses towards questions regarding self-reported quantitative and qualitative adherence for one week and one month along with information on pill burden, socio-demographic and other factors were recorded using a mobile application. RESULTS Among 379 participants living in urban slum communities, who were prescribed anti-hypertensive or oral anti-diabetic medications previously, mean medication adherence over previous one week was 67.99% (standard deviation (SD) ± 38.32) and 6.87 (SD ± 3.62) on a ten-point numeric scale. The medication adherence for one month showed a strong significantly positive correlation with that of 1 week for both percentage-based (r = +0.910, 95% CI = 0.864 to 0.950, P < .0001) and Likert (ρ = +0.836, 95% CI = 0.803 to 0.863, P < .0001) scales. Age (r = 0.219, 95% CI = 0.120 to 0.313, P = .043) and pill burden (r = -0.231, 95% CI = -0.145 to -0.322, P < .0001) were found to significantly affect medication adherence. The odds of random blood sugar reduction were found to be significant (OR 1.98, 95% CI = 1.30 to 3.00, P = .001) with adequate adherence. A linear regression equation was developed to predict medication adherence percentage for a patient which was found to have 61.8% predictive power using multilayer perceptron modelling. CONCLUSION Overall, medication adherence was sub-optimal. Adherence assessments can be reliably performed using either one week or one month recall periods. With further refinement and validation, the regression equation could prove to be a useful tool for physicians.

Malaria has been an important public health all over the globe. Although conventional light microscopy is the gold standard of diagnosis, light microscopes are heavy, fragile, costly, and electricity dependent. Rapid diagnostic tests (RDTs) have become more popular but perform badly in temperate climate. This is because the RDT kits require maintenance of cold chain for its optimal use. In this regard, there is a recent interest in handheld malaria microscopy at the point of care in the field setting. Foldscopes are cheap, handy, nonfragile, and use mobile camera for illumination. The purpose of the study was to find whether foldscope can be used in the national vector borne disease control program (NVBDCP) in India.Ten laboratory technicians were trained in identifying malaria parasites using foldscope and their mobiles. Later, they were provided with unassembled foldscope to document their test results for the preidentified malaria slides. The blood smears were stained as per the protocol of NVBDCP. The report of the index test (foldscope microscopy) was compared with the reference test (conventional microscopy).The sensitivity and specificity of the index test was found to be 13.3% (6.257-26.18), specificity of 97.78% (88.43-99.61), positive predictive value 85.71% (48.69-97.43), and negative predictive value 53.01% (42.38-63.38). The devise failure rate and test failure rate were 20% and 11.7%. The kappa agreement between the index and reference microscopy was only 11% and the McNemarThe ×400 foldscope at its present magnification and illumination cannot be utilized in the field under NVBDCP.

Background Periodic information on risk factor distribution is critical for public health response for reduction in non-communicable disease (NCDs). For this purpose, the WHO has developed STEPs wise approach. State representative population-based STEPS survey was last conducted in 2007–08 in seven states of In India. Since then no such work has been reported from low ETL states. This survey was carried out to assess the prevalence of risk factors associated with NCDs and the prevalence of NCDs in the low ETL state of Madhya Pradesh using the WHO STEPs approach. Methods A total of 5680 persons aged 18–69 years were selected from the state of Madhya Pradesh using multi-stage cluster random sampling. Using the WHO STEPs approach, details were collected on demographics, STEP 1 variables (tobacco consumption, alcohol consumption, physical activity, diet), STEP 2 variables (weight, height, waist circumference, blood pressure) and STEP 3 variables (fasting blood glucose, blood cholesterol). Results We found that 9.4% individuals smoked tobacco, 15.3% were overweight/obese, 22.3% had hypertension, and 6.8% have diabetes mellitus. As compared to women, men were less likely to be overweight or obese, but more likely to smoke tobacco, and have diabetes mellitus. Hypertension was also more common in men. Overall, about a fourth of all adults had three or more risk factors for cardiovascular disease. Conclusion The survey shows that a large section of the population from Madhya Pradesh is either suffering from NCDs or have risk factors which predispose them to acquire NCDs. This state representative survey provides benchmarking information for behavioural and biological risk factor distribution for recently scaled up National Programme for the Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS).

This computational workflow protocol contains all the steps, necessary files and R code to perform incidence modelling and estimating transmission parameters of COVID-19 outbreak in India. This computational workflow protocol is being submitted in accordance with PLoS One publication policy and contains all of the code and datasets and files necessary for reproducibility of the analyses reported in the manuscript.

Background: Recognizing the need for good quality, scientific and reliable information for strengthening mental health policies and programmes, the National Mental Health Survey (NMHS) of India was implemented by National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, in the year 2015–2016. Aim: To estimate the prevalence, socio-demographic correlates and treatment gap of mental morbidity in a representative population of India. Methods: NMHS was conducted across 12 Indian states where trained field investigators completed 34,802 interviews using tablet-assisted personal interviews. Eligible study subjects (18+ years) in households were selected by a multi-stage, stratified, random cluster sampling technique. Mental morbidity was assessed using MINI 6. Three-tier data monitoring system was adopted for quality assurance. Weighted and specific prevalence estimates were derived (current and lifetime) for different mental disorders. Mental morbidity was defined as those disorders as per the International Statistical Classification of Diseases, Tenth Revision Diagnostic Criteria for Research (ICD-10 DCR). Multivariate logistic regression was conducted to examine risk for mental morbidity by different socio-demographic factors. Survey was approved by central and state-level institutional ethical committees. Results: The weighted lifetime prevalence of ‘any mental morbidity’ was estimated at 13.67% (95% confidence interval (CI) = 13.61, 13.73) and current prevalence was 10.56% (95% CI = 10.51, 10.61). Mental and behavioural problems due to psychoactive substance use (F10–F19; 22.44%), mood disorders (F30–F39; 5.61%) and neurotic and stress-related disorders (F40–F48; 3.70%) were the most commonly prevalent mental morbidity in India. The overall prevalence was estimated to be higher among males, middle-aged individuals, in urban-metros, among less educated and in households with lower income. Treatment gap for overall mental morbidity was 84.5%. Conclusion: NMHS is the largest reported survey of mental morbidity in India. Survey estimated that nearly 150 million individuals suffer from one or the other mental morbidity in India. This information is to be used for planning, delivery and evaluating mental health programming in the country.

There is sparsity of studies evaluating blood pressure in children with sickle cell disease (SCD), which have shown inconsistent results. Few of the studies have documented lower office blood pressure (BP) in SCD patients, whereas, others have shown presence of masked hypertension and abnormal ambulatory blood BP monitoring (ABPM). Thus, the present study was conducted to examine 24 h ABPM parameters and renal dysfunction in children with SCD and compare them with healthy controls.A cross-sectional study was conducted on 56 children (30 children having SCD and 26 controls). ABPM and evaluation of renal functions including serum creatinine, serum urea, urinary creatinine, urinary protein and specific gravity was performed.Spot urinary protein to creatinine ratio was found to be higher in patients with SCD (63.3%) as compared to controls (p 0.001). Proteinuria was observed in 1/4th of the SCD patients less than ten years of age. Masked hypertension was present in 2 (6.6%) patients, ambulatory hypertension in 4 (13.3%), ambulatory pre-hypertension in 1 (3.3%) and abnormal dipping in 60%. A statistically significant correlation of BMI for age Z-score and standard deviation score (SDS/Z) of 24 h systolic BP (r = 0.56, p = 0.002); estimated glomerular filtration rate (eGFR) with 24 h diastolic BP SDS (r = -0.52; p = 0.038) and age with e GFR (r = 0.54; p = 0.025) was found in the present study.The present study corroborates that ABPM abnormalities (ambulatory hypertension, non-dipping pattern, ambulatory prehypertension) and early onset proteinuria are significant findings in patients with SCD. This underscores the importance of regular screening for proteinuria and ABPM in routine care, for early detection and prevention of progressive renal damage in SCD.

Background National and statewide assessment of cardiovascular risk factors needs to be conducted periodically in order to inform public health policy and prioritise allocation of funds, especially in LMICs. Although there have been studies from India which have explored the determinants of cardiovascular risk factors, they have mostly been from high epidemiological transition states. The present study assessed the determinants of cardiovascular (CVD) risk factors in a low epidemiological transition state (Madhya Pradesh) using the WHO STEPwise approach to surveillance (STEPS). Methods A total of 5,680 persons aged 18–69 years were selected from the state of Madhya Pradesh through multi-stage cluster random sampling. Key CVD risk factors we sought to evaluate were from behavioural (tobacco, alcohol, physical activity, diet) and biological domains (overweight or obese, Hypertension, Diabetes, and Raised serum cholesterol). Key socio-demographic factors of interest were the caste and tribe groups, and rural vs urban location, in addition to known influencers of CVD risk such as age, gender and education level Results Those belonging to the scheduled tribes were more at risk of consuming tobacco (OR 2.13 (95% CI [1.52–2.98]), and a diet with less than five servings of fruits and vegetables (OR 2.78 (95% CI [1.06–7.24]), but had had the least risk of physical inactivity (OR 0.31 (95% CI [0.02–0.54]). Residence in a rural area also reduced the odds of physical inactivity (OR 0.65 (95% CI [0.46–0.92])). Lack of formal education was a risk factor for both tobacco consumption and alcohol intake (OR 1.40 (95% CI [1.08–1.82]) for tobacco use; 1.68 (95% CI [1.14–2.49]) for alcohol intake). Those belonging to schedules tribes had much lower risk of being obese (OR 0.25; 95% CI [0.17–0.37]), but were at similar risk of all other clinical CVD risk factors as compared to other caste groups. Conclusion In the current study we explored socio-demographic determinants of behavioural and biological CVD risks, and found that in Madhya Pradesh, belonging to a scheduled tribe or living in a rural location, protects against being physically inactive or being overweight or obese. Increasing age confers a greater CVD-risk in all domains. Being a male, and lack of formal education confers a greater risk for behavioural domains, but not for most clinical risk domains. Future efforts at curbing CVDs should be therefore two pronged –a population-based strategy targeting biological risk factors, and a more focussed approach directed at those displaying risky behaviour.

Global development goals increasingly rely on country-specific estimates for benchmarking a nation's progress. To meet this need, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 estimated global, regional, national, and, for selected locations, subnational cause-specific mortality beginning in the year 1980. Here we report an update to that study, making use of newly available data and improved methods. GBD 2017 provides a comprehensive assessment of cause-specific mortality for 282 causes in 195 countries and territories from 1980 to 2017. The Lancet Publishing Group