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Objective: To describe the utilization and perceptions of existing neonatal health services in rural Uttar Pradesh, India.Design: A prospective observational study.Setting: The study was located in Shivgarh, a rural block of Uttar Pradesh, India.Participants: One hundred and fifty-three households that utilized a healthcare provider for their sick neonates.Interventions: None.Main Outcome Measure: Perceived neonatal health improvement after utilization of neonatal health services; satisfaction with aspects of neonatal health services: 'overall care', 'interaction with provider', 'waiting time' and 'explanations of immediate care and follow-up care'.Results: Unqualified allopathically oriented providers (UAOPs) were utilized by 110 households (71.8%), while qualified allopathically oriented providers (QAOPs) by 43 households (28.2%). The odds of perceived neonatal health improvement were significantly higher among households utilizing UAOPs (n = 88/110, 80.0%) than those using QAOPs (n = 23/43, 53.5%) [adjusted odds ratio (OR): 3.3, 95% confidence interval (CI): 1.5-7.5]. The median healthcare fee charged was higher for UAOPs (Rs. 25) than those for QAOPs (Rs. 1). Household satisfaction with 'overall care' of neonatal health service was significantly higher among households that utilized UAOPs compared with those that used QAOPs (OR: 2.4, 95% CI: 1.2-5.0).Conclusion: Households that utilized UAOPs reported better perceived neonatal health outcomes and higher satisfaction levels than those that used QAOPs, despite higher costs for the former. Future research should assess what dimensions of neonatal care are important to households and identify incentive structures that promote healthcare providers to deliver better perceived care in high-mortality settings such as rural Uttar Pradesh, India. [ABSTRACT FROM AUTHOR]

The differences between slow calcium blocking agents with respect to effects on heart rate, myocardial contractility and atrioventricular conducting time are well described; the relevance of such differences to the treatment of patients with impaired left ventricular function due to coronary heart disease is uncertain. The haemodynamic effects of equivalent hypotensive doses of nifedipine and verapamil were therefore compared in 20 patients with severe angina pectoris associated with angiographically documented coronary artery disease. The plasma concentrations of nifedipine (mean 57 +/- 19; range 27-77 ng/ml) and verapamil (mean 147 +/- 14; range 117-260 ng/ml) at the time of the haemodynamic measurements were of an order usually associated with substantial pharmacodynamic activity. Sitting at rest nifedipine resulted in reduction in systemic arterial pressure (P less than 0.05) and vascular resistance (P less than 0.01); both the heart rate (P less than 0.01) and cardiac output (P less than 0.05) increased without any significant change in the left heart filling pressure. In contrast, verapamil, which similarly reduced systemic blood pressure (P less than 0.05) and vascular resistance (P less than 0.01), increased cardiac output (P less than 0.05) and left heart filling pressure (P less than 0.05) without any change in heart rate. During upright bicycle exercise both drugs attenuated the angina induced in all subjects during the control exercise period. Despite reductions in systemic blood pressure and vascular resistance the cardiac output was unaltered on either drug at the same workload as in the control assessment. The reduction in exercise blood pressure following nifedipine induced a reflex tachycardia; this was not present, despite the similar hypotensive action, after verapamil.(ABSTRACT TRUNCATED AT 250 WORDS) [ABSTRACT FROM AUTHOR]

Objective To assess the impact of the newborn health component of a large-scale community-based integrated nutrition and health programme. Methods Using a quasi-experimental design, we evaluated a programme facilitated by a nongovernmental organization that was implemented by the Indian government within existing infrastructure in two rural districts of Uttar Pradesh, northern India. Mothers who had given birth in the 2 years preceding the surveys were interviewed during the baseline (n = 14 952) and endline (n = 13 826) surveys. The primary outcome measure was reduction of neonatal mortality. Findings In the intervention district, the frequency of home visits by community-based workers increased during both antenatal (from 16% to 56%) and postnatal (from 3% to 39%) periods, as did frequency of maternal and newborn care practices. In the comparison district, no improvement in home visits was observed and the only notable behaviour change was that women had saved money for emergency medical treatment. Neonatal mortality rates remained unchanged in both districts when only an antenatal visit was received. However, neonates who received a postnatal home visit within 28 days of birth had 34% lower neonatal mortality (35.7 deaths per 1000 live births, 95% confidence interval, CI: 29.2DS42.1) than those who received no postnatal visit (53.8 deaths per 1000 live births, 95% CI: 48.9DS58.8), after adjusting for sociodemographic variables. Three-quarters of the mortality reduction was seen in those who were visited within the first 3 days after birth. The effect on mortality remained statistically significant when excluding babies who died on the day of birth. Conclusion The limited programme coverage did not enable an effect on neonatal mortality to be observed at the population level. A reduction in neonatal mortality rates in those receiving postnatal home visits shows potential for the programme to have an effect on neonatal deaths. Copyright © 2008 World Health Organization [ABSTRACT FROM AUTHOR]

OBJECTIVE: To establish a surveillance network for cardiovascular diseases (CVD) risk factors in industrial settings and estimate the risk factor burden using standardized tools. METHODS: We conducted a baseline cross-sectional survey (as part of a CVD surveillance programme) of industrial populations from 10 companies across India, situated in close proximity to medical colleges that served as study centres. The study subjects were employees (selected by age and sex stratified random sampling) and their family members. Information on behavioural, clinical and biochemical determinants was obtained through standardized methods (questionnaires, clinical measurements and biochemical analysis). Data collation and analyses were done at the national coordinating centre. FINDINGS: We report the prevalence of CVD risk factors among individuals aged 20-69 years (n = 19 973 for the questionnaire survey, n = 10 442 for biochemical investigations); mean age was 40 years. The overall prevalence of most risk factors was high, with 50.9% of men and 51.9% of women being overweight, central obesity was observed among 30.9% of men and 32.8% of women, and 40.2% of men and 14.9% of women reported current tobacco use. Self-reported prevalence of diabetes (5.3%) and hypertension (10.9%) was lower than when measured clinically and biochemically (10.1% and 27.7%, respectively). There was marked heterogeneity in the prevalence of risk factors among the study centres. CONCLUSION: There is a high burden of CVD risk factors among industrial populations across India. The surveillance system can be used as a model for replication in India as well as other developing countries. Copyright © 2006 World Health Organization [ABSTRACT FROM AUTHOR]

Background: Undernutrition below two years of age remains a major public health problem in India. We conducted an evaluation of an integrated nutrition and health program that aimed to improve nutritional status of young children by improving breast and complementary feeding practices over that offered by the Government of India's standard nutrition and health care program., Methods: In Uttar Pradesh state, through multi-stage cluster random sampling, 81 villages in an intervention district and 84 villages in a comparison district were selected. A cohort of 957 third trimester pregnant women identified during house-to-house surveys was enrolled and, following childbirth, mother-child dyads were followed every three months from birth to 18 months of age. The primary outcomes were improvements in weight-for-age and length-for-age z scores, with improved breastfeeding and complementary feeding practices as intermediate outcomes., Findings: Optimal breastfeeding practices were higher among women in intervention than comparison areas, including initiating breastfeeding within one hour of delivery (17.4% vs. 2.7%, p<0.001), feeding colostrum (34.7% vs. 8.4%, p<0.001), avoiding pre-lacteals (19.6% vs. 2.1%, p<0.001) and exclusively breastfeeding up to 6 months (24.1% vs. 15.3%, p = 0.001). However, differences were few and mixed between study arms with respect to complementary feeding practices. The mean weight-for-age z-score was higher at 9 months (-2.1 vs. -2.4, p = 0.0026) and the prevalence of underweight status was lower at 12 months (58.5% vs. 69.3%, p = 0.047) among intervention children. The prevalence of stunting was similar between study arms at all ages. Coefficients to show the differences between the intervention and comparison districts (0.13 cm/mo) suggested significant faster linear growth among intervention district infants at earlier ages (0-5 months)., Interpretation: Mothers participating in the intervention district were more likely to follow optimal breast, although not complementary feeding practices. The program modestly improved linear growth in earlier age and weight gain in late infancy. Comprehensive nutrition and health interventions are complex; the implementation strategies need careful examination to improve feeding practices and thus impact growth., Trial Registration: The trial was registered with ClinicalTrials.gov, NCT00198835.

Background: Integrated nutrition and health programs seek to reduce undernutrition by educating child caregivers about infant feeding and care. Data on the quality of program implementation and consequent effects on infant feeding practices are limited. This study evaluated the effectiveness of enhancing a nutrition and health program on breastfeeding and complementary-feeding practices in rural India., Methods: Utilizing a quasi-experimental design, one of the implementing districts of a Cooperative for Assistance and Relief Everywhere (CARE) nutrition and health program was randomly selected for enhanced services and compared with a district receiving the Government of India's standard nutrition and health package alone. A cohort of 942 mother-child dyads was longitudinally followed from birth to 18 months. In both districts, the evaluation focused on responses to services delivered by community-based nutrition and health care providers [anganwadi workers (AWWs) and auxiliary nurse midwives (ANMs)]., Findings: The CARE enhanced program district showed an improvement in program coverage indicators (e.g., contacts, advice) through outreach visits by both AWWs (28.8-59.8% vs. 0.7-12.4%; all p<0.05) and ANMs (8.6-46.2% vs. 6.1-44.2%; <0.05 for ages ≥6 months). A significantly higher percentage of child caregivers reported being contacted by the AWWs in the CARE program district (20.5-45.6% vs. 0.3-21.6%; p<0.05 for all ages except at 6months). No differences in ANM household contacts were reported. Overall, coverage remained low in both areas. Less than a quarter of women received any infant feeding advice in the intervention district. Earlier and exclusive breastfeeding improved with increasing number or quality of visits by either level of health care provider (OR: 2.04-3.08, p = <0.001), after adjusting for potentially confounding factors. Socio-demographic indicators were the major determinants of exclusive breastfeeding up to 6 month and age-appropriate complementary-feeding practices thereafter in the program-enhanced but not comparison district., Interpretation: An enhanced nutrition and health intervention package improved program exposure and associated breastfeeding but not complementary-feeding practices, compared to standard government package., Trial Registration: ClinicalTrials.gov NCT00198835.

Background: About a million newborns die each year in India, accounting for about a fourth of total global neonatal deaths. Infections are among the leading causes of neonatal mortality. Care practices immediately following delivery contribute to newborns' risk of infection and mortality., Objectives: This study examined the association between clean cord care practices and neonatal mortality in rural Uttar Pradesh, India., Methods: The study used data from a household survey conducted to evaluate a community-based intervention program in two districts of Uttar Pradesh, India. Analysis included data from 5741 singleton live births delivered at home during 2005. The association between clean cord care (clean instrument used to cut cord, clean thread used to tie cord and antiseptics or nothing applied to the cord) and neonatal mortality was estimated using multivariate logistic regression models., Results: Thirty per cent of the study mothers practiced clean cord care. Neonatal mortality rate was significantly lower among newborns exposed to clean cord care (36.5/1000 live births, 95% CI 28.0 to 46.8) than those who did not practice (53.0/1000 live births, 95% CI 46.1 to 60.6). Clean cord care was associated with 37% lower neonatal mortality (OR=0.63; 95% CI 0.46 to 0.87) after adjusting for mother's age, education, caste/tribe, religion, household wealth, newborn thermal care practice and care-seeking during the first week after birth and study arms., Conclusions: Promoting clean cord care practice among neonates in community-based maternal and newborn care programs has the potential to improve neonatal survival in rural India and similar other settings.

Background: This study explored the relationship between the knowledge of community health workers (CHWs)-anganwadi workers (AWWs) and auxiliary nurse midwives (ANMs)-and their antenatal home visit coverage and effectiveness of the visits, in terms of essential newborn health care practices at the household level in rural India., Methods: We used data from 302 AWWs and 86 ANMs and data from recently delivered women (RDW) (n=13,023) who were residents of the CHW catchment areas and gave birth to a singleton live baby during 2004-05. Using principal component analysis, knowledge scores for preventive care and danger signs were computed separately for AWWs and ANMs and merged with RDW data. A multivariate logistic regression model was used to estimate the adjusted effect of knowledge level. A generalized estimating equation (GEE) was used to account for clustering., Results: Coverage of antenatal home visits and newborn care practices were positively correlated with the knowledge level of AWWs and ANMs. Initiation of breastfeeding in the first hour of life (odds ratio 1.97; 95% confidence interval (CI): 1.55-2.49 for AWW, and odds ratio 1.62; 95% CI: 1.25-2.09 for ANM), clean cord care (odds ratio 2.03; 95% CI: 1.64-2.52 for AWW, and odds ratio 1.43; 95% CI: 1.17-1.75 for ANM) and thermal care (odds ratio 2.16; 95% CI: 1.64-2.85 for AWW and odds ratio 1.88; 95% CI: 1.43-2.48 for ANM) were significantly higher among women visited by AWWs or ANMs who had better knowledge compared with those with poor knowledge., Conclusion: CHWs' knowledge is one of the crucial aspects of health systems to improve the coverage of community-based newborn health care programmes as well as adherence to essential newborn care practices at the household level.

Background: Migration from rural areas of India contributes to urbanisation and may increase the risk of obesity and diabetes. We tested the hypotheses that rural-to-urban migrants have a higher prevalence of obesity and diabetes than rural nonmigrants, that migrants would have an intermediate prevalence of obesity and diabetes compared with life-long urban and rural dwellers, and that longer time since migration would be associated with a higher prevalence of obesity and of diabetes., Methods and Findings: The place of origin of people working in factories in north, central, and south India was identified. Migrants of rural origin, their rural dwelling sibs, and those of urban origin together with their urban dwelling sibs were assessed by interview, examination, and fasting blood samples. Obesity, diabetes, and other cardiovascular risk factors were compared. A total of 6,510 participants (42% women) were recruited. Among urban, migrant, and rural men the age- and factory-adjusted percentages classified as obese (body mass index [BMI] >25 kg/m(2)) were 41.9% (95% confidence interval [CI] 39.1-44.7), 37.8% (95% CI 35.0-40.6), and 19.0% (95% CI 17.0-21.0), respectively, and as diabetic were 13.5% (95% CI 11.6-15.4), 14.3% (95% CI 12.2-16.4), and 6.2% (95% CI 5.0-7.4), respectively. Findings for women showed similar patterns. Rural men had lower blood pressure, lipids, and fasting blood glucose than urban and migrant men, whereas no differences were seen in women. Among migrant men, but not women, there was weak evidence for a lower prevalence of both diabetes and obesity among more recent (

This analysis identifies salient features of team management that were critical to the efficiency of program implementation and the effectiveness of behavior change management to promote essential newborn care practices in Uttar Pradesh, India. In May 2003, the Johns Hopkins Bloomberg School of Public Health and King George Medical University initiated a cluster-randomized, controlled neonatal health research program. In less than 2 years, the trial demonstrated rapid adoption of several evidence-based newborn care practices and a substantial reduction in neonatal mortality in intervention clusters. Existing literature involving research program management in resource-constrained areas of developing countries is limited and fails to provide models for team organization and empowerment. The neonatal research project examined in this paper developed a unique management strategy that provides an effective blueprint for future projects. Transferable learning points from the project include emphasizing a common vision, utilizing a live-in field site office, prioritizing character and potential in the hiring process, implementing a learning-by-doing training program, creating tiers of staff recognition, encouraging staff autonomy, ensuring a broad staff knowledge base to seamlessly handle absences, and maintaining the flexibility to change partnerships or strategies.

Background & Objective: Ethambutol (EMB) resistance, thought to be occurring due to mutations in embB gene of Mycobacterium tuberculosis on the rise is a cause of grave concern. The present study was planned to investigate the presence of EMB resistance in M. tuberculosis isolates and to look for prevalent mutations in embB gene., Methods: A total of 591(283 from new and 308 from previously treated cases) sputum samples from the same number of pulmonary tuberculosis cases were cultured. Isolates were tested by 1 per cent proportion method for resistance to isoniazid, rifampicin streptomycin and ethambutol. Minimum inhibitory concentration (MIC) of EMB was measured by absolute concentration method. Ten randomly selected isolates were subjected to single strand conformational polymorphism (SSCP) and direct DNA sequencing to look for mutation in 364 bp segments of embB gene., Results: Of 353 isolates of M. tuberculosis from 591 sputum samples, 62 (17.58%) were resistant to EMB, of which, 16 (25.8%) showed initial resistance and 46 (74.2%) acquired. Mono resistance to EMB was rare. Only two isolates showed resistance to EMB alone. From 62 EMB resistant isolates, 88.7 per cent (55) were resistant to INH, 82.2 per cent (51) to rifampicin and 61.2 per cent (38) were resistant to streptomycin. Co-resistance to isoniazid and rifampicin (multidrug resistant, MDR-TB) with EMB resistance was seen in 41(66.1%) isolates. High level of EMB resistance was seen in 16.5 per cent isolates. SSCP showed altered mobility in 8 of 10 isolates tested. Among the 8 mutants, 4 had known mutations at codon Met 306 being replaced by Val/ Leu. The second most frequent mutation encountered was at codon Phe 287 being replaced by Val, Cys or Leu (novel mutations). Sequence analysis revealed 10 novel mutations in codon 221, 225, 227, 271, 272, 281, 282, 287, 293 and 294 within embB gene., Interpretation & Conclusion: Presence of high frequency of EMB resistance, occurrence of high level EMB resistance, co-existence of MDR-TB with EMB resistance and novel mutations in emb B gene of M. tuberculosis clinical isolates reported highlight the need to work on larger samples to identify the diagnostic marker of EMB resistance in mycobacteria.

Background: In rural India, most births take place in the home, where high-risk care practices are common. We developed an intervention of behaviour change management, with a focus on prevention of hypothermia, aimed at modifying practices and reducing neonatal mortality., Methods: We did a cluster-randomised controlled efficacy trial in Shivgarh, a rural area in Uttar Pradesh. 39 village administrative units (population 104,123) were allocated to one of three groups: a control group, which received the usual services of governmental and non-governmental organisations in the area; an intervention group, which received a preventive package of interventions for essential newborn care (birth preparedness, clean delivery and cord care, thermal care [including skin-to-skin care], breastfeeding promotion, and danger sign recognition); or another intervention group, which received the package of essential newborn care plus use of a liquid crystal hypothermia indicator (ThermoSpot). In the intervention clusters, community health workers delivered the packages via collective meetings and two antenatal and two postnatal household visitations. Outcome measures included changes in newborn-care practices and neonatal mortality rate compared with the control group. Analysis was by intention to treat. This study is registered as International Standard Randomised Control Trial, number NCT00198653., Findings: Improvements in birth preparedness, hygienic delivery, thermal care (including skin-to-skin care), umbilical cord care, skin care, and breastfeeding were seen in intervention arms. There was little change in care-seeking. Compared with controls, neonatal mortality rate was reduced by 54% in the essential newborn-care intervention (rate ratio 0.46 [95% CI 0.35-0.60], p<0.0001) and by 52% in the essential newborn care plus ThermoSpot arm (0.48 [95% CI 0.35-0.66], p<0.0001)., Interpretation: A socioculturally contextualised, community-based intervention, targeted at high-risk newborn-care practices, can lead to substantial behavioural modification and reduction in neonatal mortality. This approach can be applied to behaviour change along the continuum of care, harmonise vertical interventions, and build community capacity for sustained development., Funding: USAID and Save the Children-US through a grant from the Bill & Melinda Gates Foundation.

Background & Objective: Multi-drug resistant (MDR) Mycobacterium tuberculosis isolates may be transmitted within communities due to dense population and poor hygienic conditions. For proper management and control of MDR-TB, understanding drug susceptibility pattern of M. tuberculosis isolates and their transmission pattern in every health care setting are essential. In the present study, we attempted to describe the current prevalence of MDR-TB in Lucknow district, Uttar Pradesh, and our observations on transmission of MDR isolates among populations in and around this area., Methods: Patients diagnosed as that of pulmonary tuberculosis (PTB) were enrolled from primary level (PLH), secondary level (SLH) and tertiary level (TLH) healthcare centres from Lucknow district. Detailed history of intake of antitubercular drug in the past was taken to decipher initial/ acquired drug resistance. Sputum samples were cultured on Lowenstein-Jensen media to isolate mycobacteria. Drug susceptibility patterns of isolated M. tuberculosis isolates were recorded using 1 per cent proportion method. Transmission of MDR isolates in community was accessed by random amplified polymorphic DNA (RAPD). Isolates showing same band pattern on RAPD were retyped using different primers targeted to the inverted repeat sequence of IS6110 copies in M. tuberculosis genome., Results: A total of 686 M. tuberculosis isolates were obtained from 1162 patients, of which 318 were from untreated subjects and 368 were from patients who were treated for tuberculosis in the past. Prevalence of MDR was 19.8 per cent, initial and acquired being 13.2 and 25.5 per cent respectively. Prevalence of resistance to any drug, MDR and individual drug resistance to isoniazid, streptomycin, ethambutol and rifampicin was significantly higher in patients who were treated in the past. Drug resistance was significantly higher at tertiary level health care compared to primary level health care. Genotypically similar clusters were seen at all levels of health care. It was not always possible to establish geographic connections within clusters., Interpretation & Conclusion: High prevalence of both initial and acquired MDR was noted in M. tuberculosis isolates collected from pulmonary tuberculosis patients. Presence of small clusters of MDR isolates at all health care levels suggests transmission within the studied community.

Background: Susceptibility/resistance to Plasmodium falciparum malaria has been correlated with polymorphisms in more than 30 human genes with most association analyses having been carried out on patients from Africa and south-east Asia. The aim of this study was to examine the possible contribution of genetic variants in the TNF and FCGR2A genes in determining severity/resistance to P. falciparum malaria in Indian subjects., Methods: Allelic frequency distribution in populations across India was first determined by typing genetic variants of the TNF enhancer and the FCGR2A G/A SNP in 1871 individuals from 55 populations. Genotyping was carried out by DNA sequencing, single base extension (SNaPshot), and DNA mass array (Sequenom). Plasma TNF was determined by ELISA. Comparison of datasets was carried out by Kruskal-Wallis and Mann-Whitney tests. Haplotypes and LD plots were generated by PHASE and Haploview, respectively. Odds ratio (OR) for risk assessment was calculated using EpiInfotrade mark version 3.4., Results: A novel single nucleotide polymorphism (SNP) at position -76 was identified in the TNF enhancer along with other reported variants. Five TNF enhancer SNPs and the FCGR2A R131H (G/A) SNP were analyzed for association with severity of P. falciparum malaria in a malaria-endemic and a non-endemic region of India in a case-control study with ethnically-matched controls enrolled from both regions. TNF -1031C and -863A alleles as well as homozygotes for the TNF enhancer haplotype CACGG (-1031T>C, -863C>A, -857C>T, -308G>A, -238G>A) correlated with enhanced plasma TNF levels in both patients and controls. Significantly higher TNF levels were observed in patients with severe malaria. Minor alleles of -1031 and -863 SNPs were associated with increased susceptibility to severe malaria. The high-affinity IgG2 binding FcgammaRIIa AA (131H) genotype was significantly associated with protection from disease manifestation, with stronger association observed in the malaria non-endemic region. These results represent the first genetic analysis of the two immune regulatory molecules in the context of P. falciparum severity/resistance in the Indian population., Conclusion: Association of specific TNF and FCGR2A SNPs with cytokine levels and disease severity/resistance was indicated in patients from areas with differential disease endemicity. The data emphasizes the need for addressing the contribution of human genetic factors in malaria in the context of disease epidemiology and population genetic substructure within India.

Background: Stigma and discrimination, particularly in access to healthcare, remains a major problem for people Infected with HIV in most parts of India., Methods: We did a multicentre study (n = 10) with a cross-sectional survey design using a standardized, interviewer-administered questionnaire., Results: A total of 2200 healthcare providers participated. The knowledge, attitude and practice (KAP) related to HIV service delivery were very poor with a mean overall KAP score of only 49.7% (CI: 49.1-50.3). Only 5%, 5% and 1% of the participants scored more than 75% separately for the dimensions of knowledge, attitude and practice, respectively. Only 24.4% and 36.7% of responders knew that HIV screening was not recommended prior to surgery and pre-employment check-up. Many doctors (19.4%) had refused treatment to people living with HIV/AIDS (PLHA) at least some of the time and nearly half (47.2%) identified and labelled them; 23.9% isolated them in separate care areas and 13.3% postponed or changed treatment based on the patient's HIV status. Screening for HIV prior to elective surgery was done by 67% of providers. While 64.7% of responders were aware of the existence of national guidelines on and recommendations for HIV testing, only 38.4% had read the policy document., Conclusion: There is a growing need to provide care, support and treatment to a large number of PLHA. The capacity of healthcare providers must be urgently built up so as to improve their knowledge of and attitude to HIV to enable them to deliver evidence-based and compassionate care to PLHA in various healthcare settings.

Background: Domestic spousal violence against women has far-reaching mental health implications., Aims: To determine the association of domestic spousal violence with poor mental health., Method: In a household survey of rural, urban non-slum and urban slum areas from seven sites in India, the population of women aged 15-49 years was sampled using probability proportionate to size. The Self Report Questionnaire was used to assess mental health status and a structured questionnaire elicited spousal experiences of violence., Results: Of 9938 women surveyed, 40% reported poor mental health. Logistic regression showed that women reporting 'any violence' -- 'slap', 'hit', 'kick' or 'beat' (OR 2.2, 95% CI 2.0-2.5) -- or 'all violence' -- all of the four types of physically violent behaviour (OR 3.5, 95% CI 2.94-3.51) -- were at increased risk of poor mental health., Conclusions: Findings indicate a strong association between domestic spousal violence and poor mental health, and underscore the need for appropriate interventions.

Setting: Out- and in-patient services of the Department of Tuberculosis and Chest Diseases, King George's Medical College, Lucknow, India., Objective: To analyse diagnostic practices for pulmonary tuberculosis (PTB) among doctors of modern medicine and to estimate their association with diagnostic accuracy., Design: A consecutive case series. The diagnostic practices of 518 doctors who had prescribed treatment for PTB to 270 patients were analysed., Results: Almost all of the doctors (99.8%, 95% CI 98.9-100.0) used chest X-ray, while 49.2% (95% CI 44.8-53.6) advised chest X-ray alone for diagnosis of PTB. On the other hand, 50.6% (95% CI 46.2-55.0) performed sputum microscopy while none used it without chest X-ray. Sputum microscopy was used three times more frequently by chest specialists compared with non-chest specialists (81.9% vs. 25.8%, P = 0.0000). Non-utilisation of sputum microscopy was associated with a significantly higher probability of prescribing anti-tuberculosis treatment for PTB in patients with non-tuberculous conditions (odds ratio 5.0; 95% CI 2.72-9.83)., Conclusion: Non-utilisation of sputum smear microscopy and continued reliance on chest X-ray only by up to 49% of practitioners of modern medicine might have serious public health implications. Strategies for their continued medical education and audit of their practices should be implemented without delay.

Setting: Out- and in-patient services of the Department of Tuberculosis and Chest Diseases at King George's Medical College, Lucknow, India., Objective: To analyse the prescribing patterns of allopathic doctors for treatment of new cases of pulmonary tuberculosis (PTB), and to compare their practices with the current national and World Health Organization (WHO) recommendations., Design: A consecutive case series. Tuberculosis treatment practices of 449 primary doctors who had prescribed treatment for PTB to 218 patients were analysed., Results: Thirty-three different drug combination regimens were prescribed by 449 primary doctors. Approximately 45% (95%CI 41.5-49.9) of doctors did not practise the current NTP/WHO recommended drug regimens. Overall 75% (95%C1 70.4-78.8) of doctors made prescription errors with respect to one or more aspects of treatment, including treatment duration (64.5%) and drug dosages (30%). The most frequent prescription error was treatment for longer than necessary (60.2%; 95%CI 55.5-64.8). Overall, both chest specialists and non-chest specialists made prescription errors with almost equal frequency (77.5% vs. 72.2%, P = 0.228). The majority of the doctors (70.2%; 95%CI 65.7-74.5) used fixed-dose formulations of two to four drugs., Conclusion: For effective tuberculosis control, strategies for targeted continuing medical education and auditing of the practices of all doctors need to be implemented without delay.

Alprazolam was evaluated in the treatment of 62 patients of chronic tension type headache using a double blind cross over design with random allocation to drug or placebo. The duration of the trial was 4 months with a 2 week run in period and 2 week washout period separating two treatment periods of 4 weeks each. The patients were followed up for 4 weeks at the completion of the trial. 48 patients completed the trial. There was no significant difference in the overall response rate based in terms of percentage reduction in headache frequency per week, however a significant decrease in headache index was observed during treatment with alprazolam as compared to placebo (P < 0.05). The mean analgesic intake per week was also significantly lower during treatment with alprazolam as compared to the run in period. Side effects were seen in 16.67% patients. In none of the patients was it significant enough to require withdrawal from the study.

The purpose of the present study was to determine the safety and efficacy of induction chemotherapy followed by concomitant chemoradiotherapy. Thirty-eight patients were randomised to receive induction chemotherapy, consisting of cyclophosphamide and methotrexate followed by concomitant 5-fluorouracil and irradiation (study group) or irradiation alone (control group). There were non-significant differences in the initial tumor clearance rates in the two groups. Median disease-free survival (in complete responders) was 17 months (6-60+) vs 11 months (5-60+) (p = 0.407) and overall survival 11 months (1-60+) vs 14 months (2-60+) (p = 0.428) in the study and control groups respectively. Acute morbidity and deaths during intervention were higher in the study group (p = 0.007). This study suggests that induction along with concomitant chemoradiotherapy is too toxic for routine use and also fails to provide a survival benefit.

Nifedipine was evaluated in the prophylaxis of 28 patients each of migraine and tension headache using a double blind cross over design with random allocation to drug or placebo group. The duration of the trial was 3 months with a 2 week run-in period and 2 week wash-oat period separating two treatment periods of 4 weeks each. A satisfactory response was obtained in 71.4% of migraineurs (p < 0.001) and 28.6% of patients with tension headache (p = N.S). Minor side effects were observed in 5 patients. Nifedipine is a useful agent for the management of migraine as it reduces frequency and severity of pain but the drug cannot be recommended for tension headache.

We conducted a placebo controlled randomised clinical trial to evaluate the effects of 6 months therapy with metoprolol on resting and exercise haemodynamics in 31 patients with isolated mitral stenosis in sinus rhythm. Twenty six of them (placebo n = 13, metoprolol n = 13) completed the study protocol. Their mean age was 23.1 +/- 7.9 years and the mean mitral valve area was 0.93 +/- 0.25 cm2. The dose of metoprolol ranged between 50-100 mg per day. The primary outcome variables for the study were the resting and exercise mean pulmonary capillary wedge pressure (PCWP) and cardiac index (CI) and the secondary outcome variables consisted of resting and exercise heart rate, mean pulmonary artery pressure (PAP), mean pulmonary vascular resistance (PVR) and clinical improvement on visual analog scale. These outcome variables were assessed blindly. The resting and exercise mean PCWP (mmHg) increased by 9.1 +/- 3.1 and 16.4 +/- 6.4 on placebo and 2.5 +/- 2.1 and -4.6 +/- 2.3 on metoprolol after 6 months therapy. These differences were statistically significant (p < 0.01). The resting and exercise CI (liters/min/m2) decreased by 0.2 +/- 0.1 and 0.1 +/- 0.1 on placebo and 0.3 +/- 0.5 and 0.3 +/- 1.0 on metoprolol. These haemodynamic effects were accompanied with much better symptomatic improvement in patients treated with metoprolol. The differences in change in mean PAP and PVR in two groups were statistically not significant. Our results suggest that the symptomatic patients with MS, waiting for definitive intervention for 6 months or less, would benefit if given beta blockers during this period.

We conducted a randomised controlled trial to study the effects of metoprolol and diltiazem on the total ischaemic burden--sum of symptomatic and silent myocardial ischaemia, in 146 patients with stable angina pectoris. One-hundred thirty-four completed the study protocol. Sixty-eight patients received metoprolol (100 mg twice daily, n = 52, 50 mg twice daily, n = 16) while 66 received diltiazem (90 mg three times daily, n = 50, 60 mg three times daily, n = 16). The drugs were given for 4 weeks. The primary outcome variables were frequency and duration of total ischaemic burden, silent and symptomatic myocardial ischaemia. These were measured on 48 h of Holter monitoring. The reductions in duration and frequency of total ischaemic burden by metoprolol, 76% and 40%, respectively, were significantly higher than by diltiazem, 43% and 24%, respectively (P < 0.01 and P < 0.02). The frequency and duration of silent myocardial ischaemia, which constituted more than 80% of the total ischaemic burden in the two groups showed similar results. However, the reduction in frequency of symptomatic myocardial ischaemia only was significantly greater by metoprolol (63% than diltiazem (24%) as the difference in reduction of duration of symptomatic ischaemia was insignificant (85% vs. 75%; P > 0.05). Whether a greater reduction of total ischaemic burden by metoprolol as compared to diltiazem has any implications for prognosis in patients with chronic stable angina remains to be established.

One hundred and ninety two consecutive patients with isolated mitral regurgitation (MR) with an audible murmur were studied for determination of etiology. There were 95 males & 97 females (mean age 24.5 +/- 10.8 years; range 13 to 58 years) with 102 patients in NYHA classes I and II, 81 in class III and 9 in NYHA class IV. The etiological grouping was: rheumatic 74 (38.5%), probable rheumatic 28 (15%), mitral valve prolapse 26 (13.5%), dilated cardiomyopathy 15 (8%), infective endocarditis 12 (6%), isochaemic heart disease 10 (5%), miscellaneous group (including rupture chordae tendinae, aortoarteritis etc) 9 (4.5%) and patients with indeterminate etiology 18 (9.5%). Etiology could be determined in 174 out of 192 cases. The clinical methods combined with echocardiography were helpful in 79 cases while echocardiography alone could diagnose etiology in 89 cases. Clinical features alone gave the diagnosis in 6 patients. The findings of gross morphology of the surgically removed mitral valves in 30 patients of this study were similar to their pre-operative etiologic diagnosis based on clinical and echocardiographic features. These findings may be of value in planning treatment and prophylactic strategies in cases of isolated MR.

The influence of the compression state of a model Lung Surfactant Surface Layer LSSL on the oxygen permeation kinetics was studied in vitro at 37 degrees C. In an attempt to mimic in vivo conditions, the oxygen from the air was allowed to cross a dipalmitoylphosphatidylcholine DPPC layer situated at an air/deaerated saline interface in an electrochemical vessel. The time dependent concentration change of the oxygen diffusing through this layer into the deaerated saline hypophase was measured electrochemically using a Hanging Mercury Drop Electrode HMDE, situated at a definite depth in the bulk of the saline. The surface pressure in the monolayer was monitored using a Wilhelmy balance. The oxygen permeability was measured through two differently compressed DPPC layers in which the area/phospholipid molecule differed by 30%. This is consistent with the difference in the alveolar area at the end-points of the compressed and expanded lung. The results, submitted to a linear regression analysis, showed that the DPPC film compression influences the oxygen permeation kinetics. The denser the lipid film, the slower the oxygen uptake by the deaerated hypophase. The results suggest that the LSSL might play an important role in the oxygen transport kinetics, the oxygen permeation through it being dependent on the actual lung area.

We report the results of a randomized controlled trial of intravenous streptokinase in a subset of patients with unstable angina. Seventy-six patients were admitted with prolonged (more than 20 minutes) angina at rest of less than 3 weeks onset. Fifty-two patients continued to have more than 3 episodes of prolonged angina in 48 hours on medical therapy with metoprolol, isosorbide dinitrate, nifedipine and intravenous nitroglycerin. Forty-eight patients consented to enter the study and were randomized into two groups. The first group, of 24 patients, received 1.5 million units of streptokinase infusion and the second group, also of 24 patients, received a placebo. Pain relief within 48 hours was achieved in 19/24 (79.1%) patients after streptokinase infusion as compared to 9/24 (37.5%) of the controls (P less than 0.05). Approximately 90% (17/19) of patients responding to streptokinase therapy were relieved of chest pain within the first six hours as against none in the controls. The incidence of acute myocardial infarction within six months was 12.5% (3/24) in those receiving streptokinase and 25% (6/24) in the controls. Mortality at six months stood at 8.33% (2/24) in the treated patients and 16.6% (4/24) in the controls. Intravenous streptokinase thus appears to be of benefit in patients with angina at rest of recent onset which does not respond to conventional medical therapy.

The acute haemodynamic effects of beta-blockade with propranolol and combined alpha-blockade and beta-blockade with labetalol were compared in a randomised study in 12 patients with coronary artery disease proved by angiography. Propranolol induced significantly greater depression of left ventricular function both at rest and during exercise than labetalol. This difference was probably attributable to the vasodilator activity of labetalol and the associated reduction in afterload offsetting the haemodynamic disadvantages of blockade of cardiac beta-adrenoceptors alone. The haemodynamic advantages of combined alpha-blockade and beta-blockade over beta-blockade alone may thus have therapeutic implications for the use of these treatments in patients with coronary heart disease.

The immediate hemodynamic effects of intravenous frusemide (1 mg/kg) and intravenous isosorbide dinitrate (50-200 micrograms/kg/h) were compared in a prospective, randomized, between-group study in 28 men with radiographic and hemodynamic evidence of left ventricular failure following acute myocardial infarction. The diuresis induced by frusemide reduced the left-heart filling pressure and cardiac output and transiently raised systemic blood pressure. In contrast, isosorbide dinitrate was accompanied by a reduction in systemic blood pressure and peripheral resistance, with the result that the cardiac output was not decreased despite a large fall in the pulmonary vascular and left-heart filling pressures. The results indicate that reduction of excessive preload by venodilatation may be hemodynamically superior to that induced by diuresis in terms of both reducing myocardial oxygen consumption and maintaining peripheral perfusion. The influence of these contrasting treatments on the prognosis of these high-risk patients warrants further study.

The circulatory effects induced by two sequential intravenous treatment programs with a diuretic, arteriolar or venodilator , and a positive inotropic drug were studied in a randomized between-group trial in 20 male patients with radiographic and hemodynamic evidence of left ventricular (LV) failure following acute myocardial infarction (AMI). Furosemide induced a substantial diuresis in both groups of patients, in association with reductions in LV filling pressure (p less than 0.01) and cardiac output (p less than 0.05), without significant change in heart rate or systemic arterial pressure. The addition of isosorbide dinitrate was followed by reductions in the systemic arterial (p less than 0.01) and LV filling pressures (p less than 0.01) without significant change in the heart rate or cardiac output. Hydralazine after furosemide reduced systemic vascular resistance (p less than 0.01), but the fall in mean blood pressure (p less than 0.01) was limited by the increase in cardiac output (p less than 0.01); heart rate was also increased (p less than 0.01) and LV filling pressure fell (p less than 0.05). The final addition of the beta-1 adrenoceptor agonist, prenalterol, increased systemic arterial systolic pressure (p less than 0.05), cardiac output (p less than 0.05), and heart rate (p less than 0.01), and reduced systemic vascular resistance (p less than 0.01) in both groups; these changes were greatest in those pretreated with furosemide and isosorbide dinitrate. In both treatment pathways compared with control the reductions in systemic vascular resistance and left heart filling pressure were accompanied by increases in heart rate and cardiac output without substantial changes in systemic blood pressure. Which of these hemodynamic pathways offers the optimum prognosis awaits further study.

In patients with acute myocardial infarction the haemodynamic relevance of the ancillary pharmacological properties of cardioselectivity and of intrinsic sympathomimetic activity (ISA) possessed by beta-blocking drugs is unclear. The dose-response effects of atenolol and acebutolol, two cardioselective compounds, the latter also possessing a degree of ISA, were therefore compared in a single-blind, dose-response, crossover study in patients within 18 h of suffering an uncomplicated acute myocardial infarction. The logarithmic cumulative dosage schedule achieved plasma concentrations in the clinical therapeutic ranges for both atenolol (0.05 +/- 0.04-0.19 +/- 0.03 micrograms/ml) and acebutolol (0.22 +/- 0.14-0.8 +/- 0.29 micrograms/ml). Incremental doses of intravenous atenolol (cumulative, 1-8 mg) resulted in significant decreases in systolic blood pressure, heart rate, cardiac output, stroke volume, and stroke work index (p less than 0.01 for each). Pulmonary artery occluded pressure (p less than 0.05) and systemic vascular resistance (p less than 0.01) increased. Incremental doses of intravenous acebutolol (cumulative, 10-80 mg) also resulted in significant decreases in systolic blood pressure, heart rate, cardiac output, stroke volume, and stroke work index (p less than 0.01 for each). Systemic vascular resistance increased (p less than 0.01); there was no consistent change in the pulmonary artery occluded pressure. Within the limits of the experimental protocol, the additional property of ISA possessed by acebutolol resulted in no statistically significant haemodynamic differences from atenolol. This may reflect either an insufficient degree of ISA possessed by acebutolol to confirm the original hypothesis, or its haemodynamic irrelevance in the presence of the increased sympathetic tone that is frequently present following acute myocardial infarction.

A double-blind placebo controlled study of angina pectoris with penbutolol was undertaken in parallel groups in fifty-two patients. The duration of the study was six weeks. The dosage range for penbutolol was 8 mg to 50 mg per day. Six patients were dropped from the analysis. Seventeen patients (81%) in the penbutolol series exhibited a 50% reduction in anginal attacks, NTG consumption and subjective improvement. Significant reduction in nitrite intake was observed. Effort tolerance was improved significantly in those receiving penbutolol. Penbutolol was well-tolerated.