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

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

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

AIMS: To identify profiles of type 2 diabetes from continuous glucose monitoring (CGM) data using ambulatory glucose profile (AGP) indicators and examine the association with prevalent complications. METHODS: Two weeks of CGM data, collected between 2015 and 2019, from 5901 adult type 2 diabetes patients were retrieved from a clinical database in Chennai, India. Non-negative matrix factorization was used to identify profiles as per AGP indicators. The association of profiles with existing complications was examined using multinomial and logistic regressions adjusted for glycated hemoglobin (HbA1c; %), sex, age at onset, and duration of diabetes. RESULTS: Three profiles of glycemic variability (GV) were identified based on CGM data—Profile 1 [“TIR Profile”] (n = 2271), Profile 2 [“Hypo”] (n = 1471), and Profile 3 [“Hyper”] (n = 2159). Compared with time in range (TIR) profile, those belonging to Hyper had higher mean fasting plasma glucose (202.9 vs. 167.1, mg/dL), 2-h postprandial plasma glucose (302.1 vs. 255.6, mg/dL), and HbA1c (9.7 vs. 8.6; %). Both “Hypo profile” and “Hyper profile” had higher odds of nonproliferative diabetic retinopathy (“Hypo”: 1.44, 1.20–1.73; “Hyper”: 1.33, 1.11–1.58), macroalbuminuria (“Hypo”: 1.58, 1.25–1.98; “Hyper”: 1.37, 1.10–1.71), and diabetic kidney disease (DKD; “Hypo”: 1.65, 1.18–2.31; “Hyper”: 1.88, 1.37–2.58), compared with “TIR profile.” Those in “Hypo profile” (vs. “TIR profile”) had higher odds of proliferative diabetic retinopathy (PDR; 2.84, 1.65–2.88). CONCLUSIONS: We have identified three profiles of GV from CGM data. While both “Hypo profile” and “Hyper profile” had higher odds of prevalent DKD compared with “TIR profile,” “Hypo profile” had higher odds of PDR. Our study emphasizes the clinical importance of recognizing and treating hypoglycemia (which is often unrecognized without CGM) in patients with type 2 Diabetes Mellitus.

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

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

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

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

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

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

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

The prevalence of mental health concerns is growing worldwide, along with lack of access to and receipt of needed treatment. Current gaps in treatment provision have led to exploring alternative methods of prevention, with research linking nutrition and mental health, of particular relevance in low- and middle-income countries, with a high prevalence of undernutrition.To examine whether exposure to a protein-energy nutritional supplement during the first 1000 d of life decreased odds of mental distress in adulthood among men and women in Guatemala compared with receiving a low energy-no protein supplement or supplementation outside the 1000-d window.Data from participants (n = 1249) in a longitudinal cohort protein-energy supplementation trial (early-life, supplementation data from 1969 to 1977, ages 0-7 y; life course, outcome data from 2017-2018 follow-up, ages 40-57 y) were analyzed for associations between nutrition in the first 1000 d and mental distress in adulthood (WHO Self-Reporting Questionnaire 20 [SRQ-20]), controlling for early-life variables and current life stress; life course variables (e.g. education) were examined as potential mediators of this relation. Generalized linear mixed models and zero-inflated Poisson generalized linear mixed models were utilized.Both partial and full supplementation with Atole during the first 1000 d were associated with 63% (95% CI: 0.16, 0.87) and 56% (95% CI: 0.19, 1.03) lower odds, respectively, of experiencing mental distress in adulthood. Results did not differ by sex. These inverse relations remained relatively unchanged (partial OR = 0.34 [95% CI: 0.14, 0.83]; full OR = 0.38 [95% CI: 0.16, 0.92]) after controlling for early-life and life course variables, including life stress.Protein-energy supplementation during the first 1000 d of life in Guatemala, where undernutrition is prevalent, may reduce the prevalence of later mental distress in adulthood. This effect appears to occur directly, rather than indirectly, through pathways of life course variables such as education, wealth, and marital status.

In this study, we contrast the impacts of surface coating bacterial nanocellulose small-diameter vascular grafts (BNC-SDVGs) with human albumin, fibronectin, or heparin–chitosan upon endothelialization with human saphenous vein endothelial cells (VEC) or endothelial progenitor cells (EPC) in vitro. In one scenario, coated grafts were cut into 2D circular patches for static colonization of a defined inner surface area, in another scenario, they were mounted on a customized bioreactor and subsequently perfused for cell seeding. We evaluated the colonization by emerging metabolic activity and the preservation of endothelial functionality by water soluble tetrazolium salts (WST-1), acetylated low-density lipoprotein (AcLDL) uptake assays, and immune fluorescence staining. Uncoated BNC scaffolds served as controls. The fibronectin coating significantly promoted adhesion and growth of VECs and EPCs, while albumin only promoted adhesion of VECs, but here, the cells were functionally impaired as indicated by missing AcLDL uptake. The heparin–chitosan coating led to significantly improved adhesion of EPCs, but not VECs. In summary, both fibronectin and heparin–chitosan coatings could beneficially impact the endothelialization of BNC-SDVGs and might therefore represent promising approaches to help improve the longevity and reduce the thrombogenicity of BNC-SDVGs in the future.

Objective We study how life course objective socioeconomic position (SEP) predicts subjective social status (SSS) and the extent to which SSS mediates the association of objective SEP with nutritional status and mental health outcomes. Methods We use data from participants of the INCAP Longitudinal Study 1969–2018 (n = 1258) from Guatemala. We use the MacArthur ladder for two measures of SSS - perceived community respect and perceived economic status. We estimate the association of SSS with health outcomes after adjusting for early life characteristics and life course objective SEP (wealth, schooling, employment) using linear regression. We use path analysis to study the extent of mediation by SSS on the health outcomes of body mass index (BMI; kg/m2), psychological distress (using the WHO Self-Reported Questionnaire; SRQ-20) and happiness, using the Subjective Happiness Scale (SHS). Results Median participant rating was 5 [IQR: 3–8] for the perceived community respect and 3 [IQR: 1–5] for the perceived economic status, with no differences by sex. Objective SEP in early life and adulthood were predictive of both measures of SSS in middle adulthood as well as health outcomes (BMI, SRQ-20 and SHS). Perceived community respect (z-scores; 1 z = 3.1 units) was positively associated with happiness (0.13, 95 % CI: 0.07, 0.19). Perceived economic status (z-scores; 1 z = 2.3 units) was inversely associated with psychological distress (−0.28, 95 % CI: −0.47, −0.09). Neither measure of SSS was associated with BMI. Neither perceived community respect nor perceived economic status attenuated associations of objective SEP with health outcomes on inclusion as a mediator. Conclusions Subjective social status was independently associated with happiness and psychological distress in middle adulthood after adjusting for objective SEP. Moreover, association of objective SEP with health was not mediated by SSS, suggesting potentially independent pathways., Highlights • Subjective social status (SSS) is a self-appraisal of one's objective measures of socio-economic position (SEP; such as education and wealth) and social identity relative to their community. • Perceived community respect and perceived economic status were positively associated with happiness and inversely associated with psychological distress respectively. • Neither measure of SSS were associated with body mass index. • The associations of objective SEP measures with health outcomes were not attenuated after adjusting for SSS, suggesting independent pathways.

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

Objectives: India has historically displayed high levels of child stunting and low levels of child overweight. Using newly released data, we evaluated changes in priority indicators of child growth from 2006 to 2019 and examined the role of human development measures in these changes. Methods: We estimated cumulative and annualized changes in state- and district-level child growth indicators using three rounds of National Family Health Surveys (2005-06, 2015-16, 2019-20) in 22 states. Outcomes included stunting, underweight, wasting, and overweight. Human development was measured using a principal components analysis of nine survey-based items. We contrasted expected versus observed changes in district-level growth indicators between 2015 and 2019 based on changes in development measures using two-way Blinder Oaxaca decomposition. Results: From 2006 to 2019, the prevalence of stunting and underweight decreased by 10.9 percentage points (pp) and 7.1 pp, respectively, while the prevalence of wasting and overweight increased by 2.8 pp and 2.2 pp, respectively. Annualized rates of change for stunting, wasting, and underweight were lower from 2015 to 2020 compared with the 2006 to 2015 period, while rates of change in overweight were higher. Simultaneously, all nine human development indicators improved between 2006 and 2020. A unit increase between 2015 and 2020 in the human development score predicted a -4.7 pp (95% CI: - 5.7, -3.6) change in stunting, yet stunting declined by just -0.3 pp. Conclusions: Population-level reductions in child undernutrition have stalled and the rise in child overweight has accelerated between 2015 and 2020 relative to the 10 years preceding this period.

Background Asset-based indices are widely-used proxy measures of wealth in low and middle-income countries (LMIC). The stability of these indices within households over time is not known. Methods We develop a harmonized household asset index using Principal Component Analysis for the participants (n = 2392) of INCAP Longitudinal Study, Guatemala using data from six waves of follow-up over the period of 1965–2018. We estimate its cross-sectional association with parental schooling (in 1967–75) and attained schooling (in 2015–18) of cohort members. We study how patterns of cross-sectional loadings change over time and between urban-rural settings. We assess its robustness to omission of assets or study waves and alternate specifications of factor extraction procedure (exploratory factor analysis, multiple correspondence analysis). Results The harmonized index constructed using 8 assets and 11 housing characteristics explained 32.4% of the variance. Most households increased in absolute wealth over time with median wealth (25th percentile, 75th percentile; households) increasing from − 3.74 (− 4.42, − 3.07; 547) in 1967 to 2.08 (1.41, 2.67; 1145) in 2017–18. Ownership of television, electricity, quality of flooring and sanitary installation explained the largest proportion of variance. The index is positively associated with measures of schooling (maternal: r = 0.16; paternal: r = 0.10; attained: r = 0.35, all p Conclusion A temporally harmonized asset index constructed from consistently administered surveys in a cohort setting over time may allow study of associations of life-course social mobility with human capital outcomes in LMIC contexts. The approach permits exploration of trends in household wealth of the sample over a follow-up period against repeated cross-sectional surveys which permit the estimation of only the mean trajectory.

Background Wealth mobility, as both relative (positional) and absolute (material) wealth acquisition, may counteract negative consequences of early life adversities on adult health. Methods We use longitudinal data (1967–2018) from the INCAP birth cohort, Guatemala (n = 1386). Using wealth as a measure of socio-economic position, we assess the association of life course relative mobility using latent class analysis and absolute material gains using conditional wealth measures. We estimate associations of wealth mobility with indicators of human capital, specifically height, weight status (BMI in kg/m2), psychological distress (WHO SRQ-20 score) and fluid intelligence (Ravens Progressive Matrices score; RPM) in middle adulthood. Results We identified four latent classes of relative mobility – Stable Low (n = 498), Stable High (n = 223), Downwardly Mobile (n = 201) and Upwardly Mobile (n = 464). Attained schooling (years) was positively associated with membership in Upwardly Mobile (odds ratio; 1.50, 95%CI: 1.31, 1.71) vs Stable Low, and inversely with membership in Downwardly Mobile (0.65, 95%CI: 0.54, 0.79) vs Stable High. Being Upwardly Mobile (vs Stable Low) was positively associated with height (1.88 cm, 95%CI: 1.04, 2.72), relative weight (1.32 kg/m2, 95%CI: 0.57, 2.07), lower psychological distress (−0.82 units, 95%CI: 1.34, −0.29) and fluid intelligence (0.94 units, 95%CI: 0.28, 1.59). Being Downwardly Mobile (vs Stable High) was associated with lower fluid intelligence (−2.69 units, 95%CI: 3.69, −1.68), and higher psychological distress (1.15 units, 95%CI: 0.34, 1.95). Absolute wealth gains (z-scores) from early to middle adulthood were positively associated with relative weight (0.62 kg/m2, 95%CI: 0.28, 0.96), lower psychological distress (−0.37 units, 95%CI: 0.60, −0.14) and fluid intelligence (0.50 units, 95%CI: 0.21, 0.79). Conclusions Higher attained schooling provided a pathway for upward relative mobility and higher absolute wealth gains as well as protection against downward relative mobility. Upward mobility was associated with lower psychological distress and higher fluid intelligence but also higher weight status., Highlights • Early life wealth and educational attainment are associated with upward wealth mobility, both in relative and absolute terms. • Upward relative mobility is associated with lower psychological distress, and higher fluid intelligence and BMI. • Downward relative mobility is associated with lower fluid intelligence, lower height, and higher psychological distress. • Wealth gains from early to middle adulthood were associated with higher BMI and intelligence and lower psychological distress.

Chest tube thoracostomy is a standard procedure in every intensive care unit. Although it is regarded as a safe procedure in experienced hands, rare complications do occur. This report describes iatrogenic perforation of the left ventricle after placement of an intercostal catheter and the successful surgical management of this injury. Various operative situations that may arise in relation to iatrogenic perforation of the left ventricle are also discussed, as well as steps to manage this potentially life-threatening complication.

BACKGROUND Anemia prevalence in India remains high despite preventive iron supplementation programs. Consequently, concurrent national policies of iron fortification of staple foods have been initiated. OBJECTIVES This study evaluated the relation between dietary iron intake and anemia (hemoglobin

Objectives: Minimally invasive extracorporeal circulation circuits provide several advantages compared to conventional extracorporeal circulation circuits. We compared the results of a minimally invasive extracorporeal circulation system with those of conventional extracorporeal circulation system, in patients undergoing isolated coronary artery bypass grafting. Methods: We identified 753 consecutive patients who underwent coronary artery bypass grafting at our centre between October 2014 and September 2016. These patients were divided into two groups: a minimally invasive extracorporeal circulation group (M, n = 229) and a conventional extracorporeal circulation group (C, n = 524). Baseline parameters, details of cardiac surgery as well as postoperative complications and outcomes were compared by means of a propensity-matched analysis of 180 matched pairs. Results: The median EuroSCORE II was 1.3%. Transfusion requirement of packed red blood cells (p = 0.002) was lower in Group M compared to conventional extracorporeal circulation systems. There were no differences in hospital mortality or in rates of adverse events between the matched groups. Total in-hospital mortality of the cohort was 1.7%. Conclusion: The use of minimally invasive extracorporeal circulation is associated with a significantly lower use of blood products after isolated coronary revascularisation. There were no differences concerning duration of surgery, complication rates and mortality between the groups. Therefore, the application of minimally invasive extracorporeal circulation systems should be considered as preferred technique in isolated coronary artery bypass grafting procedures.

Background In India, the prevalences of stunting and anemia have declined in the last decade, but continue to remain high in many regions, whereas those of overweight and obesity have increased in all age and socioeconomic groups. Determining whether these forms of malnutrition cluster is important for the development of appropriate interventions. Objectives Our objective was to describe the prevalence of a comprehensive list of dual burdens of malnutrition in individuals and households across the 36 states and 640 districts of India. Methods We analyzed data from the National Family Health Survey-4, 2015-2016, including 655,156 women aged 15-49 y and 145,653 children aged 6-59 mo in India. We measured the coexistence of 19 combinations of women's anemia, underweight, and overweight and children's stunting, underweight, overweight, and anemia at the individual and household levels. We aggregated this information to the state (n = 36) and district (n = 640) levels. We examined whether the observed dual burden prevalence exceeded the expected prevalence, and whether any such excess was related to household wealth. Results Of the 19 dual burdens examined, 8 had significant excess prevalence at the state level and 5 had significant excess prevalence at the district level. All but 1 of these instances reflected an excess dual burden of undernutrition as opposed to clustering of overweight with a form of undernutrition. Household wealth was not positively associated with any clustering of burdens. Conclusions While dual burdens of anemia, stunting, and underweight are prevalent, there is no evidence of clustering of overweight with other forms of malnutrition in India.

Left ventricular rupture, also called atrioventricular disruption, remains a rare but lethal complication of mitral valve replacement. Available measures for preventing such a complication are limited to preservation of the posterior mitral leaflet and avoidance of overzealous decalcification of the annulus. Moreover, these strategies are not always feasible when annular calcifications prevent proper suture placement or when an abscess involves the mitral annulus. This report describes a surgical technique practiced in our clinic (Department of Cardiothoracic Surgery, University Hospital, Otto-von-Guericke-University, Magdeburg, Germany) that can be used in such high-risk patients to avoid left ventricular rupture.