An assessment of atmospheric concentrations and spatiotemporal variation of BTEX and associated pollutants in India.

Benzene, toluene, ethylbenzene, and xylene (BTEX) pollution poses a serious threat to public health and the environment because of its respiratory and neurological effects, carcinogenic properties, and adverse effects on air quality. BTEX exposure is a matter of grave concern in India owing to the growing vehicular and development activities, necessitating the assessment of atmospheric concentrations and their spatial variation. This paper presents a comprehensive assessment of ambient concentrations and spatiotemporal variations of BTEX in India. The study investigates the correlation of BTEX with other criteria pollutants and meteorological parameters, aiming to identify interrelationships and diagnostic indicators for the source characterization of BTEX emissions. Additionally, the paper categorizes various regions in India according to the Air Quality Index (AQI) based on BTEX pollution levels. The results reveal that the northern zone of India exhibits the highest levels of BTEX pollution compared to central, eastern, and western regions. In contrast, the southern zone experiences the least pollution with BTEX. Seasonal analysis indicates that winter and post-monsoon periods, characterized by lower temperatures, are associated with higher BTEX levels due to the accumulation of localized emissions. When comparing the different zones in India, high traffic emissions and localized activities, such as solvent use and solvent evaporation, are found to be the primary sources of BTEX. The findings of the current study aid in source characterization and identification, and better understanding of the region's air quality problems, which helps in the development of focused BTEX pollution reduction and control strategies.

Coexistence of Pulmonary Thromboembolism, Pulmonary Tuberculosis and Granulomatosis with Polyangiitis: A flimsy triple dribble.

Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease with multi-system involvement. It involves the upper respiratory tract, lungs and kidneys. A 36-year-old female patient presented to a tertiary care referral hospital in Central India in 2023 with complaints of low-grade fever, dry cough and loss of appetite initially followed by dyspnoea, purpuric skin lesions, right lower limb swelling with pain and redness. Her chest radiograph revealed right upper lobe cavitary lesion with consolidation in the right lower lobe. Mycobacterium tuberculosis was detected in sputum and broncho alveolar lavage via cartridge based nucleic acid amplification assay. Later, computed tomography pulmonary angiography revealed bilateral pulmonary artery thromboembolism. Furthermore, her cytoplasmic-antineutrophil cytoplasmic antibody test was positive, serum creatinine was rising, urine microscopy had red cell casts and lower limb venous doppler revealed deep venous thrombosis. Histopathological examination of the skin lesion revealed vasculitis. Based on these findings, the patient was diagnosed with GPA. The patient improved with pulse steroids, cyclophosphamide, anticoagulants and anti-tuberculous therapy.

What enhances the quality of death and dying? A perspective from patients with terminal cancer.

AIM: This study aimed to determine which factors improve the quality of dying and death from the point of view of patients with cancer who are nearing the end of their lives. The goal was to find out what they think are necessary conditions for a good death and how they would like to be cared for and supported at the end of their lives. METHODS: This study used an exploratory research approach. Purposive sampling was used to select 21 participants from two hospices in Bengaluru and Hyderabad (Karunashraya and Sparsh), and Karnataka Cancer Hospital in Bangalore, India. Semi-structured interviews were undertaken to obtain data from the patients. Thematic analysis was used to examine the data. RESULTS: Four themes were identified: 1) Spirituality and religiosity, 2) socioemotional support, 3) Breaking silence about the stage of the disease and 4) Preparation for and embracing death. There were distinct sub-themes within some of these that were highlighted using quotes from the participants. CONCLUSIONS: The study provided a comprehensive understanding of end-of-life care, the criteria for a high-quality end of life, strategies for achieving it, and the quality of the dying process and death in advanced cancer patients. Studying patients' experiences will help inform a more robust intervention strategy and action plan to improve the quality of end-of-life care in the Indian community.

Effectiveness of 675-nm Wavelength Laser Therapy in the Treatment of Androgenetic Alopecia Among Indian Patients: Clinical Experimental Study.

BACKGROUND: Androgenetic alopecia (AGA) is the most prevalent cause of hair loss around the world. OBJECTIVE: The purpose of this study was to evaluate the efficacy of laser stimulation with a 675-nm wavelength for the treatment of AGA in male and female Indian patients. METHODS: A total of 20 Indian healthy patients aged 23-57 years who presented a grade of alopecia stage I to stage V underwent one single pass with a 675-nm laser to the scalp area twice a week for a total of 8 sessions, followed by once a week for 4 sessions and once in 2 weeks for 2 sessions. There are 14 laser treatments in total. Macro- and dermatoscopic images have been acquired at T0 (baseline) and T1 (4 months). The vertex, frontal, and parietal areas of the scalp were evaluated. Many parameters were analyzed including hair count and hair density of terminal; mean thickness; vellus follicles; total follicular units; units with 1 hair, 2 hairs, 3 hairs, 4 hairs, and >4 hairs; unit density; and average hair/unit. RESULTS: The macroimages and dermatoscopic evaluations showed good improvement over the entire treated area, with a clear increase in the number of hairs and hair thickness. General parameters such as hair count and hair density showed a percentage increase of around 17%. The hair mean thickness parameters showed a significant (P<.001) percentage increase of 13.91%. Similar results were obtained for terminal and vellus hair: terminal hair count and hair density significantly (P=.04 and P=.01, respectively) increased by 17.45%, vellus hair count increased by 16.67% (P=.06), and the density of vellus hair increased by 16.61% (P=.06). CONCLUSIONS: The study findings demonstrate that the 675-nm laser system improved AGA in Indian patients, facilitating the anagen phase and improving hair density and other positive hair parameters.

Economic burden of suicide deaths in India (2019): a retrospective, cross-sectional study.

Background: India has the highest number of suicide deaths in the world. Suicide prevention requires policy attention and resource allocation. Evidence of economic losses due to disease burden can influence such allocations. We assessed the economic burden and its distribution across states and demographic groups in India. Methods: We used the human capital approach in this retrospective cross-sectional analysis to assess the economic burden of suicide in India for the year 2019 for 28 Indian states and 3 union territories (UTs). We calculated the monetary value for the years of life lost disaggregated by states, age groups, and sexes. For sensitivity, we present a library of estimates using different discount rates, life expectancy thresholds, and estimates specific to the populations that can participate in the workforce. Findings: The national economic burden of suicide was US$ 16,749,079,455 (95% Uncertainty Interval: 11,913,034,910-22,404,233,468). The top three states, Karnataka, Tamil Nadu, and Maharashtra, contributed to 44.82% of the total burden in India. The age group 20-34 years had the largest suicide burden and contributed to 53.05% of the overall national economic burden (US$ 8,885,436,385 [6,493,912,818-11,694,138,884]). Twenty states and UTs had a greater economic burden for females than males. Interpretation: The current analysis ascertains a high economic burden of suicide among the Indian youth and females, necessitating concerted multisectoral efforts and immediate investments. Funding: None.

Persistently high HIV incidence among men who have sex with men and people who inject drugs attending integrated care centres in India: a longitudinal assessment of clinic-based data.

INTRODUCTION: Globally, there have been significant declines in HIV incidence over the past two decades, but this decline is slowing, and in some settings, declines have stalled or are growing-particularly where epidemics are concentrated in key populations (KPs). Understanding temporal changes in HIV incidence among KP is critical yet, due to logistical constraints, there are few sources of longitudinal incidence data, particularly among KP. METHODS: We present HIV incidence rates from June 2014 to December 2022 among cisgender men who have sex with men (MSM) and people who inject drugs (PWID) attending community-based integrated care centres (ICCs) in 15 Indian cities. ICCs, established between 2014 and 2017, provide HIV testing and other services to MSM (eight sites) or PWID (eight sites). Client HIV testing data were included in the analysis if they had ≥2 tests and were not positive on the first test. We calculated incidence rates per 100 person-years (PY), stratified by KP, city/site and year. Poisson regression explored associations of incidence with time, age, gender (PWID only) and ICC use. RESULTS: From June 2014 to December 2022, 13,501 clients (5722 MSM, 7779 PWID) had ≥2 HIV tests over a median of 1.8 years. There were a total of 1093 incident HIV acquisitions. Overall incidence rates for MSM and PWID were 1.9/100 PY (95% CI: 1.7-2.2) and 4.1 (3.9-4.4), respectively. Among MSM sites, incidence ranged from 0.4 to 3.5 and in PWID sites from 0.6 to 17.9. From adjusted models, incidence increased by 17% annually among MSM. Among PWID, incidence increased by 11% annually up until 2020 and then decreased by 29% after 2020; when excluding the outlier of New Delhi, incidence was stable among PWID. MSM and PWID 21-25 years old had the highest risk of HIV and among PWID, those more consistently engaged in medication for opioid use disorder were at the lowest risk. CONCLUSIONS: While there was substantial geographic variability, MSM and PWID engaged in a free community-based clinic experienced persistently high HIV incidence (>2/100 PY). KP in low- and middle-income countries should be a focus when considering novel strategies such as long-acting pre-exposure prophylaxis to curtail incidence.

Minimum dietary diversity is associated with lower risk of childhood underweight: Evidence from the 2019/2021 National Family Health Survey of India.

A lack of consumption of a diversified diet is associated with poor physical and cognitive development in children. Evidence on the relationship between minimum dietary diversity (MDD) and childhood malnutrition remains inconclusive in India. We hypothesized that children aged 6 to 23 months on a diversified diet (five out of eight defined foods and beverages) are less likely to be malnourished (stunting, wasting, and underweight) compared to their counterparts who are not on a diversified diet. This cross-sectional study was based on the 2019-2021 National Family Health Survey of India, comprising a weighted sample of 57,714 children aged 6 to 23 months. Multilevel logistic regression was conducted for data analysis. The results showed a significant protective effect of dietary diversity on underweight (odds ratios [OR] = 0.91; 95% confidence intervals [CI]: 0.86-0.96). In addition, children who did not consume eggs (OR = 1.09; 95% CI; 1.03-1.15), dairy products (OR = 1.22; 95% CI: 1.17-1.27), or fruits and vegetables (OR = 1.11; 95% CI: 1.06-1.17) were more likely to be underweight than children who did. Children who did not consume dairy products, fruits, and vegetables were also more likely to be stunted and wasted. However, we did not find significant associations of MDD with wasting and stunting. Nutritional interventions promoting daily consumption of dairy products, eggs, fruit, and vegetables are recommended to address the growing problem of childhood malnutrition in India. Regions with higher rates of malnutrition and those lacking MDD, such as Uttar Pradesh and Rajasthan, should be prioritized.

A Systematic Review and Meta-Analysis to Develop a Landscape Map of Antibiotic Resistance for Six WHO Priority Pathogens in East and North-East India from 2011 to 2022.

BACKGROUND: Determining regional patterns of antimicrobial resistance to bacterial infections in the healthcare setting (AMR) identifies surveillance gaps and informs policies for mitigation. We estimated the prevalence of AMR for six WHO priority pathogens in diagnostic and surveillance samples in the twelve east and north-east Indian states from 2011 to 2022 (PROSPERO ID: CRD42021278961). METHODS: Studies were searched on Medline, Scopus, and Web of Science. Observational, descriptive, and cross-sectional studies, reporting AMR based on laboratory diagnostics, in individuals from east and north-east India from 2011 to 2022 were included. Four reviewers in pairs conducted abstract, full-text screening, and data extraction. We estimated the prevalence of resistance in fifty-four pathogen-antibiotic combinations, and six antibiotic resistance patterns. Pooled estimates of prevalence (Ɵ), heterogeneity (I2), and 95% confidence intervals were calculated using the random effects model. RESULTS: Fifty-five studies were included. Information was available for nine states, none from Arunachal Pradesh, Mizoram, and Nagaland. E. coli was most frequently isolated (59.2%, 95% CI: 48.8-69.6%), followed by S. aureus (36.2%, 95% CI: 20.2-52.2%), Enterococcus (27.5%, 95% CI: 11.2-43.7%), Klebsiella (25%, 95% CI: 15-35%), Acinetobacter (15.7%, 95% CI: 2.3-29.1%) and Pseudomonas aeruginosa (15.7%, 95% CI: 4.1-27.3%). There was high prevalence of ESBL (45%, 95% CI: 35-55%) and carbapenem resistance (30%, 95% CI: 22-38%). AmpC (23%, 95% CI: 9-37%) and colistin resistance was lower (10%, 95% CI: 0-22%) but supporting data was limited. Overall prevalence of MRSA was 26% (95% CI: 14-39%), and VRE was 9% (95% CI: 0-17%). CONCLUSION: High prevalence of resistance was seen to all first-line antibiotics. Gram positive bacteria had high resistance to penicillins, and Gram negatives to third-generation cephalosporins, beta-lactam/beta-lactamase inhibitors, and carbapenems. Aminoglycosides, fluoroquinolones and trimethoprim-sulphamethoxazole resistance was common across all genera. Critical regional AMR information gaps exist.

Sex Differences in the Associations Between Chronic Diseases and Insomnia Symptoms Among Older Adults in India.

Background: Sleep problems are a critical issue in the aging population, affecting quality of life, cognitive efficiency, and contributing to adverse health outcomes. The coexistence of multiple diseases is common among older adults, particularly women. This study examines the associations between specific chronic diseases, multimorbidity, and insomnia symptoms among older Indian men and women, with a focus on the interaction of sex in these associations. Methods: Data were drawn from 31,464 individuals aged 60 and older in the Longitudinal Ageing Study in India, Wave-1 (2017-18). Insomnia symptoms were assessed using four questions adapted from the Jenkins Sleep Scale (JSS-4), covering difficulty falling asleep, waking up, waking too early, and feeling unrested during the day. Multivariable logistic regression models, stratified by sex, were used to analyze the associations between chronic diseases and insomnia symptoms. Results: Older women had a higher prevalence of insomnia symptoms than men (44.73% vs 37.15%). Hypertension was associated with higher odds of insomnia in both men (AOR: 1.20) and women (AOR: 1.36). Women with diabetes had lower odds of insomnia (AOR: 0.80), while this association was not significant in men. Neurological or psychiatric disorders, stroke, and bone and joint diseases were linked to higher odds of insomnia in both sexes. Chronic lung disease was associated with insomnia in men (AOR: 1.65), but not in women. Additionally, having three or more chronic diseases significantly increased the odds of insomnia in both men (AOR: 2.43) and women (AOR: 2.01). Conclusion: Hypertension, bone and joint diseases, lung diseases, stroke, neurological or psychiatric disorders, and multimorbidity are linked to insomnia symptoms in older Indian adults. Disease-specific management and routine insomnia screening are crucial for promoting healthy aging in this vulnerable population.

Prevalence, Clinico-Laboratory Features and Outcomes of Paediatric Scrub Typhus Cases in a Tertiary Care Centre in Eastern India: A prospective observational study.

Objectives: Scrub typhus is the most common rickettsial disease in India, caused by Orientia tsutsugamushi and transmitted by chigger mites. Previously prevalent in South India, a resurgence of scrub typhus cases has recently affected Eastern India. This study aimed to estimate the prevalence and describe the clinico-laboratory profile of scrub typhus in paediatric patients (1-12 years old) living in Eastern India. Methods: This prospective observational study was conducted from January to December 2019 at the Dr B C Roy Post Graduate Institute of Paediatric Sciences, Kolkata, India. All acute undifferentiated cases of febrile illness, in patients aged between 1-12 years, were tested using scrub typhus serology by ELISA. Demographic details, clinical features, laboratory findings, complications and treatment outcomes of these scrub typhus patients were extracted and analysed. Results: Out of 1,473 patients with acute febrile illness, 67 (4.5%) children were diagnosed with scrub typhus. The mean age of the selected patients was 5.22 ± 3.05 years, and the majority (64.2%) had been running a fever since the preceding 7-14 days. Gastrointestinal symptoms such as vomiting (43.3%) and abdominal pain (32.8%) were most frequently observed. Major clinical signs of scrub typhus were hepatomegaly (41.8%) and splenomegaly (31.3%). Complications were observed in 74.6% of patients, with thrombocytopenia (40.3%) and meningoencephalitis (29.9%) occurring more frequently. The case fatality rate of the study sample was 1.5%. Conclusion: Classical eschar was absent in three-fourth of the studied patients. Hence, this study advocates laboratory scrub typhus tests for all suspected cases in the endemic region (Eastern India). Prompt treatment with doxycycline and/or azithromycin could prevent complications such as thrombocytopenia/meningoencephalitis and reduce mortality.

Experience of health care utilization for inpatient and outpatient services among older adults in India.

Background: Patient experiences have not been documented at all India level among older adults for inpatient and outpatient services. We provide all-India and sub national estimates on six domains of patient experience, namely: waiting time, respectful treatment, clarity of explanation provided, privacy during consultation, treated by provider of choice, and cleanliness of facility. Methods: Unit records of adults aged 45 years and above for their inpatient (n = 4330) or outpatient (n = 33,724) service use were assessed from the Longitudinal Ageing Survey of India (LASI), conducted in 2017-18. We identified patient experience as negative if the respondent rated it as either "Bad" or "Very Bad" on a five-point Likert scale. We computed proportion of negative experience by socio-economic status, geographic location, and type of healthcare facilities. We used binary logistic regression to estimate predictors of negative patient experience, and a three-level logistic regression model to partition the total geographic variation of patient experiences. Findings: Most individuals rated their experience in all six domains as "Good". Negative experiences were higher among patients who used public facilities, specifically for waiting time and cleanliness of facility. Among inpatients, the higher-than-average negative experience was noted in the north and northwest, while among outpatients, it was higher in the northeast. The largest geographic variation in negative patient experience was attributable to the villages/CEBs for all domains in outpatient services and three domains of inpatient services, whereas states accounted for the other three inpatient domains. Interpretation: Majority of older adults rated their experience of healthcare use positively, but less for public health facilities.

Individual-level determinants of breast and cervical cancer screening and early testing in two regionally representative urban Indian populations.

Introduction: Region-specific data on individual factors associated with uptake of breast and cervical cancer screening or early testing in diverse Indian populations are limited. Aim: To assess the prevalence and individual determinants of uptake of breast and/or cervical cancer screening or testing among women aged 30-69 years in regionally representative populations of two large Indian cities: New Delhi and Chennai. Methods: We conducted an analysis of the cross-sectional data (2016-2017) nested within the Centre for Cardiometabolic Risk Reduction in South Asia cohort, established in 2010-2011 with 12,271 participants (5365 in New Delhi; 6906 in Chennai). Among 3310 women participants, we evaluated the associations of demographic, socioeconomic, lifestyle, medical, psychosocial, and reproductive factors with breast and/or cervical cancer screening or testing using multivariable logistic regression models with results expressed as adjusted odds ratios (OR) and 95% confidence intervals (CI). Results: At any point prior to 2016-2017, 193 women self-reported having undergone evaluations for breast and/or cervical cancer. The reasons for evaluation were 'general examination' or 'physician's advice' (i.e., screening) or 'being symptomatic' (i.e., early testing). The overall prevalence was 5.8% for screening or testing and 2.5% for screening alone. Formal education (OR:1.88; 95% CI:1.12-3.15), high monthly household income (OR:2.27; 95% CI:1.59-3.25) and less 'fear-of-judgement' (OR:1.65; 95% CI:1.05-2.58) were positively associated with screening or testing uptake. When screening uptake was analysed separately, the results were generally similar. Conclusion: Our findings may have important implications for interventions at community-level (e.g., reducing 'fear-of-judgement', increasing awareness to screening programs and early symptoms) and health-system level (e.g., opportunistic screening).

Exploring the link between eustress and adolescent health in India: An empirical study.

BACKGROUND: Modern psychological research challenges the conventional view of stress as solely detrimental by introducing the concept of eustress versus distress, emphasizing the potentially positive aspects of stress. In the context of India, limited studies have investigated the distinct effects of eustress and distress on adolescents, a group prone to stress-related health issues. This study aims to bridge this gap by examining the correlation between eustress and both mental and physical well-being among adolescents attending government schools in two districts of Haryana, India. MATERIALS AND METHODS: A non-experimental quantitative research approach was adopted to achieve this objective. The study involved a sample of 400 adolescent students, equally split between genders, aged 15 to 18 years, enrolled in grades 10 to 12. Participants were selected through systematic random sampling from two districts in Haryana. The assessment tools employed in the study included the Post Graduate Institute Health Questionnaire and the Eustress Scale, which were utilized to evaluate the participants' mental, physical, and eustress levels. RESULTS: In our study involving Indian adolescents, we discovered a substantial positive correlation (r = 0.563, P < 0.01) between eustress and mental health, underlining the valuable role of positive stress in enhancing psychological well-being. Notably, male participants exhibited significantly higher eustress scores (mean = 26.63) than their female counterparts (mean = 22.82, P < 0.01), indicating gender-specific variations in stress responses. Furthermore, our findings emphasized the influence of cultural nuances inherent to the Indian context on how adolescents perceived and experienced eustress. These outcomes emphasize the urgency of culturally sensitive interventions to promote adolescents' well-being. CONCLUSION: This investigation contributes valuable insights into the nexus between eustress and adolescent health in the Indian context. The study accentuates the potential advantages of leveraging eustress to foster positive development by underlining the differential influence of eustress and distress on adolescent health. Future research endeavors and policy formulation could delve into the mechanisms underpinning eustress and distress, thus guiding strategies to enhance adolescents' health and overall well-being.

Lessons Pharmacy Practice in India Should Adopt From Advanced Nations: A Review.

In India, pharmacy practice is still at a developing stage with the majority of the graduates taking the industry pathway. Currently, there are only a few pharmacists who have been board-certified by the Board of Pharmacy Specialities (BPS), which is the most established pharmacist board certification program globally. Even though India is the largest global exporter of generic medications, pharmacy practice is yet to gain stronghold within its healthcare scenarios. In this article, we aim to examine the development of pharmacy practice from a global viewpoint and scale down to the recent modern practice, particularly in advanced nations. Furthermore, we assess the ways through which pharmacy practice can be enhanced in India. Notably, with several pharmacy practice graduates completing their studies in India yearly, pharmacy practice is projected to significantly grow in the coming years. Gaining a proper understanding of and embracing advanced clinical pharmacy practices will improve the domain of pharmacy practice among both junior and senior pharmacists. Moreover, enrolling in and receiving international accreditations such as the Board of Pharmacy Specializations (BPS) will validate the practice standards being offered in India as compared to other developed countries, i.e., the US. The main objective of this review is to assess various means through which pharmacy practice can be improved in India.

Incidence of Kawasaki disease among children in Chandigarh, India during 2015-2019: a trend analysis.

Background: Only limited information exists regarding the epidemiology of Kawasaki disease (KD) in low-income and middle-income countries. The present study provides the incidence of KD during 2015-2019 in Chandigarh, north India. Our centre follows the largest KD cohort in India. Methods: Children with KD at Chandigarh diagnosed during January 2015-December 2019 were enrolled in the study. Annual incidence rates were determined using decadal growth rates of the National Census 2011. We computed the incidence of KD in children aged <5, and <15 years. We also undertook linear trend analysis using our incidence data from 1994 to 2019. Findings: During 2015-2019, 83 patients (66 males, 17 females) were diagnosed with KD in Chandigarh. Incidence rates during these 5 years were 5.64, 9.25, 9.11, 9.87, and 9.72/100,000 in children aged <5 years, and 2.65, 4.44, 3.86, 5.07, 4.74/100,000 in children aged <15 years. The median age at diagnosis was 48 months (range: 12 days to 15 years). Compared to previous data (2009-2014), there was a 53.1% increase in annual incidence of KD in children aged <5 years, and a 53.7% increase in children aged <15 years. Coronary artery abnormalities during acute phase were noted in 16.9%, and in 7.2% of patients at 6 weeks of follow-up. The trend analysis indicated a monthly rise of 0.002 cases per 100,000 children aged <5 years, and 0.0165 cases per 100,000 children aged <15 years. Interpretation: The incidence of KD has continued to show an upward trend in Chandigarh over the period 2015-2019. This may indicate a true rise in the occurrence of KD or may reflect better disease ascertainment as a result of greater awareness about KD amongst healthcare professionals. Funding: None.

Trends and determinants of the use of episiotomy in a prospective population-based registry from central India.

BACKGROUND: Findings from research and recommendations from the World Health Organization favor restrictive use of episiotomy, but whether this guidance is being followed in India, and factors associated with its use, are not known. This study sought to document trends in use of episiotomy over a five-year period (2014-2018); to examine its relationship to maternal, pregnancy, and health-system characteristics; and to investigate its association with other obstetric interventions. METHODS: We conducted a secondary analysis of data collected by the Maternal Newborn Health Registry, a prospective population-based pregnancy registry established in Central India (Nagpur, Eastern Maharashtra). We examined type of birth and use of episiotomy in vaginal deliveries from 2014 to 2018, as well as maternal and birth characteristics, health systems factors, and concurrent obstetric interventions associations with its use with multivariable Poisson regression models. RESULTS: During the five-year interval, the rate of episiotomy in vaginal birth rose from 13 to 31% despite a decline in assisted vaginal birth. Associations with episiotomy were found for the following factors: prior birth, multiple gestations, seven or more years of maternal education, higher gestational age, higher birthweight, delivery by an obstetrician (as compared to midwife or general physician), and birth in hospital (as compared to clinic or health center). After adjusting for these factors, year over year rise in episiotomy was significant with an adjusted incidence rate ratio (AIRR) of 1.10 [95% confidence interval (CI) 1.08-1.12; p = 0.002]. We found an association between episiotomy and several other obstetric interventions, with the strongest relationship for maternal treatment with antibiotics (AIRR 4.23, 95% CI 3.12-5.73; p = 0.001). CONCLUSIONS: Episiotomy in this population-based sample from central India steadily rose from 2014 to 2018. This increase over time was observed even after adjusting for patient characteristics, obstetric risk factors, and health system features, such as specialty of the birthing provider. Our findings have important implications for maternal-child health and respectful maternity care given that most women prefer to avoid episiotomy; they also highlight a potential target for antibiotic stewardship as part of global efforts to combat antimicrobial resistance. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov under reference number NCT01073475.

Episiotomy is a surgical procedure to widen the vaginal opening for childbirth. It was once commonly used worldwide. However, because the procedure can cause pain to mothers and place them at risk for infections and serious tears to the vagina­especially when the cut is directly downward­research suggests it should be used sparingly. As such, it is now less often practiced in high-income countries, but whether the same is true in India is not known. To answer this question, we used a large population-based pregnancy registry, the Maternal Newborn Health Registry, from Central India (Nagpur) to assess the frequency of episiotomy use between 2014 and 2018 and if there were certain maternal characteristics, features of the health care system, and other pregnancy interventions that were related with its use. Over this five-year period, the use of episiotomy during vaginal birth rose more than two-fold. It was more often used on women who had never delivered a baby before, were further along in pregnancy, had higher levels of education, had heavier babies, or were carrying more than one baby. Obstetricians were more likely to perform episiotomy than midwives or general physicians and it was more likely to be performed in hospitals than in clinics or primary health centers. This rise during the five-year interval was significant even when accounting for these patient and provider characteristics, suggesting a shift in medical practice. Because this was an observational study more research is needed to determine if the associations we found are causal.

Report of a new species of sand fly, Phlebotomus (Anaphlebotomus) ajithii n. sp. (Diptera: Psychodidae), from Western Ghats, India.

BACKGROUND: Western Ghats is a biodiversity treasure trove with reports of indigenous leishmaniasis cases. Hence, systematic sand fly surveillance was carried out among the tribal population. The present study reports a novel sand fly species, Phlebotomus (Anaphlebotomus) ajithii n. sp. (Diptera: Psychodidae), discovered in the Western Ghats of India. METHODS: A comprehensive sand fly survey was conducted across the Kollam, Thrissur, Idukki, Kasaragod and Malappuram districts of Kerala, India. The survey spanned both indoor and outdoor habitats using standard collection methods over a 3-year, 3-month period. DNA barcoding of samples was performed targeting mitochondrial cytochrome c oxidase subunit I (COI) gene, and the sequence generated was subjected to phylogenetic analysis. RESULTS: Phlebotomus (Anaphlebotomus) ajithii, a new sand fly species, is recorded and described in this communication. The morphological relationship of the new species to other members of the subgenus Anaphlebotomus is discussed. Mitochondrial COI barcode followed by phylogenetic analysis confirmed that specimens of Ph. ajithii belong to the same taxonomic group, while a genetic distance of 11.7% from congeners established it as a distinct species. CONCLUSIONS: The Western Ghats, known for its rich biodiversity, has lacked systematic entomological surveys focusing on sand flies. This study aims to fill this gap and reports and describes a new species of sand fly.

Expanding single-venue services to better engage young people who inject drugs: insights from India.

BACKGROUND: Over the last decade, India has had an alarming rise in injection of opioids across several cities. Although scale-up of public sector services for people who inject drugs (PWID) in India has occurred over decades, accessibility has been diminished by fragmented services across physical locations. To circumvent this barrier, and in alignment with the World Health Organization's guidelines to provide comprehensive care to key populations, Integrated Care Centers (ICCs) were established across 8 Indian cities as a public-private service delivery model for providing free single-venue services to PWID. ICCs have been very successful in expanding service availability and convenience for PWID generally. However, few studies from low- and middle-income countries (LMIC) have evaluated how well young PWID (defined as those ≤ 29 years of age) engage with single-venue service models like ICCs or specific services provided in such models. Young PWID are an important subpopulation in India, as they bear a disproportionate burden of new HIV infections because of greater risk and evidence of lower receipt of HIV testing and harm reduction services compared to older PWID. In this comment, we offer insights specific to young PWID drawn from multiple quantitative and qualitative studies examining the reach and effectiveness of ICCs, which may provide generalizable insights into limitations of services for young PWID more broadly in India and globally. FINDINGS: Our studies suggest that while ICCs have expanded service availability, particularly in cities with emerging injection drug use epidemics, population-level reach to foster initial engagement among young PWID can be optimized. Additionally, young PWID who do engage with ICCs experience gaps in substance use treatment receipt and retention, and experience barriers to receipt of ICC services that are distinct from those experienced by older PWID. Notably, HIV incidence among ICC clients is concentrated in young PWID. Finally, ICCs were not intended to reach adolescent PWID, and new services are needed for this subpopulation. CONCLUSIONS: In addition to co-locating services, iterative optimization of models such as ICCs should incorporate youth-specific differentiated interventions and be accompanied by policy changes that are critical to improving the reach and effectiveness of harm reduction and HIV services among young PWID in India.

Strengthening facility-based integrated emergency care services for time sensitive emergencies at all levels of healthcare in India: An implementation research study protocol.

BACKGROUND: The healthcare system in India is tiered and has primary, secondary and tertiary levels of facilities depending on the complexity and severity of health challenges at these facilities. Evidence suggests that emergency services in the country is fragmented. This study aims to identify the barriers and facilitators of emergency care delivery for patients with time-sensitive conditions, and develop and implement a contextually relevant model, and measure its impact using implementation research outcomes. METHODS: We will study 85 healthcare facilities across five zones of the country and focus on emergency care delivery for 11 time-sensitive conditions. This implementation research will include seven phases: the preparatory phase, formative assessment, co-design of Model "Zero", co-implementation, model optimization, end-line evaluation and consolidation phase. The "preparatory phase" will involve stakeholder meetings, approval from health authorities and the establishment of a research ecosystem. The "formative assessment" will include quantitative and qualitative evaluations of the existing healthcare facilities and personnel to identify gaps, barriers and facilitators of emergency care services for time-sensitive conditions. On the basis of the results of the formative assessment, context-specific implementation strategies will be developed through meetings with stakeholders, providers and experts. The "co-design of Model 'Zero'" phase will help develop the initial Model "Zero", which will be pilot tested on a small scale (co-implementation). In the "model optimization" phase, iterative feedback loops of meetings and testing various strategies will help develop and implement the final context-specific model. End-line evaluation will assess implementation research outcomes such as acceptability, adoption, fidelity and penetration. The consolidation phase will include planning for the sustenance of the interventions. DISCUSSION: In a country such as India, where resources are scarce, this study will identify the barriers and facilitators to delivering emergency care services for time-sensitive conditions across five varied zones of the country. Stakeholder and provider participation in developing consensus-based implementation strategies, along with iterative cycles of meetings and testing, will help adapt these strategies to local needs. This approach will ensure that the developed models are practical, feasible and tailored to the specific challenges and requirements of each region.