"We are everyone's ASHAs but who's there for us?" a qualitative exploration of perceptions of work stress and coping among rural frontline workers in Madhya Pradesh, India.

OBJECTIVE: More than a million female village-level lay providers called 'Accredited Social Health Activists (ASHAs)', who deliver primary care, face high levels of stress due to work demands and low compensation, within the context of poverty and gender inequality. Evidence on ASHAs has focused on workplace challenges from a system perspective, without sufficient probing into individual-level stress. This study aims to gain perspectives into the experiences of work stress, the related health symptoms, and the responses to stress among ASHAs in India. METHODS: Focus group discussions (FGDs) conducted with ASHAs in Sehore district, Madhya Pradesh, were audio-recorded and transcribed. Grounded theory was used to generate themes under the various domains of ASHAs' work and domestic life. We identified pathways between the conditions that trigger stressful events, experiences of these events, resulting perceptions, effects on health and wellbeing, and approaches used by ASHAs to respond to stress. RESULTS: Six FGDs with 59 ASHAs generated the following themes: (a) Facility: Workload, undue pressures, unstructured work; ASHAs' relationships with seniors (e.g., feelings of being disrespected, blamed, or targeted), and low access to physical and administrative resources; (b) Home: Feelings of guilt for putting less time for family/child care; disrespect by the elderly for a poorly incentivised job; (c) Community: Low acceptance by the villagers; caste- and gender-bias; difficult community-level relationships (emotional labour, fear/stigma towards her services); (d) Somatic and psychological symptoms: headache, exhaustion, depressive symptoms (to cite a few); and (e) Responses to stress: Motivation (support from peers, family, a sense of identity/pride, incentives), Individual strengths (e.g., social responsibility), and spiritual recourse mechanisms. CONCLUSIONS: This study will inform the development of a strengths-based coaching intervention to address work stress among ASHAs. The findings are relevant to building the evidence on alleviation of work stress among female frontline cadres in low-resource settings globally.

Integration of hatha yoga and evidence-based psychological treatments for common mental disorders: An evidence map.

BACKGROUND: Interest in the use of yoga to enhance engagement with and augment the benefits of psychological treatment has grown. However, a systematic approach to reviewing existing research examining the use of yoga with psychological treatment is lacking. MATERIALS AND METHODS: This mapping review identified and synthesised research trialling yoga as an integrated or adjunct therapy with evidence-based psychological interventions for the treatment of anxiety, depression, PTSD, and eating disorders. RESULTS: Overall, the review identified ten published and three unpublished studies, representing either single group or small quasi-experimental research designs. DISCUSSION: Limited but promising findings were shown for yoga with CBT for anxiety and depression, and the integration of yoga within intensive treatment models for PTSD. CONCLUSIONS: Future research is encouraged to focus on controlled trials that enable examination of the component effect of yoga when applied with evidence-based psychological treatment and acceptability and feasibility data to further knowledge regarding a role for yoga in clinical practice.

Men with and without Alcohol Dependence: A Comparative Study of Triguna, Nonattachment, Personality and Subjective Well-Being.

Context: Indian models of personality are seldom explored in relation to alcohol dependence. Triguna is an Indian model of personality originating from the Sankhya philosophy, whereby three gunas, Sattva, Rajas and Tamas describe personality features. Additionally, the trait of Non attachment which is a concept discussed extensively in Bhagavad Gita is also studied along with Triguna. Aims: The current study discusses these concepts and attempts to explore their relationship with personality and subjective well-being, among men with and without alcohol dependence. Subjects and Methods: A cross-sectional survey method was adopted, with a sample of 84 men from the community without alcohol dependence, screened through alcohol use disorders identification test and 30 men diagnosed with alcohol dependence. Informed consent was obtained from all the participants. Statistical Analysis Used: The data were analyzed using descriptive statistics, independent sample t-test, and Mann-Whitney U-test. Results: Men without alcohol dependence scored significantly higher on variables such as Sattva, extraversion and conscientiousness, positive affect, and life satisfaction, than men in the clinical group. Men who were diagnosed with alcohol dependence, scored significantly higher on Tamas, neuroticism, and negative affect. Conclusions: This novel understanding of the personality structure of patients with alcohol dependence from the Triguna perspective may be helpful in the development of indigenous psychological interventions for alcohol dependence.

Comparison of the clinical performance of the i-gelTM, LMA SupremeTM, and Ambu AuraGainTM in adult patients during general anesthesia: a prospective and randomized study.

BACKGROUND: Supraglottic airway devices (SADs) are routinely used for securing the airway. In this study, the clinical performance of three SADs in adult patients under general anesthesia was compared. METHODS: American Society of Anesthesiologists physical status I-III subjects were randomly assigned to the i-gelTM (I), LMA SupremeTM (L), or Ambu AuraGainTM (A) group (30 per group). The primary objective of this study was to compare insertion times. Additionally, the ease of insertion, number of attempts, oropharyngeal leak pressure (OLP), airway maneuver requirement, difficulty with gastric tube placement, and complications were assessed. RESULTS: Demographic data did not differ between the groups. Group I (16.9 ± 4.9 s) had a significantly shorter time of insertion than Group L (19.6 ± 5.2 s) and Group A (22.1 ± 5.7 s) (P = 0.001). The OLP for Group A (29.8 ± 3.0 cmH2O) was higher than those for Group L (24.1 ± 6.3 cmH2O) and Group I (9.4 ± 6.1 cmH2O) (P < 0.001). The number of insertion attempts (P = 0.232), ease of insertion (P = 0.630), airway maneuver requirement (P = 0.585), difficulty with gastric tube placement (P = 0.364), and complications (P = 0.873) were not significantly different between the groups. CONCLUSIONS: All three devices are convenient and effective for airway management in adults under general anesthesia. However, the shorter insertion time required for the i-gel may make it more suitable for resuscitation and emergencies, while aspiration risk may be reduced with the Ambu AuraGain, given its high OLP.

What Do Preschool Children in India Understand About Death?: An Exploratory Study.

Most people avoid talking about death with children even when required, as they are unsure at what age children start understanding the concept of death. Although this question has been researched in the west, it has not been answered in the Indian context. Therefore, this study was conducted in India with 25 children (14 females, 11 males; 3-5 years), using play and joint story construction method, along with semistructured interviews. Results indicated that majority of the children understood that everyone has to die, including significant people like their own parents (i.e., universality) and also, many children understood that death is final (i.e., irreversibility). However, only few children understood that all cognitive/behavioral functions cease at death (i.e., nonfunctionality). In conclusion, only a small proportion of preschoolers seems to have had a mature concept of death.

A fluoroscopic assessment of brachial plexus block by the supraclavicular approach: Have we been overmedicating?

BACKGROUND: Ultrasonography-guided supraclavicular brachial plexus block has demonstrated safety as compared with landmark or nerve stimulation techniques. However, the minimum effective analgesic volume (MEAV) necessary for adequate blockade has not been determined. This study was undertaken to assess under fluoroscopy the postinjection spread of different drug volumes with clinical correlation. Secondary outcome measures included correlation of onset of block, block quality, and incidence of side effects. METHODS: This randomized, multiarm, cross-sectional, observational study was conducted at a single tertiary care center. A total of 549 patients were randomly allocated to 3 groups (20 ml, 30 ml, and 40 ml of drug mixture). A local anesthetic drug mixture with a radiopaque dye was administered under ultrasonographic guidance, and postinjection fluoroscopic drug spread was studied. RESULTS: Surgical anesthesia was achieved in 494 (89.98%) patients with 85.25%, 92.97%, and 91.71% in 20-, 30-, and 40-ml groups, respectively, being significantly low (p = 0.0317) in the 20-mL group. Cephalad and infraclavicular spread was higher in the 40-mL group than in other two groups (p = 0.103). Horner syndrome (HS) was seen in 51.18% of patients. First, ipsilateral superficial cervical plexus block was also observed in 40.22% of patients. Among patients who developed both, ∼60% of patients (99/167) belonged to the 40-mL group. CONCLUSIONS: Optimal MEAV appears between 20 and 30 mL. Higher drug volumes are associated with more cephalad spread and side effects. Drug spread can predict block efficacy as well. It is postulated that loss of sensation in the ipsilateral neck can be used to predict development of hemidiaphragmatic paresis similar to HS.

A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body.

BACKGROUND AND AIMS: The effect of stellate ganglion blocks (SGBs) was examined in complex regional pain syndromes (CRPS) of the upper body. MATERIAL AND METHODS: A total of 287 SGB were given to patients with documented CRPS on medications. Spontaneous and provoked pain assessment was done with numeric pain rating scale (NPRS). The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion (ROM) was recorded before and after each blockade. Difference between a 15-point "global rating of change" scale determined the minimal clinically important difference of the DASH score. RESULTS: The overall mean pain reduction was 73.2% (r = 0.83, P < 0.001) considering spontaneous and 55.8% (r = 0.77, P < 0.001) on provoked pain. Mean DASH score decreased from 53 (range 36-63; P = 0.14) to 10.4 (range 10-49.2; P = 0.005). The sensitivity to change was 6.9 for spontaneous and 4.9 for provoked pain. Increase in ipsilateral limb temperature has a good correlation with Horner's syndrome (HS) and sympathetic blockade. Minor, self-limiting complications, such as hoarseness, dysphagia, local hematoma, and ipsilateral brachial plexus block occurred in 11.5%. A rare complication of contralateral HS was documented. One patient developed a small pneumothorax, but it did not require intervention. CONCLUSIONS: SGB are relatively safe and effective management in patients with neuropathic conditions already on pharmacotherapy. Serial blocks attained an average reduction in pain by >3 NPRS points from the baseline for both spontaneous and provoked pain with a decrease in mean DASH score and improvement in ROM.

Effect of Yoga on anxiety, depression and self-esteem in orphanage residents: A pilot study.

INTRODUCTION: There has been an increase in a number of orphanages and children living in orphanages in last few years. The children living in orphanages often have psychological problems among which anxiety, depression, and low self-esteem are considered to be most prominent. Yoga is a noninvasive, cost-effective, and safe intervention among complementary and alternative medicine which is known to have a positive impact on psychological problems. AIMS: The present pilot study intended to assess the effect of a two week Yoga intervention on anxiety, depression, and self-esteem of adolescents and young adults living in an orphanage. MATERIALS AND METHODS: Adolescent and young adults participants who were the permanent residents of an orphanage (n = 34; males = 27, females = 7) between age ranges of 12-20 years underwent 2 week of Yoga intervention. Yoga intervention comprised Asana (Yogic postures), Pranayama (Yogic breathing practices), and Dharana-Dhyana (Yogic relaxation techniques) for 1 h daily over 15 days. Hospital anxiety and depression and Rosenberg self-esteem scale were administered at baseline and after the intervention to assess anxiety, depression, and self-esteem, respectively. RESULTS: There was a significant reduction (P = 0.001) in anxiety, depression, and significant improvement in self-esteem (P = 0.001) at the end of 2 weeks Yoga intervention. CONCLUSIONS: This pilot study suggests that 2 weeks of Yoga practice potentially reduced anxiety and depression and improved self-esteem of orphanage adolescents and young adults. These findings need confirmation from studies with a larger sample size and randomized controlled design, which are implicated in the future.

TNF-α, IL-6, and IL-8 cytokines and their association with TNF-α-308 G/A polymorphism and postoperative sepsis.

INTRODUCTION: Early prediction of postoperative sepsis remains an enormous clinical challenge. Association of TNF-α-308 G/A polymorphism with sepsis remains controversial. We, therefore, investigated this polymorphism with serum levels of cytokines TNF-α, IL-6, and IL-8 in relation to development of sepsis following major gastrointestinal surgery. METHODS: Two hundred and thirty-nine patients undergoing major gastrointestinal surgery were enrolled. Polymorphism was studied through the analysis of restriction fragments of Nco1-digested DNA with the polymerase chain reaction. All patients were followed for 1 month following surgery for evidence of sepsis. Levels of serum cytokines TNF-α, IL-6, and IL-8 were measured preoperatively and postoperatively by enzyme-linked immunosorbent assay (ELISA). RESULTS: Forty-seven (19.66 %) patients developed postoperative sepsis. Patients with postoperative sepsis were significantly (p = 0.002) more likely to possess AA homozygous genotype with higher capacity to produce cytokines TNF-α (p < 0.0001), IL-6 (p < 0.0001), and IL-8 (p < 0.0001) as compared to other genotypes. When compared with patients carrying at least one G allele, the AA genotype was associated with a significantly higher probability (odds ratio (OR) = 4.17; p = 0.003; 95 % confidence interval (CI) = 1.5-11.48) of developing sepsis. Compared with the GG genotype, AA was associated with a significantly higher probability (OR = 5.18; p = 0.0008; 95 % CI = 1.82-14.76) of sepsis development. CONCLUSION: TNF-α-308 G/A polymorphism is significantly associated with the development of postoperative sepsis and with increased expression of cytokines TNF-α, IL-6, and IL-8.

Tumor necrosis factor-ß Nco1 polymorphism and susceptibility to sepsis following major elective surgery.

BACKGROUND: Post-operative sepsis remains a substantial cause of morbidity and mortality. In injured patients, that a polymorphism of the gene for tumor necrosis factor-ß (TNF-ß) has been related to the development of sepsis. Genetic factors may also have a role in etio-pathogenesis of sepsis following surgery. We investigated the relationship of the polymorphism of the gene for TNF-ß and the serum concentration of TNF-α to the development of sepsis after elective major surgery. METHODS: The study population consisted of 211 patients undergoing major elective surgery. The NcoI polymorphism of TNF-ß was studied in genomic DNA through the analysis of restriction fragments of Nco1-digested DNA with the polymerase chain reaction (PCR). All patients were followed for 1 mo after surgery for any evidence of sepsis. Serum concentrations of TNF-α were measured pre- and post-operatively by enzyme linked immunosorbent assay (ELISA). Genotypes of TNF-ß and the production of TNF-α were related to the occurrence of sepsis. RESULTS: Post-operative sepsis developed in 21.8% (n=46) of the patients. The overall mortality was 4.2% (n=9). The overall allele frequency of the TNF-ß genotype was 0.32 for TNFB1 and 0.68 for TNFB2. Within the TNF-ß genotype, 11.84% (n=25) of the patients were homozygous recessive for TNFB1, 41.23% (n=87) were heterozygous, with TNFB1/TNFB2, and 46.91% (n=99) were homozygous dominant for TNFB2. The incidence of post-operative sepsis was significantly (p=0.01) higher in patients homozygous for the TNFB2 allele. When compared with patients carrying at least one TNFB1 allele (TNFB1 homozygous and heterozygous genotype), the TNFB2 homozygous genotype was associated with an odds ratio (OR) of 2.60 (p=0.005; 95% CI 1.32-5.15) for the development of sepsis. As compared with that for the heterozygous genotype, the OR for the homozygous TNFB2 genotype was 3.00 (p=0.003; 95% CI 1.39-6.44). In patients with post-operative sepsis, serum concentrations of TNF-α were significantly higher (p=0.02) in TNFB2 homozygous individuals than in those of individuals of the other TNF-ß genotypes. CONCLUSION: The development of sepsis was associated with a greater capacity to produce TNF-α after surgery. The Nco1 polymorphism of the TNF-ß gene was associated with the development of post-operative sepsis with an increased serum concentration of TNF-α. In patients without post-operative sepsis, polymorphism of the TNF-ß gene was not related to different levels of TNF-α production. This indicates an association between polymorphism of the TNF-ß gene and post-operative sepsis, suggesting the TNFB2/B2 genotype as a high-risk factor for the development of sepsis after elective surgery.