Community health volunteer for blood pressure control in rural people with stroke in India: Pilot randomised trial.

OBJECTIVE: To test the hypothesis that an Accredited social health activist (ASHA), a community health volunteer in a task-sharing model can help in sustained control of systolic blood pressure (BP) in rural people with Stroke and hypertension at 6 months follow up. METHODS: In this randomized trial two rural areas (Pakhowal and Sidhwan bet) with 70 and 94 villages respectively were screened for people with stroke and hypertension. They were assigned to either ASHA-assisted BP control in addition to standard-of-care (Pakhowal-intervention Group) or standard-of-care alone (Sidhwan bet- Control Group). Assessors blinded to intervention conducted the baseline and 6 months follow-up visits to measure risk factors in both the rural areas. RESULTS: A total of 140 people with stroke with mean age of 63.7 ± 11.5 years and 44.3% females were randomised. The baseline systolic BP was higher in the intervention group (n = 65,173.5 ± 22.9 mmHg) compared to the control group (n = 75,163 ± 18.7 mmHg, p = 0.004). The follow-up systolic BP was lower in the intervention group compared to the control group 145 ± 17.2 mmHg and 166.6 ± 25.7 mmHg respectively (p < 0.0001). According to the intention-to-treat analysis a total of 69.2% of patients in the intervention group achieved systolic BP control compared to 18.9% in the control group patients (OR 9, 95% CI 3.9-20.3; p < 0.0001). CONCLUSION: Task sharing with ASHA a community health volunteer can improve BP control in rural people with stroke and hypertension. They can also help in the adoption of healthy behaviour. CLINICAL TRIAL REGISTRATION NUMBER: ctri.nic.in, CTRI/2018/09/015709.

Rural Stroke Surveillance and Establishment of Acute Stroke Care Pathway Using Frontline Health Workers in Rural Northwest India: The Ludhiana Experience.

BACKGROUND AND PURPOSE: The role of community health workers (CHWs) in stroke surveillance and in establishing the stroke care pathway has not been studied. The aim of the study was to evaluate the feasibility of using CHWs in the public health system to identify stroke patients for population-based stroke registration and to study the establishment of acute stroke care pathway in rural areas of Ludhiana, Punjab, Northwest India. METHODS: Two rural blocks in Ludhiana district, comprising 164 villages and a population of 259,778, were selected. Phase-1 (feasibility study) was from August to November 2016 and phase-2 from December 2016 to November 2018. All first-ever stroke cases in adults (aged ≥18 years) were included. The accredited social health activists (ASHAs) were trained to identify stroke patients in the community, who were later evaluated by a neurologist. Stroke characteristics were recorded, and the outcome was assessed at 6 months using modified Rankin scale (0-2, good outcome). FINDINGS: During phase-2, 359 first-ever stroke patients and 102 stroke mimics were identified. The age-standardized incidence rate was 218.5/100,000 and 197∙6/100,000 for each year. Half (52.4%) of the patients reached health-care facilities within 4.5 h, yet none of them received thrombolysis. Very few patients (1.9%) utilized free government 108 ambulance service to reach a health-care facility. Out of 359 stroke cases, the majority (306, 85.23%) were reported by ASHAs and 14.77% were reported by other sources. Brain imaging was available in 127 (35.4%) patients, and 100 (78.7%) had ischemic stroke. The most common risk factor was hypertension (320, 89%) and drug abuse (154, 42.9%). At 6 months, 168 (64%) patients had a good outcome. CONCLUSION: ASHAs were able to identify stroke patients in the villages. Despite high numbers of patients reaching health-care facilities within a window period, the hospitals were unable to provide acute stroke treatment like thrombolysis. The health-care system needs to be strengthened to improve stroke care.

Establishment of population-based stroke registry in Ludhiana city, northwest India: feasibility and methodology.

BACKGROUND/AIMS: The Indian Council of Medical Research (ICMR) initiated the Task Force Project to evaluate the feasibility of conducting a population-based stroke registry in Ludhiana city, Punjab, Northwest India. METHODS: All first-ever, stroke patients over 18 years from the city of Ludhiana were included in the study from March 26th 2010 to March 25th 2011. Stroke information was collected based on the WHO STEPS approach from the participating hospitals, scan centres and doctors. Modified Rankin Scale (mRS) was administered by telephonic interview at 28 days after stroke. The information on stroke deaths was obtained from the Municipal Corporation (MC) office. RESULTS: A total of 905 first-ever stroke patients were documented. After excluding duplicate cases and patients from outside the city, 493 patients were included. The practical issues identified in data collection from these centres were reluctance to take informed consent, lack of willingness to share the data, difficulty to identify key persons from each centre, retrieving medical records from public hospitals and poor documentation of deaths in MC office. CONCLUSION: Population-based stroke registry was feasible in an urban population with the above methodology. The issues related to feasibility were identified and necessary changes were made for the main phase of the registry.

Ultrasonication and microwave pre-treated locust protein hydrolysates enhanced the storage stability of meat emulsion.

Locust protein hydrolysates (LoProHs) pre-processed with microwave and ultrasonication were developed and evaluated for their potential for enhancing the quality of the stored meat emulsion (MEmul). Locust protein (LoPro) samples pre-processed with ultrasonication (Ult) or microwave (Mic) or with no treatment (Not) were hydrolysed with alcalase enzyme (3%). The microwave pre-processed (Mic-LoProHs) and ultrasonicated (Ult-LoProHs) hydrolysates showed significantly (P < 0.05) higher antioxidant [FRAP (ferric reducing antioxidant power) and ABTS and DPPH radical scavenging activities] and antimicrobial [minimum inhibitory concentration (MIC) and inhibitory halos (mm)] potential. The MEmul samples incorporated with Mic-LoProHs and Ult-LoProHs at the maximum level of 1.5% exhibited significantly (P < 0.05) improved results for all the quality parameters such as antioxidant potential (FRAP, ABTS and DPPH), protein oxidation (total carbonyl content), lipid stability, and microbial quality during refrigerated storage (4 ± 1 °C) of two-weeks compared to the control MEmul without any LoProHs. A positive (P < 0.05) impact of the LoProHs was found on the sensory quality of MEmul samples after one week of storage. The digestion simulation improved (P < 0.05) the antioxidant potential of the MEmul samples.

Transient Ischemic Attack (TIA) Incidence with Geographic Information Systems (GIS) Mapping for Stroke Prevention Interventions.

OBJECTIVES: GIS mapping as a public health tool has been increasingly applied to chronic disease control. While evaluating TIA incidence from an existing regional stroke registry in Ludhiana city, India, we aim to apply the innovative concept of regional TIA GIS mapping for planning targeted stroke prevention interventions. METHODS: TIA patient data was obtained from hospitals, scan centers and general practitioners from March 2010 to March 2013 using WHO-Stroke STEPS based surveillance as part of establishing a population-based stroke registry in Ludhiana city. From this registry, patients with TIA (diagnosed by MRI image-based stroke rule-out, or clinically) were chosen and data analyzed. RESULTS: A total of 138 TIA patients were included in the final analysis. The annual TIA incidence rate for Ludhiana city was 7.13/100,000 (95% confidence interval: 5.52 to 8.74) for 2012-2013. Mean age was 58.5 ± 13.9 years (range: 22-88 years) and 87 (63%) were men. Majority of the TIA cases had anterior circulation TIAs. Hypertension (87.4%) was the most common risk factor. Using Geographic Information System (GIS) mapping, high TIA incidence was seen in central, western, and southern parts and clustering of TIA cumulative incidence was seen in the central part of Ludhiana city. CONCLUSION: Incidence rate of TIA was lower than that expected from a low- and middle-income country (LMIC). TIA GIS mapping, looking at regional localization, can be a novel option for developing targeted, cost-effective stroke prevention programs.

Exposure to a high selenium environment in Punjab, India: Effects on blood chemistry.

Many studies have shown that overexposure to environmental selenium may exert a wide pattern of adverse effects on human health, but much uncertainty still surrounds some of them as well as the exact amounts of exposure involved. In particular, very few studies have addressed the possible changes in blood chemistry following high selenium exposure. In a Northeastern part of Punjab, India, very high soil selenium content has been documented, with a value exceeding 2 mg/kg (up to 5) as compared with the <0.5 mg/kg selenium content characterizing the surrounding referent areas. In seven villages located in that seleniferous areas, we carried out a survey by recruiting volunteers and sampling blood, hair and nail specimens. We administered a questionnaire to the participants and analyzed the specimens for the selenium, along with a series of biochemical and haematological parameters in blood. We included 680 adult volunteers (267 men and 413 women), who showed median selenium levels of 171.30 µg/L in serum, 1.25 µg/g in hair, and 5.7 µg/g in nails. Overall, increasing selenium exposure tended to correlate with higher levels of total cholesterol, albumin, free triiodothyronine, deionidase activity, and with red cell and platelet counts. After stratifying the subjects according to category of selenium exposure, we observed a dose-response relation between serum selenium and risk of high total cholesterol, and between hair selenium and risk of high total and low-density lipoprotein cholesterol, high pancreatic lipase, altered thyroid-stimulating hormone and free triiodothyronine levels. Nail selenium exposure category positively correlated with risk of high alanine-aminotransferase, altered albumin levels, high pancreatic lipase and low levels of thyroid-stimulating hormone. Chronic selenium overexposure appears to adversely affect lipid profiles and pancreatic, liver, and thyroid function, with selenium biomarkers having different abilities to predict such effects.

Multicomponent Short-Term Training of ASHAs for Stroke Risk Factor Management in Rural India.

Background Stroke is one of the leading causes of disability-adjusted life years and may be the leading cause of death in rural regions in India. We aim to train the ASHAs (Accredited Social Health activist) for nonpharmacological management of risk factors for secondary stroke prevention in rural India. We tested the hypothesis that focused, multicomponent, short-term training on secondary prevention of stroke enhances the knowledge of ASHAs about risk factor management. Objectives To test the hypothesis that focused, multicomponent, short-term training on secondary prevention of stroke enhances the knowledge of ASHAs about risk factor management. Materials and Methods This study is part of the ASSIST trial (Training ASHA to Assist in Secondary Stroke Prevention in Rural Population). The study design is quasi-experimental (pretest and posttest). Culturally appropriate and pragmatic training material was developed by the study team. Three focused group training sessions were conducted in Sidhwan Bet and Pakhowal blocks of Ludhiana district, Punjab. Results A total of 274 ASHAs from 164 villages with mean ± SD age of 39.5 ± 7.6 years participated in the three training sessions. The perceived knowledge of stroke risk factors and blood pressure assessment was 67.5 ± 18.3% and 84.4 ± 16.7%, respectively. The objective baseline knowledge about stroke prevention and management among ASHAs was lower 58.7 ± 19.7% compared with perceived knowledge ( p = 0.04). This increased to 82.5 ± 16.36% ( p < 0.001) after the mop-up training after a mean of 191 days. More than 30% increment was seen in knowledge about the stroke symptoms (35.9%, p < 0.001), avoiding opium after stroke for treatment (39.5%, p < 0.001), causes of stroke (53.3%, p < 0.001), modifiable risk factors for stroke (45.4%, p < 0.001), and lifestyle modifications for stroke prevention (42.1%, p < 0.001). Conclusions Focused group training can help enhance the knowledge of ASHAs about stroke prevention and management. ASHAs are also able to retain this complex multicomponent knowledge over a 6-month period. ASHA may be able to partake in reducing the secondary stroke burden in rural India.

HIV sero-prevalence and knowledge, behaviour and practices regarding HIV/AIDS in specific population groups in Ludhiana, Punjab.

OBJECTIVES: To assess HIV serostatus, knowledge, behaviour and practices regarding HIV/AIDS among blood donors, pregnant women and the general population in Ludhiana and to find out any association between these factors. METHODS: The descriptive cross sectional study was conducted among blood donors attending the blood bank, pregnant women attending the antenatal clinics of the peripheral health centres of the department of Community Medicine, Christian Medical College Ludhiana, and the general population of the field practice areas of the Department, aged 15 years or more and willing to join the investigation. The study subjects were interviewed through a self-administered questionnaire and screened for HIV using ELISA technique. Seropositivity rates in the population groups and possible risk factors were compared, using EpiInfo 6.04d software. RESULTS: Prevalence of HIV infection was found to be 0.30 % (95 % CI 0.10 - 0.70) in the general population studied, 0.12 % (95 % CI 0.05 - 0.28) in the blood donors, and nil in the pregnant women. The respondents were deficient in knowledge about the modes of spread of HIV/AIDS. No significant association was established between HIV sero-positivity and gender, age group, education, occupation, HbsAg status, or knowledge about the modes of spread of HIV/AIDS. Sexually active unmarried young people 15-24 years old, those indulging in extra-marital sex, and those addicted to opium/poppy-husk were observed to be at higher risk of HIV infection. CONCLUSIONS: The studied population groups have very low HIV seroprevalence. Misconceptions and lack of knowledge need to be corrected through education and awareness to avoid high-risk behaviour and prevent HIV infection.

Pattern of Ocular Morbidity in the Elderly Population of Northern India.

INTRODUCTION: The frequency of eye diseases has been suggested to start increasing around 40 years of age, with an even steeper increase beginning around 60 years of age. Health promotions and curative and rehabilitative services for the visually impaired elderly population should therefore be a priority in the coming years especially in low and middle income countries. AIM: To examine the changing pattern of ocular morbidity in the elderly population of Northern India and to determine the socioeconomic status in relation to ocular morbidities. MATERIALS AND METHODS: A team from the Department of Ophthalmology and Department of Community Medicine, conducted house visits and did a complete eye examination of 450 elderly subjects. They were selected by systematic random sampling from the data base available in the Department of Community Medicine. RESULTS: A total of 900 eyes were examined. Visual impairment and blindness was seen in 135 (30%) and 36 (8%) individuals respectively. The most common cause of blindness was cataract, followed by corneal opacity, glaucoma, refractive error, diabetic retinopathy, macular scar, age related macular degeneration, retinal detachment, retinitis pigmentosa. Visual impairment was more in individuals with low socioeconomic status. CONCLUSION: The results of this study suggest that though cataract remains the main cause of blindness, there is an increase in blindness and visual impairment due to corneal diseases and glaucoma which was not seen earlier. The availability and accessibility to eye care facilities particularly for corneal diseases and glaucoma should be increased to reduce blindness in Northern India.

Uterine Prolapse: Should Hysterectomy Specimens be Subjected for Histopathological Examination?

CONTEXT: Uterine prolapse accounts for one of the common gynecological problems in India. The excised uterus is not expected to have any pathological finding other than atrophic endometrium and may be an ulcer because of the prolapse. AIMS: The aim of this study is to assess the hysterectomy specimen for unsuspected pathology. SUBJECTS AND METHODS: The study is done over two and half years at a tertiary care hospital. Hysterectomy specimens done with a clinical indication of prolapse were included in the study. Histopathological examination done, findings noted, and data analyzed. STATISTICAL ANALYSIS USED: Descriptive analysis was used in this study. RESULTS: Of the total hysterectomy specimens, 55 (6%) were done for uterovaginal prolapse. Patients age ranged from 32 to 78 years; mean 51.1 ± 11.9 years. Majority (46; 83.6%) of the patients were above 40 years of age, whereas only (9; 16.4%) were < 40 years of age (P < 0.0001) Vaginal hysterectomy was done in most 38 (69.1%) cases as compared to abdominal hysterectomy in 17 (30.9%) cases (P < 0.001). Adnexae were removed in only 3 (5.5%) cases as compared to 52 (94.5%) cases, in which adnexae were preserved (P < 0.001). Chronic cervicitis was seen in 100% of cases. Majority (18:32.7%) of the endometrium was in atrophic phase, secretory in 8 (14.5%), cystic regressive hyperplasia and chronic endometritis in 4 (7.2%) each. Myometrium was unremarkable in 43 (79%) cases, whereas focal adenomyosis in 12 (21%) cases. All the adnexa received were histologically unremarkable. CONCLUSIONS: Grossly unremarkable specimens can have unsuspected histopathological lesion which could be potential premalignant or malignant lesions. Therefore, all hysterectomy specimens should be subjected to the histopathological examination for accurate diagnosis and proper categorization of lesions.

Stroke profile and outcome between urban and rural regions of Northwest India: Data from Ludhiana population-based stroke registry.

INTRODUCTION: The objective of this study is to compare the clinical profile, risk factors, type and outcome of stroke patients in urban and rural areas of Punjab, India. METHODS: The primary data source was from the Ludhiana urban population-based stroke registry. The data of first-ever stroke patients with age ≥18 years were collected using WHO stepwise approach from all hospitals, general practitioners, physiotherapy and scan centres between 26 March 2011 and 25 March 2013. RESULTS: A total of 4989 patients were included and out of 4989 patients, 3469 (69%) were from urban areas. Haemorrhagic stroke was seen more in rural as compared to urban regions (urban 1104 (32%) versus rural 552 (36%); p = 0.01). There were significant differences seen in stroke risk factors; hypertension (urban 1923 (84%) versus rural 926 (89%); p = 0.001) and hyperlipidaemia (urban 397 (18%) versus rural 234 (23%); p = 0.001) between two groups. In the multivariable analysis the rural patients were more likely to be younger (age < 40 years) (OR: 1.82; 95% CI: 1.24-2.68; p = 0.002), Sikhs (OR: 2.57; 95% CI: 1.26-5.22; p = 0.009), farmers (OR: 9.41; 95% CI: 5.36-16.50; p < 0.001), housewives (OR: 2.71; 95% CI: 1.45-5.06; p = 0.002), and consumed alcohol (OR: 1.57; 95% CI: 1.19-2.06; p = 0.001) as compared to urban patients. In addition, use of imaging was higher in rural patients (OR: 1.99; 95% CI: 1.06-3.74; p = 0.03) as compared to urban patients. DISCUSSION AND CONCLUSION: In this large cohort of patients, rural and urban differences were seen in risk factors and type of stroke. Stroke prevention strategies need to take into consideration these factors including regional sociocultural practices.

Profile of Risk Factors for Non-Communicable Diseases in Punjab, Northern India: Results of a State-Wide STEPS Survey.

BACKGROUND: Efforts to assess the burden of non-communicable diseases risk factors has improved in low and middle-income countries after political declaration of UN High Level Meeting on NCDs. However, lack of reliable estimates of risk factors distribution are leading to delay in implementation of evidence based interventions in states of India. METHODS: A STEPS Survey, comprising all the three steps for assessment of risk factors of NCDs, was conducted in Punjab state during 2014-15. A statewide multistage sample of 5,127 residents, aged 18-69 years, was taken. STEPS questionnaire version 3.1 was used to collect information on behavioral risk factors, followed by physical measurements and blood and urine sampling for biochemical profile. RESULTS: Tobacco and alcohol consumption were observed in 11.3% (20% men and 0.9% women) and 15% (27% men and 0.3% women) of the population, respectively. Low levels of physical activity were recorded among 31% (95% CI: 26.7-35.5) of the participants. The prevalence of overweight and obesity was 28.6% (95% CI: 26.3-30.9) and 12.8% (95% CI: 11.2-14.4) respectively. Central obesity was higher among women (69.3%, 95% CI: 66.5-72.0) than men (49.5%, 95% CI: 45.3-53.7). Prevalence of hypertension in population was 40.1% (95% CI: 37.3-43.0). The mean sodium intake in grams per day for the population was 7.4 gms (95% CI: 7.2-7.7). The prevalence of diabetes (hyperglycemia), hypertriglyceridemia and hypercholesterolemia was 14.3% (95% CI: 11.7-16.8), 21.6% (95% CI: 18.5-25.1) and 16.1% (95% CI: 13.1-19.2), respectively. In addition, 7% of the population aged 40-69 years had a cardiovascular risk of ≥ 30% over a period of next 10 years. CONCLUSION: We report high prevalence of risk factors of chronic non-communicable diseases among adults in Punjab. There is an urgent need to implement population, individual and programme wide prevention and control interventions to lower the serious consequences of NCDs.

Incidence, short-term outcome, and spatial distribution of stroke patients in Ludhiana, India.

OBJECTIVE: To estimate the incidence, short-term outcome, and spatial distribution of stroke patients and to evaluate the completeness of case ascertainment in Ludhiana. METHODS: This population-based prospective cohort study was conducted in Ludhiana, Punjab, Northwest India. All first-ever stroke patients (≥18 years) were included between March 2010 and March 2013 using WHO Stepwise Approach Surveillance methodology from the city. Stroke patient data were obtained from hospitals, scan centers, and general practitioners, and details of deaths from the Municipal Corporation. RESULTS: Out of 7,199 stroke patients recruited, 3,441 were included in final analysis. The mean age was 59 ± 15 years. The annual incidence rate was 140/100,000 (95% confidence interval [CI] 133-147) and age-adjusted incidence rate was 130/100,000 (95% CI 123-137). The annual incidence rate for stroke in the young (18-49 years) was 46/100,000 (95% CI 41-51). The case fatality at 28 days was 22%. Patients above 60 years of age (p = 0.03) and patients who were managed in public hospitals had poor survival (p = 0.01). Hot spots for cumulative incidence were seen in central and southern parts of the city, and hot spots for poor outcome were seen in the outskirts of the city. CONCLUSIONS: The incidence rates are similar to other studies from India. Stroke patient survival is poor in public hospitals. The finding of spatial analysis is of public health significance for stroke prevention and strengthening of stroke services.

Prevalence and association of physical activity with obesity: an urban, community-based, cross-sectional study.

AIM: To study levels of physical activity and various measures of obesity and their association in an urban population. STUDY DESIGN: Cross sectional. MATERIALS AND METHODS: One thousand and forty-seven individuals between the ages 25-64 years systematically sampled from a community-based population database were contacted through a house-to-house survey. We adopted the WHO STEPS guidelines for conducting this study. Anthropological measures collected were height, weight, and waist and hip circumference. RESULTS: Physical Activity (PA) levels declined with age and the decline was greater among females. The Pearson's correlation coefficient for age against PA among males was found to be negative and weak (r = -0.104) and that among females was found to be similar (r = -0.206). The prevalence of obesity was higher among females (28.8 %) than among males (13.3 %) and the difference was statistically significant. There was a progressive increase in abdominal obesity with age in both genders. The prevalence of overweight and obesity was higher among individuals with low levels of PA as compared to those with high levels of PA. CONCLUSION: Sedentary behavior is prevalent in more than half of the current study sample. This was more so with increasing age, female gender and increasing obesity. PA is an important component on long-term weight control, and therefore adequate levels of activity should be prescribed to combat the obesity epidemic. Habitual moderate physical activity may be beneficial in preventing excess accumulation of fat.