Task shifting of frontline community health workers for cardiovascular risk reduction: design and rationale of a cluster randomised controlled trial (DISHA study) in India.

BACKGROUND: Effective task-shifting interventions targeted at reducing the global cardiovascular disease (CVD) epidemic in low and middle-income countries (LMICs) are urgently needed. METHODS: DISHA is a cluster randomised controlled trial conducted across 10 sites (5 in phase 1 and 5 in phase 2) in India in 120 clusters. At each site, 12 clusters were randomly selected from a district. A cluster is defined as a small village with 250-300 households and well defined geographical boundaries. They were then randomly allocated to intervention and control clusters in a 1:1 allocation sequence. If any of the intervention and control clusters were <10 km apart, one was dropped and replaced with another randomly selected cluster from the same district. The study included a representative baseline cross-sectional survey, development of a structured intervention model, delivery of intervention for a minimum period of 18 months by trained frontline health workers (mainly Anganwadi workers and ASHA workers) and a post intervention survey in a representative sample. The study staff had no information on intervention allocation until the completion of the baseline survey. In order to ensure comparability of data across sites, the DISHA study follows a common protocol and manual of operation with standardized measurement techniques. DISCUSSION: Our study is the largest community based cluster randomised trial in low and middle-income country settings designed to test the effectiveness of 'task shifting' interventions involving frontline health workers for cardiovascular risk reduction. TRIAL REGISTRATION: CTRI/2013/10/004049 . Registered 7 October 2013.

Structured Lifestyle Modification Interventions Involving Frontline Health Workers for Population-Level Blood Pressure Reduction: Results of a Cluster Randomized Controlled Trial in India (DISHA Study).

Background Population-wide reduction in mean blood pressure is proposed as a key strategy for primary prevention of cardiovascular disease. We evaluated the effectiveness of a task-sharing strategy involving frontline health workers in the primary prevention of elevated blood pressure. Methods and Results We conducted DISHA (Diet and lifestyle Interventions for Hypertension Risk reduction through Anganwadi Workers and Accredited Social Health Activists) study, a cluster randomized controlled trial involving 12 villages each from 4 states in India. Frontline health workers delivered a custom-made and structured lifestyle modification intervention in the selected villages. A baseline survey was conducted in 23 and 24 clusters in the control (n=6663) and intervention (n=7150) groups, respectively. The baseline characteristics were similar between control and intervention clusters. In total 5616 participants from 23 clusters in the control area and 5699 participants from 24 clusters in the intervention area participated in a repeat cross-sectional survey conducted immediately after the intervention phase of 18-months. The mean (SD) systolic blood pressure increased from 125.7 (18.1) mm Hg to 126.1 (16.8) mm Hg in the control clusters, and it increased from 124.4 (17.8) mm Hg to 126.7 (17.5) mm Hg in the intervention clusters. The population average adjusted mean difference in difference in systolic blood pressure was 1.75 mm Hg (95% CI, -0.21 to 3.70). Conclusions Task-sharing interventions involving minimally trained nonphysician health workers are not effective in reducing population average blood pressure in India. Expanding the scope of task sharing and intensive training of health workers such as nurses, nutritionists, or health counselors in management of cardiovascular risk at the population level may be more effective in primary prevention of cardiovascular disease. Registration URL: https://www.ctri.nic.in; Unique identifier: CTRI/2013/10/004049.

Novel Mutations in a Patient with Triple A Syndrome.

BACKGROUND: Triple A syndrome (Allgrove syndrome), a rare autosomal recessive disorder, is characterized by adrenal insufficiency, achalasia cardia and alacrimia. It is caused by mutations in AAAS gene which encodes a protein called ALADIN. CASE CHARACTERISTICS: 8-year-old boy who presented with hypoglycemic seizures, dysphagia, dry eyes and hyperpigmentation. Investigations confirmed achalasia cardia and adrenal insufficiency. Sequencing of AAAS gene revealed two novel mutations in compound heterozygous state (c.1101delG/ c.1310_1311delCT). OUTCOME: Patient was managed with hydrocortisone and artificial tears. MESSAGE: Sequencing analysis should be done to confirm the diagnosis of clinically suspected Triple A syndrome.

Recurrent ascites with severe hypoproteinemia in 4-year-old child: A diagnostic dilemma - An atypical presentation of hypothyroidism.

Hypothyroidism is frequently encountered condition to a pediatrician. Passive effusions into serous cavities, sometimes to considerable amount are frequently noted. However, the significant ascites caused by this is rare in a child and in no instance, it is too excessive. So diagnosis is frequently delayed and patient frequently receive unnecessary procedures such as liver, even gastrointestinal biopsies. Analysis of ascitic fluid shows exudative nature with high protein. The case we present here is a 4-year-old female child with recurrent ascites, developmental delay and hypoproteinemia. High index of suspicion can lead to diagnosis. Over all prognosis is excellent after stating replacement therapy with L-thyroxine.

Paroxysmal vascular events in Sturge-Weber syndrome: Role of aspirin.

Sturge-Weber syndrome (SWS) is a rare, sporadically occurring neurocutaneous disorder with a frequency of approximately 1 per 50,000. The hallmark is an intracranial leptomeningeal vascular angioma in association with a port wine nevus, usually involving ophthalmic or maxillary distribution of trigeminal nerve. Other clinical findings associated with SWS are seizures, glaucoma, hemiparesis and mental retardation. The radiological hallmark is "Tram-line" or "Gyri-form" calcification. 25 to 56% of patients experience recurrent episodes of paroxysmal focal neurological deficits in form of transient hemiparesis, which may be due to vascular ischemia or postictal in origin. EEG helps to differentiate the exact etiology, as it is normal in former. Aspirin prophylaxis in those, due to ischemia decreases their recurrences and improves overall neurological prognosis. We report a 25-month-old child of SWS with recurrent episodes of transient hemiparesis and atypical midline location of facial vascular nevus.

Predicators for weight gain in children treated for severe acute malnutrition: a prospective study at nutritional rehabilitation center.

Introduction. Despite being an important health problem in developing countries, there is little information available on factors affecting the severe acute malnutrition, especially nondietary factors. Objective. To study the impact of various factors, especially nondietary ones affecting directly or indirectly the weight gain in children with severe acute malnutrition. Method. A total of 300 children in the age group of 6 to 60 months meeting the WHO criteria for severe acute malnutrition were enrolled in the study. These children were provided special therapeutic diet as recommended by WHO/UNICEF protocol. Children were called for followup every 15 days up to 2 months after discharge to evaluate whether these children have achieved a final target weight gain of 15% of their admission weight. The impact of nondietary factors related to child, mother, and socioeconomic status was evaluated. Data collected through structured questionnaire were analyzed. Result. 172 (57.4%) of the total 300 children did not gain final target weight despite giving adequate diet. We observed that impact of various nondietary factors like mother's educational status and her knowledge about feeding practices, socioeconomic status, previous history, and present evidence of infection in child was important in determining the weight of child. No association was found with gender of child, BMI of mother, and father's educational status on the weight gain of child. Conclusion. The findings of this study confirm the association of many nondietary factors with weight gain in children treated for severe acute malnutrition. To reduce malnutrition emphasis should be given on these factors.

Pantoea dispersa: an unusual cause of neonatal sepsis.

Neonatal septicemia is the most important cause of neonatal mortality. A wide variety of bacteria both aerobic and anaerobic can cause neonatal sepsis. Genus Pantoea is a member of Enterobacteriaceae family that inhabits plants, soil and water and rarely causes human infections, however, Pantoea dispersa has not been reported as a causative organism for neonatal sepsis. We hereby report two neonates with early onset sepsis caused by Pantoea dispersa. Early detection and appropriate antibiotic therapy can improve overall outcome of this rare infection in neonates.

Orchidopexy san ligation technique of orchidopexy.

Pediatric hernia surgery is the most common operation done by pediatric general surgeons and it is a core competency for general surgeons in the developing world. Herniotomy is performed for the surgical repair of hernia and along with orchiopexy for the closure of associated patent processus vaginalis. Traditionally, ligation of hernial sac during orchiopexy is considered mandatory to prevent postoperative development of hernia. The present report was designed to study the results of non-ligation of the hernial sac during orchiopexy. It was found that non-ligation has no untoward effect on early complications and recurrence rate on long-term follow-up. It is suggested that it is not necessary to ligate the hernial sac during orchiopexy in children.

Pantoea dispersa: an unusual cause of neonatal sepsis

Neonatal septicemia is the most important cause of neonatal mortality. A wide variety of bacteria both aerobic and anaerobic can cause neonatal sepsis. Genus Pantoea is a member of Enterobacteriaceae family that inhabits plants, soil and water and rarely causes human infections, however, Pantoea dispersa has not been reported as a causative organism for neonatal sepsis. We hereby report two neonates with early onset sepsis caused by Pantoea dispersa. Early detection and appropriate antibiotic therapy can improve overall outcome of this rare infection in neonates.