Effectiveness of a School-Based Educational Intervention to Improve Hypertension Control Among Schoolteachers: A Cluster-Randomized Controlled Trial.

Background The control of hypertension is low in low- and middle-income countries like India. We evaluated the effects of a nurse-facilitated educational intervention in improving the control rate of hypertension among school teachers in India. Methods and Results This was a cluster-randomized controlled trial involving 92 schools in Kerala, which were randomly assigned equally into a usual care group and an intervention group. Participants were 402 school teachers (mean age, 47 years; men, 29%) identified with hypertension. Participants in both study groups received a leaflet containing details of a healthy lifestyle and the importance of regular intake of antihypertensive medication. In addition, the intervention participants received a nurse-facilitated educational intervention on hypertension control for 3 months. The primary outcome was hypertension control. Key secondary outcomes included systolic blood pressure, diastolic blood pressure, and the proportion of participants taking antihypertensive medications. For the primary outcome, we used mixed-effects logistic regression models. Two months after a 3-month educational intervention, a greater proportion of intervention participants (49.0%) achieved hypertension control than the usual care participants (38.2%), with an odds ratio of 1.89 (95% CI, 1.06-3.35), after adjusting for baseline hypertension control. The odds of taking antihypertensive medications were 1.6 times higher in the intervention group compared with the usual care group (odds ratio, 1.62; 95% CI, 1.08-2.45). The reduction in mean systolic blood pressure was significantly greater in the intervention group by 4.2 mm Hg (95% CI, -7.2 to -1.1) than in the usual care group. Conclusions A nurse-facilitated educational intervention was effective in improving the control and treatment rates of hypertension as well as reducing systolic blood pressure among schoolteachers with hypertension. Registration URL: https://www.ctri.nic.in; Unique Identifier: CTRI/2018/01/011402.

Validation of Malayalam Version of Everyday Abilities Scale for India.

BACKGROUND: Cognitive impairment is usually associated with impairment in everyday activities. Scales to assess activities of daily living, like the Everyday Abilities Scale for India (EASI), have been employed as screening tools for dementia or major neurocognitive disorder. EASI had not been validated in Malayalam. This study's objective was to validate the Malayalam version of EASI (M-EASI) in those aged ≥60 years. METHODS: In a study undertaken in a tertiary care center, those aged ≥60 years attending psychiatry, neurology, or geriatric clinic of general medicine departments were evaluated using M-EASI and the Malayalam version of Addenbrooke's Cognitive Examination (M-ACE). A total of 304 participants were recruited for this questionnaire validation. Information for M-EASI was obtained from a reliable informant. RESULTS: The mean age of the sample was 70.04 years (standard deviation-7.33). The majority of them were males (58.6%) and educated up to primary school (42.4%), while the majority of the informants were sons/daughters/siblings (47.7%) and were females (73.7%). Taking M-ACE scores as the gold standard for diagnosing MNCD according to Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition criteria, there were 162 cases of MNCD and 142 normal controls. Cronbach's α was 0.91. At an optimal cut-off of 4.5, adequate sensitivity (77.8%), and specificity (75.4%) were observed. The positive predictive value was 78.6%, and the negative predictive value, 74.5%. CONCLUSION: M-EASI has adequate psychometric properties as a screening tool for MNCD.

Do women with epilepsy benefit from epilepsy specific pre-conception care?

BACKGROUND: To determine how pre-conception care (PCC) influenced the outcome of epilepsy, pregnancy and malformation risk in women with epilepsy (WWE). METHODS: All primigravida in the Kerala registry of epilepsy and pregnancy (KREP) with the final outcome of pregnancy known who were enrolled prospectively in pre-conception stage (PCC group) or first trimester of pregnancy (PRG group) were included. The two groups were compared for fetal and maternal outcomes including seizure control and complications of pregnancy. RESULTS: There were 320 (30.4 %) in PCC group and 732 in PRG group. Both groups were comparable for epilepsy classification, maternal birth defects and family history of epilepsy but the PCC group had significantly higher education (48.9 %, p = .027) and employment (22.1 %, p < .001). They had higher usage of folate in pre-pregnancy month (87.5 %, p < .001) and first trimester (96.3 %, p < .001) than PRG group. Fewer women in the PCC group were off AEDs in first trimester (5 % vs 9.3 %, p = .018). Within monotherapy group, use of levetiracetam (10.8 %, p = .017), valproate (34 %, p = .002) in PCC group and carbamazepine (39.1 %, p = .04), phenobarbitone (13.3 %, p = .001) in PRG group was significantly high. More women in PCC group were seizure free during pregnancy (62.8 %, p = .005) than PRG group. Early fetal loss was better captured in PCC (90.6 %,p = .025) than in the PRG. There was no difference in malformation rate between PCC (7.2 %) and PRG groups (6.1 %, p = .3). CONCLUSION: PCC reduced the risk of seizures during pregnancy and improved the periconceptional use of folate but did not influence the fetal malformation risk.

Predictors of dementia-free survival after bilateral subthalamic deep brain stimulation for Parkinson's disease.

OBJECTIVE: Bilateral subthalamic nucleus deep brain stimulation (STN DBS) improves motor complications and quality of life (QOL) in patients with Parkinson's disease (PD). However, it does not delay or prevent the occurrence of dementia. The deleterious effects of dementia on QOL and activities of daily living (ADL) underscore the importance of identifying predictors of dementia-free survival in PD patients considered for STN DBS. AIMS AND METHODS: The baseline clinical and neuropsychological data and the occurrence of dementia recorded during the longitudinal follow-up of a cohort of patients with PD with at least 2 years follow-up after bilateral STN DBS, were reviewed. RESULTS: One hundred and sixteen patients operated between 1999 to 2014 satisfied the inclusion criteria. Their mean age was 56.5 (±10) years and the mean duration of PD at surgery was 11.2 (±4.2) years. During the 542 person-years of follow-up, 30 patients developed dementia. The mean dementia-free survival after surgery was 8.7 [95% confidence interval (CI): 7.8-9.6] years. In univariate analysis, the baseline factors of older age, longer disease duration, past history of depression or psychosis, freezing of gait in OFF phase, worse ADL scores in ON phase, lower levodopa response of the Unified Parkinson's Disease Rating Scale (UPDRS) III axial sub-scores, and poor performances in the Addenbrooke's Cognitive Examination and Wisconsin Card Sorting Test (WCST) were associated with a shorter dementia-free survival. Among these, only freezing of gait and poor performance in WCST were independent predictors. CONCLUSION: Presence of freezing of gait in the drug OFF state and executive dysfunction predict the occurrence of earlier dementia in PD patients who otherwise qualify for bilateral STN DBS.

Alignment efficiency of coaxial tubular superelastic nickel-titanium vs single-stranded superelastic nickel-titanium in relieving mandibular anterior crowding in extraction cases: A single-centre randomized controlled clinical trial.

OBJECTIVES: To compare the alignment efficiency of coaxial tubular and single-stranded 0.016" superelastic NiTi archwires in relieving mandibular anterior crowding in extraction cases and to evaluate whether alignment efficiency differed as the initial irregularity increased. SETTING AND SAMPLE POPULATION: Forty female patients aged between twelve and twenty years from the postgraduate orthodontic clinic at the authors' centre. MATERIALS AND METHODS: All patients in this single-centre, 2-arm parallel trial were randomly allocated in a 1:1 ratio and the mandibular anterior irregularity was measured from the mandibular cast at 0-, 4-, 8- and 12-week intervals using a digital calliper. RESULTS: All forty patients (mean age, 15.08 ± 2.11) completed the study with either coaxial tubular superelastic NiTi (mean age, 15.30 ± 2.36) or single-stranded superelastic NiTi (mean age, 14.85 ± 1.84). The largest mean irregularity index reduction of -4.88 ± 2.74 and -6.17 ± 2.38 in the single-stranded superelastic NiTi and the coaxial tubular superelastic NiTi groups, respectively (P = 0.122) was at 4 weeks. Student's t test and repeated measures ANOVA indicated that none of the mean comparisons were statistically significant at a 5% level. Pearson's correlation value (r) indicated no statistically significant influence of initial crowding on alignment efficiency. CONCLUSIONS: There was no statistically significant difference between the alignment efficiency of coaxial tubular superelastic NiTi and single-stranded superelastic NiTi in extraction cases, and the degree of initial crowding had no influence on the alignment efficiency.

Teratogenicity of antiepileptic dual therapy: Dose-dependent, drug-specific, or both?

OBJECTIVE: To determine the relative risk (RR) of major congenital malformations (MCMs) in infants with antenatal exposure to antiepileptic drug (AED) dual therapy and to explore the influence of specific AEDs vs dose. METHODS: All completed pregnancies prospectively enrolled in the Kerala Registry of Epilepsy and Pregnancy from 1998 until December 2013 on AED dual therapy exposure during the first trimester were analyzed for the outcome, MCMs. Dose was expressed as ratio of prescribed to daily defined dose (PDD/DDD), and the RR for malformation was referenced to lamotrigine monotherapy. RESULTS: Of 1,688 completed pregnancies, 368 women were on dual therapy. The risk of MCM with dual therapy was 1.6 times more than with monotherapy (p = 0.0015). The frequency of renal, alimentary, and skeletal malformations was higher with dual therapy, while cardiac malformations were more common with monotherapy. The risk of MCM was highest with topiramate dual therapy (14.82, 95% confidence interval [CI] 1.88-113.83). No MCMs were seen with levetiracetam or lamotrigine dual therapy. There was a marked reduction in the risk of MCM when dual therapies involving topiramate or valproate were excluded (RR 1.78, 95% CI 1.00-3.15). The risk of MCM with dual therapy was higher even at lower doses (8.2%, PDD/DDD 0.5-1), and the subsequent dose-dependent increment was less profound than with monotherapy. CONCLUSIONS: Our data indicate that the excess risk of dual therapy over monotherapy is contributed largely by topiramate or valproate. The complex pharmacokinetic and pharmacodynamic effects of dual therapy adversely influence MCM risk.

Adapting and Validating the Global Physical Activity Questionnaire (GPAQ) for Trivandrum, India, 2013.

INTRODUCTION: A limitation of the Global Physical Activity Questionnaire (GPAQ) in assessing physical activity in India is that it does not capture the diversity of activities across cultures and by sex. The purpose of this study was to culturally adapt and validate the GPAQ by using an accelerometer in Thiruvananthapuram City, India. METHODS: We developed a modified version of the GPAQ by adding a physical activity chart specific to the locale. We identified local physical activities through in-depth interviews, group discussions, and observation, and used Actigraph GT3X accelerometers to validate the modified GPAQ for a subsample of 47 women. Participants were drawn from a cross-sectional survey of 1,303 women aged 18 to 64 years, selected by multistage cluster sampling. Spearman rank correlation coefficients and intraclass correlation coefficients (ICC) were calculated to determine the correlation and level of agreement in moderate-to-vigorous physical activity (MVPA) on the basis of accelerometer measurement and the modified GPAQ. RESULTS: The correlation for MVPA between the modified GPAQ (overall) and the accelerometer (non-bouted MVPA) was 0.69 (95% confidence interval [CI], 0.39-0.85) with a moderately high ICC of 0.78 (95% CI, 0.56-0.90). The correlation for MVPA between the modified GPAQ and the accelerometer-based MVPA within bouts of at least 10 minutes was 0.60 (95% CI, 0.26-0.80) with an ICC of 0.55 (95% CI, 0.20-0.77) indicating a moderate level of agreement. CONCLUSION: The GPAQ can be used for assessing physical activity among women in India, and its adaptation and validation may be useful in other low-income or middle-income countries where activities are diverse in type and intensity.

Utilization of maternal health care services in post-conflict Nepal.

BACKGROUND: Despite a decade-long armed conflict in Nepal, the country made progress in reducing maternal mortality and is on its way to achieve the Millennium Development Goal Five. This study aimed to assess the degree of the utilization of maternal health care services during and after the armed conflict in Nepal. METHODS: This study is based on Nepal Demographic and Health Survey data 2006 and 2011. The units of analysis were women who had given birth to at least one child in the past 5 years preceding the survey. First, we compared the utilization of maternal health care services of 2006 with that of 2011. Second, we merged the two data sets and applied logistic regression to distinguish whether the utilization of maternal health care services had improved after the peace process 2006 was underway. RESULTS: In 2011, 85% of the women sought antenatal care at least once. Skilled health workers for delivery care assisted 36.1% of the women, and 46% of the women attended postnatal care visit at least once. These figures were 70%, 18.7%, and 16%, respectively, in 2006. Similarly, women were more likely to utilize antenatal care at least once (odds ratio [OR] =2.18, confidence interval [CI] =1.95-2.43), skilled care at birth (OR =2.58, CI =2.36-2.81), and postnatal care at least once (OR =4.13, CI =3.75-4.50) in 2011. CONCLUSION: The utilization of maternal health care services tended to increase continuously during both the armed conflict and the post-conflict period in Nepal. However, the increasing proportion of the utilization was higher after the Comprehensive Peace Process Agreement 2006.