Alpha and SSVEP power outperform gamma power in capturing attentional modulation in human EEG.

Attention typically reduces power in the alpha (8-12 Hz) band and increases power in gamma (>30 Hz) band in brain signals, as reported in macaque local field potential (LFP) and human electro/magneto-encephalogram (EEG/MEG) studies. In addition, EEG studies often use flickering stimuli that produce a specific measure called steady-state-visually-evoked-potential (SSVEP), whose power also increases with attention. However, effectiveness of these neural measures in capturing attentional modulation is unknown since stimuli and task paradigms vary widely across studies. In a recent macaque study, attentional modulation was more salient in the gamma band of the LFP, compared to alpha or SSVEP. To compare this with human EEG, we designed an orientation change detection task where we presented both static and counterphasing stimuli of matched difficulty levels to 26 subjects and compared attentional modulation of various measures under similar conditions. We report two main results. First, attentional modulation was comparable for SSVEP and alpha. Second, non-foveal stimuli produced weak gamma despite various stimulus optimizations and showed negligible attentional modulation although full-screen gratings showed robust gamma activity. Our results are useful for brain-machine-interfacing studies where suitable features are used for decoding attention, and also provide clues about spatial scales of neural mechanisms underlying attention.

Killer Phonon Caught: Femtosecond Stimulated Raman Spectroscopy Identifies Phonon-Induced Control of Photophysics in Rubrene Derivatives.

Molecular reaction coordinates are defined by the interplay of a number of orthogonal nuclear coordinates and are inherently multidimensional for large molecules. Identifying how specific nuclear motions along these reaction coordinates can be used to drive and control chemical processes is a promising approach for the optimization of chemical outcomes and targeted synthetic design. Here, we used femtosecond stimulated Raman spectroscopy (FSRS) to quantify the effects of individual phonon nuclear motions on singlet fission in rubrene derivatives. Rubrene readily undergoes singlet fission and is amendable to chemical derivatization, yet the factors that impact the singlet fission yield are not fully understood. Crystal packing is known to play a significant role in both fission and carrier transport, and thus, we focused on the impact of phonon nuclear motions on the photophysics. We used four halogen-substituted rubrene crystals and successfully identified one specific phonon mode that suppresses singlet fission in these crystals. We used FSRS with single-pulse excitation and double-pulse excitation to coherently amplify each phonon mode and quantify its effects on the excited-state process. We found that coherent amplification of the specific phonon vibration involving twisting of the peripheral phenyl rings and tetracene core motions resulted in less ground-state depletion and fewer triplet state absorption. Our study demonstrated that it is possible to use coherent phonon excitation to influence the photophysical outcome, while also showing that FSRS with double-pulse excitation can be a successful tool for quantifying mode-selective contributions to photophysics.

Sympathetic Neurofunction Testing in Gestational Hypertension and Relationship with Developing Preeclampsia and Eclampsia: Real-world Evidences from Clinical Pharmacology Clinics.

BACKGROUND: Gestational hypertension carries a high-risk for adverse maternal and fetal outcomes, and it can also develop into preeclampsia. A relative decrease in parasympathetic and increase in sympathetic activity has been seen in normal pregnancy which returns to baseline after delivery. The present study aimed to detect any abnormality in sympathetic neurofunction in gestational hypertension and to identify its possible association with the development of preeclampsia/eclampsia. METHODS: A prospective, observational study was carried out among gestational hypertensive patients between 24 and 26 weeks of gestation, who were sent to clinical pharmacology clinics for autonomic neurofunction testing, along with their 24-hour urinary protein testing reports. Preisometric handgrip (IHG) and post-IHG differences in diastolic blood pressure (DBP) were noted. The association between Δ DBP and the development of eclampsia/preeclampsia was probed. RESULTS: A total of 52 pregnancy-induced hypertension (PIH) participants, both multigravida (n = 15) and primigravida (n = 37) were included in one arm (PIH arm), and 52 matched (age and gravida) pregnant women, those do not have PIH included in another arm for comparative analysis. On comparing the PIH arm and normal arm, prehand grip DBP (p ≤ 0.0001), posthand grip DBP, and Δ DBP were significantly higher in the PIH arm. Correlation between Δ DBP and 24 hours' proteinuria was observed in the PIH arm, with a significant positive correlation. CONCLUSION: A high-rise in DBP post-IHG exercise is associated with gestational hypertensive mothers and this rise is strongly correlated with the development of preeclampsia and eclampsia, which suggests that addressing sympathetic hyperactivity could be a potential area to target therapeutics while managing gestational hypertension.

EUS-guided coil and glue injection versus endoscopic glue injection for gastric varices: International multicentre propensity-matched analysis.

BACKGROUND: Gastric varices (GVs) are conventionally managed with endoscopic cyanoacrylate (E-CYA) glue injection. Endoscopic ultrasound (EUS)-guided therapy using combination of coils and CYA glue (EUS-CG) is a relatively recent modality. There is limited data comparing the two techniques. METHODOLOGY: This international multicentre study included patients with GV undergoing endotherapy from two Indian and two Italian tertiary care centres. Patients undergoing EUS-CG were compared with propensity-matched E-CYA cases from a cohort of 218 patients. Procedural details such as amount of glue, number of coils used, number of sessions required for obliteration, bleeding after index procedure rates and need for re-intervention were noted. RESULTS: Of 276 patients, 58 (male 42, 72.4%; mean age-44.3 ± 12.1 years) underwent EUS-CG and were compared with 118 propensity-matched cases of E-CYA. In the EUS-CG arm, complete obliteration at 4 weeks was noted in 54 (93.1%) cases. Compared to the E-CYA cohort, EUS-CG arm showed significantly lower number of session (1.0 vs. 1.5; p < 0.0001) requirement, lower subsequent-bleeding episodes (13.8% vs. 39.1%; p < 0.0001) and lower re-intervention (12.1% vs. 50.4%; p < 0.001) rates. On multivariable regression analysis, size of the varix (aOR-1.17; CI 1.08-1.26) and technique of therapy (aOR-14.71; CI 4.32-50.0) were significant predictors of re-bleeding. A maximum GV size >17.5 mm had a 69% predictive accuracy for need for re-intervention. CONCLUSION: Endoscopic ultrasound-guided therapy of GV using coil and CYA glue is a safe technique with better efficacy and lower re-bleeding rates on follow-up compared to the conventional endoscopic CYA therapy.

Infection prevention and control for COVID-19 response in the Rohingya refugee camps in Bangladesh: an intra-action review.

BACKGROUND: Infection Prevention and Control (IPC) is critical in controlling the COVID-19 pandemic and is one of the pillars of the WHO COVID-19 Strategic Preparedness and Response Plan 2020. We conducted an Intra-Action Review (IAR) of IPC response efforts to the COVID-19 pandemic in Cox's Bazar, Bangladesh, to identify best practices, challenges, and recommendations for improvement of the current and future responses. METHODS: We conducted two meetings with 54 participants purposively selected from different organizations and agencies involved in the frontline implementation of IPC in Cox's Bazar district, Bangladesh. We used the IPC trigger questions from the WHO country COVID-19 IAR: trigger question database to guide the discussions. Meeting notes and transcripts were then analyzed manually using content analysis, and results were presented in text and quotes. RESULTS: Best practices included: assessments, a response plan, a working group, trainings, early case identification and isolation, hand hygiene in Health Facilities (HFs), monitoring and feedback, general masking in HFs, supportive supervision, design, infrastructure and environmental controls in Severe Acute Respiratory Infection Isolation and Treatment Centers (SARI ITCs) and HFs and waste management. Challenges included: frequent breakdown of incinerators, limited PPE supply, inconsistent adherence to IPC, lack of availability of uniforms for health workers, in particular cultural and gender appropriate uniforms and Personal Protective Equipment (PPE). Recommendations from the IAR were: (1) to promote the institutionalization of IPC, programs in HFs (2) establishment of IPC monitoring mechanisms in all HCFs, (3) strengthening IPC education and training in health care facilities, and (4) strengthen public health and social measures in communities. CONCLUSION: Establishing IPC programmes that include monitoring and continuous training are critical in promoting consistent and adaptive IPC practices. Response to a pandemic crisis combined with concurrent emergencies, such as protracted displacement of populations with many diverse actors, can only be successful with highly coordinated planning, leadership, resource mobilization, and close supervision.

Virus related acute pancreatitis and virus superinfection in the 'Dual disease' model of acute pancreatitis and SARS-Co-V2 infection: A multicentre prospective study.

BACKGROUND: SARS-CoV-2 can cause acute pancreatitis (AP) and SARS-CoV-2 superinfection can occur in patients with AP during prolonged hospitalisation. Our objective was to characterize SARS-CoV-2 related AP and study the impact of SARS-CoV-2 superinfection on outcomes in AP. METHODS: In this multicentre prospective study, all patients with AP and SARS-CoV-2 infection between August 2020 and February 2021 were divided into two groups: SARS-CoV-2-related AP and superadded SARS-CoV-2 infection in patients with AP. The two groups were compared with each other and the whole cohort was compared with a non-COVID AP cohort. RESULTS: A total of 85 patients with SARS-CoV-2 and AP (SARS-CoV-2-related AP; n = 18 and AP with SARS-CoV-2 superadded infection; n = 67) were included during the study period. They had a higher mortality [28 (32.9%) vs. 44 (19.1%), aOR 2.8 (95% CI, 1.5-5.3)] than 230 propensity matched non-COVID AP patients. Mortality in SARS-CoV-2 and AP patients was due to critical COVID. SARS-CoV-2-related- AP (n = 18) had a higher but statistically insignificant mortality than SARS-CoV-2 superinfection in AP [8/18 (44.4%) vs 20/67 (29.8%), p = 0.24]. On multivariable analysis, infection with SARS-CoV-2 (aHR 2.3; 95% CI, 1.43.7) was a predictor of in-hospital mortality in addition to organ failure (OF) in patients with AP. CONCLUSION: Patients with AP and SARS-CoV-2 infection had a higher mortality than matched non-COVID AP patients which was largely attributable to the severity of COVID-19. SARS-CoV-2 related AP had higher OF and in-hospital mortality.

Vibration-Assisted Intersystem Crossing in the Ultrafast Excited-State Relaxation Dynamics of Halocoumarins.

Due to its numerous applications, triplet formation and resulting phosphorescence remain a frontier area of research for over eight decades. Facile intersystem crossing (ISC) is the primary requirement for triplet formation and observation of phosphorescence. The incorporation of a heavy atom in molecules is one of the common approaches employed to facilitate ISC. A detailed study of the excited state dynamics that governs ISC is necessary to understand the mechanism of heavy atom effect (HAE). Incorporation of iodine at the 3 position of coumarin-1 reduces fluorescence quantum yield (ϕf) drastically as expected, whereas bromine substitution at the same position increased the ϕf. Such a contrasting effect of the two heavy atoms suggests that there are other features yet to be discovered to fully understand the HAE. Detailed steady state and femtosecond transient absorption studies along with theoretical calculations suggest that the C3-X (X = Br, I) bond vibration plays an important role in the ISC process. The study reveals that while in the case of the iodo-derivative there is no energy barrier in the singlet triplet crossing path, there is a barrier in the case of the bromo-derivative, which slows the ISC process. Such an unexpected phenomenon is not limited to halocoumarins as this rationalizes the photobehavior of 1-bromo-/iodo-substituted naphthalenes as well.

Decoding of Attentional State Using High-Frequency Local Field Potential Is As Accurate As Using Spikes.

Local field potentials (LFPs) in visual cortex are reliably modulated when the subject's focus of attention is cued into versus out of the receptive field of the recorded sites, similar to modulation of spikes. However, human psychophysics studies have used an additional attention condition, neutral cueing, for decades. The effect of neutral cueing on spikes was examined recently and found to be intermediate between cued and uncued conditions. However, whether LFPs are also precise enough to represent graded states of attention is unknown. We found in rhesus monkeys that LFPs during neutral cueing were also intermediate between cued and uncued conditions. For a single electrode, attention was more discriminable using high frequency (>30 Hz) LFP power than spikes, which is expected because LFP represents a population signal and therefore is expected to be less noisy than spikes. However, previous studies have shown that when multiple electrodes are used, spikes can outperform LFPs. Surprisingly, in our study, spikes did not outperform LFPs when discriminability was computed using multiple electrodes, even though the LFP activity was highly correlated across electrodes compared with spikes. These results constrain the spatial scale over which attention operates and highlight the usefulness of LFPs in studying attention.

Training nurse simulation educators at scale to improve maternal and newborn health: a case study from Bihar, India.

BACKGROUND: Simulation has been shown to improve clinical and behavioral skills of birth attendants in low-resource settings at a low scale. Populous, low-resource settings such as Bihar, India, require large cadres of simulation educators to improve maternal and newborn health. It's unknown if simulation facilitation skills can be adopted through a train of trainers' cascade. To fill this gap, we designed a study to evaluate the simulation and debrief knowledge, attitudes and skills of a third generation of 701 simulation educators in Bihar, India. In addition, we assessed the physical infrastructure where simulation takes place in 40 primary healthcare facilities in Bihar, India. METHODS: We performed a 1 year before-after intervention study to assess the simulation facilitation strengths and weaknesses of a cadre of 701 nurses in Bihar, India. The data included 701 pre-post knowledge and attitudes self-assessments; videos of simulations and associated debriefs conducted by 701 providers at 40 primary healthcare centers. RESULTS: We observed a statistically significant difference in knowledge and attitude scores before and after the 4-day PRONTO simulation educator training. The average number of participants in a simulation video was 5 participants (range 3-8). The average length of simulation videos was 10:21 minutes. The simulation educators under study, covered behavioral in 90% of debriefs and cognitive objectives were discussed in all debriefs. CONCLUSION: This is the first study assessing the simulation and debrief facilitation knowledge and skills of a cadre of 701 nurses in a low-resource setting. Simulation was implemented by local nurses at 353 primary healthcare centers in Bihar, India. Primary healthcare centers have the physical infrastructure to conduct simulation training. Some simulation skills such as communication via whiteboard were widely adopted. Advanced skills such as eliciting constructive feedback without judgment require practice.

Dynamics of Anthracene Excimer Formation within a Water-Soluble Nanocavity at Room Temperature.

Excited anthracene is well-known to photodimerize and not to exhibit excimer emission in isotropic organic solvents. Anthracene (AN) forms two types of supramolecular host-guest complexes (2:1 and 2:2, H:G) with the synthetic host octa acid in aqueous medium. Excitation of the 2:2 complex results in intense excimer emission, as reported previously, while the 2:1 complex, as expected, yields only monomer emission. This study includes confirming of host-guest complexation by NMR, probing the host-guest structure by molecular dynamics simulation, following the dynamics AN molecules in the excited state by ultrafast time-resolved experiments, and mapping of the excited surface through quantum chemical calculations (QM/MM-TDDFT method). Importantly, time-resolved emission experiments revealed the excimer emission maximum to be time dependent. This observation is unique and is not in line with the textbook examples of time-independent monomer-excimer emission maxima of aromatics in solution. The presence of at least one intermediate between the monomer and the excimer is inferred from time-resolved area normalized emission spectra. Potential energy curves calculated for the ground and excited states of two adjacent anthracene molecules via the QM/MM-TDDFT method support the model proposed on the basis of time-resolved experiments. The results presented here on the excited-state behavior of a well-investigated aromatic molecule, namely the parent anthracene, establish that the behavior of a molecule drastically changes under confinement. The results presented here have implications on the behavior of molecules in biological systems.

Mid-upper arm circumference in pregnant women and birth weight in newborns as substitute for skinfold thickness: findings from the MAASTHI cohort study, India.

BACKGROUND: Estimating total body fat in public hospitals using gold-standard measurements such as air displacement plethysmography (ADP), deuterium oxide dilution, or dual-energy X-ray absorptiometry (DXA) is unaffordable, and it is challenging to use skinfold thickness. We aimed to identify the appropriate substitute marker for skinfold thickness to estimate total body fat in pregnant women and infants. METHODS: The study is part of a prospective cohort study titled MAASTHI in Bengaluru, from 2016 to 19. Anthropometric measurements such as body weight, head circumference, mid-upper arm circumference (MUAC), and skinfold thickness were measured in pregnant women between 14 and 36 weeks of gestational age; while measurements such as birth weight, head, chest, waist, hip, mid-upper arm circumference, and skinfold thickness were recorded for newborns. We calculated Kappa statistics to assess agreement between these anthropometric markers with skinfold thickness. RESULTS: We found the highest amount of agreement between total skinfold thickness and MUAC (Kappa statistic, 0.42; 95 % CI 0.38-0.46) in pregnant women. For newborns, the highest agreement with total skinfold thickness was with birth weight (0.57; 95 % CI 0.52-0.60). Our results indicate that MUAC higher than 29.2 cm can serve as a suitable alternative to total skinfolds-based assessments for obesity screening in pregnancy in public facilities. Similarly, a birth weight cut-off of 3.45 kg can be considered for classifying obesity among newborns. CONCLUSION: Mid-upper arm circumference and birth weight can be used as markers of skinfold thickness, reflecting total body fat in pregnant women and the infant, respectively. These two anthropometric measurements could substitute for skinfold thickness in low- and middle-income urban India settings.

Transmission dynamics of COVID-19 among index case family clusters in Beijing, China.

The outbreak of coronavirus disease-2019 (COVID-19) impacts public health dramatically around the world. The demographic characteristics, exposure history, dates of illness onset and dates of confirmed diagnosis were collected from the data of 24 family clusters from Beijing. The characteristics of the cases and the estimated key epidemiologic time-to-event distributions were described. The basic reproductive number (R0) was calculated. Among 89 confirmed COVID-19 patients from 24 family clusters, the median age was 38.0 years and 43.8% were male. The median of incubation period was 5.08 days (95% confidence interval (CI) 4.17-6.21). The median of serial interval was 6.00 days (95% CI 5.00-7.00). The basic reproductive number (R0) was 2.06 (95% CI 2.02-2.08). The median of onset-to-care-seeking days and the median of onset-to-hospital admission days were significantly reduced after 23 January 2020, which implied the enhanced public health awareness among families. With epidemic containment measures in place, the results can inform health authorities about possible extent of epidemic transmission within families. Furthermore, following initiation of interventions, public health measures are not only important for curbing the epidemic spread at the community level but also improve health seeking behaviour at the individual level.

Marcus Relationship Maintained During Ultrafast Electron Transfer Across a Supramolecular Capsular Wall.

Photoinduced electron transfer across an organic capsular wall between excited donors and ground-state acceptors is established to occur with rate constants varying in the range 0.32-4.0 × 1011 s-1 in aqueous buffer solution. The donor is encapsulated within an anionic supramolecular capsular host, and the cationic acceptor remains closer to the donor separated by the organic frame through Coulombic attraction. Such an arrangement results in electron transfer proceeding without diffusion. Free energy of the reaction (ΔG°) and the rate of electron transfer show Marcus relation with inversion. From the plot, λ and Vel were estimated to be 1.918 and 0.0058 eV, respectively. Given that the donor remains within the nonpolar solvent-free confined space, and there is not much change in the environment around the acceptor, the observed λ is believed to be because of "internal" reorganization rather than "solvent" reorganization. A similarity exists between the capsular assembly investigated here and glass and crystals at low temperature where the medium is rigid. The estimated electronic coupling (Vel) implies the existence of interaction between the donor and the acceptor through the capsular wall. Existence of such an interaction is also suggested by 1H NMR spectra. Results of this study suggest that molecules present within a confined space could be activated from outside. This provides an opportunity to probe the reactivity and dynamics of radical ions within an organic capsule.

Training and evaluating simulation debriefers in low-resource settings: lessons learned from Bihar, India.

BACKGROUND: To develop effective and sustainable simulation training programs in low-resource settings, it is critical that facilitators are thoroughly trained in debriefing, a critical component of simulation learning. However, large knowledge gaps exist regarding the best way to train and evaluate debrief facilitators in low-resource settings. METHODS: Using a mixed methods approach, this study explored the feasibility of evaluating the debriefing skills of nurse mentors in Bihar, India. Videos of obstetric and neonatal post-simulation debriefs were assessed using two known tools: the Center for Advanced Pediatric and Perinatal Education (CAPE) tool and Debriefing Assessment for Simulation in Healthcare (DASH). Video data was used to evaluate interrater reliability and changes in debriefing performance over time. Additionally, twenty semi-structured interviews with nurse mentors explored perceived barriers and enablers of debriefing in Bihar. RESULTS: A total of 73 debriefing videos, averaging 18 min each, were analyzed by two raters. The CAPE tool demonstrated higher interrater reliability than the DASH; 13 of 16 CAPE indicators and two of six DASH indicators were judged reliable (ICC > 0.6 or kappa > 0.40). All indicators remained stable or improved over time. The number of 'instructors questions,' the amount of 'trainee responses,' and the ability to 'organize the debrief' improved significantly over time (p < 0.01, p < 0.01, p = 0.04). Barriers included fear of making mistakes, time constraints, and technical challenges. Enablers included creating a safe learning environment, using contextually appropriate debriefing strategies, and team building. Overall, nurse mentors believed that debriefing was a vital aspect of simulation-based training. CONCLUSION: Simulation debriefing and evaluation was feasible among nurse mentors in Bihar. Results demonstrated that the CAPE demonstrated higher interrater reliability than the DASH and that nurse mentors were able to maintain or improve their debriefing skills overtime. Further, debriefing was considered to be critical to the success of the simulation training. However, fear of making mistakes and logistical challenges must be addressed to maximize learning. Teamwork, adaptability, and building a safe learning environment enhanced the quality enhanced the quality of simulation-based training, which could ultimately help to improve maternal and neonatal health outcomes in Bihar.

Ultrafast Solvation Dynamics Reveal that Octa Acid Capsule's Interior Dryness Depends on the Guest.

Coumarins are well-known to exhibit environment-dependent excited-state behavior. We have exploited this feature to probe the accessibility of solvent water molecules to coumarins (guest) encapsulated within an organic capsule (host). Two sets of coumarins, one small that fits well within the capsule and the other larger that fits within an enlarged capsule, are used as guests. In our study, the two sets of coumarins serve different purposes: one is employed to explore electron transfer across the capsule and the other to release photoprotected acids into the aqueous environment. The capsule is made up of two molecules of octa acid (OA) and is soluble in an aqueous medium under slightly basic conditions. Molecular modeling studies revealed that while the OA capsule is fully closed with no access to water in the case of smaller coumarins, with the larger molecules, the capsule is not tight and the guest is in contact with water molecules, the number being dependent on the size of the coumarin. We have used the ultrafast time-dependent Stokes shift method to understand the solvent dynamics around the above guest molecules encapsulated within an OA capsule in an aqueous medium. Results depict that for the smaller sets of coumarins, water cannot access the guests within the OA cavity during their excited state lifetime. However, the case is completely different for the larger coumaryl esters. Distorted capsule structure exposes the guest to water, and a dynamics Stokes shift is observed. The average solvation time decreases with the increasing size of guests that clearly indicates accessibility of the encapsulated guests toward greater number of water molecules as the capsule structure distorts with increasing size of the guests. Results of the ultrafast solvation dynamics are consistent with that of molecular dynamics simulation.

Barriers and facilitators to the provision of optimal obstetric and neonatal emergency care and to the implementation of simulation-enhanced mentorship in primary care facilities in Bihar, India: a qualitative study.

BACKGROUND: Globally, an estimated 275,000 maternal deaths, 2.7 million neonatal deaths, and 2.6 million third trimester stillbirths occurred in 2015. Major improvements could be achieved by providing effective care in low- and middle-income countries, where the majority of these deaths occur. Mentoring programs have become a popular modality to improve knowledge and skills among providers in low-resource settings. Thus, a detailed understanding of interrelated factors affecting care provision and mentorship is necessary both to improve the quality of care and to maximize the impact of mentoring programs. METHODS: In partnership with the Government of Bihar, CARE India and PRONTO International implemented simulation-enhanced mentoring in 320 primary health clinics (PHC) across the state of Bihar, India from 2015 to 2017, within the context of the AMANAT mobile nurse mentoring program. Between June and August 2016, we conducted semi-structured interviews with 20 AMANAT nurse mentors to explore barriers and facilitators to optimal care provision and to implementation of simulation-enhanced mentorship in PHCs in Bihar. Data were analyzed using the thematic content approach. RESULTS: Mentors identified numerous factors affecting care provision and mentorship, many of which were interdependent. Such barriers included human resource shortages, nurse-nurse hierarchy, distance between labor and training rooms, cultural norms, and low skill level and resistance to change among mentees. In contrast, physical resource shortages, doctor-nurse hierarchy, corruption, and violence against providers posed barriers to care provision alone. Facilitators included improved skills and confidence among providers, inclusion of doctors in training, increased training frequency, establishment of strong mentor-mentee relationships, administrative support, and nursing supervision and feedback. CONCLUSIONS: This study has identified many interrelated factors affecting care provision and mentorship in Bihar. The mentoring program was not designed to address several barriers, including resource shortages, facility infrastructure, corruption, and cultural norms. These require government support, community awareness, and other systemic changes. Programs may be adapted to address some barriers beyond knowledge and skill deficiencies, notably hierarchy, violence against providers, and certain cultural taboos. An in-depth understanding of barriers and facilitators is essential to enable the design of targeted interventions to improve maternal and neonatal survival in Bihar and related contexts.

Living with HIV in West Bengal, India: perceptions of infected children and their caregivers.

Children living with HIV (CLH) face several physical and psychological challenges. The impact of the disease is not limited to the affected CLH, but also affects their caregivers and family members. We qualitatively explored the experiences, knowledge, concerns, and perceptions of primary caregivers and triangulated those aspects with those expressed by their CLH. We conducted 34 in-depth interviews (IDI) with primary caregivers of 8- to 15-year-old CLH residing in West Bengal, India. Four focus group discussions (FGD) with CLH were held, two each with children aged 8-12 and 13-15 years. Participants were recruited with the help of a community-based organization providing need-based services to adults and CLH. Five major themes shared by caregivers and children were identified, including concerns about HIV, medications, discriminatory behaviors, having a "healthy mind", and the advantages and limitations of available HIV-related health services. Two primary themes exclusively from IDI with caregivers were caregiving challenges and concerns about the future of their CLH. Indian CLH and their caregivers face many daily challenges, and there are many unmet but relevant expectations. Caregiving goes beyond the child-caregiver dynamic, and is intertwined with the local community and the healthcare and support system structures. The current study underscores the need for comprehensive care programs focusing on improving support to both CLH and caregivers.

Health-related quality of life (HRQoL) and its correlates among community-recruited children living with HIV and uninfected children born to HIV-infected parents in West Bengal, India.

PURPOSE: Helping children living with HIV (CLH) to attain an optimum quality of life is an important goal for HIV programs around the world. Our principal objectives were to determine the association of HIV infection with different domains of health-related quality of life (HRQoL) among 8- to 15-year-old CLH in India and to compare the HRQoL parameters between CLH and HIV-negative children born to HIV-infected parents ("HIV-affected"). We also assessed whether antiretroviral therapy (ART) and CD4 lymphocyte counts were associated with HRQoL among CLH. METHODS: Using the "Quality of Life (health-related) of Children Living with HIV/AIDS in India" instrument, we interviewed 199 CLH and 194 HIV-affected children from three districts of West Bengal, India. Participants were asked to quantify the difficulties faced by them in six HRQoL domains: physical, emotional, social, school functioning, symptoms, and discrimination. RESULTS: The mean age of the participants was 11.6 (SD ± 2.5) years. CLH, compared to HIV-affected children, had poorer scores on all HRQoL domains except 'discrimination.' Among CLH, there were no significant differences in HRQoL domain scores (except in the 'discrimination' domain) between ART-treated and -untreated groups. CD4 lymphocyte count was found to be a significant positive predictor of the 'symptom' scale score. CONCLUSIONS: In India, interventions for CLH mostly focus on biological disease. However, the current study revealed that HRQoL among CLH was much poorer than that of a socio-demographically comparable group. Culturally and developmentally appropriate psychosocial support measures for Indian CLH are urgently needed.

Evaluation of the mobile nurse training (MNT) intervention - a step towards improvement in intrapartum practices in Bihar, India.

BACKGROUND: Evidence shows that improving the quality of intrapartum care is critical for maternal survival. However, a significant rise in the proportion of facility-based births over the last decade in India - attributable to a cash transfer program - has not resulted in a corresponding reduction in maternal mortality, thanks, in part, to low-skilled care at facilities. The current study evaluated a mobile knowledge-based intervention aimed at improving quality of care by mentoring in-service staff nurses at public obstetric facilities. METHODS: An independent evaluation team conducted baseline and post-intervention assessments at every facility using a mix of methods that included training assessments and Direct Observation of Deliveries. The assessment involved passive observation of pregnant women from the time of their admission at the facility and recording the obstetric events and delivery-related practices on a pre-formatted checklist-based tool. Maternal practices were classified into positive and negative ones and scored. Linear regression analysis was used to evaluate the association of MNT intervention with summary scores for positive, negative and overall practice scores. We evaluated retention of intervention effect by comparing the summary scores at baseline, immediately following intervention and 1 year after intervention. RESULTS: In both unadjusted and adjusted analyses, the intervention was found to be significantly associated with improvement in positive practice score (Unadjusted: parameter estimate (ß) = 16.90; 95% confidence interval (CI) = 15.20, 18.60. Adjusted: ß = 13.14; 95% CI = 10.97, 15.32). The intervention was also significantly associated with changes in negative practice score, which was reverse coded to represent positive change (Unadjusted: ß = 11.66; 95% CI = 10.06, 13.27. Adjusted: ß = 2.99; 95% CI = 1.35, 4.63), and overall practice score (Unadjusted: ß = 15.74; 95% CI = 14.39, 17.08; Adjusted: ß = 10.89; 95% CI = 9.18, 12.60). One year after the intervention, negative practices continued to improve, albeit at a slower rate; positive labor practices and overall labor practice remained higher than the baseline but with some decline over time. CONCLUSIONS: Findings suggest that in low resource settings, interventions to strengthen quality of human resources and care through mentoring works to improve intrapartum maternal care.

Care of the mother-infant dyad: a novel approach to conducting and evaluating neonatal resuscitation simulation training in Bihar, India.

BACKGROUND: As the global under-five mortality rate declines, an increasing percentage is attributable to early neonatal mortality. A quarter of early neonatal deaths are due to perinatal asphyxia. However, neonatal resuscitation (NR) simulation training in low-resource settings, where the majority of neonatal deaths occur, has achieved variable success. In Bihar, India, the poorest region in South Asia, there is tremendous need for a new approach to reducing neonatal morality. METHODS: This analysis aims to assess the impact of a novel in-situ simulation training program, developed by PRONTO International and implemented in collaboration with CARE India, on NR skills of nurses in Bihar. Skills were evaluated by clinical complexity of the simulated scenario, which ranged from level 1, requiring NR without a maternal complication, to level 3, requiring simultaneous management of neonatal and maternal complications. A total of 658 nurses at 80 facilities received training 1 week per month for 8 months. Simulations were video-recorded and coded for pre-defined clinical skills using Studiocode™. RESULTS: A total of 298 NR simulations were analyzed. As simulation complexity increased, the percentage of simulations in which nurses completed key steps of NR did not change, even with only 1-2 providers in the simulation. This suggests that with PRONTO training, nurses were able to maintain key skills despite higher clinical demands. As simulation complexity increased from level 1 to 3, time to completion of key NR steps decreased non-significantly. Median time to infant drying decreased by 7.5 s (p = 0.12), time to placing the infant on the warmer decreased by 21.7 s (p = 0.27), and time to the initiation of positive pressure ventilation decreased by 20.8 s (p = 0.12). Nevertheless, there remains a need for improvement in absolute time elapsed between delivery and completion of key NR tasks. CONCLUSIONS: PRONTO simulation training enabled nurses in Bihar to maintain core NR skills in simulation despite demands for higher-level triage and management. Although further evaluation of the PRONTO methodology is necessary to understand the full scope of its impact, this analysis highlights the importance of conducting and evaluating simulation training in low-resource settings based on simultaneous care of the mother-infant dyad.