The impact of the introduction of fidaxomicin on the management of Clostridium difficile infection in seven NHS secondary care hospitals in England: a series of local service evaluations.

Clostridium difficile infection (CDI) is associated with high mortality. Reducing incidence is a priority for patients, clinicians, the National Health Service (NHS) and Public Health England alike. In June 2012, fidaxomicin (FDX) was launched for the treatment of adults with CDI. The objective of this evaluation was to collect robust real-world data to understand the effectiveness of FDX in routine practice. In seven hospitals introducing FDX between July 2012 and July 2013, data were collected retrospectively from medical records on CDI episodes occurring 12 months before/after the introduction of FDX. All hospitalised patients aged ≥18 years with primary CDI (diarrhoea with presence of toxin A/B without a previous CDI in the previous 3 months) were included. Recurrence was defined as in-patient diarrhoea re-emergence requiring treatment any time within 3 months after the first episode. Each hospital had a different protocol for the use of FDX. In hospitals A and B, where FDX was used first line for all primary and recurrent episodes, the recurrence rate reduced from 10.6 % to 3.1 % and from 16.3 % to 3.1 %, with a significant difference in 28-day mortality from 18.2 % to 3.1 % (p < 0.05) and 17.3 % to 6.3 % (p < 0.05) for hospitals A and B, respectively. In hospitals using FDX in selected patients only, the changes in recurrence rates and mortality were less marked. The pattern of adoption of FDX appears to affect its impact on CDI outcome, with maximum reduction in recurrence and all-cause mortality where it is used as first-line treatment.

Role of Yoga as an Adjunct in the Management of Migraine Headache-Current Status and Future Indications.

Migraine headache is a painful, disabling condition afflicting 7% of the population. The long-term effort of coping with a chronic headache disorder predisposes the individual to other psychiatric illnesses, ischemic cerebrovascular disease as well as medicine overuse headache. The use of nonpharmacological methods to reduce the stress and pain associated with headache can improve the overall quality of life and reduce the burden of the disease. To examine the utility of yoga as an adjunct to pharmacological treatment of migraine headache. The review article is based on the secondary literature collected through the Google Scholar database between the years 2010 and 2020. Several themes were identified regarding the burden of migraine/headache and the need for the integration of yoga into the existing healthcare system. Despite the limitations and the need for greater scientific rigor, there have been consistent reports of the beneficial effects of yoga in the reduction of stress, anxiety, depression, and an enhanced quality of life, as well as better pain management in chronic diseases. Studies on the role of yoga in the treatment of migraine have been few in number. They have consistently shown that yoga can be a valuable adjunct to the existing pharmacological interventions in the management of migraine headache. In recent years, the Indian government has made enormous strides in establishing yoga outreach programs throughout the country. The need of the hour is to integrate evidence-based yoga with the wellness centers and noncommunicable diseases treatment plan. It can help to reduce the burden on the existing health care resources.

Comparison of propofol deep sedation versus moderate sedation during endosonography.

BACKGROUND: The purposes of this study are: (1) to prospectively evaluate clinically relevant outcomes including sedation-related complications for endoscopic ultrasound (EUS) procedures performed with the use of propofol deep sedation administered by monitored anesthesia care (MAC), and (2) to compare these results with a historical case-control cohort of EUS procedures performed using moderate sedation provided by the gastrointestinal (GI) endoscopist. MATERIALS AND METHODS: Patients referred for EUS between January 1, 2001 and December 31, 2002 were enrolled. Complication rates for EUS using MAC sedation were observed and also compared with a historical case-control cohort of EUS patients who received meperidine/midazolam for moderate sedation, administered by the GI endoscopist. Logistic regression analysis was used to isolate possible predictors of complications. RESULTS: A total of 1,000 patients underwent EUS with propofol sedation during the period from January 1, 2001 through December 31, 2002 (mean age 64 years, 53% female). The distribution of EUS indications based on the primary area of interest was: 170 gastroduodenal, 92 anorectal, 508 pancreaticohepatobiliary, 183 esophageal, and 47 mediastinal. The primary endpoint of the study was development of sedation-related complications occurring during a performed procedure. A total of six patients experienced complications: duodenal perforation (one), hypotension (one), aspiration pneumonia (one), and apnea requiring endotracheal intubation (three). The complication rate with propofol was 0.60%, compared with 1% for the historical case-control (meperidine/midazolam moderate sedation) group. CONCLUSIONS: There does not appear to be a significant difference between complication rates for propofol deep sedation with MAC and meperidine/midazolam administered for moderate sedation.

Effectiveness of introducing blood culture collection packs to reduce contamination rates.

Contaminated blood cultures result in a significant waste of healthcare resources and can lead to inappropriate antibiotic therapy. Practitioners have taken measures to reduce contamination rates. These include thorough skin disinfection, effective hand decontamination, introduction of a standardised approach to collection, and the introduction of blood culture collection packs (BCCP). This study aims to assess the impact of introducing BCCP and staff training on the rate of contamination. The study demonstrated that contamination rates are greatest in high patient throughput units where practitioners are under most pressure. The introduction of blood culture packs and staff training has reduced contamination rate significantly from 43% to 25% of the total number of positives, equating to an overall reduction of 42%. Thus, there is a demonstrable benefit in the purchase of commercially produced blood culture packs and the investment in staff training.

Nutritional risk factors in esophageal cancer.

OBJECTIVE: The present case-control study was undertaken with the objective to study the nutritional risk factors associated with esophageal cancer. METHODOLOGY: One hundred and fifty diagnosed esophageal cancer patients and an equal number of healthy individuals constituted the patient and control groups, respectively. Dietary consumption pattern during the preceding 20 years prior to the diagnosis of esophageal cancer was assessed utilising the standard food frequency questionnaire method. Information on alcohol consumption, smoking habits, chewing of betel leaf with tobacco was also collected. RESULTS: Multivariate analysis revealed that the risk of esophageal cancer was 7.81 times (p < 0.01) higher with daily consumption of alcohol. The risk increased to 3.16 times (p < 0.01) with the daily habit of chewing of betel leaf with tobacco. Nearly a two fold risk was observed when the consumption of "other vegetables" was less than four times per week. A 1.95 times (p < 0.01) increase in risk was observed with the daily habit of bidi smoking. CONCLUSION: Cancers in general are multifactorial in origin, and several environmental interactions are possible. It is not easy to quantify the contribution of diet to cancer risk. However, the results of the present study suggested that nutritional factors do play a role.

Organoleptic study of deacidified and deodourised palm oil.

Deficiency of vitamin A has long been identified as a serious and preventable nutritional disorder, associated with increased risk of mortality and morbidity amongst children. The present study was conducted with the objectives (i) to perform organoleptic testing of food products cooked in Deacidified and Deodourised Palm Oil (DDPO), by sensory evaluation method and (ii) to compare the characteristics of these food products with the same products cooked in routinely used oil. Eleven commonly used weaning food items were prepared with routinely used oil (Group A). The same recipes were also prepared with DDPO (Group B). A food testing panel conducted the sensory evaluation for assessing the acceptability of the various food items. It was observed that with respect to all characteristics there was no significant difference in the recipes made with the two types of oil. Results Indicated that DDPO can be used in India for preparation of weaning foods which are routinely given to young children.

Assessment of status of salt iodization in Delhi.

The National Capital Territory (NCT) of Delhi was identified as an iodine deficiency endemic area in 1980. The government of NCT of Delhi banned the sale of non-iodised salt since 1989. The present study was aimed to estimate the iodine content of salt consumed in the households of the state. Thirty clusters were selected using population proportionate to size cluster sampling procedure. In each identified cluster one primary school was randomly selected. In each school, 60 salt samples were collected from an equal number of school children. The iodine content of a total of 1854 salt samples collected was analyzed using the standard iodometric titration method. Forty one per cent of families consumed salt with an iodine content of less than 15 ppm. Salt with nil iodine content was consumed only by 1.4% of the beneficiaries which indicated successful implementation of universal salt iodization programme in the state.

Iodine deficiency in district Kinnaur, Himachal Pradesh.

The state of Himachal Pradesh is a known iodine deficiency endemic region since the last 40 years. The state government is supplying iodised salt to the district since 1970. No recent survey has been conducted on the prevalence of iodine deficiency from the district Kinnaur which is located at an average altitude of 10,000 feet above sea level. A total of 1094 children in the age group of 6-10 years were included in the study and clinically examined. The total goitre prevalence of 6.1% was found in the subjects studied. Urine samples were collected from 226 children and were analysed using standard laboratory procedures. It was found that the percentage of children with < 2 mcg/dl, 2-4.9 mcg/dl, 5-9.9 mcg/dl and 10 and above mcg/dl of urinary iodine excretion (UIE) level was 1.3, 5.8, 10.6 and 82.3 respectively. A total of 242 salt samples were collected and analysed using the standard iodometric titration method. Results showed that almost 90% of the families were consuming salt with an iodine content of 15 ppm and more which is the stipulated level of iodisation of salt. The findings of the study indicate that iodine nutrition is in the transition phase from iodine deficient to iodine sufficient. Findings revealed a need for further strengthening the monitoring of the quality of salt being distributed in Kinnaur to achieve elimination of iodine deficiency.

Prevalence of underweight, stunting and wasting.

PIP: The z-score classification system was used to assess the prevalence of underweight, stunting, and wasting in 630 children under 6 years of age from two urban slums in Delhi, India. Z-scores for weight-for-age, height-for-age, and weight-for-height were calculated with US National Center for Health Statistics reference data as standards. According to the weight-for-age criteria, 57.6% of children were undernourished and 20.3% fell under Grade II of z-score scales. 53.0% of children were stunted and 22.5% were wasted. Stunting was most prevalent in the 48-59 month age group, while underweight occurred most often among children 24-35 months old and the highest prevalence of wasting was observed in the second year of life. An analysis of 24-hour dietary intake recall data on a subsample of 225 children revealed that the underweight, wasted, and stunted children had significantly lower energy and protein intakes than normal children (p 0.05). This study demonstrates that the z-score classification system, recommended by the World Health Organization for assessing the nutritional status of preschool children, is a feasible methodology in this population.^ieng

National nutrition supplementation programmes.

PIP: Currently major nutrition supplementation programs in India are: 1) Integrated Child Development Services Scheme (ICDS); 2) Mid-day meal Programs (MDM); 3) Special Nutrition Programs (SNP); 4) Wheat Based Nutrition Programs (WNP); 5) Applied Nutrition Programs (ANP); 6) Balwadi Nutrition Programs (BNP); 7) National Nutritional Anaemia Prophylaxis Program (NNAPP); 8) National Program for Prevention of Blindness due to Vitamin A Deficiency; and 9) National Goiter Control Program (NGCP). The history of the respective programs, their beneficiaries, objectives, activities, organization, and evaluation are detailed. The ICDS beneficiaries are children below 6 years, pregnant and lactating mothers, and women aged 15-44 years, who are provided the following: supplementary nutrition; immunization; health check-ups; referral services; treatment of minor illnesses; pre-school education to children aged 3-6 years. The MDM program's intended beneficiaries are children attending the primary school. Children belonging to backward classes, scheduled caste, and scheduled tribe families are given priority. The SNP is to provide supplementary nutrition and health care services including supply of vitamin A solution and iron and folic acid tablets to pre-school children, and pregnant and lactating mothers of poor groups in urban slums and tribal areas. The ANP strives to make people conscious of their nutritional needs and to provide supplementary nutrition to children aged between 3-6 years and to pregnant and lactating mothers. The beneficiaries of the WNP scheme are children of pre-school age and nursing and expectant mothers in areas with high infant mortality such as urban slums and backward rural areas. The program of BNP aims to supply about one-third of the calorie and half of the protein requirements of pre-school children between the age of 3-5 years to improve the nutritional status. The NNAPP scheme beneficiaries are children in the 1-5 age group and pregnant and nursing mothers, female acceptors of terminal methods of family planning and IUDs. The NGCP aims to supply iodized salt to the entire country by 1992.^ieng

Utility of growth monitoring: its relevance in the promotion of child health.

PIP: Growth monitoring (GM) in India is a strategy to detect early growth retardation, promote optimum growth, create awareness about growth among mothers, enhance delivery of primary health care, and identify those at risk of malnutrition. Anthropometric measures include weight, height, mid-upper arm circumference, chest circumferences, and the ratio of chest to head circumference. Weight-for-age is the recommended measure of growth, because of the measure's sensitivity to change. In developing countries preventive growth charts are used. In developed countries curative growth charts are used and require decimals of age and the ability to use graphs. The weight measure is sensitive to changes due to malnutrition. Maternal maintenance of a growth card provides a visual reminder about the nutrition and health of her child, an immunization record, feeding patterns, and child spacing. Growth monitoring programs involved weighing, maintaining growth charts, promoting health advice among mothers, following-up by health workers, arranging mothers' meetings, maintaining home visits by health workers, and supplying other health care services such as immunization, birth spacing promotion, and oral rehydration information and supplies. Growth monitoring and growth surveillance are different but complementary. Growth monitoring is not just periodic nutritional assessment. Growth monitoring involves improving interactions between mothers and the community, educating about nutrition, and improving child health. 33% of India's administrative blocks (2600 blocks) are involved in the Integrated Child Development Services (ICDS), which promote child health and nutritional status. The "anganwadi" worker serves as the main functionary for an area of about 1000 total population. Slowness of growth has been reported as disregarded in favor of attention to severe malnourishment. Success of growth monitoring was determined to be contingent on early identification of growth faltering, being part of the primary care system, having adequate supplies of weighing equipment, providing nutrition and health education, having community support, and providing referral services. Deficits in selected ICDS programs were lack of skills to use growth charts. Quality of programs varied widely. Recommendations were made for future improvements.^ieng

Status of growth monitoring activities in selected ICDS projects of Rajasthan.

PIP: Growth monitoring (GM) is conducted in India on a regular basis as part of the Integrated Child Development Service (ICDS) scheme operative in over 3900 administrative blocks. GM can serve as a focal point for offering child and family welfare services and provide data for the assessment of a community's nutritional status. To evaluate GM knowledge and practices among Anganwadi workers (AWWs), a survey of 120 AWWs from ICDS projects in Jaipur, Ajmer, Udaipur, Bharatput, and Bikaner districts was conducted. 67% of AWWs had worked in the ICDS program for more than 5 years and 88% had completed primary school. Although 88.3% received pre-placement training and 67.5% participated in subsequent in-service training, GM was not included. Growth charts were available to 83.3% of AWWs, but 75% were unable to use weighing scales properly. Half plotted weights incorrectly on the chart, and 57% were unable to interpret a flattened growth curve. 90% lacked knowledge of the sequence of steps involved in GM. Only 33% conducted GM, primarily to identify malnourished children. A record review indicated the weights of only 60% of children were being recorded regularly. 40% of the severely malnourished children were not being weighed regularly. Mothers' participation in improving their child's nutritional status was not solicited. These findings suggest that the potential of GM activities in India is being impeded by inadequate knowledge and training on the part of AWWs, faulty equipment, and a lack of community participation.^ieng

Status of iodine deficiency in selected blocks of Kangra District, Himachal Pradesh.

PIP: In response to a 1954 study revealing an iodine deficiency prevalence of 41.2% in India's Kangra District (Himachal Pradesh), a salt iodization program was launched in the district in 1963. To assess the long-term impact of this ongoing program, the prevalence of goiter was investigated in 1995 in 1358 children 8-10 years of age recruited from primary schools in 4 of the district's 13 administrative blocks. The overall prevalence of goiter was 5.7% (range, 2.4-9.0%). The median urinary iodine excretion in a subsample of 245 children was 16.5 mcg/dl. 2.5% of these children had severe iodine deficiency, 4.1% had moderate deficiency, 17.1% had mild deficiency, and 76.3% had no iodine deficiency. 77% of salt samples analyzed had adequate iodine content (15 ppm and above). These findings confirm that the universal iodization of salt represents an effective means of lowering the prevalence of iron deficiency disorders.^ieng

Assessment of iodine deficiency disorders using the 30 cluster approach in the National Capital Territory of Delhi.

OBJECTIVE: Iodine Deficiency Disorders (IDD) are a major public health problem in India. The National Capital Territory (NCT) of Delhi is a known iodine deficiency endemic area. The Delhi Government banned the sale of non-iodised salt since 1989. The present study was conducted to assess the status of IDD after 7 years of salt iodisation programme in the state. DESIGN: Cross sectional. METHODOLOGY: The recent indicators recommended by the World Health Organization-United Nations Childrens Fund-International Council for the Control of Iodine Deficiency Disorders (WHO-UNICEF-ICCIDD) were utilized for the assessment of IDD. A total of 30 clusters were selected using population proportionate to size cluster sampling procedure. In each identified cluster, one primary school was selected using random sampling. A total of 6911 school children in the age group of 8-10 years were included for the study. RESULTS: The total goiter prevalence rate was 8.6% while 2.1, 8.4, 17.6 and 71.9% of the children had urinary iodine excretion levels of < 2, 2-4.9, 5-9.9 and 10 and above mcg/dl, respectively. The median urinary iodine excretion was 17 mcg/dl. Of the 1854 salt samples analyzed, salt with a nil iodine content was consumed only by 1.4% of the beneficiaries. Forty one per cent of families consumed salt with an iodine content of less than 15 ppm. CONCLUSION: IDD continues to be a public-health problem in the NCT of Delhi. There is a need of strengthening the existing monitoring system for the quality of iodised salt.

Use of milk based commercial weaning foods amongst scheduled caste communities in Haryana.

PIP: Although breast milk is the best food for an infant until age 4-6 months, there has been a recent trend in urban areas to increasingly provide milk-based commercial weaning foods (CWF). This study was conducted to assess the use of CWF among the scheduled caste population in two districts of Haryana State. The data presented are part of a larger study on breast feeding and weaning practices in Haryana. 818 children aged 0-35 months from 44 villages were included in the study. 68 had received milk-based CWF at the time of survey or sometime previously. There was no significant difference between the socioeconomic characteristics of children who were given milk-based CWF and those who did not receive it. 36% of women who used CWF reported having done so because of insufficient lactation, while 37% cited the high price of animal milk. Family members were the most important source of advice for initiating the use of CWF, followed by medical functionaries. 65% of all children surveyed received home-based weaning foods. The percentages of children receiving such foods in the age groups 0-5, 6-11, 12-17, 18-23, 24-29, and 30-35 months were 1%, 56%, 77%, 97%, 95%, and 96%, respectively. Only 73.7% of children older than age 3 months were breastfed together with CWF.^ieng

Breast-feeding practices in Schedule Caste communities in Haryana state.

A study was conducted to assess exclusive breast-feeding, continued breast-feeding, bottle-feeding, predominant breast-feeding, timely complementary feeding and other breast-feeding practices in 818 children in the age group of 0-3 years belonging to the Schedule Caste communities of Haryana. The exclusive breast-feeding rate was 0.15 and the predominant breast-feeding rate 0.75 in children < 4 months. Timely complementary feeding rate was 0.42. The continued breast-feeding rate at 1 year and 2 years was 0.84 and 0.58, respectively. The bottle-feeding rate, ever breast-fed rate, timely first-suckling rate and exclusive breast-feeding rate by mother were 0.09, 1.0, 0.0 and 0.15, respectively. The median duration of breast-feeding was 16 months.

PIP: Data on 818 children aged 0-3 years belonging to the schedule caste population from 44 villages in Faridabad and Hisar districts of Haryana State, India, were analyzed to determine the current status of breast feeding practices in this underprivileged population. All the children had been breast fed. The exclusive breast feeding rate during the first 4 months of life was only 15%. Even though water intake increases the risk of diarrhea, mothers supplemented breast feeding with water in 85% of children to improve hydration status. 98% of the children were given ghutti (an herbal decoction) to improve their digestive abilities. The median duration of breast feeding was 16 months. 2% of infants aged less than 1 year received infant formula. Overall, bottle feeding rate among this age group was 9%. 75% of infants aged less than 4 months were predominantly breast fed. 42% of infants aged 6-9 months received supplementary feedings. 84% of children aged 12-15 months were still breast feeding at 12 months. The timely first-suckling rate was zero. Other baseline surveys should be conducted in other areas of India so breast feeding promotional programs can be evaluated.

Assessment of knowledge and skills about growth monitoring amongst medical officers, child development project officers and multi purpose workers.

PIP: The study used interpretations of data filled on growth charts and questionnaires to assess the knowledge of medical officers (MOs), child development officers (CDPOs), and multipurpose workers (MPWs) about growth monitoring. The sample was drawn from health personnel who had worked in the CDS health blocks in Haryana state in India. Included were 48 CDPOs, who had worked more than 4 years; 24 MOs, who had worked more than 3 years; and 34 MPWs, who had worked for more than 10 years. All had to have had some measure of in-service or course training. All MOs and MPWs knew that adequate nutrition was necessary for an ascending growth curve; only 81% of CDPOs had this knowledge. 95% of MOs, 92% of CDPOs, and 82% of MPWs knew that inadequate food intake over a prolonged period of time yielded a depressed growth curve. Only 27% of CDPOs were aware that a flattened growth curve after a bout of the measles meant growth delays due to infection, while 100% of MPWs and 95% of MOs were aware. About 96% of MOs, 83% of CDPOs, and 100% of MPWs interpreted the descending growth curve as a decline in nutritional status. The general finding was that growth curves could be used to identify at-risk children and no weight gain by most personnel; however, MOs did not have adequate knowledge of the importance of age in assessment of growth monitoring, of the importance of weighing malnourished children monthly, or of the importance of weighing every 3 months above the age of 3 years. Adequate training needed to be provided to MOs in growth monitoring, because the MOs supervised the health program, which included health check-ups, immunization, nutritional health, and referral. Most of the health personnel could interpret growth charts accurately.^ieng

Dr. P. C. Sen Memorial Award Paper. Status of salt iodisation and iodine deficiency in selected districts of different states of India.

Iodine deficiency disorders (IDD) is a major public health problem. Surveys conducted by the National Goitre Survey team of the Directorate General of Health Services during the past three decades have revealed a high prevalence of endemic goitre in different states. Out of a total of 267 districts surveyed till date, 226 have been reported to be endemic to iodine deficiency. A successful measure for the prevention of IDD is salt iodisation. The Salt department, Government of India has taken an intensive programme of production of iodised salt in the country. The production has increased from 1.5 lakh metric tonnes in 1984 to 40 lakh metric tonnes in 1996. To assess the impact of increased production of iodised salt on the availability of iodised salt at the beneficiary and trader level and also on the status of iodine deficiency, surveys were undertaken in selected districts of 10 states and 2 union territories of the country. These studies have been presented and discussed here.

Diarrhoea amongst under three children in rural Haryana.

A community based study was conducted to assess the magnitude of the problem of diarrhoea and factors associated with it amongst children below three years of age. Two districts in Haryana state were selected by using multistage random sampling procedure. Eight hundred eighteen children in the age group of 0-35 months belonging to scheduled caste communities were studied. All children suffering from diarrhoea at the time of survey or within last 2 weeks were included for the detailed study. The occurrence of diarrhoea was highest in age group 6-11 months (28%) and was lowest in age group 0-5 months (16%). No relationship was found between the nutritional status of children and the occurrence of diarrhoea. The percentage prevalence of diarrhoea was 42, 32 and 36 per cent amongst normally, moderately and severely malnourished children, respectively. Thirty seven percent of children suffering from diarrhoea received bottle feed.

PIP: In 44 rural villages in Faridabad and Hisar districts of Harynana state, India, interviews with mothers of 818 children were conducted to determine the extent of diarrhea among scheduled caste communities. 172 children either had diarrhea at the time of or 2 weeks before the interview. Diarrhea incidence was greatest among the 6-11 month olds, the time when weaning begins and children are given foods and fluids other than breast milk. Incidence was lowest among 0-5 month olds, when many infants are exclusively breast fed. No correlation between nutritional status and diarrhea existed. Children with normal nutritional status were somewhat more likely to have or recently have had diarrhea than moderately and severely malnourished children (42.4% vs. 35.7% and 31.9%, respectively). Weaning practices with the highest proportion of children with an episode of diarrhea were commercial weaning foods (40%) and bottle feeding (36.8%).