Health Care Innovation for Low-Resource Settings: The Value of Local Immersion and Partnership.

Health Care Innovation is the creation, development, and translation of new and better solutions to health care challenges. At its core, this endeavor does not require extending the frontiers of science or the creation of new fundamental technologies. Rather, it is primarily focused on the use of existing science and established technologies in the design of new solutions to problems in health care. Successfully innovating for low- and middle-income countries (LMICs) requires a needs and stakeholder-driven approach to enable development and adoption of available, accessible, and acceptable solutions tailored to the specific need and context of care.

Perception of Dentists about Caries-risk Assessment tools in Jaipur, India: A Cross-sectional Study.

BACKGROUND: Caries risk assessment (CRA) is an essential element of contemporary clinical care for infants, children, and adolescents. CRA tools aid in the detection as well as documentation of caries risk predictors and let the health care professionals to be more active in identifying and referring high-risk patients for proper treatment and required prevention. The aim of the study was to assess the information-seeking behavior of dental practitioners of Jaipur regarding CRA tools. MATERIALS AND METHODS: A cross-sectional questionnaire-based survey was conducted among the dental practitioners of Jaipur city. A 17-itemed questionnaire was personally administered to 373 dental practitioners of Jaipur and their knowledge was assessed based on the questions about CRA tools and Cariogram. The data were analyzed using Chi-square test. RESULTS: Around 80.5% of the practitioners were aware of CRA tools among which only one-fourth were practicing CRA. Significant correlation of qualification, specialty, and years of practice was found with knowledge of CRA tools, practice of CRA and preventive treatment and attitude toward risk assessment. CONCLUSIONS: A substantial percentage of dentists did not practice CRA, but were interested in receiving more education about CRA and its tools.

Strategies to manage hepatitis C virus (HCV) infection disease burden - volume 2.

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries, and the relative impact of two scenarios was considered: (i) increased treatment efficacy while holding the treated population constant and (ii) increased treatment efficacy and increased annual treated population. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. In most countries, the annual treated population had to increase several fold to achieve the largest reductions in HCV-related morbidity and mortality. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. In most of the studied countries, the majority of patients were born between 1945 and 1985.

The present and future disease burden of hepatitis C virus (HCV) infections with today's treatment paradigm - volume 2.

Morbidity and mortality attributable to chronic hepatitis C virus (HCV) infection are increasing in many countries as the infected population ages. Models were developed for 15 countries to quantify and characterize the viremic population, as well as estimate the number of new infections and HCV related deaths from 2013 to 2030. Expert consensus was used to determine current treatment levels and outcomes in each country. In most countries, viremic prevalence has already peaked. In every country studied, prevalence begins to decline before 2030, when current treatment levels were held constant. In contrast, cases of advanced liver disease and liver related deaths will continue to increase through 2030 in most countries. The current treatment paradigm is inadequate if large reductions in HCV related morbidity and mortality are to be achieved.

Mothers' sense of coherence and oral health related quality of life of preschool children in Udupi Taluk.

OBJECTIVE: To assess the relationship between mothers' Sense of Coherence (SOC) and oral health related quality of life (OHRQoL) of 3-5 year old preschool children in Udupi Taluk. PARTICIPANTS: 388 mothers aged 24-48 years old and their preschool children. BASIC RESEARCH DESIGN: A cross sectional study of mother-child pairs, randomly selected from 8 preschools. METHOD: Information was obtained about mothers' sociodemographic factors along with the short version (SOC 13) of Antonovsky's sense of coherence scale and children's OHRQoL using the early childhood oral health impact scale (ECOHIS). Chi-square tests and multivariate logistic regression were used for analysis. MAIN OUTCOME MEASURES: Mothers' SOC and children's OHRQoL. RESULTS: Mothers' SOC and fathers' education were significantly associated with children's OHRQoL in multivariate analysis. Children of mothers with high SOC were 12.9 times as likely to have high OHRQoL as mothers with low SOC (p < 0.01). Children of fathers with college/university education were twice as likely to have high OHRQoL as those with primary education (p < 0.05). CONCLUSION: Our results suggest that mother's SOC could be a psychosocial determinant of the OHRQoL of their preschool children. Family environment should be considered when designing interventions to promote or improve the oral health as well as OHRQoL of preschool children.

Kinship care at community is better model to ensure psychosocial and economic security to orphans living with HIV than from care homes.

BACKGROUND: There were about 24,000 children affected by AIDS living in Nepal in 2010; of these 5,000 AIDS orphans were in need of immediate support. The objective of this study was to investigate which model of care and support is more appropriate for improving psychosocial and economic security of AIDS orphans. METHODS: With the documented 5200 cases of AIDS orphans from 42 districts at National Association of People Living with HIV, we purposively selected five districts - one from each development region, based on the highest number of AIDS orphans reported. From five districts, 56 HIV positive double orphans aged 8-18 years and their 42 caregivers were interviewed to find their psychosocial and economic situation. RESULTS: Thirty nine (70%) orphans were found living in kinship care, while 17(30%) were living in institutional care homes. Orphans living in kinship were more optimistic, as they were backed by their close relatives 35 (90%), had birth certificates 35 (90%), ensured inherent family property 21 (54%), obtained basic needs like food, education and shelter from grandparents 23 (59%), and had more than five friends who visited their homes 26 (67%). While, the orphans living in institutional care homes 17(30%) had no birth certificates, fewer contacts with siblings 2 (12%), and none had friends outside the care homes. CONCLUSIONS: Kinship care is better model for psychosocial and economic security for AIDS orphans in Nepal, rather than institutional care. Families can provide good protection to AIDS orphans if government provides minimum support to them.

Assessment and validation of the oral impact on daily performance (OIDP) instrument among adults in Karnataka, South India.

OBJECTIVES: The objective of the study was to test the applicability of abbreviated version of the oral impact on daily performance (OIDP) inventory among the adults visiting dental outreach centre in Karnataka, South India. BASIC RESEARCH DESIGN: Cross sectional study. CLINICAL SETTING: Dental outreach centre in Udupi District, Karnataka. PARTICIPANTS: 312 adults aged 35-44 years attending the centre. INTERVENTIONS: Face-to-face interview followed by oral health examination. The questionnaire in Kannada version of OIDP, perceived general and oral health and satisfaction with dental appearance were used. MAIN OUTCOME MEASURES: Reliability and Validity of OIDP instrument, Prevalence of oral impacts in study population. RESULTS: Majority of the participants (71.2%) reported oral health problems affecting at least one daily performance in the 6 months preceding the survey. The performance most affected was 'eating' (52.2%) followed by 'cleaning teeth' (32.4%). Cronbach's alpha for the OIDP frequency items was 0.70. Construct validity was proved by significant association of OIDP scores and self-rated oral, general health status and perceived satisfaction with appearance of teeth; with those more satisfied having fewer oral impacts (p < 0.001). Criterion validity was demonstrated in that the OIDP scores increased significantly as the number of decayed and missing teeth increased (p < 0.001). CONCLUSION: The Kannada version of OIDP had excellent psychometric properties for applicability among the adults in Karnataka. Thus, the study highlighted the limits of focusing exclusively on normative needs and suggested the incorporation of oral quality of life measures into the oral healthcare services.

Power Doppler sonography in the diagnosis of hemophilic synovitis--a promising tool.

BACKGROUND: Recurrent hemarthroses in hemophilia results in synovitis and joint arthropathy. Primary prophylaxis when universally instituted at current doses can prevent joint deterioration but is expensive. Alternatively, the selective implementation of prophylaxis would require a more sensitive tool for detecting synovitis than possible with clinical surveillance or plain radiographs. Magnetic resonance imaging (MRI) is such a tool and is utilized for the evaluation of hemophilic joint disease (HJD). However, it is expensive, and requires sedation in younger children precluding its utility for monitoring of synovitis. Ultrasonography (USG) with power Doppler (USG-PDS) has been utilized to detect and quantitate synovial vascularity in other arthritides and could provide an equally effective but less costly tool for HJD, particularly in children who would not require sedation. OBJECTIVES: To determine whether USG-PDS is comparable to MRI in the evaluation of hemophilic synovitis. PATIENTS: A prospective cohort of 31 subjects including 33 joints (knees, elbows, ankles) underwent dynamic contrast enhanced (DCE)-MRI and USG-PDS. RESULTS: USG-PDS measurements of synovial thickness(r = 0.70, P < 0.0001) and synovial vascularity (r = 0.73, P < 0.0001) correlated strongly with those obtained with DCE-MRI. A cutoff of PDS intensity of 1.3 decibels (dB) per mm(2) was found to yield a sensitivity of 100% and a specificity of 94.1% in 17 joints with/without a history of hemarthroses. Pettersson radiographic scores correlated significantly with synovial thickness in adults but not children. CONCLUSIONS: Our data suggest that USG-PDS may be an inexpensive and easily implemented imaging tool for detecting hemophilic synovitis and could be useful in tailoring effective prophylaxis.

Application of "the Sequential Organ Failure Assessment (SOFA) score" in predicting outcome in ICU patients with SIRS.

BACKGROUND: Various scoring systems have been developed to prioritize patient admission and management in ICU. The objective of this prospective, observational cohort study was to evaluate application of one such system, the Sequential Organ Failure Assessment (SOFA) Score in predicting outcome in ICU patients with SIRS. PATIENTS AND METHODS: Fifty patients admitted to a six bed multidisciplinary ICU with SIRS were consecutively enrolled in the study and SOFA scores were calculated at zero hour, after 48 hrs, and after 96 hrs and patients followed till discharge from hospital. RESULTS: When compared to outcome, the non survivors had high initial, mean and highest SOFA scores as compared to survivors. (p value = 0.002, <0.001, <0.001 respectively). Delta SOFA was not significantly associated with outcome. (p value= 0.117). The initial SOFA score > 11 predicted a mortality of 90%. (OR 23.72, 95%CI2.68-209.78, p=0.004). Similarly, mean SOFA score of > 7 predicted a mortality of 73.9% (OR 22.7, 95%CI 5.0 - 103.5, p<0.001) and high SOFA score > 11 predicted a mortality of 87.5% (OR 32.66, 95%CI 5.82-183.179, p< 0.001). Area under receiver operating characteristic (ROC) curve for mean SOFA was 0.825, for high SOFA was 0.817 and for initial SOFA was 0.708. Thus mean, high and initial SOFA scores were helpful in predicting between the survivors and the non survivors. CONCLUSION: The SOFA scoring system is useful in predicting outcomes in ICU and thus help in proper utilization of ICU resources.

Viral hepatitis in India.

Viral hepatitis is a major public health problem in India, which is hyperendemic for HAV and HEV. Seroprevalence studies reveal that 90%-100% of the population acquires anti-HAV antibody and becomes immune by adolescence. Many epidemics of HEV have been reported from India. HAV related liver disease is uncommon in India and occurs mainly in children. HEV is also the major cause of sporadic adult acute viral hepatitis and ALF. Pregnant women and patients with CLD constitute the high risk groups to contract HEV infection, and HEV-induced mortality among them is substantial, which underlines the need for preventive measures for such groups. Children with HAV and HEV coinfection are prone to develop ALF. India has intermediate HBV endemicity, with a carrier frequency of 2%-4%. HBV is the major cause of CLD and HCC. Chronic HBV infection in India is acquired in childhood, presumably before 5 years of age, through horizontal transmission. Vertical transmission of HBV in India is considered to be infrequent. Inclusion of HBV vaccination in the expanded programme of immunization is essential to reduce the HBV carrier frequency and disease burden. HBV genotypes A and D are prevalent in India, which are similar to the HBV genotypes in the West. HCV infection in India has a population prevalence of around 1%, and occurs predominantly through transfusion and the use of unsterile glass syringes. HCV genotypes 3 and 2 are prevalent in 60%-80% of the population and they respond well to a combination of interferon and ribavirin. About 10%-15% of CLD and HCC are associated with HCV infection in India. HCV infection is also a major cause of post-transfusion hepatitis. HDV infection is infrequent in India and is present about 5%-10% of patients with HBV-related liver disease. HCC appears to be less common in India than would be expected from the prevalence rates of HBV and HCV. The high disease burden of viral hepatitis and related CLD in India, calls for the setting up of a hepatitis registry and formulation of government-supported prevention and control strategies.

User fees, self-selection and the poor in Bangladesh.

The widespread uncontrolled introduction of user fees in any developing country is likely to have a disastrous impact on poorer patients. Furthermore, traditional targeting schemes aimed at their exemption are often expensive, difficult to administer and ineffective at reaching those in greatest need. This research study examines how user fees can raise revenue and target poorer patients, under the right market conditions, without resorting to costly targeting schemes. The authors draw their findings from case studies of cost recovery in the health and population sectors in Bangladesh. The mechanism suggested in the paper is to use self-selection. It is argued that under certain market conditions poorer patients will choose the health-care option that is appropriate to their means. They will thus identify themselves as poor without having to be selected or tested by an independent authority. This self-selection allows the relevant authorities to cross-subsidize their market choice by over-charging the non-poor in other segments of the market.

Environment and gender issues: need to revisit SAP.

PIP: It is now recognized that environmental degradation, gender inequality, access to and control over resources, gender-based division of labor in survival and management tasks related to the environment, and the feminization of poverty are all interconnected and must be approached with an interdisciplinary, gender perspective. Because women play a vital role in managing biodiversity and socioecological systems, measures that reinforce women's lack of control over resources threaten biodiversity as well as women's position. Creation of truly sustainable and equitable development policies and practices will require a transformation in economic, social, and gender relations that will result in a proper valuing of women's roles as managers of their environments and providers to their families. Policies designed to promote environmental sustainability would also result in desirable population changes. Instead, structural adjustment programs (SAPs) have had a disastrous effect on the environment because they favor large-scale projects over energy-saving projects, are export-driven and stimulate over-exploitation of natural resources, and serve a private market that fails to reimburse environmental costs. Kutznets' Curve explains that environmental pollution is inevitable in the early stages of economic development, prolonged by SAPs, and can only be mitigated when development generates enough money. Until this happens, vulnerable women are experiencing deterioration in their living conditions, and state policies are required to improve this situation.^ieng

Nutritional and medical status of lactating women and their infants in the Kathmandu valley of Nepal.

In six villages in the Kathmandu valley of Nepal, an intensive health and nutrition study was conducted on 26 lactating women and their 2--6-month-old infants. Analysis of 24-h duplicate diet composites indicated that the mothers were consuming approximately 2100 kcal energy/d. The diets contained approximately 62 g protein (11.6% of the calories), 392 g carbohydrate (73.3% of the calories), and 20.9 g fat (8.6% of the calories) and a mean of 24 g neutral detergent fiber. Although anthropometric measurements indicated that the mothers had mild protein malnutrition and inadequate energy reserves, their infants exhibited low-normal weight and length for age. All the mothers had hepatitis A antibodies; 92% had tropical eosinophilia, indicating intestinal parasites; 16% had cheilosis and angular stomatitis, indicating a possible B-vitamin deficiency; and 8% had elevated urinary nitrite, indicating urinary tract infection. There were no unusual physical findings on the infants. Although the children appeared healthy, the mothers showed evidence of multiple infections and possible nutrient deficiencies.

PIP: In 6 villages in the Kathmandu valley of Nepal, an intensive health and nutrition study was conducted on 26 lactating women and their 2-6-month-old infants. Analysis of 24-hour duplicate diet composites indicated that the mothers were consuming approximately 2100 kcal energy/d. The diets contained approximately 62 g protein (11.6% of the calories), 392 g carbohydrate (73.3% of the calories), and 20.9% g fat (8.6% of the calories) and a mean of 24 g neutral detergent fiber. Although anthropometric measurements indicated that the mothers had mild protein malnutrition and inadequate energy reserves, their infants exhibited low-normal weight and length for age. All the mothers had hepatitis A antibodies; 92% had tropical eosinophilia, indicating intestinal parasites; 16% had cheilosis and angular stomatitis, indicating a possible B-vitamin deficiency; and 8% had elevated urinary nitrite, indicating urinary tract infection. There were no unusual physical findings on the infants. Although the children appeared healthy, the mohters showed evidence of multiple infections and possible nutrient deficiencies.

Bedside ultrasonography. A low-cost definitive diagnostic procedure in obstructive jaundice.

We evaluated real-time ultrasonography carried out by gastroenterologists for its diagnostic accuracy in 89 patients with obstructive jaundice. The positive predictive values for the site and nature of the obstruction were 94.3 and 89.9%, respectively. The advanced stage of disease in our patients and the clinical background of the investigators may have contributed to the high diagnostic accuracy of ultrasonography in this study. Nevertheless, we recommend that gastroenterologists themselves perform bedside ultrasonography for a definitive diagnosis in patients with obstructive jaundice. The high degree of precision achieved by ultrasound in our setting makes more expensive investigations unnecessary as routine procedures.