Pro-poor policies and improvements in maternal health outcomes in India.

BACKGROUND: Since 2005, India has experienced an impressive 77% reduction in maternal mortality compared to the global average of 43%. What explains this impressive performance in terms of reduction in maternal mortality and improvement in maternal health outcomes? This paper evaluates the effect of household wealth status on maternal mortality in India, and also separates out the performance of the Empowered Action Group (EAG) states and the Southern states of India. The results are discussed in the light of various pro-poor programmes and policies designed to reduce maternal mortality and the existing supply side gaps in the healthcare system of India. Using multiple sources of data, this study aims to understand the trends in maternal mortality (1997-2017) between EAG and non EAG states in India and explore various household, economic and policy factors that may explain reduction in maternal mortality and improvement in maternal health outcomes in India. METHODS: This study triangulates data from different rounds of Sample Registration Systems to assess the trend in maternal mortality in India. It further analysed the National Family Health Surveys (NFHS). NFHS-4, 2015-16 has gathered information on maternal mortality and pregnancy-related deaths from 601,509 households. Using logistic regression, we estimate the association of various socio-economic variables on maternal deaths in the various states of India. RESULTS: On an average, wealth status of the households did not have a statistically significant association with maternal mortality in India. However, our disaggregate analysis reveals, the gains in terms of maternal mortality have been unevenly distributed. Although the rich-poor gap in maternal mortality has reduced in EAG states such as Bihar, Odisha, Assam, Rajasthan, the maternal mortality has remained above the national average for many of these states. The EAG states also experience supply side shortfalls in terms of availability of PHC and PHC doctors; and availability of specialist doctors. CONCLUSIONS: The novel contribution of the present paper is that the association of household wealth status and place of residence with maternal mortality is statistically not significant implying financial barriers to access maternal health services have been minimised. This result, and India's impressive performance with respect to maternal health outcomes, can be attributed to the various pro-poor policies and cash incentive schemes successfully launched in recent years. Community-level involvement with pivotal role played by community health workers has been one of the major reasons for the success of many ongoing policies. Policy makers need to prioritise the underperforming states and socio-economic groups within the states by addressing both demand-side and supply-side measures simultaneously mediated by contextual factors.

Development of recombinant vaccine candidate molecule against Shigella infection.

Shigellosis is an acute bacillary diarrheal disease caused by the gram negative bacillus Shigella. The existence of multiple Shigella serotypes and their growing resistance to antibiotics stress the urgent need for the development of vaccine that is protective across all serotypes. Shigella's IpaB antigen is involved in translocon pore formation, promotes bacterial invasion and induces apoptosis in macrophages. S. Typhi GroEL (Hsp 60) is the immunodominant antigen inducing both arms of immunity and has been explored as adjuvant in this study. The present study evaluates the immunogenicity and protective efficacy of recombinant IpaB domain-GroEL fusion protein in mice against lethal Shigella infection. The IpaB domain and GroEL genes were fused using overlap extension PCR and cloned in pRSETA expression vector. Fused gene was expressed in Escherichia coli BL-21 cells and the resulting 90 KDa fusion protein was purified by affinity chromatography. Intranasal (i.n.) immunization of mice with fusion protein increased the IgG and IgA antibody titers as compared to the group immunized with IpaB and GroEL and control PBS immunized group. Also IgG1 and IgG2a antibodies induced in fusion protein immunized mice were higher than co-immunized group. Significant increase in lymphocyte proliferation and cytokine levels (IFN-γ, IL-4 and IL-10), indicates induction of both Th1 and Th2 immune responses in both immunized groups. Immunization with fusion protein protected 90-95% of mice whereas 80-85% survivability was observed in co-immunized group against lethal challenge with S. flexneri, S. boydii and S. sonnei. Passive immunization conferred 60-70% protection in mice against all these Shigella species. Organ burden and histopathology studies also revealed significant decrease in lung infection as compared to the co-immunized group. Since IpaB is the conserved dominant molecule in all Shigella species, this study will lead to an ideal platform for the development of safe, efficacious and cost-effective recombinant vaccine against Shigella serotypes.

Comparative assessment of platelet GpIIb/IIIa receptor occupancy ratio with Eptifibatide/Tirofiban in patients presenting with ACS and undergoing PCI.

BACKGROUND: The level of platelet inhibition by a Glycoprotein IIb/IIIa (GpIIb/IIIa) antagonist therapy necessary to minimize thrombotic complications in patients undergoing percutaneous coronary intervention (PCI) is a subject of debate. The degree of platelet inhibition obtained 10 min after start of GpIIb/IIIa antagonist therapy predicts adverse events after PCI. The aim of this study was to look at platelet inhibition and to compare platelet GpIIb/IIIa receptors occupancy ratio (GpRO) with Eptifibatide and Tirofiban using various dose regimens and correlate with 30-day clinical outcomes in patients presenting with high-risk acute coronary syndromes (ACS) and undergoing PCI. METHODS: The patients were divided into four sub groups: (1) Eptifibatide two intracoronary bolus (180 µg/kg) alone (E(B)); or (2) two intravenous bolus (180 µg/kg) followed by infusion at 2 µg/kg/min for 24 h (E(B + Inf)); and (3) Tirofiban standard bolus dose (0.4 µg/kg) over 30 min followed by infusion at 0.1 µg/kg/min (T(Std)); or (4) at ADVANCE dose bolus (25 µg/kg) over 3 min, followed by infusion at 0.1 µg/kg/min (T(Adv)). Number of GpIIb/IIIa receptors was assessed by flow cytometry at baseline and 10 min after the bolus and percentage of free receptors was determined to calculate the GpRO. Patients were followed for 30 days for any major adverse cardiac events (MACE). RESULTS: 200 consecutive patients (including 74% with ST-elevation ACS) were enrolled. GpRO in groups E(B) (n = 48) and E(B + Inf) (n = 44) were 62.7% ± 27.2% and 61.4% ± 6.1% respectively while in the groups T(Std) (n = 96) and T(Adv) (n = 12) groups were 35.1% ± 17.74% and 68.8% ± 27.3% respectively. The GpRO was similar in E(B), E(B + Inf) and T(Adv) groups and was significantly higher than T(Std) group (p < 0.0001). The 30-day MACE rates in E(B) (4.2%), E(B + Inf) (4.5%) and T(Adv) (4.2%) were significantly lower than T(Std) group (12.5%) (p < 0.01). CONCLUSIONS: Standard dose Tirofiban results in significantly lower rates of GpIIb/IIIa receptor occupancy ratio and this correlated with higher incidence of 30-day MACE in high-risk ACS patients undergoing PCI.

Observer agreement in the assessment of narrowband imaging system surface patterns in Barrett's esophagus: a multicenter study.

BACKGROUND AND STUDY AIMS: The clinical utility of narrow-band imaging (NBI) for Barrett's esophagus is limited by the multiplicity of classification schemes. We evaluated the interobserver agreement and accuracy of a new consensus-driven simplified binary classification of NBI surface patterns.

Physical growth assessment in adolescence.

OBJECTIVE: To describe ponderosity indices body mass index--"BMI" and ponderal index "PI" and skin fold thicknesses (triceps, biceps, subscapular and suprailiac) for affluent Indian school going adolescents. DESIGN: Cross sectional. METHODS: Measurements were recorded in healthy affluent school going adolescents in public schools of 12 cities in India (boys=11,863 and girls 7,694). Means and percentiles of ponderosity indices and skinfold thicknesses at yearly intervals were derived for each sex and related to sexual maturity. RESULTS: BMI, PI and skin fold thickness (SFT) were higher in girls. There was lower variability of these parameters with sexual maturity rating (breast/genital development stages) as compared to age, suggesting use of these indices in relation to sexual maturity for assessment of adolescent growth. CONCLUSION: Pediatricians and endocrinologists can use these indices for assessment of thinness and obesity, in adolescent Indian children, in relation to sexual maturity for the age.

An assessment of peripheral immunity in patients with sarcoidosis using measurements of serum vitamin D3, cytokines and soluble CD23.

The aetiology of the peripheral anergy in sarcoidosis is unclear. To investigate this further we measured the serum levels of several factors important in different aspects of immune regulation to obtain a profile of those factors which promote and inhibit immune activation in sarcoidosis. Thirty-seven patients with sarcoidosis and 20 healthy controls of similar sex and age comprised the study group. Serum IL-10, interferon-gamma (IFN-gamma), soluble CD23 (sCD23), IL-8, granulocyte-macrophage colony-stimulating factor (GM-CSF), IL-1beta and tumour necrosis factor-alpha (TNF-alpha) were measured using in-house ELISAs. Vitamin D3 was measured using a radioreceptor assay. Serum levels of sCD23 and IL-10 were significantly elevated in patients with sarcoidosis relative to controls (median 13.9 versus 9.5 arbitrary units/ml, P<0.01 for sCD23, and 9.6 versus 5.0 pg/ml, P<0.04 for IL-10). Regardless of steroid therapy or disease activity, serum levels of IFN-gamma, TNF-alpha, IL-1beta, GM-CSF and IL-8 were no different in patients with sarcoidosis and controls. Vitamin D3 levels were significantly higher in patients with sarcoidosis versus normal controls (medians 78.0 versus 56.0, P<0.001), active sarcoidosis (n = 20) versus inactive disease (n = 17) (medians 81.5 versus 66.0, P<0.03) and active sarcoidosis versus controls (medians 81.5 versus 56.0, P<0.0002). The levels were no different between patients with inactive sarcoidosis and controls. We suggest that IL-10 and vitamin D3 may contribute to the peripheral anergy in sarcoidosis. The elevated serum sCD23 suggests an increase in peripheral humoral immunity. Consistent with a quiescent peripheral immune system, factors capable of monocyte/macrophage activation (TNF-alpha, IFN-gamma, GM-CSF and IL-8) were not elevated in the peripheral circulation.

An investigation to determine whether clusters of cancer types exist in nine breast-ovary families.

Monte-Carlo simulations were carried out on nine BRCA1-linked families selected from the 1993 Breast Cancer Linkage Consortium. These families all displayed a prevalence of both breast and ovarian cancers, but little evidence was found to conclude that sufferers of either type formed clusters in particular branches of families. It was noted that the application of these methods to larger pedigrees with known probands would be useful in further clarifying the issue.

Infant feeding practices in educated mothers from upper socio-economic status.

One hundred and twenty mothers from upper socio-economic status and education up to graduation level were assessed for infant feeding practices using a pre-tested questionnaire. Prelacteal feed of honey was administered by 51.7% and initiation of breast feeding delayed by more than 24 hours by 68.3% of mothers. Colostrum was discarded by 53% mothers; 83% introduced bottle feeding in the first month of life; and poor bottle hygiene was seen in 54% cases. Addition of semisolids was delayed by almost 50% of mothers, the reason given being fear of liver disorders. These observations highlight ignorance about basic infant feeding practices in the educated elite section of our country. Health education in schools, colleges, non formal gatherings and during the antenatal period are suggested as means to remove this ignorance.

PIP: 120 mothers from upper socioeconomic status and education to the graduate level were assessed for infant feeding practices using a pretested questionnaire. Prelacteal feed of honey was administered by 51.7% and initiation of breastfeeding was delayed by more than 24 hours in 68.3% of the mothers. Colostrum was discarded by 53% of the mothers, 83% introduced bottlefeeding in the 1st month of life, and poor bottle hygiene was seen in 54% of the cases. The addition of semisolids was delayed by almost 50% of the mothers, the reason being fear of liver disorders. These observations highlight ignorance about infant feeding practices among the educated elite in India. Health education in schools, colleges, nonformal gatherings, and during the antenatal period are suggested as means to change this situation.