In vitro inflammation and toxicity assessment of pre- and post-incinerated organomodified nanoclays to macrophages using high-throughput screening approaches.

BACKGROUND: Organomodified nanoclays (ONC), two-dimensional montmorillonite with organic coatings, are increasingly used to improve nanocomposite properties. However, little is known about pulmonary health risks along the nanoclay life cycle even with increased evidence of airborne particulate exposures in occupational environments. Recently, oropharyngeal aspiration exposure to pre- and post-incinerated ONC in mice caused low grade, persistent lung inflammation with a pro-fibrotic signaling response with unknown mode(s) of action. We hypothesized that the organic coating presence and incineration status of nanoclays determine the inflammatory cytokine secretary profile and cytotoxic response of macrophages. To test this hypothesis differentiated human macrophages (THP-1) were acutely exposed (0-20 µg/cm2) to pristine, uncoated nanoclay (CloisNa), an ONC (Clois30B), their incinerated byproducts (I-CloisNa and I-Clois30B), and crystalline silica (CS) followed by cytotoxicity and inflammatory endpoints. Macrophages were co-exposed to lipopolysaccharide (LPS) or LPS-free medium to assess the role of priming the NF-κB pathway in macrophage response to nanoclay treatment. Data were compared to inflammatory responses in male C57Bl/6J mice following 30 and 300 µg/mouse aspiration exposure to the same particles. RESULTS: In LPS-free media, CloisNa exposure caused mitochondrial depolarization while Clois30B exposure caused reduced macrophage viability, greater cytotoxicity, and significant damage-associated molecular patterns (IL-1α and ATP) release compared to CloisNa and unexposed controls. LPS priming with low CloisNa doses caused elevated cathepsin B/Caspage-1/IL-1ß release while higher doses resulted in apoptosis. Clois30B exposure caused dose-dependent THP-1 cell pyroptosis evidenced by Cathepsin B and IL-1ß release and Gasdermin D cleavage. Incineration ablated the cytotoxic and inflammatory effects of Clois30B while I-CloisNa still retained some mild inflammatory potential. Comparative analyses suggested that in vitro macrophage cell viability, inflammasome endpoints, and pro-inflammatory cytokine profiles significantly correlated to mouse bronchioalveolar lavage inflammation metrics including inflammatory cell recruitment. CONCLUSIONS: Presence of organic coating and incineration status influenced inflammatory and cytotoxic responses following exposure to human macrophages. Clois30B, with a quaternary ammonium tallow coating, induced a robust cell membrane damage and pyroptosis effect which was eliminated after incineration. Conversely, incinerated nanoclay exposure primarily caused elevated inflammatory cytokine release from THP-1 cells. Collectively, pre-incinerated nanoclay displayed interaction with macrophage membrane components (molecular initiating event), increased pro-inflammatory mediators, and increased inflammatory cell recruitment (two key events) in the lung fibrosis adverse outcome pathway.

Prioritizing tobacco control & its cessation under sustainable development goals with a focus on India.

Sustainable development goals (SDGs) were meant to put each and everywhere 'at par'. The tobacco epidemic globally is one major deterrent to their achievement. While it gets addressed under SDG 3 through the Framework Convention on Tobacco Control (FCTC) - the World Health Organization (WHO) global treaty (the target 3.a of SDG 3), the progress made globally and by India is slow. As a result, many countries may fall short of achieving the target of reducing tobacco usage (taking 2016 as base year) by 30 per cent by the year 2030. India with its high burden of tobacco use and abysmally low quitting along with soaring economic costs of tobacco related diseases and deaths can do better with the engagement of multisectoral stakeholders to strengthen tobacco control under SDGs. Moreover, there is a need to emphasize that the goal of O - Offer to Quit of WHO MPOWER can be achieved through increasing 'onus' on policy makers, and strategists, and opportunities for masses, tobacco users, healthcare professionals (HCPs) and enforcers to have tobacco cessation delivered optimally. By doing so, the United Nations can significantly facilitate a reduction in tobacco use and the resultant economic costs. Furthermore, it will assist the WHO to fulfil the targets set for 2030 under SDG 3.a by the FCTC member countries. In addition, it will fulfil the vision and mission defined in the Chandigarh declaration of the 5th National Conference on Tobacco or Health for India to be tobacco free by 2030.

Non-contact wound area assessment by digital planimetry using photo editing software.

To objectively assess wound healing utilizing a novel digital photo planimetry method. 58 wounds mostly of traumatic origin were studied. In method I (control or gold standard), a transparent plastic graph paper sheet with 2.5 mm squares was placed on the wound to trace the wound edges. This was scanned and analyzed in Adobe Photoshop (PS6) to estimate the area. In the novel method (method II), we clicked a photo with one-inch lines marked (on either side of the wound). This photo was similarly assessed in PS6. A two-sample t-test was used for analysis. Photos were clicked every third day. The time taken to calculate the resultant area was also noted. 484 photos and 1936 values were analyzed. The mean areas obtained were 10690 mm 2 and 10859 mm 2 respectively by methods I and II. The mean difference was 0.824%, 95% CI [-0.05, 1.60] and p = 0.923. The inter and intra- observer variation was < 2% for all readings. The time taken by the novel method was much lesser than the time-tested method (mean = 82 sec vs 178 sec; p < 0.01). The difference in area by the two methods is not statistically significant. The accuracy of both methods is therefore comparable. Our novel method is easier, more cost-effective, equally accurate, safer and reproducible in comparison with the transparency squares method, especially for flat or 2-dimensional wounds.

Assessing the asymmetric impact of physical infrastructure and trade openness on ecological footprint: An empirical evidence from Pakistan.

This study analyzed the asymmetric impact of the physical infrastructure and trade openness on Pakistan's ecological footprint over the period 1970-2019 using the non-linear autoregressive distributed lag model. The study results posit that positive and negative shocks to physical infrastructure increase and decrease the ecological footprint asymmetrically in the short-run and symmetrically in the long-run. Likewise, the positive and negative shocks to trade openness increase and decrease the ecological footprint asymmetrically, both in the short and in the long run. Furthermore, urbanization also positively and significantly increases Pakistan's ecological footprint in the short and long run. Moreover, a 1% increase in physical infrastructure increases the ecological footprint by 0.32%, while a 1% decrease in physical infrastructure decreases the ecological footprint by 0.33% in the long run. Similarly, a 1% increase in trade openness causes a 0.09% increase in the ecological footprint in the long term, while a 1% reduction in trade openness causes a 0.61% reduction in the ecological footprint. The results also conclude that urbanization is a major determinant of Pakistan's long-term ecological footprint. Thus, a 1% increase in urbanization causes a 1.31% increase in the ecological footprint in the long run. Finally, this study recommends that policies regarding physical infrastructure be formulated keeping in view its environmental impact. In addition, strict environmental policies should be implemented to reduce the environmental degradation effect of trade openness.

Assessment of DNA aptamers targeting GlcB and HspX antigens for application in the diagnosis of abdominal tuberculosis.

The diagnosis of abdominal tuberculosis (aTB) is challenging and there is an urgent need for an accurate diagnostic test. We have developed a high affinity DNA aptamer against GlcB antigen of Mycobacterium tuberculosis (Mtb). We further compared the diagnostic utility of in-house-generated high affinity DNA aptamers and polyclonal antibodies against two Mtb antigens, namely GlcB and HspX, in ascitic fluid samples. These diagnostic reagents were assessed in patients (n = 94) who were categorized as 'Definite TB', 'Probable TB', 'Possible TB' (taken together as aTB) and 'Non-TB' disease. Receiver operating characteristic curves were used to derive cut-off values to provide ≥93% specificity. Aptamer Linked Immobilized Sorbent Assay (ALISA) for HspX and GlcB exhibited a sensitivity of ∼84% and 50%, respectively (p-value <0.01). In contrast, antibody-based ELISA exhibited a lower sensitivity of ∼18% and ∼28% for HspX and GlcB, respectively (p-value <0.0001 and p = 0.05 for HspX and GlcB ELISA vs. ALISA, respectively). HspX ALISA detected 32/38 aTB cases, while Xpert detected only 9 samples. In conclusion, HspX aptamer-based test was found to be superior to the other tests for diagnosing aTB and it nearly fulfils the sensitivity criteria of WHO's 'Target Product Profile' for extrapulmonary tuberculosis (sensitivity ≥80%, specificity 98%).

Development of integrated model of communication for implementing media strategy to prevent hypertension in a northern state of India.

OBJECTIVE: Media plays a major role in inculcating positive changes or averting negative changes in health-related behaviors across populations. Although various mass media interventions have proven their effectiveness in changing individuals' behavior for various diseases and risk factors, current literature is limited regarding a conceptual framework/model for the prevention of hypertension and cardiovascular diseases. The present study describes the process of development and implementation of a comprehensive and need-based media strategy with an aim to generate politico-administrative support for strengthening hypertension services in the state of Punjab, India. METHODS: The preparation of theoretical framework underwent two stages, that is, item generation and item reduction. The item generation involved extensive literature search, development of consensus among experts using Delphi technique and its validation. The item reduction involved the selection of models among existing communication and health promotion models, placement of items in the selected models and development of final conceptual framework model. RESULTS: Based upon the review and expert's consensus, we zeroed in on three models of communication - communication campaign model, paid earned social owned model, and staircase model - in order to come up with the framework requisite for a systematic media strategy. The model focused upon context-specific messages involving both traditional and modern means and tools of communication. This model (conceptual framework) was the product of intense literature review followed by opinion of the experts from various disciplines such as medical professionals, public health specialists, communication experts, social scientists, politicians, bureaucrats, state-level representatives, media journalists and hypertensive patients. CONCLUSION: The present model can effectively be used by the program implementers, educators and policy makers in similar settings.

Regional needs assessment for emergency physician audit and feedback.

OBJECTIVES: Audit and feedback is widely used to improve physician performance. Many data metrics are being provided to physicians, yet most of these are driven by the regulatory environment. We sought to conduct a needs assessment of audit and feedback metrics that were most useful to clinicians within our health care region. METHODS: We conducted a Web-based survey of five clinical practice sites in our region and asked that physicians rank 49 clinical practice metrics. In addition, we assessed their readiness for audit and feedback and their preferences for data confidentiality. We collected data on duration of training, gender, and site of practice (academic v. community) allowing for comparison between groups. RESULTS: A total of 104 emergency medicine physicians participated in the survey (52.3% response rate). There was a significant readiness for participation in audit and feedback activities. Top ranked metrics were emergency department return rates and colleague's assessment of collegiality and quality of care, which were common across all sites. Small yet significant differences were noted between genders and academic v. community practitioners. CONCLUSION: This study represents the first regional analysis of physician preferences for audit and feedback activities and implementation. It demonstrates that physicians are interested in audit and feedback activities and provides a roadmap for the development of a regional audit and feedback structure. It will also be used as a guiding document for regional change management.

Quantitative vs. semiquantitative assessment of intratumoral susceptibility signals in patients with different grades of glioma.

BACKGROUND: Susceptibility weighted imaging (SWI) provides vascular information and plays an important role in improving the diagnostic accuracy of preoperative glioma grading. Intratumoral susceptibility signal intensities (ITSS) obtained from SWI has been used in glioma grading. However, the current method for estimation of ITSS is semiquantitative, manual count-dependent, and includes hemorrhage as well as vasculature. PURPOSE: To develop a quantitative approach that calculates the vasculature volume within tumors by filtering out the hemorrhage from ITSS using R2 * values and connected component analysis-based segmentation algorithm; to evaluate the accuracy of the proposed ITSS vasculature volume (IVV) for differentiating various grades of glioma; and compare it with reported semiquantitative ITSS approach. STUDY TYPE: Retrospective. SUBJECTS: Histopathologically confirmed 41 grade IV, 19 grade III, and 15 grade II glioma patients.Field Strength/Sequence: SWI (four echoes: 5.6, 11.8, 18, 24.2 msec) along with conventional MRI sequences (T2 -weighted, T1 -weighted, 3D-fluid-attenuated inversion recovery [FLAIR], and diffusion-weighted imaging [DWI]) at 3.0T. ASSESSMENT: R2 * relaxation maps were calculated from multiecho SWI. The R2 * cutoff value for hemorrhage ITSS was determined. A segmentation algorithm was designed, based on this R2 * hemorrhage combined with connected component shape analysis, to quantify the IVV from all slices containing tumor by filtering out hemorrhages. Semiquantitative ITSS scoring as well as total ITSS volume (TIV) including hemorrhages were also calculated. STATISTICAL TESTS: One-way analysis of variance (ANOVA) and Tukey-Kramer post-hoc tests were performed to see the difference among the three grades of the tumor (II, III, and IV) in terms of semiquantitative ITSS scoring, TIV, and IVV. Receiver operating characteristic (ROC) curve analysis was used to evaluate the performance of the three methods individually in discriminating between grades of glioma. RESULTS: One-way ANOVA showed that only the proposed IVV significantly differentiated different grades of gliomas having visible ITSS. ROC analysis showed that IVV provided the highest AUC for the discrimination of grade II vs. III (0.93), grade III vs. IV (0.98), and grade II vs. IV glioma (0.94). IVV also provided the highest sensitivity and specificity for differentiating grade II vs. III (87.44, 98.41), grade III vs. IV (97.15, 94.12), and grade II vs. IV (98.72, 92.31). DATA CONCLUSION: The proposed quantitative method segregates hemorrhage from tumor vasculature. It scores above the existing semiquantitative method in terms of ITSS estimation and grading accuracy. LEVEL OF EVIDENCE: 4 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;51:225-233.

Socio-demographic and socioeconomic differences in tobacco use prevalence among Indian youth.

The study aims to assess the association between socio-demographic factors such as age, gender, area of residence, father's education, and standard of living and the likelihood of tobacco use in adolescence. We conducted secondary data analysis on a large scale cross-sectional study comprising of 1386 adolescents, living in regions representative of three different socioeconomic positions in New Delhi. Data was collected through clinical oral examination and interviewer-administered questionnaire. Multiple logistic regression analysis with an unadjusted model for assessing the association between the respective explanatory variable and ever tobacco use. Sequential models were adjusted for confounders as well as the other explanatory variables. The number of tobacco users was 185 (13%). Gender wise tobacco use shows significant (P = 0.001) difference between girls vs. boys; the girls are about 40% less likely to use tobacco than boys (OR = 0.58, 95% CI = 0.42-0.80). Among socio-economic classes, residents of resettlement colonies were twice as likely to use tobacco as middle/upper middle class residents (OR = 2.26, 95% CI = 1.45-3.53). Adolescents with fathers educated up to the primary or secondary levels were almost twice likely to have used tobacco than those with fathers educated till graduation or above (OR = 2.08 95% CI = 1.30-3.34 vs. OR = 2.24, 95% CI = 1.43-3.51, respectively). Significant (P = 0.001) difference in tobacco use among adolescents was also observed based on their standard of living. A significant association exists in terms of area of residence, father's education, and standard of living.

Geographic Inequities in Coverage of Maternal and Child health Services in Haryana State of India.

Introduction India aims to achieve universal health coverage, with a focus on equitable delivery of services. There is significant evidence on extent of inequities by income status, gender and caste. In this paper, we report geographic inequities in coverage of reproductive, maternal and child health (MCH) services in Haryana state of India. Methods Cross-sectional data on utilization of maternal, child health and family planning services were collected from 12,191 women who had delivered a child in the last one year, 10314 women with 12-23 months old child, and 45864 eligible couples across all districts in Haryana state. Service coverage was assessed based on eight indicators - 6 for maternal health, one for child health and one for family planning. Inter- and intra-district inequalities were compared based on four and three indicators respectively. Results Difference in coverage of full ante-natal care, full immunization and contraceptive prevalence rate between districts performing best and worst was found to be 54%, 65% and 63% respectively. More than one-thirds of the sub-centres (SCs) in Panchkula, Ambala, Gurgaon and Mewat districts had their ante-natal care coverage less than 50% of the respective district average. Similarly, a significant proportion of SCs in Mewat, Panipat and Hisar districts had full immunization rate below 50% of the district average. Conclusion Widespread inter- and intra-district inequities in utilization of MCH services exist. A comprehensive geographical targeting to identify poor performing districts, community development blocks and SCs could result in significant equity gains, besides contributing to quick achievement of sustainable development goals.

Out-of-pocket expenditure for health care: District level estimates for Haryana state in India.

INTRODUCTION: In this paper, we present district level out-of-pocket (OOP) expenditures with respect to outpatient consultation within last 15 days and hospitalization in last 1 year for Haryana state. METHODS: The data from a large cross-sectional household survey covering all 21 districts of Haryana comprising of randomly selected 79 742 households were analyzed. Of the total sample, 56 056 households consisting of 314 639 individuals in 21 districts of Haryana state were surveyed to gather information on OOP expenditure incurred on outpatient consultation within last 15 days. Similarly, 59 901 households and 324 977 respondents were interviewed to elicit OOP expenditures for any hospitalization during the 1 year preceding the survey. Mean OOP expenditure per OP consultation, per hospitalization as well as per capita were computed. Mean OOP expenditure was also estimated by the type of provider, gender, and district. RESULTS: The mean OOP expenditure for OP consultation and hospitalization in Haryana was Indian National Rupees (INR) 1005 (US Dollar [USD] 16.1; 95% CI: INR 934-1076) and INR 22 489 (USD 360.0; 95% CI: INR 21 375-23 608), respectively. Mean per capita OOP expenditure for OP consultation, which was INR 85 (USD 1.3) in Haryana, varied from INR 595 (USD 9.5) in district Panipat to INR 29 (USD 0.5) in district Kaithal. CONCLUSION: This is the first study to comprehensively present district level estimates for OOP expenditure for health care. These estimates are useful for policy planning, and preparation for district and state health accounts.

Factors associated with stillbirths in Haryana, India: a qualitative study.

Background: Each year, 2.6 million babies are stillborn worldwide, almost all in low- and middle-income countries. Several global initiatives, including the Sustainable Development Goals and the Every Newborn Action Plan, have contributed to a renewed focus on prevention of stillbirths. Despite being relatively wealthy, the state of Haryana in India has a significant stillbirth rate. This qualitative study explored the factors that might contribute to these stillbirths. Methods: This was a sub-study of a case-control study of factors associated with stillbirth in 15 of the 21 districts of Haryana in 2014-2015. A total of 43 in-depth interviews were conducted with mothers who had recently experienced a stillbirth, or with a family member. By use of reflexive and inductive qualitative methodology, the data set was coded to allow categories to emerge. Results: Two categories and several subcategories were identified. First, factors occurring before the woman reached a health-care facility were: lack of awareness of the mothers and family members; intake of sex-selection drugs during pregnancy, in order to have a male child; non-adherence to treatment for high blood pressure; lack of prior identification of an appropriate health-care facility for delivery; and transportation to a health-care facility for delivery. Second, factors occurring once the health-care facility was reached were: lack of timely and adequate management; and use of medication during labour. Conclusion: Intrapartum stillbirths are closely linked to the availability and accessibility of appropriate medical care. Timely and appropriate treatment and care, provided by a trained and skilled health worker during pregnancy and labour, as well as soon after delivery, is an absolute requirement for averting these stillbirths. This study underscores the importance of imparting and increasing awareness regarding factors that have a significant bearing on stillbirth and can be mitigated through prompt and adequate obstetric health-care services.

Exposure to second hand smoke and its correlates in Northern State of India.

BACKGROUND: Second-hand smoke (SHS) has enormous adverse health impacts with grave health implications for the next generation. Section 4 of Indian legislation, Cigarettes and Other Tobacco Products Act, prohibits smoking at public places, thus protecting people from SHS. OBJECTIVE: The objective of present study was to assess the exposure to SHS at home and working areas in Punjab, India. METHODS: The present cross-sectional study was conducted from December 2015 to March 2016. A three-stage sampling technique was used for collecting data from three randomly selected districts representing three major regions of Punjab, India. A sample size of 510 individuals was divided equally into an urban and rural area with proportionate sampling on the basis of subsets of age groups and gender. The questionnaire based on tobacco questions for the survey, a subset of key questions from global adult tobacco survey was used. RESULTS: At home, the odds of exposure to SHS exposure was higher (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 0.6-7.3) in urban area, females, low educational status, and nongovernment employee as compared to their counterparts. At workplace, (OR = 3.9 and 95% CI = 1.11-14.3) SHS exposure was higher in rural area, among males, primary and middle education and nongovernment or self-employed occupation. CONCLUSION: SHS exposure was low in Punjab, India especially in females as compared to other states of the country. The socio-economic disadvantaged groups and people with low education were more likely to experience exposure to SHS at workplace, which should be targeted to reduce tobacco consumption.

Short-Term Pulmonary Toxicity Assessment of Pre- and Post-incinerated Organomodified Nanoclay in Mice.

Organomodified nanoclays (ONCs) are increasingly used as filler materials to improve nanocomposite strength, wettability, flammability, and durability. However, pulmonary risks associated with exposure along their chemical lifecycle are unknown. This study's objective was to compare pre- and post-incinerated forms of uncoated and organomodified nanoclays for potential pulmonary inflammation, toxicity, and systemic blood response. Mice were exposed via aspiration to low (30 µg) and high (300 µg) doses of preincinerated uncoated montmorillonite nanoclay (CloisNa), ONC (Clois30B), their respective incinerated forms (I-CloisNa and I-Clois30B), and crystalline silica (CS). Lung and blood tissues were collected at days 1, 7, and 28 to compare toxicity and inflammation indices. Well-dispersed CloisNa caused a robust inflammatory response characterized by neutrophils, macrophages, and particle-laden granulomas. Alternatively, Clois30B, I-Clois30B, and CS high-dose exposures elicited a low grade, persistent inflammatory response. High-dose Clois30B exposure exhibited moderate increases in lung damage markers and a delayed macrophage recruitment cytokine signature peaking at day 7 followed by a fibrotic tissue signature at day 28, similar to CloisNa. I-CloisNa exhibited acute, transient inflammation with quick recovery. Conversely, high-dose I-Clois30B caused a weak initial inflammatory signal but showed comparable pro-inflammatory signaling to CS at day 28. The data demonstrate that ONC pulmonary toxicity and inflammatory potential relies on coating presence and incineration status in that coated and incinerated nanoclay exhibited less inflammation and granuloma formation than pristine montmorillonite. High doses of both pre- and post-incinerated ONC, with different surface morphologies, may harbor potential pulmonary health hazards over long-term occupational exposures.

Early Assessment and Correlations of Nanoclay's Toxicity to Their Physical and Chemical Properties.

Nanoclays' functionalization with organic modifiers increases their individual barrier properties, thermal stability, and mechanical properties and allows for ease of implementation in food packaging materials or medical devices. Previous reports have shown that, while organic modifiers integration between the layered mineral silicates leads to nanoclays with different degrees of hydrophobicity that become easily miscible in polymers, they could also pose possible effects at inhalation or ingestion routes of exposure. Through a systematic analysis of three organically modified and one pristine nanoclay, we aimed to relate for the first time the physical and chemical characteristics, determined via microscopical and spectroscopical techniques, with the potential of these nanoclays to induce deleterious effects in in vitro cellular systems, i.e. in immortalized and primary human lung epithelial cell lines. To derive information on how functionalization could lead to toxicological profiles throughout nanoclays' life cycle, both as-received and thermally degraded nanoclays were evaluated. Our analysis showed that the organic modifiers chemical composition influenced both the physical and chemical characteristics of the nanoclays as well as their toxicity. Overall, when cells were exposed to nanoclays with organic modifiers containing bioreactive groups, they displayed lower cellular numbers as well more elongated cellular morphologies relative to the pristine nanoclay and the nanoclay containing a modifier with long carbon chains. Additionally, thermal degradation caused loss of the organic modifiers as well as changes in size and shape of the nanoclays, which led to changes in toxicity upon exposure to our model cellular systems. Our study provides insight into the synergistic effects of chemical composition, size, and shape of the nanoclays and their toxicological profiles in conditions that mimic exposure in manufacturing and disposal environments, respectively, and can help aid in safe-by-design manufacturing of nanoclays with user-controlled functionalization and lower toxicity levels when food packaging applications are considered.

A composite indicator to measure universal health care coverage in India: way forward for post-2015 health system performance monitoring framework.

BACKGROUND: There is limited work done on developing methods for measurement of universal health coverage. We undertook a study to develop a methodology and demonstrate the practical application of empirically measuring the extent of universal health coverage at district level. Additionally, we also develop a composite indicator to measure UHC. METHODS: A cross-sectional survey was undertaken among 51 656 households across 21 districts of Haryana state in India. Using the WHO framework for UHC, we identified indicators of service coverage, financial risk protection, equity and quality based on the Government of India and the Haryana Government's proposed UHC benefit package. Geometric mean approach was used to compute a composite UHC index (CUHCI). Various statistical approaches to aggregate input indicators with or without weighting, along with various incremental combinations of input indicators were tested in a comprehensive sensitivity analysis. FINDINGS: The population coverage for preventive and curative services is presented. Adjusting for inequality, the coverage for all the indicators were less than the unadjusted coverage by 0.1-6.7% in absolute term and 0.1-27% in relative term. There was low unmet need for curative care. However, about 11% outpatient consultations were from unqualified providers. About 30% households incurred catastrophic health expenditures, which rose to 38% among the poorest 20% population. Summary index (CUHCI) for UHC varied from 12% in Mewat district to 71% in Kurukshetra district. The inequality unadjusted coverage for UHC correlates highly with adjusted coverage. CONCLUSION: Our paper is an attempt to develop a methodology to measure UHC. However, careful inclusion of others indicators of service coverage is recommended for a comprehensive measurement which captures the spirit of universality. Further, more work needs to be done to incorporate quality in the measurement framework.

Quitline Activity in Rajasthan, India.

Quitline activity in Rajasthan, India is a voluntary activity of Rajasthan Cancer Foundation (RCF) since April 2013. To kick-off, it took the benefit of the State Government- PIRAMAL SWASTHYA (PS)1 collaborative 104 Health Information Helpline that existed already in public-private partnership. It is a reactive quitline that helps callers through the counselors and nursing staff trained specifically through the weekly sessions held by the first author, the RCF resource on quitline. Besides structuring of the scripts for primary intervention and follow-ups after 1 week, 1 month, 6 months and a year, he also monitors calls, advices and coordinates with the supervisors to manage and analyze the data base, and reports to the PS lead at the Jaipur Center on overall performance and to plan strategic communication with the State Government on its outcomes. The quitline has limitations of its informal existence through a voluntary effort of RCF, no specific resource allocation, suboptimal data management, minimal awareness in the masses due to poor IEC (Information, Education and Communication; except its efforts made by RCF in last 1 year through the government-run State TV and City Radio) and staff shortage and its attrition due to lack of plan for career advancement. Despite these challenges in the year 2013, the quit line has registered a quit rate (for complete abstinence) of 19.93% amongst 1525 callers. The quit rate were 58.01% (304/ 524) among the responders at the 3rd follow-up at 18 months (in September 2014)2. In view of an increase in quit rate by 5- 9 times over the prevailing quit rate in the former ever daily users [both smokers and the users of smokeless tobacco (SLT)], efforts are being made by RCF in concurrence with PS to have this cost-effective model established formally with optimal resource allocation in collaboration with willing agencies (the State and Central Governments and the International Quitline Agencies) and its replication in 4 more states where PS is collaborating with the respective state governments similarly (Assam, Chhattisgarh, Jharkhand and Karnataka).

Assessment of brain cognitive functions in patients with vitamin B12 deficiency using resting state functional MRI: A longitudinal study.

INTRODUCTION: The resting state functional MRI (rsfMRI) approach is useful to explore the brain's functional organization in health and disease conditions. In this study, using rsfMRI the alteration in brain due to vitamin B12 deficiency and reversibility of these alterations following therapy was studied. METHODS: Thirteen patients with clinical and biochemical evidence of vitamin B12 deficiency were recruited in this study. Fifteen age and sex matched healthy controls were also included. Patients and controls were clinically evaluated using neuropsychological test (NPT). The analysis was carried out using regional homogeneity (ReHo) and low frequency oscillations (LFO) of BOLD signals in resting state. Six patients were also evaluated with rsfMRI and NPT after 6 weeks replacement therapy. RESULTS: ReHo values in patients with vitamin B12 deficiency were significantly lower than controls in the entire cerebrum and the brain networks associated with cognition control, i.e., default mode, cingulo-opercular and fronto-parietal network. There was no significant difference using LFO and it did not show significant correlations with NPT scores. ReHo showed significant correlation with NPT scores. All the 6 patients showed increase in ReHo after replacement therapy. CONCLUSION: We conclude that brain networks associated with cognition control are altered in patients with vitamin B12 deficiency, which partially recover following six weeks of replacement therapy. This is the first study to evaluate the rsfMRI in the light of clinical neuropsychological evaluation in patients. rsfMRI may be used as functional biomarker to assess therapeutic response in vitamin B12 deficiency patients.

Coverage and Financial Risk Protection for Institutional Delivery: How Universal Is Provision of Maternal Health Care in India?

BACKGROUND: India aims to achieve universal access to institutional delivery. We undertook this study to estimate the universality of institutional delivery care for pregnant women in Haryana state in India. To assess the coverage of institutional delivery, we analyze service coverage (coverage of public sector institutional delivery), population coverage (coverage among different districts and wealth quintiles of the population) and financial risk protection (catastrophic health expenditure and impoverishment as a result of out-of-pocket expenditure for delivery). METHODS: We analyzed cross-sectional data collected from a randomly selected sample of 12,191 women who had delivered a child in the last one year from the date of data collection in Haryana state. Five indicators were calculated to evaluate coverage and financial risk protection for institutional delivery--proportion of public sector deliveries, out-of-pocket expenditure, percentage of women who incurred no expenses, prevalence of catastrophic expenditure for institutional delivery and incidence of impoverishment due to out-of-pocket expenditure for delivery. These indicators were calculated for the public and private sectors for 5 wealth quintiles and 21 districts of the state. RESULTS: The coverage of institutional delivery in Haryana state was 82%, of which 65% took place in public sector facilities. Approximately 63% of the women reported no expenditure on delivery in the public sector. The mean out-of-pocket expenditures for delivery in the public and private sectors in Haryana were INR 771 (USD 14.2) and INR 12,479 (USD 229), respectively, which were catastrophic for 1.6% and 22% of households, respectively. CONCLUSION: Our findings suggest that there is considerably high coverage of institutional delivery care in Haryana state, with significant financial risk protection in the public sector. However, coverage and financial risk protection for institutional delivery vary substantially across districts and among different socio-economic groups and must be strengthened. The success of the public sector in providing high coverage and financial risk protection in maternal health provides encouragement for the role that the public sector can play in universalizing health care.