Sex and Racial Disparities in Peripheral Artery Disease.

Several studies have shown that women and racial and ethnic minority patients are at increased risk of developing lower extremity peripheral artery disease and suffering adverse outcomes from it, but a knowledge gap remains regarding the underlying causes of these increased risks. Both groups are more likely to be underdiagnosed, have poorly managed contributory comorbidities, and incur disparities in treatment and management postdiagnosis. Opportunities for improvement in the care of women and racial and ethnic minorities with peripheral artery disease include increased rates of screening, higher rates of clinical suspicion (particularly in the absence of typical symptoms of intermittent claudication), and more aggressive risk factor management before and after the diagnosis of peripheral artery disease.

PGC1α Regulates the Endothelial Response to Fluid Shear Stress via Telomerase Reverse Transcriptase Control of Heme Oxygenase-1.

OBJECTIVE: Fluid shear stress (FSS) is known to mediate multiple phenotypic changes in the endothelium. Laminar FSS (undisturbed flow) is known to promote endothelial alignment to flow, which is key to stabilizing the endothelium and rendering it resistant to atherosclerosis and thrombosis. The molecular pathways responsible for endothelial responses to FSS are only partially understood. In this study, we determine the role of PGC1α (peroxisome proliferator gamma coactivator-1α)-TERT (telomerase reverse transcriptase)-HMOX1 (heme oxygenase-1) during shear stress in vitro and in vivo. Approach and Results: Here, we have identified PGC1α as a flow-responsive gene required for endothelial flow alignment in vitro and in vivo. Compared with oscillatory FSS (disturbed flow) or static conditions, laminar FSS (undisturbed flow) showed increased PGC1α expression and its transcriptional coactivation. PGC1α was required for laminar FSS-induced expression of TERT in vitro and in vivo via its association with ERRα(estrogen-related receptor alpha) and KLF (Kruppel-like factor)-4 on the TERT promoter. We found that TERT inhibition attenuated endothelial flow alignment, elongation, and nuclear polarization in response to laminar FSS in vitro and in vivo. Among the flow-responsive genes sensitive to TERT status, HMOX1 was required for endothelial alignment to laminar FSS. CONCLUSIONS: These data suggest an important role for a PGC1α-TERT-HMOX1 axis in the endothelial stabilization response to laminar FSS.

Carotid Intima-Media Thickness (cIMT) and Cognitive Performance: A Population-Based Cross-Sectional Study From North India.

INTRODUCTION: Atherosclerosis has been shown to impact cognitive impairment, with most of the evidence originating from European, African, or East Asian populations that have employed carotid intima-media thickness (cIMT) as a biomarker for atherosclerosis. Vascular disease is related to dementia/cognitive decline. There is no community-based study from India that has looked at the association of cIMT with cognitive performance. METHODS: In this cross-sectional study between December 2014 and 2019, we recruited 7505 persons [(mean age 64.6 (9.2) y) and 50.9% women] from a community-dwelling population in New Delhi. These persons underwent carotid ultrasound to quantify cIMT and a cognitive test battery that tapped into memory, processing speed, and executive function. We also computed the general cognitive factor (g-factor), which was identified as the first unrotated component of the principal component analysis and explained 37.4% of all variances in the cognitive tests. We constructed multivariate linear regression models adjusted for age, sex, education, and cardiovascular risk factors. Additional adjustment was made for depression, anxiety, and psychosocial support in the final model. RESULTS: We found a significant association of higher cIMT with worse performance in general cognition (ß=-0. 01(95% CI: -0.01; -0.01); P<0.001), processing speed (ß=-0.20; 95% CI: -0.34; -0.07); P=0.003), memory (ß=-0.29; 95% CI: -0.53; -0.05); P=0.016), and executive function (ß=-0.54; 95% CI: -0.75; -0.33); P=<0.001). There was no statistically significant association of cIMT with Mini-Mental Status Examination score (ß=0.02; 95% CI: -0.34; 0.40; 0.89). CONCLUSION: The cross-sectional study found significant associations of increased cIMT with worse performance in global cognition, information processing, memory, and executive function.

Prevalence of postpartum depression & anxiety among women in rural India: Risk factors & psychosocial correlates.

BACKGROUND OBJECTIVES: Postpartum depression and anxiety (PPD/A) impact a woman's physical and psychological wellbeing. In the absence of corroboratory evidence from the community setting in India, the present study was undertaken to examine the prevalence, psychosocial correlates and risk factors for PPD/A in the rural community of India. METHODS: This cross-sectional study included 680 women during the postpartum period from a rural community in northern India. Screening for PPD/A was done using Edinburg Postnatal Depression Scale and State and Trait Anxiety Inventory. Diagnostic assessment of screened-positive women was done using Mini-International Neuropsychiatric Interview (MINI). The psychosocial evaluation was done on parameters including women's social support, bonding with the child, functionality, parental stress, interpersonal violence and marital satisfaction. RESULTS: The overall prevalence of PPD/A/both in community women was 5.6 per cent, with a specific prevalence of 2.2 per cent for PPD, 0.74 per cent for PPA and 2.8 per cent for both disorders. Comparative analysis indicated that women with PPD/A/both experienced significantly higher levels of parenting stress, poor lifestyle (prior two weeks), less support from their partner, parents-in-law and parents, less marital satisfaction, high intimate partner violence, poor bonding with infants and higher infant-focussed anxiety. On multivariable logistic regression analysis, higher education, marital satisfaction, support from partners and in-laws were associated with reducing the risk of PPD/A/both. INTERPRETATION CONCLUSIONS: Rural Indian women experience PPD/A/both which causes stress and impacts their functionality, bonding with the infant and relationship with their spouse and parents. Higher education, marital satisfaction and higher support from partners and in-laws reduce the risk of developing PPD/A/both.

Metabolic risk factors and psychosocial problems independently explain poor sleep quality and obstructive sleep apnea symptoms among adults in urban India.

STUDY OBJECTIVES: To determine if metabolic risk factors are associated with poor sleep quality and obstructive sleep apnea-like symptoms (OSA symptoms) independent of psychosocial problems and demographic and lifestyle factors in older Indian adults. METHODOLOGY: We analyzed baseline data from adults (≥ 50 years) from a population-based cohort, the LoCARPoN study, in India. Variables were grouped as (a) demographic and lifestyle factors such as smoking, alcohol use, and physical activity; (b) psychosocial problems including symptoms of depression, anxiety, and perceived stress; and (c) metabolic risk factors including glycated hemoglobin, high-density lipoprotein, low-density lipoprotein, total cholesterol, body mass index, and hypertension. Variables were examined as predictors of poor sleep quality and OSA symptoms. Groups of variables were added stepwise to a logistic regression. Variance explained by nested models was quantified using McFadden's pseudo R2, and change was formally tested with the log-likelihood ratio test. RESULTS: Among 7505 adults, the prevalence of poor sleep quality was 16.9% (95% CI: 16.0, 17.7), and OSA symptoms were present in 7.0% (95% CI: 6.4, 7.6). Psychosocial problems had a strong independent association with both poor sleep quality (pseudo R2 increased from 0.10 to 0.15, p < 0.001) and more OSA symptoms (pseudo R2 increased from 0.08 to 0.10, p < 0.001). Metabolic risk factors had a modest independent association with sleep quality (pseudo R2 increased from 0.14 to 0.15, p < 0.01), but a strong association with OSA symptoms (pseudo R2 increased from 0.08 to 0.10, p < 0.001). CONCLUSION: Psychosocial and metabolic risk factors were independently associated with sleep quality and OSA symptoms. This fact implied that OSA symptoms may affect both mental health and physical health. Our findings have public health implications because the number and proportion of the elderly in India is increasing, while the prevalence of metabolic risk factors and psychosocial problems is high already. These facts have the potential to exacerbate not only the burden of sleep disorders and OSA symptoms but also associated cardiovascular and neurologic sequelae, further stretching the Indian health-care system.

Association of obstructive sleep apnea and sleep quality with cognitive function: a study of middle-aged and elderly persons in India.

INTRODUCTION: Symptoms of obstructive sleep apnea (OSA) and poor sleep quality affect around one in ten people in India. We aimed to determine if OSA symptoms and poor sleep quality are independently associated with cognition in middle-aged and elderly urban Indian populations. METHODS: We studied the cross-sectional association between OSA symptoms (by Berlin Questionnaire), poor sleep quality (by Pittsburgh Sleep Quality Index), and cognitive function in adults ≥ 50 years. Using a standard neuropsychological battery for cognitive function, a G-factor was derived as the first rotated principal component assessing domains of information processing, memory, and executive function. The associations of exposures with cognitive measures were modeled using linear regression, adjusted for metabolic risk factors, lifestyle factors, and psychosocial problems, followed by stratified analysis by decadal age group. RESULTS: A total of 7505 adults were enrolled. Excluding those with MMSE < 26 (n 710), of 6795 individuals (49.2% women), mean (SD) age 64.2 (9.0) years, 38.3% had high risk of OSA symptoms, and 15.9% had poor sleep quality. OSA symptoms were negatively associated with cognitive domains of information processing (adjusted beta coefficient of z-score - 0.02, p-value 0.006), memory (- 0.03, 0.014), and G-factor (- 0.11, 0.014) in full-model. Stratified analysis by age group showed significant adverse effects of OSA symptoms on cognition for middle-aged people (50-60 years) (- 0.26, 0.001), but not in later age groups. Poor sleep quality was also associated with lower cognitive scores for G-factor (- 0.48, < 0.001), memory (- 0.08, 0.005), and executive domains (- 0.12, < 0.001), but not with information domain. CONCLUSION: The findings suggest that both symptoms of OSA and poor sleep quality have a direct adverse impact on cognition in an Indian setting. A modest effect of age on the relationship of OSA and cognition was also observed.

Association of Common Mental Disorders with Diabetes Mellitus - Evidence from Community-based Matched Case-Control Study in North India.

BACKGROUND: Diabetes mellitus (DM) and depression are major public health problems globally. Evidence of linkage of common mental disorders (CMDs) including depression and anxiety disorders with DM is sparsely reported from community-based settings. OBJECTIVE: The present study aimed to study the association between CMDs and DM among adult population (>30 years) residing in a rural area of North India. MATERIALS AND METHODS: A community-based case-control study was conducted in 28 villages of Ballabgarh block of Faridabad district of Haryana. Cases (diabetes) were recruited from the community with at least 1 year of diabetes. Age- and sex-matched two neighborhood controls were selected from the same community. Diabetic status was confirmed using glycated hemoglobin. CMDs such as depression and anxiety disorders were screened using PRIME-MD Hindi version. Conditional logistic regression was used to study the relationship between diabetes and CMDs. RESULTS: Total 211 cases (diabetic) and 273 controls (nondiabetic) were approached for the study, of which 173 cases and 175 controls were analyzed. Cases and controls were comparable with respect to age, sex, and socioeconomic status. CMDs were found more among cases as compared to controls (67.5% vs. 37.5%) (P < 0.001). On conditional logistic regression analysis, CMDs were significantly higher among diabetes cases (adjusted odds ratio - 3.2, 95% confidence interval: 1.9-5.2). CONCLUSION: Strong evidence of coexistence of CMDs and DM from this population-based study necessitates the need of incorporation of management of CMDs into diabetes control program in India.

Virulence gene mutations as a differentiator of clinical phenotypes: insights from community-acquired uropathogenic Escherichia coli.

Uropathogenic Escherichia coli (UPEC) remains an important cause of urinary tract infection during pregnancy. Multiple molecular virulence determinants and antibiotic resistant genes facilitate its pathogenesis and virulence phenotype. Hence it is hypothesized that there will be considerable variation in genes among the isolates from symptomatic as well as asymptomatic bacteriuria (ABU) during pregnancy. The aim of this study was to decipher the genetic variation among the two phenotypes. Six different UPEC isolates collected from urine specimens of consecutive pregnant females (five, symptomatic bacteriuria and one, ABU) were tested for their growth kinetics, and biofilm formation. A total of 87 virulence determinants and 56 antibiotic resistance genes were investigated using whole-genome sequencing, to identify putative drives of virulence phenotype. In this analysis, we identified eight different types of fully functional toxin antitoxin (TA) systems [HipAB, YefM-YoeB, YeeU-YeeV (CbtA), YhaV-PrlF, ChpBS, HigAB, YgiUT and HicAB] in the isolates from symptomatic bacteriuria; whereas partially functional TA system with mutations were observed in the asymptomatic one. Isolates of both the groups showed equivalent growth characteristics and biofilm-formation ability. Genes for an iron transport system (Efe UOB system, Fhu system except FhuA) were observed functional among all symptomatic and asymptomatic isolates, however functional mutations were observed in the latter group. Gene YidE was observed predominantly associated with the biofilm formation along with few other genes (BssR, BssS, YjgK, etc.). This study outlines putative critical relevance of specific variations in the genes for the TA system, biofilm formation, cell adhesion and colonization among UPEC isolates from symptomatic and asymptomatic bacteriuria among pregnant women. Further functional genomic study in the same cohort is warranted to establish the pathogenic role of these genes.

Test concordance and diagnostic accuracy of three serological assays for detection of anti-SARS-CoV-2 antibody: result from a population-based sero-epidemiological study in Delhi.

BACKGROUND: Several methodological tests are available to detect SARS-CoV-2 antibody. Tests are mostly used in the aid of diagnosis or for serological assessment. No tests are fully confirmatory and have variable level of diagnostic ability. We aimed at assessing agreement with three serological tests: quantitative anti receptor binding domain ELISA (Q-RBD), qualitative ELISA (WANTAI SARS-CoV-2 Ab) and qualitative chemiluminescence assay (CLIA). METHODS: This study was a part of a large population based sero-epidemiological cohort study. Participants aged 1 year or older were included from 25 randomly selected clusters each in Delhi urban (urban resettlement colony of South Delhi district) and Delhi rural (villages in Faridabad district, Haryana). Three type of tests were applied to all the baseline blood samples. Result of the three tests were evaluated by estimating the total agreement and kappa value. RESULTS: Total 3491 blood samples collected from March to September, 2021, out of which 1700 (48.7%) from urban and 1791 (51.3%) from rural. Overall 44.1% of participants were male. The proportion of sero-positivity were 78.1%, 75.2% and 31.8% by Wantai, QRBD and CLIA tests respectively. The total agreement between Wantai and QRBD was 94.5%, 53.1% between Wantai and CLIA, and 56.8% between QRBD and CLIA. The kappa value between these three tests were 0.84 (95% CI 0.80-0.87), 0.22 (95% CI 0.19-0.24) and 0.26 (95% CI 0.23-0.28). CONCLUSIONS: There was strong concordance between Wantai and QRBD test. Agreement between CLIA with other two tests was low. Wantai and QRBD tests measuring the antibody to same S protein can be used with high agreement based on the relevant scenario.

Antibiotic resistance of uropathogens among the community-dwelling pregnant and nonpregnant female: a step towards antibiotic stewardship.

BACKGROUND: Indiscriminate and widespread use of antibiotics has resulted in emergence of many antibiotic-resistant organisms. Antibiotic administration during pregnancy is mostly avoided, unless there is compelling medical condition. We hypothesized that the uropathogens isolated from pregnant women would be more susceptible to antibiotics compared to those isolated from nonpregnant women, thus will be helpful in formulating separate empiric guideline for pregnant women based on the resistance pattern. METHODS: This was a prospective cross-sectional study conducted over a period of 2 years in which females with the clinical diagnosis of either cystitis or asymptomatic bacteriuria during pregnancy were included from the community settings. Uropathogen species and their antimicrobial resistance pattern were compared between the pregnant and nonpregnant groups. After accounting for centre-to-centre variation and adjusting for age and socio-economic status, the adjusted odds ratio for antibiotic resistance was calculated and compared between pregnant and nonpregnant women using logistic regression analysis. RESULTS: A total of 1758 women (pregnant: 43.3%; nonpregnant: 56.6%) were screened in the study over a period of 2 years, out of which 9.3% (163/1758) were having significant bacteriuria. Escherichia coli and Klebsiella pneumoniae were the two commonest uropathogen in both the groups; their prevalence being 83.6% in pregnant women and 85.2% in nonpregnant women, respectively. Resistance against ampicillin, cefixime, cefoxitin, ceftazidime, ceftriaxone and amoxicillin-clavulanic acid were found significantly lower in the pregnant women compared to nonpregnant. After adjusting the age and socio-economic status accounting for centre-to-centre variation, the odds of resistance for cefixime, amoxicillin-clavulanic acid and co-trimoxazole were found lower and statistically significant among the pregnant women group. CONCLUSIONS: The antimicrobial resistance was significantly higher among the community-dwelling nonpregnant women compared to pregnant women in case of few antibiotics. The study highlighted the need of building local antibiogram that could help to initiate the empirical treatment and thus prevent emergence of antimicrobial resistance.

New Delhi, India: Perceptions & apprehensions: A qualitative studyOral HIV self-testing among men who have sex with men in.

Background & objectives: The overall adult prevalence of HIV in India was estimated to be 0.22 per cent in 2019. The HIV prevalence among men who have sex with men (MSM), a high-risk group for HIV, was estimated to be 4.3 per cent, which is 16 times higher than the national average. In Delhi, the estimated prevalence among MSM was 1.8 per cent. Despite free HIV testing services being made available by the National AIDS Control Programme for more than two decades, many MSM were not aware about their HIV status. Therefore, newer testing strategies are needed. Oral HIV self-testing (HIVST) has proved to be one such promising innovation. At present, there are no programme guidelines on HIVST and oral HIVST kit is not available in India. The aim of this study was to understand the perceived advantages and disadvantages of introduction of oral HIVST strategy among MSM. Methods: MSM who were registered with the selected non-governmental organizations working as targeted intervention sites in Delhi, India, were recruited for focus group discussions (FGDs) between January and May 2021. For the purpose of this study, MSM were defined as males who had anal/oral sex with male/hijra partner in the past one month. A total of six FGDs were conducted using a prepared FGD guide. The FGD guide included questions on problems faced during conventional HIV testing, participants' awareness, acceptability and perceptions of oral HIVST. The data were manually coded and entered in NVivo release 1.5 and themes were identified. Results: A total of 67 respondents participated in the FGDs. A total of 28.4 per cent MSM were beggars at traffic lights, 12 per cent were sex workers and 11.9 per cent were bar/event dancers. Nearly half (50.7%) of the participants had undergone HIV testing less than twice in the preceding one year. None of the MSM were aware about oral HIVST. Perceived advantages of oral HIVST were ease of use, confidentiality and the non-invasive pain-free procedure. Perceived concerns included lack of post-test counselling, linkage to care, poor mental health outcomes and forced testing. Interpretation & conclusions: Most MSM had positive perceptions about oral HIVST. Therefore, it is likely that the introduction of oral HIVST may result in higher uptake of HIV testing among MSM.

Comparison of prevention of parent-to-child HIV transmission programme & national biennial HIV sentinel surveillance data for tracking HIV epidemic in India.

Background & objectives: HIV sentinel surveillance (HSS) among antenatal women in India has been used to track the epidemic for many years. However, reliable tracking at the local level is not possible as ANC sentinel sites are limited in number and cover a smaller sample size at each site. Prevention of parent-to-child-transmission (PPTCT) programme data has a potential advantage due to better geographical coverage, which could provide more precise HIV case estimates; therefore, we compared HSS ANC data with PPTCT programme data for HIV tracking. Methods: Out of the 499 surveillance sites, where HSS and PPTCT programme was being conducted in 2015, 210 sites (140 urban and 70 rural) were selected using a stratified random sampling method. HSS (n=72,981) and PPTCT (n=112,832) data records were linked confidentially. The sociodemographic characteristics of HSS and PPTCT attendees were compared. HIV prevalence from HSS ANC was compared with the PPTCT programme data using Chi-square test. State- and site-level correlation of HIV prevalence was also done. Concordance between HSS and PPTCT HIV positivity was estimated using kappa statistics. Results: The age distribution of HSS and PPTCT attendees was similar (range: 23 to 27 yr); however, HSS ANC participants were better educated, whereas PPTCT recorded a higher proportion of homemakers. The correlation of HIV prevalence between HSS and PPTCT was high (r=0.9) at the State level and moderate at the site level (r=0.7). The HIV positivity agreement between HSS ANC and PPTCT was good (kappa=0.633). A similar prevalence was reported across 26 States, whereas PPTCT had a significantly lower prevalence than HSS in three States where PPTCT coverage was low. Overall HIV prevalence was 0.31 per cent in HSS and 0.22 per cent in PPTCT (P<0.001). Interpretation & conclusions: High-quality PPTCT programme data can provide reliable HIV trends in India. An operational framework for PPTCT-based surveillance should be pilot-tested in a phased manner before replacing HSS with PPTCT.

Excess Screen Time and its Associated Factors among Young Men in a Rural Community of North India.

Screen-based media usage among young people is blooming rapidly due to technological and digital revolution. We conducted community-based cross-sectional study to determine the prevalence of excess screen time and its association with sociodemographic and behavioral patterns in a rural block of Haryana, India. A semi-structured interview schedule was administered by trained physicians to ascertain screen time in a typical day and various socioeconomic and behavioral factors among a random sample of 860 young men aged 18-24 years. The prevalence of excess screen time was 61.8% (95% confidence interval [CI] 58.4-65.1). It was significantly associated with education (adjusted odds ratio [AOR] 1.7, 95% CI 1.1-2.6) and occupation (AOR 2.2, 95% CI 1.2-3.9) of the father and their sleep duration of ≤8 h (AOR 1.6, 95% CI 1.2-2.3). Limiting the screen time as per international standards and behavioral interventions are needed for this young population.

Spirometry-based prevalence of chronic obstructive pulmonary disease & associated factors among community-dwelling rural elderly.

Background & objectives: Chronic obstructive pulmonary disease (COPD) is a major public health problem in India. Its magnitude is particularly high among the elderly. Old age and comorbidity may lead to misdiagnosis and under treatment of this condition. COPD is not curable; however, various forms of treatment can help control symptoms and improve the quality of life. Most of the earlier studies lacked uniformity in definitions, designs, methodology and reporting techniques. Studies based on spirometry are only a few. Understanding the current prevalence and associated factors of COPD is important for planning control strategies. Hence, this study was conducted to determine the prevalence of COPD and associated factors among the elderly. Methods: In this community-based study among 449 elderly persons in a rural area, information regarding socio-demographic details, selected health conditions and exposure to risk factors was recorded. The assessment of airway obstruction was done by using a portable spirometer (MIR Spirolab). The diagnosis of COPD was based on the GOLD criteria. The association of COPD with sociodemographic and other variables was analysed by the multivariate logistic regression. Results: Acceptable spirometry findings were available for 392 (87.3%) participants. The prevalence of COPD was 42.9 per cent (95% confidence interval 37.9-47.7%). The prevalence was 54.5 per cent among men and 33.4 per cent among women. Smoking, higher age group and low body mass index were significantly associated with COPD. Interpretation & conclusions: The prevalence of COPD was found to be high among the rural elderly in this study. Interventions aimed at cessation of smoking and preparedness of health systems for diagnosis and management of COPD are hence required.

Point-of-Care Testing Using Invasive and Non-Invasive Hemoglobinometers: Reliable and Valid Method for Estimation of Hemoglobin among Children 6-59 Months.

INTRODUCTION: Globally around 47.4% of children and in India, 58% of children aged 6-59 months are anemic. Diagnosis of anemia in children using accurate technologies and providing adequate treatment is essential to reduce the burden of anemia. Point-of-care testing (POCT) devices is a potential option for estimation of hemoglobin in peripheral and field settings were the hematology analyzer and laboratory services are not available. OBJECTIVES: To access the validity of the POCTs (invasive and non-invasive devices) for estimation of hemoglobin among children aged 6-59 months compared with hematology analyzer. METHODS: The study participants were enrolled from the pediatric outpatient department in Haryana, India, from November 2019 to January 2020. Hemoglobin levels of the study participants were estimated in Sahli's hemoglobinometer and invasive digital hemoglobinometers (DHs) using capillary blood samples. Hemoglobin levels in non-invasive DH were assessed from the finger/toe of the children. Hemoglobin levels measured in POCTs were compared against the venous blood hemoglobin estimated in the hematology analyzer. RESULTS: A total of 120 children were enrolled. The mean (SD) of hemoglobin (g/dl) estimated in auto-analyzer was 9.4 (1.8), Sahli's hemoglobinometer was 9.2 (1.9), invasive DH was 9.7 (1.9), and non-invasive DH was 11.9 (1.5). Sahli's hemoglobinometer (95.5%) and invasive DH (92.2%) had high sensitivity for the diagnosis of anemia compared with non-invasive DH (24.4%). In contrast, non-invasive DH had higher specificity (96.7%) compared with invasive DH (83.3%) and Sahli's hemoglobinometer (70%). Invasive DH took the least time (2-3 min) for estimation of hemoglobin per participant, followed by Sahli's (4-5 min) and non-invasive DH (5-7 min). CONCLUSION: All three POCT devices used in this study are reasonable and feasible for estimating hemoglobin in under-5 children. Invasive DHs are potential POCT devices for diagnosis of anemia among under-5 children, while Sahli's can be considered as a possible option, where trained and skilled technicians are available. Further research and development are required in non-invasive DH to improve accuracy. Lay summaryIn India, anemia is a serious public health problem, where 58% of the children aged 6-59 months are anemic. Point-of-care testing (POCT) using digital hemoglobinometers (DHs) has been recommended as one of the key interventions by the Anemia Mukt Bharat program since 2018 in India. These POCT devices are easy to use, less invasive, can be carried to field, require minimal training and results are available immediately. Therefore this study assessed the validity of POCT devices-invasive DH, non-invasive DH and Sahli's hemoglobinometer among 6-59 months children in facility setting compared with the gold standard hematology analyzer. A total of 120 children under 6-59 months of age were enrolled from the pediatric outpatient department in Haryana, India, from November 2019 to January 2020. The (mean hemoglobin in g/dl) invasive (9.7) and non-invasive DH (11.9) overestimated hemoglobin value, while Sahli's (9.2) underestimated hemoglobin compared with hematology analyzer (9.4). Invasive DH (92.2%) and Sahli's hemoglobinometer (95.5%) reported high ability to correctly identify those with anemia compared with non-invasive DH (24.4%). In contrast, non-invasive DH (96.73%) had higher ability to correctly identify those without the anemia compared with invasive DH (83.3%) and Sahli's (70%).

Mitogen Kinase Kinase (MKK7) Controls Cytokine Production In Vitro and In Vivo in Mice.

Mitogen kinase kinase 4 (MKK4) and mitogen kinase kinase 7 (MKK7) are members of the MAP2K family that can activate downstream mitogen-activated protein kinases (MAPKs). MKK4 has been implicated in the activation of both c-Jun N-terminal kinase (JNK) and p38 MAPK, while MKK7 has been reported to activate only JNK in response to different stimuli. The stimuli, as well as the cell type determine which MAP2K member will mediate a given response. In various cell types, MKK7 contributes to the activation of downstream MAPKs, JNK, which is known to regulate essential cellular processes, such as cell death, differentiation, stress response, and cytokine secretion. Previous studies have also implicated the role of MKK7 in stress signaling pathways and cytokine production. However, little is known about the degree to which MKK4 and MKK7 contribute to innate immune responses in macrophages or during inflammation in vivo. To address this question and to elucidate the role of MKK4 and MKK7 in macrophage and in vivo, we developed MKK4- and MKK7-deficient mouse models with tamoxifen-inducible Rosa26 CreERT. This study reports that MKK7 is required for JNK activation both in vitro and in vivo. Additionally, we demonstrated that MKK7 in macrophages is necessary for lipopolysaccharide (LPS)-induced cytokine production, M1 polarization, and migration, which appear to be a major contributor to the inflammatory response in vivo. Conversely, MKK4 plays a significant, but minor role in cytokine production in vivo.

Tobacco use and nicotine dependence among patients with diabetes and hypertension in Ballabgarh, India.

 Tobacco use is one of the most important modifiable risk factors for cardiovascular mortality and has a synergistic effect with diabetes and hypertension. This study was conducted to estimate the prevalence of tobacco use and nicotine dependence among adult diabetic and/or hypertensive patients. We conducted a cross-sectional study among 419 consecutively enrolled patients from the non-communicable diseases (NCDs) outpatient clinic of a secondary level hospital in Ballabgarh, India between July 2018 and January 2019. We administered a pre-tested questionnaire to assess tobacco use and Fagerstrom Test for Nicotine Dependence (FTND) to assess nicotine dependence. Current tobacco users were defined as those who smoked in the past seven days. Nicotine dependence was classified as low, moderate or high for the FTND score of 0 -3, 4-6, and 7-10, respectively. Seventy-nine patients had diabetes, 226 had hypertension, and 114 had both. The prevalence of tobacco use was 20.8% (95% CI : 17.1 - 24.9); prevalence of smoking was 15% (95% CI: 11.9 â€" 18.8) and smokeless tobacco use was 7.2% (95% CI: 5 - 10.1). Moderate to high nicotine dependence was found among 59.7% of tobacco users; 75.9% tobacco users attempted to quit tobacco in the past one month. One-fifth of attendees of a NCD clinic in a secondary level hospital used tobacco, most of whom had moderate-to-high nicotine dependence.  High level of nicotine dependence and inability to quit despite making an attempt for it necessitates the inclusion of tobacco cessation services in the management of patients with non-communicable diseases.

A quality improvement intervention to improve early initiation of breastfeeding among newborns delivered at a secondary level hospital in northern India.

BACKGROUND: Early initiation of breastfeeding (EIBF) has been shown to be associated with reduced neonatal mortality, but many barriers exist that lead to the delay of EIBF. We aimed at improving EIBF among newborns delivered at a secondary care hospital using standard quality improvement methods of root-cause analysis and the Plan-Do-Study-Act (PDSA) cycle. METHODS: The study was conducted in the year 2016-17 at a 50-bedded secondary care hospital in northern India. A baseline assessment of the timing of breastfeeding initiation was done, and factors contributing to delayed initiation of breastfeeding were analysed. Interventions were planned and implemented in short sequential PDSA cycles. The rapid-cycle aspect of PDSA began with piloting a new process, followed by examining results and responding by problem-solving, after which the next PDSA cycle was initiated. The percentage of newborns receiving breastfeeding within 1 h of birth was assessed on a monthly basis. RESULTS: The rate of early initiation of breastfeeding improved from 52% at baseline to 97% in the immediate post-training phase. After an initial fall due to the shortage of staff, the EIBF rate was sustained at 91% after six months. CONCLUSION: EIBF can be achieved through the involvement of all stakeholders, team-building, and commitment from managerial staff using the QI (Quality Improvement) approach.

Direct and indirect patient costs of tuberculosis care in India.

OBJECTIVE: To synthesise the evidence for estimating the direct and indirect patient costs of drug-sensitive and drug-resistant tuberculosis care in India. METHOD: PubMed, Embase, Web of Science, IndMED and Google Scholar were searched for studies conducted in India between 2000 and 2018 and published in English. The search terms were "tuberculosis" AND "costs" (cost Analysis, economics, cost of illness, health care costs, health expenditures, direct service costs, catastrophic cost) AND "India". The cost of TB care was from the patient's perspective. Data regarding costs were extracted, indexed to the year 2018 using cumulative inflation rate and converted to US dollars at the exchange rate of 2018. RESULTS: Thirteen studies were included in this review. The mean (unweighted) total cost incurred by patients being treated for drug-sensitive TB in a public health facility was $ 235.00 (SD- 222.10), and the median of means was $ 170.60 (range - 43.70-718.40). The mean direct cost was 45.5% of the total cost. Only one study, which was conducted in a private facility, reported the mean total cost for drug-resistant TB as $ 7778.04. Catastrophic cost (total cost ≥ 20% of the total annual household income) was experienced by 7% to 32.4% of drug-sensitive TB patients and by 68% of drug-resistant TB patients. CONCLUSION: Despite free diagnostic and treatment services provided under the Revised National Tuberculosis Control Programme, the patient cost of tuberculosis care is high. Relevant studies vary widely in methodology and cost reporting.

OBJECTIF: Synthétiser les données probantes permettant d'estimer les coûts directs et indirects des soins anti-TB pour les patients avec une TB sensible ou résistante aux médicaments en Inde. MÉTHODE: PubMed, Embase, Web of Science, IndMED et Google Scholar ont été recherchés pour des études menées en Inde entre 2000 et 2018 et publiées en anglais. Les termes de recherche étaient 'tuberculose' ET 'coûts' (analyse des coûts, économie, coût de la maladie, coûts des soins de santé, dépenses de santé, coûts directs des services, coût catastrophique) ET 'Inde'. Le coût des soins anti-TB était du point de vue du patient. Les données concernant les coûts ont été extraites, indexées pour l'année 2018 en utilisant le taux d'inflation cumulé et converties en dollars US au taux de change de 2018. RÉSULTATS: Treize études ont été incluses dans cette revue. Le coût total moyen (non pondéré) encouru par les patients traités pour une TB sensible aux médicaments dans un établissement de santé public était de 235,00 USD (SD-222,10), et la médiane des moyennes était de 170,60 USD (intervalle - 43,70 - 718,40). Le coût direct moyen était de 45,5% du coût total. Une seule étude, qui a été menée dans un établissement privé, a rapporté le coût moyen total pour la TB résistante aux médicaments équivalent à 7.778,04 USD. Des coûts catastrophiques (coût total ≥ 20% du revenu annuel total du ménage ) ont été subis par 7% à 32,4% des patients avec une TB sensible aux médicaments et par 68% des patients avec une TB résistante aux médicaments. CONCLUSION: Malgré les services gratuits de diagnostic et de traitement fournis dans le cadre du Programme National Révisé de Lutte contre la TB, le coût des soins anti-TB pour les patients est élevé. Les études pertinentes varient considérablement dans la méthodologie et la communication des coûts.

Findings from the 2017 HIV estimation round & trend analysis of key indicators 2010-2017: Evidence for prioritising HIV/AIDS programme in India.

Background & objectives: The National AIDS Control Organisation (NACO) and the ICMR-National Institute of Medical Statistics, the nodal agency for conducting HIV estimations in India, have been generating HIV estimates regularly since 2003. The objective of this study was to describe India's biennial HIV estimation 2017 process, data inputs, tool, methodology and epidemiological assumptions used to generate the HIV estimates and trends of key indicators for 2010-2017 at national and State/Union Territory levels. Methods: Demographic Projection (DemProj) and AIDS Impact Modules (AIM) of Spectrum 5.63 software recommended by the United Nations Programme on HIV and AIDS Global Reference Group on HIV Estimates, Modelling and Projections, were used for generating HIV estimations on key indicators. HIV sentinel surveillance, epidemiological and programme data were entered into Estimation Projection Package (EPP), and curve fitting was done using EPP classic model. Finally, calibration was done using the State HIV prevalence of two rounds of National Family Health Survey (NFHS) -3 and -4 and Integrated Biological and Behavioural Surveillance (IBBS), 2014-2015. Results: The national adult prevalence of HIV was estimated to be 0.22 per cent in 2017. Mizoram, Manipur and Nagaland had the highest prevalence over one per cent. An estimated 2.1 million people were living with HIV in 2017, with Maharashtra estimated to have the highest number. Of the 88 thousand annual new HIV infections estimated nationally in 2017, Telangana accounted for the largest share. HIV incidence was found to be higher among key population groups, especially people who inject drugs. The annual AIDS-related deaths were estimated to be 69 thousand nationally. For all indicators, geographic variation in levels and trends between States existed. Interpretation & conclusions: With a slow decline in annual new HIV infections by only 27 per cent from 2010 to 2017 against the national target of 75 per cent by 2020, the national target to end AIDS by 2030 may be missed; although at the sub-national level some States have made better progress to reduce new HIV infection. It calls for reinforcement of HIV prevention, diagnosis and treatment efforts by geographical regions and population groups.