Diabetic retinopathy screening uptake after health education with or without retinal imaging within the facility in two AYUSH hospitals in Hyderabad, India: A nonrandomized pilot study.

Purpose: In India, people with diabetes (PwDM) often seek care in the government-approved alternative medicine system, AYUSH (Ayurveda, Yoga and naturopathy, Unani, Siddha and Homeopathy). The purpose of this pilot study was to assess whether health education plus retinal imaging for diabetic retinopathy (DR) within an AYUSH hospital increased the uptake of screening for DR compared with health education and referral. Methods: The study was a nonrandomized pilot conducted in two AYUSH hospitals. Both hospitals received intervention on educating the AYUSH practitioners about DR screening and distributing health education materials to diabetic patients. In one hospital in addition to education, retinal imaging by a trained technician with remote grading by an ophthalmologist was provided, while in another hospital PwDM were referred to nearby eye hospitals for screening. The uptake of screening was assessed through registers and phone calls. Results: At baseline, only 10.7% of 178 PwDM were aware of DR and only 8% had undergone DR screening. After the intervention, in the hospital where screening was provided, all (100%) eligible patients (101) underwent digital imaging, whereas in the other hospital only 25% of 77 eligible patients underwent screening in eye hospitals (P < 0.001). Conclusion: AYUSH hospitals could provide a feasible and acceptable location for providing DR screening services. Further studies are required to assess scale-up of such intervention.

Care practices and neonatal survival in 52 neonatal intensive care units in Telangana and Andhra Pradesh, India: A cross-sectional study.

BACKGROUND: The Indian government supports both public- and private-sector provision of hospital care for neonates: neonatal intensive care is offered in public facilities alongside a rising number of private-for-profit providers. However, there are few published reports about mortality levels and care practices in these facilities. We aimed to assess care practices, causes of admission, and outcomes from neonatal intensive care units (NICUs) in public secondary and private tertiary hospitals and both public and private medical colleges enrolled in a quality improvement collaborative in Telangana and Andhra Pradesh-2 Indian states with a respective population of 35 and 50 million. METHODS AND FINDINGS: We conducted a cross-sectional study between 30 May and 26 August 2016 as part of a baseline evaluation in 52 consenting hospitals (26 public secondary hospitals, 5 public medical colleges, 15 private tertiary hospitals, and 6 private medical colleges) offering neonatal intensive care. We assessed the availability of staff and services, adherence to evidence-based practices at admission, and case fatality after admission to the NICU using a range of tools, including facility assessment, observations of admission, and abstraction of registers and telephone interviews after discharge. Our analysis is adjusted for clustering and weighted for caseload at the hospital level and presents findings stratified by type and ownership of hospitals. In total, the NICUs included just over 3,000 admissions per month. Staffing and infrastructure provision were largely according to government guidelines, except that only a mean of 1 but not the recommended 4 paediatricians were working in public secondary NICUs per 10 beds. On admission, all neonates admitted to private hospitals had auscultation (100%, 19 of 19 observations) but only 42% (95% confidence interval [CI] 25%-62%, p-value for difference is 0.361) in public secondary hospitals. The most common single cause of admission was preterm birth (25%) followed by jaundice (23%). Case-fatality rates at age 28 days after admission to a NICU were 4% (95% CI 2%-8%), 15% (9%-24%), 4% (2%-8%) and 2% (1%-5%) (Chi-squared p = 0.001) in public secondary hospitals, public medical colleges, private tertiary hospitals, and private medical colleges, respectively, according to facility registers. Case fatality according to postdischarge telephone interviews found rates of 12% (95% CI 7%-18%) for public secondary hospitals. Roughly 6% of admitted neonates were referred to another facility. Outcome data were missing for 27% and 8% of admissions to private tertiary hospitals and private medical colleges. Our study faced the limitation of missing data due to incomplete documentation. Further generalizability was limited due to the small sample size among private facilities. CONCLUSIONS: Our findings suggest differences in quality of neonatal intensive care and 28-day survival between the different types of hospitals, although comparison of outcomes is complicated by differences in the case mix and referral practices between hospitals. Uniform reporting of outcomes and risk factors across the private and public sectors is required to assess the benefits for the population of mixed-care provision.

Time motion study using mixed methods to assess service delivery by frontline health workers from South India: methods.

BACKGROUND: In India, amidst the increasing number of health programmes, there are concerns about the performance of frontline health workers (FLHW). We assessed the time utilisation and factors affecting the work of frontline health workers from South India. METHODS: This is a mixed methods study using time and motion (TAM) direct observations and qualitative enquiry among frontline/community health workers. These included 43 female and 6 male multipurpose health workers (namely, auxiliary nurse midwives (ANMs) and male-MPHWs), 12 nutrition and health workers (Anganwadi workers, AWWs) and 53 incentive-based community health workers (accredited social health activists, ASHAs). We conducted the study in two phases. In the formative phase, we conducted an in-depth inductive investigation to develop observation checklists and qualitative tools. The main study involved deductive approach for TAM observations. This enabled us to observe a larger sample to capture variations across non-tribal and tribal regions and different health cadres. For the main study, we developed GPRS-enabled android-based application to precisely record time, multi-tasking and field movement. We conducted non-participatory direct observations (home to home) for consecutively 6 days for each participant. We conducted in-depth interviews with all the participants and 33 of their supervisors and relevant officials. We conducted six focus group discussions (FGDs) with ASHAs and one FGD with ANMs to validate preliminary findings. We established a mechanism for quality assurance of data collection and analysis. We analysed the data separately for each cadre and stratified for non-tribal and tribal regions. RESULTS: On any working day, the ANMs spent median 7:04 h, male-MPHWs spent median 5:44 h and AWWs spent median 6:50 h on the job. The time spent on the job was less among the FLHWs from tribal areas as compared to those from non-tribal areas. ANMs and AWWs prioritised maternal and child health, while male-MPHWs were involved in seasonal diseases and school health. ASHAs visited homes to provide maternal health, basic curative care, and follow-up of tuberculosis patients. The results describe issues related with work planning, time management and several systemic, community-based and personnel factors affecting work of FLHWs. CONCLUSION: TAM study with mixed methods can help researchers as well as managers to periodically review work patterns, devise appropriate job responsibilities and improve the efficiency of health workers.

Risk factors for orofacial clefts in India: A case-control study.

BACKGROUND: Orofacial clefts (OFC) are linked with several genetic and environmental factors. The aim of this study was to explore the association of potential risk factors with OFCs in India. METHODS: This was a hospital-based, matched case-control (1:4 ratio; matching done for parity) study conducted in Hyderabad, Bengaluru, and Delhi-National Capital Region. Cases (nonsyndromic clefts) were recruited from treatment centers, while controls (live births) were recruited from maternity centers. Information on exposures was collected during personal interviews. Exposures of interest included folic acid supplementation during the peri-conceptional period, consanguineous marriage, exposure to drugs, infections during pregnancy, family history of OFC, and dietary factors. RESULTS: A total of 785 participants were included in the study: 157 cases and 628 controls. A family history of cleft lip/palate (adjusted odds ratio [AOR], 15.48; 95% confidence interval [CI], 4.36-54.96; p value = 0.001), exclusive vegetarianism (AOR, 4.47; 95% CI, 1.83-10.98; p value = 0.001), and delayed first conception (AOR, 2.55, 95% CI, 1.25-5.21, p = 0.01) were found to be strongly associated with higher risk of OFCs. Supplementation with folic acid during first 3 months of pregnancy was not found to be protective against OFCs (AOR, 1.24; 95% CI, 0.59-2.58; p value = 0.56). CONCLUSION: Our study confirmed the importance of family history as a risk factor for OFC. Our study did not show an association with folic acid supplementation but was underpowered to detect small effects. Our finding of higher risk among vegetarians requires replication. Birth Defects Research 109:1284-1291, 2017. © 2017 The Authors. Birth Defects Research Published by Wiley Periodicals, Inc.

Nitric Oxide Ameliorates Zinc Oxide Nanoparticles Phytotoxicity in Wheat Seedlings: Implication of the Ascorbate-Glutathione Cycle.

The present study investigates ameliorative effects of nitric oxide (NO) against zinc oxide nanoparticles (ZnONPs) phytotoxicity in wheat seedlings. ZnONPs exposure hampered growth of wheat seedlings, which coincided with reduced photosynthetic efficiency (Fv/Fm and qP), due to increased accumulation of zinc (Zn) in xylem and phloem saps. However, SNP supplementation partially mitigated the ZnONPs-mediated toxicity through the modulation of photosynthetic activity and Zn accumulation in xylem and phloem saps. Further, the results reveal that ZnONPs treatments enhanced levels of hydrogen peroxide and lipid peroxidation (as malondialdehyde; MDA) due to severely inhibited activities of the following ascorbate-glutatione cycle (AsA-GSH) enzymes: ascorbate peroxidase, glutathione reductase, monodehydroascorbate reductase and dehydroascorbate reductase, and its associated metabolites ascorbate and glutathione. In contrast to this, the addition of SNP together with ZnONPs maintained the cellular functioning of the AsA-GSH cycle properly, hence lesser damage was noticed in comparison to ZnONPs treatments alone. The protective effect of SNP against ZnONPs toxicity on fresh weight (growth) can be reversed by 2-(4carboxy-2-phenyl)-4,4,5,5-tetramethyl- imidazoline-1-oxyl-3-oxide, a NO scavenger, and thus suggesting that NO released from SNP ameliorates ZnONPs toxicity. Overall, the results of the present study have shown the role of NO in the reducing of ZnONPs toxicity through the regulation of accumulation of Zn as well as the functioning of the AsA-GSH cycle.

Folate, vitamin B12, ferritin and haemoglobin levels among women of childbearing age from a rural district in South India.

BACKGROUND: Low folate and vitamin B12 levels have negative effect on pregnancy outcomes but there is paucity of data on their levels among Indian women. Ferritin and haemoglobin are associated with maternal mortality and low birth-weight. Our aim was to estimate the prevalence of deficiency of serum folate and vitamin B12, and low levels of serum ferritin and blood haemoglobin among women of childbearing age from a rural population of South India. METHODS: We conducted a community-based cross-sectional study among 15-35 year women in a rural district. We used multistage stratified random sampling. Trained staff interviewed women to collect socio-demographic information and draw blood samples. We analysed samples for serum folate, vitamin B12, ferritin and blood haemoglobin levels and computed means and medians. We computed the proportion of deficiency based on cut-offs recommended by WHO. We examined the association of levels with age, parity and current pregnancy or breastfeeding by multi-variable regression using Stata 13.0. RESULTS: We recruited 979 women. One-fifth (185, 19%) were pregnant and one-fifth (196, 20%)were breastfeeding. Median serum folate levels were 2.5 ng/ml (IQR, 1.2-4.8), median vitamin B12 levels were 228.0 pg/ml (IQR, 121 - 390), median ferritin levels were 13.0 µg/l (IQR, 6.0 - 20.0) and median blood haemoglobin levels were 12.1 mg/dl (IQR, 10.7 - 13.6). Low levels of serum folate, vitamin B12, ferritin and haemoglobin were found in 57% (95% CI, 54-60%), 44% (95% CI, 41-48%), 46% (95% CI, 43-49%) and 28% (95% CI, 25-31%) respectively. Women with folic acid deficiency had two times higher prevalence of having vitamin B12 deficiency. In adjusted regression analysis folate levels were lower in older and breastfeeding women, but not associated with parity and were higher among pregnant women. Similar associations were not found with Vitamin B12 deficiency. Ferritin levels were higher in older women; but not associated with parity, pregnancy or breastfeeding. Haemoglobin levels were lower in pregnant and breastfeeding women. CONCLUSION: Our findings suggest that folic acid, vitamin B12 and iron deficiency are important public health problems in India. We observed that half of the women of childbearing age were deficient in these nutrients. Folic acid and vitamin B12 deficiencies co-exist and should be supplemented together.

A Mixed-Method Study to Determine the Benefits of Periconceptional Folic Acid Supplementation and Effects of Folic Acid Deficiency in Mothers on Birth Outcomes.

BACKGROUND: Evidence from high income countries shows mothers who are supplemented with folic acid in their periconceptional period and early pregnancy have significantly reduced adverse outcomes like birth defects. However, in India there is a paucity of data on association of birth defects and folic acid supplementation. We identified a few important questions to be answered using separate scientific methods and then planned to triangulate the information. OBJECTIVE: In this paper, we describe the protocol of our study that aims to determine the association of folic acid and pregnancy outcomes like neural tube defects (NTDs) and orofacial clefts (OFCs). We decided to fill the gaps in knowledge from India to determine public health consequences of folic acid deficiency and factors influencing dietary and periconceptional consumption of folic acid. METHODS: The proposed study will be carried out in five stages and will examine the questions related to folic acid deficiency across selected locations in South and North India. The study will be carried out over a period of 4 years through the hierarchical evidence-based approach. At first a systematic review was conducted to pool the current birth prevalence of NTDs and orofacial clefts OFCs in India. To investigate the population prevalence, we plan to use the key informant method to determine prevalence of NTDs and OFCs. To determine the normal serum estimates of folic acid, iron, and vitamin B12 among Indian women (15-35 years), we will conduct a population-based, cross-sectional study. We will further strengthen the evidence of association between OFCs and folic acid by conducting a hospital-based, case-control study across three locations of India. Lastly, using qualitative methods we will understand community and health workers perspective on factors that decide the intake of folic acid supplements. RESULTS: This study will provide evidence on the community prevalence of birth defects and prevalence folic acid and vitamin B12 deficiency in the community. The case-control study will help understand the association of folic acid deficiency with OFCs. CONCLUSIONS: The results from this study are intended to strengthen the evidence base in childhood disability for planning and policy initiatives.

Dimethoate modifies enhanced UV-B effects on growth, photosynthesis and oxidative stress in mung bean (Vigna radiata L.) seedlings: implication of salicylic acid.

The present study is aimed to investigate implication of salicylic acid (SA) in regulation of dimethoate (30 and 150 ppm designated as D1 and D2, respectively) and enhanced UV-B radiation (ambient + supplemental; ambient + 4.0 kJ m(-2) and ambient + 8.0 kJ m(-2), designated as UV-B1 and UV-B2, respectively) induced responses in mung bean seedlings. Seeds of Vigna radiata L. cv. Narendra 1 were surface sterilized, washed thoroughly and soaked for 24 h in sterilized distilled water. Soaked seeds were sown in acid washed sterilized sand filled in plastic trays, and incubated in dark at 26 ± 2 °C for 2 days. The seedlings were grown in growth chamber at 26 ± 2 °C with 12 h photoperiod (350 µmol photons m(-2 )s(-1), PAR) and watered regularly. Six day old seedlings of equal size were gently transferred in 0.2 strength Rorison nutrient medium (pH 6.8) for acclimatization. Thereafter, dimethoate (30 and 150 ppm designated as D1 and D2, respectively) and enhanced UV-B radiation treatments were given. On the 12th day, seedlings of each set were harvested and various parameters related to growth, pigments, photosynthesis, oxidative stress and antioxidant system were analyzed. The D2 dose of dimethoate and UV-B1 and UV-B2 alone and together significantly (P < 0.05) declined growth, photosynthetic pigments and photosynthesis (Fv/Fm and qP except NPQ) which were accompanied by significant decrease in SA level. Similarly, D2 and UV-B also enhanced (P < 0.05) accumulation of reactive oxygen species and concomitantly damaging effects on lipids, proteins and membrane stability were observed. In contrast, in SA-pretreated seedlings damaging impacts of D2, UV-B1 and UV-B2 alone and together were significantly (P < 0.05) alleviated. Besides this, interestingly D1 dose of dimethoate alone had stimulatory effect on growth and it also ameliorated damaging effects of both the doses of UV-B. The activity of superoxide dismutase was stimulated by all the combinations. However, catalase, glutathione reductase and dehydroascorbate reductase activities were significantly (P < 0.05) inhibited by D2, UV-B1 and UV-B2 while SA-pretreatment ameliorated D2 and UV-B-induced inhibitions in activities of these enzymes. Total ascorbate and glutathione pools also decreased by D2 and both doses of UV-B; however, in SA-pretreated seedlings their amounts were significantly (P < 0.05) higher than D2, UV-B1 and UV-B2 alone. Interestingly, D1 also alleviated damaging impact of UV-B1 and UV-B2 on total ascorbate and glutathione pools. Results revealed that D2, UV-B1 and UV-B2 might alter SA biosynthesis that results into declined SA level which might be related with their toxicity. However, SA-pretreatment might act as a signal that reduces oxidative stress by triggering up-regulation of antioxidants hence improved growth and photosynthesis noticed. Alleviation of UV-B toxicity by D1 suggests about hormesis that triggers SA biosynthesis and hence protection against both doses of UV-B was observed.

Role of traditional birth attendants (TBAs) in provision of antenatal and perinatal care at home amongst the urban poor in Delhi, India.

More than 80% of deliveries amongst the urban poor are conducted at home, mostly by traditional birth attendants (TBAs). In all, 29 eligible TBAs in the study area were identified and interviewed to assess their knowledge and practices regarding antenatal and perinatal care. Their knowledge about complications in antenatal and perinatal period was inadequate. The majority provided inadequate advice to the mothers. Over seventy-nine percent (79.3%) gave injections of oxytocin. Sixteen (55.2%) did not wait or waited for less than 10 minutes for the mother to expel the placenta. Fourteen (48.3%) encountered excessive vaginal bleeding, but none knew how to manage it. Overall knowledge and care provided by the TBAs was poor.