Prevalence of mild behavioral impairment in mild cognitive impairment and subjective cognitive decline, and its association with caregiver burden.

BACKGROUND: Mild behavioral impairment (MBI) describes later life acquired, sustained neuropsychiatric symptoms (NPS) in cognitively normal individuals or those with mild cognitive impairment (MCI), as an at-risk state for incident cognitive decline and dementia. We developed an operational definition of MBI and tested whether the presence of MBI was related to caregiver burden in patients with subjective cognitive decline (SCD) or MCI assessed at a memory clinic. METHODS: MBI was assessed in 282 consecutive memory clinic patients with SCD (n = 119) or MCI (n = 163) in accordance with the International Society to Advance Alzheimer's Research and Treatment - Alzheimer's Association (ISTAART-AA) research diagnostic criteria. We operationalized a definition of MBI using the Neuropsychiatric Inventory Questionnaire (NPI-Q). Caregiver burden was assessed using the Zarit caregiver burden scale. Generalized linear regression was used to model the effect of MBI domains on caregiver burden. RESULTS: While MBI was more prevalent in MCI (85.3%) than in SCD (76.5%), this difference was not statistically significant (p = 0.06). Prevalence estimates across MBI domains were affective dysregulation (77.8%); impulse control (64.4%); decreased motivation (51.7%); social inappropriateness (27.8%); and abnormal perception or thought content (8.7%). Affective dysregulation (p = 0.03) and decreased motivation (p=0.01) were more prevalent in MCI than SCD patients. Caregiver burden was 3.35 times higher when MBI was present after controlling for age, education, sex, and MCI (p < 0.0001). CONCLUSIONS: MBI was common in memory clinic patients without dementia and was associated with greater caregiver burden. These data show that MBI is a common and clinically relevant syndrome.

Nutritional Indicators for Gujarat, Its Determinants and Recommendations: A Comparative Study of National Family Health Survey-4 and National Family Health Survey-5.

Malnutrition is a public health problem globally. Gujarat is one of the states facing challenges in dealing with malnutrition and anemia. The NFHS-5 (National Family Health Survey-5) data reveals that the gains made in NFHS-4 (National Family Health Survey-4) were reversed in NFHS-5. Despite numerous schemes and policies in place, Gujarat has yet to reach the full potential of these mandated policies to showcase exponential results in malnutrition and anemia. This study presents an overview of the nutritional status of districts in Gujarat, compared with NFHS-4, by illuminating its potential determinants and inter-district variabilities. An increased prevalence was seen in children under five who are stunted and severely wasted; however, the prevalence of children under five who are wasted improved in Gujarat. The prevalence of anemia increased across all age groups, showing an immediate sign of caution. The study observed decreased prevalence of immediate determinants and increased coverage of nutrition-specific interventions in NFHS-5 compared to NFHS-4 for nutritional indicators in Gujarat. Underlying determinants like households with electricity and improved drinking water have improved drastically in Gujarat. Furthermore, it elaborates on the gaps and improvements observed in inter-district variabilities among determinants in their coverage. This study also consists of actions taken by states that have fared better concerning nutritional indicators instead of improving the nutritional indicators for Gujarat. The study has categorized the districts into top-priority, priority, average, and front-runner districts of Gujarat based on the prevalence of nutritional indicators.

Bal Poshan Yojana: A Novel Approach to Facility-Based Severe Acute Malnutrition Management.

Introduction Severe acute malnutrition (SAM) carries severe implications for a child's development. The survival of a child suffering from severely acute malnourishment is majorly dependent on the management of SAM, and scaling up the framework for addressing malnutrition is one of its main components. A severely malnourished child has a higher risk of mortality as compared to an ideally nourished child. Bal Poshan Yojana under the aegis of Project Tushti, a public-private partnership (PPP) model, aims at strengthening the framework of treatment for SAM children by working towards building a sustainable eco-system through engaging the government body, private practitioners and implementing bodies. Methods Bal Poshan Yojana is a novel approach implemented for the first time in the Devbhumi Dwarka district of Gujarat for the management of SAM under a PPP model. The private practitioners and centres were empanelled and trained on the treatment of SAM. SAM children with medical complications were screened through anthropometric measurements and appetite tests carried out by Rashtriya Bal Swasthya Karyakram (or RBSK, a program for child health) medical team. High-risk cases were referred to the nearest empanelled Bal Poshan Centre in the area. Children were treated for 14 days at the Bal Poshan Centre as per the protocol of the National Rehabilitation Centre and then discharged if the children fulfilled the criteria. The treatment included a 14-day treatment protocol and three follow-ups in an interval of 15 days each. The data was analyzed with appropriate statistical tests. Results Since its inception, a total of 102 severely malnourished children under five years of age have completed their treatment successfully, including three follow-ups. Around 60.79% of SAM children have been found to become normal in their nutritional status. The mean weight gain upon discharge was 0.57 kg and after three follow-ups, it was 1.051 kg. Conclusion Bal Poshan Yojana is a one of its kind initiative to tackle the growing burden of malnutrition among under-five age group children. The initiative has a focused approach. Strong referral and verification mechanisms ensure complete transparency and yielding of desired results.

Author Correction: A cartridge based Point-of-Care device for complete blood count.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Recent Progress in Birdcage RF Coil Technology for MRI System.

The radio frequency (RF) coil is one of the key components of the magnetic resonance imaging (MRI) system. It has a significant impact on the performance of the nuclear magnetic resonance (NMR) detection. Among numerous practical designs of RF coils for NMR imaging, the birdcage RF coil is the most popular choice from low field to ultra-high field MRI systems. In the transmission mode, it can establish a strong and homogeneous transverse magnetic field B1 for any element at its Larmor frequency. Similarly, in the reception mode, it exhibits extremely high sensitivity for the detection of even faint NMR signals from the volume of interest. Despite the sophisticated 3D structure of the birdcage coil, the developments in the design, analysis, and implementation technologies during the past decade have rendered the development of the birdcage coils quite reasonable. This article provides a detailed review of the recent progress in the birdcage RF coil technology for the MRI system.

A cartridge based Point-of-Care device for complete blood count.

We demonstrate a proprietary lab-on-chip/µ TAS technology platform for a regulatory grade portable instrument for complete blood count (CBC) hematology tests including 3 part differential WBCs, RBCs, platelet and hemoglobin for rapid diagnostics at the point of care in resource-poor settings. Presently, diagnostics based on blood tests are confined to centralized laboratory settings, dependent on large footprint and expensive cytometers or on a microscope, requiring trained laboratory technicians. Consequently, such facilities are not present in rural and semi-urban settings, where there are opportunities and challenges in delivering efficient healthcare infrastructure at an affordable cost in resource-challenged environments. Our proposed design leverages advances in microfluidics and lab-on-chip fabrication techniques to miniaturize the conventional cytometer and bring down the cost significantly. The device can be operated autonomously, without skilled manpower, by primary healthcare professionals in the field and by patients (like glucose self-test devices). The instrument consists of a single-use chip, the size of a credit card, pre-loaded with reagents, in which the sample is loaded, and which is fluidically insulated from the environment. The controller, the size of a toaster, performs the necessary fluid handling and the impedance measurements to deliver the results in minutes.

Enhanced hypertension care through private clinics in Pakistan: a cluster randomised trial.

BACKGROUND: Hypertension in Pakistan affects 33% of people aged ≥45 years, and in urban areas around 70% of basic health care occurs in private facilities. AIM: To assess whether enhanced care at urban private clinics resulted in better control of hypertension, cardiovascular disease (CVD) risk factors, and treatment adherence. DESIGN & SETTING: A two-arm cluster randomised controlled trial was conducted at 26 private clinics (in three districts of Punjab) between January 2015-September 2016. Both arms had enhanced screening and diagnosis of hypertension and related conditions, and patient recording processes. Intervention facilities also had a clinical care guide, additional drugs for hypertension, a patient lifestyle education flipchart, associated training, and mobile phone follow-up. METHOD: Clinics were randomised in a 1:1 ratio (sealed envelope lottery method). A total of 574 intervention and 564 control patients in 13 clusters in each arm were recruited (male and female, aged ≥25 years, systolic blood pressure [SBP] >140 mmHg, and/or diastolic blood pressure [DBP] >90 mmHg). The primary outcome was change in SBP from baseline to 9-month follow-up.Staff and patients were not blinded, but outcome assessors were blinded. RESULTS: Nine-month primary outcomes were available for 522/574 (90.9%) intervention and 484/564 (85.8%) control participants (all clusters). The unadjusted cluster-level analysis results were as follows: mean intervention outcome was -25.2 mmHg (95% confidence intervals [CI] = -29.9 to-20.6); mean control outcome was -9.4 mmHg (95% CI = 21.2 to 2.2); and mean control-intervention difference was 15.8 (95% CI = 3.6 to 28.0; P = 0.01). CONCLUSION: The findings and separate process evaluation support the scaling of an integrated CVD-hypertension care intervention in urban private clinics in areas lacking public primary care in Pakistan.

Feasibility of delivering integrated COPD-asthma care at primary and secondary level public healthcare facilities in Pakistan: a process evaluation.

BACKGROUND: In Pakistan,the estimated prevalence of chronic obstructive pulmonary disease (COPD) and asthma are 2.1% and 4.3% respectively, and existing care is grossly lacking both in coverage and quality. An integrated approach is recommended for delivering COPD and asthma care at public health facilities. AIM: To understand how an integrated care package was experienced by care providers and patients, and to inform modifications prior to scaling up. DESIGN & SETTING: The mixed-methods study was conducted as part of cluster randomised trials on integrated COPD and asthma care at 30 public health facilities. METHOD: The care practices were assessed by analysing the clinical records of n = 451 asthma and n = 313 COPD patients. Semi-structured interviews with service providers and patients were used to understand their care experiences. A framework approach was applied to analyse and interpret qualitative data. RESULTS: Utilisation of public health facilities for chronic lung conditions was low, mainly because of the non-availability of inhalers. When diagnosed, around two-thirds (69%) of male and more than half (55%) of female patients had severe airway obstruction. The practice of prescribing inhalers differed between intervention and control arms. Patient non-adherence to follow-up visits remained a major treatment challenge (though attrition was lower and slower in the intervention arm). Around half of the male responders who smoked at baseline reported having quit smoking. CONCLUSION: The integrated care of chronic lung conditions at public health facilities is feasible and leads to improved diagnosis and treatment in a low-income country setting. The authors recommend scaling of the intervention with continued implementation research, especially on improving patient adherence to treatment.

Effectiveness of delivering integrated COPD care at public healthcare facilities: a cluster randomised trial in Pakistan.

BACKGROUND: In Pakistan chronic obstructive pulmonary disease (COPD) prevalence is 2.1% in adults aged >40 years. Despite being a health policy focus, integrated COPD care has remained neglected, with wide variation in practice. AIM: To assess whether enhanced care at public health facilities resulted in better control of COPD, treatment adherence, and smoking cessation. DESIGN & SETTING: A two-arm cluster randomised controlled trial was undertaken in 30 public health facilities (23 primary and 7 secondary), across three districts of Punjab, between October 2014-December 2016. Both arms had enhanced diagnosis and patient recording processes. Intervention facilities also had clinical care guides; drugs for COPD; patient education flipcharts; associated staff training; and mobile phone follow-up. METHOD: Facilities were randomised in a 1:1 ratio (sealed envelope independent lottery method), and 159 intervention and 154 control patients were recruited. The eligibility criteria were as follows: diagnosed with COPD, aged ≥18 years, and living in the catchment area. The primary outcome was change in BODE (Body mass index, airway Obstruction, Dyspnoea, Exercise capacity) index score from baseline to final follow-up visit. Staff and patients were not blinded. RESULTS: Six-month primary outcomes were available for 147/159 (92.5%) intervention and 141/154 (91.6%) control participants (all clusters). The primary outcome results cluster-level analysis were as follows: mean intervention outcome = -1.67 (95% confidence intervals [CI] = -2.18 to -1.16); mean control outcome = -0.66 (95% CI = -1.09 to -0.22); and covariate-adjusted mean intervention-control difference = -0.96 (95% CI = -1.49 to -0.44; P = 0.001). CONCLUSION: The findings of this trial and a separate process evaluation study support the scaling of this integrated COPD care package at primary and secondary level public health facilities in Pakistan and similar settings.

Process evaluation of integrated diabetes management at primary healthcare facilities in Pakistan: a mixed-methods study.

BACKGROUND: Integrated care for diabetes and associated conditions at primary level health facilities can make care available to a much larger population, especially in rural areas. AIM: This process evaluation was to understand how the authors' integrated care was implemented and experienced by the care providers and patients, and to inform modifications prior to province-wide scale-up. DESIGN & SETTING: The mixed-method study was conducted as part of a cluster randomised trial on integrated diabetes care at 14 public health facilities. METHOD: The care practices were assessed by analysing the routine clinical records of 495 registered patients with diabetes. Then semi-structured interviews with service providers and patients were used to understand their respective care experiences. A framework approach was applied to analyse and interpret the qualitative data. RESULTS: The intervention and the study were implemented as intended under routine conditions in rural health centres. Key service processes effectively delivered included: skill-based training; screening and diagnostic tests; treatment card records; and the additional case management as per desk guide, including monitoring progress in glucose and weight at follow-up consultations, and mobile phone calls to help adherence. However, social and cultural factors affected clients' ability to change lifestyles, especially for women. The intervention effect was limited by the short study follow-up of only 9 months. CONCLUSION: Integrated diabetes care was feasible, both for providers and patients, and potentially scalable at primary care facilities under routine conditions in Pakistan. Additional operational interventions are required for sustained drug supplies, supervision, in-service training, and to address the social challenges to healthy activity and eating, especially for women.

Delivering integrated hypertension care at private health facilities in urban Pakistan: a process evaluation.

BACKGROUND: In Pakistan about 18% of all adults are affected by hypertension, and only one in eight of the prevalent cases have their hypertension controlled. As in many other low-middle income countries, a public-private partnership approach is being considered for delivering non-communicable disease care in urban areas. AIM: This process evaluation was undertaken to understand how an integrated care intervention was experienced by the care providers and patients, and to inform modifications before possible scaling. DESIGN & SETTING: The mixed-methods study was conducted as part of a cluster randomised trial on integrated hypertension care at 26 private clinics. METHOD: The care practices were assessed by analysing the clinical records of 1138 registered patients with hypertension. Then semi-structured interviews with service providers and patients were used to understand their respective care experiences. A framework approach was applied to analyse and interpret the qualitative data. RESULTS: District-led objective selection and context-sensitive staff training helped to get the clinics engaged in partnership working. About one-third of patients with hypertension had associated diabetes or renal compromise. The prescription of drugs is influenced by multiple non-clinical considerations of providers and patients. Many doctors allowed the use of home-based remedies as supplements to the prescribed allopathic drugs. Female patients faced more challenges in managing lifestyle changes. The intervention improved adherence to follow-up visits, but patient attrition remained a challenge. CONCLUSION: The integrated hypertension care intervention at private clinics is feasible, and leads to improved diagnosis and treatment in low-income country urban setting. The authors recommend continued implementation research and informed scaling of hypertension care at private clinics.

The effect of oil pulling with rice bran oil, sesame oil, and chlorhexidine mouth rinsing on halitosis among pregnant women: A comparative interventional study.

CONTEXT: Rice bran oil, owing to its potential antioxidant benefits, could be an effective and novel alternative to sesame oil for oil pulling. As it is safe and a growingly popular edible oil, it may be acceptable during pregnancy, especially in the Indian context where women may be hesitant to use chemical plaque control methods for preventing halitosis. AIMS: The present study was conducted to compare the effects of oil pulling with rice bran oil, oil pulling with sesame oil, and oil pulling with chlorhexidine mouth rinsing on reducing halitosis among pregnant women. SETTINGS AND DESIGN: Thirty pregnant women who attended the Gynecology Outpatient Department (OPD) of Muslim Medical Hospital, Haran Khana Road, Pani Gate, Vadodara, Gujarat, India, were recruited in the present randomized double-blind interventional study. SUBJECTS AND METHODS: Eligible pregnant women individuals who gave consent for the study were randomly allocated to receive the interventions under investigation. Halitosis was measured at baseline and after 14 days of intervention using TANITA breath checker HC-212M-BL. STATISTICAL ANALYSIS USED: Data entry was done in Microsoft Excel 2007, and statistical analysis was performed using SPSS version 17. Wilcoxon signed rank tests were used to interpret the differences in baseline and postintervention halitosis levels. One-way ANOVA was done to compare the mean reduction in halitosis scores of the three intervention groups. RESULTS: There was a statistically significant reduction in the grades of halitosis at baseline and 14 days after intervention for all the three groups. There was no statistically significant difference between chlorhexidine mouth rinsing, oil pulling with sesame oil, and oil pulling with rice bran oil in halitosis reduction. CONCLUSIONS: Rice bran oil when used in oil pulling was effective in reducing halitosis. It performed comparably and marginally superior to other agents tested in the study when change in halitosis postintervention was considered.

Urdu Nasta'liq text recognition using implicit segmentation based on multi-dimensional long short term memory neural networks.

The recognition of Arabic script and its derivatives such as Urdu, Persian, Pashto etc. is a difficult task due to complexity of this script. Particularly, Urdu text recognition is more difficult due to its Nasta'liq writing style. Nasta'liq writing style inherits complex calligraphic nature, which presents major issues to recognition of Urdu text owing to diagonality in writing, high cursiveness, context sensitivity and overlapping of characters. Therefore, the work done for recognition of Arabic script cannot be directly applied to Urdu recognition. We present Multi-dimensional Long Short Term Memory (MDLSTM) Recurrent Neural Networks with an output layer designed for sequence labeling for recognition of printed Urdu text-lines written in the Nasta'liq writing style. Experiments show that MDLSTM attained a recognition accuracy of 98% for the unconstrained Urdu Nasta'liq printed text, which significantly outperforms the state-of-the-art techniques.

Identification, evolution, and association study of a novel promoter and first exon of the human NOD2 (CARD15) gene.

Mutations in the NOD2 (CARD15) gene predispose to Crohn's disease (CD), a human chronic inflammatory bowel disorder, and can cause Blau syndrome. During an investigation of an apparent correlation between a frameshifting mutation in the canonical first exon of NOD2 of marmoset and tamarin species and their susceptibility to chronic colitis, we found that, contrary to previous reports, the basal levels of NOD2 transcripts in tissues relevant to CD arise from a distinct novel promoter and first exon. The canonical first exon, by contrast, seems to be of negligible transcriptional importance under physiological conditions, and its reading frame has been disrupted twice during primate evolution. Thus the main NOD2/CARD15 protein isoform produced in humans and other primates is 27 amino acids shorter than previously reported, starting at a conserved methionine in exon 2. We show that there is no significant association between variants in the novel NOD2 promoter region and CD.