Tuberculosis Pathways to Care and Transmission of Multidrug Resistance in India.

Rationale: India is experiencing a regional increase in cases of multidrug-resistant tuberculosis (MDR-TB). Objectives: Given the complexity of MDR-TB diagnosis and care, we sought to address key knowledge gaps in MDR risk factors, care delays, and drivers of delay to help guide disease control. Methods: From January 2018 to September 2019, we conducted interviews with adults registered with the National TB Elimination Program for MDR (n = 128) and non-MDR-TB (n = 269) treatment to quantitatively and qualitatively study care pathways. We collected treatment records and GeneXpert-TB/RIF diagnostic reports. Measurements and Main Results: MDR-TB was associated with young age and crowded residence. GeneXpert rifampicin resistance diversity was measured at 72.5% Probe E. Median time from symptom onset to diagnosis of MDR was 90 days versus 60 days for non-MDR, Wilcoxon P < 0.01. Delay decreased by a median of 30 days among non-MDR patients with wider access to GeneXpert, Wilcoxon P = 0.02. Pathways to care were complex, with a median (interquartile range) of 4 (3-5) and 3 (2-4) encounters for MDR and non-MDR, respectively. Of patients with MDR-TB, 68% had their first encounter in the private sector, and this was associated with a larger number of subsequent healthcare encounters and catastrophic expenditure. Conclusions: The association of MDR with young age, crowding, and low genotypic diversity raises concerns of ongoing MDR transmission fueled by long delays in care. Delays are decreasing with GeneXpert use, suggesting the need for routine use in presumptive TB. Qualitatively, we identify the need to improve patient retention in the National TB Elimination Program and highlight patients' trust relationship with private providers.

Anemia control program in india needs to be more comprehensive.

Iron-deficiency anemia has continued to remain high in India. It is possibly due to relying on only iron-folic acid (IFA) supplementation through Anemia Control Program (ACP) that is National Iron Plus Initiative (NIPI). Based on the WHO's recommendations, we studied different interventions that can help to increase the effectiveness of NIPI such as Vitamin C supplementation with IFA, low-dose iron (LDI) with intensified health education (IHE), LDI with Vitamin C, and iron-rich food items to increase hemoglobin (Hb%) among adolescent girls through public-private partnership named Rashtriya Kishor Swasthya Karyakram. Increments in Hb after 12 weeks of interventions were compared with that of control groups one with NIPI and the other without any intervention. Highest increment in Hb% was observed in IFA under NIPI plus Vitamin C group, followed by LDI plus IHE group which was comparable to Hb increment in only the NIPI group. It emphasizes the need of making existing NIPI more stringent and comprehensive by integrating effective measures based on up-to-date scientific knowledge.

Challenges to Cardiac Rehabilitation Post Coronary Artery Bypass Grafting: A Qualitative Study in Pune.

Background Adherence to cardiac rehabilitation (CR) regimen is crucial in the post-coronary artery bypass grafting (CABG) period. Cardiac rehabilitation involves various lifestyle changes, including diet and exercise, regular follow-up in OPD, and implementing secondary prevention recommendations. This study aims to understand the challenges to CR post-CABG. Methodology Seven in-depth interviews using an interview guide were carried out in the outpatient section of the cardiothoracic vascular surgery (CTVS) department of a tertiary health care facility in Pune, India. A purposive sampling technique was followed. Results The qualitative study revealed that dietary restrictions were difficult to follow, that some patients could not quit smoking even after surgery, and that transportation costs were an issue regarding CR follow-up. The majority of the participants appreciated the importance of regular exercise in their post-surgery life. Conclusion Despite the hurdles, the majority of participants stated that the fact that CABG is a major treatment pushed them to attend routine CR follow-ups and adhere to the CR regimen. A solid CR team was one of the study's strengths, and the team established a routine of telephonic reminders for regular follow-up, which resulted in lower rates of loss to follow-up.

Lymphopenia with Altered T Cell Subsets in Hospitalized COVID-19 Patients in Pune, India.

The cellular immune cell subsets affecting COVID-19 disease severity are being studied by researchers from many countries. The current study was carried out to investigate the alteration of peripheral blood mononuclear cells (PBMCs) and their subsets in hospitalized COVID-19 patients in a tertiary care center in Pune, India. The PBMCs were isolated from enrolled study participants, and flow cytometry analysis was done to assess peripheral white blood cell alterations. The lymphocyte subsets of naive, effector, central memory, and effector memory CD4+ or CD8+ T cells were then evaluated in COVID-19 patients with different disease categories and compared to healthy controls. The immunophenotypic characterization of the immune cell subset was done for 139 COVID-19 patients and 21 healthy controls. These data were evaluated based on the disease severity. A total of 139 COVID-19 patients were classified as mild (n = 30), moderate (n = 57), or severe (n = 52) cases. The decreased percentages of total lymphocytes, CD3+ T cells, CD4+ T cells, naive T cells, central memory T cells, and Natural Killer (NK) cytotoxic cells were found, and there was increase in effector T (TEf) cells and effector memory T cells in patients with severe COVID-19 compared to healthy controls. The severity of SARS-CoV-2 infection has an effect on lymphocyte subsets, resulting in reduced T memory cells and NK cells but increased TEf cells in severe cases. Clinical Trial Registration: CTRI ID-CTRI/2021/03/032028.

Utility of a real-time fluorescence imaging device in guiding antibiotic treatment in superficial skin infections.

The prescription of antibiotics empirically without confirmation of an infective etiology is on the rise. Administration of appropriate antibiotics can be guided by real-time fluorescence imaging using a point-of-care device. These composite images show the presence, type and the burden of infection. The time saved by this method over microbiological testing, especially in resource-poor settings, can lead to a paradigm shift in treatment by facilitating prompt and adequate antimicrobial therapy, surgical debridement as well as follow-up. Thumbnail sketches of a series of four cases highlighting different scenarios in which a fluorescent imaging device utilizing artificial intelligence and machine learning was found useful is presented in this report.

Vision centre helps reduce blindness and vision impairment. Proof of concept in a four-year longitudinal study in an urban area in India.

Purpose: To estimate the prevalence of blindness and severe visual impairment (SVI) by using a door-to-door screening and vision center (VC) examination strategy in an urban area in western Maharashtra (Pune), India and repeat the exercise after 4 years to study its impact. Methods: Four trained community health workers measured the visual acuity and performed an external ocular examination in patients' homes. People with vision <6/18 were requested to visit the VC for a comprehensive eye examination by an optometrist. An ophthalmologist examined people whose vision did not improve to 6/12. A home examination was done for people who did not visit the VC despite two requests. The same population was examined twice in an interval of 4 years. Results: In the study, 44,535 people in 2015-16 and 98.14% (n = 43,708) of them in 2018-19 were examined. Blindness (vision < 3/60 in better eye), and moderate-to-severe visual impairment (MSVI, vision 6/18-6/60 in better eye) were 0.26% and 1.3%, respectively, in the first cohort, and 0.16% and 1.1%, respectively, in the second cohort (P < 0.001). When the worse eye was considered, the prevalence of blindness reduced from 0.72% to 0.44%, SVI reduced from 0.1% to 0.07%, and MVI decreased from 1.7% to 1.49% between 2015 and 2019 (P < 0.001). Females (P < 0.001) and older individuals (P < 0.001) were more likely to have blindness or SVI. In the VC, 8211 people were examined in 4 years. Conclusion: The reduction of blindness and MSVI in the urban area of Pune can be partly ascribed to the presence of a VC and attendant screening in this locality.

Awareness about "Ten Steps for Successful Breastfeeding" among Medical and Nursing Students.

BACKGROUND: Baby-friendly Hospital Initiative (BFHI) is a vital intervention supported by World Health Organization and UNICEF to reduce infant mortality and has been included as a part of the curriculum in nursing and medical courses. To know the extent of knowledge of students about BFHI along with its understanding and to find out the gap in their knowledge about BFHI steps. METHODS: A descriptive cross sectional study was carried out among the nursing (4(th) year) and medical students (3(rd) year MBBS) about ten steps of BFHI by a pretested and predesigned questionnaire. After ethical clearance, information was collected about their awareness and correct understanding concerning ten steps. RESULTS: A total of 102 (51.6%) medical and 96 (48.4%) nursing students comprising of 57 (28.8%) males and 141 (71.2%) females were interviewed, had similar mean score about the ten steps of BFHI. Female respondents 82.3% had best understood the step 2 (training), as compared to males 80.7%. About step 6 (no supplements) 94.3% females and 86% males had well understood the step. Step 7 (rooming in) was known to 85.8% females and 54.4% males respectively. Step 9 (no pacifiers) was known to 80.1% females while among males 56.1% were aware. There was statistically significant difference in their knowledge about the steps 2 and 4 (skin to skin), 5 (counseling), 7, and 9 as females were more aware about these steps than males. The least understood steps in medical and nursing students were step 1 (written policy) (15.7%, 15.6%), step 3 (prenatal education) (27.5%, 29.2%), step 8 (cues) (10.8%, 24%) and step ten (community support) (8.8%, 11.5%) respectively. CONCLUSIONS: BFHI is one of the successful international efforts undertaken to promote, protect and support breast feeding. Acquiring knowledge about the same by medical and nursing students is most crucial tool for better practices by them in the future. Continued medical education, workshops and seminars by lactation specialists in addition to the regular teaching about BFHI as part of the curriculum may be considered to ensure and update their knowledge about BFHI.

Study of susceptibility towards varicella by screening for the presence of IgG antibodies among nursing and medical students of a tertiary care teaching hospital in pune, India.

BACKGROUND: It is believed that all suffer from chickenpox infection in their childhood. Many studies abroad and some in India clearly indicate that many individuals escape the infection in childhood, and thus, remain susceptible in adulthood. Adulthood chickenpox is a more serious infection than childhood. Prior screening of health care workers for the presence of IgG antibodies against Varicella will not only prevent hospital outbreaks but also economic and academic loss faced by the students. This will also have an important implication in terms of patient care as there is a threat of spreading Varicella to immuno-compromised patients. Definite history of prior infection of chickenpox is considered as an indicator for immunity towards the same. However, the reliability of this needs to be tested. AIM: A study to assess the susceptibility of nursing and medical students towards Varicella infection by screening for IgG antibodies against Varicella virus and to identify any risk factors for the same. SETTINGS AND DESIGN: A hospital-based cross-sectional study in nursing and medical students. MATERIALS AND METHODS: Total 78 nursing and medical students participated in the study. They were given prestructured and pretested questionnaires. After obtaining informed consent, blood sample was collected and screened for the presence of IgG antibodies against Varicella by Enzyme Linked Immunosorbent Assay (ELISA) by using a commercial kit. STATISTICAL ANALYSIS: Epi_info 2002 was used for analysis. Age of the study subjects were summarized as mean age and standard deviation. Susceptibility was analyzed as percentage with 95% confidence interval and Chi Square test was used to find association of susceptibility status with sex and region of residence in childhood. Relevance of definite history as an indicator for immunity was assessed by calculating sensitivity, specificity, positive and negative predictive values with 95% confidence interval. RESULTS: Twenty males (25.6%) and 58 females (74.4%) participated in the study from medical and nursing students. The mean age ± standard deviation of mean was 19.4 ± 1.42 years for female students and 20.8 ± 2.13 years for male students. Total 20 (25.6%) students were found to be susceptible to Varicella with the confidence interval ranging from 15.8% to 35.4%. With respect to the gender of the students, the difference between the susceptibility percentage in female students (32%) and in male students (14.3%) was only a numerical difference and not statistically significant (χ(2) = 2.098, P=0.147, d.f. = 2). Also, the susceptibility was seen significantly more among Keralite students (Pearson Chi-Square=16.736, d.f=6, P=0.008; Likelihood Ratio=15.086, d.f=6, P=0.035; Fisher's Exact Test=13.569, p=0.022). The sensitivity of definite history of prior chickenpox infection as an indicator of immunity was only 55.17%, with C.I ranging from 43.9% to 66.4%, specificity was 80%, with C.I. ranging from 70.9% to 86%, and positive predictive value was 88.8% with C.I of 81.7% to 89% and negative predictive value of history of 66.6% with C.I. of 56% to 77.2%. CONCLUSION: Total 20 (25.6%) students were found to be susceptible to Varicella with the confidence interval ranging from 15.8% to 35.4%. Thus, there is a need for vaccination of all susceptible individuals. Definite history of prior chickenpox infection is not a reliable indicator of immunity against the same. The investigators recommend screening for IgG antibodies against Varicella of all students selected for the M.B.B.S. (Bachelor of Medicine and Bachelor of Surgery) and nursing course, and vaccination for susceptible individuals to prevent institutional outbreak and academic loss.