Mental Health Programme in India: Has the tide really turned?

Mental disorders in India form a major public health concern and the efforts to tackle these dates back to four decades, by way of the National Mental Health Programme (NMHP) and its operational arm, the District Mental Health Programme (DMHP). Although the progress of NMHP (and DMHP) was relatively slower till recently, the last 4-5 years have seen rapid strides with several initiatives, including (i) expansion of DMHPs to 90 per cent of the total districts of the country, (ii) the National Mental Health Policy and (iii) strengthening the Mental Health Legislation by way of providing explicit provisions for rights of persons with mental illnesses. Among others, factors responsible for this accelerated growth include the easily accessible digital technology as well as judicial activism. Federal and State cooperation is another notable feature of this expansion. In this review, the authors summarize the available information on the evolution of implementation and research aspects related to India's NMHP over the years and provide a case for the positive turn of events witnessed in the recent years. However, the authors caution that these are still baby steps and much more remains to be done.

Greater COVID-19 Severity and Mortality in Hospitalized Patients in the Delta-phase Compared to the Others: A Single Center Prospective Registry.

BACKGROUND AND OBJECTIVE: To compare clinical and laboratory features, and outcomes in the second COVID-19 phase (delta variant) with the first and third phases in India we performed a registry-based study. METHODS: Patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were recruited over the study period from March 2020 to July 2022. In the first phase (wild type, March-December 2020) of the 7,476 suspected, 1,395 (18.7%) were positive and 863 (61.8%) were hospitalized, in the second phase (delta, January-July 2021) out of 8,680 suspected, 1,641 (19.4%) tested positive and 388 (23.6%) were hospitalized, and in the third phase (omicron, January-July 2022) out of 5,188 suspected patients, 886 (17.1%) tested positive and 94 (10.6%) were hospitalized. We compared details of admission clinical and laboratory features and in-hospital management and outcomes in the three phases. RESULTS: A total of 2,352 patients were recruited. The majority of the patients were men, aged <45 years were 20% and about 20% of patients had hypertension, diabetes, and cardiovascular diseases. Patients in the second phase had significantly more cough, fever, shortness of breath, and lower oxygen saturation (SpO2) at admission and also had more lymphopenia, C-reactive proteins (CRPs), interleukin-6, ferritin, lactic dehydrogenase, and transaminases than patients in the other two phases. In the second vs the first and third phases, the requirement of supplementary oxygen (47.9 vs 33.1 and 23.4%), proning (89.2 vs 37.1 and 5.3%), high flow nasal oxygen (15.7 vs 8.71 and 5.3%), noninvasive ventilation (14.4 vs 9.1 and 11.7%), invasive ventilation (16.2 vs 9.1 and 9.6%), steroids (94.1 vs 83.4 and 37.2%), remdesivir (91.2 vs 73.8 and 39.4%), and anticoagulants (94.3 vs 83.0 and 61.7%) was significantly more (p < 0.001). The median length of stay in days [interquartile range (IQR)] was longer in the second phase [8 (6-10)] vs the first [7 (5-10)] and the third phase [4 (3-6) days]. The intensive care unit (ICU) stay in the second phase [9 (5-13) days] was also significantly more than the first [6 (2-10)] and third [0 (0-3)] phases (p <0.001). Overall, in-hospital deaths occurred in 176 patients (12.8%). Deaths were significantly higher in the second phase (19.3%), compared to the first (11.0%) and the third (3.3%) phases (p <0.01). We also observed that greater disease severity at presentation was associated with higher mortality in all the phases. CONCLUSION: This study shows that COVID-19 patients that were hospitalized in the second (delta) phase of the epidemic had more severe disease compared to the first and third phases. In the second phase of patients, there was a significantly higher duration of hospitalization, ICU hospitalization, greater oxygen requirement, noninvasive and invasive ventilatory support, and more deaths.

Implementation fidelity of village health and nutrition days in Hardoi District, Uttar Pradesh, India: a cross-sectional survey.

BACKGROUND: Village Health and Nutrition Days (VHNDs) are a cornerstone of the Government of India's strategy to provide first-contact primary health care to rural areas. Recent government programmes such as the Janani Suraksha Yojana (JSY) and Mission Indradhanush (MI) have catalysed important changes impacting VHNDs. To learn how VHNDs are currently being delivered, we assessed the fidelity of services provided as compared to government norms in a priority district of Uttar Pradesh. METHODS: We fielded a cross-sectional study of VHNDs to provide a snapshot of health services functioning. Process evaluation data were collected via administrative sources, non-participant observation using a standardised form, and structured questionnaires. Questionnaires were designed using a framework to assess implementation fidelity. Key respondents were VHND participants, front-line workers involved in VHND delivery, and VHND non-participants (pregnant women due for antenatal care or children due for vaccination as per administrative records). Results were summarised as counts, frequencies, and proportions. RESULTS: In the 30 villages randomly selected for inclusion, 36 VHNDs were scheduled but four (11.1%) were cancelled and one VHND was not surveyed. Vaccination and antenatal care were offered at 96.8% (30/31) and child weighing at 83.9% (26/31) of VHNDs. Other normed services were infrequently provided or completely absent. Health education and promotion were particularly weak; institutional delivery was the only topic discussed in a majority of VHNDs. The true proportion of any serious problem impeding vaccine delivery was 47.2% (17/36), comprising 4 VHND cancellations and 13 VHNDs experiencing vaccine shortages. Of the 13 incidents of vaccine shortage, 11 related to an unexpected global shortage of injectable polio vaccine (IPV). Over the 31 VHNDs, 37.8% (171 of the 452 scheduled beneficiaries) did not participate. Analysis of missed opportunities for vaccination highlighted inaccuracies in beneficiary identification and tracking and demand side-factors. CONCLUSIONS: The transformative potential of VHNDs to improve population health is only partially being met. A core subset of high-priority services for antenatal care, institutional delivery, and vaccination associated with high-priority government programmes (JSY, MI) is now being provided quite successfully. Other basic health promotion and prevention services are largely not provided, constituting a critical missed opportunity.

Transthoracic echocardiographic assessment of spindle cell sarcoma of the pulmonary artery in a child.

In this report, we present a case of spindle cell sarcoma of the pulmonary artery diagnosed by transthoracic echocardiography. To the best of our knowledge, this case is the youngest reported case of pulmonary artery sarcoma (PAS) to date. PAS is frequently confused for pulmonary embolism; in this case, echocardiographic findings allowed for differentiation between pulmonary embolism and solid tumor.

Biomarkers and outcomes in hospitalised patients with COVID-19: a prospective registry.

OBJECTIVES: To determine association of biomarkers-high-sensitivity C reactive protein (hsCRP), D-dimer, interleukin-6 (IL-6), lactic dehydrogenase (LDH), ferritin and neutrophil-lymphocyte ratio (NLR)-at hospitalisation with outcomes in COVID-19. DESIGN AND SETTING: Tertiary-care hospital based prospective registry. PARTICIPANTS: Successive virologically confirmed patients with COVID-19 hospitalised from April 2020 to July 2021 were prospectively recruited. Details of clinical presentation, investigations, management and outcomes were obtained. PRIMARY AND SECONDARY OUTCOME MEASURES: All biomarkers were divided into tertiles to determine associations with clinical features and outcomes. Primary outcome was all-cause deaths and secondary outcome was oxygen requirement, non-invasive and invasive ventilation, dialysis, duration of stay in ICU and hospital. Numerical data are presented in median and interquartile range (IQR 25-75). Univariate and multivariate (age, sex, risk factors, comorbidities, treatments) ORs and 95% CIs were calculated. RESULTS: 3036 virologically confirmed patients with COVID-19 were detected and 1251 hospitalised. Men were 70.0%, aged >60 years 44.8%, hypertension 44.1%, diabetes 39.6% and cardiovascular disease 18.9%. Median symptom duration was 5 days (IQR 4-7) and oxygen saturation 95% (90%-97%). Total white cell count was 6.9×109/L (5.0-9.8), neutrophils 79.2% (68.1%-88.2%), lymphocytes 15.8% (8.7%-25.5%) and creatinine 0.93 mg/dL (0.78-1.22). Median (IQR) for biomarkers were hsCRP 6.9 mg/dL (2.2-18.9), D-dimer 464 ng/dL (201-982), IL-6 20.1 ng/dL (6.5-60.4), LDH 284 mg/dL (220-396) and ferritin 351 mg/dL (159-676). Oxygen support at admission was in 38.6%, subsequent non-invasive or invasive ventilatory support in 11.0% and 11.6%, and haemodialysis in 38 (3.1%). 173 (13.9%) patients died and 15 (1.2%) transferred to hospice care. For each biomarker, compared with the first, those in the second and third tertiles had more clinical and laboratory abnormalities, and oxygen, ventilatory and dialysis support. Multivariate-adjusted ORs (95% CI) for deaths in second and third versus first tertiles, respectively, were hsCRP 2.24 (1.11 to 4.50) and 12.56 (6.76 to 23.35); D-dimer 3.44 (1.59 to 7.44) and 14.42 (7.09 to 29.30); IL-6 2.56 (1.13 to 5.10) and 10.85 (5.82 to 20.22); ferritin 2.88 (1.49 to 5.58) and 8.19 (4.41 to 15.20); LDH 1.75 (0.81 to 3.75) and 9.29 (4.75 to 18.14); and NLR 3.47 (1.68 to 7.14) and 17.71 (9.12 to 34.39) (p<0.001). CONCLUSION: High levels of biomarkers-hsCRP, D-dimer, IL-6, LDH, ferritin and NLR-in COVID-19 are associated with more severe illness and higher in-hospital mortality. NLR, a widely available investigation, provides information similar to more expensive biomarkers.

Social and Behavior Change Communication Interventions Delivered Face-to-Face and by a Mobile Phone to Strengthen Vaccination Uptake and Improve Child Health in Rural India: Randomized Pilot Study.

BACKGROUND: In resource-poor settings, lack of awareness and low demand for services constitute important barriers to expanding the coverage of effective interventions. In India, childhood immunization is a priority health strategy with suboptimal uptake. OBJECTIVE: To assess study feasibility and key implementation outcomes for the Tika Vaani model, a new approach to educate and empower beneficiaries to improve immunization and child health. METHODS: A cluster-randomized pilot trial with a 1:1 allocation ratio was conducted in rural Uttar Pradesh, India, from January to September 2018. Villages were randomly assigned to either the intervention or control group. In each participating village, surveyors conducted a complete enumeration to identify eligible households and requested participation before randomization. Interventions were designed through formative research using a social marketing approach and delivered over 3 months using strategies adapted to disadvantaged populations: (1) mobile health (mHealth): entertaining educational audio capsules (edutainment) and voice immunization reminders via mobile phone and (2) face-to-face: community mobilization activities, including 3 small group meetings offered to each participant. The control group received usual services. The main outcomes were prespecified criteria for feasibility of the main study (recruitment, randomization, retention, contamination, and adoption). Secondary endpoints tested equity of coverage and changes in intermediate outcomes. Statistical methods included descriptive statistics to assess feasibility, penalized logistic regression and ordered logistic regression to assess coverage, and generalized estimating equation models to assess changes in intermediate outcomes. RESULTS: All villages consented to participate. Gaps in administrative data hampered recruitment; 14.0% (79/565) of recorded households were nonresident. Only 1.4% (8/565) of households did not consent. A total of 387 households (184 intervention and 203 control) with children aged 0 to 12 months in 26 villages (13 intervention and 13 control) were included and randomized. The end line survey occurred during the flood season; 17.6% (68/387) of the households were absent. Contamination was less than 1%. Participation in one or more interventions was 94.0% (173/184), 78.3% (144/184) for the face-to-face strategy, and 67.4% (124/184) for the mHealth strategy. Determinants including place of residence, mobile phone access, education, and female empowerment shaped intervention use; factors operated differently for face-to-face and mHealth strategies. For 11 of 13 intermediate outcomes, regression results showed significantly higher basic health knowledge among the intervention group, supporting hypothesized causal mechanisms. CONCLUSIONS: A future trial of a new intervention model is feasible. The interventions could strengthen the delivery of immunization and universal primary health care. Social and behavior change communication via mobile phones proved viable and contributed to standardization and scalability. Face-to-face interactions remain necessary to achieve equity and reach, suggesting the need for ongoing health system strengthening to accompany the introduction of communication technologies. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 44840759; https://doi.org/10.1186/ISRCTN44840759.

Surgical Algorithm for Rheumatic Tricuspid Disease.

Rheumatic involvement of the tricuspid valve frequently occurs in patients with mitral and aortic valve disease. Inadequate attention to tricuspid valve function can lead to increased morbidity and may necessitate reoperation. A surgical algorithm is developed and presented for treatment of rheumatic heart disease. Seventy-four patients underwent tricuspid valve repair. Competent tricuspid valve (not more than mild tricuspid regurgitation) could be achieved in all of these patients.

Experimental investigation of performance and emissions of a VCR diesel engine fuelled with n-butanol diesel blends under varying engine parameters.

The continuous rise in the cost of fossil fuels as well as in environmental pollution has attracted research in the area of clean alternative fuels for improving the performance and emissions of internal combustion (IC) engines. In the present work, n-butanol is treated as a bio-fuel and investigations have been made to evaluate the feasibility of replacing diesel with a suitable n-butanol-diesel blend. In the current research, an experimental investigation was carried out on a variable compression ratio CI engine with n-butanol-diesel blends (10-25% by volume) to determine the optimum blending ratio and optimum operating parameters of the engine for reduced emissions. The best results of performance and emissions were observed for 20% n-butanol-diesel blend (B20) at a higher compression ratio as compared to diesel while keeping the other parameters unchanged. The observed deterioration in engine performance was within tolerable limits. The reductions in smoke, nitrogen oxides (NO x ), and carbon monoxide (CO) were observed up to 56.52, 17.19, and 30.43%, respectively, for B20 in comparison to diesel at rated power. However, carbon dioxide (CO2) and hydrocarbons (HC) were found to be higher by 17.58 and 15.78%, respectively, for B20. It is concluded that n-butanol-diesel blend would be a potential fuel to control emissions from diesel engines. Graphical abstract ᅟ.

Optical and radiative properties of aerosols over Desalpar, a remote site in western India: Source identification, modification processes and aerosol type discrimination.

Aerosol optical properties are analyzed for the first time over Desalpar (23.74°N, 70.69°E, 30m above mean sea level) a remote site in western India during October 2014 to August 2015. Spectral aerosol optical depth (AOD) measurements were performed using the CIMEL CE-318 automatic Sun/sky radiometer. The annual-averaged AOD500 and Ångström exponent (α440-870) values are found to be 0.43±0.26 and 0.69±0.39, respectively. On the seasonal basis, high AOD500 of 0.45±0.30 and 0.61±0.34 along with low α440-870 of 0.41±0.27 and 0.41±0.35 during spring (March-May) and summer (June-August), respectively, suggest the dominance of coarse-mode aerosols, while significant contribution from anthropogenic sources is observed in autumn (AOD500=0.47±0.26, α440-870=1.02±0.27). The volume size distribution and the spectral single-scattering albedo also confirm the presence of coarse-mode aerosols during March-August. An overall dominance of a mixed type of aerosols (~56%) mostly from October to February is found via the AOD500 vs α440-870 relationship, while marine aerosols contribute to ~18%. Spectral dependence of α and its second derivative (α') are also used for studying the aerosol modification processes. The average direct aerosol radiative forcing (DARF) computed via the SBDART model is estimated to range from -27.08Wm-2 to -10.74Wm-2 at the top of the atmosphere, from -52.21Wm-2 to -21.71Wm-2 at the surface and from 10.97Wm-2 to 26.54Wm-2 within the atmosphere. This atmospheric forcing translates into heating rates of 0.31-0.75Kday-1. The aerosol properties and DARF are also examined for different trajectory clusters in order to identify the sources and to assess the influence of long-range transported aerosols over Desalpar.

Need for Prophylactic Cholecystectomy in Silent Gall Stones in North India.

One of the criteria for recommending cholecystectomy for silent gall stones, is gall stones in regions with high incidence of gall bladder cancer. Both gall stones and gall bladder cancer are common in North India. All tertiary care centres in India report high rates of gall bladder cancer (GBC) incidence and poor treatment outcomes in the majority of cases due to advanced stage of presentation. Csendes of Chile has reported very high incidence of gallbladder cancer in Chile and Bolivia and advocated prophylactic cholecystectomy in asymptomatic patients. Incidence rate of gall bladder cancer in Indian males is equal to that of Chile, whereas in females, the rates are almost double the rates of Chile. Indians have also been found to have high concentrations of heavy metals in gall bladder wall, and antibodies to tumor suppressor genes. In India, gall bladder cancer is the commonest GI cancer in women and fourth commonest cancer overall in the female population. In view of the epidemiology and clinical scenario of gall bladder cancer and proven safety of laparoscopic cholecystectomy, there is a need to act before it is too late in the current rates of gall bladder cancer. This study looks at the evidence correlating gall stones and gall bladder cancer, in relation to India. There is pressing evidence today to justify a strategy of prophylactic cholecystectomy in silent gall stones in North India. Data for this study was selected through an internet based search for literature concerning gall stones and gall bladder cancer in India, and for prophylactic cholecystectomy.

Emphysematous epididymo-orchitis: A rare entity.

Emphysematous epididymo-orchitis is a rare cause of an acute scrotum and is a surgical emergency. Diagnosis is clinically difficult, and sonography with a high-frequency probe is useful to pick up gas shadows in the scrotal wall or testicular substance. A diabetic patient presented with fever, urinary tract infection, and an acute scrotal swelling. The patient needed orchidectomy and scrotal debridement. As in emphysematous pyelonephritis, this condition occurs in diabetics, and patients may need surgery. There is a need to perform sonography in all diabetic patients with an acutely inflamed scrotum, because detection of gas shadows makes surgical intervention more likely.

Left atrial appendage aneurysm.

Aneurysms of the left atrial appendage are exceedingly rare. Patients most commonly present with atrial tachyarrhythmias and thromboembolism. Resection of the aneurysm is usually curative. We present a case report of a 60-year-old female with a long-standing history of atrial arrhythmias found to have a large left atrial appendage aneurysm with additional bi-atrial enlargement and a family history of atrial arrhythmias. The patient was successfully treated with resection of the aneurysm and a Cox-Maze III procedure.

Surgical treatment of ascending aortic aneurysms in patients with giant cell aortitis.

BACKGROUND: Giant cell aortitis is a rare cause of ascending aortic aneurysm disease despite giant cell arteritis being a common cause of vasculitis. We evaluated an 8-year experience with surgical repair with regard to preoperative variables, extent of disease, required surgical procedures, and the propensity to develop additional great vessel aneurysms. METHODS: Thirty-seven patients (29 female, 8 male; aged 69.6 +/- 9.5 years) were operated on from 1995 to 2002. Ten (27%) patients had a history of steroid treatment for temporal arteritis or polymyalgia rheumatica 8.9 +/- 3.9 years before. Nineteen (51%) patients had +3 or +4 aortic regurgitation. Maximal aneurysm size was 6.1 +/- 0.8 cm. Thirty (81%) patients underwent polyethylene terephthalate fiber (Dacron) tube graft replacement of the ascending aorta, 4 (11%) had a modified Bentall procedure, 2 (5%) had a valve-sparing aortic root reconstruction, and 1 (3%) had aortorrhaphy. Twenty-two (59%) patients required 22 +/- 9 minutes of hypothermic circulatory arrest for hemiarch or complete aortic arch replacement. Twenty-six (70%) patients had concomitant cardiac procedures. RESULTS: There was no early mortality. Morbidity was reexploration for bleeding in 3 (8%) patients, stroke in 3 (8%), left vocal cord paralysis in 2 (5%), renal failure in 2 (5%), and gastrointestinal bleeding in 1 (3%). Mean follow-up was 2.8 +/- 2.3 years. Four-year actuarial survival was 74% (95% confidence interval, 57% to 94%). Other descending or abdominal aortic or great vessel aneurysms occurred in 17 (46%) patients. Four patients had prior aneurysm surgery, 8 are monitored with aneurysms, and 5 underwent repair of an aneurysm in the follow-up period. Of 8 late deaths, 3 were caused by complications of a descending thoracic aneurysm. No patient required replacement of a native aortic valve that was preserved during the initial operative procedure. CONCLUSIONS: Ascending aortic aneurysms caused by giant cell aortitis can involve the aorta from the aortic root through the aortic arch, thus requiring a tailored operative approach. The aortic valve tissue is spared from the pathologic process. Other aneurysms of the aorta and great vessels occur in nearly half of patients. Frequent surveillance of the remaining aorta is mandatory.