A Survey on Factors Affecting Knowledge and Satisfaction with Care Among Persons with Diabetes Mellitus in an Urban Health Centre and its Outreach Clinics in South India.

Objective: To determine the level of knowledge and factors affecting knowledge and satisfaction with diabetes care among persons with diabetes at urban health centre (UHC) and community health worker (CHW)-led outreach clinics (ORC) in South India. Methodology: A cross-sectional study was carried out using a structured questionnaire. One hundred patients at the UHC and 200 patients at the ORC were included. Results: Patients with DM of more than eight years, with co-morbidities and maintained on insulin had good knowledge at the UHC. At the ORC, participants who received education beyond the primary level and belonging to non - Hindu religion had higher knowledge. Patients at the ORC experienced better satisfaction in terms of waiting time for appointments, consultation, registration system and counselling. At the UHC, those who received primary education or those with lower educational attainment had better satisfaction. Overall, knowledge (p = 0.03) and satisfaction (p = 0.00001) of diabetes care was better at the ORC than at the UHC. Conclusions: Our study found better knowledge and satisfaction with diabetes care at the ORC than at the UHC. Whether or not the difference can be attributed to CHW-based clinics in the community needs to be further elucidated.

Pioneering family physicians and the mechanisms for strengthening primary health care in India-A qualitative descriptive study.

India has one of the most unequal healthcare systems globally, lagging behind its economic development. Improved primary care and primary health care play an integral role in overcoming health disparities. Family medicine is a subset of primary care-delivered by family physicians, characterized by comprehensive, continuous, coordinated, collaborative, personal, family and community-oriented services-and may be able to fill these gaps. This research aims to understand the potential mechanisms by which family physicians can strengthen primary health care. In this qualitative descriptive study, we interviewed twenty family physicians, identified by purposeful and snowball sampling, who are among the first family physicians in India who received accredited certification in FM and were identified as pioneers of family medicine. We used the Contribution of Family Medicine to Strengthening Primary Health Care Framework to understand the potential mechanisms by which family medicine strengthens primary health care. Iterative inductive techniques were used for analysis. This research identifies multiple ways family physicians can strengthen primary health care in India. They are skilled primary care providers and support mid and low-level health care providers' ongoing training and capacity building. They develop relationships with specialists, ensure appropriate referral systems are in place, and, when necessary, work with governments and organizations to access the essential resources needed to deliver care. They motivate the workforce and change how care is delivered by ensuring providers' skills match the needs of communities and engage communities as partners in healthcare delivery. These findings highlight multiple mechanisms by which family physicians strengthen primary health care. Investments in postgraduate training in family medicine and integrating family physicians into the primary care sector, particularly the public sector, could address health disparities.

The emergence of family medicine in India-A qualitative descriptive study.

Countries globally are introducing family medicine to strengthen primary health care; however, for many, that process has been slow. Understanding the implementation of family medicine in a national context is complex but critical to uncovering what worked, the challenges faced, and how the process can be improved. This study explores how family medicine was implemented in India and how early cohort family physicians supported the field's emergence. In this qualitative descriptive study, we interviewed twenty family physicians who were among the first in India and recognized as pioneers. We used Rogers's Diffusion of Innovation Theory to describe and understand the roles of family physicians, as innovators and early adopters, in the process of implementation. Greenhalgh's Model of Diffusion in Service Organizations is applied to identify barriers and enablers to family medicine implementation. This research identifies multiple mechanisms by which pioneering family physicians supported the implementation of family medicine in India. They were innovators who developed the first family medicine training programs. They were early adopters willing to enter a new field and support spread as educators and mentors for future cohorts of family physicians. They were champions who developed professional organizations to bring together family physicians to learn from one another. They were advocates who pushed the medical community, governments, and policymakers to recognize family medicine's role in healthcare. Facilitators for implementation included the supportive environment of academic institutions and the development of family medicine professional organizations. Barriers to implementation included the lack of government support and awareness of the field by society, and tension with subspecialties. In India, the implementation of family medicine has primarily occurred through pioneering family physicians and supportive educational institutions. For family medicine to continue to grow and have the intended impacts on primary care, government and policymaker support are needed.

A Review of Factor VIII and Factor IX Assay Methods for Monitoring Extended Half-Life Products in Hemophilia A and B.

Clinical trials have used a variety of coagulation factor assay methods to assess treatment with recombinant Factor VIII (rFVIII) and recombinant Factor IX (rFIX) extended half-life (EHL) products. However, diagnostic laboratories may use different reagent combinations for routine use or for field trials of EHL products. The focus of this review is on the choice of one-stage clotting and chromogenic Factor VIII and Factor IX methods and the influence that assay principle and components may have on results, including the effects of different activated partial thromboplastin time reagents and factor-deficient plasma. Our aim is to tabulate the findings for each method and reagent group to give laboratories practical guidance as to how the reagent combinations used in their local laboratory compare to others, for the various EHLs available.

Study protocol: 'a large cohort study of postnatal events in a not-for-profit referral centre in Vellore, South India'.

INTRODUCTION: In a large developing country, with diverse population characteristics and differential access to healthcare, it is important to identify factors that influence postnatal health. This knowledge will help frame recommendations to enhance universal postnatal care. METHODS AND ANALYSIS: A prospective cohort study will be conducted by recruiting all participants who deliver in a referral centre in South India during a 1-year period after written consent is obtained from them. In addition to clinical information pertaining to their delivery and demographics, details of physical health, mental health socioeconomic status and emotional support will also be collected. Every participant will be followed up physically and/or by telephonic consultation at 3, 9 and 18 months of their postnatal period to reassess their status and that of their babies. As there are several independent and dependent variables requiring multivariate analysis, a sample size of 10 000 is considered adequate. Any unplanned visits to a health facility will be enquired into and documented for analysis.During data analysis, the effect of Caesarean section, high-risk characteristics and gestational age of the baby at delivery on various outcome measures and postnatal status will be evaluated. Interpretation of the large volume of collected data will help frame recommendations to improve postnatal care ETHICS AND DISSEMINATION: The study is approved by the Institutional Review Boards (Research and Ethics Committees) of Christian Medical College, Vellore, Tamil Nadu, India (IRB 12178 date 24 June 2020).Women are provided with a detailed information sheet and written consent is obtained. They are reassured that their care will not be compromised if they do not consent to the study. Data will be available on the clinical trial portal to assist in the dissemination of results after the project is published. TRIAL REGISTRATION NUMBER: CTRI/2022/03/041343.

Common mental disorders among women and its social correlates in an urban marginalized populace in South India.

BACKGROUND: Common mental disorders (CMD) cause a range of health, social and economic burden, and disorders like depression and anxiety are more prevalent among women. Prevalence and factors contributing to increased vulnerability for CMDs have regional variation. Identification of factors contributing to the vulnerability is essential to both psychiatric epidemiology and in addressing mental health challenges in the community. METHODS: This cross-sectional study aimed at understanding the burden of CMD and its association with social determinants of mental health. Women hailing from urban slum attending the outpatient family care facility for their medical problems constituted the sample. Data was collected using a clinical research form with variables such as sociodemographic profile, health profile, and psychosocial profile. The questionnaire had specific questions on indicators of poverty, certain stressors, and support system. Presence of CMD was assessed using Clinical Interview Schedule-Revised (CIS-R), a standard tool for CMD research in primary care settings. A cut off score of 12 and above was considered for detecting CMD. Research ethical principles were adhered to and data was analyzed using SPSS 21.0. RESULTS: Among 172 women, 77 (44.8%) were diagnosed to have CMDs. Univariate analysis revealed a significant association between age, marital status, living arrangement, educational level, difficulty with buying food, presence of debt, chronic medical illness, husband's alcohol use, marital satisfaction, experiencing abuse, family support, religious participation, and a diagnosis of CMD. Multivariate analysis showed high burden with nuclear family arrangement, difficulty to buy food, experiencing abuse and, low burden with higher educational level, family support, and religious participation. CONCLUSION: Considering the high prevalence and the treatment gap of CMDs in primary setting, family-physician should be sensitized for detection and management of CMDs. Social interventions targeting poverty, women's education and empowerment, and support system are likely to decrease the burden of CMDs in this population.

Primary care for the urban poor in India during the pandemic: Uninterrupted management of non-communicable diseases and home-based care of patients with COVID-19 infection.

Problem: The two waves of COVID-19 severely affected the healthcare system in India. The government responded to the first wave with a strict nationwide lockdown which disrupted primary care, including the management of non-communicable diseases (NCDs). The second wave overwhelmed healthcare facilities leading to inadequate access to hospital services. Collectively, these issues required urgent responses, including the adaptation of primary care. Approach: The Low-Cost Effective Care Unit (LCECU) of Christian Medical College, Vellore (CMC) has a network of community volunteers, community health workers, an outreach nurse, social workers and doctors who operate clinics in six poorer areas of Vellore. The network adapted quickly, responding to the lockdown during the first wave and ensuring ongoing primary care for patients with non-communicable diseases. During the second wave, the team developed a system in collaboration with other CMC departments to provide home-based care for patients with COVID-19. Local setting: The LCECU is a 48-bed unit of the Department of Family Medicine, part of the 3,000-bed CMC. It originated in 1982, aiming to care for the poor populations of Vellore town. It has been actively working among urban communities since 2002, with a focus on delivering Community Oriented Primary Care (COPC), for six poor urban communities since 2016. Relevant changes: During the first wave of COVID the LCECU team ensured patients with NCDs had uninterrupted primary care and medications by visiting them in their homes. The team also addressed food insecurity by organizing a daily lunch service for 600 people for over 2 months. In the second wave, the team responded to community needs by organizing and delivering home-based care to monitor patients affected by COVID-19. Lessons learned: The COVID-19 pandemic raises many questions about the preparedness of health systems for disasters that disproportionately affect marginalized populations globally. COVID-19 is only one of the many potential disasters, including non-communicable diseases, mental health problems, pollution, climate change, and lifestyle illness. There is an urgent need to study models of care that support vulnerable communities in an accessible, cost-effective, and patient-oriented way, particularly in low- and middle-income countries. This paper outlines lessons on how the LCECU team addressed disaster management:1. The COVID-19 pandemic has highlighted the importance of primary care-based rapid response interventions in disaster management.2. The LCECU model demonstrated the effectiveness of a primary care intervention based on pre-existing networks and familiarity between primary care teams and the community.3. Establishing community-based health care via interdisciplinary teams, including community health workers, community volunteers, outreach nurses, and doctors, is key.4. Addressing other social determinants of health, such as food insecurity, is an important component of care delivery.

Extending the post-thaw viability of cryoprecipitate.

BACKGROUND: Cryoprecipitate has a short post-thaw expiry time of 6 h. The aim of this study was to assess the stability and function of cryoprecipitate components (FVIII, fibrinogen, vWF, and FXIII) and cryoprecipitate sterility up to 120 h post-thawing when stored at two temperatures (2-6°C and room temperature [20-24°C]). METHODS AND MATERIALS: Twenty batches (110 individual units) of time-expired, thawed cryoprecipitate were collected. Units were sampled at the 6-h expiration mark and then stored at 2-6°C or room temperature (RT). They were resampled every 24 h for 120 h. One unit from each batch was sent for sterility testing at 120 h. Samples had FVIII (one stage and chromogenic), fibrinogen, FXIII, vWFag, and vWF:RCo assays performed in batches. Rotational thromboelastometry (ROTEM) was also performed. RESULTS: FVIII levels declined significantly at 120 h post-thawing at both RT and 2-6°C, but still met international standards for FVIII content. Fibrinogen, vWF antigen, and FXIII levels reduced minimally over 120 h and always met international standard requirements when stored at either temperature. ROTEM analysis demonstrated that fibrinogen function was not compromised at 120 h post-thawing under both storage conditions. vWF:RCo levels declined significantly over 120 h at both storage temperatures. No bacterial contamination was detected in 20 units of cryoprecipitate following storage for 120 h post-thawing. CONCLUSION: These results demonstrate that extension of the storage time of thawed cryoprecipitate to 120 h, stored at either 2-6°C or RT, is feasible while still maintaining required FVIII, fibrinogen, and vWFag levels. Storage at 2-6°C has the advantage of reduced risk of potential bacterial contamination.

Encapsulated VEGF121-PLA microparticles promote angiogenesis in human endometrium stromal cells.

BACKGROUND: In this study, Vascular Endothelial Growth Factor 121 expressed abundantly in endometrial stromal cells is encapsulated with poly-l-lactide and characterized the properties for endometrial angiogenesis. We studied the migration, proliferation and the protein levels of human immortalized endometrium stromal cells after treating the cells with recombinant Vascular Endothelial Growth Factor (200 and 500 nanogram), and poly-l-lactide loaded Vascular Endothelial Growth Factor 121 (day 1, 20 and 30). The present study explains endometrium angiogenesis because endometrium plays an important role in pregnancy. RESULTS: Migration and proliferation studies in endometrium cells proved the efficiency of Vascular Endothelial Growth Factor and poly-l-lactide loaded Vascular Endothelial Growth Factor 121. This proliferated and increased the migration of the cells in vitro and also activated the Protein kinase B, Phosphatidylinositol-4, 5-Bisphosphate 3-Kinase Catalytic Subunit Beta, α-Smooth muscle actin and vascular endothelial growth factor receptor 2 pathways. Western blot analysis showed the increased expression levels of kinases, smooth muscle actin and vascular endothelial growth factor receptor 2 after the treatment with Vascular Endothelial Growth Factor and poly-l-lactide loaded Vascular Endothelial Growth Factor 121 particles in comparison to the control group. The elevated levels of α-Smooth muscle actin in endometrium cells with Vascular Endothelial Growth Factor prove the regulation of angiogenesis in vitro. CONCLUSION: Endometrium thickness is one of the important factors during implantation of embryo and pregnancy. Slow release of VEGF from PLA encapsulated microparticle further controls the endothelial cell proliferation and migration and helps in the promotion of angiogenesis. The combined effect studied in vitro could be used as a pro-angiogenic drug on further in vivo confirmation.

A multicenter laboratory assessment of a new automated chemiluminescent assay for ADAMTS13 activity.

BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is a rare but potentially fatal disorder caused by ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) deficiency. Prompt identification/exclusion of TTP can thus be facilitated by rapid ADAMTS13 testing. The most commonly utilized (enzyme-linked immunosorbent assay [ELISA]-based) assay takes several hours to perform and so does not generally permit rapid testing. OBJECTIVES: To evaluate the utility of a new automated test for ADAMTS13 activity, the HemosIL AcuStar ADAMTS13 Activity assay, based on chemiluminescence and able to be performed on an ACL AcuStar instrument within 33 minutes. PATIENTS/METHODS: This multicenter (n = 8) assessment included testing of more than 700 test samples, with similar numbers of prospective (n = 348) and retrospective (n = 385) samples. The main comparator was the Technozym ADAMTS13 Activity ELISA. We also assessed comparative performance for detection of ADAMTS13 inhibitors using a Bethesda assay. RESULTS: Overall, the chemiluminescent assay yielded similar results to the comparator ELISA, albeit with slight negative bias. ADAMTS13 inhibitor detection was also comparable, albeit with slight positive bias with the AcuStar assay. Assay precision was similar with both assays, and we also verified assay normal reference ranges. CONCLUSIONS: The HemosIL AcuStar ADAMTS13 Activity assay provided results rapidly, which were largely comparable with the Technozym ADAMTS13 Activity ELISA assay, albeit lower on average. Conversely, inhibitor levels tended to be identified at a higher level on average. Thus, the HemosIL AcuStar ADAMTS13 Activity assay provides a fast and accurate means to quantitate plasma levels of ADAMTS13 for TTP/ADAMTS13 identification/exclusion, and potentially also for other applications.

Primary care for India's urban dwellers living in informal settlements during the COVID-19 pandemic: The experience of the Christian Medical College, Vellore, Department of Family Medicine.

COVID-19 disproportionally affects India's 81 million people living in urban informal settlements, where inadequate housing, water and sanitation increase the risk and rate of infection.

Molecular Modelling and Insilico Engineering of PapMV-CP Towards Display and Development of Capripox Viral Like Particles Based on Immunogenic P32 Envelop Protein is the Homologous of the Vaccinia-Viral H3L Gene: An Insilico Approach.

Viral-like particles are assembled from capsid protein structural subunits of different viruses and have ability to establish research in biomedicals, like construction of novel safety vaccines, gene therapy vectors by delivering systems for nucleic acids, small biomolecules and diagnostics. Papaya Mosaic Viral nanoparticals can provide as a vaccine candidate helps to increase the immunity by fusing the epitope based peptide antigen. Capripox viruses are the genus comprises Lymphy skin-disease, Sheep and Goat pox Viruses are notified by The World Animal Health Organization (OIE) based on their economic impotence act as a transboundary animal diseases viruses of sheep, goat, and cattle's respectively. Plant viral based innovative vaccines have been emerged ineffective vaccine development. This research describes the engineering and development of a new vaccine candidate by display immunogenic peptide using the carrier capsid protein of Papaya Mosaic Virus. The Capripox virus P32 immunogenic protein is homologous of the vaccinia virus H3L gene displayed PapMV CP. The antigenicity of P32 protein epitope lowest score among epitopes C-terminally docked epitopes are EP6 > EP3 > EP8 as well the lowest score among epitopes N-terminally docked epitopes are EP8 > EP3 > EP6 presented on the N-terminus of PMV CP region which are found to be suitable for epitope display. And these modelled immunogenic peptide could be used to develop a viral like particles. Epitope based Antibody developed against immunogenic epitopic regions can contribute to a novel and robust protection from infection. As well might be used for developing cost effective detection kits for Transboundary animal disease viruses.

Evaluation of recombinant human vascular endothelial growth factor VEGF121-loaded poly-l-lactide microparticles as a controlled release delivery system.

Vascular endothelial growth factor A (VEGF-A) is an important growth factor that plays a major role in angiogenesis. With different isoforms distributed in various tissues, the shortest isoform of VEGF-A is VEGF121, one of the physiologically functional variants next to VEGF165. It is well known that VEGF has a shorter half-life, and the stability of the protein must be considered in therapeutic aspects. Poly-l-lactide (PLA) microparticles can release the encapsulated protein in a sustained release mode. In this study, the VEGF121 gene was cloned and expressed in a prokaryotic expression system (Escherichia coli). The recombinant VEGF121 was encapsulated with PLA microparticles and studied in vitro  and ex ovo  for the sustained release mechanism. The PLA-VEGF microparticles and the recombinant VEGF121 were explored for their bioactivity in human umbilical vein endothelial cells (HUVEC). VEGF released in vitro  from PLA microparticles on days 1, 20, and 30 showed remarkable biological activity compared to PBS-loaded PLA microparticles such as the ability of the cells to proliferate, migrate, and form tubes similar to recombinant VEGF121. Besides, PLA-VEGF microparticles and the recombinant VEGF121 were also tested for their proangiogenic action in embryonated eggs by chicken chorioallantoic membrane assay (CAM), and the effect was observed in both forms. This study suggests that PLA-loaded VEGF microparticles in a sustainable release format can be effectively used in proangiogenic therapy and reduce the adverse effects caused due to multiple dosages.

Management of diabetic ketosis and ketoacidosis with intramuscular regular insulin in a low-resource family medicine setting.

BACKGROUND: India is facing an epidemic of diabetes mellitus (DM). Effective management of complications of DM is a challenge in resource-poor areas of India. This study addresses the need to explore low-cost methods to manage diabetic ketosis (DK) and diabetic ketoacidosis (DKA). OBJECTIVES: To demonstrate the use of intramuscular (IM) regular insulin as a safe alternative method to control DK and DKA in a family practice setting. MATERIALS AND METHODS: A retrospective chart review was done for 34 patients admitted with DK and DKA in a family medicine unit for the urban poor over 5 years. Data on age, sex, precipitating factors, blood pressure, number of days of hospitalization, amount of insulin, and time required to control blood glucose (BG) and to correct acidosis were entered into EpiData version 3.1 and analyzed using SPSS software version 17. RESULTS: Administration of IM regular insulin was effective in reducing the BG to < 250 mg/dL in patients with DK and DKA. The mean time required for this in the ketosis group was 3.8 h and in the ketoacidosis group was 3.9 h. The mean amount of insulin required for correction of acidosis in the ketoacidosis group was 72.3 units and the mean time to achieve this was 33 h. Of the 34 patients, only one in the ketoacidosis group had hypoglycemia. There was no fatality or referral of any patient. CONCLUSION: This study demonstrates that IM regular insulin is a safe alternative method in managing DK and DKA in a family medicine setting.

The value of an ENT specialist outreach service in a Family Medicine Unit for the urban poor in India.

OBJECTIVES: To assess the function of an otolaryngology (ENT) specialist outreach service in a Family Medicine (FM) Unit for the urban poor attached to a Tertiary Teaching Hospital in India. MATERIALS AND METHODS: The study investigated the pattern of ENT diseases in patients who came to the FM Unit and the proportion of these patients who were referred to the ENT specialist clinic at the unit. The study also analyzed the ENT problems that were managed by the ENT specialist at the unit and the conditions, which needed referral to the Tertiary Hospital. Data was collected by chart review. SETTING: Weekly ENT specialist outreach service in an FM Unit for the urban poor in India attached to a Tertiary Teaching Hospital. RESULTS: Among the outpatients who attended the unit in 12 months, 12.89% had ENT-related problems, of which 23.9% were referred to the visiting ENT specialist, 88.30% of these patients were managed in the FM Unit with basic ENT facilities. CONCLUSION: This study demonstrated that majority of the patients with ENT-related problems who presented to an FM Unit could be managed by the FM specialists. Of those patients who required the expertise of a specialist in ENT, the majority could be managed in the FM Unit, with basic ENT examination and treatment facilities. Triage and management by the family physician and the visiting ENT surgeon in the FM Unit is a prudent use of resources and will improve the quality of care people receive for their ENT problems.

An uncommon cause for vomiting.

Thyrotoxicosis may present with a variety of non specific symptoms in elderly patients. Gastrointestinal symptoms such as nausea, vomiting and abdominal discomfort can occasionally be the presenting feature of thyrotoxicosis in this age group. We describe an elderly patient in whom thyrotoxicosis was diagnosed after extensive evaluation for nausea, vomiting and anorexia. This patient was also found to have hypercalcemia. This case highlights the importance of recognizing thyrotoxicosis in older patients presenting with GI symptoms and mild hypercalcemia.