Burden of Tuberculosis among tribal populations of India: A systematic review and meta-analysis.

ABSTRACT: Tuberculosis (TB) continues to impose a significant burden on tribal populations in India, a high-risk group for the disease. Despite its preventable and curable nature, TB remains a formidable health challenge for these communities. However, a critical knowledge gap exists regarding the population-based prevalence of TB among tribal populations in India. The current systematic review and meta-analysis were carried out to provide a single, population-based estimate. A comprehensive search was conducted on PubMed, Embase, Scopus, and Web of Science databases using the keywords 'tuberculosis', 'TB', and 'tribal' or 'tribes'. This search encompassed articles published between 1 January 2000 and 1 March 2023. The included articles underwent a quality assessment screening to ensure their reliability and relevance. Subsequently, a pooled estimate of TB prevalence among tribal populations was quantified using a random-effects model. To investigate potential sources of heterogeneity in the prevalence estimates, subgroup analyses were performed. We identified 14 studies that encompassed a substantial population of 267,377 individuals from various regions in India belonging to tribal communities. The application of a random-effects model yielded a pooled prevalence estimate of 894.4 per 100,000 population, with a 95% confidence interval ranging from 523.5 to 1361.9. The assessment of heterogeneity using the Cochrane Q test indicated significant variability among the included studies (I2 = 99.17%; P < 0.001). Notably, the prevalence of TB among tribal populations was found to be higher than the national prevalence. The scientific evidence available for the prevalence of TB among tribal populations is restricted to a few tribes only. Conducting further research to estimate the prevalence among other tribes all over the country is the need of the hour and should be addressed accordingly.

Perceptions and Attitudes Toward Community Medicine Among Medical Students: A Systematic Review.

Community medicine is yet to become a popular discipline as a choice for postgraduation and career among medical students in India. Our objective is to find the proportion of students opting for community medicine as a choice for a career. We also aim to find out the perceptions and attitudes of medical students about the subject of community medicine. Our inclusion criteria encompassed studies of any design, written or translated into the English language, and published from their inception up to the last date of our search, which was 15th August 2023. Our comprehensive search covered prominent databases, including PubMed, Scopus, and Embase, as well as an extensive screening of the first 10 pages of Google Scholar and Google. The risk of bias in the studies was evaluated by using the quality assessment tools recommended by the Joanna Briggs Institute critical appraisal tool for prevalence studies. In the initial search, 2069 articles were identified, with 1109 duplicates removed. The remaining 960 articles underwent title and abstract screening, leading to the exclusion of 931 articles. After applying eligibility criteria and reviewing the full text of 29 articles, seven studies were excluded. Ultimately, 22 studies were deemed eligible for inclusion in the systematic review. Among the total of 5106 students, 1032 students expressed a willingness to choose community medicine as their career. The pooled estimate, derived through a random effects model, was 0.21, with a 95% CI of 0.14 to 0.27. Studies conducted in India revealed a willingness of 0.23 (95% CI: 0.13- 0.33), whereas studies conducted outside India reported a lower proportion of 0.17 (0.14-0.24). When considering the year of study, a combined willingness of 0.02 (95% CI: 0.00-0.03) was observed among first and second-year students, contrasting with a higher proportion of 0.18 (95% CI: 0.04-0.32) among third-year students. Fourth-year students and interns demonstrated a willingness of 0.03 (95% CI: 0.00-0.06). The factors for disliking the subject included the perceived absence of clinical engagements, concerns about financial rewards, limited prospects for recognition and fame, etc. By actively engaging in the solution of these challenges, medical educators and policymakers can contribute to the vitalization of community medicine as a coveted and attractive specialty.

The Independent Association of Non-alcoholic Fatty Liver Disease With Incident Cardiovascular Disease: A GRADE Evaluation of the Evidence Through a Systematic Review and Meta-analysis.

Background: We conducted a systematic review and meta-analysis to study the association between non-alcoholic fatty liver disease (NAFLD) and incident cardiovascular disease (CVD). Methods: We searched Medline, Embase, Cochrane database and TRIP database. Random-effects model meta-analyses were used to obtain pooled effect sizes and 95% confidence intervals. The certainty in evidence was rated using the GRADE tool. Results: Altogether 36 studies including a total of 7,068,007 participants were included in the systematic review and meta-analysis. Pooled data from 19 cohort studies demonstrated a significant increase in the risk of non-fatal CVD events in patients with NAFLD (HR 1.57, 95% CI 1.33-1.85, I2 = 95%). Pooled data from eight studies showed a significant increase in fatal CVD (HR 1.40, 95% CI 1.24-1.57, I2 =27%), and eight cohort studies suggested a significant increase in combined non-fatal and fatal CVD (HR 1.41, 95% CI 1.13-1.76, I2 =80%). Meta-analysis of studies reporting adjusted estimates in NAFLD patients with fibrosis revealed a significant increase in CVD events with acceptable level of heterogeneity (HR 1.64, 95% CI 1.25-2.16, I2 = 31%). The anticipated absolute increase in the risk of combined fatal and non-fatal CVD was estimated to be 29 more per thousand with NAFLD; that of fatal CVD events 16 more per thousand and that of non-fatal CVD events 19 more per thousand with NAFLD. The GRADE rating ranged from very low to low for overall and subgroup analyses. Conclusion: The present systematic review suggests that NAFLD increases the risk of incident CVD. Cohort studies with the ability to analyze subgroup effects based on severity, along with randomized controlled trials that provide experimental evidence demonstrating a decrease in cardiovascular disease events through the treatment of non-alcoholic fatty liver disease, are necessary to validate and reinforce these findings.

Initiation of the First Preventive Health and Screening Outpatient Department in a Tertiary Teaching Hospital in India.

Background The Preventive Health and Screening Outpatient Department (OPD) was started in Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India with the vision of promoting health (primordial and primary prevention), counseling, screening, early diagnosis, and treatment and referral services (secondary prevention). The objective of the study is to describe the process of establishing the Preventive Health and Screening OPD in a tertiary hospital in Delhi and illustrate the functioning of the newly established OPD. Methodology This study is based on observation of the day-to-day functioning of the OPD, record checking of registers, and reviewing the records of the hospital registration system. Here, we describe the functioning of the OPD from its initiation in October 2021 until December 2022. Results The routine services provided at the OPD include health promotion and education, especially focusing on non-communicable diseases, screening, diagnosis, treatment, lifestyle counseling; general OPD services; growth monitoring and counseling; group discussion for harms of tobacco usage; counseling for tobacco cessation, hepatitis B, and dT vaccination; group counseling for antenatal women; and screening for breast cancer. A few events such as the breast cancer screening camp and the non-communicable disease screening camp were also conducted under the purview of the new OPD. Such OPDs are the need of the hour for the provision of comprehensive healthcare, including promotive and preventive healthcare, along with curative health services, at tertiary healthcare levels. Conclusions Healthcare services are incomplete without the preventive, promotive, and screening components of healthcare. For mainstreaming health promotion and preventive healthcare, Preventive Health and Screening OPDs are essential at hospitals. The benefits of prevention extend beyond managing chronic diseases and longer lives.

Diagnostic performance of non-invasive liver fibrosis risk scores in biopsy-proven non-alcoholic fatty liver disease patients in India.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide. India and other developing countries are witnessing an unprecedented rise in the prevalence of NAFLD. As part of population-level strategy, at primary healthcare, an efficient risk stratification is crucial to ensure appropriate and timely referral of individuals who require care at secondary and tertiary levels. The present study was conducted to assess the diagnostic performance of two non-invasive risk scores, fibrosis-4 (FIB-4), and NAFLD fibrosis score (NFS), in Indian patients of biopsy-proven NAFLD. METHODS: We conducted a retrospective analysis of biopsy-proven NAFLD patients that reported to our center between 2009 and 2015. Clinical and laboratory data were collected and two non-invasive fibrosis scores, NFS and FIB-4 score, were calculated using the original formulas. Liver biopsy was utilized as gold standard for diagnosis of NAFLD, diagnostic performance was determined by plotting receiver operator characteristic (ROC) curves and area under the ROC curve (AUROC) was calculated for each score. RESULTS: The mean age of 272 patients included was 40 (11.85) years and 187 (79.24%) were men. We found that the AUROCs for FIB-4 score (0.634) was higher for any degree of fibrosis as compared to NFS (0.566). The AUROC for FIB-4 for advanced liver fibrosis was 0.640 (.550-.730). The performance of the scores for advanced liver fibrosis was comparable with overlapping confidence intervals for both scores. CONCLUSION: The present study found an average performance of FIB-4 and NFS risk scores for detecting advanced liver fibrosis in Indian population. This study highlights the need for devising novel context-specific risk scores for efficient risk stratification of NAFLD patients in India.

Recent advances in obstetric anaesthesia and critical care.

Newer modalities in labour analgesia and anaesthesia for caesarean section including regional anaesthesia techniques and airway management are emerging constantly. Techniques such as point of care ultrasound, especially of the lungs and stomach and point of care tests of coagulation based on viscoelastometry are about to revolutionise perioperative obstetric care. This has improved the quality of care thereby ensuring good perioperative outcomes in the parturient with comorbidities. Critical care for obstetrics is an emerging field that requires a multidisciplinary approach with obstetricians, maternal-foetal medicine experts, intensivists, neonatologists, and anaesthesiologists working together with enhanced preparedness and uniform protocols. Newer techniques and concepts of understanding have thus been established in the traditional speciality of obstetric anaesthesia over the last decade. These have improved maternal safety and neonatal outcomes. This article touches upon some recent advances that have made a significant impact in the field of obstetric anaesthesia and critical care.

Validation of Hindi version of the obstetric quality of recovery score-11 (ObsQoR-11 H) following elective caesarean section.

Background and Aims: Obstetric quality of recovery score-11 (ObsQoR-11) was developed in English to evaluate the quality of recovery in the caesarean section. We aimed to validate the Hindi version of ObsQoR-11 (ObsQoR-11H) for Hindi-speaking patients to evaluate the quality of recovery following the elective caesarean section. Methods: The ObsQoR-11 was translated into Hindi and assessed for validity, acceptability and feasibility. The questionnaire was administered postoperatively at 24 and 48 hours, and the Global Health Numeric Rating Scale (NRS) was used to evaluate recovery. Results: The mean (standard deviation [SD]) (95% confidence interval [CI]) ObsQoR-11 H was 75.94 (4.09)(95% CI 75.1, 76.7) and 80.25 (4.08)(95% CI 79.5, 81) at 24 and 48 hours, respectively. The mean (SD) (95%CI) Global Health NRS scores were 71.22 (5.97)(95% CI 70, 72.4) and 77.37 (5.79)(95% CI 76.2, 78.5) at 24 and 48 hours, respectively. Convergent validity showed a strong correlation between ObsQoR-11H and Global Health NRS (Spearman's correlation coefficient [rs] >0.8 and 0.78) scores at 24 and 48 hours, respectively. Discriminant validity was significant in appreciating the difference between good and poor recovery (P < 0.001). Split-half coefficient of 0.69 and 0.65 and Cronbach's alpha (α) of 0.91 and 0.82 at 24 and 48 hours suggested good score reliability. The acceptability and feasibility of the score were also good. Conclusion: The ObsQoR-11H discriminated well between 'good' and 'poor' recovery and correlated strongly with Global Health NRS scores. It was found to be a valid, reliable, acceptable and feasible tool for psychometric recovery evaluation after elective caesarean section in Hindi-speaking women.

Underweight, Overweight, and Anemia among Elderly Persons in a rural area of Ballabgarh, Haryana.

BACKGROUND: Underweight, overweight, and anemia are common public health problems among elderly individuals. OBJECTIVES: The current study was conducted in a rural area of Ballabgarh, Haryana, to estimate the prevalence of underweight, overweight, and anemia among elderly persons and to find their association with sociodemographic variables. MATERIALS AND METHODS: A total of 420 elderly persons aged ≥60 years were selected by simple random sampling. Information on variables was collected by an interview schedule. Body mass index (BMI) was calculated from height and arm-span of elderly persons. Hemoglobin was estimated with HemoCue® Hb 201+ system. RESULTS: Of the total participants, 33.6% were underweight, 13.8% were overweight, 15.6% were obese, and 37.0% had normal BMI. None of the sociodemographic variables was found to be significantly associated with being underweight. Being female was significantly associated with being overweight/obese. The prevalence of anemia was 36.4%. None of the sociodemographic variables was associated with anemia. CONCLUSIONS: Underweight and anemia are common among elderly persons in rural areas. These need to be addressed through community-based interventions.

Use of web-based health information portals in primary health care: Experience from a rural Primary Health Centre in Haryana.

BACKGROUND: Health care informatics is the scientific field that deals with the data capture, storage, retrieval, and use of biomedical data, information, and knowledge for problem solving and decision-making. The objectives of the study were to describe the web-based portals used at the Primary Health Centre (PHC) and to appraise its utilization at the local level. METHODS: Various methodologies included observation of portal use, record review, interview of stakeholders using the portals. RESULTS: Health Workers workload increased because of physical record entry and time spent for entry in web-based health information portals. Web-based portals did not have options for utilization of the data generated at the PHC level. The options of feedback and helpline were not universally available. CONCLUSION: Web-based portals are integral part of health system at primary healthcare level. Adequate utilization of web-based health information portals may lead to efficient provision of health services at the primary health care level.

Effects of two different doses of 3% hypertonic saline with mannitol during decompressive craniectomy following traumatic brain injury: A prospective, controlled study.

Background and Aims: The current study was designed to compare the effects of two different doses of 3% hypertonic saline with mannitol on intraoperative events during decompressive craniectomy in traumatic brain injury (TBI). Primary outcome measures included assessment of intraoperative brain relaxation, hemodynamic variables, and serum electrolytes. Effect on the postoperative outcome, in terms of the Glasgow coma scale (GCS), length of stay in the ICU, and mortality were the secondary outcome measures. Material and Methods: Ninety patients with TBI undergoing craniotomy were enrolled. Patients were assigned to receive 300 mL (328 mOsm) of mannitol (n = 26, M) only or 300 mL of mannitol with 150 mL (482 mOsm) of 3% HS (n = 35, HS1) or with 300 mL (636 mOsm) of 3% HS (n = 29, HS2). Brain relaxation was assessed and if required, a rescue dose of mannitol (150 mL) was given. GCS was assessed preoperatively, 24 h postoperatively, and at the time of discharge from the ICU and total duration of stay was noted. Results: Acceptable brain relaxation was observed in 89.66% (n = 26, HS2) and 80% (n = 28, HS1) patients as compared to 46.1% (n = 12, M) patients (P < 0.001) with significantly less number of patients requiring rescue doses of mannitol in groups HS1 and HS2(n = 7 and 3, respectively) as compared to group M (n = 14) (P < 0.05). There was a significant improvement in GCS at 24 h and at the time of discharge from the ICU in patients with a severe head injury in group HS2 (P = 0.029). In patients with moderate head injury there was a significant improvement in GCS at the time of discharge among all the three groups (P < 0.05). Conclusion: Increasing osmotic load by addition of 3% HS to mannitol provides better intraoperative brain relaxation than mannitol alone during decompressive craniectomy. An addition of 300mL 3% HS was found to be more effective in improving GCS in patients with severe TBI.

Management of pregnant laboring women during COVID-19 pandemic.

Since its first outbreak in December 2019 in Wuhan, China, coronavirus disease 2019 (COVID-19) has become a global public health threat. In the midst of this rapidly evolving pandemic condition, the unique needs of pregnant women should be kept in mind while making treatment policies and preparing response plans. Management of COVID-19 parturients requires a multidisciplinary approach consisting of a team of anesthesiologists, obstetricians, neonatologists, nursing staff, critical care experts, infectious disease, and infection control experts. Labor rooms as well as operating rooms should be in a separate wing isolated from the main wing of the hospital. In the operating room, dedicated equipment and drugs for both neuraxial labor analgesia and cesarean delivery, as well as personal protective equipment, should be readily available. The entire staff must be specifically trained in the procedures of donning, doffing, and in the standard latest guidelines for disposal of biomedical waste of such areas. All protocols for the management of both COVID-19 suspects as well as confirmed patients should be in place. Further, simulation-based rehearsal of the procedures commonly carried out in the labor room and the operation theaters should be ensured.

Systematic review of barriers to, and facilitators of, the provision of high-quality midwifery services in India.

BACKGROUND: The Indian government has committed to implementing high-quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high-quality midwifery care in India. METHODS: We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high-quality midwifery care in India. RESULTS: Thirty-two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands-on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women's experiences of maternity care, and improving health system infrastructure. CONCLUSIONS: The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India's plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.

Prevalence, awareness, treatment, and control of diabetes and hypertension among elderly persons in a rural area of Ballabgarh, Haryana.

BACKGROUND: In India, from 1971 to 2011, the proportion of elderly population has increased from 5.3% to 8.6%. According to the National Sample Survey, 60th round (2004), out of every 1000 elderly persons living in rural India, 40 were estimated to be diabetic, and 36 were estimated to be hypertensive. The objective of the study was to find the prevalence of diabetes and hypertension in elderly persons in a rural area of Ballabgarh, Haryana, and to assess the awareness, treatment, and control among them. METHOD: A total of 420 persons aged 60 years and above were selected by simple random sampling. House-to-house visit was done. A pretested interview schedule was administered. Blood pressure was measured using digital blood pressure machine. Two milliliters of venous blood was collected in vials for HbA1c estimation. RESULTS: Of the 420 participants, 386 were available for blood pressure measurement, and 374 were available for HbA1c estimation. The prevalence of diabetes was 21.7%, and that of hypertension was 50.3%. Among diabetics, 45.7% were aware, of which, 94.6% were treated, and among them, 34.3% had their blood sugar under control. Among hypertensives, 58.8% were aware, of which, 96.5% were treated, and of the treated participants, 24.5% had controlled blood pressure. CONCLUSION: The high prevalence, low awareness, and low proportion of controlled diseased population highlights the importance of strengthening primary care and improving awareness about diabetes and hypertension among elderly persons in rural areas.

Controlled hypotension for FESS: A randomised double-blinded comparison of magnesium sulphate and dexmedetomidine.

BACKGROUND AND AIMS: Intense bleeding during general anaesthesia (GA) is the major limitation during functional endoscopic sinus surgery (FESS). This study was aimed to compare the efficacy of dexmedetomidine and magnesium sulphate (MgSO4) for controlled hypotension in FESS. METHODS: Sixty eight patients undergoing FESS were randomised to receive either dexmedetomidine 1 µg/kg over 10 min followed by infusion at 0.2 to 0.7 µg/kg/h (Group D) or MgSO4 40 mg/kg over 10 min followed by an infusion at 10 to 15 mg/kg/h (Group M). Anaesthesia and infusion rates for study drugs were maintained with sevoflurane to keep MAP between 60-70 mmHg throughout the surgery. The time to reach the target MAP, the number of patients requiring a minimum and maximum infusion doses of study drugs were noted. RESULTS: The mean time to achieve target mean arterial pressure (MAP) was less in group D (10.59 ± 2.04) as compared with (21.32 ± 4.65 min) group M (P < 0.001). The target MAP was achieved between 5-15 min in 73.52% patients (Group D) with an infusion dose of 0.2-0.4 µg/kg/h of dexmedetomidine without the use of sevoflurane, while 82.35% patients in group M required 4% sevoflurane along with >12-15 mg/kg/hr infusion of MgSO4 to achieve target MAP in 10-20 min. CONCLUSION: Dexmedetomidine is superior to MgSO4 in achieving target MAP in lesser time with minimum infusion dose.

Ionic selectivity and coordinated transport of Na+ and K+ in flag leaves render differential salt tolerance in rice at the reproductive stage.

MAIN CONCLUSION: The present study shows that salt tolerance in the reproductive stage of rice is primarily governed by the selective Na+ and K+ transport from the root to upper plant parts. Ionic discrimination at the flag leaf, governed by differential expression of Na+- and K+-specific transporters/ion pumps, is associated with reduced spikelet sterility and reproductive stage salt tolerance. Reproductive stage salt tolerance is crucial in rice to guarantee yield under saline condition. In the present study, differential ionic selectivity and the coordinated transport (from root to flag leaf) of Na+ and K+ were investigated to assess their impact on reproductive stage salt tolerance. Four rice genotypes having differential salt sensitivity were subjected to reproductive stage salinity stress in pots. The selective Na+ and K+ transport from the root to upper plant parts was observed in tolerant genotypes. We noticed that prolonged salt exposure did not alter flag leaf greenness even up to 6 weeks; however, it had a detrimental effect on panicle development especially in the salt-susceptible genotype Sabita. But more precise chlorophyll fluorescence imaging analysis revealed salinity-induced damages in Sabita. The salt-tolerant genotype Pokkali (AC41585), a potential Na+ excluder, managed to sequester higher Na+ load in the roots with little upward transport as evident from greater expression of HKT1 and HKT2 transporters. In contrast, the moderately salt-tolerant Lunidhan was less selective in Na+ transport, but possessed a higher capacity to Na+ sequestration in leaves. Higher K+ uptake and tissue-specific redistribution mediated by HAK and AKT transporters showed robust control in selective K+ movement from the root to flag leaf and developing panicles. On the contrary, expressions of Na+-specific transporters in developing panicles were either down-regulated or unaffected in tolerant and moderately tolerant genotypes. Yet, in the panicles of the susceptible genotype Sabita, some of the Na+-specific transporter genes (SOS1, HKT1;5, HKT2;4) were upregulated. Apart from the ionic regulation strategy, cellular energy balance mediated by different plasma-membrane and tonoplastic H+-pumps were also associated with the reproductive stage salt tolerance in rice.

Letter to the editor regarding the article 'individual and household risk factors of severe acute malnutrition among underfive children in Mao, Chad: a matched casecontrol study'.

We would like to thank the authors Jovana Dodos et al., for the article "Individual and household risk factors of severe acute malnutrition among underfive children in Mao, Chad: a matched casecontrol study".

Neuraxial techniques of labour analgesia.

In recent years, many neuraxial techniques have been introduced to initiate and maintain labour analgesia, with low-dose mixtures of local anaesthetics and opioids, which have improved the quality of analgesia and made it safer for both mother and neonate. An independent search of the databases of PubMed, Medline, and Cochrane controlled trial data was conducted by two researchers, and randomized controlled trials that compared different methods of neuraxial analgesia and the different techniques of maintaining labor analgesia were retrieved and analyzed. The advantages, disadvantages, and indications of each technique along with the doses of intrathecal and epidural drugs are discussed. The myths and controversies involving neuraxial labor analgesia and the current consensus on their effect on the maternal and foetal outcomes are also outlined.

Physiological and molecular characterisation for high temperature stress in Lens culinaris.

In the present study, 11 lentil (Lens culinaris Medik) genotypes including heat tolerant and heat sensitive genotypes identified after a screening of 334 accessions of lentil for traits imparting heat tolerance, were characterised based on physiological traits and molecular markers. Results showed a higher reduction in pollen viability among sensitive genotypes (up to 52.3%) compared with tolerant genotypes (up to 32.4%) at 43°C. Higher photosynthetic electron transport rate was observed among heat tolerant genotypes and two heat tolerant lentil genotypes, IG 4258 (0.43) and IG 3330 (0.38) were having highest Fv/Fm values. However, membrane stability was significantly higher in only one heat tolerant genotype, ILL 10712, indicating that different mechanisms are involved to control heat tolerance in lentil. The molecular characterisation of lentil genotypes with 70 polymorphic SSR and genic markers resulted into distinct clusters in accordance with their heat stress tolerance. A functional marker ISM11257 (intron spanning marker) amplifying an allele of 205bp in size was present only among heat tolerant genotypes, and could be further used in a breeding program to identify heat tolerant lentil genotypes. The findings of this study will contribute to the development of heat tolerant lentil cultivars.