Evolution of reactive oxygen species cellular targets for plant development.

Reactive oxygen species (ROS) are the key players in regulating developmental processes of plants. Plants have evolved a large array of gene families to facilitate the ROS-regulated developmental process in roots and leaves. However, the cellular targets of ROS during plant evolutionary development are still elusive. Here, we found early evolution and large expansions of protein families such as mitogen-activated protein kinases (MAPK) in the evolutionarily important plant lineages. We review the recent advances in interactions among ROS, phytohormones, gasotransmitters, and protein kinases. We propose that these signaling molecules act in concert to maintain cellular ROS homeostasis in developmental processes of root and leaf to ensure the fine-tuning of plant growth for better adaptation to the changing climate.

Structured Counselling and Regular Telephonic follow up to improve Referral flow and compliance in Nepal for Diabetic Retinopathy(SCREEN-D Study): a randomised controlled trial.

BACKGROUND: Diabetic Retinopathy (DR) is an emerging public health issue, leading to severe visual impairment or blindness. Early identification and prompt treatment play a key role in achieving good visual outcomes. The objective of the study was to estimate the effectiveness of SCREEN package on improving referral compliance from peripheral centres to a tertiary eye centre in Nepal. METHODS: In this facility-based cluster-randomized trial, ten out of 19 referring centres of the tertiary eye care centre in Lumbini zone, Nepal were randomized into intervention and control groups. A SCREEN packagewereprovided as intervention for DR patients who require advanced treatment in the tertiary centres and was compared with the current practice of the control arm, where structured counselling and follow-up mechanism are absent. Compliance was estimated by a weekly follow-up between the referring centre and the referred hospital. RESULTS: We recruited 302 participantsof whom 153 were in the intervention arm. The mean age of the participants was 57.8 years (Standard deviation [SD]±11.7 years). With implementation of SCREEN package71.2% (n=109) in the intervention group and 42.9% (n=64) in the control group were compliant till three months of follow-up (Difference 28.3%, 95% CI: 17.6- 39.0, p<0.05). Compliance was 43% (n=66) with counselling alone, and 66% (n=103) with first telephonic follow-up in the intervention arm. The mean duration to reach the referral centre was 14.7 days (SD± 9.4 days) and 18.2 days (SD± 9.1 days) in the intervention and the control arm, respectively (Difference 3.5 days, 95% CI: 0.7 to 6.4 days). CONCLUSIONS: Counselling& follow-up to patients is the key factor to improve the utilization of the health services by patients with DR. Health systems must be strengthened by optimizing the existing referral structure in Nepal. TRIAL REGISTRATION: ClinicalTrials.gov Protocol Registration and Results System, ClinicalTrials.gov Identifier: NCT04834648 , 08/04/2021.

Does MPK4/12-HT1 function as a CO2/bicarbonate sensor to regulate the stomatal conductance under high CO2 levels?

KEY MESSAGE: Recently, a HT1 protein has been identified which causes continuous opening of stomata because of its kinase activity. However, reversible interaction between MAP4/12 and HT1 protein acts as a CO2/bicarbonate sensor and causes the closing of stomata by inhibiting HT1 kinase activity.

Zinc induced regulation of PCR1 gene for cadmium stress resistance in rice roots.

In this study, the interaction between zinc (Zn) and cadmium (Cd) was investigated in rice roots to evaluate how Zn can protect the plants from Cd stress. Rice seedlings were treated with Cd (100 µM) and Zn (100 µM) in different combinations (Cd alone, Zn alone, Zn+ Cd, Zn+ Cd+ L-NAME, Zn+ Cd+ L-NAME+ SNP). Rice roots treated with only Zn also displayed similar toxic effects, however when combined with Cd exhibited improved growth. Treating the plant with Zn along with Cd distinctly reduced Cd concentration in roots while increasing its own accumulation due to modulation in expression of Zinc-Regulated Transporter (ZRT)-/IRT-Like Protein (OsZIP1) and Plant Cadmium Resistance1 (OsPCR1). Cd reduced plant biomass, cell viability, pigments, photosynthesis and causing oxidative stress due to inhibition in ascorbate-glutathione cycle. L-NAME (NG-nitro L-arginine methyl ester), prominently suppressed the beneficial impacts of Zn against Cd stress, whereas the presence of a NO donor, sodium nitroprusside (SNP), significantly reversed this effect of L-NAME. Collectively, results point that NO signalling is essential for Zn- mediated cross-tolerance against Cd stress via by modulating uptake of Cd and Zn and expression of OsZIP1 and OsPCR1, and ROS homeostasis due to fine tuning of ascorbate-glutathione cycle which finally lessened oxidative stress in rice roots. The results of this study can be utilized to develop new varieties of rice through genetic modifications which will be of great significance for maintaining crop productivity in Cd-contaminated areas throughout the world.

The influence of complex matrices on method performance in extracting and monitoring for microplastics.

Previous studies have evaluated method performance for quantifying and characterizing microplastics in clean water, but little is known about the efficacy of procedures used to extract microplastics from complex matrices. Here we provided 15 laboratories with samples representing four matrices (i.e., drinking water, fish tissue, sediment, and surface water) each spiked with a known number of microplastic particles spanning a variety of polymers, morphologies, colors, and sizes. Percent recovery (i.e., accuracy) in complex matrices was particle size dependent, with ∼60-70% recovery for particles >212 µm, but as little as 2% recovery for particles <20 µm. Extraction from sediment was most problematic, with recoveries reduced by at least one-third relative to drinking water. Though accuracy was low, the extraction procedures had no observed effect on precision or chemical identification using spectroscopy. Extraction procedures greatly increased sample processing times for all matrices with the extraction of sediment, tissue, and surface water taking approximately 16, 9, and 4 times longer than drinking water, respectively. Overall, our findings indicate that increasing accuracy and reducing sample processing times present the greatest opportunities for method improvement rather than particle identification and characterization.

Nitric oxide and hydrogen peroxide mediated regulation of chromium (VI) toxicity in wheat seedlings involves alterations in antioxidants and high affinity sulfate transporter.

Chromium contamination of the soil is a major scientific concern with reference to crop productivity and human health. In recent years, several approaches are being employed in managing metal toxicity in crop plants. Here, we have investigated about potential and probable crosstalk of nitric oxide (NO) and hydrogen peroxide (H2O2) in mitigating hexavalent chromium [Cr(VI)] toxicity in wheat seedlings. Cr(VI) toxicity reduced the fresh mass and overall growth due to accumulation of reactive oxygen species (ROS) and decreased efficiency of AsA-GSH cycle and downregulation of high affinity sulfate transporter. However, exogenous treatment of NO and H2O2 significantly alleviated Cr toxicity. Application of NO and ROS scavengers reversed stress mitigating effects of NO and H2O2, respectively suggesting that endogenous NO and H2O2 are necessary for rendering Cr toxicity tolerance. Furthermore, NO rescued negative effect of diphenylene iodonium (DPI, NADPH oxidase inhibitor) and H2O2 reversed the negative effect of c-PTIO suggesting that they exhibit independent signalling in mitigating Cr stress. Altogether, data indicated that NO and H2O2 rendered mitigation of Cr stress by up-regulating enzymes (activity and relative gene expression) and metabolites of AsA-GSH cycle, high affinity sulfate transporter (relative gene expression) and glutathione biosynthesis which collectively controlled occurrence of oxidative stress.

Evaluation of Dakshata, a scale-up WHO SCC and mentoring-based program, for improving quality of intrapartum care in public sector in Rajasthan, India: repeated mixed-methods surveys.

BACKGROUND: The Dakshata program in India aims to improve resources, providers' competence, and accountability in labour wards of public sector secondary care hospitals. Dakshata is based on the WHO Safe Childbirth Checklist coupled with continuous mentoring. In Rajasthan state, an external technical partner trained, mentored and periodically assessed performance; identified local problems, supported solutions and assisted the state in monitoring implementation. We evaluated effectiveness and factors contributing to success and sustainability. METHODS: Using three repeated mixed-methods surveys over an 18-month period, we assessed 24 hospitals that were at different stages of program implementation at evaluation initiation: Group 1, training had started and Group 2, one round of mentoring was complete. Data on recommended evidence-based practices in labour and postnatal wards and in-facility outcomes were collected by directly observing obstetric assessments and childbirth, extracting information from case sheets and registers, and interviewing postnatal women. A theory-driven qualitative assessment covered key domains of efficiency, effectiveness, institutionalization, accountability, sustainability, and scalability. It included in-depth interviews with administrators, mentors, obstetric staff, and officers/mentors from the external partner. RESULTS: Overall, average adherence to evidence-based practices improved: Group 1, 55 to 72%; and Group 2, 69 to 79%, (for both p < 0.001) from baseline to endline. Significant improvement was noted in several practices in the two groups during admission, childbirth, and within 1 hour of birth but less in postpartum pre-discharge care. We noted a dip in several evidence-based practices in 2nd assessment, but they improved later. The stillbirth rate was reduced: Group 1: 1.5/1000 to 0.2; and Group 2: 2.5 to 1.1 (p < 0.001). In-depth interviews revealed that mentoring with periodic assessments was highly acceptable, efficient means of capacity building, and ensured continuity in skills upgradation. Nurses felt empowered, however, the involvement of doctors was low. The state health administration was highly committed and involved in program management; hospital administration supported the program. The competence, consistency, and support from the technical partner were highly appreciated by the service providers. CONCLUSION: The Dakshata program was successful in improving resources and competencies around childbirth. The states with low capacities will require intensive external support for a head start.

GABA: a key player of abiotic stress regulation.

Abiotic stress is considered as the main culprit for reduction of global food production. Recent studies have reported GABA as a major regulator of abiotic stress and thus opening new avenues in research on emerging roles of GABA in abiotic stress acclimation in plants.

Quantitative assessment of visual microscopy as a tool for microplastic research: Recommendations for improving methods and reporting.

Microscopy is often the first step in microplastic analysis and is generally followed by spectroscopy to confirm material type. The value of microscopy lies in its ability to provide count, size, color, and morphological information to inform toxicity and source apportionment. To assess the accuracy and precision of microscopy, we conducted a method evaluation study. Twenty-two laboratories from six countries were provided three blind spiked clean water samples and asked to follow a standard operating procedure. The samples contained a known number of microplastics with different morphologies (fiber, fragment, sphere), colors (clear, white, green, blue, red, and orange), polymer types (PE, PS, PVC, and PET), and sizes (ranging from roughly 3-2000 µm), and natural materials (natural hair, fibers, and shells; 100-7000 µm) that could be mistaken for microplastics (i.e., false positives). Particle recovery was poor for the smallest size fraction (3-20 µm). Average recovery (±StDev) for all reported particles >50 µm was 94.5 ± 56.3%. After quality checks, recovery for >50 µm spiked particles was 51.3 ± 21.7%. Recovery varied based on morphology and color, with poorest recovery for fibers and the largest deviations for clear and white particles. Experience mattered; less experienced laboratories tended to report higher concentration and had a higher variance among replicates. Participants identified opportunity for increased accuracy and precision through training, improved color and morphology keys, and method alterations relevant to size fractionation. The resulting data informs future work, constraining and highlighting the value of microscopy for microplastics.

Nitric oxide and hydrogen peroxide independently act in mitigating chromium stress in Triticum aestivum L. seedlings: Regulation of cell death, chromium uptake, antioxidant system, sulfur assimilation and proline metabolism.

In this study, we have explored potential of a nitric oxide (NO) donor (SNP, sodium nitroprusside) and hydrogen peroxide (H2O2) in curtailing stress of hexavalent chromium [Cr(VI)] in wheat seedlings. Cr(VI) stress caused a significant decline in growth (30%) and photosynthesis (13%) as a result of enhanced uptake of Cr(VI) and root tips cell death. Further, Cr(VI) stress also accelerated indices of oxidative stress but differentially regulated antioxidant system. But application of either NO or H2O2 separately significantly mitigated Cr(VI) stress by reducing cell death and Cr(VI) uptake in roots, and oxidative stress markers. The application of c-PTIO [2-(4-carboxy-2-phenyl)-4,4,5,5-tetramethylimidazoline-1-oxyl-3-oxide, a scavenger of NO] and N-acetyl-L-cysteine (a scavenger of ROS) reserved alleviatory effect of NO and H2O2, respectively and thus further increased Cr(VI) toxicity. Application of diphenylene iodonium (DPI, an inhibitor of NADPH oxidases) also further increased Cr(VI) toxicity. But SNP and H2O2 significantly rescued negative effects of DPI and c-PTIO, respectively under Cr(VI) stress. Overall results suggested that NO and H2O2 both independently act in mitigating Cr(VI) stress in wheat seedlings by minimizing cell death, restricting Cr(VI) uptake in roots, and increasing antioxidant system, sulfur assimilation and proline metabolism.

Effect of WHO-SCC based intra-department mentoring program on quality of intrapartum care in public sector secondary hospitals in Andhra Pradesh, India: Pre-post mixed methods evaluation.

Quality of intrapartum care is essential for improving pregnancy outcomes; several models for improving performance are tested, globally. Dakshata is one such WHO SCC-based national program-improving resources, providers' competence, and accountability-in public sector secondary care hospitals of India. Andhra Pradesh state devised strategy of mentoring by the handpicked member from within the obstetric team, supported by external technical partner. We evaluated the effectiveness and assessed contextual factors to success of the program. We conducted pre and post mentoring mixed-method surveys to evaluate the change in evidence-based intrapartum and newborn care practices and stillbirth rates, across 23 of 38 eligible hospitals. We directly observed obstetric assessments and childbirth, extracted data from casesheets and registers, interviewed beneficiaries and conducted facility surveys. We in-depth interviewed stakeholders from state, district and facility managers, mentors and obstetric staff, and external managers for theory-driven qualitative assessment. After one year we found, average adherence to practices sustained high during admission (81%, 81%); improved during childbirth (78%, 86%; p = 0.016); moderate within one hour of birth (72%, 71%), and poor postpartum care before discharge (46% to 43%). Stillbirths reduced from 11(95% CI, 9-13) to 4(3-5) per 1000 births (p<0.001). Some practices did not improve even after sustained reinforcement. Commitment from state, engaging district officers, monitoring and feedback by external managers enabled supportive setting. The structured training and mentoring package, and periodic assessments delivered under supervision ensured the standards of mentoring. The mentoring model is acceptable, effective, less costly and scalable; appears sustainable if state commits to institutionalising a long-term mentoring with adequate monitoring. We conclude that the SCC-based mentoring and skill building program showed improvement in practices during childbirth while it sustained high levels of care during admission, but no improvement in postpartum care. The state needs to monitor and ensure continuous mentoring with required infrastructural support.

Regulation of ascorbate-glutathione cycle by exogenous nitric oxide and hydrogen peroxide in soybean roots under arsenate stress.

The role of nitric oxide (NO) and hydrogen peroxide (H2O2) is well known for regulating plant abiotic stress responses. However, underlying mechanisms are still poorly understood. Therefore, the present study investigated the involvement of NO and H2O2 signalling in the regulation of arsenate toxicity (AsV) in soybean roots employing a pharmacological approach. Results show that AsV toxicity declined root length and biomass due to greater As accumulation in the cell wall and cellular organelles. Arsenate induced cell death due to enhanced levels of reactive oxygen species, lipid and protein oxidation and down-regulation in ascorbate-glutathione cycle and redox states of ascorbate and glutathione. These results correlate with lower endogenous level of NO. Interestingly, addition of L-NAME increased AsV toxicity. However, addition of SNP reverses effect of L-NAME, suggesting that endogenous NO has a role in mitigating AsV toxicity. Exogenous H2O2 also demonstrated capability of alleviating AsV stress, while NAC reversed the protective effect of H2O2. Furthermore, DPI application further increased AsV toxicity, suggesting that endogenous H2O2 is also implicated in mitigating AsV stress. SNP was not able to mitigate AsV toxicity in the presence of DPI, suggesting that H2O2 might have acted downstream of NO in accomplishing amelioration of AsV toxicity.

Effect of collaborative quality improvement on stillbirths, neonatal mortality and newborn care practices in hospitals of Telangana and Andhra Pradesh, India: evidence from a quasi-experimental mixed-methods study.

BACKGROUND: Improving quality of care is a key priority to reduce neonatal mortality and stillbirths. The Safe Care, Saving Lives programme aimed to improve care in newborn care units and labour wards of 60 public and private hospitals in Telangana and Andhra Pradesh, India, using a collaborative quality improvement approach. Our external evaluation of this programme aimed to evaluate programme effects on implementation of maternal and newborn care practices, and impact on stillbirths, 7- and 28-day neonatal mortality rate in labour wards and neonatal care units. We also aimed to evaluate programme implementation and mechanisms of change. METHODS: We used a quasi-experimental plausibility design with a nested process evaluation. We evaluated effects on stillbirths, mortality and secondary outcomes relating to adherence to 20 evidence-based intrapartum and newborn care practices, comparing survey data from 29 hospitals receiving the intervention to 31 hospitals expected to receive the intervention later, using a difference-in-difference analysis. We analysed programme implementation data and conducted 42 semi-structured interviews in four case studies to describe implementation and address four theory-driven questions to explain the quantitative results. RESULTS: Only 7 of the 29 intervention hospitals were engaged in the intervention for its entire duration. There was no evidence of an effect of the intervention on stillbirths [DiD - 1.3 percentage points, 95% CI - 2.6-0.1], on neonatal mortality at age 7 days [DiD - 1.6, 95% CI - 9-6.2] or 28 days [DiD - 3.0, 95% CI - 12.9-6.9] or on adherence to target evidence-based intrapartum and newborn care practices. The process evaluation identified challenges in engaging leaders; challenges in developing capacity for quality improvement; and challenges in activating mechanisms of change at the unit level, rather than for a few individuals, and in sustaining these through the creation of new social norms. CONCLUSION: Despite careful planning and substantial resources, the intervention was not feasible for implementation on a large scale. Greater focus is required on strategies to engage leadership. Quality improvement may need to be accompanied by clinical training. Further research is also needed on quality improvement using a health systems perspective.

Additional calcium and sulfur manages hexavalent chromium toxicity in Solanum lycopersicum L. and Solanum melongena L. seedlings by involving nitric oxide.

In recent years, nutrient management has gained much attention for mitigating metal stress. But, role of nutrients like calcium (Ca) and sulfur (S) in mitigating Cr(VI) toxicity along with their mechanism of action are still limited. Therefore, the present study was performed to explore role of Ca and S in ameliorating Cr(VI) toxicity in 21 days old seedlings of Solanum lycopersicum L. and Solanum melongena L. Chromium (VI) reduced tolerance index and altered root traits due to greater Cr accumulation in the cell wall and cellular organelles due to down-regulation in thiols and phytochelatins that lead to alterations in photosynthesis. However, Ca or S stimulated vacuolar sequestration of Cr(VI) and reduced its uptake at the cell wall. This was coincided with up-regulation in glutathione-S-transferase activity, and amounts of thiols and phytochelatins. Cr(VI) caused oxidative stress together with up-regulation in superoxide dismutase and catalase, and proline metabolism while Ca and S reversed these effects. Chromium (VI) inhibited nitrate reductase activity while Ca and S reversed this response. NG-nitro-l-arginine methyl ester augmented Cr(VI) toxicity but sodium nitroprusside (SNP) mitigated Cr(VI) toxicity. Overall results show that Ca and S both are able in ameliorating Cr(VI) toxicity and require nitric oxide for this task.

A brief appraisal of ethylene signaling under abiotic stress in plants.

For years, ethylene has been known to humankind as the plant hormone responsible for fruit ripening. However, the multitasking aspect of ethylene is still being investigated as ever. It is one of the most diversified signaling molecules which acclimatize plant under adverse conditions. It promotes adventitious root formation, stem and petiole elongation, opening and closing of stomatal aperture, reduces salinity and metal stress, etc. Presence of ethylene checks the production and scavenging of reactive oxygen species by strengthening the antioxidant machinery. Meanwhile, it interacts with other signaling molecules and initiates a cascade of adaptive responses. In the present mini review, the biosynthesis and sources of ethylene production, interaction with other signaling molecules, and its exogenous application under different abiotic stresses have been discussed.

Diabetic retinopathy screening uptake after health education with or without retinal imaging within the facility in two AYUSH hospitals in Hyderabad, India: A nonrandomized pilot study.

Purpose: In India, people with diabetes (PwDM) often seek care in the government-approved alternative medicine system, AYUSH (Ayurveda, Yoga and naturopathy, Unani, Siddha and Homeopathy). The purpose of this pilot study was to assess whether health education plus retinal imaging for diabetic retinopathy (DR) within an AYUSH hospital increased the uptake of screening for DR compared with health education and referral. Methods: The study was a nonrandomized pilot conducted in two AYUSH hospitals. Both hospitals received intervention on educating the AYUSH practitioners about DR screening and distributing health education materials to diabetic patients. In one hospital in addition to education, retinal imaging by a trained technician with remote grading by an ophthalmologist was provided, while in another hospital PwDM were referred to nearby eye hospitals for screening. The uptake of screening was assessed through registers and phone calls. Results: At baseline, only 10.7% of 178 PwDM were aware of DR and only 8% had undergone DR screening. After the intervention, in the hospital where screening was provided, all (100%) eligible patients (101) underwent digital imaging, whereas in the other hospital only 25% of 77 eligible patients underwent screening in eye hospitals (P < 0.001). Conclusion: AYUSH hospitals could provide a feasible and acceptable location for providing DR screening services. Further studies are required to assess scale-up of such intervention.

Management and referral for high-risk conditions and complications during the antenatal period: knowledge, practice and attitude survey of providers in rural public healthcare in two states of India.

BACKGROUND: Appropriate antenatal care improves pregnancy outcomes. Routine antenatal care is provided at primary care facilities in rural India and women at-risk of poor outcomes are referred to advanced centres in cities. The primary care facilities include Sub-health centres, Primary health centres, and Community health centres, in ascending order of level of obstetric care provided. The latter two should provide basic and comprehensive obstetric care, respectively, but they provide only partial services. In such scenario, the management and referrals during pregnancy are less understood. This study assessed rural providers' perspectives on management and referrals of antenatal women with high obstetric risk, or with complications. METHODS: We surveyed 147 health care providers in primary level public health care from poor and better performing districts from two states. We assessed their knowledge, attitudes and practices regarding obstetric care, referral decisions and pre-referral treatments provided for commonly occurring obstetric high-risk conditions and complications. RESULTS: Staff had sub-optimal knowledge of, and practices for, screening common high-risk conditions and assessing complications in pregnancy. Only 31% (47/147) mentioned screening for at least 10 of the 16 common high-risk conditions and early complications of pregnancy. Only 35% (17/49) of the staff at Primary health centres, and 51% (18/35) at Community health centres, mentioned that they managed these conditions and, the remaining staff referred most of such cases early in pregnancy. The staff mentioned inability to manage childbirth of women with high-risk conditions and complications. Thus in absence of efficient referral systems and communication, it was better for these women to receive antenatal care at the advanced centres (often far) where they should deliver. There were large gaps in knowledge of emergency treatment for obstetric complications in pregnancy and pre-referral first-aid. Staff generally were low on confidence and did not have adequate resources. Nurses had limited roles in decision making. Staff desired skill building, mentoring, moral support, and motivation from senior officers. CONCLUSION: The Indian health system should improve the provision of obstetric care by standardising services at each level of health care and increasing the focus on emergency treatment for complications, appropriate decision-making for referral, and improving referral communication and staff support.

Care practices and neonatal survival in 52 neonatal intensive care units in Telangana and Andhra Pradesh, India: A cross-sectional study.

BACKGROUND: The Indian government supports both public- and private-sector provision of hospital care for neonates: neonatal intensive care is offered in public facilities alongside a rising number of private-for-profit providers. However, there are few published reports about mortality levels and care practices in these facilities. We aimed to assess care practices, causes of admission, and outcomes from neonatal intensive care units (NICUs) in public secondary and private tertiary hospitals and both public and private medical colleges enrolled in a quality improvement collaborative in Telangana and Andhra Pradesh-2 Indian states with a respective population of 35 and 50 million. METHODS AND FINDINGS: We conducted a cross-sectional study between 30 May and 26 August 2016 as part of a baseline evaluation in 52 consenting hospitals (26 public secondary hospitals, 5 public medical colleges, 15 private tertiary hospitals, and 6 private medical colleges) offering neonatal intensive care. We assessed the availability of staff and services, adherence to evidence-based practices at admission, and case fatality after admission to the NICU using a range of tools, including facility assessment, observations of admission, and abstraction of registers and telephone interviews after discharge. Our analysis is adjusted for clustering and weighted for caseload at the hospital level and presents findings stratified by type and ownership of hospitals. In total, the NICUs included just over 3,000 admissions per month. Staffing and infrastructure provision were largely according to government guidelines, except that only a mean of 1 but not the recommended 4 paediatricians were working in public secondary NICUs per 10 beds. On admission, all neonates admitted to private hospitals had auscultation (100%, 19 of 19 observations) but only 42% (95% confidence interval [CI] 25%-62%, p-value for difference is 0.361) in public secondary hospitals. The most common single cause of admission was preterm birth (25%) followed by jaundice (23%). Case-fatality rates at age 28 days after admission to a NICU were 4% (95% CI 2%-8%), 15% (9%-24%), 4% (2%-8%) and 2% (1%-5%) (Chi-squared p = 0.001) in public secondary hospitals, public medical colleges, private tertiary hospitals, and private medical colleges, respectively, according to facility registers. Case fatality according to postdischarge telephone interviews found rates of 12% (95% CI 7%-18%) for public secondary hospitals. Roughly 6% of admitted neonates were referred to another facility. Outcome data were missing for 27% and 8% of admissions to private tertiary hospitals and private medical colleges. Our study faced the limitation of missing data due to incomplete documentation. Further generalizability was limited due to the small sample size among private facilities. CONCLUSIONS: Our findings suggest differences in quality of neonatal intensive care and 28-day survival between the different types of hospitals, although comparison of outcomes is complicated by differences in the case mix and referral practices between hospitals. Uniform reporting of outcomes and risk factors across the private and public sectors is required to assess the benefits for the population of mixed-care provision.

Evaluation of the Safe Care, Saving Lives (SCSL) quality improvement collaborative for neonatal health in Telangana and Andhra Pradesh, India: a study protocol.

BACKGROUND: The collaborative quality improvement approach proposed by the Institute for Healthcare Improvement has the potential to improve coverage of evidence-based maternal and newborn health practices. The Safe Care, Saving Lives initiative supported the implementation of 20 evidence-based maternal and newborn care practices, targeting labour wards and neonatal care units in 85 public and private hospitals in Telangana and Andhra Pradesh, India. OBJECTIVE: We present a protocol for the evaluation of this programme which aims to (a) estimate the effect of the initiative on evidence-based care practices and mortality; (b) evaluate the mechanisms leading to changes in adherence to evidence-based practices, and their relationship with contextual factors; (c) explore the feasibility of scaling-up the approach. METHODS: The mixed-method evaluation is based on a plausibility design nested within a phased implementation. The 29 non-randomly selected hospitals comprising wave II of the programme were compared to the 31 remaining hospitals where the quality improvement approach started later. We assessed mortality and adherence to evidence-based practices at baseline and endline using abstraction of registers, checklists, observations and interviews in intervention and comparison hospitals. We also explored the mechanisms and drivers of change in adherence to evidence-based practices. Qualitative methods investigated the mechanisms of change in purposefully selected case study hospitals. A readiness assessment complemented the analysis of what works and why. We used a difference-in-difference approach to estimate the effects of the intervention on mortality and coverage. Thematic analysis was used for the qualitative data. DISCUSSION: This is the first quality improvement collaborative targeting neonatal health in secondary and tertiary hospitals in a middle-income country linked to a government health insurance scheme. Our process evaluation is theory driven and will refine hypotheses about how this quality improvement approach contributes to institutionalization of evidence-based practices.

Management of chromium (VI) toxicity by calcium and sulfur in tomato and brinjal: Implication of nitric oxide.

To reduce pressure of toxic metals on crop plants, several strategies are being employed of which nutrient management is gaining much importance. Moreover, whether nitric oxide (NO), has any role in nutrients-mediated management/amelioration of metal toxicity is still not known. Therefore, the role of Ca and S in managing Cr(VI) toxicity was investigated in tomato and brinjal with an emphasis on possible involvement of NO. Cr(VI) reduced growth in both vegetables which was accompanied by increased accumulation of Cr(VI), lignin and reactive oxygen species (ROS), and altered cell cycle dynamics and photochemistry of photosynthesis. However, external addition of either Ca or S reversed these effects and hence improved growth noticed in both vegetables. Cr(VI) toxicity was further increased by NG-nitro-l-arginine methyl ester even with additional Ca and S while sodium nitroprusside either restored growth up to the control level or increased it in both vegetables, even in the presence of L-NAME, suggesting that NO might have a positive role in nutrients-mediated management/amelioration of Cr(VI) toxicity. In this study, role of Ca, S and NO with reference to Cr(VI) and NO accumulation, components of phenylpropanoid pathway, cell cycle dynamics, photosynthesis, ROS and antioxidant potential in managing Cr(VI) toxicity is discussed.