A community health worker-led program to improve access to gestational diabetes screening in urban slums of Pune, India: Results from a mixed methods study.

The World Health Organization recommends all pregnant women receive screening for gestational diabetes (GDM) with a fasting oral glucose tolerance test (OGTT). However, very few women receive recommended screening in resource-limited countries like India. We implemented a community health worker (CHW)-delivered program to evaluate if home-based, CHW-delivered OGTT would increase GDM screening in a low-resource setting. We conducted a mixed methods study in two urban slum communities in Pune, India. CHWs were trained to deliver home-based, point-of-care fasting OGTT to women in their third trimester of pregnancy. The primary outcome was uptake of CHW-delivered OGTT. Secondary outcomes included GDM prevalence and linkage to GDM care. Individual interviews were conducted with purposively sampled pregnant women, CHWs, and local clinicians to assess barriers and facilitators of this approach. From October 2021-June 2022, 248 eligible pregnant women were identified. Of these, 223 (90%) accepted CHW-delivered OGTT and 31 (14%) were diagnosed with GDM. Thirty (97%) women diagnosed with GDM subsequently sought GDM care; only 10 (33%) received lifestyle counseling or pharmacologic therapy. Qualitative interviews indicated that CHW-delivered testing was considered highly acceptable as home-based testing saved time and was more convenient than clinic-based testing. Inconsistent clinical management of GDM was attributed to providers' lack of time to deliver counseling, and perceptions that low-income populations are not at risk for GDM. Convenience and trust in a CHW-delivered GDM screening program resulted in high access to gold-standard OGTT screening and identification of a high GDM prevalence among pregnant women in two urban slum communities. Appropriate linkage to care was limited by clinician time constraints and misperceptions of GDM risk. CHW-delivered GDM screening and counseling may improve health education and access to preventive healthcare, offloading busy public clinics in high-need, low-resource settings.

The Association of Gestational Diabetes with HIV Infection and Tuberculosis in Indian Women.

Infection of HIV is associated with an increased diabetes risk, which also increases tuberculosis risk. It is unknown if similar associations exist with gestational diabetes (GDM). We screened pregnant women living with and without HIV for GDM using oral glucose tolerance testing. In a subgroup of women with latent tuberculosis (positive interferon-gamma [IFN-γ] release assay), we used supernatants from tuberculosis antigen tubes to compare cytokine levels from women with and without GDM, matched by age and HIV status. Of 234 women, 21 (9%) had GDM, 13.9% living with HIV, and 6.5% without HIV (P = 0.06). Compared with women without GDM, women with GDM had lower median IFN-γ (19.1 versus 141.9 pg/mL, P = 0.03) and interleukin-2 (18.7 versus 249 pg/mL, P < 0.01). Our study suggests that HIV infection is associated with an increased risk of GDM, which is associated with decreased Mycobacterium tuberculosis immune responses. Gestational diabetes screening should be prioritized in tuberculosis-endemic countries, especially in women living with HIV.

Inflammatory profile associated with insulin resistance in non-overweight versus overweight people living with HIV in Pune, Western India.

BACKGROUND: People living with HIV have greater diabetes (T2DM) than the general population despite lower prevalence of overweight/obesity. Both insulin resistance (IR), a T2DM precursor, and HIV are independently associated with chronic inflammation. Inflammation may be a pathophysiological link explaining IR in people living with HIV who are not overweight but is not well understood. AIMS: To study the association between inflammation and IR in non-overweight and overweight people living with HIV. METHODS: In a cohort of adult people living with HIV with undetectable viral load in Pune, India, we measured fasting insulin, glucose, and 9 inflammatory markers. IR was defined as HOMA-IR ≥2, and non-overweight as BMI ≤23 kg/m2. We used modified Poisson regression to evaluate the association between inflammatory markers and IR in overweight and non-overweight. RESULTS: Of 288 participants, 66% (n = 189) were non-overweight. Among non-overweight, prevalence of IR was 34% (n = 65). Each doubling of MCP-1 and leptin was associated with IR on univariate analysis (prevalence ratio (PR) 1.29, 95%CI 1.07-1.53, p < 0.01; PR 1.13 95%CI 1.01-1.26, p = 0.03). Leptin remained associated with IR after adjustment for age, MCP-1, gender, cholesterol, and waist circumference (adjusted PR 1.20 95%CI 1.06-1.36, p < 0.01). Among overweight, prevalence of IR was 69% and no markers were associated with IR. CONCLUSIONS: One in 3 non-overweight people living with HIV in India with controlled viremia have IR. Leptin was associated with IR among non-overweight people living with HIV and may provide insight into the pathophysiology of metabolic disease in this population.

Normal-pressure hydrocephalus: A rare cause of reversible dementia.

ABSTRACT: Normal-pressure hydrocephalus (NPH) is characterized by the clinical triad of dementia, gait instability, and urinary incontinence. The estimated annual incidence is 1.8 cases in 100,000 persons, making NPH a rare diagnosis and uncommon cause of dementia. NPH is a form of communicating hydrocephalus that can easily be missed in older adults with multiple comorbidities, so clinicians must exclude reversible causes of dementia before diagnosing irreversible causes such as Alzheimer disease.

Gestational diabetes in rural central India: low prevalence but absence of typical risk factors.

INTRODUCTION: The reported prevalence of gestational diabetes mellitus (GDM) varies widely across India. Given the short-term, long-term, and multigenerational health impacts of GDM, understanding its frequency and risk factors is important for population screening strategies. We estimated the prevalence of GDM and determined associated risk factors in rural, central India, where data is sparse. METHODS: We conducted a cross-sectional study of a convenience sample of 575 pregnant women attending antenatal care (ANC) clinics at Jan Swasthya Sahyog's (JSS) outreach clinics in rural Chhattisgarh, India. Study participants underwent a non-fasting 75g oral glucose tolerance test (OGTT) between 24-28 weeks gestation. Using Diabetes in Pregnancy Study Group of India (DIPSI) criteria, a 2-hour post-OGTT glucose ≥140 mg/dL was used to diagnose GDM. RESULTS: We found 11 patients (1.9%) who met diagnostic criteria for GDM. Median age, systolic blood pressure, and diastolic blood pressure were higher in those with GDM (26 vs 23 years, p = 0.02; 117 vs 106 mmHg, p = 0.04, 77 vs 68 mmHg, p < 0.01, respectively). Pre-hypertension was associated with increased odds of GDM on multivariate analysis (OR 4.0, 95% CI: 1.1, 14.8). BMI was not associated with GDM. With appropriate management there were no differences in fetal complications between GDM and normal glucose tolerance (NGT) groups. CONCLUSIONS: In rural, central India the prevalence of GDM was 1.9% in the absence of traditional risk factors such as increased BMI. Further research is needed to define the applicability of optimal screening strategies in such settings.

Quality of anticoagulation with warfarin in rural Chhattisgarh, India.

Background & objectives: In most of rural India, warfarin is the only oral anticoagulant available. Among patients taking warfarin, there is a strong association between poor control of the international normalized ratio (INR) and adverse events. This study was aimed to quantify INR control in a secondary healthcare system in rural Chhattisgarh, India. Methods: The INR data were retrospectively obtained from all patients taking warfarin during 2014-2016 at a secondary healthcare system in rural Chhattisgarh, India. Patients attending the clinic had their INR checked at the hospital laboratory and their warfarin dose adjusted by a physician on the same day. The time in therapeutic range (TTR) was calculated for patients who had at least two INR visits. Results: The 249 patients had 2839 INR visits. Their median age was 46 yr, and the median body mass index was 17.7 kg/m[2]. They lived a median distance of 78 km (2-3 h of travel) from the hospital. The median INR was 1.7 for a target INR of 2.0-3.0 (n=221) and 2.1 for a target of 2.5-3.5 (n=28). The median TTR was 13.0 per cent, and INR was subtherapeutic 66.0 per cent of the time. Distance from the hospital was not correlated with TTR. Interpretation & conclusions: INR values were subtherapeutic two-thirds of the time, and TTR values were poor regardless of distance from the health centre. Future studies should be done to identify interventions to improve INR control.

The risk of refeeding syndrome among severely malnourished tuberculosis patients in Chhattisgarh, India.

BACKGROUND: A secondary care hospital in rural India serving a highly tuberculosis (TB) and malnutrition endemic region. OBJECTIVE: In this study conducted on patients with chronic protein energy malnutrition (PEM) and TB, we sought to compare nurse-estimated vs. smartphone photograph analytic methods for assessing caloric intake and determine the incidence of refeeding hypophosphatemia (RH) and refeeding syndrome (RFS) in patients with TB. METHODS: Inpatients were prospectively enrolled. Baseline demographic, comorbidity and preadmission caloric data were collected. Nurse estimated caloric intake was compared with digital "before and after" meal images. Serum phosphorus was measured on days 1, 3 and 7 post admission. Patients with RH underwent further evaluation for RFS-associated findings. RESULTS: 27 patients were enrolled. 85% were at risk of RFS by National Institute for Health and Care Excellence (NICE) criteria. Significant discrepancy (>700 calories) was noted between nurse-estimated caloric intake compared to digital images. RH was found in 37% (10/27). None developed clinical RFS. CONCLUSIONS: Our study suggests more standardized methods of caloric intake are needed in resource-limited settings with high co-prevalence of PEM and TB. We noted that despite RH being common in inpatients with PEM+TB given high caloric diets, RFS was not detected.

Intensified Short Symptom Screening Program for Dengue Infection during Pregnancy, India.

Mosquitoborne diseases (e.g., malaria, dengue, and chikungunya) are endemic to India and pose diagnostic challenges during pregnancy. We evaluated an intensified short symptom screening program in India to diagnose dengue during pregnancy. During October 2017-January 2018, we screened pregnant women during antenatal surveillance for symptoms of mosquitoborne diseases (fever only, fever with conjunctivitis, fever with rash, or all 3 symptoms) within the previous 15 days. Of 5,843 pregnant women screened, 52 were enrolled and tested for dengue, chikungunya, and Zika viruses by using a Trioplex real-time reverse transcription PCR. Of 49 who had complete results, 7 (14%) were dengue positive. Of these ocular pain was seen in 4 (57%) and conjunctivitis in 7 (100%). Intensified symptom screening using conjunctivitis, in addition to rash, in pregnant women with fever might improve dengue case detection and can be included in routine symptom screening during pregnancy.

Bacteremia in hemodialysis patients with hepatitis C.

BACKGROUND: Hepatitis C virus (HCV) infection and bacteremia are common comorbidities in hemodialysis patients. A specific relationship between HCV infection and bacteremia has not been defined; however, there is evidence of immune compromise in both HCV-infected and uremic patients, suggesting that this group may be at higher risk for infection. METHODS: We investigated risk factors and mortality associated with bacteremia in HCV-infected hemodialysis patients from the United States Renal Data System. RESULTS: During the 4-year study period, HCV was present in 2.1% of 355,084 patients initiating hemodialysis. When compared with the total population, the rate of bacteremia was significantly higher in patients with HCV (38.3% versus 21.8%). The adjusted relative risk (RR) for bacteremia was higher in HCV versus all patients (relative risk, 95% confidence interval [CI]) in the presence of methicillin-resistant Staphylococcus aureus infection (2.64, CI: 2.58-2.70 versus 2.32, CI: 2.27-2.38), HIV (1.93, CI: 1.85-2.02 versus 1.86, CI: 1.77-1.95) urinary tract infection (1.79, CI: 1.77, 1.82 versus 1.64, CI: 1.61-1.67) and cirrhosis (1.49, CI: 1.45-1.54 versus 1.29, CI: 1.25-1.34). The hazard ratio (95% CI) for death was higher in HCV versus all patients at 1.69 (CI: 1.58-1.81) versus 1.54 (CI: 1.53-1.56). CONCLUSIONS: These data indicate that several clinical covariates increase the risk of bacteremia in hemodialysis patients, with the magnitude of that risk being further increased by HCV infection. Improving outcomes in HCV-infected hemodialysis patients will likely be dependent on aggressive diagnosis and treatment of both HCV and bacteremia.