Early Utilization of Mechanical Circulatory Support in Acute Myocardial Infarction Complicated by Cardiogenic Shock: The National Cardiogenic Shock Initiative.

BACKGROUND: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Mechanical circulatory support (MCS) devices increase systemic blood pressure and end organ perfusion while reducing cardiac filling pressures. METHODS AND RESULTS: The National Cardiogenic Shock Initiative (NCT03677180) is a single-arm, multicenter study. The purpose of this study was to assess the feasibility and effectiveness of utilizing early MCS with Impella in patients presenting with AMI-CS. The primary end point was in-hospital mortality. A total of 406 patients were enrolled at 80 sites between 2016 and 2020. Average age was 64±12 years, 24% were female, 17% had a witnessed out-of-hospital cardiac arrest, 27% had in-hospital cardiac arrest, and 9% were under active cardiopulmonary resuscitation during MCS implantation. Patients presented with a mean systolic blood pressure of 77.2±19.2 mm Hg, 85% of patients were on vasopressors or inotropes, mean lactate was 4.8±3.9 mmol/L and cardiac power output was 0.67±0.29 watts. At 24 hours, mean systolic blood pressure improved to 103.9±17.8 mm Hg, lactate to 2.7±2.8 mmol/L, and cardiac power output to 1.0±1.3 watts. Procedural survival, survival to discharge, survival to 30 days, and survival to 1 year were 99%, 71%, 68%, and 53%, respectively. CONCLUSIONS: Early use of MCS in AMI-CS is feasible across varying health care settings and resulted in improvements to early hemodynamics and perfusion. Survival rates to hospital discharge were high. Given the encouraging results from our analysis, randomized clinical trials are warranted to assess the role of utilizing early MCS, using a standardized, multidisciplinary approach.

Disparities in the management of non-ST-segment elevation myocardial infarction in the United States.

Guidelines recommend managing patients aged ≥75 with non-ST-segment elevation myocardial infarction (NSTEMI) similar to younger patients. We analyze disparities in NSTEMI management and compare those ≥80 years to those <80 years. This is a matched case-control study using the 2016 National Inpatient Sample data of adults with NSTEMI receiving percutaneous coronary intervention with drug-eluting stent (PCI-DES) - one artery or no intervention. We included the statistically significant variables in univariate analysis in exploratory multivariate logistic regression models. Total sample included 156,328 patients, out of which 43,265 were ≥ 80 years, and 113,048 were < 80 years. Patients ≥80 years were more likely to not have an intervention (73.3%) when compared to those <80 (44.1%), P < 0.0005. Regardless of age, PCI-DES-one artery improved survival compared to no intervention (Age < 80: OR 0.230, 95% CI 0.189-0.279, and ≥ 80: OR 0.265, 95% CI 0.195-0.361, P < 0.0005). Women (OR 0.785, 95% CI 0.766-0.804, P < 0.0005) and non-white race (OR 0.832, 95% CI 0.809-0.855, P < 0.0005) were less likely to receive an intervention. Non-Medicare/Medicaid insurance was associated with 40% lower likelihood of dying in <80 age group (OR 0.596, 95% CI 0.491-0.724, P < 0.0005), and 16% higher chance of intervention overall (OR 1.160, 95% CI 1.125-1.197, P < 0.0005). Patients aged ≥80 with NSTEMI were 29% less likely to receive an intervention compared to patients aged <80, even though patients >80 derived similar mortality benefits from the intervention. There were gender, payor, and race-based disparities in NSTEMI management in 2016.

Aortic Valve Replacement and Exclusion of Sinus of Valsalva Aneurysm With Balloon-Expandable Transcatheter Aortic Valve.

An 85-year-old female with severe aortic valve stenosis presented with heart failure complicated with cardiogenic shock and was found to have a right coronary cusp sinus of Valsalva aneurysm. We report the first case of successful exclusion of a sinus of Valsalva aneurysm during transcatheter aortic valve replacement using a balloon-expandable valve. (Level of Difficulty: Intermediate.).

Evolution of prescribing practices and outcomes in the COVID-19 pandemic in metropolitan areas.

Introduction: We wanted to characterize the evolution of the COVID-19 pandemic in a typical metropolitan area. Methods: Data were extracted from the Detroit COVID-19 Consortium database for hospitalized COVID-19 patients treated in Southeast Michigan over the 12-month period from March 2020 to February 2021. Demographic and outcomes data were compared to CDC data. Results: A total of 4,775 patients were enrolled during the study period. We divided the pandemic into three phases: Phase-1 (Spring Surge); Phase-2 (Summer Lull); and Phase-3 (Fall Spike). Changes in hydroxychloroquine, remdesivir, corticosteroid, antibiotic and anticoagulant use closely followed publication of landmark studies. Mortality in critically-ill patients decreased significantly from Phase-1 to Phase-3 (60.3% vs. 47.9%, Chisq p=0.0110). Monthly mortality of all hospitalized patients ranged between 14.8% - 21.5% during Phase-1 and 9.7 to 13.4% during Phase 3 (NS). Discussion: The COVID-19 pandemic presented in three unique phases in Southeast Michigan. Medical systems rapidly modified treatment plans, often preceding CDC and NIH recommendations. Despite improved treatment regimens, intubation rates and mortality for hospitalized patients remained elevated. Conclusion: Preventive measures aimed at reducing hospitalizations for COVID-19 should be emphasized.

Sociodemographic factors associated with knowledge of type 2 diabetes in rural Tamil Nadu, India.

INTRODUCTION: This study aimed to investigate awareness of type 2 diabetes and how sociodemographic factors influence diabetes knowledge in a rural population of Tamil Nadu, India. Previous research has identified poor awareness of diabetes in several low and middle-income countries, which can lead to a high prevalence of undiagnosed diabetes. India having the second highest prevalence of diabetes globally, it is increasingly important to assess how diabetes can be addressed in rural Indian populations. METHODS: Systematic random sampling was used to gather study participants in 17 villages within the Krishnagiri district of Tamil Nadu, India. Data on diabetes knowledge was collected using a validated questionnaire. Knowledge score range was 0-8; a score of zero was designated as 'low knowledge', scores 1-4 as 'moderate knowledge', and scores 5-8 as 'good knowledge'. Associations between sociodemographic factors and composite diabetes knowledge score were assessed using a multinomial logistic GLLAMM model in Stata. RESULTS: A total of 753 individuals participated in the study. The average age of participants was 47 years and 55% were women. Overall awareness of diabetes was low, with 66% of individuals having no knowledge of diabetes. Only 16% and 17% achieved a moderate and a good knowledge score, respectively. Achieving a moderate knowledge score was significantly positively associated with education, wealth, participation in the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA), and business ownership as a source of income. Achieving a good knowledge score was significantly positively associated with education, wealth, rurality, participation in MGNREGA, business ownership as a source of income, and frequency of healthcare utilization. Rurality was significantly negatively associated (relative risk ratio (95% confidence interval)) with both moderate knowledge score (0.34 (0.19-0.59)), and good knowledge score (0.43 (0.24-0.74)). The strongest predictor of having a good knowledge score was having a high-school graduate or post-secondary education (11.07 (4.44-27.61)). Enrolment in MGNREGA employment was the strongest predictor for having a moderate knowledge score (3.27 (1.93-5.54)), as well as strongly associated with having a good knowledge score (2.39 (1.31-4.36)). CONCLUSION: The low awareness of diabetes among participants of this study raises serious concerns for public health in India. Public health efforts must prioritize health equity to lessen the impacts of diabetes in rural populations, where individuals face systemic barriers to receiving prevention and treatment for conditions such as diabetes.

Vasopressors independently associated with mortality in acute myocardial infarction and cardiogenic shock.

BACKGROUND: Increasing vasopressor dose is associated with increasing mortality in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS). It is unknown whether the use of vasopressors is independently harmful or if their use is secondary to decreasing intrinsic cardiac power output (CPO). Mechanical circulatory support (MCS) devices enhance CPO. We sought to evaluate the independent impact of increasing vasopressor dose on survival in the National Cardiogenic Shock Initiative (NCSI). METHODS: The NCSI is a single arm prospective trial evaluating outcomes associated with the use of MCS using Impella in patients with AMICS. Early initiation of MCS placement before percutaneous coronary intervention (PCI) and rapid de-escalation of vasopressors guided by systematic use of invasive hemodynamic measures led to 70% in-hospital survival for the first 300 patients enrolled from July 2016 to December 2019 in 57 U.S. sites. RESULTS: Hemodynamic measures were obtained immediately after MCS and PCI. Survival curves were constructed based on CPO and use of vasopressors. For patients with CPO ≤0.6 W, survival was 77.3%, 45.0%, and 35.3% when 0, 1, or ≥ 2 vasopressors were used (p = 0.02). Similarly, for patients with CPO >0.6 W survival was 81.7%, 72.6%, and 56.8%, respectively (p = 0.01). Logistic regression analysis demonstrated that increasing vasopressor requirements were independently associated with increasing mortality (p = 0.02). CONCLUSION: Increasing vasopressor requirement is associated with increased mortality in AMICS independent of underlying CPO. Methods to decrease the need for vasopressors may enhance survival in AMICS.

Patient engagement with digital disease management and readmission rates: The case of congestive heart failure.

Congestive heart failure (CHF) is one of the most common diagnoses in the elderly United States Medicare (⩾ age 65) population. This patient population has a particularly high readmission rate, with one estimate of the 6-month readmission rate topping 40%. The rapid rise of mobile health (mHealth) presents a promising new pathway for reducing hospital readmissions of CHF, and, more generally, the management of chronic conditions. Using a randomized research design and a multivariate regression model, we evaluated the effectiveness of a hybrid mHealth model-the integration of remote patient monitoring with an applied health technology and digital disease management platform-on 45-day hospital readmissions for patients diagnosed with CHF. We find a 78% decrease in the likelihood of CHF hospital readmission for patients who were assigned to the digital disease management platform as compared to patients assigned to control.

Successful resuscitation of acute cardiogenic shock presenting as ventricular fibrillation via Bipella approach: a case report.

BACKGROUND: The use of mechanical circulatory support (MCS) in acute myocardial infarction and cardiogenic shock (AMICS) complicated by biventricular failure is poorly discussed in the literature. CASE SUMMARY: We present successful treatment of a 52-year-old old man presenting with AMICS following cardiac arrest and prolonged CPR via a Bipella approach for biventricular support and restoration of haemodynamic stability. DISCUSSION: This case demonstrates the importance of understanding the role of MCS in the management of cardiogenic shock; the value of the cardiac power output and pulmonary artery pulsatility index as haemodynamic metrics to assess the cardiac function of a patient with cardiogenic shock; and the importance of a Bipella MCS approach in high inpatient morbidity and mortality AMICS with biventricular failure.

Impending Paradoxical Embolism Traversing Three Cardiac Chambers Presenting With Stroke and Pulmonary Embolism.

A straddling thrombus within a patent foramen ovale (PFO), also known as an impending paradoxical embolism, is an infrequent event that is rarely encountered in clinical practice. This should be considered whenever there is an arterial embolism in the presence of right-sided thromboembolic disease. Symptoms are widely variable depending on the severity of thrombus and obstructive embolic events. We present a patient who arrived at the hospital with signs and symptoms consistent with a cerebrovascular disease that was ultimately diagnosed with small foci of acute ischemic cerebral infarcts, bilateral pulmonary emboli, and a straddling thrombus traversing three cardiac chambers. Treatment included PFO closure, inferior vena cava filter placement, and surgical thrombectomy with a successful outcome. Consensus for treatment of an impending paradoxical embolism in the medical literature is a subject of controversy and is our reason behind contributing this case presentation with our treatment strategy.

Intravascular ultrasound-guided mechanical thrombectomy using the INARI ClotTriever device of an iatrogenic deep venous thrombosis.

Deep vein thrombosis (DVT) is a common disorder affecting 1 to 2 per 1000 Americans annually, resulting in significant morbidity and mortality. Anticoagulation is the mainstay management strategy for DVT. However, this could prove insufficient in cases where a mechanical obstruction is responsible for the DVT. We are presenting an interesting case of iatrogenic DVT incurred after Prolene suturing of lacerated iliac vein and the management employed for this challenging case with a successful and significant improvement in the clinical outcome.

Socio-demographic patterning of the individual-level double burden of malnutrition in a rural population in South India: a cross-sectional study.

BACKGROUND: The double burden of malnutrition is the co-occurrence of undernutrition (e.g. underweight, stunting, and micronutrient deficiencies) and over-nutrition (e.g. obesity, type 2 diabetes, and cardiovascular disease) at the population, household, or individual level. The objectives of this study were to determine the extent and determinants of individual-level co-morbid anemia and overweight and co-morbid anemia and diabetes in a population in rural Tamil Nadu, South India. METHODS: We undertook a cross-sectional study of adults (n = 753) in a rural region of Tamil Nadu, South India. A survey assessed socio-demographic factors, physical activity levels, and dietary intake. Clinical measurements included body-mass index, an oral glucose tolerance test, and blood hemoglobin assessments. Multivariable logistic regression analyses were used to determine associations between risk factors and two co-morbid double burden pairings: (1) anemia and overweight, and (2) anemia and diabetes. RESULTS: Prevalence of co-morbid anemia and overweight was 23.1% among women and 13.1% among men. Prevalence of co-morbid anemia and diabetes was 6.2% among women and 6.3% among men. The following variables were associated with co-morbid anemia and overweight in multivariable models [odds ratio (95% confidence interval)]: female sex [2.3 (1.4, 3.85)], high caste [3.2 (1.34, 7.49)], wealth index [1.1 (1.00, 1.12)], rurality (0.7 [0.56, 0.85]), tobacco consumption [0.6 (0.32, 0.96)], livestock ownership [0.5 (0.29, 0.89)], and energy-adjusted meat intake [1.8 (0.61, 0.94)]. The following variables were associated with co-morbid anemia and diabetes in multivariable models: age [1.1 (1.05, 1.11)], rurality [0.8 (0.57, 0.98)], and family history of diabetes [4.9 (1.86, 12.70). CONCLUSION: This study determined the prevalence and factors associated with individual-level double burden of malnutrition. Women in rural regions of India may be particularly vulnerable to individual-level double burden of malnutrition and should be a target population for any nutrition interventions to address simultaneous over- and undernutrition.

Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Cardiogenic Shock.

OBJECTIVES: This study sought to compare outcomes of patients enrolled in the NCSI (National Cardiogenic Shock Initiative) trial who were treated using a revascularization strategy of percutaneous coronary intervention (PCI) of multivessel PCI (MV-PCI) versus culprit-vessel PCI (CV-PCI). BACKGROUND: In patients with multivessel disease who present with acute myocardial infarction and cardiogenic shock (AMICS), intervening on the nonculprit vessel is controversial. There are conflicting published reports and lack of evidence, particularly in patients treated with early mechanical circulatory support (MCS). METHODS: From July 2016 to December 2019, patients who presented with AMICS to 57 participating hospitals were included in this analysis. All patients were treated using a standard shock protocol emphasizing early MCS, revascularization, and invasive hemodynamic monitoring. Patients with multivessel coronary artery disease (MVCAD) were analyzed according to whether CV-PCI or MV-PCI was undertaken during the index procedure. RESULTS: Of 198 patients with MVCAD, 126 underwent MV-PCI (64%) and 72 underwent CV-PCI (36%). Demographics between the cohorts were similar with respect to age, sex, history of diabetes, prior PCI or coronary artery bypass grafting, and prior history of myocardial infarction. Patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance on presentation, and cardiac performance was significantly worse at 12 h. However, 24 h from PCI, the hemometabolic derangements were similar. Survival and rates of acute kidney injury were not significantly different between groups (69.8% MV-PCI vs. 65.3% CV-PCI; p = 0.51; and 29.9% vs. 34.2%; p = 0.64, respectively). CONCLUSIONS: In patients with MVCAD presenting with AMICS treated with early MCS, revascularization of nonculprit lesions was associated with similar hospital survival and acute kidney injury when compared with culprit-only PCI. Selective nonculprit PCI can be safety performed in AMICS in patients supported with mechanical circulatory support.

Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative.

BACKGROUND: The National Cardiogenic Shock Initiative is a single-arm, prospective, multicenter study to assess outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI). METHODS: Between July 2016 and February 2019, 35 sites participated and enrolled into the study. All centers agreed to treat patients with AMICS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those of the "SHOCK" trial with an additional exclusion criteria of intra-aortic balloon pump counter-pulsation prior to MCS. RESULTS: A total of 171 consecutive patients were enrolled. Patients had an average age of 63 years, 77% were male, and 68% were admitted with AMICS. About 83% of patients were on vasopressors or inotropes, 20% had a witnessed out of hospital cardiac arrest, 29% had in-hospital cardiac arrest, and 10% were under active cardiopulmonary resuscitation during MCS implantation. In accordance with the protocol, 74% of patients had MCS implanted prior to PCI. Right heart catheterization was performed in 92%. About 78% of patients presented with ST-elevation myocardial infarction with average door to support times of 85 ± 63 min and door to balloon times of 87 ± 58 min. Survival to discharge was 72%. Creatinine ≥2, lactate >4, cardiac power output (CPO) <0.6 W, and age ≥ 70 years were predictors of mortality. Lactate and CPO measurements at 12-24 hr reliably predicted overall mortality postindex procedure. CONCLUSION: In contemporary practice, use of a shock protocol emphasizing best practices is associated with improved outcomes.

Successful Catheter-Directed Thrombolysis of Massive Bilateral Upper Extremity DVT Presenting as Superior Vena Cava Syndrome.

Superior vena cava syndrome (SVCS) is traditionally associated with malignancy. However, approximately one-third of SVCS cases are due to intravascular devices and pacemakers. No specific guidelines exist for managing catheter-associated SVCS. We present catheter-associated SVCS resistant to anticoagulation, angioplasty, and thrombectomy but resolved with ultrasound-assisted catheter directed thrombolysis. (Level of Difficulty: Intermediate.).

Burden and Determinants of Anemia in a Rural Population in South India: A Cross-Sectional Study.

BACKGROUND/OBJECTIVES: To determine the prevalence and determinants of blood haemoglobin level and mild, moderate, and severe anemia in a sample of adults from rural Tamil Nadu, India. SUBJECTS/METHODS: We recruited a sample of men and nonpregnant women aged 20 years and older. Clinical health measures included blood haemoglobin concentration and body mass index. We assessed associations between anemia outcomes and sociodemographic and dietary factors using linear and logistic regression modeling. RESULTS: A total of 753 individuals (412 women and 341 men) participated in this study. The prevalence of anemia was 57.2% among women and 39.3% among men (P<0.001). Prevalence of anemia increased with age among men (P<0.001) but not women (P>0.05). Iron intake was low; 11.7% women and 24.1% of men reported iron intakes above recommended dietary allowances (P<0.001). Factors (OR (95% CI)) associated with mild or moderate anemia among women included television ownership (0.27 (0.13, 0.58)), livestock ownership (0.46 (0.28, 0.75)), refined grain consumption (1.32 (1.02, 1.72)), meat consumption (0.84 (0.71, 0.99)), and commercial agriculture production (mild: 4.6 (1.1, 18.8); moderate: 6.8 (1.98, 23.1)). Factors associated with mild, moderate, or severe anemia among men included rurality (0.50 (0.25, 0.99)), sugar consumption (1.04 (1.01, 1.06)), egg consumption (0.80 (0.65, 0.99)), and high caste (7.3 (1.02, 52.3)). CONCLUSION: Both women and men in this region may be particularly vulnerable to anemia, and future research must expand beyond dietary risk factors to examine the impacts of sociodemographic and environmental factors.

Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: The Detroit cardiogenic shock initiative.

OBJECTIVE: The 'Detroit Cardiogenic Shock Initiative' is a single-arm, multicenter study to assess the feasibility of early mechanical circulatory support (MCS) in patients who present with acute myocardial infarction complicated by cardiogenic shock (AMICS) who undergo percutaneous coronary intervention. METHODS: Between July 2016 and February 2017, 4 metro Detroit sites participated in the study. The centers agreed to treat patients with AMICS using a mutually agreed-upon protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those from the 'SHOCK' trial with an additional exclusion criteria being use of intra-aortic balloon pump counter pulsation prior to MCS. RESULTS: A total of 41 consecutive patients were included. Patients had an average age of 65 ± 14 years, 71% were male and 59% of patients were admitted to the hospital in cardiogenic shock. Prior to receiving MCS, 93% of patients were on vasopressors or inotropes, 15% of patients had a witnessed out of hospital cardiac arrest, 27% of patients had an in-hospital cardiac arrest, and 17% were under active cardiopulmonary resuscitation while MCS was being implanted. In accordance to the protocol recommendation, 66% of patients had a MCS device inserted prior to PCI. Right heart catheterization and hemodynamic monitoring was performed in 83% of patients. Door to support times averaged 83 ± 58 minutes and 71% of patients were able to reduce the levels of inotropes and vasopressors within the first 24-hours of their index procedure. Pre-procedure cardiac power output (CPO) was 0.57 W and post-procedure CPO was 0.95 W, a 67% increase (p < 0.001). Survival to explant for the entire cohort was 85% a significant improvement from institutional historical controls (85% vs 51% p < 0.001) and survival to discharge was 76%. CONCLUSION: Centers who adopted a regional shock protocol emphasizing the delivery of early MCS with invasive hemodynamic monitoring can achieve rapid door to support times and can improve survival in patients who present with AMICS. Larger national studies will be needed to further validate this pilot feasibility study.

Determinants of internal migrant health and the healthy migrant effect in South India: a mixed methods study.

BACKGROUND: Internal labour migration is an important and necessary livelihood strategy for millions of individuals and households in India. However, the precarious position of migrant workers within Indian society may have consequences for the health of these individuals. Previous research on the connections between health and labour mobility within India have primarily focused on the negative health outcomes associated with this practice. Thus, there is a need to better identify the determinants of internal migrant health and how these determinants shape migrant health outcomes. METHODS: An exploratory mixed methods study was conducted in 26 villages in the Krishnagiri district of Tamil Nadu. Sixty-six semi-structured interviews were completed using snowball sampling, followed by 300 household surveys using multi-stage random sampling. For qualitative data, an analysis of themes and content was completed. For quantitative data, information on current participation in internal labour migration, in addition to self-reported morbidity and determinants of internal migrant health, was collected. Morbidity categories were compared between migrant and non-migrant adults (age 14-65 years) using a Fisher's exact test. RESULTS: Of the 300 households surveyed, 137 households (45.7%) had at least one current migrant member, with 205 migrant and 1012 non-migrant adults (age 14-65 years) included in this study. The health profile of migrant and non-migrants was similar in this setting, with 53 migrants (25.9%) currently suffering from a health problem compared to 273 non-migrants (27.0%). Migrant households identified both occupational and livelihood factors that contributed to changes in the health of their migrant members. These determinants of internal migrant health were corroborated and further expanded on through the semi-structured interviews. CONCLUSIONS: Internal labour migration in and of itself is not a determinant of health, as participation in labour mobility can contribute to an improvement in health, a decline in health, or no change in health among migrant workers. Targeted public health interventions should focus on addressing the determinants of internal migrant health to enhance the contributions these individuals can make to their households and villages of origin.

From food security to food wellbeing: examining food security through the lens of food wellbeing in Nepal's rapidly changing agrarian landscape.

This paper argues that existing food security and food sovereignty approaches are inadequate to fully understand contradictory human development, nutrition, and productivity trends in Nepalese small-scale agriculture. In an attempt to bridge this gap, we developed a new food wellbeing approach that combines insights from food security, food sovereignty, and social wellbeing perspectives. We used the approach to frame 65 semi-structured interviews in a cluster of villages in Kaski district in the mid-hills of Nepal on various aspects of food security, agriculture, off-farm livelihood opportunities, and women's wellbeing. Our results indicate that context-specific subjective and social relational factors highlighted by the food wellbeing approach are key to understanding a paradox of increased food security, yet decreasing sustainability of small-scale agriculture. Increased levels of male out-migration and opportunities for local off-farm work have increased local capacity to purchase food. The positive consequences for food security are indicated by evidence that households with non-farm income sources had better food sufficiency, absorption capacity, nutritional quality, and stability of food supply. These off-farm employment opportunities have also led to the greater involvement of low caste groups and women in small-scale agriculture. This has been empowering for both groups and led to an increase in wellbeing, particularly for those women who have become de facto heads of household. Yet, small landholdings, persistent patterns of unequal and absentee land ownership, sharecropping, women's overwork, and the aspirations of low caste farmers and women away from agriculture are simultaneously driving the erosion of local small-scale agricultural productivity and ecological sustainability.

Decoding the Type 2 Diabetes Epidemic in Rural India.

Type 2 diabetes mellitus is an escalating public health problem in India, associated with genetic susceptibility, dietary shift, and rapid lifestyle changes. Historically a disease of the urban elite, quantitative studies have recently confirmed rising prevalence rates among marginalized populations in rural India. To analyze the role of cultural and sociopolitical factors in diabetes onset and management, we employed in-depth interviews and focus groups within a rural community of Tamil Nadu. The objectives of the study were to understand sources and extent of health knowledge, diabetes explanatory models, and the impact of illness on individual, social, and familial roles. Several cultural, socioeconomic, and political factors appear to contribute to diabetes in rural regions of India, highlighting the need to address structural inequities and empower individuals to pursue health and well-being on their own terms.