Indian Model of Integrated Healthcare (IMIH): a conceptual framework for a coordinated referral system in resource-constrained settings.

INTRODUCTION: With the escalating burden of chronic disease and multimorbidity in India, owing to its ageing population and overwhelming health needs, the Indian Health care delivery System (HDS) is under constant pressure due to rising public expectations and ambitious new health goals. The three tired HDS should work in coherence to ensure continuity of care, which needs a coordinated referral system. This calls for optimising health care through Integrated care (IC). The existing IC models have been primarily developed and adopted in High-Income Countries. The present study attempts to review the applicability of existing IC models and frame a customised model for resource-constrained settings. METHODS: A two-stage methodology was used. Firstly, a narrative literature review was done to identify gaps in existing IC models, as per the World Health Organization framework approach. The literature search was done from electronic journal article databases, and relevant literature that reported conceptual and theoretical concepts of IC. Secondly, we conceptualised an IC concept according to India's existing HDS, validated by multiple rounds of brainstorming among co-authors. Further senior co-authors independently reviewed the conceptualised IC model as per national relevance. RESULTS: Existing IC models were categorised as individual, group and disease-specific, and population-based models. The limitations of having prolonged delivery time, focusing only on chronic diseases and being economically expensive to implement, along with requirement of completely restructuring and reorganising the existing HDS makes the adoption of existing IC models not feasible for India. The Indian Model of Integrated Healthcare (IMIH) model proposes three levels of integration: Macro, Meso, and Micro levels, using the existing HDS. The core components include a Central Gateway Control Room, using existing digital platforms at macro levels, a bucket overflow model at the meso level, a Triple-layered Concentric Circle outpatient department (OPD) design, and a three-door OPD concept at the micro level. CONCLUSION: IMIH offers features that consider resource constraints and local context of LMICs while being economically viable. It envisages a step toward UHC by optimising existing resources and ensuring a continuum of care. However, health being a state subject, various socio-political and legal/administrative issues warrant further discussion before implementation.

The Impact of Alternate Methodological and Structural Assumptions on Results of Cost-effectiveness Analysis: Empirical Evidence using Three Indian Economic Evaluations.

BACKGROUND: Despite advancement in methods and application of economic evaluations (EEs), there are several uncertainties. OBJECTIVES: To assess the impact of alternate methodological and structural assumptions for four key principles of EE, on the results of cost-effectiveness analysis. MATERIALS AND METHODS: Three previously published model-based EEs were used: (1) Integrated Management of Neonatal and Childhood Illnesses (IMNCIs) intervention; (2) intervention for multiple myeloma, and (3) safety-engineered syringes (SES) intervention. A series of empirical analyses was undertaken to assess the impact of alternate assumptions for discount-rate, time-horizon, study perspective, and health outcome measure, on incremental cost-effectiveness ratio (ICER), and interpretation of cost-effectiveness. RESULTS: Increasing discount rate resulted in an increase in ICERs, for all three case-studies; however, there was no change in the conclusions. Using shorter time-horizons resulted in a significant increase in ICERs, the multiple myeloma intervention remained cost-ineffective, SES intervention became cost-ineffective, whereas IMNCI intervention remained cost-effective, despite a three-fold increase in ICER. On using disability adjusted life years instead of quality adjusted life years, ICERs increased to 0.04, 2 and 4 times for SES, IMNCI and multiple myeloma interventions, respectively. On analyzing results from a societal perspective, a decline in ICERs was observed. The decline was significant for IMNCI where the intervention turned dominant/cost-saving. In the other two case-studies decline in ICERs was modest, 32% for multiple myeloma, and 4% for SES. CONCLUSION: We observed a significant impact of using alternate assumptions on ICERs which can potentially impact resource-allocation decisions. Our findings provide strong argument in favor of standardization of processes and development of country-specific guidelines for conduct of EE.

Long-term safety and efficacy of sublingual ketamine troches/lozenges in chronic non-malignant pain management.

BACKGROUND: Chronic non-malignant pain is a disabling condition that results in a reduction in function and quality of life when inadequately managed. Sublingual ketamine has been shown to be efficacious for use in chronic pain. Despite its use for decades in chronic non-malignant pain, there is no published long-term data on safety, side-effects or adverse drug reactions. AIM: The aim of this case-series is to provide the initial evidence for safety and efficacy in this patient group. METHODS: We present a retrospective review of 29 (n = 29) patients from a metropolitan tertiary pain service who have been receiving sublingual ketamine troches/lozenges between the period of 2012 and 2019. Patients were identified from the outpatient pain clinic, who had been admitted for inpatient subcutaneous ketamine infusions as part of opiate detoxification or management of central sensitisation due to a chronic neuropathic pain syndrome. An initial review was performed to check the patient started taking the ketamine troches. Each of these medical records was reviewed manually to extract information to a datasheet. RESULTS: There was a wide range of dosages used from 25 to 600 mg in divided doses. The duration of treatment ranged 2-89 months. There was no association with either the dosage or duration of treatment and frequency of side-effects. There was an overall reduction in the use of opioids, gabapentinoids or benzodiazepines in 59% of patients with 39% having a complete cessation of an analgesic agent. Side-effects were reported in 24%, but only 7% discontinued the treatment due to the side-effect (drowsiness). There were no reports of renal impairment, cystitis or hepatotoxicity. DISCUSSION: This retrospective case-series has demonstrated that sublingual ketamine is a safe and effective analgesic agent to use in chronic non-malignant pain management. It is indicated in a variety of chronic pain conditions and has an excellent safety profile, with no association between the frequency in side-effects and duration of therapy or total daily dosages. The study has also shown that the 'safe' dose may be higher than the previous consensus.

The application of telehealth to remote and rural Australians with chronic neurological conditions.

BACKGROUND: Patients with chronic disease in rural and remote regions endure limited access to specialised medicine. Telehealth has addressed this issue with demonstrable benefits such as a reduction in costs to patients. AIMS: To explore the patient satisfaction of telehealth in Australia. METHODS: Patients from all around Australia, including Queensland, Victoria, Tasmania, South Australia, Australian Capital Territory and even Western Australia were referred to a Sydney-based neurologist. After their initial face to face consultation, review consultations were performed by telehealth. All had chronic diseases (trigeminal neuralgia, facial pain or Parkinson disease) and received a standardised questionnaire comprising of demographics, satisfaction of technical aspects and quality of the consultation. The questionnaires were administered by the Practice Manager to remove observer bias. RESULTS: Twenty-nine patient questionnaires were completed by 13 patients who had follow-up telehealth consultations. One hundred per cent of patients reported satisfaction with the overall telehealth experience and would use it again. All were satisfied with the specialist and the privacy. The majority were satisfied with the voice quality (86%), visual quality (79%), ease of connectivity (93%) and length of the consultation (97%). In total, they saved nearly $17 000 in travel costs and on average, each patient avoided 937 km and saved $550. CONCLUSION: Telehealth has proven to have multiple advantages, including improved access to healthcare, decreased costs, reduced inconvenience and improved management of chronic and complex conditions. The positive results advocate the use of telehealth for follow up of rural and remote patients with chronic disease.

Adherence to country-specific guidelines among economic evaluations undertaken in three high-income and middle-income countries: a systematic review.

OBJECTIVE: To assess the adherence of economic evaluations to the recommendations on principles of economic evaluation as stated in the country-specific guidelines for three countries across different income groups, namely, Canada, South Africa, and Egypt. METHODS: Searches were undertaken in three databases to identify economic evaluations meeting predefined inclusion criteria. Methodological and reporting standards listed in the country-specific guidelines were converted into discrete binary variables to calculate mean adherence scores. Quality appraisal was done using Drummond's checklist. Stratified analysis was undertaken to identify independent variables affecting adherence. RESULTS: We identified forty-four, seventy-nine, and sixteen economic evaluations for Canada, South Africa, and Egypt, respectively. The mean adherence score was the highest for Canada (71%), followed by South Africa (65%) and Egypt (60%). Adherence to guidelines was positively correlated with quality of studies, r = .72. Furthermore, the mean adherence score was significantly (p < .05) higher for studies using a cost-utility analysis design (72%), having local/national funding aid (72%), undertaken by a health economist (71%) and for pharmacoeconomic evaluations (70%). CONCLUSION: The quality of economic evaluations improves with adherence to country-specific guidelines. Locally funded and health-economist led health technology assessments (HTAs) should be encouraged for greater adherence to the guidelines. The HTA researchers and the HTA bodies should lay emphasis on adherence to the country-specific guidelines for improving the quality of HTA evidence.

Impact of online classes on the satisfaction and performance of students during the pandemic period of COVID 19.

The aim of the study is to identify the factors affecting students' satisfaction and performance regarding online classes during the pandemic period of COVID-19 and to establish the relationship between these variables. The study is quantitative in nature, and the data were collected from 544 respondents through online survey who were studying the business management (B.B.A or M.B.A) or hotel management courses in Indian universities. Structural equation modeling was used to analyze the proposed hypotheses. The results show that four independent factors used in the study viz. quality of instructor, course design, prompt feedback, and expectation of students positively impact students' satisfaction and further student's satisfaction positively impact students' performance. For educational management, these four factors are essential to have a high level of satisfaction and performance for online courses. This study is being conducted during the epidemic period of COVID- 19 to check the effect of online teaching on students' performance.

Ketamine as a potential option in the treatment of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing.

A number of treatment options have been used over the years in short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) with variable results. The most common preventive treatments include carbamazepine, lamotrigine, indomethacin, gabapentin and topiramate. Ketamine is being increasingly used in the treatment of neuropathic pain. The parentral formulations are generally used as oral preparations have poor bioavailability. Recently, ketamine lozenges have been shown to have sufficiently high bioavailability to support their use as a preventive treatment in a number of conditions causing intractable neuropathic pain. We report a 58-year-old man whose symptoms of SUNCT were not responsive to conventional preventive treatments but responded well to a subcutaneous, sub-anaesthetic ketamine infusion and subsequently, sublingual ketamine lozenges.

Comprehensive measurement of health system performance at district level in India: Generation of a composite index.

There have been limited attempts at measurement of health system performance at decentralized levels in low- and middle-income countries. This study was undertaken to develop a composite indicator to measure health system performance at district level in India. Primary data were collected from 377 public health facilities in 21 districts of Haryana state in India using health facility surveys. In addition, 1700 health care providers and 800 clients visiting health facilities were interviewed. Routine health management information system data at district and state level were also analyzed. These data were used for computing 67 input and process indicators covering six health system building blocks. Indicators were normalized and aggregated to generate domain-specific and overall composite health system performance index (HSPI) for each district. Several sensitivity analyses were performed to assess robustness of results. Overall, Panchkula and Ambala districts were found to be the best performing in the state (with HSPI scores of 0.64 and 0.62 out of 1), while Mewat, Faridabad, and Palwal districts had the poorest performance (with HSPI scores of 0.46, 0.49, and 0.48 out of 1). Significant variation in performance was observed for each health system building block. Sensitivity analyses results showed that study findings were robust to variations in methods of aggregation of indicators. Our study provides a framework and methods to measure health system performance at district level in a comprehensive manner. The composite indicator provides a summary snapshot to benchmark performance, while building block and domain scores provide critical information for programmatic action.

Out-of-pocket expenditure for health care: District level estimates for Haryana state in India.

INTRODUCTION: In this paper, we present district level out-of-pocket (OOP) expenditures with respect to outpatient consultation within last 15 days and hospitalization in last 1 year for Haryana state. METHODS: The data from a large cross-sectional household survey covering all 21 districts of Haryana comprising of randomly selected 79 742 households were analyzed. Of the total sample, 56 056 households consisting of 314 639 individuals in 21 districts of Haryana state were surveyed to gather information on OOP expenditure incurred on outpatient consultation within last 15 days. Similarly, 59 901 households and 324 977 respondents were interviewed to elicit OOP expenditures for any hospitalization during the 1 year preceding the survey. Mean OOP expenditure per OP consultation, per hospitalization as well as per capita were computed. Mean OOP expenditure was also estimated by the type of provider, gender, and district. RESULTS: The mean OOP expenditure for OP consultation and hospitalization in Haryana was Indian National Rupees (INR) 1005 (US Dollar [USD] 16.1; 95% CI: INR 934-1076) and INR 22 489 (USD 360.0; 95% CI: INR 21 375-23 608), respectively. Mean per capita OOP expenditure for OP consultation, which was INR 85 (USD 1.3) in Haryana, varied from INR 595 (USD 9.5) in district Panipat to INR 29 (USD 0.5) in district Kaithal. CONCLUSION: This is the first study to comprehensively present district level estimates for OOP expenditure for health care. These estimates are useful for policy planning, and preparation for district and state health accounts.

Out-of-pocket expenditure for hospitalization in Haryana State of India: Extent, determinants & financial risk protection.

BACKGROUND & OBJECTIVES: India aspires to achieve universal health coverage, which requires ensuring financial risk protection (FRP). This study was done to assess the extent of out-of-pocket (OOP) expenditure and FRP for hospitalization in Haryana State, India. Further, the determinants for FRP were also evaluated. METHODS: Data collected as a part of a household level survey conducted in Haryana 'Concurrent Evaluation of National Rural Health Mission: Haryana Health Survey' were analyzed. Descriptive analysis was undertaken to assess socio-demographic characteristics, hospitalization rate, extent and determinants of OOP expenditure and FRP. Prevalence of catastrophic health expenditure (CHE) (more than 40% of non-food expenditure) and impoverishment (Int$ 1.25) were estimated. Multivariate logistic regression was used to assess determinants of FRP. RESULTS: Hospitalization rate was found to be 3106 persons or 3307 episodes per 100,000 population. Median OOP expenditure on hospitalization was ₹ 8000 (USD 133), which was predominantly attributed to medicines (37%). Prevalence of CHE was 25.2 per cent with higher prevalence amongst males [odds ratio (OR)=1.30], those belonging to scheduled caste and scheduled tribes (OR=1.35), poorest 20 per cent households (OR=3.05), having injuries (OR=4.03) and non-communicable diseases (OR=3.13) admitted in a private hospital (OR=2.69) and those who were insured (OR=1.74). There was a 12 per cent relative increase in poverty head count due to OOP payments on healthcare. INTERPRETATION & CONCLUSIONS: Our findings showed that hospitalization resulted in significant OOP expenditure, leading to CHEs and impoverishment of households. Impact of OOP expenditures was inequitably more on the vulnerable groups. OOP expenditure may be curtailed through provision of free medicines and diagnostics and removal of any form of user charges.

Cost analysis of a simulation-based training for health workforce in India.

BACKGROUND: Training of health-care workforce including doctors, staff nurses, and Auxiliary Nurse Midwives using simulation techniques for skill enhancement have been used in a variety of clinical settings to improve the quality of training. India adopted the skills laboratories model for capacity building of health workers in maternal and child health in Bihar state. OBJECTIVE: Current economic evaluation was performed with the objective of assessing the financial and economic cost of implementing skills laboratories. METHODS: Data on all resources spent for the development of skill laboratory and implementing training during financial year 2011 were collected from Patna district in Bihar state. We used standard methods to estimate the full financial and economic costs of implementing the skills laboratories from a health system perspective. RESULTS: Overall cost of implementing 20 permanent and 10 mobile skills laboratory training in Bihar was Indian Rupee (INR) 8849895 from a financial perspective. The cost was nearly two times higher when using an economic perspective to account for opportunity cost of all resources used. The unit cost of training a participant using permanent and mobile laboratory was INR 6856 and INR 7474, respectively assuming an annual volume of 90 training. The optimum number of training which should be operated annually in a skills laboratory to make it most efficient is about 70-80 training per annum. CONCLUSIONS: Economic implications of skills laboratory organization should be borne while planning scale up in Bihar and other states. Further research on the effectiveness of two models of skill laboratory, that is, permanent and mobile and their cost is recommended.

Constipation and Outcomes of Cecostomy.

Constipation, defined as delay or difficulty in defecation, present for 2 or more weeks, is a common problem encountered by both primary and specialty medical providers. There are no randomized controlled trials on the use of antegrade enemas in the pediatric population. Most published papers are based on the experience at a particular center. The aim of this article is to describe the pathophysiology of constipation, review the contribution of colonic manometry to the diagnosis of constipation, summarize the advancements in the management of constipation through the use of antegrade enemas, and study the outcomes of cecostomy at different centers. This study is a comprehensive literature review generated by computerized search of literature, supplemented by review of monographs and textbooks in pathology, gastroenterology, and surgery. Literature search was performed using the publications from 1997 to 2012. The search included publications of all types presenting or reviewing data on cecostomy. The antegrade continence enema is a therapeutic option for defecation disorders when maximal conventional therapy is not successful. Symptoms of defecation disorders in children with different underlying etiologies improve significantly after a cecostomy is created. In addition, there is a benefit on the patients' physical activity, healthcare utilization, and general well-being. Based on the review of published literature it seems that antegrade enemas are a successful therapeutic option in children with severe constipation and/or fecal incontinence. With the advent of cecostomy buttons, patient compliance and the overall cosmetic appearance have improved.

The management of eosinophilic gastroenteritis.

Eosinophilic gastroenteritis (EG) is a rare disorder characterized by eosinophilic infiltration of the gastrointestinal tract. No medication at present is approved by the Food and drug administration of United States for the treatment of EG. The rarity of the disease limits our experience with the different management options. It also limits the ability to conduct randomized controlled trials that could clearly delineate the efficacy of new therapeutic agents. This review assesses the various management options that have been tried on patients with EG.

Impact of referral transport system on institutional deliveries in Haryana, India.

BACKGROUND & OBJECTIVES: Creation of a strong referral transport network across the country is necessary for improving physical access to public sector health facilities. In this study we evaluated the referral transport services in Haryana, i.e. Haryana Swasthya Vaahan Sewa (HSVS), now known as National Ambulance Service (NAS), to assess the extent and pattern of utilization, and to ascertain its effect on public sector institutional deliveries. METHODS: Secondary data on 116,562 patients transported during April to July 2011 in Haryana state were analysed to assess extent and pattern of NAS utilization. Exit interviews were conducted with 270 consecutively selected users and non- users of referral services respectively in Ambala (High NAS utilization), Hisar (medium utilization) and Narnaul (low utilization) districts. Month-wise data on institutional deliveries in public facilities during 2005-2012 were collected in these three districts, and analysed using interrupted time series analysis to assess the impact of NAS on institutional deliveries. RESULTS: Female gender (OR=77.7), rural place of residence (OR=5.96) and poor socio-economic status (poorest wealth quintile OR=2.64) were significantly associated with NAS ambulance service usage. Institutional deliveries in Haryana rose significantly after the introduction of NAS service in Ambala (OR=137.4, 95% CI=22.4-252.4) and Hisar (OR=215, 95% CI=88.5-341.3) districts. No significant increase was observed in Narnaul (OR=4.5, 95% CI=-137.4 to 146.4) district. INTERPRETATION & CONCLUSIONS: The findings of the present study showed a positive effect of referral transport service on increasing institutional deliveries. However, this needs to be backed up with adequate supply of basic and emergency obstetric care at hospitals and health centres.

Comparison of indirect cyanmethaemoglobin method and TrueHb haemometer point of care test with direct cyanmethaemoglobin (gold standard) method for strengthening anaemia detection at primary health care level.

Introduction: The most reliable indicator for anaemia diagnosis at the population level is haemoglobin (Hb) estimation. The direct cyanmethaemoglobin method is considered the gold standard method for haemoglobin estimation. However, for resource constraint areas like primary health care (PHC) level, either blood samples are transported on filter paper for Hb testing (indirect cyanmethaemoglobin method) in laboratory or point of care testing is commonly used. Therefore, a comparative analysis of haemoglobin estimation of direct with indirect cyanmethaemoglobin method and also with TrueHb (Wrig Nanosystems Pvt. Ltd.) haemometer was done to strengthen anaemia diagnosis at the PHC level. Materials and Methods: This was a cross-sectional study. A total of 90 participants above 9 years of age, who visited the outpatient department (OPD) of health centre, Kheri and gave consent were included. Comparative analysis was done between Hb concentration assessed by indirect cyanmethaemoglobin method and TrueHb haemometer device against the gold standard method. Results: The mean Hb value estimated by direct method, TrueHb haemometer and indirect methods (filter paper A, B and C) was 11.42 ± 1.59 g/dl, 11.52 ± 1.54 g/dl, 10.66 ± 1.52 g/dl, 9.84 ± 1.50 g/dl and 10.19 ± 1.62 g/dl, respectively. There was no significant difference found between the mean Hb concentration estimated by the direct method and the TrueHb haemometer device. However, there was a significant difference in mean Hb values between the direct method and the indirect method. Therefore, regression analysis was done to estimate the correction factor for the indirect method. Conclusion: TrueHb metre device gave promising results in comparison to the gold standard method and can be used if resource permits in PHC centres. Indirect methods of haemoglobin estimation can be an alternative in resource-constraint settings, specifically for surveys. However, further studies are required for the validation of the indirect method.

Prevalence and sociodemographic determinants of common mental disorders (CMDs) symptoms in a rural adult population of Haryana, North India.

Objectives: Common mental disorders (CMDs), including depression, anxiety, and somatoform disorders, affect all stages of life and impact individuals, families, and communities. This study aimed to determine the magnitude of CMDs and their sociodemographic determinants in the adult population of a rural block in North India. Material and Methods: A cross-sectional, quantitative, community-based study was conducted among adult residents of a rural block in Haryana, North India, using a multistage random sampling technique. The Hindi version of the General Health Questionnaire (GHQ-12), a well-validated tool, was used to screen participants for CMDs. Scores of 4 or above denoted the presence of CMDs. Bivariate analyses were performed to determine the associations between CMDs and sociodemographic characteristics. Results: Of the 180 residents selected for the study, most were women (60.0%) and aged between 31 and 50 years (52.3%). The prevalence of CMDs symptoms in the study population was 20.0%. The presence of CMDs symptoms was significantly higher among those who were aged 60 years or older [OR=12.33, 95% CI 3.21-47.38], widowed, divorced or separated [OR=7.50, 95% CI 1.09-51.52], illiterate [OR= 6.25, 95% CI 2.84-13.77], had monthly family income below 10,000 INR [OR=3.33, 95% CI 1.54-7.20], had any chronic physical illness [OR=8.28, 95% CI 3.70-18.56] and had a family history of any psychiatric illness [OR=5.56, 95% CI 1.52-19.42]. Conclusion: The burden of CMDs was quite high among adults in rural North India. The presence of CMDs was closely associated with sociodemographic characteristics. Primary care and community-based settings need to screen for, diagnose, and manage CMDs to address this growing problem.

Association of Child Growth Failure Indicators With Household Sanitation Practices in India (1998-2021): Spatiotemporal Observational Study.

BACKGROUND: Undernutrition among children younger than 5 years is a subtle indicator of a country's health and economic status. Despite substantial macroeconomic progress in India, undernutrition remains a significant burden with geographical variations, compounded by poor access to water, sanitation, and hygiene services. OBJECTIVE: This study aimed to explore the spatial trends of child growth failure (CGF) indicators and their association with household sanitation practices in India. METHODS: We used data from the Indian Demographic and Health Surveys spanning 1998-2021. District-level CGF indicators (stunting, wasting, and underweight) were cross-referenced with sanitation and sociodemographic characteristics. Global Moran I and Local Indicator of Spatial Association were used to detect spatial clustering of the indicators. Spatial regression models were used to evaluate the significant determinants of CGF indicators. RESULTS: Our study showed a decreasing trend in stunting (44.9%-38.4%) and underweight (46.7%-35.7%) but an increasing prevalence of wasting (15.7%-21.0%) over 15 years. The positive values of Moran I between 1998 and 2021 indicate the presence of spatial autocorrelation. Geographic clustering was consistently observed in the states of Madhya Pradesh, Jharkhand, Odisha, Uttar Pradesh, Chhattisgarh, West Bengal, Rajasthan, Bihar, and Gujarat. Improved sanitation facilities, a higher wealth index, and advanced maternal education status showed a significant association in reducing stunting. Relative risk maps identified hotspots of CGF health outcomes, which could be targeted for future interventions. CONCLUSIONS: Despite numerous policies and programs, malnutrition remains a concern. Its multifaceted causes demand coordinated and sustained interventions that go above and beyond the usual. Identifying hotspot locations will aid in developing control methods for achieving objectives in target areas.

A digital health intervention to support patients with chronic pain during prescription opioid tapering: a pilot randomised controlled trial.

Introduction: Recent changes in opioid prescribing guidelines have led to an increasing number of patients with chronic pain being recommended to taper. However, opioid tapering can be challenging, and many patients require support. Objectives: We evaluated the feasibility, acceptability, and potential efficacy of a codesigned digital health intervention to support patients with chronic pain during voluntary prescription opioid tapering. Methods: In a pilot randomised controlled trial, participants received a psychoeducational video and 28 days of text messages (2 SMS/day) in addition to their usual care (intervention) or usual care alone (control). The feasibility, acceptability, and potential efficacy of the intervention were evaluated. The primary outcome was opioid tapering self-efficacy. Secondary outcomes were pain intensity and interference, anxiety and depression symptom severity, pain catastrophising, and pain self-efficacy. Results: Of 28 randomised participants, 26 completed the study (13 per group). Text message delivery was high (99.2%), but fidelity of video delivery was low (57.1%). Most participants rated the messages as useful, supportive, encouraging, and engaging; 78.5% would recommend the intervention to others; and 64.2% desired a longer intervention period. Tapering self-efficacy (Cohen d = 0.74) and pain self-efficacy (d = 0.41) were higher, and pain intensity (d = 0.65) and affective interference (d = 0.45) were lower in the intervention group at week 4. Conclusion: First evidence supports the feasibility, acceptability, and potentially efficacy of a psychoeducational video and SMS text messaging intervention to support patients with chronic pain during voluntary prescription opioid tapering. Definitive trials with longer intervention duration are warranted.

Normative data for insulin-like growth factor-1 (IGF-1) in healthy children and adolescents from India.

BACKGROUND: Serum IGF-1 is an important biochemical tool to diagnose and monitor GH-related disorders. However, ethnic-specific Indian data following consensus criteria for the establishment of normative data, are not available. Our objective was to generate chronological age (CA)-, bone age (BA)- and Tanner stage-specific normative data for IGF-1 in healthy Indian children and adolescents. METHODS: A cross-sectional epidemiological study was conducted in schools and the community, which enrolled apparently healthy children and adolescents with robust exclusion criteria. The outcome measure was serum IGF-1 assessed using an electro-chemiluminescence immunoassay (ECLIA). The 2.5th, 5th, 10th, 25th, 50th (median), 75th, 90th, 95th, and 97.5th centiles for IGF-1 were estimated using generalized additive models. RESULTS: We recruited 2226 apparently healthy participants and following exclusion, 1948 (1006 boys, 942 girls) were included in the final analysis. Girls had median IGF-1 peak at CA of 13 years (321.7 ng/mL), BA of 14 years (350.2 ng/mL) and Tanner stage IV (345 ng/mL), while boys had median IGF-1 peak at CA of 15 years (318.9 ng/mL) BA of 15 years (340.6 ng/mL) and Tanner stage III (304.8 ng/mL). Girls had earlier rise, peak and higher IGF-1 values. The reference interval (2.5th-97.5th percentile) was broader during peri-pubertal ages, indicating a higher physiological variability. CONCLUSION: This study provides ethnicity-specific normative data on serum IGF-1 and will improve the diagnostic utility of IGF-1 in the evaluation and management of growth disorders in Indian children and adolescents.