Mobile and Computer-Based Applications for Rehabilitation Monitoring and Self-Management After Knee Arthroplasty: Scoping Review

BACKGROUND

Successful post-knee replacement rehabilitation requires adequate access to health information, social support, and periodic monitoring by a health professional. Mobile health (mHealth) and computer-based technologies are used for rehabilitation and remote monitoring. The extent of technology use and its function in post-knee replacement rehabilitation care in low and middle-income settings are unknown.

OBJECTIVE

To inform future mHealth intervention development, we conducted a scoping review to map the features and functionality of existing technologies and determine users' perspectives on telerehabilitation and technology for self-management.

METHODS

We followed the Joanna Briggs Institute methodology for scoping reviews. We searched the Embase, Medline, PsycINFO via OVID, and Cochrane Central Register of Controlled Trials databases for manuscripts published from 2001 onward. We included original research articles reporting the use of mobile or computer-based technologies by patients, health care providers, researchers, or family members. Studies were divided into the following 3 categories based on the purpose: validation studies, clinical evaluation, and end user feedback. We extracted general information on study design, technology features, proposed function, and perspectives of health care providers and patients. The protocol for this review is accessible in the Open Science Framework.

RESULTS

Of the 5960 articles, 158 that reported from high-income settings contributed to the qualitative summary (64 studies on mHealth or telerehabilitation programs, 28 validation studies, 38 studies describing users' perceptions). The highest numbers of studies were from Europe or the United Kingdom and North America regarding the use of a mobile app with or without wearables and reported mainly in the last decade. No studies were from low and middle-income settings. The primary functions of technology for remote rehabilitation were education to aid recovery and enable regular, appropriate exercises; monitoring progress of pain (n=19), activity (n=20), and exercise adherence (n=30); 1 or 2-way communication with health care professionals to facilitate the continuum of care (n=51); and goal setting (n=23). Assessment of range of motion (n=16) and gait analysis (n=10) were the commonly validated technologies developed to incorporate into a future rehabilitation program. Few studies (n=14) reported end user involvement during the development stage. We summarized the reasons for satisfaction and dissatisfaction among users across various technologies.

CONCLUSIONS

Several existing mobile and computer-based technologies facilitate post-knee replacement rehabilitation care for patients and health care providers. However, they are limited to high-income settings and may not be extrapolated to low-income settings. A systematic needs assessment of patients undergoing knee replacement and health care providers involved in rehabilitation, involving end users at all stages of development and evaluation, with clear reporting of the development and clinical evaluation can make post-knee replacement rehabilitation care in resource-poor settings accessible and cost-effective.

Frailty among middle-aged and older women and men in India: findings from wave 1 of the longitudinal Ageing study in India

OBJECTIVES

Few studies have examined frailty in Indian adults, despite an increasing population of older adults and an escalating burden of chronic diseases. We aimed to study the prevalence and correlates of frailty in middle-aged and older Indian adults.

SETTING

Cross-sectional data from Wave 1 of Longitudinal Ageing Study in India, conducted in 2017-2018 across all states and union territories, were used.

PARTICIPANTS

The final analytical sample included 57 649 participants aged 45 years and above who had information on frailty status.

PRIMARY OUTCOME MEASURE

The deficits accumulation approach to measuring frailty was employed, creating a frailty index between 0 and 1, based on 40 deficits. Individuals with a frailty index of 0.25 or more were defined as 'frail'.

RESULTS

Prevalence of frailty among 45+ adults was 30%. 60+ women were two times as likely to be frail compared with 60+ men, after adjusting for a wide range of sociodemographic, economic and lifestyle factors. The sex difference was more pronounced in adults aged 45-59 years. Odds of hospitalisation in the last 12 months, and having falls in the past 2 years, were two times as high in frail adults compared with non-frail adults. Frail middle-aged and older adults had 33% and 39% higher odds, respectively, of having poor cognition than non-frail adults. The relative increase was higher in women for all three outcomes, although not statistically significant.

CONCLUSIONS

There needs to be careful consideration of sex differences when addressing frailty, particularly for optimising frailty interventions. Frailty, although typically assessed in older adults, was shown in this study to be also prevalent and associated with adverse outcomes in middle-aged Indian adults. More research into assessment of frailty in younger populations, its trajectory and correlates may help develop public health measures for prevention of frailty.

Lung Function and Respiratory Morbidity Among Informal Workers Exposed to Cement Dust: A Comparative Cross-Sectional Study

Background

Cement dust is a significant source of occupational exposure affecting lung function and respiratory health. A higher burden of respiratory morbidity is known among factory workers involved in cement production. Globally or from India, there are no estimates of this burden from informal workers exposed to cement dust.

Objective

To assess difference in lung function and respiratory symptoms among informal workers exposed to cement and those unexposed, using a comparative community based cross-sectional study from purposively selected areas in Delhi, India.

Methods

Using a portable spirometer we measured lung function and collected respiratory symptoms from conveniently sampled informal workers (n = 100) exposed to cement dust, 50 indoor informal workers (tailors), and 50 outdoor (vegetable) vendors. Regression analyses were performed to compare respiratory symptom score and lung function parameters, adjusted for age, body mass index, smoking, socioeconomic status, and years of occupational exposure.

Findings

Exposed workers had significantly lower lung function (PEF = -750 ml/s and -810 ml/s and FEV1/FVC (%) = -3.87 and -2.11) compared to indoor and outdoor groups, with three times higher chronic respiratory symptoms when compared to the unexposed groups. The cement dust exposure was observed to be associated with PEF (mean difference (MD) = -0.75L, 95%CI = -1.36 to -0.15, p = 0.01), %FEV1/FVC (MD = -3.87, 95%CI = -6.77 to -0.96, p = 0.03) and respiratory symptoms (p < 0.001).

Conclusion

This study generates evidence regarding the respiratory burden of occupational exposure among vulnerable informal workers. There is an urgent need for policy reforms to safeguard health from occupational exposures, especially among informal workers.

Ischemia-guided vs routine non-culprit vessel angioplasty for patients with ST segment elevation myocardial infarction and multi-vessel disease: the IAEA SPECT STEMI trial

BACKGROUND

In patients with multi-vessel disease presenting with ST elevation myocardial infarction (STEMI), the efficacy and safety of ischemia-guided, vs routine non-culprit vessel angioplasty has not been adequately studied.

METHODS

We conducted an international, randomized, non-inferiority trial comparing ischemia-guided non-culprit vessel angioplasty to routine non-culprit vessel angioplasty, following primary PCI for STEMI. The primary outcome was the between-group difference in percent ischemic myocardium at follow-up stress MPI. All MPI images were processed and analyzed at a central core lab, blinded to treatment allocation.

RESULTS

In all, 109 patients were enrolled from nine countries. In the ischemia-guided arm, 25/48 (47%) patients underwent non-culprit vessel PCI following stress MPI. In the routine non-culprit PCI arm, 43/56 (77%) patients underwent angioplasty (86% within 6 weeks of randomization). The median percentage of ischemic myocardium on follow-up imaging (mean 16.5 months) was low, and identical (2.9%) in both arms (difference 0.13%, 95%CI - 1.3%-1.6%, P < .0001; non-inferiority margin 5%).

CONCLUSION

A strategy of ischemia-guided non-culprit PCI resulted in low ischemia burden, and was non-inferior to a strategy of routine non-culprit vessel PCI in reducing ischemia burden. Selective non-culprit PCI following STEMI offers the potential for cost-savings, and may be particularly relevant to low-resource settings. (CTRI/2018/08/015384).

An extension MID credibility item addressing construct proximity is a reliable alternative to correlation item

OBJECTIVE

To extend the anchor-based minimal important differences (MIDs) credibility instrument by adding an item addressing construct proximity as the alternative to the correlation item.

STUDY DESIGN AND SETTING

The credibility instrument includes one core items addressing the correlation between the patient-reported outcome measure (PROM) and the anchor. However, the majority of MID studies in the literature fail to report the correlation. As an alternative item, we added a subjective assessment of similarity of the constructs (i.e., construct proximity) between the PROM and anchor and generated principles for the assessment. We sampled 101 MIDs and analyzed the assessments performed by each pair of raters. By calculating weighted Cohen's kappa, we assessed the reliability of the assessments.

RESULTS

Construct proximity assessment is based on the anticipated association between the anchor and PROM constructs: the closer the anticipated association, the higher the rating. Our detailed principles address the most frequently used anchors: transition ratings, measures of satisfaction, other PROMs, and clinical measures. The assessments showed acceptable agreement (weighted kappa 0.74, 95% CI 0.55 to 0.94) between raters.

CONCLUSION

In the absence of a reported correlation coefficient, construct proximity assessment provides a useful alternative in the credibility assessment of anchor-based MID estimates.

321 Cancer risk with topical pimecrolimus and tacrolimus for atopic dermatitis: systematic review and Bayesian meta-analysis

Atopic dermatitis affects millions worldwide and is effectively managed by topical treatments, including topical calcineurin inhibitors, pimecrolimus and tacrolimus. In 2005 and 2011, the FDA released reviews associating topical calcineurin inhibitors with a theoretical cancer risk, albeit an uncertain association. We systematically reviewed the risk of cancer in patients with atopic dermatitis exposed to topical calcineurin inhibitors. We systematically identified randomized controlled trials, comparative, and non-comparative non-randomized studies from database inception to 6 June 2022, from MEDLINE, EMBASE, GREAT, LILACS, ICTRP, FDA, EMA, company registers and relevant citations. We included studies in any language addressing the risk of cancer in patients with atopic dermatitis exposed to topical calcineurin inhibitors for greater than 3 weeks. We excluded split-body studies. We conducted a Bayesian meta-analysis and used the GRADE approach to determine the certainty of the evidence. A multidisciplinary panel including patients, advocacy groups and care providers, set an a priori threshold of 1 in 1000 risk difference as a clinically important effect. We analysed 121 studies (52 randomized controlled trials and 69 non-randomized studies) including 3.4 million patents followed for a mean of 11 months (range: 0.7–120). The absolute risk of any cancer with topical calcineurin inhibitor exposure was neither different from controls (absolute risk 4.70 per 1000 with topical calcineurin inhibitor exposure vs. 4.56 per 1000 without; odds ratio 1.03 [95% credible interval 0.94–1.11], moderate-certainty evidence) nor the general US population (4.6 per 1000). Findings were similar in infants, children, and adults, and were robust to trial sequential, subgroup and sensitivity analyses. Among infants, children and adults with atopic dermatitis, moderate-certainty evidence shows that topical calcineurin inhibitors do not increase the risk of cancer. These findings support the safe use of topical calcineurin inhibitors in the management of patients with atopic dermatitis. Our findings provide actional information to inform updated clinical practice guidelines, product labels and continuing education for care providers, to clarify the safe usage of topical calcineurin inhibitors.

Cancer risk with topical calcineurin inhibitors, pimecrolimus and tacrolimus, for atopic dermatitis: a systematic review and meta-analysis

BACKGROUND

Atopic dermatitis is a prevalent condition in children and can be effectively managed with medications such as topical calcineurin inhibitors (pimecrolimus or tacrolimus). A key unresolved safety concern is whether use of topical calcineurin inhibitors is associated with cancer. We systematically reviewed the risk of cancer in patients with atopic dermatitis exposed to topical calcineurin inhibitors.

METHODS

As part of the 2022 American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters atopic dermatitis guidelines, we searched MEDLINE, Embase, the Latin American and Caribbean Health Sciences Literature database, the Índice Bibliográfico Espanhol de Ciências da Saúde database, the Global Resource of Eczema Trials database, WHO's International Clinical Trials Registry Platform, the US Food and Drug Administration database, the European Medicines Agency database, company registers, and relevant citations from inception to June 6, 2022. We included randomised controlled trials and comparative and non-comparative non-randomised studies in any language addressing cancer risk in patients with atopic dermatitis using topical calcineurin inhibitors. We excluded split-body studies and studies with less than 3 weeks of follow-up. Paired reviewers independently screened records, extracted data, and assessed risk of bias in duplicate. We used Bayesian models to estimate the probability for cancer due to topical calcineurin inhibitor exposure and the GRADE approach to determine the certainty of the evidence. Patients, advocacy groups, and care providers set a priori thresholds of important effects. This study is registered with Open Science Framework, https://osf.io/v4bfc.

FINDINGS

We identified and analysed 110 unique studies (52 randomised controlled trials and 69 non-randomised studies [11 were non-randomised study extensions of randomised controlled trials]) including 3·4 million patients followed up for a mean of 11 months (range 0·7-120). The absolute risk of any cancer with topical calcineurin inhibitor exposure was not different from controls (absolute risk 4·70 per 1000 with topical calcineurin inhibitors vs 4·56 per 1000 without; odds ratio 1·03 [95% credible interval 0·94-1·11]; moderate certainty). For all age groups and using data from observational studies and randomised controlled trials, the use of pimecrolimus (OR 1·05 [95% credible interval 0·94-1·15]) or tacrolimus (0·99 [0·89-1·09]) is likely to have had little to no association with cancer compared with no topical calcineurin inhibitor exposure. For pimecrolimus versus tacrolimus, the finding was similar (0·95 [95% credible interval 0·83-1·07]). Findings were similar in infants, children, and adults, and robust to trial sequential, subgroup, and sensitivity analyses.

INTERPRETATION

Among individuals with atopic dermatitis, moderate-certainty evidence shows that topical calcineurin inhibitors do not increase the risk of cancer. These findings support the safe use of topical calcineurin inhibitors in the optimal treatment of patients with atopic dermatitis.

FUNDING

American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology via the Joint Task Force on Practice Parameters.

Serious reporting deficiencies exist in minimal important difference studies: Current state and suggestions for improvement

OBJECTIVE

To evaluate reporting of minimal important difference (MID) estimates using anchor-based methods for patient-reported outcome measures (PROMs), and the association with reporting deficiencies on their credibility.

STUDY DESIGN AND SETTING

Systematic survey of primary studies empirically estimating MIDs. We searched Medline, EMBASE, PsycINFO, and the Patient-Reported Outcome and Quality of Life Instruments Database until October 2018. We evaluated study reporting, focusing on participants' demographics, intervention(s), characteristics of PROMs and anchors, and MID estimation method(s). We assessed the impact of reporting issues on credibility of MID estimates.

RESULTS

In 585 studies reporting on 5,324 MID estimates for 526 distinct PROMs, authors frequently failed to adequately report key characteristics of PROMs and MIDs, including minimum and maximum values of PROM scale, measure of variability accompanying the MID estimate and number of participants included in the MID calculation. Across MID estimates (n=5,324), the most serious reporting issues impacting credibility included infrequent reporting of the correlation between the anchor and PROM (66%), inadequate details to judge precision of MID point estimate (13%), and insufficient information about the threshold used to ascertain MIDs (16%).

CONCLUSION

Serious issues of incomplete reporting in the MID literature threaten the optimal use of MID estimates to inform the magnitude of effects of interventions on PROMs.

Coronary Computed Tomography Angiography Analysis of Calcium Content to Identify Non-culprit Vulnerable Plaques in Patients With Acute Coronary Syndrome

Background

Aside from the culprit plaque, the presence of vulnerable plaques in patients with acute coronary syndrome (ACS) may be associated with future cardiac events. A link between calcification and plaque rupture has been previously described.

Aim

To assess whether analysis of the calcium component of coronary plaques using CT angiography, coronary computed tomographic angiography (CCTA) can help to detect additional vulnerable plaques in patients with non-ST elevation myocardial infarction (NSTEMI).

Materials And Methods

Cross sectional study of consecutive patients referred for NSTEMI from 30 July to 30 August 2018 with CCTA performed before coronary angiography with systematic optical coherence tomography (OCT) analysis of all coronary arteries within 24 h of clinical onset of NSTEMI. Three types of plaques were defined: culprit plaques defined by angiography (vulnerable culprit plaques–VCP) – plaques with a fibrous cap thickness < 65 microns or thrombus in OCT (vulnerable non-culprit plaque–VNCP) – plaques with a fibrous cap thickness ≥ 65 microns in OCT (stable plaque–SP).

Results

A total of 134 calcified plaques were identified in 29 patients (73% male, 59 ± 14 years) with 29(22%) VCP, 28(21%) VNCP and 77(57%) SP. Using CCTA analysis of the calcium component, factors associated with vulnerable plaques were longer calcification length, larger calcification volume, lower calcium mass, higher Agatston score plaque-specific (ASp), presence of spotty calcifications and an intimal position in the wall. In multivariate analysis, ASp, calcification length and spotty calcifications were independently associated to vulnerable plaques. There was no difference between VCP and VNCP.

Conclusions

CCTA analysis of calcium component of the plaque could help to identify additional vulnerable plaques in NSTEMI patients.

Childhood Head Growth and Educational Attainment in an Indian Cohort

BACKGROUND

There is minimal information about the association of head growth at different stages of childhood with cognitive ability.

OBJECTIVE

To determine the relationship of newborn head size and head growth during infancy, childhood and adolescence with attained education, a proxy for cognitive ability.

STUDY DESIGN

Prospective birth cohort study.

SETTING

Married women living in South Delhi between 1969 and 1973.

PARTICIPANTS

The New Delhi Birth Cohort study followed up 8030 newborns born in 1969-1973 with head circumference, weight and height measurements at birth and 6-12 monthly until adulthood. Of these, 1526 men and women were followed up at the age of 26-32 years.

OUTCOMES

Association between years of schooling, as an indicator of cognitive ability, and newborn head circumference and conditional measures of head growth during infancy, childhood and adolescence.

RESULTS

In unadjusted analyses, newborn head size was positively associated with years of education [(b (95% CI)=0.30 (0.14 to 0.47) years per SD head circumference], as was head growth from birth to 6 months [b (95% CI)=0.44 (0.28 to 0.60) years per SD conditional head growth], 6 months to 2 years [b (95% CI)=0.31 (0.15 to 0.47) years per SD conditional head growth] and 2 to 11 years [b (95% CI)=0.20 (0.03 to 0.36) years per SD conditional head growth]. There were similar findings for height and body mass index (BMI). In the adjusted model containing all growth measures, gestational age, and socio-economic status (SES) at birth as predictors, only SES was positively associated with educational attainment.

CONCLUSION

Educational attainment in this population is positively associated with socioeconomic status and its influence on inter-related early life (fetal, infant and childhood) factors like nutritional status and brain growth.

Is IV iron sucrose a cost-effective option for treatment of severe anaemia in pregnancy as compared with oral iron?

Anaemia in pregnancy is a public health concern because it is strongly associated with maternal and perinatal morbidity and mortality. An open label randomized controlled trial (RCT) was conducted in India across four government medical colleges, comparing intravenous (IV) iron sucrose and oral iron for the treatment of anaemia in pregnancy. This RCT failed to demonstrate superiority of IV iron sucrose compared with oral iron therapy in reducing adverse clinical (maternal and foetal/neonatal) outcomes in moderate-to-severe anaemia in pregnancy. However, IV iron sucrose seemed to reduce the need for blood transfusion among women with severe anaemia. The study objective was to conduct a cost-effectiveness analysis of IV iron sucrose over oral therapy for treatment of severe anaemia in pregnancy, alongside the RCT, to inform policy. The outcome of interest in our study was a 'safe delivery' defined by the absence of composite maternal and foetal/neonatal adverse clinical outcomes. Incremental cost-effectiveness ratio (ICER) was calculated from a limited societal perspective. IV iron sucrose was found to be more costly but more effective than the oral therapy for treatment of severe anaemia. The ICER was calculated at INR 31 951 (USD 445.2) per safe delivery. We considered a threshold of half the gross national income for decision-making. Considering this threshold of India (INR 57 230, USD 797.4), IV iron-sucrose remained cost-effective in 67% of the iterations in the model. At the current ICER, for every 32 severely anaemic pregnant woman treated with IV iron sucrose one additional pregnant woman will have a safe delivery. Such analyses can complement the national strategy to support evidence-based action.

Development of the Instrument to assess the Credibility of Effect Modification Analyses (ICEMAN) in randomized controlled trials and meta-analyses

BACKGROUND

Most randomized controlled trials (RCTs) and meta-analyses of RCTs examine effect modification (also called a subgroup effect or interaction), in which the effect of an intervention varies by another variable (e.g., age or disease severity). Assessing the credibility of an apparent effect modification presents challenges; therefore, we developed the Instrument for assessing the Credibility of Effect Modification Analyses (ICEMAN).

METHODS

To develop ICEMAN, we established a detailed concept; identified candidate credibility considerations in a systematic survey of the literature; together with experts, performed a consensus study to identify key considerations and develop them into instrument items; and refined the instrument based on feedback from trial investigators, systematic review authors and journal editors, who applied drafts of ICEMAN to published claims of effect modification.

RESULTS

The final instrument consists of a set of preliminary considerations, core questions (5 for RCTs, 8 for meta-analyses) with 4 response options, 1 optional item for additional considerations and a rating of credibility on a visual analogue scale ranging from very low to high. An accompanying manual provides rationales, detailed instructions and examples from the literature. Seventeen potential users tested ICEMAN; their suggestions improved the user-friendliness of the instrument.

INTERPRETATION

The Instrument for assessing the Credibility of Effect Modification Analyses offers explicit guidance for investigators, systematic reviewers, journal editors and others considering making a claim of effect modification or interpreting a claim made by others.

Estimation of Expenditure and Challenges Related to Rehabilitation After Knee Arthroplasty: A Hospital-Based Cross-Sectional Study

BACKGROUND

Expenditure for rehabilitation following knee arthroplasty for osteoarthritis- and rehabilitation-related challenges following discharge to home after surgery is not available in the Indian context.

OBJECTIVES

To estimate cost of rehabilitation and document challenges in following rehabilitation advices, from a patient perspective.

METHODS

We conducted a hospital-based cross-sectional study of patients visiting the orthopedic department at a tertiary care public-funded hospital in New Delhi and included those who recently (less than 4 months) underwent primary knee arthroplasty for osteoarthritis. A trained physiotherapist not involved in clinical care collected information on expenditures incurred after discharge from hospital, patient's ability to recall the advices given by the physician and challenges they experienced using a semi-structured questionnaire. We report median costs by category of direct and indirect cost and used linear regression to explore determinants of cost.

RESULTS

We interviewed 82 consecutive patients (mean age 60.8 years and 68% females) with median time since surgery of 28 days. More than half (52%) sought some support for physiotherapy. The median cost of rehabilitation was INR 18,395 (Interquartile-range 11,325-27,775). Direct medical cost contributed to 74% of total cost (32% fee for services, 21% medications and lab investigations, 21% assistive devices). Twenty percent higher costs were incurred among those undergoing bilateral knee surgery after adjusting for age, sex, income, and type of physiotherapy support sought. Challenges were related to recall of advices, not understanding the recovery process and pain management.

CONCLUSION

About half patients undergoing knee arthroplasty seek support for rehabilitation after discharge to home contributing to a major portion of expenses incurred during rehabilitation. Cost-effective support mechanism for home-based rehabilitation is required for improving patient rehabilitation experiences.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00405-6.

Challenges in Timely Pharmacological Reperfusion Therapy of Acute ST-Elevation Myocardial Infarction Patients: A Cross-sectional Study

Introduction: Acute ST-Elevation Myocardial Infarction (STEMI) is the most severe presentation of an Acute Coronary Syndrome (ACS) resulting from sudden occlusion of one of the major epicardial coronary arteries resulting in myocardial injury and necrosis within minutes to few hours. Despite Primary Percutaneous Coronary Intervention (PPCI) being the gold standard, thrombolytic therapy is still the most common form of reperfusion therapy in eligible patients of acute STEMI even in large metropolitan cities in India. Aim: To find the proportion of STEMI patients receiving thrombolytic therapy within four hours of the onset of symptoms and within 30 minutes of reaching the hospital and to explore factors related to Pain-To-Door (P2D) delay. Materials and Methods: This was a single-centre cross-sectional observational study of 147 STEMI patients conducted at a tertiary care hospital in the National Capital Territory (India). from February to May 2017. Ethical clearance was obtained from the Institute’s Ethics Committee. All patients were interviewed and their medical records reviewed. Factors related to delay in reaching hospital and association of patient characteristics with those receiving thrombolytic therapy were explored using univariable and multivariable logistic regression. Results: Mean age of the study population was 52.1±13.1 years and 121 (82.3%) were men. Median P2D time was 4.7 hours (IQR- 2.2-17.0). Overall, 64 (43.5%) of 147 patients reached the hospital within four hours of chest pain. Only 5 (3.4%) patients availed ambulance to reach the hospital. Distance from the hospital, seeking care elsewhere and delay in reaction to symptom were reasons for the delay (>4 hours). Median Door-To-Needle (D2N) time was 45.9 minutes (IQR- 30.6-61.2). Patients who reached the hospital at night were more likely to be thrombolysed after adjusting for time to reach the hospital. Conclusion: Significant P2D and Door-To-Balloon (D2B) delays still exist in large metro cities in India. Action is needed both at the population level as well as system level to reduce these delays.

Efficacy and safety of convalescent plasma for severe COVID-19 based on evidence in other severe respiratory viral infections: a systematic review and meta-analysis

BACKGROUND

The safety and efficacy of convalescent plasma in severe coronavirus disease 2019 (COVID-19) remain uncertain. To support a guideline on COVID-19 management, we conducted a systematic review and meta-analysis of convalescent plasma in COVID-19 and other severe respiratory viral infections.

METHODS

In March 2020, we searched international and Chinese biomedical literature databases, clinical trial registries and prepublication sources for randomized controlled trials (RCTs) and nonrandomized studies comparing patients receiving and not receiving convalescent plasma. We included patients with acute coronavirus, influenza and Ebola virus infections. We conducted a meta-analysis using random-effects models and assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

Of 1099 unique records, 6 studies were eligible, and none of these included patients with COVID-19. One nonrandomized study (n = 40) on convalescent plasma in severe acute respiratory syndrome coronavirus (SARS-CoV) provided uninformative results regarding mortality (relative risk [RR] 0.10, 95% confidence interval [CI] CI 0.01 to 1.70). Pooled estimates from 4 RCTs on influenza (n = 572) showed no convincing effects on deaths (4 RCTs, RR 0.94, 95% CI 0.49 to 1.81), complete recovery (2 RCTs, odds ratio 1.04, 95% CI 0.69 to 1.64) or length of stay (3 RCTs, mean difference -1.62, 95% CI -3.82 to 0.58, d). The quality of evidence was very low for all efficacy outcomes. Convalescent plasma caused few or no serious adverse events in influenza RCTs (RR 0.85, 95% CI 0.56 to 1.29, low-quality evidence).

INTERPRETATION

Studies of non-COVID-19 severe respiratory viral infections provide indirect, very low-quality evidence that raises the possibility that convalescent plasma has minimal or no benefit in the treatment of COVID-19 and low-quality evidence that it does not cause serious adverse events.

Evaluating the credibility of anchor based estimates of minimal important differences for patient reported outcomes: instrument development and reliability study

OBJECTIVE

To develop an instrument to evaluate the credibility of anchor based minimal important differences (MIDs) for outcome measures reported by patients, and to assess the reliability of the instrument.

DESIGN

Instrument development and reliability study.

DATA SOURCES

Initial criteria were developed for evaluating the credibility of anchor based MIDs based on a literature review (Medline, Embase, CINAHL, and PsycInfo databases) and the experience of the authors in the methodology for estimation of MIDs. Iterative discussions by the team and pilot testing with experts and potential users facilitated the development of the final instrument.

PARTICIPANTS

With the newly developed instrument, pairs of masters, doctoral, or postdoctoral students with a background in health research methodology independently evaluated the credibility of a sample of MID estimates.

MAIN OUTCOME MEASURES

Core credibility criteria applicable to all anchor types, additional criteria for transition rating anchors, and inter-rater reliability coefficients were determined.

RESULTS

The credibility instrument has five core criteria: the anchor is rated by the patient; the anchor is interpretable and relevant to the patient; the MID estimate is precise; the correlation between the anchor and the outcome measure reported by the patient is satisfactory; and the authors select a threshold on the anchor that reflects a small but important difference. The additional criteria for transition rating anchors are: the time elapsed between baseline and follow-up measurement for estimation of the MID is optimal; and the correlations of the transition rating with the baseline, follow-up, and change score in the patient reported outcome measures are satisfactory. Inter-rater reliability coefficients (ĸ) for the core criteria and for one item from the additional criteria ranged from 0.70 to 0.94. Reporting issues prevented the evaluation of the reliability of the three other additional criteria for the transition rating anchors.

CONCLUSIONS

Researchers, clinicians, and healthcare policy decision makers can consider using this instrument to evaluate the design, conduct, and analysis of studies estimating anchor based minimal important differences.

Safety and effectiveness of intravenous iron sucrose versus standard oral iron therapy in pregnant women with moderate-to-severe anaemia in India: a multicentre, open-label, phase 3, randomised, controlled trial

BACKGROUND

Intravenous iron sucrose is a promising therapy for increasing haemoglobin concentration; however, its effect on clinical outcomes in pregnancy is not yet established. We aimed to assess the safety and clinical effectiveness of intravenous iron sucrose (intervention) versus standard oral iron (control) therapy in the treatment of women with moderate-to-severe iron deficiency anaemia in pregnancy.

METHODS

We did a multicentre, open-label, phase 3, randomised, controlled trial at four government medical colleges in India. Pregnant women, aged 18 years or older, at 20-28 weeks of gestation with a haemoglobin concentration of 5-8 g/dL, or at 29-32 weeks of gestation with a haemoglobin concentration of 5-9 g/dL, were randomly assigned (1:1) to receive intravenous iron sucrose (dose was calculated using a formula based on bodyweight and haemoglobin deficit) or standard oral iron therapy (100 mg elemental iron twice daily). Logistic regression was used to compare the primary maternal composite outcome consisting of potentially life-threatening conditions during peripartum and postpartum periods (postpartum haemorrhage, the need for blood transfusion during and after delivery, puerperal sepsis, shock, prolonged hospital stay [>3 days following vaginal delivery and >7 days after lower segment caesarean section], and intensive care unit admission or referral to higher centres) adjusted for site and severity of anaemia. The primary outcome was analysed in a modified intention-to-treat population, which excluded participants who refused to participate after randomisation, those who were lost to follow-up, and those whose outcome data were missing. Safety was assessed in both modified intention-to-treat and as-treated populations. The data safety monitoring board recommended stopping the trial after the first interim analysis because of futility (conditional power 1·14% under the null effects, 3·0% under the continued effects, and 44·83% under hypothesised effects). This trial is registered with the Clinical Trial Registry of India, CTRI/2012/05/002626.

FINDINGS

Between Jan 31, 2014, and July 31, 2017, 2018 women were enrolled, and 999 were randomly assigned to the intravenous iron sucrose group and 1019 to the standard therapy group. The primary maternal composite outcome was reported in 89 (9%) of 958 patients in the intravenous iron sucrose group and in 95 (10%) of 976 patients in the standard therapy group (adjusted odds ratio 0·95, 95% CI 0·70-1·29). 16 (2%) of 958 women in the intravenous iron sucrose group and 13 (1%) of 976 women in the standard therapy group had serious maternal adverse events. Serious fetal and neonatal adverse events were reported by 39 (4%) of 961 women in the intravenous iron sucrose group and 45 (5%) of 982 women in the standard therapy group. At 6 weeks post-randomisation, minor side-effects were reported by 117 (16%) of 737 women in the intravenous iron sucrose group versus 155 (21%) of 721 women in the standard therapy group. None of the serious adverse events was found to be related to the trial procedures or the interventions as per the causality assessment made by the trial investigators, ethics committees, and regulatory body.

INTERPRETATION

The study was stopped due to futility. There is insufficient evidence to show the effectiveness of intravenous iron sucrose in reducing clinical outcomes compared with standard oral iron therapy in pregnant women with moderate-to-severe anaemia.

FUNDING

WHO, India.

Higher Disability in Women Than Men Scheduled for Total Knee Arthroplasty for Degenerative Osteoarthritis: A Cross-Sectional Analysis From India

Objective

Higher level impairments and activity limitation among those scheduled for total knee arthroplasty (TKA) is known. Sex differences in participation restriction which is the final domain of disablement pathway is not known. No data from developing countries exist on sex differences in disability levels at the time of TKA.

Methods

In a cross‐sectional analysis of 240 patients (188 women; 72 men) scheduled for TKA, impairment (pain, symptoms, quadricep muscle strength, and knee range of motion [ROM]), activity limitation (self‐reported and objective performance‐based measurements), and participation restriction were compared. Multivariable regression analyses were used to adjust for key sociodemographic and clinical characteristics. Associations between impairments and participation restriction were analyzed.

Results

Compared with men, women were more likely to have higher levels of impairment (knee injury and osteoarthritis outcome pain score adjusted mean difference [aMD]: −6.9 [95% confidence interval {CI} −13.7 to −0.18]; flexion ROM of less than 100° adjusted odds ratio: 5.7 [95% CI 1.6‐20.3]; and 36% lower muscle strength [95% CI 24%‐49%]) and lower objectively measured functional ability (walking speed aMD: −0.12 m/s [95% CI −0.23 to −0.02]; stair climbing time aMD: 9.5 s [95% CI 1.5‐17.5]). Participation restriction was higher in women compared with men. Of the impairment measures (pain, ROM, and muscle strength), pain contributed to participation restriction in both sexes.

Conclusion

This study demonstrated higher levels of disability in women than in men at the time of TKA. Effect of pain on participation restriction was higher compared with muscle strength and ROM. Evidence of delay in decision‐making to undergo TKA and reasons for delay need to be studied specifically in the context of lower middle–income countries.

Percutaneous mitral commissurotomy versus surgical commissurotomy for rheumatic mitral stenosis: a systematic review and meta-analysis of randomised controlled trials

AIM

Patients with severe mitral stenosis (MS) and their clinicians typically choose percutaneous transvenous mitral commissurotomy (PTMC) over surgical commissurotomy (SC). However, the durability of PTMC relative to SC is uncertain. We compared the efficacy, safety and durability of PTMC with SC for the treatment of MS.

METHODS

We searched EMBASE, MEDLINE and WHO ICTRP registers for randomised controlled trials (RCTs) comparing PTMC, and open and/or closed mitral commissurotomy. The principal outcomes were rate of re-intervention and symptomatic improvement as inferred from the surrogate measures of immediate postprocedural mitral valve area (MVA), MVA at ≥6 month follow-up, incidence of mitral regurgitation (MR) and restenosis. We calculated weighted mean differences (WMD) for continuous outcomes, relative risks (RR) for binary outcomes and pooled outcomes using random-effects models and assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Seven RCTs with 553 patients proved eligible. Pooled estimates showed no convincing difference in the risk of restenosis or re-intervention (15/100 fewer with PTMC, 95% CI (-20 to +8); quality of evidence: moderate) or in symptoms as inferred from immediate MVA (WMD 0.15, 95% CI (-0.18 to 0.48): very low), from the incidence of postprocedural severe MR (3/100 more with PTMC, 95% CI (-1 to +10): moderate) or from MVA at 30 months.

CONCLUSION

Until data demonstrating convincing superiority of SC over PTMC become available, our results support the current practice of recommending PTMC to young patients with MS and favourable valve morphology, as it is associated with lower peri-procedural morbidity.

PROSPERO REGISTRATION NUMBER

PROSPERO 2017 (CRD42017079512).

Prevalence and factors associated with frailty among community-dwelling older people in rural Thanjavur district of South India: a cross-sectional study

OBJECTIVE

There is sparse data on the prevalence of frailty from rural parts of India. Our aim was to estimate prevalence of frailty among community-dwelling older people in rural South Indian population and explore socio-demographic factors associated with frailty. We further explored the associations between frailty with fear of falling and falls.

DESIGN

Community based cross-sectional study.

SETTING

Four villages in Thanjavur district of Southern India.

PARTICIPANTS

Random sample of adults aged 60 years and above from four villages.

METHODS

We sampled community-dwelling older adults from the electoral list of four villages using stratified random sampling. We report prevalence of frailty as defined by physical definition (Fried's Phenotype), accumulation of deficits (Frailty Index) and multi-domain definition (Tilburg Frailty Indicator). We report proportion of agreement of frailty status between the frailty tools. We used logistic regressions with robust SEs to examine the associations between socio-demographic determinants with frailty and the association between frailty with fear of falling and falls.

RESULTS

Among the 408 participants, the weighted (non-response and poststratification for sex) prevalence and 95% CI of frailty was 28% (18.9 to 28.1) for physical definition, 59% (53.9 to 64.3) for accumulation of deficits and 63% (57.4 to 67.6) for multi-domain definition. Frailty Index and Tilburg Frailty Indicator had good agreement (80%). Age, female, lower education, lower socioeconomic status, minimum physical activity in routine work were independently associated with frailty irrespective of the frailty definitions. Frail elderly had higher odds of falls as well as fear of falling compared with non-frail, irrespective of the definitions.

CONCLUSION

Prevalence of frailty among older people in rural Thanjavur district of South India was high compared with low-income and middle-income countries. Understanding the modifiable determinants of frailty can provide a valuable reference for future prevention and intervention.

A systematic survey identified 36 criteria for assessing effect modification claims in randomized trials or meta-analyses

OBJECTIVE

The objective of the study was to systematically survey the methodological literature and collect suggested criteria for assessing the credibility of effect modification and associated rationales.

STUDY DESIGN AND SETTING

We searched MEDLINE, Embase, and WorldCat up to March 2018 for publications providing guidance for assessing the credibility of effect modification identified in randomized trials or meta-analyses. Teams of two investigators independently identified eligible publications and extracted credibility criteria and authors' rationale, reaching consensus through discussion. We created a taxonomy of criteria that we iteratively refined during data abstraction.

RESULTS

We identified 150 eligible publications that provided 36 criteria and associated rationales. Frequent criteria included significant test for interaction (n = 54), a priori hypothesis (n = 49), providing a causal explanation (n = 47), accounting for multiplicity (n = 45), testing a small number of effect modifiers (n = 38), and prespecification of analytic details (n = 39). For some criteria, we found more than one rationale; some criteria were connected through a common rationale. For some criteria, experts disagreed regarding their suitability (e.g., added value of stratified randomization; trustworthiness of biologic rationales).

CONCLUSION

Methodologists have expended substantial intellectual energy providing criteria for critical appraisal of apparent effect modification. Our survey highlights popular criteria, expert agreement and disagreement, and where more work is needed, including testing criteria in practice.

Preoperative Quadriceps Muscle Strength and Functional Ability Predict Performance-Based Outcomes 6 Months After Total Knee Arthroplasty: A Systematic Review

BACKGROUND

One-third of individuals report limitations in activities of daily living even 6 months after total knee arthroplasty (TKA). Moderate-quality evidence exists for several sociodemographic and clinical predictors of patient-reported outcome measures of perceived functionality. Objectively measured performance-based measures (PBMs) provide a less subjective approach to informing patient treatment after TKA; however, information about predictors of functionally relevant PBMs is scarce.

PURPOSE

This systematic review synthesized the available research on preoperative predictors of PBMs after primary TKA for osteoarthritis.

DATA SOURCES

In June 2016 and January 2017, MEDLINE, EMBASE, and PsycINFO databases were searched.

STUDY SELECTION

Cohort studies exploring preoperative predictors of stair climbing, walking speed, and gait speed measured ≥6 months after primary TKA were included. Screening of abstracts and selection of full texts were undertaken by 2 independent reviewers.

DATA EXTRACTION

Information on study design, patient characteristics, analysis, and results was extracted using pilot-tested forms. Two independent reviewers assessed risk of bias using modified Quality in Prognostic Studies criteria.

DATA SYNTHESIS

Of the eligible 12 studies involving 6 prospective cohorts, 10 studies reported information on baseline predictors. Meta-analysis of predictors was not possible because of missing information on effect size or standard errors. Narrative synthesis of evidence of predictors was therefore performed.

LIMITATIONS

The quality of evidence was low because of the risk of bias and heterogeneity of included studies as well as nonreporting of measures of effect.

CONCLUSIONS

Low-quality evidence exists for an association of preoperative functional ability and quadriceps muscle strength with functionality at 6 months after TKA. Improved reporting of predictor analyses is needed to enable evidence generation for clinical management.

Digoxin and clinical outcomes in the Global Rheumatic Heart Disease Registry

OBJECTIVE

Digoxin is widely used in patients with rheumatic heart disease (RHD) despite a lack of data on its impact on clinical outcomes. We aimed to determine the association of digoxin use on clinical outcomes in patients with RHD.

METHODS

We performed a retrospective analysis of the association of digoxin use with mortality at 2 years in a large RHD registry. Secondary outcomes were recurrent heart failure (HF) and hospitalisation for any cause. We assessed associations using multivariable logistic regression in the entire cohort and in subgroups of patients with atrial fibrillation (AF) and HF. We also estimated average treatment effects from propensity-adjusted analyses using inverse probability treatment weighting.

RESULTS

Information on digoxin use at baseline was available for 98.7% (3298/3343) of patients. In the overall population, digoxin was significantly associated with mortality (OR 1.63, 95% CI 1.30 to 2.04, p<0.0001) and recurrent HF (OR 1.48, 95% CI 1.07 to 2.04, p=0.019). On propensity-weighted analyses, this effect was markedly attenuated (OR 1.05, 95% CI 1.01 to 1.09, p=0.005). Patients in sinus rhythm without HF had a higher propensity-adjusted odds of death with digoxin use (OR 1.06, 95% CI 1.01 to 1.12, p=0.015), but those with both AF and HF had lower mortality (OR 0.88, 95% CI 0.80 to 0.98, p=0.019).

CONCLUSION

Digoxin use is associated with higher mortality in patients with RHD, but this is greatly attenuated on propensity adjustment, indicating the presence of substantial treatment bias. The adjusted estimates may therefore not be reliable, and large randomised trials are needed to determine the true effect of digoxin in patients with RHD.

Motivating and demotivating factors for community health workers: A qualitative study in urban slums of Delhi, India

Background Community health workers play an important role in delivering health-care services, especially to underserved populations in low- and middle-income countries. They have been shown to be successful in providing a range of preventive, promotive and curative services. This qualitative study investigated the factors motivating or demotivating community health workers in urban settings in Delhi, India. Methods In this sub-study of the ANCHUL (Ante Natal and Child Healthcare in Urban Slums) implementation research project, four focus-group discussions and nine in-depth interviews were conducted with community health workers and medical officers. Utilizing a reflexive and inductive qualitative methodology, the data set was coded, to allow categories of motivating and demotivating factors to emerge. Results Motivating factors identified were: support from family members for their work, improved self-identity, job satisfaction and a sense of social responsibility, prior experiences of ill health, the opportunity to acquire new skills and knowledge, social recognition and status conferred by the community, and flexible work and timings. Negative experiences in the community and at health centres, constraints in the local health system in response to the demand generated by the community health workers, and poor pay demotivated community health workers in this study, even causing some to quit their jobs. Conclusion Community-health-worker programmes that focus on ensuring the technical capacity of their staff may not give adequate attention to the factors that motivate or discourage these workers. As efforts get under way to ensure universal access to health care, it is important that these issues are recognized and addressed, to ensure that community health worker programmes are effective and sustainable.

Association of antenatal care and place of delivery with newborn care practices: evidence from a cross-sectional survey in rural Uttar Pradesh, India

BACKGROUND

Appropriate immediate newborn care is vital for neonatal survival. Antenatal period is a crucial time to impart knowledge and awareness to mothers regarding newborn care, either during facility visits or during home visits by community health workers (CHWs) especially in the rural context. In this paper, we report newborn care practices in rural Uttar Pradesh (UP) and have explored association between newborn care practices with antenatal care, contact with community health workers during pregnancy and place of childbirth.

METHODS

We use cross-sectional baseline data (which is part of a larger intervention project) collected from 129 gram panchayats (GPs) from 15 administrative blocks spread over five districts of UP in 2013. From currently married women (n = 2208) of 15-49 years, who delivered 15 months prior to the survey, we collected information on women's demographic and socio-economic characteristics, knowledge and practice of reproductive, maternal, newborn, child health and nutrition behaviours. Association of newborn practices with antenatal care, contacts by community health worker during pregnancy and place of childbirth were tested using random intercept logistic regression, adjusting for socio-economic and demographic factors and accounting for clustering at the GP and block levels.

RESULTS

Eighty-three percent of 2208 mothers received ANC, but only half of the respondents received a minimum of three ANC visits. More than two thirds of respondents delivered at a health facility. Practice of newborn care was poor: merely one fourth of women practised clean cord care, one third of women followed good breastfeeding practices (initiation with an hour of birth, fed colostrum and did not give pre-lacteal feeds) and one third provided adequate thermal care (kept baby warm and delayed bathing). Only 5% followed all above practices with evidence of clustering of newborn care practices at the block and GP levels. While facility-based childbirth was strongly associated with appropriate newborn care practices, ANC visits and contacts with CHWs was not associated with all newborn care practices.

CONCLUSION

The quality of ANC care provided needs to be improved to have an impact on newborn care practices. Our finding emphasizes the importance of facility-based birthing. There is a need for training CHWs to strengthen their counselling skills on newborn care. Variation of newborn care practices between communities should be taken into consideration while implementing any intervention to optimize benefits.

Functional compared to anatomical imaging in the initial evaluation of patients with suspected coronary artery disease: An international, multi-center, randomized controlled trial (IAEA-SPECT/CTA study)

OBJECTIVE

To test the hypothesis that, in the initial evaluation of patients with suspected coronary artery disease (CAD), stress myocardial perfusion imaging (MPI) would result in less downstream testing than coronary computed tomographic angiography (CCTA).

METHODS

In this international, randomized trial, mildly symptomatic patients with an intermediate likelihood of having CAD, and asymptomatic patients at intermediate risk of cardiac events, underwent either initial stress-rest MPI or CCTA. The primary outcome was downstream noninvasive or invasive testing at 6 months. Secondary outcomes included cumulative effective radiation dose (ERD) and costs at 12 months.

RESULTS

We recruited 303 patients (151 MPI and 152 CTA) from 6 centers in 6 countries. The initial MPI was abnormal in 29% (41/143) and CCTA in 56% (79/141) of patients. Fewer patients undergoing initial stress-rest MPI had further downstream testing at 6 months (adjusted OR 0.51, 95% CI 0.28-0.91, P = 0.023). There was a small increase in the median cumulative ERD with MPI (9.6 vs. 8.8 mSv, P = 0.04), but no difference in costs between the two strategies at 12 months.

CONCLUSION

In the management of patients with suspected CAD, a strategy of initial stress MPI is substantially less likely to require further downstream testing than initial testing with CCTA.

TRIAL REGISTRATION

clinicaltrials.gov identification number NCT01368770.

Determinants of childhood immunisation coverage in urban poor settlements of Delhi, India: a cross-sectional study

OBJECTIVES

Aggregate data on childhood immunisation from urban settings may not reflect the coverage among the urban poor. This study provides information on complete childhood immunisation coverage among the urban poor, and explores its household and neighbourhood-level determinants.

SETTING

Urban poor community in the Southeast district of Delhi, India.

PARTICIPANTS

We randomly sampled 1849 children aged 1-3.5 years from 13 451 households in 39 clusters (cluster defined as area covered by a community health worker) in 2 large urban poor settlements. Of these, 1343 completed the survey. We collected information regarding childhood immunisation (BCG, oral polio vaccine, diphtheria-pertussis-tetanus vaccine, hepatitis B and measles) from vaccination cards or mothers' recall. We used random intercept logistic regression to explore the sociodemographic determinants of complete immunisation.

RESULTS

Complete immunisation coverage was 46.7% and 7.5% were not immunised. The odds of complete vaccination (OR, 95% CI) were lower in female children (0.70 (0.55 to 0.89)) and Muslim households (0.65 (0.45 to 0.94)). The odds of complete vaccination were higher if the mother was literate (1.6 (1.15 to 2.16)), if the child was born within the city (2.7 (1.97 to 3.65)), in a health facility ( 1.5 (1.19 to 2.02)), belonged to the highest wealth quintile (compared with the poorest; 2.46 (1.5 to 4.02)) or possessed a birth certificate (1.40 (1.03 to 1.91)). Cluster effect due to unmeasured neighbourhood factors expressed as median OR was 1.32.

CONCLUSIONS

Immunisation coverage in this urban poor area was much lower than that of regional surveys reporting overall urban data. Socioeconomic status of the household, female illiteracy, health awareness and gender inequality were important determinants of coverage in this population. Hence, in addition to enhancing the infrastructure for providing mother and child services, efforts are also needed to address these issues in order to improve immunisation coverage in deprived urban communities.

TRIAL REGISTRATION NUMBER

CTRI/2011/091/000095.

Reproductive healthcare utilization in urban poor settlements of Delhi: Baseline survey of ANCHUL (Ante Natal and Child Health care in Urban Slums) project

BACKGROUND

Disparity in utilization of reproductive healthcare services between the urban poor and the urban non-poor households in the developing nations is well known. However, disparity may also exist within urban poor households. Our objective was to document the extent of disparity in reproductive healthcare utilization among the urban poor and to identify the socio-demographic determinants of underutilization with a view to characterizing this vulnerable subpopulation.

METHODS

A survey of 16,221 households was conducted in 39 clusters from two large urban poor settlements in Delhi. From 13,451 consenting households, socio-demographic data and information on births, maternal and child deaths within the previous year was collected. Details of antenatal care (ANC) was collected from 597 pregnant women. Information on ANC and postnatal care was also obtained from 596 recently delivered (within six months) mothers. All data were captured electronically using a customized and validated smart phone application. Households were categorized into quintiles of socio-economic position (SEP) based on dwelling characteristics and possession of durable assets using principal component analysis. Potential socio-demographic determinants of reproductive healthcare utilization were examined using random effects logistic regression.

RESULTS

The prevalence of facility based birthing was 77% (n = 596 mothers). Of the 596 recently delivered mothers only 70% had an ANC registration card, 46.3% had ANC in their first trimester, 46% had visited a facility within 4 weeks post-delivery and 27% were using modern contraceptive methods. Low socio-economic position was the most important predictor of underutilization with a clear gradient across SEP quintiles. Compared to the poorest, the least poor women were more likely to be registered for ANC (OR 1.96, 95%CI 0.95-4.15) and more likely to have made ≥ 4 ANC visits (OR 5.86, 95%CI 2.82-12.19). They were more likely to have given birth in a facility (OR 4.87, 95%CI 2.12-11.16), to have visited a hospital within one month of childbirth (OR 3.18, 95%CI 1.62-6.26). In general, government funded health insurance and conditional cash transfers schemes were underutilized in this community.

CONCLUSION

The poorest segment of the urban poor population utilizes reproductive healthcare facilities the least. Strategies to improve access and utilization of healthcare services among the poorest of the poor may be necessary to achieve universal health coverage.

Ante natal care (ANC) utilization, dietary practices and nutritional outcomes in pregnant and recently delivered women in urban slums of Delhi, India: an exploratory cross-sectional study

BACKGROUND

Antenatal Care (ANC) is one of the crucial factors in ensuring healthy outcomes in women and newborns. Nutrition education and counselling is an integral part of ANC that influences maternal and child health outcomes. A cross sectional study was conducted in Pregnant Women (PW) and mothers who had delivered in the past three months; Recently Delivered Women (RDW) in urban slums of North-east district of Delhi, India, to explore ANC utilization, dietary practices and nutritional outcomes.

METHODS

A household survey was conducted in three urban slums to identify PW and RDW. Socio-economic and demographic profile, various components of ANC received including nutrition counselling, dietary intake and nutritional outcomes based on anthropometric indices and anaemia status were assessed. Socio-demographic characteristics, nutrient intake and nutritional status were compared between those who availed ANC versus those who did not using logistic regression. Descriptive summary for services and counselling received; dietary and nutrient intake during ANC were presented.

RESULTS

Almost 80% (274 out of 344) women received some form of ANC but the package was inadequate. Determinants for non-utilization of ANC were poverty, literacy, migration, duration of stay in the locality and high parity. Counselling on nutrition was reported by a fourth of the population. Nutrient intake showed suboptimal consumption of protein and micronutrients like iron, calcium, vitamin A, vitamin C, thiamine, riboflavin niacin, zinc and vitamin B12 by more than half of women. A high prevalence of anaemia among PW (85%) and RDW (97.1%) was observed. There was no difference in micronutrient intake and anaemia prevalence among women who received ANC versus who did not.

CONCLUSIONS

Pregnant women living in urban poor settlements have poor nutritional status. This may be improved by strengthening the nutrition counselling component of ANC which was inadequate in the ANC package received. Empowering community based health workers in providing effective nutrition counselling should be explored given the overburdened public health system.

Transient, subclinical atrial fibrillation and risk of systemic embolism in patients with rheumatic mitral stenosis in sinus rhythm

Stroke and systemic embolism occur frequently in patients with rheumatic mitral stenosis (MS) in sinus rhythm (SR), but the risk and predictors of embolic events in this population are not well studied. The aim of this study was to determine if transient, subclinical atrial fibrillation (AF) increases the risk of systemic embolism in patients with MS in SR. A single-center, prospective observational study of patients with rheumatic MS in SR was performed. The rate of the composite primary outcome of stroke, transient ischemic attack, or non-central nervous system embolism was determined, as well as the predictive value of Holter-detected episodes of transient (<30 seconds), subclinical AF for this outcome. Hazard ratios were derived for subclinical AF, after adjustment for clinical and echocardiographic predictors of systemic embolism, using Cox regression. The sensitivity, specificity, and area under the receiver-operating characteristic curve of subclinical AF were determined for the primary outcome. Among 179 patients (mean follow-up 10.2 months), the rate of the primary outcome was 5.3/100 patient-years (95% confidence interval [CI] 2.6 to 10.5). In univariate analysis, subclinical AF (hazard ratio 4.54, 95% CI 1.08 to 19.0, p = 0.038) and dense spontaneous echocardiographic contrast (hazard ratio 4.32, 95% CI 1.03 to 18.09, p = 0.045) were predictors of the primary outcome. In multivariate analysis, subclinical AF remained the only significant predictor (hazard ratio 5.02, 95% CI 1.15 to 22.0, p = 0.032). Subclinical AF had an area under the receiver-operating characteristic curve of 0.68 and high negative predictive value (97.7%) for the primary outcome. In conclusion, Holter-detected, transient (<30 seconds), subclinical AF is a predictor of stroke and systemic embolism in patients with rheumatic MS in SR. Considering the high risk for embolism, randomized trials of oral anticoagulation are needed in this population.

An Observational Study on the Use of IV Iron Sucrose Among Anaemic Pregnant Women in Government Healthcare Facilities from Two States of India

BACKGROUND/PURPOSE OF THE STUDY

In India oral iron tablets for anaemia have been distributed through the health system since many years, but there has been no significant change in the burden of anaemia. The objective of the present study was to capture the existing practices on the use of intravenous iron sucrose (an alternative treatment for anaemia) in the public health system in two states of India (Tamil Nadu and Uttar Pradesh).

METHODS

An observational study in the form of a registry was maintained for 3 months at purposively chosen public health facilities in the above-mentioned states of India. Anaemic pregnant women (n = 764) who were given intravenous iron sucrose during the antenatal or post-partum period were included in the registry. Information was collected on severity of anaemia at which intravenous iron sucrose therapy was initiated, the dose and schedule given and any adverse events noted during and immediate post-infusion period.

RESULTS

99 % of the infusions were given as slow infusion over a mean duration of 30 min, diluted with 0.9 % sodium chloride. The mean haemoglobin level at the time of start of intravenous therapy was 8.3 gm/dl. In Uttar Pradesh, 46 % of women received only one dose of iron sucrose in contrast with 15 % in Tamil Nadu.

CONCLUSIONS

Although intravenous iron sucrose is commonly used in pregnant anaemic women, standard protocols and guidelines for its usage are lacking. These need to be formulated before scaling it up across public health facilities in India.

Why women choose to give birth at home: a situational analysis from urban slums of Delhi

OBJECTIVES

Increasing institutional births is an important strategy for attaining Millennium Development Goal -5. However, rapid growth of low income and migrant populations in urban settings in low-income and middle-income countries, including India, presents unique challenges for programmes to improve utilisation of institutional care. Better understanding of the factors influencing home or institutional birth among the urban poor is urgently needed to enhance programme impact. To measure the prevalence of home and institutional births in an urban slum population and identify factors influencing these events.

DESIGN

Cross-sectional survey using quantitative and qualitative methods.

SETTING

Urban poor settlements in Delhi, India.

PARTICIPANTS

A house-to-house survey was conducted of all households in three slum clusters in north-east Delhi (n=32 034 individuals). Data on birthing place and sociodemographic characteristics were collected using structured questionnaires (n=6092 households). Detailed information on pregnancy and postnatal care was obtained from women who gave birth in the past 3 months (n=160). Focus group discussions and in-depth interviews were conducted with stakeholders from the community and healthcare facilities.

RESULTS

Of the 824 women who gave birth in the previous year, 53% (95% CI 49.7 to 56.6) had given birth at home. In adjusted analyses, multiparity, low literacy and migrant status were independently predictive of home births. Fear of hospitals (36%), comfort of home (20.7%) and lack of social support for child care (12.2%) emerged as the primary reasons for home births.

CONCLUSIONS

Home births are frequent among the urban poor. This study highlights the urgent need for improvements in the quality and hospitality of client services and need for family support as the key modifiable factors affecting over two-thirds of this population. These findings should inform the design of strategies to promote institutional births.

Short-course prophylactic zinc supplementation for diarrhea morbidity in infants of 6 to 11 months

BACKGROUND

Zinc supplementation during diarrhea substantially reduces the incidence and severity of diarrhea. However, the effect of short-course zinc prophylaxis has been observed only in children >12 months of age. Because the incidence of diarrhea is comparatively high in children aged 6 to 11 months, we assessed the prophylactic effect of zinc on incidence and duration of diarrhea in this age group.

METHODS

In this randomized, double-blind, placebo-controlled trial, we enrolled infants aged 6 to 11 months from an urban resettlement colony in Delhi, India, between January 1, 2011, and January 15, 2012. We randomly assigned 272 infants to receive either 20 mg of zinc or a placebo suspension orally every day for 2 weeks. The primary outcome was the incidence of diarrhea per child-year. All analyses were done by intention-to-treat.

RESULTS

A total of 134 infants in the zinc and 124 in the placebo groups were assessed for the incidence of diarrhea. There was a 39% reduction (crude incident rate ratio [IRR] 0.61, 95% confidence interval [CI] 0.53-0.71) in episodes of diarrhea, 39% (adjusted IRR 0.61, 95% CI 0.54-0.69) in the total number of days that a child suffered from diarrhea, and reduction of 36% in duration per episode of diarrhea (IRR 0.64, 95% CI 0.56-0.74) during the 5 months of follow-up.

CONCLUSIONS

Short-course prophylactic zinc supplementation for 2 weeks may reduce diarrhea morbidity in infants of 6 to 11 months for up to 5 months, in populations with high prevalence of wasting and stunting.

Is intravenous iron sucrose the treatment of choice for pregnant anemic women?

Anemia during pregnancy remains an important public health problem in developing countries like India. Anemia is the direct cause of 12-15% of maternal deaths. Iron deficiency is the commonest cause for anemia in the Indian subcontinent. Several preventive and therapeutic approaches are in practice. The available routes of iron supplementation are oral and intravenous. In spite of oral iron being least invasive, cheap and safe, the ineffectiveness of oral iron due to dietary inhibitors and poor compliance are well known. Intravenous iron sucrose can be a promising therapy for moderate to severely anemic pregnant women and has been in practice for quite some time in private and public health practices. In this article, we report the current evidence on the safety and efficacy of intravenous iron sucrose in anemic pregnant women on hematological and clinical outcomes. Though the evidence on its efficacy in improving hemoglobin and serum ferritin is convincing, its effect on maternal and fetal outcomes are unclear. This is primarily due to lack of well-designed and larger studies powered to detect difference in clinical outcomes. Hence, there is a need to gather evidence from a well-designed large randomized clinical trial conducted in a developing country. The results of such a study would feed into the national policy and would form the basis to frame guidelines for management of anemia in developing countries.

Common genetic variants and central adiposity among Asian-Indians

Recent studies have identified common genetic variants that are unequivocally associated with central adiposity, BMI, and/or fasting plasma glucose among individuals of European descent. Our objective was to evaluate these associations in a population of Asian-Indians. We examined 16 single-nucleotide polymorphisms (SNPs) from loci previously linked to waist circumference, BMI, or fasting glucose in 1,129 Asian-Indians from New Delhi and Trivandrum. Trained medical staff measured waist circumference, height, and weight. Fasting plasma glucose was measured from collected blood specimens. Genotype-phenotype associations were evaluated using linear regression, with adjustments for age, gender, religion, and study region. For gene-environment interaction tests, total physical activity (PA) during the past 7 days was assessed by the International Physical Activity Questionnaire (IPAQ). The T allele at the FTO rs3751812 locus was associated with increased waist circumference (per allele effect of +1.58 cm, P(trend) = 0.0015) after Bonferroni adjustment for multiple testing (P(adj) = 0.04). We also found a nominally statistically significant FTO-PA interaction (P(interaction) = 0.008). Among participants with <81 metabolic equivalent (MET)-h/wk of PA, the rs3751812 variant was associated with increased waist size (+2.68 cm; 95% confidence interval (CI) = 1.24, 4.12), but not among those with 212+ MET-h/wk (-1.79 cm; 95% CI = -4.17, 0.58). No other variant had statistically significant associations, although statistical power was modest. In conclusion, we confirmed that an FTO variant associated with central adiposity in European populations is associated with central adiposity among Asian-Indians and corroborated prior reports indicating that high PA attenuates FTO-related genetic susceptibility to adiposity.

HbA(1c) values for defining diabetes and impaired fasting glucose in Asian Indians

AIM

To determine the glycosylated haemoglobin (HbA(1c)) cut-points for diabetes and impaired fasting glucose (IFG) among Asian Indians.

METHODS

Participants (n=525) were a random sample selected from the India Health Study. Based on history and fasting plasma glucose (FPG), participants were classified into known diabetes, newly diagnosed diabetes (NDD), impaired fasting glucose (IFG) [ADA and WHO criteria] or normal fasting glucose (NFG). Receiver Operating Characteristic curves were used to identify the optimum sensitivity and specificity for defining HbA(1c) cut-points for NDD and IFG against the FPG criteria.

RESULTS

There were 64 participants with a known history of diabetes. Of the remaining 461, IFG was present in 44.7% (ADA) and 18.2% (WHO), and 10.4% were NDD. Mean HbA(1c) were 5.4 (±0.04)% for NFG; 5.7 (±0.06)% among IFG-ADA, 5.8 (±0.09)% among IFG-WHO; 7.5 (±0.33)% for NDD and 8.4 (±0.32)% for known diabetes. Optimal HbA(1c) cut-point for NDD was 5.8% (sensitivity=75%, specificity=75.5%, AUC=0.819). Cut-point for IFG (ADA) was 5.5% (sensitivity=59.7%, specificity=59.9%, AUC=0.628) and for IFG (WHO) was 5.6% (sensitivity=60.7%, specificity=65.1%, AUC=0.671).

CONCLUSION

In this study population from north and south regions of India, the HbA(1c) cut-point that defines NDD (≥5.8%) was much lower than that proposed by an international expert committee and the American Diabetes Association (≥6.5%). A cut-point of ≥5.5% or ≥5.6% defined IFG, and was slightly lower than the ≥5.7% for high risk proposed, but accuracy was less than 70%.

Assessment of follow-up, and the completeness and accuracy of cancer case ascertainment in three areas of India

BACKGROUND

A prospective study of diet and cancer has not been conducted in India; consequently, little is known regarding follow-up rates or the completeness and accuracy of cancer case ascertainment.

METHODS

We assessed follow-up in the India Health Study (IHS; 4671 participants aged 35-69 residing in New Delhi, Mumbai, or Trivandrum). We evaluated the impact of medical care access and relocation, re-contacted the IHS participants to estimate follow-up rates, and conducted separate studies of cancer cases to evaluate registry coverage (604 cases in Trivandrum) and the accuracy of self- and proxy-reporting (1600 cases in New Delhi and Trivandrum).

RESULTS

Over 97% of people reported seeing a doctor and 85% had lived in their current residence for over six years. The 2-year follow-up rate was 91% for Trivandrum and 53% for New Delhi. No cancer cases were missed among public institutions participating in the surveillance program in Trivandrum during 2003-2004; but there are likely to be unmatched cases (ranging from 5 to 13% of total cases) from private hospitals in the Trivandrum registry, as there are no mandatory reporting requirements. Vital status was obtained for 36% of cancer cases in New Delhi as compared to 78% in Trivandrum after a period of 4 years.

CONCLUSIONS

A prospective cohort study of cancer may be feasible in some centers in India with active follow-up to supplement registry data. Inclusion of cancers diagnosed at private institutions, unique identifiers for individuals, and computerized medical information would likely improve cancer registries.

Multi-center feasibility study evaluating recruitment, variability in risk factors and biomarkers for a diet and cancer cohort in India

Background

India's population exhibits diverse dietary habits and chronic disease patterns. Nutritional epidemiologic studies in India are primarily of cross-sectional or case-control design and subject to biases, including differential recall of past diet. The aim of this feasibility study was to evaluate whether a diet-focused cohort study of cancer could be established in India, providing insight into potentially unique diet and lifestyle exposures.

Methods

Field staff contacted 7,064 households within three regions of India (New Delhi, Mumbai, and Trivandrum) and found 4,671 eligible adults aged 35-69 years. Participants completed interviewer-administered questionnaires (demographic, diet history, physical activity, medical/reproductive history, tobacco/alcohol use, and occupational history), and staff collected biological samples (blood, urine, and toenail clippings), anthropometric measurements (weight, standing and sitting height; waist, hip, and thigh circumference; triceps, sub-scapula and supra-patella skin fold), and blood pressure measurements.

Results

Eighty-eight percent of eligible subjects completed all questionnaires and 67% provided biological samples. Unique protein sources by region were fish in Trivandrum, dairy in New Delhi, and pulses (legumes) in Mumbai. Consumption of meat, alcohol, fast food, and soft drinks was scarce in all three regions. A large percentage of the participants were centrally obese and had elevated blood glucose levels. New Delhi participants were also the least physically active and had elevated lipids levels, suggesting a high prevalence of metabolic syndrome.

Conclusions

A high percentage of participants complied with study procedures including biological sample collection. Epidemiologic expertise and sufficient infrastructure exists at these three sites in India to successfully carry out a modest sized population-based study; however, we identified some potential problems in conducting a cohort study, such as limited number of facilities to handle biological samples.

A cross-sectional investigation of regional patterns of diet and cardio-metabolic risk in India

Background

The role of diet in India's rapidly progressing chronic disease epidemic is unclear; moreover, diet may vary considerably across North-South regions.

Methods

The India Health Study was a multicenter study of men and women aged 35-69, who provided diet, lifestyle, and medical histories, as well as blood pressure, fasting blood, urine, and anthropometric measurements. In each region (Delhi, n = 824; Mumbai, n = 743; Trivandrum, n = 2,247), we identified two dietary patterns with factor analysis. In multiple logistic regression models adjusted for age, gender, education, income, marital status, religion, physical activity, tobacco, alcohol, and total energy intake, we investigated associations between regional dietary patterns and abdominal adiposity, hypertension, diabetes, and dyslipidemia.

Results

Across the regions, more than 80% of the participants met the criteria for abdominal adiposity and 10 to 28% of participants were considered diabetic. In Delhi, the "fruit and dairy" dietary pattern was positively associated with abdominal adiposity [highest versus lowest tertile, multivariate-adjusted OR and 95% CI: 2.32 (1.03-5.23); P_trend = 0.008] and hypertension [2.20 (1.47-3.31); P_trend < 0.0001]. In Trivandrum, the "pulses and rice" pattern was inversely related to diabetes [0.70 (0.51-0.95); P_trend = 0.03] and the "snacks and sweets" pattern was positively associated with abdominal adiposity [2.05 (1.34-3.14); P_trend = 0.03]. In Mumbai, the "fruit and vegetable" pattern was inversely associated with hypertension [0.63 (0.40-0.99); P_trend = 0.05] and the "snack and meat" pattern appeared to be positively associated with abdominal adiposity.

Conclusions

Cardio-metabolic risk factors were highly prevalent in this population. Across all regions, we found little evidence of a Westernized diet; however, dietary patterns characterized by animal products, fried snacks, or sweets appeared to be positively associated with abdominal adiposity. Conversely, more traditional diets in the Southern regions were inversely related to diabetes and hypertension. Continued investigation of diet, as well as other environmental and biological factors, will be needed to better understand the risk profile in this population and potential means of prevention.

Conduct of clinical trials in developing countries: a perspective

PURPOSE OF REVIEW

To provide a broad perspective of contextual factors involved in the conduct of clinical trials in developing countries.

RECENT FINDINGS

The quantity of research in developing countries continues to be inadequate, with clinical trials comprising a small fraction of the total research output. Most trials done in developing countries tend to be designed in developed countries and led by investigators in those nations. The main challenges in the conduct of trials in developing countries stem from the vulnerability of the populations due to illiteracy, poverty, limited research infrastructure, lack of sufficient numbers of experienced investigators and trained support personnel, and fragmented healthcare system.

SUMMARY

There is a need to formulate and conduct trials to test treatments that are context-specific and socially relevant. With careful planning in advance and shared partnership among sponsors, host-country research practitioners, government agencies and the community, many of the challenges facing clinical trial research can be overcome over the medium to long term. This would enable conformity to contemporary guidelines in both letter and spirit and hopefully develop research questions addressing the needs of developing countries.

Measurement of spices and seasonings in India: opportunities for cancer epidemiology and prevention

Bioactive components of many foods added during cooking have potential antioxidant, anti-inflammatory, antimicrobial, antibacterial and chemopreventive properties. However, epidemiologic studies generally do not collect detailed information on these items, which include spices, chilies, coconuts, garlic, onions, and oils. Since India has some of the highest spice consumption in the world, we developed a computer-based food preparer questionnaire to estimate per capita consumption of 19 spices, chilies, coconuts, garlic, onions, and 13 cooking oils among 3,625 participants in the India Health Study, a multicenter pilot study in three regions of India. We observed notable regional differences in consumption of spices, chilies, coconut, garlic, and onions. In Trivandrum, over 95 percent of the participants consumed 12 different spices, while in New Delhi and Mumbai, 95 percent of participants consumed only four and five spices, respectively. Cooking oil use also varied, as ghee was most common in New Delhi (96.8%) followed by mustard seed oil (78.0%), while in Trivandrum the primary oil was coconut (88.5%) and in Mumbai it was peanut (68.5%). There was some variation in consumption by education, income, and religion. Using a novel method for assessing food items primarly added during cooking, we successfully estimated per capita consumption within an epidemiologic study. Based on basic science research and suggestive ecologic level data on cancer incidence and spice consumption, improving epidemiologic assessment of these potentially chemopreventive food items may enhance our understanding of diet and cancer risk.