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Dubey I, Bishain R, Dasgupta J, Bhavnani S, Belmonte MK, Gliga T, Mukherjee D, Lockwood Estrin G, Johnson MH, Chandran S, Patel V, Gulati S, Divan G, Chakrabarti B. Using mobile health technology to assess childhood autism in low-resource community settings in India: An innovation to address the detection gap. Autism 2024; 28:755-769. [PMID: 37458273 PMCID: PMC10913299 DOI: 10.1177/13623613231182801] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
LAY ABSTRACT Autism is diagnosed by highly trained professionals- but most autistic people live in parts of the world that harbour few or no such autism specialists and little autism awareness. So many autistic people go undiagnosed, misdiagnosed, and misunderstood. We designed an app (START) to identify autism and related conditions in such places, in an attempt to address this global gap in access to specialists. START uses computerised games and activities for children and a questionnaire for parents to measure social, sensory, and motor skills. To check whether START can flag undiagnosed children likely to have neurodevelopmental conditions, we tested START with children whose diagnoses already were known: Non-specialist health workers with just a high-school education took START to family homes in poor neighbourhoods of Delhi, India to work with 131 two-to-seven-year-olds. Differences between typically and atypically developing children were highlighted in all three types of skills that START assesses: children with neurodevelopmental conditions preferred looking at geometric patterns rather than social scenes, were fascinated by predictable, repetitive sensory stimuli, and had more trouble with precise hand movements. Parents' responses to surveys further distinguished autistic from non-autistic children. An artificial-intelligence technique combining all these measures demonstrated that START can fairly accurately flag atypically developing children. Health workers and families endorsed START as attractive to most children, understandable to health workers, and adaptable within sometimes chaotic home and family environments. This study provides a proof of principle for START in digital screening of autism and related conditions in community settings.
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Affiliation(s)
- Indu Dubey
- University of Reading, UK
- University of Nottingham, UK
| | | | | | | | - Matthew K Belmonte
- University of Reading, UK
- The Com DEALL Trust, India
- Nottingham Trent University, UK
| | - Teodora Gliga
- University of East Anglia, UK
- University of London, UK
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Lockwood Estrin G, Mason L, Arora R, Bhavnani S, Dasgupta J, Gulati S, Gliga T, Johnson MH. Attention control in autism: Eye-tracking findings from pre-school children in a low- and middle-income country setting. Autism 2024; 28:43-57. [PMID: 36700615 DOI: 10.1177/13623613221149541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
LAY ABSTRACT The development of cognitive processes, such as attention control and learning, has been suggested to be altered in children with a diagnosis of autism spectrum disorder. However, nearly all of our understanding of the development of these cognitive processes comes from studies with school-aged or older children in high-income countries, and from research conducted in a controlled laboratory environment, thereby restricting the potential generalisability of results and away from the majority of the world's population. We need to expand our research to investigate abilities beyond these limited settings. We address shortcomings in the literature by (1) studying attention control and learning in an understudied population of children in a low- and middle-income country setting in India, (2) focusing research on a critical younger age group of children and (3) using portable eye-tracking technology that can be taken into communities and healthcare settings to increase the accessibility of research in hard-to-reach populations. Our results provide novel evidence on differences in attention control and learning responses in groups of children with and without a diagnosis of autism spectrum disorder. We show that learning responses in children that we assessed through a portable eye-tracking task, called the 'antisaccade task', may be specific to autism. This suggests that the methods we use may have the potential to identify and assess autism-specific traits across development, and be used in research in low-resource settings.
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Affiliation(s)
| | | | | | | | | | | | | | - Mark H Johnson
- Birkbeck, University of London, UK
- University of Cambridge, UK
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Mukherjee D, Bhavnani S, Lockwood Estrin G, Rao V, Dasgupta J, Irfan H, Chakrabarti B, Patel V, Belmonte MK. Digital tools for direct assessment of autism risk during early childhood: A systematic review. Autism 2024; 28:6-31. [PMID: 36336996 PMCID: PMC10771029 DOI: 10.1177/13623613221133176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
LAY ABSTRACT The challenge of finding autistic children, and finding them early enough to make a difference for them and their families, becomes all the greater in parts of the world where human and material resources are in short supply. Poverty of resources delays interventions, translating into a poverty of outcomes. Digital tools carry potential to lessen this delay because they can be administered by non-specialists in children's homes, schools or other everyday environments, they can measure a wide range of autistic behaviours objectively and they can automate analysis without requiring an expert in computers or statistics. This literature review aimed to identify and describe digital tools for screening children who may be at risk for autism. These tools are predominantly at the 'proof-of-concept' stage. Both portable (laptops, mobile phones, smart toys) and fixed (desktop computers, virtual-reality platforms) technologies are used to present computerised games, or to record children's behaviours or speech. Computerised analysis of children's interactions with these technologies differentiates children with and without autism, with promising results. Tasks assessing social responses and hand and body movements are the most reliable in distinguishing autistic from typically developing children. Such digital tools hold immense potential for early identification of autism spectrum disorder risk at a large scale. Next steps should be to further validate these tools and to evaluate their applicability in a variety of settings. Crucially, stakeholders from underserved communities globally must be involved in this research, lest it fail to capture the issues that these stakeholders are facing.
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Affiliation(s)
- Debarati Mukherjee
- Indian Institute of Public Health - Bengaluru, Public Health Foundation of India, India
| | | | | | - Vaisnavi Rao
- Institute for Democracy and Economic Affairs (IDEAS), Malaysia
| | | | | | | | - Vikram Patel
- Child Development Group, Sangath, India
- Harvard Medical School, USA
- Harvard T.H. Chan School of Public Health, USA
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Lockwood Estrin G, Bhavnani S, Goodwin A, Arora R, Divan G, Haartsen R, Mason L, Patel V, Johnson MH, Jones EJ. From the lab to the field: acceptability of using electroencephalography with Indian preschool children. Wellcome Open Res 2023; 7:99. [PMID: 37953927 PMCID: PMC10632594 DOI: 10.12688/wellcomeopenres.17334.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
Background: Measurement of social and cognitive brain development using electroencephalography (EEG) offers the potential for early identification of children with elevated risk of developmental delay. However, there have been no published reports of how acceptable EEG technology is to parents and children within communities, especially in low-resource contexts such as in low and middle income countries (LMICs), which is an important question for the potential scalability of these assessments. We use a mixed-methods approach to examine whether EEG assessments are acceptable to children and their caregivers in a low resource community setting in India. Methods: We assessed the acceptability of neurophysiology research and Braintools (a novel neurodevelopmental assessment toolkit using concurrent EEG and eye-tracking technology) using: 1) a child engagement measure, 2) interviews with caregivers (n=8); 3) survey about caregiver's experience (n=36). Framework analysis was used to analyse interview data. Results: A high level of child engagement in EEG tasks was demonstrated, with children's gaze at the screen during the task averaging at 85.4% (±12.06%) of the task time. External distractions and noise during the tasks were measured, but not found to significantly effect child's attention to the screen during EEG tasks. Key topics were examined using the framework analysis: 1) parental experience of the assessment; and 2) the acceptability of research. From topic 1, four sub-themes were identified: i) caregivers' experience of the assessment, ii) caregivers' perception of child's experience of assessment, iii) logistical barriers and facilitators to participation, and iv) recommendations for improvement. Results from interviews and the survey indicated acceptability for gaze-controlled EEG research for parents and children. From topic 2, three themes were identified: i) caregivers' understanding of the research, ii) barriers to participation, and iii) facilitators to participation. Barriers to participation mainly included logistical challenges, such as geographic location and time, whereas involvement of the wider family in decision making was highlighted as an important facilitator to partake in the research. Conclusions: We demonstrate for the first time the acceptability of conducting neurodevelopmental assessments using concurrent EEG and eye-tracking in preschool children in uncontrolled community LMIC settings. This kind of research appears to be acceptable to the community and we identify potential barriers and facilitators of this research, thus allowing for future large scale research projects to be conducted investigating neurodevelopment and risk factors for suboptimal development in LMICs.
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Affiliation(s)
- Georgia Lockwood Estrin
- Centre for Brain and Cognitive Development, Department of Psychological Sciences, Birkbeck, University of London, London, WC1E 7JL, UK, UK
- School of Psychology, University of East London, London, E16 2RD, UK, UK
| | - Supriya Bhavnani
- Child Development Grou, Sangath, House 451 BhatkarWaddo, Succor, Bardez, Goa, 403501, India
| | - Amy Goodwin
- Institute of Psychology, Psychiatry and Neurosciences, King's College London SE1 1UL, London, UK
| | - Rashi Arora
- Child Development Grou, Sangath, House 451 BhatkarWaddo, Succor, Bardez, Goa, 403501, India
| | - Gauri Divan
- Child Development Grou, Sangath, House 451 BhatkarWaddo, Succor, Bardez, Goa, 403501, India
| | - Rianne Haartsen
- Centre for Brain and Cognitive Development, Department of Psychological Sciences, Birkbeck, University of London, London, WC1E 7JL, UK, UK
| | - Luke Mason
- Centre for Brain and Cognitive Development, Department of Psychological Sciences, Birkbeck, University of London, London, WC1E 7JL, UK, UK
| | - Vikram Patel
- Child Development Grou, Sangath, House 451 BhatkarWaddo, Succor, Bardez, Goa, 403501, India
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, USA
| | - Mark H. Johnson
- Centre for Brain and Cognitive Development, Department of Psychological Sciences, Birkbeck, University of London, London, WC1E 7JL, UK, UK
- Department of Psychology, University of Cambridge, Cambridge, CB2 3EB, UK
| | - Emily J.H. Jones
- Centre for Brain and Cognitive Development, Department of Psychological Sciences, Birkbeck, University of London, London, WC1E 7JL, UK, UK
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Bhutta ZA, Bhavnani S, Betancourt TS, Tomlinson M, Patel V. Adverse childhood experiences and lifelong health. Nat Med 2023; 29:1639-1648. [PMID: 37464047 DOI: 10.1038/s41591-023-02426-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/30/2023] [Indexed: 07/20/2023]
Abstract
With the advent of the sustainable development goals, the field of global child health has shifted its focus from reducing mortality to improving health, nutrition and development outcomes - often measured as human capital. A growing knowledge of the biology of development and neuroscience has highlighted the importance of adverse environmental exposures, collectively termed adverse childhood experiences (ACEs) on health outcomes. ACEs are associated with short-term, medium-term and long-term negative consequences for health and development and their effects may be multiplicative, especially during critical periods of sensitivity and developmental plasticity. Some of these effects are compounded by emerging global threats such as climate change, conflict and population displacement. In this Review, we discuss the key mechanisms linking ACEs to health outcomes and consider promising strategies to prevent and mitigate their effects, highlighting evidence from programs in low-income and middle-income countries. Finally, we emphasize the need for early recognition of ACEs and delivery of packages of interventions spanning key sectors such as health, education, women's empowerment and social protection.
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Affiliation(s)
- Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.
- Institute for Global Health & Development, The Aga Khan University, South Central Asia, East Africa, United Kingdom, and Karachi, Pakistan.
| | | | | | - Mark Tomlinson
- Institute for Life Course Health Research, Stellenbosch University, Cape Town, South Africa
- School of Nursing and Midwifery, Queens University, Belfast, UK
| | - Vikram Patel
- Department of Global Health and Population, Harvard Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Lockwood Estrin G, Bhavnani S, Arora R, Gulati S, Divan G. Caregiver Perceptions of Autism and Neurodevelopmental Disabilities in New Delhi, India. Int J Environ Res Public Health 2023; 20:5291. [PMID: 37047907 PMCID: PMC10094583 DOI: 10.3390/ijerph20075291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/24/2023] [Accepted: 03/06/2023] [Indexed: 06/19/2023]
Abstract
Evidence suggests that parenting an autistic child or a child with neurodevelopmental disabilities can be more challenging than parenting a child meeting their developmental milestones, especially when there is a dearth of support services, such as in low- and middle-income countries (LMICs). Despite the majority of the world's children residing in LMICs, there are limited studies examining the understanding of developmental disorders and autism in these regions. We therefore aim to investigate perceptions of autism and developmental disabilities in caregivers of children in an urban setting in New Delhi, India. Thirteen semi-structured interviews with parents/caregivers of children were conducted in three groups: (1) caregivers with a child with a diagnosis of autism spectrum disorder (ASD); (2) caregivers with a child with a diagnosis of intellectual disability (ID); (3) and caregivers with children meeting their developmental milestones. Transcripts were analysed using framework analysis. Three themes on the impact of cultural and contextual factors on the recognition, interpretation, and reporting of autistic symptoms are discussed, and additional themes focus on the impact of diagnosis and family support. Our findings highlighted a vital need for greater community awareness and recognition of autism in India, for example through community and healthcare training, which may help to reduce stigma and facilitate wider family support.
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Affiliation(s)
- Georgia Lockwood Estrin
- School of Psychology, University of East London, Arthur Edwards Building, Water Lane, London E15 4LZ, UK
- Child Development Group, Sangath, Bardez 403501, India; (S.B.); (G.D.)
| | - Supriya Bhavnani
- Child Development Group, Sangath, Bardez 403501, India; (S.B.); (G.D.)
| | - Rashi Arora
- Child Development Group, Sangath, Bardez 403501, India; (S.B.); (G.D.)
| | - Sheffali Gulati
- Center of Excellence and Advanced Research on Childhood Neurodevelopmental Disorders, Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India;
| | - Gauri Divan
- Child Development Group, Sangath, Bardez 403501, India; (S.B.); (G.D.)
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McHenry MS, Mukherjee D, Bhavnani S, Kirolos A, Piper JD, Crespo-Llado MM, Gladstone MJ. The current landscape and future of tablet-based cognitive assessments for children in low-resourced settings. PLOS Digit Health 2023; 2:e0000196. [PMID: 36821551 PMCID: PMC9949664 DOI: 10.1371/journal.pdig.0000196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Interest in measuring cognition in children in low-resourced settings has increased in recent years, but options for cognitive assessments are limited. Researchers are faced with challenges when using existing assessments in these settings, such as trained workforce shortages, less relevant testing stimuli, limitations of proprietary assessments, and inadequate parental knowledge of cognitive milestones. Tablet-based direct child assessments are emerging as a practical solution to these challenges, but evidence of their validity and utility in cross-cultural settings is limited. In this overview, we introduce key concepts of this field while exploring the current landscape of tablet-based assessments for low-resourced settings. We also make recommendations for future directions of this relatively novel field. We conclude that tablet-based assessments are an emerging and promising method of assessing cognition in young children. Further awareness and dissemination of validated tablet-based assessments may increase capacity for child development research and clinical practice in low-resourced settings.
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Affiliation(s)
- Megan S. McHenry
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, United States of America
- * E-mail:
| | - Debarati Mukherjee
- Indian Institute of Public Health—Bengaluru, Life Course Epidemiology, Bengaluru, Karnataka, India
| | | | - Amir Kirolos
- Department of Women and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Joe D. Piper
- Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Maria M. Crespo-Llado
- Department of Women and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Melissa J. Gladstone
- Department of Women and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
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Economou Lundeberg J, Engstrom G, Dziubinski M, Sridar A, Healey JS, Bhavnani S, Persson A, Johnson L. A prediction model for ventricular tachycardia events using 24h ambulatory ECG. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Ventricular tachycardia (VT) is a potentially lethal condition that occurs intermittently. The aim of this study was to derive a risk prediction model for VT episodes detected on ≤30 day mobile cardiac telemetry using a 24 hour ambulatory ECG recording.
Methods
We included patients who were monitored for 2–30 full days in the USA using a full-disclosure mobile cardiac telemetry device in 2017. Patients with a VT episode ≥10 beats duration (VT≥10 beats) on the first full recording day were excluded. Arrhythmias were algorithmically detected and manually verified. A LASSO model was derived for the outcome of a VT≥10 beats detected on days 2–30. Potential predictors included age, sex, and ECG data from the first 24h: heart rate (max, min and mean), premature atrial and ventricular complexes occurring as singles, couplets, triplets, and runs ≥4 beats as well as the fastest rate for each event. The population was split into equal random training and testing samples.
Results
In a population of 19,789 patients (mean age 65.3, 43.4% men), and during a median recording time of 18 days there were 1,511 patients with at least one VT≥10 beats. The LASSO model had good discrimination in the testing sample, ROC-statistic 0.7586, 95% CI 0.7398–0.7774 (Figure 1a). A model excluding age and gender had similar discrimination (ROC 0.7528, 95% CI 0.7339–0.7717). In the testing sample the model was well calibrated (Figure 1b). In the top quintile more than one in five patients had a VT≥10 beats, enough to warrant extended monitoring.
Conclusion
A risk score based on variables easily derived from a standard 24h ECG can be used to predict high risk of VT episodes ≥10 beats within 30 days. In the top quintile VT events ≥10 beats were ten times more common than in the bottom quintile.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Hjärt-LungfondenSwedish Society for Medical Research
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Affiliation(s)
| | - G Engstrom
- Lund University, Department of Clinical Sciences , Lund , Sweden
| | | | - A Sridar
- Washington D.C. Va Medical Center, Washington , DC , United States of America
| | | | - S Bhavnani
- Scripps Clinic , San Diego , United States of America
| | - A Persson
- Lund University, Department of Clinical Sciences , Lund , Sweden
| | - L Johnson
- Lund University, Department of Clinical Sciences , Lund , Sweden
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Mukherjee D, Bhopal S, Bhavnani S, Sharma KK, Roy R, Divan G, Mandal S, Soremekun S, Kirkwood B, Patel V. The effect of cumulative early life adversities, and their differential mediation through hair cortisol levels, on childhood growth and cognition: Three-year follow-up of a birth cohort in rural India. Wellcome Open Res 2022; 7:74. [PMID: 35592545 PMCID: PMC9096148 DOI: 10.12688/wellcomeopenres.17712.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2022] [Indexed: 11/09/2023] Open
Abstract
Background: Early adversities negatively impact children's growth and development, putatively mediated by chronic physiological stress resulting from these adverse experiences. We aimed to estimate the associations between prospectively measured cumulative early adversities with growth and cognition outcomes in rural Indian preschool children and to explore if hair cortisol concentration (HCC), a measure of chronic physiological stress, mediated the above association. Methods: Participants were recruited from the SPRING cRCT in rural Haryana, India. Adversities experienced through pregnancy and the first year of life were measured in 1304 children at 12-months. HCC was measured at 12-months in 845 of them. Outcome measures were height-for-age-z-score (HAZ), weight-for-age-z-score (WAZ) and cognition, measured in 1124 children followed up at 3-years. Cognition was measured using a validated tablet-based gamified tool named DEEP. Results: Cumulative adversities at 12-months were inversely associated with all outcomes measures at 3-years. Each unit increase in adversity score led to a decrease of 0·08 units [95% confidence interval (CI):-0·11,-0·06] in DEEP-z-score; 0·12 units [-0·14,-0·09] in HAZ and 0·11 units [-0·13,-0·09] in WAZ. 12-month HCC was inversely associated with DEEP-z-score (-0·09 [-0·16,-0·01]) and HAZ (-0·12 [-0·20,-0·04]), but the association with WAZ was not significant (p = 0·142). HCC marginally mediated the association between cumulative adversities and HAZ (proportion mediated = 0·06, p = 0·014). No evidence of mediation was found for the cognition outcome. Conclusions: Cumulative early adversities and HCC measured at 12-months have persistent negative effects on child growth and cognition at 3-years. The association between adversities and these two child outcomes were differentially mediated by HCC, with no evidence of mediation observed for the cognitive outcome. Future studies should focus on other stress biomarkers, and alternate pathways such as the immune, inflammation and cellular ageing pathways, to unpack key mechanisms underlying the established relationship between early adversities and poor child outcomes.
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Affiliation(s)
- Debarati Mukherjee
- Life course Epidemiology, Indian Institute of Public Health-Bengaluru, Public Health Foundation of India, Bengaluru, Karnataka, 560023, India
| | - Sunil Bhopal
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
- Maternal & Child Health Intervention Research Group, Department of Population Health, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Supriya Bhavnani
- Child Development Group, Sangath, 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
| | - Kamal Kant Sharma
- Child Development Group, Sangath, 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
| | - Reetabrata Roy
- Maternal & Child Health Intervention Research Group, Department of Population Health, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- Child Development Group, Sangath, 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
| | - Gauri Divan
- Child Development Group, Sangath, 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
| | - Siddhartha Mandal
- Center for Chronic Disease Control, C-1/52, 2ND FL, Safdarjung Development Area, New Delhi, 110016, India
| | - Seyi Soremekun
- Department of Infection Biology, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Betty Kirkwood
- Maternal & Child Health Intervention Research Group, Department of Population Health, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Vikram Patel
- Child Development Group, Sangath, 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
- Department of Global Health & Social Medicine, Harvard Medical School, 41 Huntington Ave, Boston, MA, 02115, USA
- Department of Global Health and Population, Harvard T H Chan School of Public Health, 655 Huntington Ave, Boston, MA, 02115, USA
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10
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Mukherjee D, Bhopal S, Bhavnani S, Sharma KK, Roy R, Divan G, Mandal S, Soremekun S, Kirkwood B, Patel V. The effect of cumulative early life adversities, and their differential mediation through hair cortisol levels, on childhood growth and cognition: Three-year follow-up of a birth cohort in rural India. Wellcome Open Res 2022; 7:74. [PMID: 35592545 PMCID: PMC9096148 DOI: 10.12688/wellcomeopenres.17712.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Early adversities negatively impact children’s growth and development, putatively mediated by chronic physiological stress resulting from these adverse experiences. We aimed to estimate the associations between prospectively measured cumulative early adversities with growth and cognition outcomes in rural Indian preschool children and to explore if hair cortisol concentration (HCC), a measure of chronic physiological stress, mediated the above association. Methods: Participants were recruited from the SPRING cRCT in rural Haryana, India. Adversities experienced through pregnancy and the first year of life were measured in 1304 children at 12-months. HCC was measured at 12-months in 845 of them. Outcome measures were height-for-age-z-score (HAZ), weight-for-age-z-score (WAZ) and cognition, measured in 1124 children followed up at 3-years. Cognition was measured using a validated tablet-based gamified tool named DEEP. Results: Cumulative adversities at 12-months were inversely associated with all outcomes measures at 3-years. Each unit increase in adversity score led to a decrease of 0·08 units [95% confidence interval (CI):-0·11,-0·06] in DEEP-z-score; 0·12 units [-0·14,-0·09] in HAZ and 0·11 units [-0·13,-0·09] in WAZ. 12-month HCC was inversely associated with DEEP-z-score (-0·09 [-0·16,-0·01]) and HAZ (-0·12 [-0·20,-0·04]), but the association with WAZ was not significant (p = 0·142). HCC marginally mediated the association between cumulative adversities and HAZ (proportion mediated = 0·06, p = 0·014). No evidence of mediation was found for the cognition outcome. Conclusions: Cumulative early adversities and HCC measured at 12-months have persistent negative effects on child growth and cognition at 3-years. The association between adversities and these two child outcomes were differentially mediated by HCC, with no evidence of mediation observed for the cognitive outcome. Future studies should focus on other stress biomarkers, and alternate pathways such as the immune, inflammation and cellular ageing pathways, to unpack key mechanisms underlying the established relationship between early adversities and poor child outcomes.
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Affiliation(s)
- Debarati Mukherjee
- Life course Epidemiology, Indian Institute of Public Health-Bengaluru, Public Health Foundation of India, Bengaluru, Karnataka, 560023, India
| | - Sunil Bhopal
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
- Maternal & Child Health Intervention Research Group, Department of Population Health, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Supriya Bhavnani
- Child Development Group, Sangath, 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
| | - Kamal Kant Sharma
- Child Development Group, Sangath, 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
| | - Reetabrata Roy
- Maternal & Child Health Intervention Research Group, Department of Population Health, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- Child Development Group, Sangath, 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
| | - Gauri Divan
- Child Development Group, Sangath, 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
| | - Siddhartha Mandal
- Center for Chronic Disease Control, C-1/52, 2ND FL, Safdarjung Development Area, New Delhi, 110016, India
| | - Seyi Soremekun
- Department of Infection Biology, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Betty Kirkwood
- Maternal & Child Health Intervention Research Group, Department of Population Health, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Vikram Patel
- Child Development Group, Sangath, 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
- Department of Global Health & Social Medicine, Harvard Medical School, 41 Huntington Ave, Boston, MA, 02115, USA
- Department of Global Health and Population, Harvard T H Chan School of Public Health, 655 Huntington Ave, Boston, MA, 02115, USA
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Rodriguez Ruiz C, Hermel M, Spierling Bagsic S, Salerno M, Newlander S, Bhavnani S, Robinson A, Gonzalez J, Wesbey G. 469 LDL Particle Number Association With Plaque Burden In Patients With Normal LDL-C. J Cardiovasc Comput Tomogr 2022. [DOI: 10.1016/j.jcct.2022.06.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Pelter M, Almeida S, Bagsic S, Jayawardena E, Kinninger A, Newlander S, Robinson A, Bhavnani S, Gonzalez J, Budoff M, Wesbey G. 424 Image Quality, Radiation Dosimetry, And Diagnostic Accuracy Of Whole Heart Single Heartbeat Coronary Ct Angiography As Validated By Invasive Coronary Angiogram In A High Calcium Score Population. J Cardiovasc Comput Tomogr 2022. [DOI: 10.1016/j.jcct.2022.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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13
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Bhavnani S, Parameshwaran D, Sharma KK, Mukherjee D, Divan G, Patel V, Thiagarajan TC. The Acceptability, Feasibility, and Utility of Portable Electroencephalography to Study Resting-State Neurophysiology in Rural Communities. Front Hum Neurosci 2022; 16:802764. [PMID: 35386581 PMCID: PMC8978891 DOI: 10.3389/fnhum.2022.802764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/17/2022] [Indexed: 11/23/2022] Open
Abstract
Electroencephalography (EEG) provides a non-invasive means to advancing our understanding of the development and function of the brain. However, the majority of the world’s population residing in low and middle income countries has historically been limited from contributing to, and thereby benefiting from, such neurophysiological research, due to lack of scalable validated methods of EEG data collection. In this study, we establish a standard operating protocol to collect approximately 3 min each of eyes-open and eyes-closed resting-state EEG data using a low-cost portable EEG device in rural households through formative work in the community. We then evaluate the acceptability of these EEG assessments to young children and feasibility of administering them through non-specialist workers. Finally, we describe properties of the EEG recordings obtained using this novel approach to EEG data collection. The formative phase was conducted with 9 families which informed protocols for consenting, child engagement strategies and data collection. The protocol was then implemented on 1265 families. 977 children (Mean age = 38.8 months, SD = 0.9) and 1199 adults (Mean age = 27.0 years, SD = 4) provided resting-state data for this study. 259 children refused to wear the EEG cap or removed it, and 58 children refused the eyes-closed recording session. Hardware or software issues were experienced during 30 and 25 recordings in eyes-open and eyes-closed conditions respectively. Disturbances during the recording sessions were rare and included participants moving their heads, touching the EEG headset with their hands, opening their eyes within the eyes-closed recording session, and presence of loud sounds in the testing environment. Similar to findings in laboratory-based studies from high-income settings, the percentage of recordings which showed an alpha peak was higher in eyes-closed than eyes-open condition, with the peak occurring most frequently in electrodes at O1 and O2 positions, and the mean frequency of the alpha peak was found to be lower in children (8.43 Hz, SD = 1.73) as compared to adults (10.71 Hz, SD = 3.96). We observed a deterioration in the EEG signal with prolonged device usage. This study demonstrates the acceptability, feasibility and utility of conducting EEG research at scale in a rural low-resource community, while highlighting its potential limitations, and offers the impetus needed to further refine the methods and devices and validate such scalable methods to overcome existing research inequity.
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Affiliation(s)
- Supriya Bhavnani
- Child Development Group, Sangath, Goa, India.,Public Health Foundation of India, New Delhi, India
| | | | | | - Debarati Mukherjee
- Indian Institute of Public Health-Bengaluru, Public Health Foundation of India, Bengaluru, India
| | - Gauri Divan
- Child Development Group, Sangath, Goa, India
| | - Vikram Patel
- Child Development Group, Sangath, Goa, India.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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Bhavnani S, Lockwood Estrin G, Arora R, Kumar D, Kakra M, Vajaratkar V, Juneja M, Gulati S, Patel V, Green J, Divan G. "I was Confused … and Still am" Barriers Impacting the Help-Seeking Pathway for an Autism Diagnosis in Urban North India: A Mixed Methods Study. J Autism Dev Disord 2022; 52:1778-1788. [PMID: 34014464 PMCID: PMC8938390 DOI: 10.1007/s10803-021-05047-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2021] [Indexed: 12/27/2022]
Abstract
Timely recognition of autism in children is integral to improve developmental outcomes. This study used mixed-methods (84 case-registers and 20 in-depth interviews with caregivers of children with a diagnosis of autism) to explore the extent to which the nature of parental concerns and prior knowledge of developmental disorders impact the time between symptom recognition and autism diagnosis, and the contextual family, societal and health-system related factors that impede the autism help-seeking pathway. Lack of awareness of age-appropriate child developmental milestones, apparent amongst the community and health professionals, contributed to a 1.5-year delay between parental concerns and autism diagnosis. Recommendations to shorten this help-seeking pathway include harnessing the potential of non-specialist workers to increase awareness and enable developmental monitoring of young children through scalable tools.
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Affiliation(s)
- Supriya Bhavnani
- Child Development Group, Sangath, House 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India.
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Plot No. 47, Sector 44, Institutional Area, Gurgaon, 122002, India.
| | - Georgia Lockwood Estrin
- Centre for Brain and Cognitive Development, Birkbeck, University of London, Malet Street, WC1E 7HX, London, UK
| | - Rashi Arora
- Child Development Group, Sangath, House 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
| | - Divya Kumar
- Child Development Group, Sangath, House 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
| | - Minal Kakra
- Child Development Group, Sangath, House 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
| | - Vivek Vajaratkar
- Department of Orthopaedic Surgery, Goa Medical College, Bambolim, Goa, 403202, India
| | - Monica Juneja
- Maulana Azad Medical College, Balmiki Basti, New Delhi, India, 110002
| | - Sheffali Gulati
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Vikram Patel
- Child Development Group, Sangath, House 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA
- Department of Global Health and Population, Harvard T H Chan School of Public Health, 655 Huntington Ave, Boston, MA, 02115, USA
| | - Jonathan Green
- Royal Manchester Children's Hospital, University of Manchester and Manchester Academic Health Sciences Centre, Oxford Rd, Manchester, M13 9PL, UK
| | - Gauri Divan
- Child Development Group, Sangath, House 451 Bhatkar Waddo, Succor, Bardez, Goa, 403501, India
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Lockwood Estrin G, Bhavnani S, Goodwin A, Arora R, Divan G, Haartsen R, Mason L, Patel V, Johnson MH, Jones EJ. From the lab to the field: acceptability of using electroencephalography with Indian preschool children. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.17334.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Measurement of social and cognitive brain development using electroencephalography (EEG) offers the potential for early identification of children with elevated risk of developmental delay. However, there have been no published reports of how acceptable EEG technology is to parents and children within communities, especially in low-resource contexts such as in low and middle income countries (LMICs), which is an important question for the potential scalability of these assessments. We use a mixed-methods approach to examine whether EEG assessments are acceptable to children and their caregivers in a low resource community setting in India. Methods: We assessed the acceptability of neurophysiology research and Braintools (a novel neurodevelopmental assessment toolkit using concurrent EEG and eye-tracking technology) using: 1) a child engagement measure, 2) interviews with caregivers (n=8); 3) survey about caregiver’s experience (n=36). Framework analysis was used to analyse interview data. Results: Key topics were examined using the framework analysis: 1) parental experience of the assessment; and 2) the acceptability of research. From topic 1, four sub-themes were identified: i) caregivers’ experience of the assessment, ii) caregivers’ perception of child's experience of assessment, iii) logistical barriers and facilitators to participation, and iv) recommendations for improvement. From topic 2, three themes were identified: i) caregivers' understanding of the research, ii) barriers to participation, and iii) facilitators to participation. Conclusions: We demonstrate for the first time the acceptability of conducting neurodevelopmental assessments using concurrent EEG and eye-tracking in preschool children in uncontrolled community LMIC settings. This kind of research appears to be acceptable to the community and we identify potential barriers and facilitators of this research, thus allowing for future large scale research projects to be conducted investigating neurodevelopment and risk factors for suboptimal development in LMICs.
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Dubey I, Brett S, Ruta L, Bishain R, Chandran S, Bhavnani S, Belmonte MK, Estrin GL, Johnson M, Gliga T, Chakrabarti B. Quantifying preference for social stimuli in young children using two tasks on a mobile platform. PLoS One 2022; 17:e0265587. [PMID: 35648753 PMCID: PMC9159616 DOI: 10.1371/journal.pone.0265587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 03/07/2022] [Indexed: 11/19/2022] Open
Abstract
Children typically prefer to attend to social stimuli (e.g. faces, smiles) over non-social stimuli (e.g. natural scene, household objects). This preference for social stimuli is believed to be an essential building block for later social skills and healthy social development. Preference for social stimuli are typically measured using either passive viewing or instrumental choice paradigms, but not both. Since these paradigms likely tap into different mechanisms, the current study addresses this gap by administering both of these paradigms on an overlapping sample. In this study, we use a preferential looking task and an instrumental choice task to measure preference for social stimuli in 3-9 year old typically developing children. Children spent longer looking at social stimuli in the preferential looking task but did not show a similar preference for social rewards on the instrumental choice task. Task performance in these two paradigms were not correlated. Social skills were found to be positively related to the preference for social rewards on the choice task. This study points to putatively different mechanisms underlying the preference for social stimuli, and highlights the importance of choice of paradigms in measuring this construct.
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Affiliation(s)
- Indu Dubey
- Centre for Autism, School of Psychology & Clinical Language Sciences, University of Reading, Reading, United Kingdom
| | - Simon Brett
- Centre for Autism, School of Psychology & Clinical Language Sciences, University of Reading, Reading, United Kingdom
| | - Liliana Ruta
- Institute of Applied Sciences and Intelligent Systems, National Research Council of Italy (CNR), Messina, Italy
| | - Rahul Bishain
- Department of Computer Science and Engineering, Indian Institute of Technology Bombay, Mumbai, India
| | - Sharat Chandran
- Department of Computer Science and Engineering, Indian Institute of Technology Bombay, Mumbai, India
| | - Supriya Bhavnani
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, India
- Sangath, New Delhi, India
| | - Matthew K. Belmonte
- Com DEALL Trust, Bangalore, India
- Division of Psychology, Nottingham Trent University, Nottingham, United Kingdom
| | - Georgia Lockwood Estrin
- Centre for Brain and Cognitive Development, Birkbeck University of London, London, United Kingdom
| | - Mark Johnson
- School of Psychology, University of Cambridge, Cambridge, United Kingdom
| | - Teodora Gliga
- School of Psychology, University of East Anglia, Norwich, United Kingdom
| | - Bhismadev Chakrabarti
- Centre for Autism, School of Psychology & Clinical Language Sciences, University of Reading, Reading, United Kingdom
- Department of Psychology, Ashoka University, Sonipat, India
- India Autism Center, Kolkata, India
- * E-mail:
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Shen FX, Wolf SM, Bhavnani S, Deoni S, Elison JT, Fair D, Garwood M, Gee MS, Geethanath S, Kay K, Lim KO, Lockwood Estrin G, Luciana M, Peloquin D, Rommelfanger K, Schiess N, Siddiqui K, Torres E, Vaughan JT. Emerging ethical issues raised by highly portable MRI research in remote and resource-limited international settings. Neuroimage 2021; 238:118210. [PMID: 34062266 PMCID: PMC8382487 DOI: 10.1016/j.neuroimage.2021.118210] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 05/03/2021] [Accepted: 05/07/2021] [Indexed: 11/18/2022] Open
Abstract
Smaller, more affordable, and more portable MRI brain scanners offer exciting opportunities to address unmet research needs and long-standing health inequities in remote and resource-limited international settings. Field-based neuroimaging research in low- and middle-income countries (LMICs) can improve local capacity to conduct both structural and functional neuroscience studies, expand knowledge of brain injury and neuropsychiatric and neurodevelopmental disorders, and ultimately improve the timeliness and quality of clinical diagnosis and treatment around the globe. Facilitating MRI research in remote settings can also diversify reference databases in neuroscience, improve understanding of brain development and degeneration across the lifespan in diverse populations, and help to create reliable measurements of infant and child development. These deeper understandings can lead to new strategies for collaborating with communities to mitigate and hopefully overcome challenges that negatively impact brain development and quality of life. Despite the potential importance of research using highly portable MRI in remote and resource-limited settings, there is little analysis of the attendant ethical, legal, and social issues (ELSI). To begin addressing this gap, this paper presents findings from the first phase of an envisioned multi-staged and iterative approach for creating ethical and legal guidance in a complex global landscape. Section 1 provides a brief introduction to the emerging technology for field-based MRI research. Section 2 presents our methodology for generating plausible use cases for MRI research in remote and resource-limited settings and identifying associated ELSI issues. Section 3 analyzes core ELSI issues in designing and conducting field-based MRI research in remote, resource-limited settings and offers recommendations. We argue that a guiding principle for field-based MRI research in these contexts should be including local communities and research participants throughout the research process in order to create sustained local value. Section 4 presents a recommended path for the next phase of work that could further adapt these use cases, address ethical and legal issues, and co-develop guidance in partnership with local communities.
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Affiliation(s)
- Francis X Shen
- Professor of Law and Faculty Member, Graduate Program in Neuroscience, University of Minnesota; Instructor in Psychology, Harvard Medical School; Executive Director, MGH Center for Law, Brain & Behavior USA.
| | - Susan M Wolf
- McKnight Presidential Professor of Law, Medicine & Public Policy; Faegre Baker Daniels Professor of Law; Professor of Medicine; Chair, Consortium on Law and Values in Health, Environment & the Life Sciences, University of Minnesota USA
| | - Supriya Bhavnani
- Co-Principal Investigator, Child Development Group, Sangath, New Delhi, India
| | - Sean Deoni
- Associate Professor of Pediatrics (Research), Associate Professor of Diagnostic Imaging (Research), Brown University; Senior Program Officer, Maternal, Newborn & Child Health Discovery & Tools, Discovery & Translational Sciences, Bill & Melinda Gates Foundation USA
| | - Jed T Elison
- Associate Professor, Institute of Child Development, Department of Pediatrics, University of Minnesota USA
| | - Damien Fair
- Redleaf Endowed Director, Masonic Institute for the Developing Brain; Professor, Institute of Child Development, College of Education and Human Development; Professor, Department of Pediatrics, Medical School, University of Minnesota USA
| | - Michael Garwood
- Malcolm B. Hanson Professor of Radiology, Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota USA
| | - Michael S Gee
- Vice-Chair of Clinical Operations, Chief of Pediatric Radiology, Pediatric Imaging Research Center Director, Massachusetts General Hospital; Co-Director, Mass General Imaging Global Health Educational Programs USA
| | - Sairam Geethanath
- Associate Research Scientist, Columbia Magnetic Resonance Research Center, Columbia University USA
| | - Kendrick Kay
- Assistant Professor, Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota USA
| | - Kelvin O Lim
- Professor, Vice-Chair of Research, Drs. T. J. and Ella M. Arneson Land-Grant Chair in Human Behavior, Department of Psychiatry and Behavioral Sciences, University of Minnesota USA
| | - Georgia Lockwood Estrin
- Sir Henry Wellcome Postdoctoral Research Fellow, Centre for Brain and Cognitive Development, Department of Psychological Sciences, Birkbeck College, University of London UK
| | - Monica Luciana
- Professor, Department of Psychology; Adjunct Faculty Member, Institute of Child Development; Core Faculty Member, Center for Neurobehavioral Development, University of Minnesota USA
| | | | - Karen Rommelfanger
- Director, Neuroethics Program, Center for Ethics; Associate Professor, Departments of Neurology and Psychiatry and Behavioral Sciences, School of Medicine, Emory University USA
| | - Nicoline Schiess
- Technical Officer, Brain Health Unit, World Health Organization Switzerland
| | - Khan Siddiqui
- Chief Medical Officer and Chief Strategy Officer, Hyperfine USA
| | - Efraín Torres
- PhD Candidate in the Department of Biomedical Engineering, NSF GRFP Fellow, University of Minnesota; Garwood Lab member USA
| | - J Thomas Vaughan
- Professor in the Departments of Biomedical Engineering and Radiology, Director of the Columbia Magnetic Resonance Research Center; Principal and Investigator and MR Platform Director of the Zuckerman Institute, Columbia University; Director of the High Field Imaging Lab, Nathan Kline Institute USA
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Bhavnani S, Mukherjee D, Bhopal S, Sharma KK, Dasgupta J, Divan G, Soremekun S, Roy R, Kirkwood B, Patel V. The association of a novel digital tool for assessment of early childhood cognitive development, 'DEvelopmental assessment on an E-Platform (DEEP)', with growth in rural India: A proof of concept study. EClinicalMedicine 2021; 37:100964. [PMID: 34195580 PMCID: PMC8225699 DOI: 10.1016/j.eclinm.2021.100964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/21/2021] [Accepted: 05/28/2021] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND There is an urgent need to fill the gap of scalable cognitive assessment tools for preschool children to enable identification of children at-risk of sub-optimal development and to support their timely referral into interventions. We present the associations between growth in early childhood, a well-established marker of cognitive development, and scores on a novel digital cognitive assessment tool called DEvelopmental Assessment on an E-Platform (DEEP) on a sample of 3-year old pre-schoolers from a rural region in north India. METHODS Between February 2018 and March 2019, 1359 children from the Sustainable Programme Incorporating Nutrition and Games (SPRING) programme were followed up at 3-years age and data on DEEP, anthropometry and a clinical developmental assessment, the Bayley's Scale of Infant and Toddler Development, 3rd edition (BSID-III) was collected. DEEP data from 200 children was used to train a machine learning algorithm to predict their score on the cognitive domain of BSID-III. The DEEP score of the remaining 1159 children was then predicted using this algorithm to examine the cross-sectional and prospective association of growth with the DEEP score. FINDINGS The magnitude of the concurrent positive association between height-for-age and cognitive z-scores in 3-year olds was similar when cognition was measured by BSID-III (0.20 standard deviations increase for every unit change in specifically age-adjusted height (HAZ), 95% CI = 0.06-0.35) and DEEP (0.26 CI, 0.11-0.41). A similar positive prospective relationship was found between growth at 18 (0.21 CI, 0.17-0.26) and 12-months (0.18 CI, 0.13-0.23) and DEEP score measured at 3-years. Additionally, the relationship between growth and cognitive development was found to be dependant on socioeconomic status (SES). INTERPRETATION In this study, we suggest the utility of DEEP, a scalable, digital cognitive assessment tool, to measure cognition in preschool children. Further validation in different and larger datasets is necessary to confirm our findings. FUNDING The SPRING Programme was funded through a Wellcome Trust programme grant and the follow-up study by the Corporate Social Responsibility initiative grant from Madura Microfinance Ltd.
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Affiliation(s)
- Supriya Bhavnani
- Child Development Group, Sangath, Goa, India
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, India
| | - Debarati Mukherjee
- Indian Institute of Public Health-Hyderabad, Bengaluru Campus, Bengaluru, Karnataka, India
| | - Sunil Bhopal
- Maternal & Child Health Intervention Research Group, Department of Population Health, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Population Health Sciences Institute, Newcastle University, United Kingdom
| | | | | | - Gauri Divan
- Child Development Group, Sangath, Goa, India
| | - Seyi Soremekun
- Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London United Kingdom
- Observational and Pragmatic Research Institute, Singapore
| | - Reetabrata Roy
- Child Development Group, Sangath, Goa, India
- Maternal & Child Health Intervention Research Group, Department of Population Health, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Betty Kirkwood
- Maternal & Child Health Intervention Research Group, Department of Population Health, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Vikram Patel
- Child Development Group, Sangath, Goa, India
- Department of Global Health & Social Medicine, Harvard Medical School, United States
- Department of Global Health and Population, Harvard T H Chan School of Public Health, United States
- Corresponding author at: Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
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Bhavnani S, Divan G, Patel V. Converging disciplines for assessing child development. iScience 2021; 24:102462. [PMID: 34027320 PMCID: PMC8121958 DOI: 10.1016/j.isci.2021.102462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Supriya Bhavnani
- Child Development Group, Sangath, House 451 Bhatkar Waddo, Succor, Bardez, Goa, India 403501
| | - Gauri Divan
- Child Development Group, Sangath, House 451 Bhatkar Waddo, Succor, Bardez, Goa, India 403501
| | - Vikram Patel
- Child Development Group, Sangath, House 451 Bhatkar Waddo, Succor, Bardez, Goa, India 403501
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
- Department of Global Health and Population, Harvard T H Chan School of Public Health, 655 Huntington Avenue, Boston, MA 02115, USA
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Divan G, Bhavnani S, Leadbitter K, Ellis C, Dasgupta J, Abubakar A, Elsabbagh M, Hamdani SU, Servili C, Patel V, Green J. Annual Research Review: Achieving universal health coverage for young children with autism spectrum disorder in low- and middle-income countries: a review of reviews. J Child Psychol Psychiatry 2021; 62:514-535. [PMID: 33905120 DOI: 10.1111/jcpp.13404] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Autism presents with similar prevalence and core impairments in diverse populations. We conducted a scoping review of reviews to determine key barriers and innovative strategies which can contribute to attaining universal health coverage (UHC), from early detection to effective interventions for autism in low- and middle-income countries (LAMIC). METHODS A systematic literature search of review articles was conducted. Reviews relevant to the study research question were included if they incorporated papers from LAMIC and focused on children (<eight years old) with autism or their caregivers. The database search was supplemented with bibliographic search of included articles and key informant suggestions. Data were extracted and mapped onto a Theory of Change model toward achieving UHC for autism in LAMIC. RESULTS We identified 31 articles which reviewed data from over fifty countries across Africa, Latin America, Middle East, and Asia and addressed barriers across one or more of four inter-related domains: (a) the social context and family experience for a child with autism; (b) barriers to detection and diagnosis; (c) access to appropriate evidence-based intervention; and (d) social policy and legislation. Key barriers identified included: lack of appropriate tools for detection and diagnosis; low awareness and experienced stigma impacting demand for autism care; and the prevalence of specialist models for diagnosis and treatment which are not scalable in LAMIC. CONCLUSIONS We present a Theory of Change model which describe the strategies and resources needed to realize UHC for children with autism in LAMIC. We highlight the importance of harnessing existing evidence to best effect, using task sharing and adapted intervention strategies, community participation, and technology innovation. Scaling up these innovations will require open access to appropriate detection and intervention tools, systematic approaches to building and sustaining skills in frontline providers to support detection and deliver interventions embedded within a stepped care architecture, and community awareness of child development milestones.
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Affiliation(s)
- Gauri Divan
- Child Development Group, Sangath, Bardez, Goa, India
| | | | - Kathy Leadbitter
- Division of Neuroscience & Experimental Psychology, University of Manchester, Manchester, UK
| | - Ceri Ellis
- Division of Neuroscience & Experimental Psychology, University of Manchester, Manchester, UK
| | | | - Amina Abubakar
- Institute of Human Development, Aga Khan University, Nairobi, Kenya
| | - Mayada Elsabbagh
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Syed Usman Hamdani
- Human Development Research Foundation, Punjab, Pakistan.,University of Liverpool, Liverpool, UK
| | - Chiara Servili
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jonathan Green
- Child and Adolescent Psychiatry, University of Manchester and Manchester Academic Health Sciences Centre, Manchester, UK.,Royal Manchester Children's Hospital, Manchester, UK
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Kye J, Bagsic S, Kuo R, Cohoon T, Bhavnani S, Almeida S, Price M, Robinson A, Gonzalez J, Wesbey G. Gender interaction effect on coronary lumen volume to mass ratio after administration of sublingual GTN powder compared to tablet in coronary computed tomography angiography (CCTA). Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Nitroglycerin (GTN) results in improved CCTA image quality and diagnostic accuracy due to vasodilation and improved contrast density. Although studies have shown that sublingual (SL) GTN spray has greater vasodilation and faster onset and duration of action compared to SL tablet, it is not commonly used due to cost. The comparative efficacy of SL GTN powder in CCTA is unknown.
Purpose
The purpose of this study is to determine whether SL GTN powder can increase the coronary lumen volume (V) and the coronary lumen volume to left myocardial mass ratio (V/M) compared to SL GTN tablet.
Methods
34 patients (17 females) with 0.8 mg SL GTN powder and 34 patients (17 females) with 0.8 mg SL GTN tablet administration were included in this retrospective case-control study. GTN was given 5 minutes pre-CCTA on a 256 slice single-heartbeat CT. Inclusion criteria: CAD-RADS 0 or 1, precontrast LM + LAD AJ-130 CAC < 100, heart rate less than 75, phase of the cardiac cycle diastole, successful motion correction, Likert score 4 or 5, right- or co-dominance. The primary outcome assessed was left main plus left anterior descending (LM + LAD) V between GTN powder vs tablet. The secondary outcomes were LM + LAD V divided by 1) length of LM + LAD (derived mean area, A), and 2) M (V/M). The outcomes were measured by blinded PI with 17 yrs CCTA experience on GE workstation, 2020 version. Categorical variables were compared by Chi-Squared tests and continuous variables were compared between powder and tablet groups by unpaired t-tests if normally distributed, and Mann-Whitney U tests otherwise. Exploratory outcome analyses tested route of administration by sex interactions and main effects by Two-Way ANOVA’s. Further covariate-adjusted analyses were conducted using multiple linear regression models.
Results
Baseline characteristics were similar between powder and tablet administration. No statistically significant difference in median V, LM + LAD derived A , or median V/M was observed. A sex main effect demonstrated that females had significantly smaller V (630.6 mm3 vs 951.7 mm3, p< 0.0001) and A (4.2 mm2 vs 6.4 mm2, p< 0.0001) compared to males. These V and A sex differences were also observed when BMI or weight were included as covariates. When V and A were normalized by M, both revealed sex interactions depending on formulation. While males had higher normalized V and A in powder vs tablet (p < 0.04), females had the opposite with higher normalized V and A with tablet compared to powder (p < 0.04).
Conclusions
SL administration of the GTN powder 5 minutes before CCTA did not result in greater vasodilatory effect compared to the GTN tablet. However, gender interaction effects were observed, with greater V/M and A/M ratio in males with powder and greater V/M and A/M in women with tablet. These results suggest a potential differential gender effect based on the formulation of GTN. Prospective studies are warranted to evaluate these findings.
Abstract Figure. LM + LAD Lumen Volume to LV Mass by Sex
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Affiliation(s)
- J Kye
- Scripps Prebys Cardiovascular Institute, Pharmacy, La Jolla, United States of America
| | - S Bagsic
- Scripps Hub Academic Research Core , Scripps Whittier Diabetes Institute, La Jolla, United States of America
| | - R Kuo
- Scripps Prebys Cardiovascular Institute, Pharmacy, La Jolla, United States of America
| | - T Cohoon
- Scripps Prebys Cardiovascular Institute, Department of Medicine, La Jolla, United States of America
| | - S Bhavnani
- Scripps Prebys Cardiovascular Institute, Scripps Clinic Medical Group, Division of Cardiovascular Diseases, La Jolla, United States of America
| | - S Almeida
- HCA Midwest Heart and Vascular Specialists, Cardiology, Kansas City, United States of America
| | - M Price
- Scripps Prebys Cardiovascular Institute, Scripps Clinic Medical Group, Division of Cardiovascular Diseases, La Jolla, United States of America
| | - A Robinson
- Scripps Prebys Cardiovascular Institute, Scripps Clinic Medical Group, Division of Cardiovascular Diseases, La Jolla, United States of America
| | - J Gonzalez
- Scripps Prebys Cardiovascular Institute, Scripps Clinic Medical Group, Division of Cardiovascular Diseases and Radiology, La Jolla, United States of America
| | - G Wesbey
- Scripps Prebys Cardiovascular Institute, Scripps Clinic Medical Group, Division of Cardiovascular Diseases and Radiology, La Jolla, United States of America
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Cohoon T, Udoh E, Kolossváry M, Newlander S, Szilveszter B, Á. J, Maurovich-Horvat P, Bhavnani S, Gonzalez J, Wesbey G. Reconstructing Zero: The Impact Of Filtered Back Projection, Iterative Reconstruction, Deep Learning Reconstruction On Coronary Calcium Scoring Near Zero. J Cardiovasc Comput Tomogr 2020. [DOI: 10.1016/j.jcct.2020.06.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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23
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Udoh E, Cohoon T, Kolossváry M, Newlander S, Szilveszter B, Á. J, Maurovich-Horvat P, Bhavnani S, Gonzalez J, Wesbey G. The Effect Of Deep Learning Noise Reduction Image Reconstruction On CT Coronary Artery Calcium Agatston Score. J Cardiovasc Comput Tomogr 2020. [DOI: 10.1016/j.jcct.2020.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mukherjee D, Bhavnani S, Swaminathan A, Verma D, Parameshwaran D, Divan G, Dasgupta J, Sharma K, Thiagarajan TC, Patel V. Proof of Concept of a Gamified DEvelopmental Assessment on an E-Platform (DEEP) Tool to Measure Cognitive Development in Rural Indian Preschool Children. Front Psychol 2020; 11:1202. [PMID: 32587551 PMCID: PMC7299081 DOI: 10.3389/fpsyg.2020.01202] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 05/08/2020] [Indexed: 11/17/2022] Open
Abstract
Over 250 million children in developing countries are at risk of not achieving their developmental potential, and unlikely to receive timely interventions because existing developmental assessments that help identify children who are faltering are prohibitive for use in low resource contexts. To bridge this “detection gap,” we developed a tablet-based, gamified cognitive assessment tool named DEvelopmental assessment on an E-Platform (DEEP), which is feasible for delivery by non-specialists in rural Indian households and acceptable to all end-users. Here we provide proof-of-concept of using a supervised machine learning (ML) approach benchmarked to the Bayley’s Scale of Infant and Toddler Development, 3rd Edition (BSID-III) cognitive scale, to predict a child’s cognitive development using metrics derived from gameplay on DEEP. Two-hundred children aged 34–40 months recruited from rural Haryana, India were concurrently assessed using DEEP and BSID-III. Seventy percent of the sample was used for training the ML algorithms using a 10-fold cross validation approach and ensemble modeling, while 30% was assigned to the “test” dataset to evaluate the algorithm’s accuracy on novel data. Of the 522 features that computationally described children’s performance on DEEP, 31 features which together represented all nine games of DEEP were selected in the final model. The predicted DEEP scores were in good agreement (ICC [2,1] > 0.6) and positively correlated (Pearson’s r = 0.67) with BSID-cognitive scores, and model performance metrics were highly comparable between the training and test datasets. Importantly, the mean absolute prediction error was less than three points (<10% error) on a possible range of 31 points on the BSID-cognitive scale in both the training and test datasets. Leveraging the power of ML which allows iterative improvements as more diverse data become available for training, DEEP, pending further validation, holds promise to serve as an acceptable and feasible cognitive assessment tool to bridge the detection gap and support optimum child development.
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Affiliation(s)
- Debarati Mukherjee
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurugram, India
| | - Supriya Bhavnani
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurugram, India.,Child Development Group, Sangath, Goa, India
| | - Akshay Swaminathan
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
| | | | | | - Gauri Divan
- Child Development Group, Sangath, Goa, India
| | | | | | | | - Vikram Patel
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurugram, India.,Child Development Group, Sangath, Goa, India.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
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Bhavnani S, Mukherjee D, Dasgupta J, Verma D, Parameshwaran D, Divan G, Sharma KK, Thiagarajan T, Patel V. Development, feasibility and acceptability of a gamified cognitive DEvelopmental assessment on an E-Platform (DEEP) in rural Indian pre-schoolers - a pilot study. Glob Health Action 2019; 12:1548005. [PMID: 31154989 PMCID: PMC6338262 DOI: 10.1080/16549716.2018.1548005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Assessment of cognitive development is essential to identify children with faltering developmental attainment and monitor the impact of interventions. A key barrier to achieving these goals is the lack of standardized, scalable tools to assess cognitive abilities. Objective: This study aimed to develop a tablet-based gamified assessment of cognitive abilities of 3-year-old children which can be administered by non-specialist field workers. Methods: Workshops among domain experts, literature search for established and gamified paradigms of cognitive assessments and rapid review of mobile games for 3-year-old children was done to conceptualize games for this study. Formative household visits (N = 20) informed the design and content of the games. A cross-sectional pilot study (N = 100) was done to assess feasibility of the tool and check if increasing levels of difficulty and the expected variability between children were evident in game metrics. In-depth interviews (N = 9) were conducted with mothers of participating children to assess its acceptability. Results: Six cognitive domains were identified as being integral to learning – divided attention, response inhibition, reasoning, visual form perception and integration and memory. A narrative, musical soundtrack and positive reinforcement were incorporated into the tool to enhance participant engagement. Child performance determined level timers and difficulty levels in each game. Pilot data indicate that children differ in their performance profile on the tool as measured by the number of game levels played and their accuracy and completion time indicating that it might be possible to differentiate children based on these metrics. Qualitative data suggest high levels of acceptability of the tool amongst participants. Conclusions: A DEvelopmental assessment on an E-Platform (DEEP) has been created comprising distinct games woven into a narrative, which assess six cognitive domains, and shows high levels of acceptability and generates metrics which may be used for validation against gold standard cognitive assessments.
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Affiliation(s)
- Supriya Bhavnani
- a Centre for Chronic Conditions and Injuries , Public Health Foundation of India , Gurugram , India
| | - Debarati Mukherjee
- a Centre for Chronic Conditions and Injuries , Public Health Foundation of India , Gurugram , India
| | - Jayashree Dasgupta
- a Centre for Chronic Conditions and Injuries , Public Health Foundation of India , Gurugram , India.,b Sangath , New Delhi , India
| | | | | | | | | | | | - Vikram Patel
- d Department of Global Health and Social Medicine , Harvard Medical School and the Harvard Chan School of Public Health , Boston , MA , USA
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Dasgupta J, Bhavnani S, Estrin GL, Mukherjee D, Banerjee A, Belmonte MK, Chakrabarti B, Divan G, Dawson G, Johnson MH, McPartland JC, Singh NC, Patel V. Translating neuroscience to the front lines: point-of-care detection of neuropsychiatric disorders. Lancet Psychiatry 2016; 3:915-917. [PMID: 27692259 DOI: 10.1016/s2215-0366(16)30186-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 06/29/2016] [Accepted: 07/04/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Jayashree Dasgupta
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, India
| | - Supriya Bhavnani
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, India
| | | | - Debarati Mukherjee
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, India
| | | | | | | | | | - Geraldine Dawson
- Department of Psychiatry and Behavioral Sciences, Duke Center for Autism and Brain Development, Duke University, North Carolina, USA; Department of Pediatrics, Duke Center for Autism and Brain Development, Duke University, North Carolina, USA; Department of Psychology and Neuroscience, Duke Center for Autism and Brain Development, Duke University, North Carolina, USA
| | - Mark H Johnson
- Centre for Brain and Cognitive Development, Birkbeck College, London UK
| | | | | | - Vikram Patel
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, India; Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK.
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Lokaj P, Krivan L, Kozak M, Sepsi M, Trcka P, Vlasinova J, Spinar J, Ferraro A, Rordorf R, Belvito C, Vicentini A, Savastano S, Petracci B, Sanzo A, Landolina M, Greenberg S, Goldman D, Deering T, Epstein A, Burke J, Dalal Y, Hurley J, Robinson B, Melton C, Patel M, Saporito J, Charlton S, Sims JJ, Van Casteren L, Heidbuchel H, Rossenbacker T, Gopal R, Vanhaecke J, Van Cleemput J, Droogne W, Willems R, Rocha Costa S, Silva J, Almeida S, Reis Santos K, Cavaco D, Morgado F, Adragao P, Silva A, Kanoupakis EM, Mavrakis HE, Kallergis EM, Koutalas EP, Saloustros IG, Milathianaki M, Manios EG, Vardas PE, Richey M, Malkin RA, Masson SC, Ransbury T, Urtz M, Ideker RE, Sanders WE, Greenberg S, Deering T, Goldman D, Epstein A, Burke J, Dalal Y, Brembilla-Perrot B, Azman B, Terrier De La Chaise A, Blangy H, Sadoul N, Claudon O, Louis P, Selton O, Braunschweig F, Ekman M, Maschio M, Linde C, Cowie MR, Pignalberi C, Lavalle C, Morichelli L, Porfili A, Quarta L, Sassi A, Ricci RP, Santini M, Deering TF, Goldman DS, Greenberg S, Epstein A, Gupta M, Gall SA, Kelland NF, Tynan M, Lord SW, Plummer CJ, Mccomb JM, Treguer F, Mabo P, Tassin A, Prunier F, Furber A, Daubert JC, Leclercq C, Dupuis JM, Bertini M, Ng ACT, Borleffs CJW, Delgado V, Boriani G, Leung DY, Schalij MJ, Bax JJ, Cabrera Bueno F, Alzueta J, Pena-Hernandez J, Molina-Mora MJ, Fernandez-Pastor J, Barrera A, De Teresa E, Stockburger M, Krebs A, Rauchhaus M, Celebi O, Nitardy A, Habedank D, Knaus T, Dietz R, Varma N, Epstein A, Irimpen A, Gibson L, Love C, Hindricks G, Elsner C, Geller J, Kautzner J, Moertel HB, Piorkowski C, Schumacher B, Taborsky M, Vest R, Blanco R, Valadri R, Shukrullah I, London B, Dudley S, Zafari M, Bloom H, Caliskan K, Theuns DF, Hoedemakers YM, Ten Cate FJ, Jordaens L, Szili Torok T, Biscione F, Di Grazia A, Pandolfo L, Porzio A, Deneke T, Lemke B, Horlitz M, Reinecke J, Lawo T, Muegge A, Grewe P, Borleffs CJW, Van Rees JB, Van Welsenes GH, Van Bommel RJ, Van Der Velde ET, Van Erven L, Bax JJ, Schalij MJ, Bhavnani S, Coleman C, Guertin D, White CM, Yarlagadda R, Clyne C, Kluger J. Poster Session 2: Primary prevention. Europace 2009. [DOI: 10.1093/europace/euq203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Satchell DPN, Satchell RS, Bhavnani S. The kinetics and mechanism of the silver ion-promoted hydrolysis of thiolurethanes in aqueous solution. ACTA ACUST UNITED AC 1993. [DOI: 10.1039/p29930001543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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