A longitudinal study of incident hypertension and its determinants in Indian adults aged 45 years and older: evidence from nationally representative WHO-SAGE study (2007-2015)

Objectives

Hypertension (HT) is a leading cause of mortality and morbidity in developing countries. This study aimed to estimate the incidence of HT among adults aged 45 years and older in India and its associated risk factors.

Methods

This study used longitudinal data from the Indian sample of the first and second waves of the World Health Organization Study on Global Ageing and Adult Health (WHO-SAGE). A bivariate analysis using Pearson's chi-square test was done to examine the associations of individual, lifestyle, and household characteristics with HT status reported in Wave 2. Incident HT changes were analyzed by adjusting for various covariates in the generalized estimating equation (logit link function) with an exchangeable correlation matrix and robust standard errors.

Results

The study found that during the 8-year period from 2007 to 2015, the incidence of HT in individuals aged 45 years and over was 20.8%. Pre-hypertensive individuals had an overall incidence rate of 31.1 per 1,000 [95% confidence interval (CI): 26.20-35.9] and a 2.24 times higher odds ratio: 2.24 (95% CI: 1.65-3.03) of developing incident HT compared to those who were normotensive. Adults aged 45 years and older, overweight/obese individuals, and women were more at risk of incident HT.

Conclusion

One in five individuals had developed HT over 8 years, with a greater risk of incident HT among women than men. Pre-hypertensive individuals were at a greater risk of developing incident HT compared to normotensive individuals. The study recommends comprehensive and effective management of pre-HT to tackle the burden of HT.

Decomposition analysis of the decline in binary and triad undernutrition among preschool children in India

BACKGROUND

To examine the socio-demographic factors associated with the decline in undernutrition among preschool children in India from National Family Health Survey (NFHS)-3, 2005-06 to NFHS- 5, 2019-21.

METHODS

For this study data were obtained from India's nationally representative datasets such as NFHS-3 and NFHS-5. The outcome variables for this study were Binary undernutrition which were defined as the coexistence of anemia and either stunting or wasting and Undernutrition triad which were defined as the presence of Iron deficiency anemia, stunting and wasting, respectively. Decomposition analysis was used to study the factors responsible for a decline in undernutrition. This method was employed to understand how these factors contributed to the decline in undernutrition whether due to change in the composition (change in the composition of the population) or propensity (change in the health-related behaviour of the population) of the population over a period of 16 years.

RESULTS

Results showed that rate, which contributes 85.26% and 65.64%, respectively, to total change, was primarily responsible for a decline in both binary undernutrition and undernutrition triad. Reduction in Binary undernutrition was mainly explained by the change in the rate of education level of the mothers and media exposer during the inter-survey period. On the other hand, the decline in the Undernutrition triad can be explained by household wealth index, mother's education, birth order and a change in people's knowledge or practice about the preceding birth interval.

CONCLUSION

Identifying important factors and understanding their relationship with the decline of undernutrition can be beneficial for reorienting nutrition-specific policies to achieve the targets of the Sustainable Development Goals by 2030.

Clustering of child deaths among families in low and middle-income countries: A meta-analysis

Background and Aims

Several studies have examined the phenomenon of "death clustering," in which two or more children born to the same mother or from the same family die at an early age. Therefore, a scientific examination of the results is essential to understand how the survival status of the older siblings affects the survival of the younger siblings. By using meta-analysis, this study aims to provide a quantitative synthesis of the results of studies on "child death clustering" in low- and middle-income countries (LMICs).

Methods

This study followed the PRISMA-P 2015 guidelines. We used four electronic databases-PubMed, Medline, Scopus, and Google Scholar with search and citation analysis capabilities. Initially, 140 studies were identified, but only 27 met the eligibility criteria eventually. These were studies that had used the death of a previous child as a covariate to determine the survival status of the index child. The heterogeneity and the publication bias of the studies were examined using the Cochran test, I ² statistic, and Egger's meta-regression test.

Results

The pooled estimate of 114 study estimates for LMICs contains some bias. India's 37 study estimates were distributed more or less equally along the middle line, indicating no publication bias, while there was a slight bias in the estimates for Africa, Latin America, and Bangladesh. The odds of experiencing the death of the index child in the selected LMICs were 2.3 times higher for mothers who had lost any prior child as compared to those mothers who had not had any prior child loss. For African mothers, the odds were five times higher, whereas for Indian mothers, the odds were 1.66 times higher. Mothers' characteristics, such as education, occupation, health-seeking behavior, and maternal competence, significantly affect the child's survival status.

Conclusion

Achieving the sustainable development goals would not be possible if mothers in countries experiencing high levels of under-five mortality are not provided with better health and nutrition facilities. Mothers who have lost multiple children should be targeted for assistance.

Role of seasonality variation in prevalence and trend of childhood wasting in India: An empirical analysis using National Family Health Surveys, 2005-2021

Background

Wasting develops over a short period and can be reversed with short-term interventions. The prevalence of wasting typically varies from season to season-becoming higher during the monsoon (June to September) season as compared to the winter (October to January) and summer (February to May) seasons every year in a cyclical fashion. However, to the best of our knowledge, using nationally representative demographic surveys to extensively study the impact of the timing of the survey on the results and trends around wasting has not been done so far.

Objectives

The goal of this study is to ascertain whether seasonality has an impact on the trend and levels of wasting between NFHS-3 (2005-2006) and NFHS-5 (2019-2021).

Methods

The analysis was based on data on 51,555, 259,627, and 232,920 children under 5 years included in NFHS-3, NFHS-4, and NFHS-5 respectively. Multivariable logistic regression analysis and the predicted probabilities approach were employed to examine the effect of the months of interview on the prevalence of wasting. The analysis was conducted for 9 states of India which had data for comparable months to compute wasting levels.

Results

We found that at the national level, wasting increased in India by one per cent from NFHS-3 to NFHS-4 but declined by 2% from NFHS-4 to NFHS-5. The results show that seasonality significantly influenced the prevalence of wasting. It was observed that compared to January, the odds of wasting were particularly higher in summer and monsoon seasons, especially in the month of August across all three rounds, indicating the influence of seasonality in the prevalence of wasting in the country.

Discussion

The prevalence of wasting in India needs to be interpreted across seasonal changes as seasonality affects many of the variables intrinsically related to child health and nutritional status.

Comparing socio-economic inequalities in self-reported and undiagnosed hypertension among adults 45 years and over in India: what explains these inequalities?

BACKGROUND

Hypertension (HTN) is a leading cause of mortality and morbidity in developing countries. For India, the hidden burden of undiagnosed hypertension is a major concern. This study aims to assess and explain socio-economic inequalities among self-reported and undiagnosed hypertensives in India.

METHODS

The study utilized data from the Longitudinal Aging Study in India (LASI), a nationally-representative survey of more than 72,000 older adults. The study used funnel plots, multivariable logistic regression, concentration indices, and decomposition analysis to explain the socio-economic gap in the prevalence of self-reported and undiagnosed hypertension between the richest and the poorest groups.

RESULTS

The prevalence of self-reported and undiagnosed hypertension was 27.4 and 17.8% respectively. Monthly per capita consumption expenditure (MPCE) quintile was positively associated with self-reported hypertension but negatively associated with undiagnosed hypertension. The concentration index for self-reported hypertension was 0.133 (p < 0.001), whereas it was - 0.047 (p < 0.001) for undiagnosed hypertension. Over 50% of the inequalities in self-reported hypertension were explained by the differences in the distribution of the characteristics whereas inequalities remained unexplained for undiagnosed hypertension. Obesity and diabetes were key contributors to pro-rich inequality.

CONCLUSIONS

Results imply that self-reported measures underestimate the true prevalence of hypertension and disproportionately affect the poorer MPCE groups. The prevalence of self-reported HTN was higher in the richest group, whereas socio-economic inequality in undiagnosed hypertension was significantly concentrated in the poorest group. As majority of the inequalities remain unexplained in case of undiagnosed hypertension, broader health systems issues including barriers to access to health care may be contributing to inequalities.

Validity of self-reported hypertension in India: Evidence from nationally representative survey of adult population over 45 years

Self‐reported measures of health, in the context of developed countries, are well‐researched and commonly regarded as reliable predictors of the underlying health of the population. However, the validity of these measures is under‐researched and questionable in the context of low‐ and middle‐income countries. The authors used Longitudinal Ageing Study in India (LASI) survey data from India to compare self‐reported hypertension with biometrically‐measured hypertension. The results are reported in terms of sensitivity, specificity, and kappa as a measure of agreement. Logistic regression was undertaken to examine the characteristics of those who were unaware of their hypertensive status. Our analysis showed a low sensitivity of 56% and a high specificity of 90.5%. Agreement between self‐reported data and biometric measurement of hypertension was observed to be moderate (κ = 0.48). Large variations were observed among states and sub‐groups. The odds of false negative reporting of hypertension were lower in the individuals with higher age, high education, and greater wealth status. The authors conclude that self‐reported hypertension has important limitations and may be a source of systematic bias. It is recommended that planning and policy‐making in India be based more on an objective assessment of hypertension.

Diagnosis and Treatment of Hypertension Among People Aged 45 Years and Over in India: A Sub-national Analysis of the Variation in Performance of Indian States

Introduction: Cardiovascular disease (CVD) is the single largest contributor to non-communicable disease (NCD) deaths, with hypertension contributing to a significant proportion of these deaths. This study aims to provide estimates of the prevalence, awareness, treatment and control of hypertension at sub-national levels in India and identifies well and under-performing states with respect to the diagnosis and treatment of hypertension. Methods: The study utilises data from the Longitudinal Study of Ageing in India (LASI), a nationally representative survey of more than 72,000 individuals. Age-sex adjusted prevalence rates of self-reported hypertension was calculated using the direct standardisation method. Multivariable logistic regression was performed to assess the association of self-reported hypertension with the various individual co-morbidity, lifestyle, and household factors. Self-reported prevalence was compared with an objective measure of hypertension for each state, and funnel plots were constructed to assess the performance of states. Results: Our findings suggest that the overall prevalence of age-sex adjusted self-reported hypertension was 25.8% in India with significant variation among states. Results based on logistic regression confirm that those individuals who are elderly, obese, belong to a higher socio-economic group and have associated co-morbidities are at increased odds of reporting hypertension. Overall, 4 out of 10 adults over 45 years of age in India are not aware of their hypertensive condition, and of those who are aware, 73% are currently taking medication, and only 10% of these have their hypertension under control. Based on the performance, states were classified into high and low performing categories. States with an increased proportion of population below the poverty line had significantly lower performance with respect to the diagnosis of hypertension, whereas states with higher literacy rates and greater availability of specialist doctors at community health centres (CHCs) had significantly better performance with respect to treatment-seeking behaviour. Conclusion: The findings of this study and its policy implications are discussed. Based on state performance, strategies are proposed in terms selective targeting vs. population-based strategies. High impact states and sub-groups are identified where intense efforts are needed to tackle the growing menace of hypertension in India.

1283 The Management of Multiple Morton’s Neuromas in the Same Foot: A Systematic Review

Aim

The optimal treatment strategy for the presentation of multiple Morton’s neuromas in adjacent intermetatarsal spaces of the same foot is yet to be determined. This systematic review aims to summarise and assess the efficacy of current treatment strategies.

Method

A systematic review was performed using the PRISMA guidelines. The review is registered in the international prospective register of systematic reviews (CRD42020213631). A computer-based search was completed in PubMed, Embase, Cinahl, Web of Science, Scopus and Emcare, for articles reporting the treatment of multiple neuromas in the same foot. Two authors independently performed title/abstract and full text screening according to a-priori selection criteria. Considering the four studies reporting treatment of a cohort containing both patients with a single neuroma and those with multiple neuromas, the proportion of cases in the latter group was 51/354 (14.41%).

Results

A total of 253 articles were identified, with 7 articles, involving 383 patients being included in the review. The most common treatment strategy reported was simultaneous neuroma excision using a single incision, whilst two studies each describe simultaneous excision with two separate incisions and delayed excision, respectively. The proportion of patients

Discussion

There is no strong evidence favouring use of delayed excision or multiple incisions. However, there is currently a lack of evidence focusing on this presentation of neuroma specifically. A number of studies fail to separate results of single and multiple neuroma excision. Further high-quality research is therefore required to make more definitive conclusions and future research should investigate other strategies such as non-operative treatment.

Pro-poor policies and improvements in maternal health outcomes in India

BACKGROUND

Since 2005, India has experienced an impressive 77% reduction in maternal mortality compared to the global average of 43%. What explains this impressive performance in terms of reduction in maternal mortality and improvement in maternal health outcomes? This paper evaluates the effect of household wealth status on maternal mortality in India, and also separates out the performance of the Empowered Action Group (EAG) states and the Southern states of India. The results are discussed in the light of various pro-poor programmes and policies designed to reduce maternal mortality and the existing supply side gaps in the healthcare system of India. Using multiple sources of data, this study aims to understand the trends in maternal mortality (1997-2017) between EAG and non EAG states in India and explore various household, economic and policy factors that may explain reduction in maternal mortality and improvement in maternal health outcomes in India.

METHODS

This study triangulates data from different rounds of Sample Registration Systems to assess the trend in maternal mortality in India. It further analysed the National Family Health Surveys (NFHS). NFHS-4, 2015-16 has gathered information on maternal mortality and pregnancy-related deaths from 601,509 households. Using logistic regression, we estimate the association of various socio-economic variables on maternal deaths in the various states of India.

RESULTS

On an average, wealth status of the households did not have a statistically significant association with maternal mortality in India. However, our disaggregate analysis reveals, the gains in terms of maternal mortality have been unevenly distributed. Although the rich-poor gap in maternal mortality has reduced in EAG states such as Bihar, Odisha, Assam, Rajasthan, the maternal mortality has remained above the national average for many of these states. The EAG states also experience supply side shortfalls in terms of availability of PHC and PHC doctors; and availability of specialist doctors.

CONCLUSIONS

The novel contribution of the present paper is that the association of household wealth status and place of residence with maternal mortality is statistically not significant implying financial barriers to access maternal health services have been minimised. This result, and India's impressive performance with respect to maternal health outcomes, can be attributed to the various pro-poor policies and cash incentive schemes successfully launched in recent years. Community-level involvement with pivotal role played by community health workers has been one of the major reasons for the success of many ongoing policies. Policy makers need to prioritise the underperforming states and socio-economic groups within the states by addressing both demand-side and supply-side measures simultaneously mediated by contextual factors.

893 Intestinal Stoma - A challenge for the Patient

Introduction

Formation of intestinal stoma is a widely performed surgical procedure worldwide. It is associated with variable complications which can impact physical and mental health of the patient. The purpose of this study is to study the aspects (indications, complications, change in quality-of-life etc) and make necessary recommendations for quality improvement and to make patient experience better.

Method

study included 150 patients with stoma formation. Data categorised according to indications, complications, based on their response to change to quality of life.

Results

A total of 150 patients were included in this study. There were 89 male (59.3%), female (40.6%). 63 patients (42%) had loop ileostomy;38 patients (25.3%) had transverse colostomy. 77 patients (51.3%) had bowel malignancy, diverticular perforation in 19.3%. 21 patients (14%) mentioned change into their self-esteem following the surgery, 14% patients reported decline in their sexual life.

Conclusions

Pre & postoperative assessments should be carried out in detail with the patient to help them understand the implications of having a “stoma”. Stoma nurse involvement helps the patient to accept the changes to their life after the surgery. Psychological &sexual consultation helps in improving patient’s response to the challenge it may impose.

An epidemic of avoidable caesarean deliveries in the private sector in India: Is physician-induced demand at play?

PURPOSE AND SETTING OF RESEARCH

Caesarean section (C-section) rates of over 15% suggest overuse of the surgery which may be difficult to justify on medical grounds. One important contributor to the rise in Csection rates is the rapid expansion of unregulated private-sector providers in number of settings. This study analyses the contribution of private sector in the rapid rise in Csection deliveries in India and the extent to which these can be justified on medical grounds.

METHODS

This is a cross sectional study design using National Family Health Surveys. Logistic regression and propensity score matching (PSM) analyses are performed. The main outcome measured is avoidable C-sections in the private sector.

PRINCIPAL FINDINGS

Our findings suggest that the rising trend in C-section rates in the private sector cannot be explained by medical reasons alone. The odds of C-section among women who chose to deliver in private was over 4 times higher than women who chose to delivery in public facilities. Despite, controlling for medical complications, women's characteristics and preferences, our PSM analysis suggest that the public-private gap has doubled over the years and that the difference cannot be explained by known determinants of C-section. Over supply of avoidable C-section to the extent of 21%, as a result of physician induced demand and perverse financial incentives was observed in the private sector.

CONCLUSIONS

This paper attempts to understand the reason for the high C-section rates in the private sector in India and the extent to which these are avoidable. Our analysis supports the assumption that physician induced demand as a result of perverse financial incentives in the private sector is at play.

Assessment of Variation in Cesarean Delivery Rates Between Public and Private Health Facilities in India From 2005 to 2016

IMPORTANCE

The rates of cesarean deliveries have more than doubled in India, from 8% of deliveries in 2005 to 17% of deliveries in 2016. The World Health Organization recommends that cesarean deliveries should not exceed 10% to 15% of all deliveries in any country. An understanding of the association of private and public facilities with the increase in cesarean delivery rates in India is needed.

OBJECTIVE

To assess the association of public vs private sector health care facilities with cesarean delivery rates in India and to estimate the potential cost savings if private sector facilities followed World Health Organization recommendation for cesarean deliveries.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used institutional delivery data from the representative National Family Health Survey (NFHS) in India, including data from the NFHS-1 (1992-1993), the NFHS-3 (2005-2006), and the NFHS-4 (2015-2016). The NFHS-3 and NFHS-4 provided data on 22 647 deliveries and 195 366 deliveries, respectively. The NHFS-4 was the first survey to provide data on out-of-pocket expenditures for delivery by facility type, allowing for a comparison of cesarean deliveries and costs between public and private facilities. The primary sample comprised all pregnant women who delivered infants in public and private institutional facilities in India and who were included the NFHS-3 and the NFHS-4; data on pregnant women who were included in the NFHS-1 were used for comparison. The study's findings were analyzed through geographic mapping, data tabulation, funnel plots, multivariate logistic regression analyses, and potential cost-savings scenario analyses. Data were analyzed from June to December 2019.

MAIN OUTCOMES AND MEASURES

The main outcome was the rate of cesarean deliveries by facility type (public vs private) and by participant socioeconomic, demographic, and health characteristics. Secondary outcomes were the potential number of avoidable cesarean deliveries and the potential cost savings if private sector facilities followed the World Health Organization recommendations for cesarean deliveries.

RESULTS

In the NFHS-3, 22 610 total births occurred at institutional facilities. Of those, 2178 births (15.2%) were cesarean deliveries in public facilities, and 3200 births (27.9%) were cesarean deliveries in private facilities. Of 195 366 total institutional births in the NFHS-4, 15 165 births (11.9%) were cesarean deliveries in public facilities, and 20 506 births (40.9%) were cesarean deliveries in private facilities. The cesarean delivery rate in public health facilities increased from 7.2% in the NFHS-1 to 11.9% in the NFHS-4, whereas in private health facilities, the rate increased from 12.3% to 40.9% during the same period. A substantial increase was found in cesarean delivery rates between the NFHS-3 (2005-2006) and the NFHS-4 (2015-2016), with 22 states exceeding the World Health Organization's upper threshold of 15% in the NFHS-4. The odds ratio for cesarean deliveries in private facilities compared with public facilities increased from 1.62 (95% CI, 1.49-1.76) in the NFHS-3 to 4.17 (95% CI, 4.04-4.30) in the NFHS-4. The number of avoidable cesarean deliveries would have been 1.83 million, with a potential cost savings of $320.60 million, if private sector facilities in India had followed the 15% threshold for cesarean delivery rates recommended by the World Health Organization.

CONCLUSIONS AND RELEVANCE

In this study, private sector health facilities were associated with a substantial increase in cesarean deliveries in India. Further research is needed to assess the factors underlying the increase in cesarean deliveries in private sector facilities.

COVID-19 and BAME Group in the United Kingdom

COVID-19 is known to disproportionately affect ethnic minorities in number of settings. This phenomenon has also been reported in the UK where the black, Asian and minority ethnic (BAME) group has adverse health outcomes in terms of number of both cases and mortality rates when compared to the white local population. This trend is also observed among the BAME staff working in the National Health Service. Number of plausible explanations and the importance of various approaches including social-determinants approach is pointed out. This pandemic has re-ignited the debate on social inequalities, issues around social deprivation and health inequalities within the UK. This article concludes with some policy recommendations.

Trends, patterns and predictive factors of infant and child mortality in well-performing and underperforming states of India: a secondary analysis using National Family Health Surveys

OBJECTIVES

This paper analyses the patterns and trends in the mortality rates of infants and children under the age of 5 in India (1992-2016) and quantifies the variation in performance between different geographical states through three rounds of nationally representative household surveys.

DESIGN

Three rounds of cross-sectional survey data.

SETTING

The study is conducted at the national level: India and its selected good-performing states, namely Haryana, Kerala, Maharashtra, Punjab and Tamil Nadu, and selected poor-performing states, namely Bihar, Chhattisgarh, Madhya Pradesh and Uttar Pradesh.

PARTICIPANTS

Adopting a multistage, stratified random sampling, 601 509 households with 699 686 women aged 15-49 years in 2015-2016, 109 041 households with 124 385 women aged 15-49 years in 2005-2006, and 88 562 households with 89 777 ever married women in the age group 13-49 years in 1992-1993 were selected.

RESULTS

Through the use of maps, this paper clearly shows that the overall trend in infant and child mortality is on a decline in India. Computation of relative change shows that majority of the states have witnessed over 50% reduction in both infant and under-5 mortality rates from National Family Health Survey (NFHS)-I to NFHS-4. However, the improvements are not evenly distributed, and there is huge variation in performance between states over time. Funnel plots show that the most populous states like Uttar Pradesh Bihar and Madhya Pradesh have underperformed consistently across the survey period from 1992 to 2016. Regression analysis comparing high-performing and low-performing states revealed that female infants and women with shorter birth intervals had greater risk of infant deaths in poor-performing states.

CONCLUSION

Attempts to reduce infant and child mortality rates in India are heading in the right direction. Even so, there is huge variation in performance between states. This paper recommends a mix of strategies that reduce child and infant mortality among the high-impact states where the biggest improvements can be expected, including the need to address neonatal mortality.

Mind the gap: Temporal trends in inequalities in infant and child mortality in India (1992-2016)

•

Temporal trends in inequalities in infant and child mortality over two and half decades in India.

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Relative change in inequalities in child mortality over survey periods.

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Scatter plots to identify states with largest inequalities among wealth index groups.

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Concentration Index by various background characteristics and decomposition analysis to identify factors contributing in inequality in infant mortality between richest and poorest groups.

•

Gap between the poorest and richest groups has narrowed in most states in India in recent years.

Corticosteroid injection for Morton's neuroma with or without ultrasound guidance: a randomised controlled trial

AIMS

The objective of this double-blind randomised controlled trial was to assess whether ultrasound guidance improved the efficacy of corticosteroid injections for Morton's neuroma (MN).

PATIENTS AND METHODS

In all, 50 feet (40 patients) were recruited for this study but five feet were excluded due to the patients declining further participation. The mean age of the remaining 36 patients (45 feet) was 57.8 years (standard deviation (sd) 12.9) with a female preponderance (33F:12M). All patients were followed-up for 12 months. Treatment was randomised to an ultrasound guided (Group A) or non-ultrasound guided (Group B) injection of 40 mg triamcinolone acetonide and 2 ml 1% lignocaine, following ultrasound confirmation of the diagnosis.

RESULTS

The mean visual analogue score for pain improved significantly in both groups (Group A - from 64 mm, sd 25 mm to 29 mm, sd 27; Group B - from 69 mm, sd 23 mm to 37 mm, sd 25) with no statistical difference between them at all time-points. The failure rate within 12 months of treatment was 11/23 (48%) and 12/22 (55%) in Groups A and B, respectively (p = 0.458). The improvement in Manchester Oxford Foot Questionnaire Index and patient satisfaction favoured Group A in the short-term (three months) that almost reached statistical significance (p = 0.059 and 0.066 respectively). However, this difference was not observed beyond three months.

CONCLUSION

This study has shown that ultrasound guidance did not demonstrably improve the efficacy of corticosteroid injections in patients with MN.

TAKE HOME MESSAGE

In the presence of a clear diagnosis of MN, a trained clinician who understands the forefoot anatomy may perform an injection without ultrasound guidance with good and safe results.

An evaluation of dark field microscopy, culture and commercial serological kits in the diagnosis of leptospirosis

CONTEXT

This study was conducted to analyze the clinical utility of various leptospira diagnostic modalities.

AIMS

To evaluate the role of dark field microscopy (DFM), culture, immunochromatography (IgM Leptocheck), IgM enzyme-linked immunosorbent assay (IgM ELISA), macroscopic slide agglutination test (MSAT) and microscopic agglutination test (MAT) in diagnosing leptospirosis in febrile patients.

SETTINGS AND DESIGN

Descriptive study conducted in a tertiary care hospital from January 2011 to April 2012.

SUBJECTS AND METHODS

Blood, urine and paired sera from 100 patients with clinical suspicion of leptospirosis (study group) were collected and subjected to DFM, culture, IgM Leptocheck, IgM ELISA and MSAT. Fifty randomly selected sera from febrile patients tested positive for infections other than leptospirosis (control sera) were also subjected to the aforementioned serological assays. All the leptospira seropositive samples were subjected to MAT.

STATISTICAL ANALYSIS USED

Positive predictive values (PPV) and coefficient of agreement (kappa).

RESULTS

None of the clinical samples showed positivity by DFM. Leptospira inadai was isolated from a urine sample. The seropositivity of IgM Leptocheck, IgM ELISA and MSAT was 16%, 46% and 47%, respectively. The PPV of these assays was 14.3%, 8.7% and 6.5%, respectively. Poor agreement was obtained among these assays. Only four study group leptospira seropositive samples were confirmed by MAT with Australis being the predominant serovar. None of the leptospira-positive control sera were confirmed by MAT.

CONCLUSIONS

DFM and culture have limited utility in diagnosing leptospirosis with serology being the mainstay. The present study shows discordant results with the commercially available serological kits. Further studies should be done to evaluate the various diagnostic modalities.

The safety and feasibility of probiotics in children and adolescents undergoing hematopoietic cell transplantation

Hematopoietic cell transplantation (HCT) has become a standard treatment for many adult and pediatric conditions. Emerging evidence suggests that perturbations in the microbiota diversity increase recipients' susceptibilities to gut-mediated conditions such as diarrhea, infection and acute GvHD. Probiotics preserve the microbiota and may minimize the risk of developing a gut-mediated condition; however, their safety has not been evaluated in the setting of HCT. We evaluated the safety and feasibility of the probiotic, Lactobacillus plantarum (LBP), in children and adolescents undergoing allogeneic HCT. Participants received once-daily supplementation with LBP beginning on day -8 or -7 and continued until day +14. Outcomes were compliance with daily administration and incidence of LBP bacteremia. Administration of LBP was feasible with 97% (30/31, 95% confidence interval (CI) 83-100%) of children receiving at least 50% of the probiotic dose (median 97%; range 50-100%). We did not observe any case of LBP bacteremia (0% (0/30) with 95% CI 0-12%). There were not any unexpected adverse events related to LBP. Our study provides preliminary evidence that administration of LBP is safe and feasible in children and adolescents undergoing HCT. Future steps include the conduct of an approved randomized, controlled trial through Children's Oncology Group.

Cystathionine-gamma-lyase gene silencing with siRNA in monocytes/macrophages protects mice against acute pancreatitis

Hydrogen sulphide (H2S) is an endogenous inflammatory mediator produced by cystathionine-γ-lyase (CSE) in monocytes/macrophages. To determine the role of H2S and macrophages in inflammation, we used small interference RNA (siRNA) to target the CSE gene and investigated its effect in a mouse model of acute pancreatitis. Acute pancreatitis is characterised by increased levels of plasma amylase, myeloperoxidase (MPO) activity and pro-inflammatory cytokines and chemokines in the pancreas and lung. SiRNA treatment attenuated inflammation in the pancreas and lungs of mice following caerulein-induced acute pancreatitis. MPO activity increased in caerulein-induced acute pancreatitis (16.21 ± 3.571 SD fold increase over control) and treatment with siRNA significantly reduced this (mean 3.555 ± 2.522 SD fold increase over control) (p < 0.0001). Similarly, lung MPO activity increased following treatment with caerulein (3.56 ± 0.941 SD fold increase over control) while siRNA treatment significantly reduced MPO activity (0.8243 ± 0.4353 SD fold increase over control) (p < 0.0001). Caerulein treatment increased plasma amylase activity (7094 ± 207 U/l) and this significantly decreased following siRNA administration (5895 ± 115 U/l) (p < 0.0001). Cytokine and chemokine levels in caerulein-induced acute pancreatitis reduced following treatment with siRNA. For example, siRNA treatment significantly decreased pancreatic and lung monocyte chemoattractant protein (MCP)-1 (169.8 ± 59.75 SD; 90.01 ± 46.97 SD pg/ml, respectively) compared to caerulein-treated mice (324.7 ± 103.9 SD; 222.8 ± 85.37 SD pg/ml, pancreas and lun,g respectively) (p < 0.0001). These findings show a crucial pro-inflammatory role for H2S synthesised by CSE in macrophages in acute pancreatitis and suggest CSE gene silencing with siRNA as a potential therapeutic approach for this condition.

Septo-optic dysplasia: Magnetic Resonance Imaging findings

Septo-optic dysplasia is a rare congenital disorder involving brain and optic pathways. We present typical Magnetic Resonance Imaging (MRI) findings of a case of Septo-optic dysplasia in a 19 year old female patient.

First metatarsophalangeal joint arthrodesis - Do joint configuration and preparation technique matter?

BACKGROUND

The purpose of this study was to investigate the influence of joint configuration and preparation on first metatarsophalangeal (MTPJ) union rates.

METHODS

We performed a retrospective analysis of first MTPJ arthrodeses undertaken in our institution. Clinical notes, radiographs and postal questionnaires were used to determine outcome.

RESULTS

Two hundred first MTPJ arthrodeses (172 patients) were included in the analysis (34 male: 138 female; mean age 62 yr). The overall union rate was 93.5%. Union was achieved in 109/118 MTPJs (92.4%) prepared in the flat-on-flat configuration and in 78/82 (95%) prepared in the ball-and-socket configuration (p=0.438). Higher union rates favoured low-velocity joint preparation [using rongeur only 21/21 (100%), rongeur and burr 26/27 (96.3%) and conical reamer 31/34 (91.2%)] but this did not reach statistical significance (p=0.317). There was a 95% satisfaction rate with surgery but male patients were less satisfied (p=0.031).

CONCLUSION

Union rates were not influenced by joint configuration or preparation techniques.

A case–control study of surgical site infection following operative fixation of fractures of the ankle in a large UK trauma unit

Most of the literature on surgical site infections following the surgical treatment of fractures of the ankle is based on small series of patients, focusing on diabetics or the elderly. None have described post-operative functional scores in those patients who develop an infection. We performed an age- and gender-matched case–control study to identify patient- and surgery-related risk factors for surgical site infection following open reduction and internal fixation of a fracture of the ankle. Logistic regression analysis was used to identify significant risk factors for infection and to calculate odds ratios (OR). Function was assessed using the Olerud and Molander Ankle Score. The incidence of infection was 4% (29/717) and 1.1% (8/717) were deep infections. The median ankle score was significantly lower in the infection group compared with the control group (60 vs 90, Mann–Whitney test p < 0.0001). Multivariate regression analysis showed that diabetes (OR = 15, p = 0.031), nursing home residence (OR = 12, p = 0.018) and Weber C fractures (OR = 4, p = 0.048) were significant risk factors for infection.

A low incidence of infection following open reduction and internal fixation of fractures of the ankle was observed. Both superficial and deep infections result in lower functional scores.

Cite this article: Bone Joint J 2014;96-B:636–40.

Primary health care, now and forever? A case study of a paradigm change

The year 2008 marked the 30th anniversary of the Alma Ata Declaration that made Primary Health Care (PHC) the global health policy of member states of the World Health Organization (WHO). Why has PHC remained relevant? In part, this is because of growing evidence that health is a result of social, political, and economic environments, not merely of control of diseases and infirmities through interventions based on biomedical science. Using the conceptual framework developed by Thomas Kuhn, this article traces the emergence of PHC as a new paradigm based on social determinants to address poor health among populations (not individuals), especially those that are low-income. It traces the history of PHC over the last 30 years, focusing on policy developments within WHO. It selects three issues: definitions of PHC; financing and delivery of health services, including lay people's involvement in health care, as examples of the new paradigm; and opposition by those whose concept of health is based on the control of disease and infirmities paradigm. The article concludes by asking whether PHC will continue to be relevant and whether the question mark in the title of this article will be removed in the future.

Evidence for the transmission of neoplastic properties from transformed to normal human stem cells

The in vivo relationship between human tumor cells and interacting normal cells in their local environment is poorly understood. Here, using a uniquely developed in vitro co-culture system for human embryonic stem cells (hESCs), we examined the interactions between transformed and normal human stem cells. Co-culture of transformed-hESCs (t-hESCs) with normal hESCs led to enhanced self-renewal and niche independence in normal hESCs. Global gene expression analysis of normal hESCs after timed exposure to t-hESCs indicated a transition of the molecular network controlling the hESC state, which included epigenetic changes, towards neoplastic features. These included enhanced pluripotent marker expression and a differentiation blockade as major hallmark changes. Functional studies revealed a loss in normal terminal differentiation programs for both hematopoiesis and neural lineages after normal stem cell co-culture with transformed variants. This transmission of neoplastic properties from t-hESCs to normal hESCs was dependent on direct cell-cell contact. Our study indicates that normal human stem cells can co-opt neoplastic cancer stem cell properties, raising the possibility that assimilation of healthy cells towards neoplastic behavior maybe a contributing feature of sustained tumorigenesis in vivo.

Public views of health system issues in four Asian countries

To elicit the public's views on health system issues, we conducted an opinion poll survey in Bangladesh, Mongolia, Nepal, and Sri Lanka. We focused on health inequalities. The results show high levels of dissatisfaction with government health services in all four of the countries. Access to government health services was an important concern. A sizable number of respondents reported that their governments did not consider their views at all in shaping health care services. The policy implications of the study findings are discussed.

A renewed focus on primary health care: revitalize or reframe?

The year 2008 celebrated 30 years of Primary Health Care (PHC) policy emerging from the Alma Ata Declaration with publication of two key reports, the World Health Report 2008 and the Report of the Commission on the Social Determinants of Health. Both reports reaffirmed the relevance of PHC in terms of its vision and values in today's world. However, important challenges in terms of defining PHC, equity and empowerment need to be addressed.This article takes the form of a commentary reviewing developments in the last 30 years and discusses the future of this policy. Three challenges are put forward for discussion (i) the challenge of moving away from a narrow technical bio-medical paradigm of health to a broader social determinants approach and the need to differentiate primary care from primary health care; (ii) The challenge of tackling the equity implications of the market oriented reforms and ensuring that the role of the State in the provision of welfare services is not further weakened; and (iii) the challenge of finding ways to develop local community commitments especially in terms of empowerment.These challenges need to be addressed if PHC is to remain relevant in today's context. The paper concludes that it is not sufficient to revitalize PHC of the Alma Ata Declaration but it must be reframed in light of the above discussion.