Impact of hypothermia alert device (BEMPU) on improvement of duration of Kangaroo Mother Care (KMC) provided at home: parallel-group randomized control trial

The objective of the study was to determine if using the hypothermia-detecting bracelet (named BEMPU) improves the duration of Kangaroo Mother Care (KMC) at home by one hour. This parallel-group randomized controlled trial was conducted at a step-down nursery of a teaching hospital. Neonates between 1000 and 2000 g were randomized to BEMPU and control groups at the time of discharge. BEMPU was applied at the wrist of each newborn in the BEMPU (intervention) group. Parents were advised to keep the BEMPU in place till 4 weeks post-discharge. The BEMPU generates a beep sound as an alarm when a newborn's temperature drops below 36.5 °C. Parents in both groups were trained to provide KMC at home. Parents in the BEMPU group received the "KMC chart" and "BEMPU beep chart," while the control group received the "KMC chart" only. In the "KMC chart," parents entered information about KMC hours on a real-time basis, and in the "BEMPU beep chart," they entered information about alarm beeps from BEMPU on a real-time basis till 4 weeks post-discharge. Independent samples t-test was used to compare mean KMC hours between the two groups. A total of 128 neonates participated in the study (64 in BEMPU and 64 in Control groups). The mean(SD) gestational age for the BEMPU group was 34.04(2.84) weeks vs 34.75(2.70) weeks for the control group. In BEMPU group, mean(SD) daily time spent doing KMC was significantly higher in 1st week [4.78(2.93) vs. 3.22(2.44) h, p = 0.003], in 2nd week [4.52(3.43) vs. 2.84(2.95) h, p = 0.008], in 3rd week [4.23(3.71) vs. 2.30(2.70) h, p = 0.003], in 4th week [3.72(3.30) vs. 1.95(2.65) h, p = 0.003] as compared to control group. BEMPU improved the daily duration of KMC hours at home compared to the control group over four weeks. Clinical Trial Registration: This trial is registered at Clinical Trials Registry India with registration number: CTRI/2018/08/015154 and accessible at http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=27600&EncHid=&modid=&compid=%27,%2727600det%27 Registered on 01/08/2018.

Reducing False Alarms and Alarm Fatigue from Pulse Oximeters in a Neonatal Care Unit: A Quality Improvement Study

Background:

Pulse oximeters play a vital role in monitoring sick newborns, but majority of the times, their alarms are of little clinical significance. False alarms from pulse oximeters were frequent in our neonatal intensive care unit, causing desensitization of staff and inattention to clinically important alarms.

Objectives:

The objective of the study was to reduce the burden of false alarms and alarm fatigue.

Methods:

This was a quality improvement (QI) study. During the baseline phase, alarms for heart rate and SPO2 (percentage of oxygenated blood) were evaluated. Response to them within 30 s was checked. Major causes of false alarms were the movement of the newborns, inappropriate alarm limits, and loose probe. Fishbone chart was prepared, and Plan-Do-Study-Act (PDSA) model was designed using point of care quality improvement (POCQI) principles. During the first PDSA (implementation phase), the staff was trained to adjust alarm limits using the reference chart. A lecture on noise hazards, emphasis on muting the alarms, and advice to change probe site at beginning of their duty was given. In the second PDSA (sustenance phase), components of the first PDSA were strengthened by supportive supervision and guidance and the training of new staff.

Results:

Total 494, 329, and 162 alarms were observed during baseline, implementation, and sustenance phases, respectively. In the baseline phase majority, 364 (73.7%) were false alarms, which occurred at a frequency of 0.39 alarms/patient/h. More than one-third of the alarms were not responded timely. After QI, false alarms reduced to 214 (65%; 0.22 alarms/patient/h) and 100 (61.7%; 0.16 alarms/patient/h) in implementation and sustenance phases, respectively. Response to true alarms improved from 101 (77.7%) to 104 (90.4%) to 62 (100%) during the 3 phases consecutively.

Conclusion:

Frequent false alarms lead to desensitization of health care workers. POCQI principles can be a practical approach for reducing false alarms and improving alarm safety.

Comparison of knowledge and skills of Home-Based Newborn Care (HBNC) among Accredited Social Health Activists (ASHA) and health workers (SAKHI) of Ambuja Cement Foundation

Context:

Ambuja Cement Foundation (ACF) started replicating the famous “Gadchiroli” model to reduce neonatal mortality in Chandrapur in 2005. ACF conducted the Home-Based Newborn Care (HBNC) model through trained female health workers, viz., “SAKHIs.” In 2008, Government of India introduced community health worker, viz., Accredited Social Health Activist (ASHA). ACF withdrew its services steadily and few SAKHIs were hired as ASHAs.

Aims:

We assessed and compared the knowledge level and skills of trained ASHA workers with SAKHIs in providing HBNC.

Methods and Material:

A cross-sectional study was conducted in three blocks of Chandrapur district of Maharashtra, India. A structured questionnaire consisting of 34 questions was used for knowledge assessment and checklists assessed hand washing, weight recording, temperature recording, kangaroo mother care (KMC) position, suction and bag and mask ventilation (BMV) skills on manikins.

Results:

135 healthcare workers participated. The mean (SD) score of current SAKHIs (23.89 (1.9) was significantly higher than former SAKHIs (currently ASHAs) (17.97 (2.92), former SAKHIs (currently not engaged in HBNC) (16.73 (2.95) and ASHAs not worked as SAKHIs in the past (16.19 (3.19) [all P < 0.001]. Similar trend was seen in all skill sets. The skills of ASHAs not worked as SAKHIs previously were abysmal, with no ASHA being able to perform BMV and KMC skills, and only 4 (7.5%) who could perform suctioning. A typical trend was observed with current SAKHIs faring best followed by former SAKHIS (currently ASHAs), former SAKHIs (currently not in HBNC), and ASHAs not worked as SAKHIs faring worst.

Conclusion:

The skills and knowledge of ASHA workers are far deficient compared to SAKHIs despite similar training components, potentially hampering neonatal mortality reduction. Quality of training and supportive supervision mechanism of ASHAs should be explored.

Research Methodology Course for Postgraduate Students by National Medical Commission: A Welcome Step That Needs Complimentary Action

After decades of administrative hibernation, the Medical Council of India (MCI), now National Medical Commission (NMC), started deliberating on reforms in medical education a few years back. The MCI/NMC introduced vertical corrective actions, yet there is a need for horizontal integration, and these measures require adequate guidance on implementation strategies. All postgraduate medical students must conduct a research project as a "Thesis." This crucial opportunity to instill scientific thinking is excellent, along with patient care and clinical training. This opportunity has a long-term impact on clinical practice and research and development in medicine if implemented well. To enforce this step, the Board of Governor introduced a compulsory course in basic research methods for all postgraduate medical students, but alas, without adequate deliberations on implementation and complementary mechanisms. This critical review provides a brief history of the evolution of medicine and medical education in India and reforms in medical education. Further, it presents a balanced critique of the process, intending to brainstorm in improving the process and achieving the expected outcome from this course. Albeit many relevant issues need attention, this article will focus mainly on ways to leverage infrastructure optimally to imbibe scientific thinking in medical students of India with cursory deliberation of the relevant issues.

Effect of Almond Consumption on Metabolic Risk Factors-Glucose Metabolism, Hyperinsulinemia, Selected Markers of Inflammation: A Randomized Controlled Trial in Adolescents and Young Adults

A large percentage of the Indian population has diabetes or is at risk of pre-diabetes. Almond consumption has shown benefits on cardiometabolic risk factors in adults. This study explored the effect of almond consumption on determinants of metabolic dysfunction—blood glucose, lipids, insulin and selected inflammatory markers in adolescents and young adults aged 16–25 years from Mumbai city. This randomized controlled trial was conducted for a period of 90 days on individuals with impaired levels of fasting glucose levels between 100–125 mg/dL (5.6–6.9 mmol/L) and 2-h post-glucose value 140–199 mg/dL (7.8–11.0 mmol/L) and/or fasting insulin (≥15 mIU/ml)/stimulated insulin (≥80 mIU/ml). Of 1,313 individuals screened, 421 met the inclusion criteria, of which 275 consented to participate and 219 completed the trial. The trial was registered with Clinical Trials Registry India (CTRI) CTRI/2018/02/011927. The almonds group (n = 107) consumed 56 g almonds daily, the control group (n = 112) was provided an iso-caloric cereal-pulse based snack. At baseline and endline, blood glucose, insulin, HbA₁c, LDL-c, HDL-c, total and ox-cholesterol, triglycerides, hs-CRP, IL-6, TNF-α, adiponectin, leptin were measured and HOMA-IR and FG:FI ratios were calculated. Dietary intakes were assessed. The anthropometric measurements, biochemical markers as well as macronutrient intakes did not differ significantly between the two groups at baseline. Almond consumption significantly decreased HbA₁c, total cholesterol and LDL-c. Stimulated insulin decreased post-intervention in both groups, but the decrease was greater in the almonds group. Fasting glucose was reduced post intervention in the controls with no change in the almonds group. FG:FI ratio decreased in the almonds group. TNF-α and IL-6 decreased in the almonds group, while it increased in the control group. Our results showed that almonds reduced HbA1c, LDL-c and total cholesterol levels in just 12 weeks of consumption in these adolescents and young adults who were at risk for developing diabetes. Almonds can be considered as part of food-based strategies for preventing pre-diabetes.

Clinical Trial Registration:ClinicalTrials.gov, identifier: CTRI/2018/02/011927.

Prevalence and Pattern of Skin Diseases in Tribal Villages of Gujarat: A Teledermatology Approach

Background

The prevalence and pattern of skin diseases are influenced by the overall ecosystem of the region. There is a dearth of research about prevalence, health-care seeking, compliance, and treatment outcome in skin diseases among scheduled tribes.

Objectives

The aim of this study is to understand the magnitude of skin diseases in tribal area of Dahod, Gujarat using a simple "Store and Forward" technique of teledermatology.

Materials and Methods

A cross-sectional study was conducted in 10 randomly selected villages of Dahod and Jhalod blocks of Dahod district of Gujarat during June-August 2017. Trained surveyors visited households randomly in different localities (called Faliya) of each village ensuring representativeness. Survey responses were captured on mobile-based MAGPI portal, and images of skin conditions were capture on smart phones, and de-identified images were transferred over WhatsApp.

Results

A total of 781 households were approached in 10 villages and 2214 participants consented. Among them, 549 were identified with suspected skin diseases, but 520 consented for photograph. The skin diseases were more prevalent among males, children, and elderly. Of 520, 44 (8.5%) could not be assess due to poor quality photograph and 35 (6.7%) did not have any clinically significant condition. Thus, of 2214 participants, 441 (20%) had skin diseases, and infections and eczema were major conditions constituting two-third of the skin diseases in the study population. The treatment-seeking behavior and compliance to treatment was poor.

Conclusion

Considering the high prevalence of skin diseases in tribal villages of Dahod, Gujarat coupled with limited availability of trained dermatologist, new innovative avenues like teledermatology should be explored.

Comparing positive pressure ventilation efficacy of a novel foot operated resuscitator with self-inflating bag and mask in a manikin model

Aim

To compare positive pressure ventilation efficacy of a novel foot operated resuscitator (FOR) during positive pressure ventilation with that of self-inflating bag and mask (SIBM) using a manikin model.

Method

A comparative trial was conducted with 117 participants at a level III neonatal intensive care unit using Baby Anne (Laerdal Medical, Norway). Flow and pressure sensors were used to measure tidal volume propelled (Vp) and delivered (Vt). Each participant delivered 60 breaths, using each device targeting adequate chest-rise defined as that corresponding to a Vt of 15–21 mL. Vt, Peak Inspiratory Pressure (PIP), Leak Percentage (%), Inspiratory Time (Ti, millisecond) and other parameters were recorded using a PC (Dell, Windows V.10) on a custom application (LabView 2014 platform NI, USA). The proportion of breaths achieving target range Vt, other key ventilation parameters and their variability were compared between a generic CE approved bag and mask and a novel FOR (NeoBreathe, Phoenix Medical Systems, India).

Result

Using an SIBM, participants delivered a mean (SD) Vt of 17.52 (5.22) mL, achieving target range Vt in 46.99% of all breaths, with a mean (SD) face-mask leak per cent of 32.51% (22.25). Using the FOR, participants delivered a mean (SD) Vt of 18.31 (3.90), achieving target range Vt in 54.37% of all breaths and a mean (SD) face-mask leak per cent of 18.89% (14.45). Variability of Vt, PIP and leak per cent was significantly reduced with FOR.

Conclusion

FOR significantly reduced face-mask leak, significantly increased the proportion of breaths achieving Vt within optimal range and could offer a novel alternative to a SIBM.

Euthanasia: Past, Present and Future

In a landmark decision, the Supreme Court of India has provided a legal recognition to ‘passive euthanasia’ in March 2018. In May 2018, David Goodall, an Australian scientist ended his life through Physician Assisted Death in a Swiss clinic at the age of 104 for old age rather than terminal illness. These two events sparked a fresh debate regarding euthanasia and the proponents and opponents of euthanasia argued voraciously for and against it albeit the central theme remained same- ‘the dignity of human life’. This monograph elaborates on the philosophy and popular terminology of euthanasia. It also deliberates on the socio-cultural differences in the conceptualisation of euthanasia and an unbiased critique of the pros and cons of euthanasia with the intention to redress the balance. The monograph finally discusses the current scenario and future directions related to euthanasia.

"Self-development matters" - Perception of Sakhis (CHWs) assessing self-development outcomes of their participation in the HBNC Program

Background

Community Health Workers (CHWs) play an instrumental role in promoting socio-behavioural change at the community level, which results in changed indicators of community health. While outcomes are mostly reviewed for achieving program objectives, it is pertinent to understand the process of program implementation mainly from the perception of participating CHWs.

Methods

A qualitative study to understand the perception of Sakhi’s (CHWs) regarding the outcomes of their participation in Home-Based Neonatal Care (HBNC) Program implemented by a non-governmental organization (NGO). Data consisted of 3 FGDs and 20 in-depth unstructured interviews with participating Sakhis.

Results

Sakhis perceived their ability to take decisions at critical phases of the program as an important factor influencing their performance. The opportunity to participate as a Sakhi in the health programme initiated a process of change at the personal level. The changes perceived by Sakhis were enhancement in knowledge, skills and capabilities of Sakhis. The combination of improved skills, knowledge and attitude had culminated in the process of experiencing self-empowerment for the participating Sakhis. Their ability to positively influence the individuals and community with their initiatives to improve women and child health and save lives in critical situations facilitated development of a new identity and improved societal status in their communities. Changed power-relations at the family and community level promoted the involvement of Sakhis in the broader development agenda. Sakhis’ ability to strategize goals, evaluate their own abilities, their willingness to upgrade knowledge and take others along in bringing social change, was an evident movement towards self-development.

Conclusion

An opportunity for local women to participate in development programs creates potential for self-development as a cascading effect in addition to the accomplishment of planned program objective.

Surmounting difficulties to provide home based neonatal care - reflections of community health workers

BACKGROUND

In India, community health workers' (CHW) effectiveness in providing home-based neonatal care (HBNC) has been well documented. The nature of challenges faced and strategies adopted while providing HBNC services need to be studied in-depth.

METHODS

A qualitative study to understand the challenges faced and strategies used by Sakhis (women CHW) while providing services as part of a HBNC program implemented by a non-profit organization. Data consisted of 20 in-depth interviews and three focus group discussions (FGD) with Sakhis.

RESULTS

Sakhis negotiated with the community to start working as a CHW. They faced challenges while changing behaviors at individual level and also while bringing about a change in harmful normative practices that increased chances of maternal and neonatal mortality. Managing crises at the time of deliveries and facilitating a safe delivery was the most critical challenge faced by many Sakhis. The key strategies used by Sakhis included: proactively and persistently providing services even when they faced resistance from the woman or her family; evolving contextually suitable counseling techniques and tactics to bring about behavioral change; balancing compliance to traditional practices and promoting HBNC; defying traditional practices and assisting the woman in times of an emergency to save lives. Having on-call support from supervisors and cultivating a good working relationship with health providers facilitated effective service provision by Sakhis.

CONCLUSION

CHWs having a strong sense of commitment can develop strategies to address challenges and provide HBNC services effectively if they also have strong supervisory support.

Study protocol for Smartphone Monitoring for Atrial fibrillation in Real-Time in India (SMART-India): a community-based screening and referral programme

INTRODUCTION

Atrial fibrillation (AF), the world's most common arrhythmia, often goes undetected and untreated in low-resource communities, including India, where AF epidemiology is undefined. AF is an important risk factor for stroke, which plagues an estimated 1.6 million Indians annually. As such, early detection of AF and management of high-risk patients is critically important to decrease stroke burden in individuals with AF. This study aims to describe the epidemiology of AF in Anand District, Gujarat, India, characterise the clinical profile of individuals who are diagnosed with AF and determine the performance of two mobile technologies for community-based AF screening.

METHODS

This observational study builds on findings from a previous feasibility study and leverages two novel technologies as well as an existing community health programme to perform door-to-door AF screening for 2000 people from 60 villages of Anand District, Gujarat, India using local health workers. A single-lead ECG and a pulse-based application is used to screen each individual for AF three times over a period of 5 days. Participants with suspected arrhythmias are followed up by study cardiologist who makes final diagnoses. Participants diagnosed with AF are initiated on treatment based on current anticoagulation guidelines and clinical reasoning.

ANALYTICAL PLAN

Age-stratified and sex-stratified prevalence of AF in the Anand District will be calculated for sample and estimated for Anand distribution using survey design weights. Sociodemographic and clinical factors associated with AF will be evaluated using multivariable regression methods. Performance of each mobile technology in detecting AF will be evaluated using a 12-lead ECG interpretation as the gold standard.

ETHICS AND DISSEMINATION

This protocol was approved separately by the Institutional Review Board of University of Massachusetts Medical School and the Human Research Ethics Committee at Charutar Arogya Mandal. The findings of this study will be disseminated through peer-reviewed journals and scientific conferences.

Educational intervention to improve intravenous cannulation skills in paediatric nurses using low-fidelity simulation: Indian experience

INTRODUCTION

Inserting, monitoring and maintaining intravenous access are essential components of nursing. We evaluated simulation training on a manikin to improve cannulation skills.

METHODS

Nursing staff managing paediatric patients were asked to cannulate NITA Newborn-1800 manikin before and after appropriate training. Skills were assessed by a single assessor using an objective structured clinical examination (OSCE) checklist. Four steps were identified as critical. A score of 8/10 (80%) was considered satisfactory. Knowledge was assessed by 10 questions. A training module consisting of theoretical aspects, PowerPoint presentations, videos and hands on training over a manikin was conducted. Post-training assessment was done 1 week later.

RESULTS

Seventy-five (80.6%) nurses who completed preassessments and postassessments were assessed for paired comparisons of knowledge and skill. The majority of the nurses were females, had contractual appointment, were in their early career phase and from the paediatric wards. The mean (SD) post-training knowledge score was greater vis-a-vis pretraining score (7.52 (1.58) vs 5.32 (1.57), P<0.001). A similar result was observed for total OSCE scores (9.22 (0.66) vs 7.91 (1.11), P<0.001). Significantly higher proportion of participants exhibited intravenous cannulation satisfactorily after the training vis-a-vis pretraining assessment (69 (92%) vs 36 (48%), P<0.001).

CONCLUSION

Training using manikin showed improvement in post-training score of intravenous cannulation skill of paediatric nurses; however, this finding needs further confirmation by a randomised control trial, as our study does not have a control group.

Infant and Young Child Feeding Practices in Infants Receiving Skin to Skin Care at Birth: Follow-up of Randomized Cohort

INTRODUCTION

Skin to Skin Care (SSC) in neonatal period influences immediate breastfeeding outcomes in early childhood, especially the duration of exclusive breastfeeding.

AIM

We investigated influence of 17 hours of SSC given from day one of life on Infant and Young Child Feeding (IYCF) practices through one year of life.

MATERIALS AND METHODS

Follow-up of a Superiority Randomized Control Trial (RCT) (CTRI/2013/06/003790) conducted in a teaching hospital located in central Gujarat. Mothers of 100 neonates (48 girls, 52 boys) from previous study cohort of RCT on SSC were followed. A survey on IYCF practices during the first year of life was administered after the end of infancy. In RCT, 50 neonates had received SSC beginning of 30 min- 1 hour after birth for average 17 hours on day 1 of life. In the control group, 50 newborn were placed next to the mother and conventional care was provided. There was a significant difference between hypothermia incidences in these groups in the first two days of life.

RESULTS

There was no difference in the groups as far as the duration of exclusive breastfeeding, number of times breastfed per day, or stoppage of night feeds. No baby in either group received bottled feeds but about 53 received some form of extra lacteal feeds in the first 6 months without significant group difference. Fewer SSC mothers reported difficulties with breastfeeding or extra lacteal supplementation. All mothers who faced problems contacted physicians for advice and 20 were advised top milk and 6 given other foods. At one year of life 66% mothers were giving less than the recommended five food servings. There was no difference in practices related to hand washing, food preparation and storage, feeding habits of child and illness episodes in the children.

CONCLUSION

IYCF practices in this small group were not as per guidelines. Few positive trends were seen with fewer SSC mothers facing problems related to breastfeeding. The study was underpowered to detect differences in IYCF practices in relation to SSC.

Are Parents of Preschool Children Inclined to Give Consent for Participation in Nutritional Clinical Trials?

Objective

Micronutrient deficiencies can lead to anemia, growth restriction, and poor motor and cognitive development. A clinical trial was planned to assess the impact of nutritional supplementation on cognitive measures in preschool children. Conducting clinical trials in children is difficult due to underlying laws, hesitation of the research community, and difficult enrollment. We carried out a questionnaire-based feasibility survey to assess the interest of parents towards participation in such a nutrition-based study.

Methods

After approval from the Institutional Human Research Ethics Committee, the principals of four kindergarten schools at Vallabh Vidyanagar, Anand, Gujarat, India consented to participate. Children at the participating schools were distributed a consent form and pre-tested questionnaire, to be taken home for parents to sign, fill and return.

Results

Out of a total of 1049 consent forms and questionnaires distributed, 602 (57.39%) signed and filled forms were returned. Despite fair awareness regarding the need of research, parents’ willingness to involve their children in a 6 month duration research study, not requiring invasive measures like blood pricks, was 180 (29.9%). Nearly half (250, 41.5%) did not respond and more than a quarter (172, 28.6%) declined participation on behalf of their children.

Conclusion

The interest level of a pre-school child's parents for participation of the child in a nutrition intervention study evaluating cognitive measures like memory is low. Understanding the study population’s motivating and inhibiting factors leading to decreased participation in clinical trials is necessary to facilitate the creation of a pertinent evidence base.

Hypercoagulation and fibrinolysis in oral sub-mucous fibrosis

In seven out of seven patients suffering from oral submucous fibrosis (OSMF), we detected circulating molecules that are immunologically similar to fibrinogen (MISFI), as suggested by the hemagglutination inhibition studies using the FDP Kit (Wellcome) and by paracoagulation tests such as serial dilution protamine tests. The ethanol gelation test was positive in three of the seven patients. Cryofibrinogen developed in six of the seven patients within three to six days of incubation of plasma samples at 4 degrees C. Plasma kept at 37 degrees C did not develop any fibrous or amorphous precipitate. In OSMF, fibrinogen, fibrinogen intermediates, and fibrin degradation products deserve further scrutiny, as this may help define the etiology of OSMF which is, so far, obscure.

Various methods of lymphocyte separation and their relevance with the formation of non-immune rosettes

Lymphocytes (leukocytes mainly containing mononuclear cells) are separated by six different methods and these lymphocytes are used for non-immune rosette formation. It is found that the percentage of non-immune rosettes varies according to the method of separation of lymphocytes. Buffy coat on Dextran-70 and Gravity Sedimentation method give the best rosette yields as compared with lymphocytes separated by centrifugation of heparinized blood (unsupported centrifugation) P less than 0.001) or on Hypaque-Ficoll or Diaginol-Ficoll gradients (supported centrifugation) P less than 0.05). Furthermore, the buffy coat separated on Dextran-70, layered on Ficoll-gradients (supported centrifugation) yields lower values of rosettes (P less than 0.05). It is possible that in certain methods which yield lower values of rosettes there is loss of selected subpopulations of lymphocytes. This loss of subpopulation appears to be due to the centrifugation of the blood and the loss is appreciably more on 'unsupported' than 'supported' centrifugation.