Integrated Care for Type 1 Diabetes: The West Bengal Model

Introduction

A structured dedicated health programme for Type 1 diabetes mellitus (T1DM) has been initiated in the state of West Bengal, India.

Aim

The aim is to provide comprehensive healthcare to all children, adolescents and young adults living with T1DM, along with the provision of free supply of insulin, glucose measuring devices, blood glucose test strips, and other logistics. The strategic framework for programme implementation is to utilise the infrastructure and manpower of the already existing non-communicable disease (NCD) clinic under National Health Mission.

Methodology

Establishing dedicated T1DM clinics in each district hospital by utilising existing healthcare delivery systems, intensive training and hand-holding of named human resources; providing comprehensive healthcare service and structured diabetes education to all T1DM patients; and building an electronic registry of patients are important components of the programme. T1DM clinics run once a week on the same day throughout the state. All T1DM patients are treated with the correct dose of insulin, both human regular insulin and glargine insulin. Patients are routinely monitored monthly to ensure good glycaemic control and prevent complications of the disease. Routine anthropometric examination and required laboratory investigations are conducted in the set-up of the already existing NCD clinic. Ongoing monitoring and evaluation of the T1DM programme are being conducted in terms of glycated haemoglobin (HbA1c) values, growth and development, complication rates, psychological well-being, quality of life, and direct and indirect expenditure incurred by families. Through this programme, any bottlenecks or gaps in service delivery will be identified and corrective measures will be adopted to ensure better health outcomes for those living with T1DM.

A study on utilization of Janani Suraksha Yojana and its association with institutional delivery in the state of West Bengal, India

BACKGROUND

India launched the Janani Suraksha Yojana (JSY) on the principles of conditional cash transfer providing monetary incentive to needy women to improve access to institutional childbirth.

OBJECTIVES

This study was conducted among JSY-eligible women who delivered between April 2012 and June 2012 to assess the utilization of cash incentives toward institutional delivery, along with other associated factors influencing institutional delivery.

METHODS

It was a cross-sectional, descriptive study conducted between July 2012 and May 2013 on 946 women selected through stratified random sampling of subcentres from better and worse performing districts of West Bengal.

RESULTS

74.7% of the study population was JSY-eligible. 90.2% of those who took three antenatal check-ups (ANCs) and 36.8% JSY-noneligible women received cash. Government institutions were preferred for childbirth among all groups irrespective of JSY eligibility, receipt of cash, and number of antenatal visits. Overall, 78.8% opted for institutional delivery if they had received cash, which was significantly more than those who did not (64.5%). JSY-eligible women were 1.5 times more likely to deliver in government institutions compared to JSY-noneligible women. With no incentive, the likelihood of institutional delivery was halved. The distance of a 24 Χ 7 delivery hub beyond 5 km (74.8% vs. 81.8%), the religion of Islam (62.7% vs. 83.2%), and multiparity (63.9% vs. 83.6%) were significant deterring factors.

CONCLUSION

Despite some inclusion and exclusion errors, cash incentive under JSY was associated with increased institutional delivery, especially in government institutions though there were other factors influencing the decision as well.

Netting the malaria menace: Distribution and utilization of long-lasting insecticidal net in a malaria endemic area in Bankura, West Bengal

BACKGROUND & OBJECTIVES

Long-lasting insecticidal net (LLIN) is considered to be a highly effective intervention against malaria under National Vector Borne Disease Control Programme in India. A cross-sectional study was undertaken to assess the coverage and utilization of LLIN and the factors related thereto.

METHODS

A survey of 1300 households was carried out in Ranibandh block of Bankura district in West Bengal, India, using lot quality assurance sampling (LQAS) method. Coverage/utilization of 80% was considered as minimum acceptable norm. The weighted sample size was calculated from each village of the block. The sociodemographic, economic information of the household along with the availability and use of LLIN was collected through interview and observation.

RESULTS

In total, 7320 individuals including 840 children ≤ 5 yr were visited. Overall coverage of adequate LLIN was 65.4% (± 1.5%) and for children ≤ 5 yr, it was 60.5% (± 1.3%). Overall, 66.1% (± 1.4%) people of all ages and 63.7% (± 1.4%) children ≤ 5 yr slept under LLINs in the night before the survey. Out of 26 sub-centres, distribution of LLINs in 10 sub-centres was below the accepted norm, whereas utilization was sub-optimal in 19 sub-centres. In only 18.2% (± 0.5%) households, LLINs remained hanging during daytime. Poverty, caste, education, perception regarding malarial morbidity and preventive action of LLIN were associated significantly with the distribution of LLIN. Similarly, poverty (AOR = 2.14), threat perception regarding malarial morbidity (AOR = 1.51) and mortality (AOR = 2.52) were positively associated with the use of LLIN. Full utilization of bednets by under-fives of the households was higher in villages with sub-centres.

INTERPRETATION & CONCLUSION

Around two-third population of the study area was effectively covered with LLIN. Higher proportion of socially marginalized people received LLIN. Threat perception regarding malaria was directly associated with both receipt and use of LLIN. Behaviour change communication on utilization along with adequate access to LLIN needs to be strengthened.

Access to and utilization of voucher scheme for referral transport: a qualitative study in a district of West Bengal, India

BACKGROUND

Lack of motorized transport in remote areas and cash in resource-constrained settings are major obstacles to women accessing skilled care when giving birth. To address these issues, a cashless voucher transport scheme to enable women to give birth in a health-care institution, covering poor and marginalized women, was initiated by the National Rural Health Mission in selected districts of India in 2009.

METHODS

The access to and utilization of the voucher scheme were assessed between December 2010 and February 2011 through a qualitative study in the district of Purulia, West Bengal, India. Data were collected from in-depth interviews and focus group discussions with women, front-line health-care workers, programme managers and service providers.

RESULTS

The main factors influencing coverage and utilization of the scheme were: reliance on ill-prepared gram panchayats (village councils) for identification of eligible women; poor birth preparedness initiatives by health-care workers; over-reliance on telephone communication; restricted availability of vehicles, especially at night and in remote areas; no routine monitoring; drivers' demand for extra money in certain situations; and low reimbursement for drivers for long-distance travel.

CONCLUSION

Departure from guidelines, ritualistic implementation and little stress on preparedness of both the community and the health system were major obstacles. Increased enthusiasm among stakeholders and involvement of the community would provide opportunities for strengthening the scheme.

Association of child feeding practices with nutritional status of under-two slum dwelling children: a community-based study from West Bengal, India

A cross-sectional study was conducted among 245 under-two slum-dwelling children in Bankura town, West Bengal, to assess their feeding practices and its association with nutritional status. Child's gender, number of family members, standard of living (SLI), and household food security (HFS) were assessed through interview of mothers/ caregivers. Child feeding practices were measured with Composite Child Feeding Index comprising of age-appropriate, multiple, infant and young child feeding (IYCF) indicators and expressed in standardized IYCF score. Weight and length of the children were measured and the nutritional status was assessed using World Health Organization Growth Standard 2006. Standardized IYCF score was significantly lower in undernourished children than those with normal grades. Per unit increase in standardized IYCF score was likely to reduce the prevalence of underweight, stunting and wasting by 2-3% after adjusting for other variables. Low/ very low HFS, low SLI and female gender were associated with underweight and stunting.

Assessment of nutritional status by composite index for anthropometric failure: a study among slum children in Bankura, West Bengal

A community-based cross-sectional study was conducted to find out the prevalence of composite index of anthropometric failure (CIAF) among 117 slum dwelling under-five children in Bankura town, West Bengal and its relation with some common socio-economic factors. Among study population, the prevalence of underweight was 41.6%, whereas CIAF was 80.3%. CIAF gave a near complete estimation of undernutrition unlike underweight. Children who were unimmunized, with more number of siblings, living in a nuclear family, or with illiterate mothers were more likely to be undernourished.

Are the adolescent behaviors too risky? A school-based study in a district of West Bengal, India

A cross-sectional study was undertaken among 2068 school-going adolescents of a subdistrict area of West Bengal, India for assessment of entire array of risk behaviors and their correlates. Aggressive, suicidal, substance use and sexual risk behaviors were measured using a self-administered, multi-item, validated questionnaire in the local vernacular. Prevalence of physical fights, weapon carrying in the last 30 days and gang fights in the last 12 months were 27.1%, 7.3% and 13.0%, respectively. Current users of tobacco, alcohol and illicit substances were 7.1%, 3.4% and 2.0%, respectively. Suicidal ideation and attempts were reported by 11.7% and 3.5% of students. Almost one-tenth of respondents had premarital sexual intercourse. Male gender, low subjective economic status, exposure to electronic media and poor academic achievements were associated with most of the studied risk behaviors, except that females showed more propensities to suicidal behavior. The magnitude and pattern of adolescent risk behaviors, though less studied in India, warrants urgent, coordinated actions.

Skill of frontline workers implementing integrated management of neonatal and childhood illness: experience from a district of West Bengal, India

A cross-sectional study was conducted in Purulia district, West Bengal, India, to assess the skill of 155 frontline workers implementing Integrated Management of Neonatal and Childhood Illness (IMNCI) and the logistic support thereof. The skills of counting respiratory rate, assessing immunization status in both age groups, assessment of breastfeeding in young infants and plotting of weight in a growth chart in case of children aged 2-59 months were acquired by majority of workers. Around two-thirds workers synthesized correct classification and nearly 60% gave appropriate management of at least one subgroup. In 30-40% cases, carers received feeding advices. Around 50% casesheets were complete and timely report submission rate was nearly 70%. Necessary equipments were available with majority of workers except the utensils for preparation of ORS. The supply of essential drugs varied from 33.5 to 71.6%. These findings suggest that IMNCI program offered a scope for capacity-building and infrastructure strengthening of the health system.

Infant- and young child-feeding practices in Bankura district, West Bengal, India

A community-based, cross-sectional descriptive study was conducted during June-July 2008 to assess the infant- and young child-feeding (IYCF) practices in Bankura district, West Bengal, India. In total, 647 children aged less than two years selected through revised 40-cluster sampling using the indicators of the Integrated Management of Neonatal and Childhood Illness (IMNCI) and World Health Organization. The proportions of infants with early initiation of breastfeeding (13.6%) and exclusive breastfeeding under six months (57.1%) and infants who received complementary feeding at the age of 6-8 months (55.7%) were low. Appropriate feeding as per the IMNCI protocol was significantly less among infants aged 6-11 months (15.2%) and children aged 12-23 months (8.7%) compared to infants aged less than six months (57.1%), which could be attributable to low frequency and amount of complementary feeding. The main problems revealed from the study were late initiation of breastfeeding, low rates of exclusive breastfeeding, and inappropriate complementary feeding practices.

Coverage of ante-natal care in a block of West Bengal using lot quality assurance sampling

A cross-sectional study using lot quality technique was undertaken among a sample of 198 women in 18 sub-centers (lots) of Bankura-I Community Development Block who had delivered in last 12 months preceding the survey to find out the sub-center(s) with 'acceptable' coverage (> or = 50%) and overall coverage of 'appropriate' antenatal care of the block. Registration before 12 weeks, three antenatal check-ups with checking of BP, weight, edema and abdominal examination, distribution of 100 IFA tablets and adequate tetanus prophylaxis were taken collectively as a measure of'appropriate' antenatal care. Out of 18 sub-centers, only one had 'acceptable' coverage of appropriate antenatal care. The overall coverage of 'appropriate' antenatal care was 29.1% in the study Block.

Antitumor activity of methanolic extract of Cassia fistula L. seed against Ehrlich ascites carcinoma

Effects of methanolic extract (ME) of Cassia fistula seed on the growth of Ehrlich ascites carcinoma (EAC) and on the life span of tumor bearing mice were studied. ME treatment showed an increase of life span, and a decrease in the tumor volume and viable tumor cell count in the EAC tumor hosts. Cytological studies have revealed a reduction in the mitotic activity, and the appearance of membrane blebbing and intracytoplasmic vacuoles in the treated tumor cells. Improvement in the hematological parameters following ME treatment, like hemoglobin content, red blood cell count and bone marrow cell count of the tumor bearing mice have also been observed. The results of the present study suggest that ME of C. fistula seed has an antitumor activity.

Molecular mechanics aided design of antineoplastic agents from ruthenium coordinate complexes

Through energy minimization using molecular mechanics force field four ruthenium cordinate complexes have been synthesized. Compound I to IV showed antineoplastic activity with varying degree on EAC bearing mice. Mode of action may be through inhibition of antioxidant property of tumor cell as evident from lipid peroxidase activity. Among the complexes Bis pyridine tetrachloro ruthenium exhibits highest order of activity with respect to increase mean survival time, inhibition of tumour volume, total blood count, hemoglobin and lipid peroxidase activity.

Long-term, near-total liver replacement by transplantation of isolated hepatocytes in rats treated with retrorsine

Genetically marked hepatocytes from dipeptidyl peptidase (DPP) IV+ Fischer 344 rats were transplanted into the liver of DPPIV- mutant Fischer 344 rats after a combined treatment with retrorsine, a pyrrolizidine alkaloid that blocks the hepatocyte cell cycle, and two-thirds partial hepatectomy. In female rats, clusters of proliferated DPPIV+ hepatocytes containing 20 to 50 cells/cluster, mostly derived from single transplanted cells, were evident at 2 weeks, increasing in size to hundreds of cells per cluster at 1 month and 1000 to several thousand cells per cluster at 2 months, representing 40 to 60% of total hepatocyte mass. This level of hepatocyte replacement remained constant for up to 1 year, the duration of experiments conducted. In male rats, liver replacement occurred more rapidly and was more extensive, with transplanted hepatocytes representing 10 to 15% of hepatocyte mass at 2 weeks, 40 to 50% at 1 month, 90 to 95% at 2 months, 98% at 4 months, and 99% at 9 months. Transplanted hepatocytes were integrated into the parenchymal plates, exhibited unique hepatic biochemical functions, and fully reconstituted a normal hepatic lobular structure. The extensive proliferation of transplanted cells in this setting of persistent inhibition of resident hepatocytes represents a new general model to study basic aspects of liver repopulation with potential applications in chronic liver disease and ex vivo gene therapy.

Effect of mycotoxins isolated from Penicillium nigricans on glucose-6-phosphate dehydrogenase

A new mycotoxin product (NMP) was isolated from the culture of mutated wild strain of P. nigricans which is less toxic and has sterol derivative. NMP (LD50 > 1 g/kg) showed antimicrobial and antineoplastic activities and does not affect the hematological parameters like RBC count and hemoglobin. It maintained normal blood glucose level by increasing the enzyme activity of glucose-6-phosphate dehydrogenase (EC-1.1.1.49; G-6-PDH) by 30%. It also maintained the normal ion balance in the blood of mice. NMP decreased Km value of glucose-6-phosphate dehydrogenase and thus increased substrate affinity of the enzyme. Reduction of toxicity of NMP has been well explained by higher activity of G-6-PDH which is highly specific for production of NADPH.

Endoscopic ultrasonographic evaluation of the rectum in cirrhotic portal hypertension

Rectal endoscopic ultrasonography was performed using an ultrasound fiberscope in 20 patients with cirrhotic portal hypertension (6 alcoholic patients, 4 patients with hepatitis B surface antigen positive, and 10 cryptogenic patients) and in 10 patients with irritable bowel syndrome as controls. Rectal varices were diagnosed endoscopically when either tortuous or saccular distended veins were seen beneath the mucosa. At rectal endoscopic ultrasonography rectal varices were seen as rounded or oval echo-free structures in the submucosa. Rectal endoscopic ultrasonography also showed perirectal veins outside the rectal wall. Rectal varices were detected by endoscopy in 9 patients and by rectal endoscopic ultrasonography in 17 patients. Rectal endoscopic ultrasonography also detected submucosal veins in 3 of 10 controls. The number and size of submucosal veins seen on rectal endoscopic ultrasonography in patients with portal hypertension were greater than in controls (p < 0.01 for both number and size). The size of perirectal veins was greater in patients than in controls (p < 0.05), although their number was no different (p = NS). A perforating vein communicating between a submucosal and perirectal vein was seen in only one patient. Rectal wall thickness was not different in patients and controls (p = NS). Rectal endoscopic ultrasonography was superior to endoscopy in detecting the presence (85% versus 45%, p < 0.01), and number (p < 0.01) of rectal varices. Our study suggests that rectal endoscopic ultrasonography is useful in detecting changes in rectal and perirectal vasculature in patients with cirrhotic portal hypertension.

A study of Helicobacter pylori in north Indian subjects with non-ulcer dyspepsia

A prospective case control study was conducted in 50 patients with non-ulcer dyspepsia (NUD) and 10 age and sex matched controls to determine the prevalence of Helicobacter pylori in patients with NUD and to correlate symptoms, histology and presence of H pylori in gastric biopsies. Endoscopic biopsies from antrum and fundus were subjected to urease test and histological examination. On histology, H pylori was identified in 27 (54%) NUD patients and in one of 10 controls. Urease test was positive in 31 (62%) antral and 21 (42%) fundal biopsies in patients with NUD and in only one (10%) of 10 antral biopsies in the control group. On histology, gastritis was present in the antrum in 46 (92%) NUD patients and in the fundus in 40 (80%) cases; of these, 27 (54%) and 15 (30%) had H pylori in antral and fundal biopsies respectively. The severity of antral gastritis correlated with the density of H pylori (p < 0.05).

Emergency treatment with ketoconazole in disseminated intravascular coagulation due to metastatic prostatic carcinoma

We report the use of ketoconazole to control disseminated intravascular coagulation due to prostatic carcinoma. Clinical improvement in the condition of the patient was noted in 48 hours and coagulation profile became normal in 10 days.

Plate Tectonics 2.5 Billion Years Ago: Evidence at Kolar, South India

The Archean Kolar Schist Belt, south India, is a suture zone where two gneiss terranes and at least two amphibolite terranes with distinct histories were accrted. Amphibolites from the eastern and western sides of the schist belt have distinct incompatible element and isotopic characteristics sugesting that their volcanic protoliths were derived from dint mantle sources. The amphibolite and gneiss terranes were juxtaposed by horizontal compression and shearing between 2530 and 2420 million years ago (Ma) along a zone marked by the Kolar Schist Belt. This history of accretion of discrete crustal terranes resembles those of Phanerozoic convergent margins and thus suggests that plate tectonics operated on Earth by 2500 Ma.

Ribosomal RNA genes of Neurospora crassa: multiple copies and specificities

Ribosomal RNA genes were isolated from the germinated conidial and mycelial cells of N. crassa by repeated cycles of 3H-DNA:rRNA reactions followed by hydroxyapatite chromatography. Specificity of multiple copies of those rDNAs with respect to N. crassa cell types was studied. The fraction of N. crassa germinated conidial in vitro labelled 3H-DNA recovered in the presence of rRNA isolated from the same cell type was about 2.2%, when compared with approximately 1.2% rDNAs obtained in mycelial cells. These isolated rDNAs reacted specifically to 26S and 17S rRNAs of eukaryotic (N. crassa) organisms and did not react with 4S tRNAs. rRNA:rDNA reassociation kinetics studies indicate that 90% of the rRNA genes were homogeneous and not identical with the other 10% rRNA genes isolated from N. crassa mycelia. These studies suggest that the possible heterogeneity of rDNA sequences of N. crassa cannot be attributed to inclusion of any tDNA sequences as has been shown in the heterogeneity of rDNA sequences of the bacterium Escherichia coli. The heterogeneity of multiple copies of N. crassa rDNAs could be due to differences in internal or external spacer regions of N. crassa rRNA genes.

RNase-sensitive DNA polymerase activity in cell fractions and mutants of Neurospora crassa

RNase-sensitive DNA polymerase activity (RSDP) was tested in different cell fractions of Neurospora crassa cell types and its morphological mutants. This RSDP was found localized in the microsomal pellet fraction and absent in the purified nuclear pellets isolated from different N. crassa cell types: conidia, germinated conidia, and mycelia. This enzyme is capable of synthesizing a DNA product only in the presence of all four deoxyribonucleoside-5' - triphosphates and Mg2+. Removal of RNA from the pellet fraction by RNase strongly inhibited the DNA synthesis. The endogenous synthesis of DNA in the microsomal pellet fraction was associated with the formation of an RNA:DNA hybrid as analyzed by Cs2SO4 equilibrium density gradient centrifugation. The DNA product after alkali hydrolysis hybridizes with the RNA isolated from the same pellet fraction, as analyzed by elution from hydroxylapatite column at 60C. This DNa product did not hybridize with poly (A). A few mutants tested showed this RNase-sensitive DNA polymerase activity.