Do children in India grow well into adolescents? Longitudinal analysis of growth transitions from Young Lives panel survey in India

OBJECTIVES

Studies that examined the growth during late childhood and early adolescence beyond 8 years of age are very limited. Further, most studies have used dichotomized classification of stunting, thereby limiting the understanding of moderate stunting in childhood growth trajectory. We aimed to examine the course of stunting from childhood to adolescence by undertaking robust analyses of the Young Lives Survey (YLS) longitudinal data from India using multilevel categorization of stunting.

STUDY DESIGN

Retrospective cohort analysis was undertaken from YLS in India among 1827 children from the younger cohort born in 2001-02 with complete follow-up data in all five rounds of YLS collected in 2002, 2006, 2009, 2013, and 2016.

METHODS

A three-state multistate Markov model (not stunted, moderate, severe) was performed to estimate annual transition probabilities, mean sojourn-time, and transition-specific risk factors.

RESULTS

Between Round-one and Round-five, cross-sectional prevalence of severe stunting decreased from 10.4% (95% confidence interval [CI]: 7.8%, 13.7%) to 5.3% (95% CI: 3.8%, 7.3%), while moderate stunting increased from 19.9% (95% CI: 16.3%,23.9%) to 21.7% (95% CI: 18.4%, 24.9%). Mean Sojourn time estimation indicated a relatively concise state for moderate stunting. The stunting trajectory had shown gender differential where more faltering to severe stunting and lower recovery to the normal state was observed among girls between 8 and 12 years and among boys between 12 and 15 years. Compared with boys, girls had 40% excess likelihood (Hazard Ratio: 1.40; 95% CI 1.00 to 1.95) for moderate-to-severe stunting transition and also had 19% excess likelihood (Hazard Ratio: 1.19; 95% CI 1.01 to 1.40) of favorable transition (moderate-to-non-stunted).

CONCLUSIONS

The transition trajectory highlights preadolescence, especially among girls, as an additional window of opportunity to ensure better nutrition in adolescent life. With a fifth of adolescents living in India, study findings call for coordinated, multisectoral, age-appropriate, and gender-responsive approach to take India closer to meeting SDG-2.

289 Blood Loss in Robotic-Assisted Knee Arthroplasty: A Retrospective Analysis

Introduction

Significant blood loss is associated with a delayed postoperative recovery in joint arthroplasty. Emerging evidence suggests robotic-assisted knee arthroplasty reduces soft-tissue trauma, length of stay, and can facilitate a faster recovery. This study compares the total blood loss in patients undergoing robotic-assisted knee arthroplasty compared to conventional methods.

Method

Patients undergoing robotic-assisted total knee arthroplasty (TKA) or unicomparmental knee arthroplasty (UKA) were identified using patient records. Robotic-assisted groups were compared against contemporary sex-matched controls undergoing jig-based arthroplasty. The mean total blood loss was estimated using the Gross equation. Statistical significance was identified using the Student's t-test and Mann-Whitney U test for parametric and non-parametric data, respectively.

Results

Robotic TKA and UKA groups were successfully matched to contemporary controls (n = 50 in all groups). No differences in preoperative haematological parameters or blood volume were found between the robotic-assisted and control groups. Robotic TKA experienced 23.7% less blood loss compared to control TKA (911.0ml vs 1193.7ml, p < 0.01) which was found to be statistically significant. There was a non-significant difference in mean total blood loss in robotic UKA compared to control UKA (821.7ml vs 854.7ml, p = 0.69).

Conclusions

The use of a robotic surgical system reduces blood loss in TKA but not UKA in knee arthroplasty.

The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix

PURPOSE

The aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time.

METHODS

A study period of twelve weeks following the introduction of the nationwide "lockdown period", March 23^rd - June 14^th, 2020 was identified and compared to the same time period in 2019 as a "baseline period". A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the 'eTrauma' management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis.

RESULTS

The total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001).

CONCLUSION

In conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

Synthesis of Hydroxyapatite and ZnO Nanoparticles via Different Routes and its Comparative Analysis

Hydroxyapatite (HAp) was prepared from egg shells by various routes using hexane and acetic acid followed by heat treatment. HAp has a wide application in water treatment by removal of metal ions. XRD of the samples showed use of acetic acid followed by high temperature sintering leads to formation crystalline phases of HAp. Strong evidence of CaCO3 in calcite phase was obtained in other samples. Zinc oxide nanoparticles have also been synthesized by different methods such as sol-gel, co- precipitate and green synthesis. The effect of different synthesis methods were investigated using X-Ray Diffraction (XRD). The structural properties of nanoparticles including particle size were calculated from XRD data. The XRD reveals that the prepared ZnO samples were highly crystalline, having wurtzite crystal structure. The comparative analysis shows variations in particle size with different synthesis methods.

Availability of doctors at primary health centres of Andhra Pradesh, India

BACKGROUND

Availability of doctors at primary health centres (PHCs) is a major concern. We measured the operational availability of doctors in PHCs and examined the effect of residential distance and private practice.

METHODS

Thirty-six health centres, consisting of six randomly selected PHCs from six purposively chosen districts in Andhra Pradesh were studied. Cross-sectional data on residential distance, private practice and attendance pattern of 38 operationally available medical officers were analysed.

RESULTS

About 80% of doctors residing within 20 km attended their PHC on all 6 days of a week, compared with only 33% for those staying >40 km away. Among those staying >20 km away from their PHC, the odds of absenteeism by privately practising doctors was 3-24 times more than for those not practising privately.

CONCLUSION

Residential distance seems to affect the operational availability of doctors. Private practice by doctors living within 20 km from the PHC does not seem to affect their operational availability. However, private practice by doctors staying >20 km away from their PHC may affect their availability.

Interaction of water vapour with twenty different poly-L-amino acids and their excess hydration in presence of sodium chloride

Using the isopiestic vapour pressure technique, the magnitudes of excess binding of water and NaCl per mole of twenty different poly-L-amino acid residues, respectively in the presence of different bulk molefractions (X2) of NaCl have been evaluated from the mathematical expressions for the Gibbs surface excesses. At certain high ranges of NaCl concentration, the plot of -Gamma1 (2) versus X1/X2 becomes linear, so that moles of water and NaCl, respectively bound per mole of amino acid residue can be evaluated. -Gamma(2)1 is the excess moles of H20 per mole of amino acid residue and X1 and X2 stand for mole fractions of the water and NaCl, respectively in the sample system. Also, using the integrated form of the Gibbs absorption equation, the values of standard free energy change (deltaG(0)) for the excess adsorption of NaCl per kg of poly-L-amino acids have been evaluated. These values are all positive as a result of positive excess hydration of polyamino acids. The standard free energy of excess hydration deltaG(0)hy (equal to -deltaG(0)) is negative due to spontaneous excess hydration of polyamino acid in the presence of a salt.

Conformational properties of alpha-tubulin tail peptide: implications for tail-body interaction

The carboxy-terminal segments of the alpha/beta-tubulins are flexible regions rich in acidic amino acid residues. It is generally believed that these regions play crucial roles in tubulin polymerization and interaction with many ligands, including colchicine. Exactly how these effects are exerted are not known at present. One such interesting aspect is the pH dependence of colchicine-tubulin interaction and the influence of the alpha-tail on the binding interaction. We have investigated the location of the colchicine-binding site on tubulin by docking. It has been located on the alpha/beta interface on the N-terminal side, which is also supported by much of the solution data. This location is too far from the tail regions, suggesting that influence of the tail region is transmitted by a pH-dependent conformational change. Two-dimensional NMR studies indicate that at pH 7 a 13-residue peptide corresponding to alpha-tubulin tail shows little NOE constraints, suggesting extended conformation. On the contrary, at pH 5, a relatively compact structure was deduced from the interproton NOE constraints. Pulsed field gradient measurement of diffusion constant indicates that the peptide at pH 5 is substantially faster diffusing than at pH 7. The Perrin factors calculated from diffusion data indicates that the peptide structure at pH is significantly more compact than at pH 7. Temperature coefficients of several amide protons at pH 5 fall below 5 ppb/(o)K, indicating a degree of protection. A difference is also seen in the CD spectra obtained at different pHs, consistent with the NMR data. We have investigated the probable spatial organization of the tail of the alpha-subunit of tubulin, in the high pH extended form and the low pH compact form. On the basis of correlation of pH dependence of many properties of tubulin and the conformation of the alpha-tail peptide, we propose that the intrinsic conformational preference of the tail-region modulate the tail-body interaction, which in turn has important bearing on colchicine binding properties.

Role of the carboxy-termini of tubulin on its chaperone-like activity

Mutational analysis and the enzymatic digestion of many chaperones indicate the importance of both hydrophobic and hydrophilic residues for their unique property. Thus, the chaperone activity of alpha-crystallin is lost due to the substitution of hydrophobic residues or upon enzymatic digestion of the negatively charged residues. Tubulin, an eukaryotic cytoskeletal protein, exhibits chaperone-like activity as demonstrated by prevention of DTT-induced aggregation of insulin, thermal aggregation of alcohol dehydrogenase, betagamma-crystallin, and other proteins. We have shown that the tubulin lost its chaperone-like activity upon digestion of its negatively charged C-termini. In this article, the role of the C-terminus of individual subunits has been investigated. We observe that the digestion of C-terminus of beta-subunit with subtilisin causes loss of chaperone-like activity of tubulin. The contribution of C-terminus of alpha-subunit is difficult to establish directly as subtilisin cleaves C-terminus of beta-subunit first. This has been ascertained indirectly using a 14-residue peptide P2 having the sequence corresponding to a conserved region of MHC class I molecules and that binds tightly to the C-terminus of alpha-subunit. We have shown that the binding of P2 peptide to alphabeta-tubulin causes complete loss of its chaperone-like activity. NMR and gel-electrophoresis studies indicate that the P2 peptide has a significant higher binding affinity for the C-terminus of alpha-subunit compared to that of beta-subunit. Thus, we conclude that both the C-termini are necessary for the chaperone-like activity of tubulin. Implications for the chaperone functions in vivo have been discussed.

Cause of death reporting systems in India: a performance analysis

BACKGROUND

Reliable statistics on the causes of death in the population are essential for setting priorities in the health sector. Most cause of death reporting systems in developed countries rely on medical certification of the cause of death according to the International Classification of Death (ICD-10), and have achieved near-total coverage. Developing countries such as India, where adequate medical facilities are not available, depend on lay reporting of the cause of death in rural areas, using a sample registration system. The use of the cause of death statistics in India is questioned in view of the poor coverage, and poor compliance with guidelines for cause of death reporting, coding and classification.

METHODS

A brief description of the reporting system in India is followed by the characteristics of a usable cause of death reporting system. We identified 9 criteria based on a review of the literature and our own assessment of the problem. The performance of the cause of death reporting system for rural and urban areas of India was examined against each of the 9 criteria. We offer a subjective rating on a three-category rating scale consisting of (i) satisfactory, (ii) tolerable, and (iii) poor.

RESULTS

The major factors affecting the use of the cause of death statistics in India are: (i) poor coverage; (ii) high incidence of unclassifiable deaths; (iii) long delay and irregular publication of statistics; and (iv) lack of systematic screening.

CONCLUSIONS

We recommend the following steps to improve the usability of cause of death statistics in India. Introducing periodical reviews jointly by the Departments of Health and Municipal Administration to identify non-reporting municipalities, sample units, and further identification of non-reporting health care institutions sustained over a period of, say, five years will raise coverage substantially. The other measures include: (i) training programmes to build up cause of death report writing skills among physicians; (ii) compilation and publication of cause of death statistics at the state level; (iii) sponsored research on the cause of death reporting structure and its implications for policy-making; and (iv) computerization of filling, tabulation and flow of cause of death statistics at the municipality and the state levels. To reduce the unusually high level of unclassifiable deaths, the Registration of Births and Deaths Act should be amended to ensure that hospitals and health care institutions maintain medical records. For accurate cause of death data from rural areas, we recommend that the performance of the sample registration survey-cause of death (SRS-COD) component be evaluated according to the above criteria.

Thermodynamics of interaction of water vapour with 20 different poly-L-amino acids

The uptake of water vapour by 20 different polyaminoacids have been evaluated by an isopiestic vapour pressure technique in absence of solute at three different temperatures (22 degrees C, 30 degrees C and 37 degrees C). The water vapour adsorption isotherm for different polyaminoacids in the range of water activity varying between zero and unity apparently agreed with that expected from a type III BET isotherm. From the linear BET plots, obeyed in the lower range of water activity, the BET constants n(m) and Qm for different polyamines have been evaluated. The amount of water vapour adsorbed (n1) was calculated in moles/kg of polyaminoacids as well as in moles/mole of amino acid residue. Its value at unit water activity (deltan(o)1) has been evaluated by an extrapolation method and the results support that the multilayer adsorption of water vapour at the interface of polyaminoacids takes place. Values of deltan(o)1 are strictly comparable in terms of moles per kg rather than mole per mole unit. In case of beta lactoglobulin (betalg), lysozyme and BSA, theoretically obtained deltan(o)1 values were observed to be considerably larger than experimental values of deltan(o)1. This indicated that amino acid residues in the polypeptide release a large amount of water due to the formation of a globular structure. Using the Bull equation in the integrated form, standard free energies, deltaGo(w) for water-polyamino acid binding interaction at two different temperatures have been evaluated. Based on the Clausius-Clapeyron equation in an integrated form, the integral enthalpy for water-polyamino acid interaction has also been evaluated.

Standard free energies of binding of solute to proteins in aqueous medium. Part 1: Thermodynamic analysis for multicomponent system

Using an equilibrium dialysis technique, moles (Gamma(2)(1)) of cationic and anionic surfactants bound per kilogram of proteins of various types in aqueous media have been measured previously in this laboratory under different physicochemical conditions. From a thermodynamic analysis in the present paper, Gamma(2)(1) has been shown to be equal to the Gibbs relative excess of surfactant per kilogram of protein at a measured value of solute activity, a(2). The values of relative solvent excesses, Gamma(2)(1) (which are negative for surfactants) can be estimated from values of Gamma(2)(1) and a(2). Using the Gibbs-Duhem relationship for protein solution inside the dialysis bag and dialysate solutions respectively at equilibrium, an integrated expression for the standard free energy change, DeltaG(o) (in kilojoules per kilogram of protein for binding with ligand as a result of the change of a(2) from zero to unity) can be calculated from experimental data. The isopiestic vapour pressure technique was used extensively for evaluation of negative binding (-Gamma(2)(1)) of inorganic salts to proteins of different types for various values of a(2) of salts present in the bulk media. With some modifications of our derived equations for free energy of binding in such a system, DeltaG(o) has been evaluated for the change of mean activity of electrolyte from zero to unity in the rational scale. DeltaG(o) is positive since Gamma(2)(1) is negative and Gamma(2)(1) is positive for such ionic systems. DeltaG(o) in all cases, however, are expressed in terms of the standard state of reference of unit activity so that their magnitudes and sign can be related to the relative affinities of a solute for binding with proteins in aqueous media.

Resource allocation for public hospitals in Andhra Pradesh, India

The composition of the hospital sector has important implications for cost effectiveness accessibility and coverage. The classification of acute general hospitals is reviewed here with particular reference to India and Andhra Pradesh. Approaches to arrive at a norm for allocation of hospital expenditure among secondary and tertiary hospitals are discussed. The actual allocation of public sector hospital expenditures is analyzed with data from Andhra Pradesh. The shift in allocative emphasis away from hospitals and in favour of primary health care during the 1980s was found to have been equally shared by secondary and tertiary hospitals. The shares of recurrent (non-plan) expenditure to secondary and tertiary hospitals were 51% and 49% respectively. This can be compared to a derived norm of 66% and 33%. The opportunity that new investment funds (plan schemes) could have provided to rectify the expenditure bias against secondary level hospitals was missed as two-thirds of plan expenditure were also spent on tertiary level hospitals. The share of secondary hospital bed capacity was 45.5% against India's Planning Commission norm of 70%. Public spending strategies should explicitly consider what mix of hospital services is being financed as well as the balance between hospital and primary health care expenditures.

Social evolution of hospitals. How is it relevant for health policy?

There are different kinds of hospitals. Doctors and nurses are the most prominent and visible components of a hospital. Development of nursing profession and medical technology have been two very significant factors in making hospitals a viable proposition. The hospitals were to start with very much as social institutions. The social basis of hospitals continues to be valid today. In this way, it is tried in this paper to highlight the evolution of different types of hospitals as social and technological institutions with the help of existing literature on history of hospitals and professions associated with it.

Using hospital activity indicators to evaluate performance in Andhra Pradesh, India

The performance of secondary level public hospitals in Andhra Pradesh. India was evaluated with the help of input-output ratios of hospital activity and service mix. Indicators for emergency, clinical, diagnostic and medico-legal services have been defined. Wide variability of global hospital activities was observed. Variability of turnover rate and bed occupancy was much more than length of stay. Combined utilization and productivity analysis showed that all outlying hospitals were either in the low turnover, low occupancy group or in the high turnover, high occupancy group. Low productivity or inadequate hospital capacity seem to be the major problems. All low turnover, low occupancy hospitals also had low levels of outpatient consultations, and high turnover, high occupancy hospitals had above-average outpatient activity. About 40 per cent of hospitals did not provide emergency services. About 10 per cent of hospitals were not performing any diagnostic tests. Strengthening emergency service delivery capacity, as well as diagnostic facilities, could improve productivity and capacity utilization. Extremes of turnover and occupancy were not associated with any particular case-mix pattern. Thus, neither poor productivity and capacity utilization nor over-crowding can be explained by case-mix differences. Problems of poor performance and inadequate capacity seem to be real.

Limbs generated at site of tail amputation in marbled balloon frog after vitamin A treatment

Niazi and Saxena first observed that vitamin A has an inhibitory and modifying influence on tail regeneration in Bufo andersonii tadpoles. A positive relationship was later found between the inhibiting influence of vitamin A and the developmental stage of the regenerating tail in the same species. There have been several subsequent reports on the effects of vitamin A and its derivatives on limb development and regeneration. Thus in regenerating amphibian limbs, application of retinoids produces pattern duplication in the proximodistal and anteroposterior axes of the limb, and local application of retinoic acid to the anterior side of developing chick limbs causes duplications in the anteroposterior axis of limb. Here we show that vitamin A can cause limb development when applied to amputated tail stumps of the tadpoles of the marbled balloon frog Uperodon systoma (Anura Microhylidae). This is the first report of homeotic transformation mediated through vitamin A in vertebrates.