Risk of diabetes and expected years in life without diabetes among adults from an urban community in India: findings from a retrospective cohort.

BACKGROUND: Diabetes prevalence has increased over the past few decades, and the shift of the burden of diabetes from the older population to the younger population has increased the exposure of longer durations in a morbid state. The study aimed at ascertaining the likelihood of progression to diabetes and to estimate the onset of diabetes within the urban community of Mumbai. METHODS: This study utilized an observational retrospective non-diabetic cohort comprising 1629 individuals enrolled in a health security scheme. Ten years of data were extracted from electronic medical records, and the life table approach was employed to assess the probability of advancing to diabetes and estimate the expected number of years lived without a diabetes diagnosis. RESULTS: The study revealed a 42% overall probability of diabetes progression, with age and gender variations. Males (44%) show higher probabilities than females (40%) of developing diabetes. Diabetes likelihood rises with age, peaking in males aged 55-59 and females aged 65-69. Males aged 30-34 exhibit a faster progression (10.6 years to diagnosis) compared to females (12.3 years). CONCLUSION: The study's outcomes have significant implications for the importance of early diabetes detection. Progression patterns suggest that younger cohorts exhibit a comparatively slower rate of progression compared to older cohorts.

The lifetime risk of developing type II diabetes in an urban community in Mumbai: findings from a ten-year retrospective cohort study.

BACKGROUND: Incidence and prevalence do not capture the risk of developing diabetes during a defined period and only limited evidence exists on the lifetime risk of diabetes based on longer and continuous follow-up studies in India. Lacunae in evidence on lifetime risk can be attributed primarily to the absence of comprehensive and reliable information on diabetes incidence, mortality rates and lack of longitudinal studies in India. In light of the scarcity of evidence in India, the objective of this study was to estimate the incidence of diabetes and its lifetime risk in an urban community of Mumbai. METHODS: The research study utilized data which is extracted from the electronic medical records of beneficiaries covered under the Contributory Health Service Scheme in Mumbai. The dataset included information on 1652 beneficiaries aged 40 years and above who were non-diabetic in 2011-2012, capturing their visit dates to medical center and corresponding laboratory test results over a span ten years from January, 2012- December, 2021. Survival analysis techniques are applied to estimate the incidence of diabetes. Subsequently, the remaining life years from the life table were utilized to estimate the lifetime risk of diabetes for each gender, stratified by age group. RESULTS: A total of 546 beneficiaries developed diabetes in ten years, yielding an unadjusted incidence rate of 5.3 cases per 1000 person-years (95% CI: 4.9- 5.8 cases/ 1000 person years). The age-adjusted lifetime risk of developing type II diabetes in this urban community is estimated to be 40.3%. Notably, males aged 40 years and above had 41.5% chances of developing diabetes in their lifetime as compared to females with a risk of 39.4%. Moreover, the remaining lifetime risk of diabetes decreased with advancing age, ranging from 26.4% among 40-44 years old to 4.2% among those age 70 years and above. CONCLUSION: The findings stress the significance of recognizing age specific lifetime risk and implementing early interventions to prevent or delay diabetes onset and to focus on diabetes management programs in India.

Hepatitis C virus treatment with glecaprevir and pibrentasvir in patients co-prescribed carbamazepine: Three case reports.

BACKGROUND: Highly effective and well-tolerated direct-acting antiviral (DAA) therapies have revolutionised the management of hepatitis C virus (HCV); however, niche populations face treatment barriers. DAAs co-prescribed with several first-generation anti-epileptic drugs (AEDs) are contraindicated due to drug-drug interactions. A common example is carbamazepine whereby steady-state carbamazepine reduces the maximum concentration and area under the curve of velpatasvir, glecaprevir and pibrentasvir due to potent cytochrome P450 (CYP) 3A4 induction. Carbamazepine also induces P-glycoprotein which reduces glecaprevir and pibrentasvir's area under curve to infinite time. Sofosbuvir-velpatasvir and glecaprevir-pibrentasvir are contraindicated in patients who are co-prescribed carbamazepine due to the risk of reduced DAA therapeutic effect and consequently, virological treatment failure. This presents a challenge for patients in whom carbamazepine substitution is medically unfeasible, impractical or unacceptable. However, the properties of current generation DAA therapies, including high-potency non-structural protein 5A inhibitory effect, may be sufficient to overcome reduced bioavailability arising from carbamazepine related CYP 3A4 and P-glycoprotein induction. CASE SUMMARY: We present a case series of three patients with non-cirrhotic, treatment-naïve, genotype 1a, 1b, and 3a HCV who were treated with a 12 wk course of glecaprevir-pibrentasvir, while co-prescribed carbamazepine for seizure disorders. Glecaprevir-pibrentasvir combination therapy was chosen due to its potent in vitro activity and low barrier to pan-genotypic resistance associated variants. DAA therapy was dose-separated from carbamazepine to maximise time to peak concentration, and taken with meals to improve absorption. Sustained virological response at 12 wk was achieved in each patient with no adverse outcomes. CONCLUSION: DAA therapies, including glecaprevir-pibrentasvir, warrant consideration as a therapeutic agent in people with HCV who are co-prescribed carbamazepine, particularly if AED substitution is not feasible.

Monitoring early-season agricultural drought using temporal Sentinel-1 SAR-based combined drought index.

Early-season agricultural drought is frequent over South Asian region due to delayed or deficient monsoon rainfall. These drought events often cause delay in sowing and can even result in crop failure. The present study focuses on monitoring early-season agricultural drought in a semi-arid region of India over 5-year period (2016-2020). It utilizes hydro-climatic and biophysical variables to develop a combined drought index (CDI), which integrates anomalies in soil moisture conditions, rainfall, and crop-sown area progression. Synthetic aperture radar (SAR)-based soil moisture index (SMI) represents in situ measured soil moisture with reasonable accuracy (r=0.68). Based on the highest F1-score, SAR backscatter in VH (vertical transmit-horizontal receive) polarization with specific values for parameter threshold (-18.63 dB) and slope threshold (-0.072) is selected to determine the start of season (SoS) with a validation accuracy of 73.53%. The CDI approach is used to monitor early-season agricultural drought and identified drought conditions during June-July in 2019 and during July in 2018. Conversely, 2020 experienced consistently wet conditions, while 2016 and 2017 had near-normal conditions. Overall, the study highlights the use of SAR data for early-season agricultural drought monitoring, which is mainly governed by soil moisture-driven crop-sowing progression. The proposed methodology holds potential for effective monitoring, management, and decision-making in early-season agricultural drought scenarios.

Health status and associated factors of middle-aged and older adult cancer survivors in India: results from the Longitudinal Ageing Study in India.

BACKGROUND: The number of persons who have survived cancer has been increasing in India as elsewhere due to advances in detection and treatment of this disease. However, evidence on the standardised number of cancer survivors, their characteristics and their complex health challenges on a national level does not exist due to data limitations. This study, therefore, examines the profile of cancer survivors and their health status using the recently released Longitudinal Ageing Study in India (LASI) survey data. METHODS: LASI wave 1 is a cross-sectional nationally representative survey of 65,562 middle and older adults aged 45 and above. We first calculated the socioeconomic, demographic and geographical characteristics of cancer survivors (per 100,000 population). We later estimated the adjusted odds of poor health, sleep problems, depressive symptoms, activities of living limitations (ADL and IADL), and hospitalisation of cancer survivors using multivariable logistic regression analysis. RESULTS: According to LASI estimates, there were 2.1 million cancer survivors in India (95% CI 1.8 million to 2.6 million) in 2017-18. Overall, 440 cancer survivors have been identified in this study, with considerable state variations. The number of cancer survivors per 1,00,000 population was relatively more in non-indigenous groups, people with a history of cancer in their families, those who worked earlier but currently not working and those in the richest quintile categories. As compared to those who never had cancer, the cancer survivors are at higher risk of hospitalisation (adjusted odds ratio (aOR) = 2.61 CI 1.86, 3.67), poor self-rated health (aOR = 3.77, CI 2.55, 5.54), depressive symptoms (aOR = 1.53, CI 1.41, 2.05) and sleep problems (aOR = 2.29, CI 1.50, 3.47). They also reported higher ADL (aOR = 1.61, CI 1.11, 2.34) and IADL (aOR = 1.49, CI 1.07, 2.07) limitations. Cancer survivors who had their cancer diagnosis in the past 2 years or a cancer-related treatment in the past 2 years have significantly higher odds of poor health status than middle-aged and older adults without a cancer history. CONCLUSION: Middle-aged and older cancer survivors, particularly those who underwent cancer diagnosis or treatment in the past 2 years, are at a significantly higher risk of experiencing poor self-reported health and other health challenges, suggesting the need for an integrated healthcare approach.

Gift authorship: Two more contexts.

The emergence of multi-centric studies and collaborative research between institutions within and outside the country, and of research led by authors who are from the same family, has led to notable changes in the production of public health research evidence from India. There is a potential risk of research publications overlooking the well known ICMJE (International Committee of Medical Journal Editors) criteria for authorship, with the provision of gift authorship to researchers who can facilitate faster access to Indian data for such collaborative research. The paper calls for action to reduce the practice of gift authorship in these research settings.

Mapping novel QTLs for yield related traits from a popular rice hybrid KRH-2 derived doubled haploid (DH) population.

A doubled haploid (DH) population consisting of 125 DHLs derived from the popular rice hybrid, KRH-2 (IR58025A/KMR3R) was utilized for Quantitative Trait Loci (QTL) mapping to identify novel genomic regions associated with yield related traits. A genetic map was constructed with 126 polymorphic SSR and EST derived markers, which were distributed across rice genome. QTL analysis using inclusive composite interval mapping (ICIM) method identified a total of 24 major and minor effect QTLs. Among them, twelve major effect QTLs were identified for days to fifty percent flowering (qDFF12-1), total grain yield/plant (qYLD3-1 and qYLD6-1), test (1,000) grain weight (qTGW6-1 and qTGW7-1), panicle weight (qPW9-1), plant height (qPH12-1), flag leaf length (qFLL6-1), flag leaf width (qFLW4-1), panicle length (qPL3-1 and qPL6-1) and biomass (qBM4-1), explaining 29.95-56.75% of the phenotypic variability with LOD scores range of 2.72-16.51. Chromosomal regions with gene clusters were identified on chromosome 3 for total grain yield/plant (qYLD3-1) and panicle length (qPL3-1) and on chromosome 6 for total grain yield/plant (qYLD6-1), flag leaf length (qFLL6-1) and panicle length (qPL6-1). Majority of the QTLs identified were observed to be co-localized with the previously reported QTL regions. Five novel, major effect QTLs associated with panicle weight (qPW9-1), plant height (qPH12-1), flag leaf width (qFLW4-1), panicle length (qPL3-1) and biomass (qBM4-1) and three novel minor effect QTLs for panicle weight (qPW3-1 and qPW8-1) and fertile grains per panicle (qFGP5-1) were identified. These QTLs can be used in breeding programs aimed to yield improvement after their validation in alternative populations. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s13205-021-03045-7.

The adverse effects of Ketamine on Procedural Sedation and Analgesia (PSA) in the Emergency Department.

BACKGROUND: Procedural sedation and analgesia (PSA) in the emergency department (ED) is mainly used for wound irrigation, reduction of fractures, and wound closure. Ketamine is one of the most commonly used drugs for PSA in the ED. The study was conducted in the ED of a large tertiary care hospital in southern India to evaluate the adverse effects of Ketamine on PSA. MATERIALS AND METHODS: This is a prospective observational study performed in the ED for 6 months (October 2019-March 2020) in 151 patients who required Ketamine for PSA. Titrated doses of Ketamine was administered in all patients; hemodynamic variables and adverse events were recorded at timed intervals. RESULTS: During the study period, a total of 151 patients in the ED required PSA. The mean age of the study Cohort was 37 ± 15 years, and males accounted for 83%. All individuals obtained adequate sedation and pain relief. It was found that the incidence of adverse reactions to Ketamine was higher in young people (18- to 40-year-old), which was 63%. The most common adverse reaction in the study population was 39 cases of hypertension (44.8%), followed by vomiting in 25 cases (28.7%) and delusion in 6 cases (4%). There was no significant adverse effect in any patients which necessitated admission. CONCLUSION: Ketamine is a drug with good analgesic, sedative properties and has been shown to have a good safety profile with minimal adverse events for use as PSA in ED. Side effects were most common in the younger adult age group and hypertension was the most common side effect.

Novel major QTLs associated with low soil phosphorus tolerance identified from the Indian rice landrace, Wazuhophek.

With an objective of mapping novel low soil P (Phosphorus) tolerance loci in the non-Pup1 type donor rice line, Wazuhophek, we screened a recombinant inbred line (RIL) mapping population consisting of 330 lines derived from the cross Wazuhophek x Improved Samba Mahsuri (which is highly sensitive to low soil P) in a plot with low soil P for tolerance associated traits. Molecular mapping with SSR markers revealed a total of 16 QTLs (seven major and nine minor QTLs), which are associated with low soil P tolerance related traits. Interestingly, a QTL hotspot, harbouring 10 out of 16 QTLs were identified on the short arm of chromosome 8 (flanked by the makers RM22554 and RM80005). Five major QTLs explaining phenotypic variance to an extent of 15.28%, 17.25%, 21.84%, 20.23%, and 18.50%, associated with the traits, plant height, shoot length, the number of productive tillers, panicle length and yield, respectively, were located in the hotspot. Two major QTLs located on chromosome 1, associated with the traits, total biomass and root to shoot ratio, explaining 15.44% and 15.44% phenotypic variance, respectively were also identified. Complex epistatic interactions were observed among the traits, grain yield per plant, days to 50% flowering, dry shoot weight, and P content of the seed. In-silico analysis of genomic regions flanking the major QTLs revealed the presence of key putative candidate genes, possibly associated with tolerance.

Marker assisted improvement of low soil phosphorus tolerance in the bacterial blight resistant, fine-grain type rice variety, Improved Samba Mahsuri.

Improved-Samba-Mahsuri (ISM), a high-yielding, popular bacterial blight resistant (possessing Xa21, xa13, and xa5), fine-grain type, low glycemic index rice variety is highly sensitive to low soil phosphorus (P). We have deployed marker-assisted backcross breeding (MABB) approach for targeted transfer of Pup1, a major QTL associated with low soil P tolerance, using Swarna as a donor. A new co-dominant marker, K20-1-1, which is specific for Pup1 was designed and used for foreground selection along with functional markers specific for the bacterial blight resistance genes, Xa21, xa13, and xa5. A set of 66 polymorphic SSR marker were used for the background selection along with a pair of flanking markers for the recombination selection in backcross derived progenies and in BC2F2 generation, 12 plants, which are homozygous for Pup1, all the three bacterial blight resistance genes and possessing agro-morphological traits equivalent to or better than ISM were selected and selfed to produce BC2F3s. They were evaluated in plots with low soil P and normal soil P at ICAR-IIRR, Hyderabad for their low soil P tolerance, and bacterial blight resistance and superior lines were advanced to BC2F6. One of the lines, when tested at multiple locations in India was found promising under both normal as well as low soil P conditions.

Molecular mapping of QTLs for yield related traits in recombinant inbred line (RIL) population derived from the popular rice hybrid KRH-2 and their validation through SNP genotyping.

The study was undertaken to identify the quantitative trait loci (QTLs) governing yield and its related traits using a recombinant inbred line (RIL) population derived from the popular rice hybrid, KRH-2 (IR58025A/KMR3R). A genetic map spanning 294.2 cM was constructed with 126 simple sequence repeats (SSR) loci uniformly distributed across the rice genome. QTL analysis using phenotyping and genotyping information identified a total of 22 QTLs. Of these, five major effect QTLs were identified for the following traits: total grain yield/plant (qYLD3-1), panicle weight (qPW3-1), plant height (qPH12-1), flag leaf width (qFLW4-1) and panicle length (qPL3-1), explaining 20.23-22.76% of the phenotypic variance with LOD scores range of 6.5-10.59. Few genomic regions controlling several traits (QTL hotspot) were identified on chromosome 3 for total grain yield/plant (qYLD3-1) and panicle length (qPL3-1). Significant epistatic interactions were also observed for total grain yield per plant (YLD) and panicle length (PL). While most of these QTLs were observed to be co-localized with the previously reported QTL regions, a novel, major QTL associated with panicle length (qPL3-1) was also identified. SNP genotyping of selected high and low yielding RILs and their QTL mapping with 1,082 SNPs validated most of the QTLs identified through SSR genotyping. This facilitated the identification of novel major effect QTLs with much better resolution and precision. In-silico analysis of novel QTLs revealed the biological functions of the putative candidate gene (s) associated with selected traits. Most of the high-yielding RILs possessing the major yield related QTLs were identified to be complete restorers, indicating their possible utilization in development of superior rice hybrids.

Immunomodulator use does not prevent first loss of response to anti-tumour necrosis factor alpha therapy in inflammatory bowel disease: long-term outcomes in a real-world cohort.

BACKGROUND: Recent prospective studies suggest combination therapy with immunomodulators improves efficacy, but long-term data is limited. AIM: To assess whether anti-tumour necrosis factor alpha (anti-TNF) monotherapy was associated with earlier loss of response (LOR) than combination therapy in a real-world cohort with long-term follow up. METHODS: A retrospective audit was conducted of inflammatory bowel disease patients receiving anti-TNF therapy in a tertiary centre and specialist private practices. All patients with accurate data for anti-TNF commencement and adequate correspondence to determine end-points were included. Outcomes measured included time to first LOR, causes and biochemical parameters. RESULTS: Two hundred and twenty-four patients were identified; 139 (62.1%) on combination therapy and 85 (37.9%) on monotherapy. Forty-five percent of patients had LOR during follow up until a maximum of 8.5 years; 59.4% on combination therapy and 40.6% on monotherapy (P = 0.533). The median time to LOR was not different between groups; 1069 days for combination therapy and 1489 days for monotherapy (P = 0.533). There was no difference in time to LOR between patients treated with different combination regimens or different anti-TNF agents. CONCLUSION: In this large cohort of patients in a real-world setting, patients treated with anti-TNF monotherapy had similar rates of LOR as patients on anti-TNF combination therapy, at both short- and long-term follow up.

Implementing the WHO Safe Childbirth Checklist: lessons from a global collaboration.

The WHO Safe Childbirth Checklist (SCC) was developed to ensure the delivery of essential maternal and perinatal care practices around the time of childbirth. A research collaboration was subsequently established to explore factors that influence use of the Checklist in a range of settings around the world. This analysis article presents an overview of the WHO SCC Collaboration and the lessons garnered from implementing the Checklist across a diverse range of settings. Project leads from each collaboration site were asked to distribute two surveys. The first was given to end users, and the second to implementation teams to describe their respective experiences using the Checklist. A total of 134 end users and 38 implementation teams responded to the surveys, from 19 countries across all levels of income. End users were willing to adopt the SCC and found it easy to use. Training and the provision of supervision while using the Checklist, alongside leadership engagement and local ownership, were important factors which helped facilitate initial implementation and successful uptake of the Checklist. Teams identified several challenges, but more importantly successfully implemented the WHO SCC. A critical step in all settings was the adaptation of the Checklist to reflect local context and national protocols and standards. These findings were invaluable in developing the final version of the WHO SCC and its associated implementation guide. Our experience will provide useful insights for any institution wishing to implement the Checklist.

The national employment guarantee scheme and inequities in household spending on food and non-food determinants of health in rural India.

INTRODUCTION: Inequities in a population in spending on food and non-food items can contribute to disparities in health status. The Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS) was launched in rural India in 2006, aimed at providing at least 100 days of manual work to a member in needy households. METHODS: We used nationally representative data from the consumer expenditure surveys of 2004-05 and 2009-10 and the employment survey of 2009-10 conducted by National Sample Survey Organisation to assess the effect of MGNREGS in reducing inequities in consumption of food and non-food items between poor and non-poor households in the states of India. Variations among the states in implementation of MGNREGS were examined using the employment and unemployment survey data, and compared with official programme data up to 2012-13. Inequity in spending on food and non-food items was assessed using the ratio of monthly per capita consumer expenditure (MPCE) between the most vulnerable (labourer) and least vulnerable categories of households. RESULTS: The survey data suggested 1.42 billion person-days of MGNRGES employment in the 2009-10 financial year, whereas the official programme data reported 2.84 billion person-days. According to the official data, the person-days of MGNRGES employment decreased by 43.3% from 2009-10 to 2012-13 for the 9 large less developed states of India. Survey data revealed that the average number of MGNREGS work days in a year per household varied from 42 days in Rajasthan to less than 10 days in 14 of the 20 major states in India in 2009-10. Rajasthan with the highest implementation of MGNRGES among the 9 less developed states of India had the highest relative decline of 10.4% in the food spending inequity from 2004-05 to 2009-10 between the most vulnerable and less vulnerable households. The changes in inequity for non-food spending did not have any particular pattern across the less developed states. In the most vulnerable category, the households in Rajasthan that got 100 or more days of work in a year under MGNREGS had a 25.9% increase in MPCE. CONCLUSION: MGNREGS seems to have contributed to the reduction in food consumption inequity in rural Rajasthan in 2009-10, and has the potential of making a similar contribution with higher level of implementation of this programme in other states. Non-food consumption inequities benefited less from MGNRGES until 2009-10. The reported decrease in the MGNRGES employment person-days in the less developed states of India from 2009-10 to 2012-13 is of concern.

Social sector expenditure and child mortality in India: a state-level analysis from 1997 to 2009.

BACKGROUND: India is unlikely to meet the Millennium Development Goal for child mortality. As public policy impacts child mortality, we assessed the association of social sector expenditure with child mortality in India. METHODS AND FINDINGS: Mixed-effects regression models were used to assess the relationship of state-level overall social sector expenditure and its major components (health, health-related, education, and other) with mortality by sex among infants and children aged 1-4 years from 1997 to 2009, adjusting for potential confounders. Counterfactual models were constructed to estimate deaths averted due to overall social sector increases since 1997. Increases in per capita overall social sector expenditure were slightly higher in less developed than in more developed states from 1997 to 2009 (2.4-fold versus 2-fold), but the level of expenditure remained 36% lower in the former in 2009. Increase in public expenditure on health was not significantly associated with mortality reduction in infants or at ages 1-4 years, but a 10% increase in health-related public expenditure was associated with a 3.6% mortality reduction (95% confidence interval 0.2-6.9%) in 1-4 years old boys. A 10% increase in overall social sector expenditure was associated with a mortality reduction in both boys (6.8%, 3.5-10.0%) and girls (4.1%, 0.8-7.5%) aged 1-4 years. We estimated 119,807 (95% uncertainty interval 53,409-214,662) averted deaths in boys aged 1-4 years and 94,037 (14,725-206,684) in girls in India in 2009 that could be attributed to increases in overall social sector expenditure since 1997. CONCLUSIONS: Further reduction in child mortality in India would be facilitated if policymakers give high priority to the social sector as a whole for resource allocation in the country's 5-year plan for 2012-2017, as public expenditure on health alone has not had major impact on reducing child mortality.

Natural killer cells display impaired responses to toll like receptor 9 that support viral persistence in chronic hepatitis B.

Toll like receptors (TLR) are crucial mediators of innate immune responses, but their influence on natural killer (NK) cell function in chronic hepatitis B infection (CHB) is not well understood. Here we evaluated the responses of peripheral NK cells from CHB patients to multiple TLR agonists. CHB was associated with an impaired NK cell IFN-γ response to TLR9 stimulation compared to controls. This deficiency corrected with recombinant IFN-alpha, while anti-IFN-alpha neutralizing antibody diminished NK IFN-γ production in controls. NK cell CD69 upregulation in response to TLR9 was maintained in CHB. No differences were noted in responses to the other TLR ligands. Our results demonstrate a dichotomous NK cell response to TLR9 that is mediated by IFN-alpha and reflect the multiple mechanisms involved with NK activation. Consequently, it is possible that when activated these cells are unable to contribute to viral clearance while still having the potential to mediate tissue injury.

Inpatient care of the elderly in Brazil and India: assessing social inequalities.

The rapidly growing older adult populations in Brazil and India present major challenges for health systems in these countries, especially with regard to the equitable provision of inpatient care. The objective of this study was to contrast inequalities in both the receipt of inpatient care and the length of time that care was received among adults aged over 60 in two large countries with different modes of health service delivery. Using the Brazilian National Household Survey from 2003 and the Indian National Sample Survey Organisation survey from 2004 inequalities by wealth (measured by income in Brazil and consumption in India) were assessed using concentration curves and indices. Inequalities were also examined through the use of zero-truncated negative binomial models, studying differences in receipt of care and length of stay by region, health insurance, education and reported health status. Results indicated that there was no evidence of inequality in Brazil for both receipt and length of stay by income per capita. However, in India there was a pro-rich bias in the receipt of care, although once care was received there was no difference by consumption per capita for the length of stay. In both countries the higher educated and those with health insurance were more likely to receive care, while the higher educated had longer stays in hospital in Brazil. The health system reforms that have been undertaken in Brazil could be credited as a driver for reducing healthcare inequalities amongst the elderly, while the significant differences by wealth in India shows that reform is still needed to ensure the poor have access to inpatient care. Health reforms that move towards a more public funding model of service delivery in India may reduce inequality in elderly inpatient care in the country.

Burden of out-of-pocket expenditure for road traffic injuries in urban India.

BACKGROUND: Road traffic injuries (RTI) are an increasing public health problem in India where out-of-pocket (OOP) expenditures on health are among the highest in the world. We estimated the OOP expenses for RTI in a large city in India. METHODS: Information on medical and non-medical expenditure was documented for RTI cases of all ages that reported alive or dead to the emergency departments of two public hospitals and a large private hospital in Hyderabad. Differential risk of catastrophic OOP total expenditure (COPE-T) and medical expenditure (COPE-M), and distress financing was assessed for 723 RTI cases that arrived alive at the study hospitals with multiple logistic regression. Catastrophic expenditure was defined as expenditure > 25% of the RTI patient's annual household income. Variation in intensity of COPE-M in RTI was assessed using multiple classification analysis (MCA). RESULTS: The median OOP medical and non-medical expenditure was USD 169 and USD 163, respectively. The prevalence of COPE-M and COPE-T was 21.9% (95% CI 18.8-24.9) and 46% (95% CI 42-49.3), respectively. Only 22% had access to medical insurance. Being admitted to a private hospital (OR 5.2, 95% CI 2.7-9.9) and not having access to insurance (OR 3.8, 95% CI 1.9-7.6) were significantly associated with risk of having COPE - M. Similar results were seen for COPE - T. MCA analysis showed that the burden of OOP medical expenditure was mainly associated with in-patient days in hospital (Eta =0.191). Prevalence of distress financing was 69% (95% CI 65.5-72.3) with it being significantly higher for those reporting to the public hospitals (OR 2.8, 95% CI 1.7-4.6), those belonging to the lowest per capita annual household income quartile (OR 7.0, 95% CI 3.7-13.3), and for those without insurance access (OR 3.4, 95% CI 2.0-5.7). CONCLUSIONS: This paper has outlined the high burden of out-of-pocket medical and total expenditure associated with RTI in India. These data reinforce the need for implementing more effective financial protection mechanisms in India against the high out-of-pocket expenditure incurred on RTI.

Utilization of inpatient care from private hospitals: trends emerging from Kerala, India.

BACKGROUND: There is a gap in knowledge on the overall role and characteristics of private health care providers in India. This research is aimed at understanding changes in the consumption of inpatient care services from private hospitals between 1986 and 2004, with a particular focus on equitable outreach. METHODS: Secondary analysis of National Sample Survey data on the utilization of inpatient care services in Kerala is performed for the periods 1986-87, 1995-96 and 2004. Household survey data are examined to understand the users of the private health system as there are limitations in obtaining reliable data from unregulated private health care providers. FINDING: The annual hospitalization rate increased from 69 per 1000 population in 1986-87 to 126 per 1000 population by 2004. The proportion of persons seeking care from private rather than government hospitals increased from 55% in 1986-87 to 65% by 2004. Concentration indices revealed that the year 1995-96 witnessed the highest income inequality in hospitalization rates. A decline both in hospitalization rates and in the relative preference for private hospitals over government hospitals among the poorest two quintiles between 1986-87 and 1995-96 indicates that the poor avoided inpatient treatment. The rich-poor divide in care seeking from private hospitals was moderated by 2004. CONCLUSION: Improvements in the purchasing power of the population, and the strategy of private hospitals in this highly competitive market to generate revenue from the poorer quintiles by offering different pricing options, have reduced the observed rich-poor divide in the consumption of inpatient treatment from this sector. However, while this gap in utilization has closed, the burden of out-of-pocket expenditure is higher among the poor.

Age-specific analysis of reported morbidity in Kerala, India.

This paper attempts to provide a wider understanding of the differentials in reported health status in Kerala, while comparing morbidity in the state with other regions in the Indian subcontinent. Reported morbidity and the duration of life lived with a disease is higher in Kerala. Economic inequalities were found only in late-working ages and the elderly, primarily due to higher prevalence of life style-associated chronic conditions in these two age groups. Significant caste-wise differences among adolescents and prime working ages indicated potential for health problems induced by income deprivation in socially disadvantaged subgroups. Self-reported morbidity was 65% higher than proxy-reported morbidity. Regional differences were significant across all age groups, with high morbidity in the most developed region in the state. Results also suggested the need to factor for self- and proxy-reported status in any analysis of morbidity using similar survey data.