Childhood Head Growth and Educational Attainment in an Indian Cohort.

BACKGROUND: There is minimal information about the association of head growth at different stages of childhood with cognitive ability. OBJECTIVE: To determine the relationship of newborn head size and head growth during infancy, childhood and adolescence with attained education, a proxy for cognitive ability. STUDY DESIGN: Prospective birth cohort study. SETTING: Married women living in South Delhi between 1969 and 1973. PARTICIPANTS: The New Delhi Birth Cohort study followed up 8030 newborns born in 1969-1973 with head circumference, weight and height measurements at birth and 6-12 monthly until adulthood. Of these, 1526 men and women were followed up at the age of 26-32 years. OUTCOMES: Association between years of schooling, as an indicator of cognitive ability, and newborn head circumference and conditional measures of head growth during infancy, childhood and adolescence. RESULTS: In unadjusted analyses, newborn head size was positively associated with years of education [(b (95% CI)=0.30 (0.14 to 0.47) years per SD head circumference], as was head growth from birth to 6 months [b (95% CI)=0.44 (0.28 to 0.60) years per SD conditional head growth], 6 months to 2 years [b (95% CI)=0.31 (0.15 to 0.47) years per SD conditional head growth] and 2 to 11 years [b (95% CI)=0.20 (0.03 to 0.36) years per SD conditional head growth]. There were similar findings for height and body mass index (BMI). In the adjusted model containing all growth measures, gestational age, and socio-economic status (SES) at birth as predictors, only SES was positively associated with educational attainment. CONCLUSION: Educational attainment in this population is positively associated with socioeconomic status and its influence on inter-related early life (fetal, infant and childhood) factors like nutritional status and brain growth.

Risk factors for severe acute malnutrition in under-five children: a case-control study in a rural part of India.

OBJECTIVES: The present study was planned to identify some of the risk factors of severe acute malnutrition (SAM) in under-five children in a rural part of India. STUDY DESIGN: Case-control study. METHODS: The study was carried out in rural areas of Yavatmal district. A total of 737 cases (under-five SAM children) and an equal number of normal controls were included in the study. Data were collected using a structured questionnaire. Binary logistic regression was used for multivariate analysis using a hierarchical model. RESULTS: The odds of a child being in the SAM category increased significantly if the family: was below the poverty line, have a kuccha house, have more children in the family, have less rooms in the house, have a working mother, has a mother with a lower level of education, have an unemployed father, did not use any water purification measure, did not always ensure parents washed their hands before feeding a child, did not wash hands with soap and water after defecation, have a father with any addictive habit like tobacco or alcohol consumption, have a maternal height <145 cm, have a maternal weight <45 kg, have a lower age at marriage for mothers, had an institutional delivery, have the same food utilized more than once in a day, have no age-appropriate vaccination, give prelacteal feeds, have a lower frequency of breast feeding, do not use semisolid food during the weaning period, exclusively breast feed for less than four months or more than six months, had low birth weight, have five or more episodes of illness in the previous year, have ≤3 feeds per day apart from breast milk, and not initiation of breast feeding within 30 min of birth. CONCLUSION: Risk factors identified in the present study can be addressed through health system interventions. The strongest association was observed with child feeding practices; thus, more emphasis is required in nutritional education and counselling in strategies to fight undernutrition.

Treatment outcome and its attributes in TB-HIV co-infected patients registered under Revised National TB Control Program: a retrospective cohort analysis.

OBJECTIVES: DOTS treatment has shown to be effective in TB patients with or without HIV infection although there have been some conflicting evidence. This may be due to various factors associated with HIV-TB co-infection and its treatment. Thus the present study was planned to study the outcome of DOTS and factors associated with same in TB-HIV co-infected patients. STUDY DESIGN: A retrospective cohort analysis was done. METHODS: 886 TB-HIV co-infected patients who were registered under RNTCP were the subjects. Data from RNTCP was obtained on diagnosis of TB, HIV and TB therapy and some attributes. RESULTS: Average cure rate for NSP TB-HIV co-infected patients was 72% compared with 83% of total NSP registered patients (P < 0.001). Death rate in NSP TB-HIV co-infected patients was 16% (P < 0.001). In non-NSP TB-HIV co-infected patients, success rate was 80%. Death rate was significantly higher i.e. 12% in non-NSP TB-HIV co-infected cases as compared with 6% in total registered patients. Death rate was 19% in RT TB-HIV co-infected patients while 11% in all registered RT cases (P < 0.001). In TB-HIV co-infected patients paediatric patients, patients with extra pulmonary TB and new patients without any history of previous treatment had a higher chance of success at treatment. Patients with Pulmonary TB had higher chance of death. CONCLUSION: Success rate was significantly lower and death rate was significantly higher among the TB-HIV co-infected cohort with age, type of TB and history of previous treatment affecting the success rate of treatment and type of TB affecting the death rate.

Predictors for antenatal services and pregnancy outcome in a rural area: a prospective study in Wardha district, India.

BACKGROUND: Antenatal care is essential to reduce morbidity and mortality among newborn babies and pregnant women. AIMS: To study the pattern of utilization of antenatal services and to find out the potential predictors, their distributions and their association with antenatal care utilization and pregnancy outcomes. SETTINGS AND DESIGN: A prospective longitudinal study was conducted in Deoli, a rural teaching area of a medical college of Wardha district, Maharashtra state. MATERIALS AND METHODS: Medical social workers contacted all the registered 305 pregnant women in 1 month. A total of 274 women were included in the study. The response rate was 89.83%. STATISTICAL ANALYSIS USED: Percentages, rate ratio. RESULTS: Mean age at marriage was 19.8+/-3.6 years, and the average age at first pregnancy was 21.6+/- 4.5 years. Of the 274 pregnant women, 156 (56.9%) were pregnant for the first time (gravida 1), and the remaining 118 (43.1%) pregnant women, gravida 2 and above, had an average of 2.1 living sons and 1.9 living daughters. Only 92 (33.6%) women had undergone the minimum recommended antenatal checkup during their current pregnancy, and 188 (68.6%) women had institutional deliveries. A large proportion of women in Deoli do not receive proper health care during pregnancy and childbirth. CONCLUSION: In Deoli, antenatal services, in spite of being essential to the care of pregnant women, are being poorly delivered.

Mapping 'Occupational Health' courses in India: A systematic review.

The occupational health scenario is undergoing a paradigm shift in developing countries with rapid industrialization. Inadequate human resource is, however, a concern. The creation of Basic Occupational Health Services will demand a further increase in specialist manpower. The current training capacity of occupational health specialists has been mapped by a systematic review in India. Twenty-one institutes have been identified all across the country. They have an existing capacity for training about 460 specialists. This number is inadequate considering the population of India's working class. A mixture of strategies must be urgently planned for addressing this issue.

Immunogenicity and safety of Abhay M and M-vac vaccines in healthy infants: a phase III multicentric randomized single blind trial.

OBJECTIVE: To study immunogenicity and safety of Abhay M and M-Vac vaccines in prevention of measles in healthy infants. METHODS: In a randomized, single blind, comparative, multi-centric phase III trial, a total of 600 healthy infants between 9 - 15 months of age were recruited in the study from seven participating sites during five months. The block randomization design was used for randomizing the subjects into 2 vaccine groups (Investigational Vaccine - Abhay M and Control Vaccine - M-Vac) in the ratio 2:1. At base line (visit 1) a venous blood sample 1.5 ml was collected and subjects were then administered a single dose 0.5 ml of measles vaccine (Abhay M or M-Vac vaccine) subcutaneously according to randomization. Following administration of vaccine, subjects were observed closely for 30 - 60 minutes at the study hospitals for local reactions and systemic events. At visit 2 (follow up visit) another venous blood sample 1.5 ml was collected and the paired sera (both pre and post vaccination serum) were tested concurrently. Safety and immunogenicity were assessed through follow-up of adverse events and anti measles antibody response respectively. RESULTS: Overall 95.7 % seroconversion was achieved in both the groups, 96% in Abhay M vaccine group and 95.1%. in M-Vac vaccine group. There were no statistically significant differences in the observed seroconversion rates. In Abhay M vaccine group, the pre vaccination geometric mean titers (GMT) significantly increased from 35.5 mIU/ml to 486.9 mIU/ml after vaccination. The observed significant increase of GMT in M-Vac vaccine group was from 33.3 mIU/ml to 375.8 mIU/ml. Overall 459 (82.5%) out of 556 subjects were seroprotected after vaccination i.e. > or equal to [corrected] 200 mIU/ml (Protective levels). Of the 459 seroprotected, 315 (84.9%) subjects were in Abhay M vaccine group and 144 (77.8%) subjects were in M-Vac vaccine group. The frequencies of the reported local and general symptoms were similar between the Abhay M vaccine group and M-Vac vaccine group. CONCLUSION: Human Biologicals Institute's Abhay M vaccine is equally immunogenic and as safe as M-Vac vaccine when administered to healthy infants in single dose schedule.

Prevalence and some epidemiological factors of beta thalassaemia trait in Sindhi community of Nagpur City, India.

OBJECTIVE: To study the prevalence of Beta thalassaemia trait (bTT) in Sindhi community of Nagpur City and to study association between bTT and some epidemiological factors like age at menarche in females, past history of diagnosis and treatment of anaemia and the current haemoglobin concentration. METHODS: The present cross-sectional study was undertaken among 446, young, apparently healthy, unrelated (by blood) Sindhi individuals before marriage or before reproduction. Blood samples were processed for Beta thalassaemia trait (bTT) using two stage approaches. Two screening tests namely Naked Eye Single Tube Red Cell Osmotic Fragility Test (NESTROFT) and RBC indices including Mean Corpuscular Volume (MCV) were performed on all samples and those positive for either one or both screening tests were further investigated for HbA2 level estimation by Haemoglobin electrophoresis on Cellulose acetate paper. HbA2 level of > 4.5% was taken as confirmatory of bTT. RESULTS: The prevalence of bTT in Sindhis of Nagpur was found to be 16.81%. No significant association was found between bTT & a delayed age at menarche, however a significantly higher number of trait carrier females had past history of diagnosis and treatment of anaemia while a significantly higher number of both male and female trait carriers had current haemoglobin concentration in anaemic range. CONCLUSION: The present study confirmed high prevalence of bTT in Sindhis.

Prevalence and pattern of childhood morbidity in a tribal area of Maharastra.

Previous studies have demonstrated that tribal children suffer from a higher rate of morbidity. Gender discrimination in the form of dietary neglect of the female children has also been noted. The community based cross-sectional study was carried out in tribal PHC Salona of Chikhaldara Block, Amaravati District, Maharashtra to study the prevalence and pattern of morbidities in children. 2603 study children between 0-72 months of age were covered in a house to house survey by the investigator. Parents of eligible children were interviewed using a pre-tested questionnaire for socio-demographic details, personal habits, past and current medical history. The prevalence of overall morbidities was 34.7% and it was higher in female as compared to male children (34.8% vs. 29.7%; chi2 = 9.3, p <0.005). Among individual morbidities, the prevalence of acute respiratory infections was the highest (25.5%) followed by acute diarrhoeal diseases (5.8%), conjunctivitis (1.5%), and skin infections (1.2%).

Cirumstances and motivations for seeking abortions: a community based study in Chandrapur District, Maharashtra.

The present population based group comparison study was undertaken to study the circumstances, motivations and influencing factors for seeking abortion in women in Chandrapur District of Maharashtra. Participants of the study included 500 cases of induced abortion and the equal number of normal delivered women during the same period and in the same area as comparison group. Having two children, domestic problems and unwanted pregnancy were conditions acceptable to study subjects to terminate the pregnancy. Family and domestic problems, poor socio-economic status, short inter-pregnancy interval and completed family size were some of the important reasons quoted by study subjects for not desiring to continue the current pregnancy. Majority of the subjects felt that the decision to terminate or keep pregnancy is usually taken jointly by both the husband and wife. Family and domestic problems, poor socioeconomic status and short inter pregnancy interval were the important reasons quoted by abortion cases for seeking abortion in the current pregnancy. Only 1.80% of the cases reported failure of contraceptive method as a cause of seeking abortion services. In 78.4% of abortion cases as compared to 5.4% subjects from the comparison group, pregnancy was un-planned.

Effectiveness of Bacillus Calmette Guerin (BCG) vaccination in the prevention of leprosy: a population-based case-control study in Yavatmal District, India.

OBJECTIVE: To estimate the effectiveness of Bacillus Calmette Guerin (BCG) vaccination in the prevention of leprosy. Study design. Population-based case-control study. METHODS: The study was carried out in Yavatmal District, Maharashtra, India. It included 364 cases of leprosy (diagnosed by the World Health Organization's criteria), born since 1962, that were detected during a leprosy survey conducted by the Government of Maharashtra in 2,175,514 people. Each case was pair-matched with one neighbourhood control for age, sex and socio-economic status. Exclusion criteria for controls included past or current history of tuberculosis or leprosy. BCG vaccination status was assessed by examination for the presence of a BCG scar, immunization records if available and information from subjects/parents of children. Subjects who were uncertain about BCG vaccination were not included. RESULTS: A significant protective association between BCG and leprosy was observed [odds ratio=0.46, 95% confidence intervals (CI) 0.34-0.61]. Overall vaccine effectiveness (VE) was 54% (95% CI 39-66). BCG effectiveness against multibacillary, paucibacillary and single skin lesion leprosy was 68% (95% CI 26-86), 57% (95% CI 29-74) and 48% (95% CI 22-65), respectively. Analysis of linear trend revealed a significant linear association between the protective effect of BCG and the type of leprosy. The BCG vaccine was more effective in those aged < or =20 years compared with those aged >20 years (VE 61%, 95% CI), among females compared with males (VE 60%, 95% CI), in lower socio-economic strata compared with upper and middle strata (VE 57%, 95% CI), and in subjects who had a BCG scar size < or =5 mm compared with those with a BCG scar size >5 mm (VE 61%, 95% CI). However, these differences were not statistically significant, as reflected by the overlapping 95% CIs. The overall prevented fraction was 35% (95% CI 22-46). CONCLUSION: The current study identified a beneficial role of BCG vaccination in the prevention of leprosy in the study population.

A risk scoring system for prediction of haemorrhagic stroke.

The present pair-matched case control study was carried out at Government Medical College Hospital, Nagpur, India, a tertiary care hospital with the objective to devise and validate a risk scoring system for prediction of hemorrhagic stroke. The study consisted of 166 hospitalized CT scan proved cases of hemorrhagic stroke (ICD 9, 431-432), and a age and sex matched control per case. The controls were selected from patients who attended the study hospital for conditions other than stroke. On conditional multiple logistic regression five risk factors- hypertension (OR = 1.9. 95% Cl = 1.5-2.5). raised scrum total cholesterol (OR = 2.3, 95% Cl = 1.1-4.9). use of anticoagulants and antiplatelet agents (OR = 3.4, 95% Cl =1.1-10.4). past history of transient ischaemic attack (OR = 8.4, 95% Cl = 2.1- 33.6) and alcohol intake (OR = 2.1, 95% Cl = 1.3-3.6) were significant. These factors were ascribed statistical weights (based on regression coefficients) of 6, 8, 12, 21 and 8 respectively. The nonsignificant factors (diabetes mellitus, physical inactivity, obesity, smoking, type A personality, history of claudication, family history of stroke, history of cardiac diseases and oral contraceptive use in females) were not included in the development of scoring system. ROC curve suggested a total score of 21 to be the best cut-off for predicting haemorrhag stroke. At this cut-off the sensitivity, specificity, positive predictivity and Cohen's kappa were 0.74, 0.74, 0.74 and 0.48 respectively. The overall predictive accuracy of this additive risk scoring system (area under ROC curve by Wilcoxon statistic) was 0.79 (95% Cl = 0.73-0.84). Thus to conclude, if substantiated by further validation, this scorincy system can be used to predict haemorrhagic stroke, thereby helping to devise effective risk factor intervention strategy.

Sample size and power analysis in medical research.

Among the questions that a researcher should ask when planning a study is "How large a sample do I need?" If the sample size is too small, even a well conducted study may fail to answer its research question, may fail to detect important effects or associations, or may estimate those effects or associations too imprecisely. Similarly, if the sample size is too large, the study will be more difficult and costly, and may even lead to a loss in accuracy. Hence, optimum sample size is an essential component of any research. When the estimated sample size can not be included in a study, post-hoc power analysis should be carried out. Approaches for estimating sample size and performing power analysis depend primarily on the study design and the main outcome measure of the study. There are distinct approaches for calculating sample size for different study designs and different outcome measures. Additionally, there are also different procedures for calculating sample size for two approaches of drawing statistical inference from the study results, i.e. confidence interval approach and test of significance approach. This article describes some commonly used terms, which need to be specified for a formal sample size calculation. Examples for four procedures (use of formulae, readymade tables, nomograms, and computer software), which are conventionally used for calculating sample size, are also given.

The BCG controversy: a reappraisal of the protective effect against tuberculosis and leprosy.

BCG (Bacillus Calmette Guerin) vaccine remains a highly controversial method of preventing tuberculosis and leprosy despite more than eighty years of use. The protective effect against tuberculosis observed in various studies ranged from -56% to 98%. Case-control studies carried out at Nagpur reported moderate effectiveness of BCG vaccination in prevention of tuberculosis. Its effectiveness was higher against extra-pulmonary tuberculosis. The summary protective effects obtained from meta-analysis of trials, cohort studies and case-control studies of BCG vaccination and tuberculosis were 51 (33-64), 76 (63-85), and 65 (57-72) percent respectively. The case-control studies carried out at Nagpur also demonstrated a significant protective association between BCG vaccination and leprosy. The summary protective effects obtained from meta-analysis of trials, cohort studies and case-control studies of BCG vaccination and leprosy were 43 (27-55), 62 (53-69), and 59 (46-68) percent respectively. The results of the current study and systematic review thus supported arguments favoring use of BCG vaccine for prevention of tuberculosis and leprosy.

Meta-analysis in medicine.

When it comes to health care, everybody - medical professionals, policymakers and patients - wants to know what works and what does not. Every day clinicians debate, implicitly or explicitly, whether new research findings are convincing enough to change the way they practice. The quality of research varies, and so much information is being produced that it is impossible for anyone to know and evaluate it all. Traditionally, randomized controlled trials are considered gold standard study designs. However, if they report discordant results and generate controversies, then what should we look for? The answer to this imbroglio is meta-analysis. Steps in designing and conducting meta-analysis involve describing the purpose of meta-analysis, designing a research question, searching for studies, specifying study selection (inclusion and exclusion) and appraisal criteria, deciding data extraction procedures (including statistical reanalysis), assessing combinability of studies, selecting an analytical strategy (use of models and sensitivity analysis), anticipating systematic errors (biases) and limitations, and presenting and disseminating results of the meta-analysis. The Cochrane Collaboration is significantly contributing to the development of this area of research and making a noticeable dent on the practice of evidence based medicine across the globe. Meta-analytic approaches have been used to resolve long standing controversies in the field of medicine, including dermatology.

Hypertension among cotton textile workers.

The present cross sectional study on prevalence of hypertension was carried out among 514 cotton textile workers of Shri Bapurao Deshmukh Sut Gimi, Wardha. Using standard guidelines for measuring blood pressure and standard criteria for diagnosis of hypertension, 20.2% of the subjects were found to have raised systolic and/or diastolic blood pressure. The prevalence of hypertension was significantly higher among persons aged 35 years or more, in the present occupation for 10 years or more and those working in more noisy department.

Factors responsible for delayed immunisation among children under 5 years of age.

Although immunisation coverage has increased substantially in recent years, still a sizable proportion of children are not being immunised at appropriate time. The present hospital based, pair matched, case control study was carried out at immunoprophylactic centre of Government Medical College and Hospital, Nagpur, to identify risk factors associated with delayed immunisation among children. This study included 139 children with a delay of more than 90 days for scheduled primary immunisation and equal number of matched control (for dose) receiving immunisation at appropriate time. The study identified significant association of family size [Odd's ratio (OR) = 7.3, 95% confidence interval (CI) = 1.5-35.6], number of children < 5 years (OR = 3.17, 95% CI = 1.1-9.9), sex (OR = 3, 95% CI = 1.2-7.4), paternal education (OR = 3.7, 95% CI = 1.6-8.5), maternal education (OR = 4, 95% CI = 1.5-10.9), socio-economic status (OR = 3.7, 95% CI = 1.1-13.2) and distance from health centre (OR = 4.7, 95% CI = 1.2-17.6) with delayed immunisation. Negligence (56%) and unawareness (22.7%) of parents were main reasons for delayed immunisation. Hence more stress on identified risk factors in the study will indirectly help in reducing the frequency of delayed immunisation.