Impact of community-based health insurance and economic status on utilization of healthcare services: A household-level cross-sectional survey from rural central India.

Background: . Community-based health insurance (CBHI) is a health-financing mechanism based on voluntary membership, risk pooling, with a non-profit objective and relies on social capital as a driving force. It aims to improve equity in healthcare utilization in the community. We did this study to understand if CBHI schemes reach the poor, improve healthcare utilization and protect them from catastrophic health events. Methods: . Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sevagram, located in Wardha district of Maharashtra, India, runs a variety of CBHI schemes in surrounding villages. Many households (HHs) have opted for these schemes. We conducted a cross-sectional survey of all HHs of 35 villages and collected information about sociodemographics, inpatient healthcare utilization (in previous 5 years), outpatient healthcare utilization (in previous 1 year) and insurance status of the HHs. We derived wealth index based on 33 sociodemographic variables and classified HHs in quintiles of wealth index. We compared the distribution of healthcare utilization variables by insurance status and wealth index and used logistic regression to evaluate if health insurance independently improves healthcare utilization, after adjusting for confounders. Results: . Of a total of 7261 HHs surveyed, 2210 (30.4%) were uninsured, 4153 (57.2%) were insured under MGIMS CBHI schemes, and 898 (12.4%) had family insurance either from MGIMS or other providers. Insured HHs had a higher wealth index compared to uninsured. Mean (SD) hospitalization episodes in an HH were 0.82 (1.75) among uninsured, 1.13 (1.56) in CBHI insured and 1.21 (1.55) in those with family insurance. Within each category, healthcare utilization was lower for poor HHs (lowest quintile of wealth index) and higher for affluent HHs (higher quintiles of wealth index). Among those who were hospitalized, catastrophic health events were less in CBHI insured (7.9%) compared to uninsured (12.3%). After adjusting for socioeconomic status and other confounders, our data suggest that participating in a CBHI scheme increased odds of utilization of inpatient services (OR 1.18; 95% CI 1.04-1.33) and protected from catastrophic health events (OR 0.52; 95% CI 0.43-0.64). Conclusion: . CBHI schemes improve healthcare utilization and protect against catastrophic health expenditure among those who get hospitalized. However, there also exists a socioeconomic gradient both in membership and in utilization of healthcare services favouring those who are more affluent.

Epidemiology of confirmed coronary heart disease among population older than 60 years in rural central India-A community-based cross-sectional study.

BACKGROUND: Three-fifths of total deaths in India are attributed to noncommunicable diseases, and coronary heart disease (CHD) is one of the dominant causes. There are only few studies available in India to find confirmed CHD by pragmatic approach. This study aims to find prevalence of confirmed CHD and its risk factors in rural community of central India. MATERIALS AND METHODS: This was a community-based cross-sectional study during 2013-2014 involving adults ≥60 years from 13 villages in rural central India. We screened CHD on the basis of history and standard 12-lead ECG. Apart from the past documentation of CHD, we diagnosed confirmed CHD in symptomatic patients or with resting ECG changes by means of echocardiography, exercise ECG test or coronary angiography whenever needed. RESULTS: We screened 1190 of 1415 individuals ≥60 years for CHD. Five hundred eighty were men and 610 were women. Diagnosis of CHD was confirmed in 61 individuals (29 men and 32 women). The prevalence of CHD in individuals older than 60 years was 51.3 per 1000 population. Hypertension was the only independent risk factor associated with CHD, whereas association of diabetes mellitus, obesity, socioeconomic status and smoking with CHD was not significant. CONCLUSION: Prevalence of confirmed CHD has increased in agrarian rural community in central India, which requires further studies to find out causative factors.

Nonalbuminuric chronic kidney disease: A dominant presentation in noncommunicable disease population of rural central India.

BACKGROUND: India has largest number of people with diabetes mellitus (DM), and hypertension (HTN) is expected to double in next 25 years, which are common causes of chronic kidney disease (CKD). The focus for prevention of end-stage renal disease has shifted to detection of the iceberg of DM and HTN and its adequate control. Prevalence studies of CKD in India rural community are lacking. METHODOLOGY: We did community-based cross-sectional study with 3 monthly diagnostic camps in adults ≥20 years (n = 6278), from 13 villages for early detection of CKD in rural population around Sevagram in a group of noncommunicable disease (NCD) with DM, HTN, ischemic heart diseases (IHD), and stroke in year 2015-2016. RESULTS: Study achieved 87% (5440/6278) coverage for albuminuria screening. Prevalence of CKD in NCD population was 19.6% (220/1121) where 86% (181/220) were nonalbuminuric CKD. Prevalence of persistent albuminuria in the study population was 0.8% (45/5440); in NCD population (DM, HTN, IHD, and stroke), it was 2.8% (31/1121). Prevalence of CKD was 19% in HTN and 18.9% in diabetes. The prevalence of nonalbuminuric versus albuminuric CKD was 17.1% versus 1.9% (9 times) in hypertensive individuals and 11.3% versus 7.5% (1.5 times) in individuals with DM. CONCLUSION: Predominance of nonalbuminuric CKD in NCD participants raises suspicion of CKD with undetermined risk factors. Further studies are needed to find the prevalence of nonalbuminuric CKD in overall population and to find out if exposure of pesticides, chemical fertilizers over long duration play an important role in agrarian rural community.

Prevalence of cardiovascular risk factors among rural population of elderly in Wardha district.

BACKGROUND: Cardiovascular diseases (CVD) are a leading cause of mortality among adults in India, and their risk factors (tobacco, hypertension, diabetes, overweight, and obesity) are common. Most risk-factor surveys have focused on young and middle aged adults. We measured the prevalence of risk factors for CVD among elderly (age 60 years or more) in rural India. METHODS AND RESULTS: In a door-to-door cross-sectional survey we did a non-laboratory based assessment of risk factors (smoking or tobacco use in any form, diabetes mellitus, either known or newly detected hypertension, abnormal waist-hip-ratio, or a high body mass index) among elderly living in 23 villages in rural central India. Laboratory based assessment of risk factors was done in those who had two or more of the five measured conventional risk factors. We compared the distribution of risk factors between men and women. Among 2424 elderly included in the study (51% women, mean age 67), the prevalence of smokeless tobacco use was 50.8% (95% CI 48.1-52.8; smoking 10.5% (95% CI 9.3-11.8); and hypertension46.3% (95% CI 44.3-48.4). Only 10.2% participants were previously known to have had hypertension, and remaining 36.1% were detected to be hypertensive during the survey. A total of 8.2%(95% CI 7.0-9.5) participants were overweight and 4.1% (95% CI 3.3-4.9) had central obesity. The prevalence of dyslipidemia in those who underwent blood based tests was 40.6% (95% CI 36.5-44.9); and hyperglycemia 4.9% (95% CI 3.2-7.1). CONCLUSIONS: Strategies to reduce the risk of cardiovascular disorders among elderly should be focused on reducing tobacco use and early detection and optimal control of hypertension.

Herpes zoster encephalitis presenting as multiple cerebral hemorrhages - a rare presentation: a case report.

INTRODUCTION: An infection by herpes zoster virus is a common and important cause of encephalitis. Herpes zoster virus encephalitis if not treated promptly can result in significant morbidity and mortality. The diagnosis of herpes zoster virus encephalitis is based on clinical history, examination, neuroradiological imaging (magnetic resonance imaging and/or computed tomography scan), cerebrospinal fluid analysis and identification of the pathogen in cerebrospinal fluid by polymerase chain reaction amplification and/or anti-herpes zoster virus immunoglobulin G antibody in cerebrospinal fluid. Although ischemic intracerebral infarcts in patients with herpes zoster virus encephalitis or vasculopathy are reported in the literature, multiple intracerebral hemorrhages as a complication of herpes zoster virus encephalitis in an immunocompetent individual are extremely rare. CASE PRESENTATION: A 40-year-old Indian man presented with an acute history of four episodes of seizures, fever, headache, drowsiness, focal neurological deficits and vesicular eruptions over the abdomen in a typical dermatomal distribution. His head computed tomography scan revealed multiple cerebral hemorrhages. Investigations (positive ratio between the cerebrospinal fluid/serum quotients for anti-herpes zoster virus immunoglobulin G and total immunoglobulin G antibodies) established its infective origin due to herpes zoster virus. He developed bilateral pneumonia during the hospital course. He had an excellent recovery following a 2 weeks' course of intravenous acyclovir. CONCLUSION: Herpes zoster virus encephalitis or vasculopathy is a rare cause of multiple intracerebral hemorrhages and must be considered in the differential diagnosis of patients presenting with an acute history of fever, altered consciousness, and focal neurologic deficits with history of a typical herpetic rash. Its prompt recognition and treatment could alter the course of illness.

Accuracy and reliability of pallor for detecting anaemia: a hospital-based diagnostic accuracy study.

BACKGROUND: Anaemia is a common disorder. Most health providers in resource poor settings rely on physical signs to diagnose anaemia. We aimed to determine the diagnostic accuracy of pallor for anaemia by using haemoglobin as the reference standard. METHODOLOGY/PRINCIPAL FINDINGS: In May 2007, we enrolled consecutive patients over 12 years of age, able to consent and willing to participate and who had a haemoglobin measurement taken within a day of assessment of clinical pallor from outpatient and medicine inpatient department of a teaching hospital. We did a blind and independent comparison of physical signs (examination of conjunctivae, tongue, palms and nailbed for pallor) and the reference standard (haemoglobin estimation by an electronic cell counter). Diagnostic accuracy was measured by calculating likelihood ratio values and 95% confidence intervals (CI) at different haemoglobin thresholds and area under the receiver operating characteristic curve. Two observers examined a subset of patients (n = 128) to determine the inter-observer agreement, calculated by kappa statistics. We studied 390 patients (mean age 40.1 [SD 17.08] years); of whom 48% were women. The haemoglobin was <7 g/dL in 8% (95% confidence interval, 5, 10) patients; <9 g/dL in 21% (17, 26) patients and <12 g/dL in 64% (60, 70) patients. Among patients with haemoglobin <7 g/dL, presence of severe tongue pallor yielded a LR of 9.87 (2.81, 34.6) and its absence yielded a LR of 0. The tongue pallor outperformed other pallor sites and was also the best discriminator of anaemia at haemoglobin thresholds of 7 g/dL and 9 g/dL (area under the receiver operating characteristic curves (ROC area = 0.84 [0.77, 0.90] and 0.71[0.64, 0.76]) respectively. The agreement between the two observers for detection of anaemia was poor (kappa values = 0.07 for conjunctival pallor and 0.20 for tongue pallor). CONCLUSIONS/SIGNIFICANCE: Clinical assessment of pallor can rule out and modestly rule in severe anaemia.

Unusual presentation of orbital cysticercosis-ptosis, diminution of vision and medial rectus weakness: a case report.

Cysticercosis is the most common parasitic disease of the nervous system. The disease occurs when humans become the intermediate host in the life cycle of Taenia solium by ingesting its eggs from contaminated food. The most common sites of involvement of cysticerci are soft tissue, eye and central nervous system. Unusual location of the cysts may result in uncommon manifestations. Ocular cysticercosis can involve both the intraocular and extra ocular muscle. Extra ocular muscle cysticercosis is rare. We are reporting the unusual manifestation of ptosis, proptosis, diminution of vision and medial rectus palsy due to cysticercosis. The patient was successfully treated with systemic steroids and albendazole.

Blue toe syndrome: a rare complication of acute pancreatitis.

CONTEXT: Blue toe syndrome is an unusual complication of acute pancreatitis. It is characterized by tissue ischemia secondary to cholesterol crystal or atherothrombotic embolization leading to the occlusion of small vessels. Clinical presentation can range from a cyanotic toe to a diffuse multiorgan systemic disease that can mimic other systemic illnesses. CASE REPORT: Here we describe a young male who developed this complication after acute alcoholic pancreatitis.