The long-term effects of Kerala Diabetes Prevention Program on diabetes incidence and cardiometabolic risk: a study protocol.

INTRODUCTION: India currently has more than 74.2 million people with Type 2 Diabetes Mellitus (T2DM). This is predicted to increase to 124.9 million by 2045. In combination with controlling blood glucose levels among those with T2DM, preventing the onset of diabetes among those at high risk of developing it is essential. Although many diabetes prevention interventions have been implemented in resource-limited settings in recent years, there is limited evidence about their long-term effectiveness, cost-effectiveness, and sustainability. Moreover, evidence on the impact of a diabetes prevention program on cardiovascular risk over time is limited. OBJECTIVES: The overall aim of this study is to evaluate the long-term cardiometabolic effects of the Kerala Diabetes Prevention Program (K-DPP). Specific aims are 1) to measure the long-term effectiveness of K-DPP on diabetes incidence and cardiometabolic risk after nine years from participant recruitment; 2) to assess retinal microvasculature, microalbuminuria, and ECG abnormalities and their association with cardiometabolic risk factors over nine years of the intervention; 3) to evaluate the long-term cost-effectiveness and return on investment of the K-DPP; and 4) to assess the sustainability of community engagement, peer-support, and other related community activities after nine years. METHODS: The nine-year follow-up study aims to reach all 1007 study participants (500 intervention and 507 control) from 60 randomized polling areas recruited to the original trial. Data are being collected in two phases. In phase 1 (Survey), we are admintsering a structured questionnaire, undertake physical measurements, and collect blood and urine samples for biochemical analysis. In phase II, we are inviting participants to undergo retinal imaging, body composition measurements, and ECG. All data collection is being conducted by trained Nurses. The primary outcome is the incidence of T2DM. Secondary outcomes include behavioral, psychosocial, clinical, biochemical, and retinal vasculature measures. Data analysis strategies include a comparison of outcome indicators with baseline, and follow-up measurements conducted at 12 and 24 months. Analysis of the long-term cost-effectiveness of the intervention is planned. DISCUSSION: Findings from this follow-up study will contribute to improved policy and practice regarding the long-term effects of lifestyle interventions for diabetes prevention in India and other resource-limited settings. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry-(updated from the original trial)ACTRN12611000262909; India: CTRI/2021/10/037191.

Root-Expressed Rice PAP3b Enhances Secreted APase Activity and Helps Utilize Organic Phosphate.

Phosphate (Pi) deficiency leads to the induction of purple acid phosphatases (PAPs) in plants, which dephosphorylate organic phosphorus (P) complexes in the rhizosphere and intracellular compartments to release Pi. In this study, we demonstrate that OsPAP3b belongs to group III low-molecular weight PAP and is low Pi-responsive, preferentially in roots. The expression of OsPAP3b is negatively regulated with Pi resupply. Interestingly, OsPAP3b was found to be dual localized to the nucleus and secretome. Furthermore, OsPAP3b is transcriptionally regulated by OsPHR2 as substantiated by DNA-protein binding assay. Through in vitro biochemical assays, we further demonstrate that OsPAP3b is a functional acid phosphatase (APase) with broad substrate specificity. The overexpression (OE) of OsPAP3b in rice led to increased secreted APase activity and improved mineralization of organic P sources, which resulted in better growth of transgenics compared to the wild type when grown on organic P as an exogenous P substrate. Under Pi deprivation, OsPAP3b knock-down and knock-out lines showed no significant changes in total P content and dry biomass. However, the expression of other phosphate starvation-induced genes and the levels of metabolites were found to be altered in the OE and knock-down lines. In addition, in vitro pull-down assay revealed multiple putative interacting proteins of OsPAP3b. Our data collectively suggest that OsPAP3b can aid in organic P utilization in rice. The APase isoform behavior and nuclear localization indicate its additional role, possibly in stress signaling. Considering its important roles, OsPAP3b could be a potential target for improving low Pi adaptation in rice.

Plant phosphate status influences root biotic interactions.

Phosphorus (P) deficiency stress in combination with biotic stress(es) severely impacts crop yield. Plant responses to P deficiency overlapping with that of other stresses exhibit a high degree of complexity involving different signaling pathways. On the one hand, plants engage with rhizosphere microbiome/arbuscular mycorrhizal fungi for improved phosphate (Pi) acquisition and plant stress response upon Pi deficiency; on the other hand, this association is gets disturbed under Pi sufficiency. This nutrient-dependent response is highly regulated by the phosphate starvation response (PSR) mediated by the master regulator, PHR1, and its homolog, PHL. It is interesting to note that Pi status (deficiency/sufficiency) has a varying response (positive/negative) to different biotic encounters (beneficial microbes/opportunistic pathogens/insect herbivory) through a coupled PSR-PHR1 immune system. This also involves crosstalk among multiple players including transcription factors, defense hormones, miRNAs, and Pi transporters, among others influencing the plant-biotic-phosphate interactions. We provide a comprehensive view of these key players involved in maintaining a delicate balance between Pi homeostasis and plant immunity. Finally, we propose strategies to utilize this information to improve crop resilience to Pi deficiency in combination with biotic stresses.

Root hair-specific transcriptome reveals response to low phosphorus in Cicer arietinum.

Root hairs (RH) are a single-cell extension of root epidermal cells. In low phosphorus (LP) availability, RH length and density increase thus expanding the total root surface area for phosphate (Pi) acquisition. However, details on genes involved in RH development and response to LP are missing in an agronomically important leguminous crop, chickpea. To elucidate this response in chickpea, we performed tissue-specific RNA-sequencing and analyzed the transcriptome modulation for RH and root without RH (Root-RH) under LP. Root hair initiation and cellular differentiation genes like RSL TFs and ROPGEFs are upregulated in Root-RH, explaining denser, and ectopic RH in LP. In RH, genes involved in tip growth processes and phytohormonal biosynthesis like cell wall synthesis and loosening (cellulose synthase A catalytic subunit, CaEXPA2, CaGRP2, and CaXTH2), cytoskeleton/vesicle transport, and ethylene biosynthesis are upregulated. Besides RH development, genes involved in LP responses like lipid and/or pectin P remobilization and acid phosphatases are induced in these tissues summarizing a complete molecular response to LP. Further, RH displayed preferential enrichment of processes involved in symbiotic interactions, which provide an additional benefit during LP. In conclusion, RH shows a multi-faceted response that starts with molecular changes for epidermal cell differentiation and RH initiation in Root-RH and later induction of tip growth and various LP responses in elongated RH.

Retrospective diagnosis of COVID-19 following the detection of central retinal artery occlusion.

Thromboembolic complications are being increasingly reported in patients with COVID-19 due to the associated hypercoagulability and are an important cause for morbidity and mortality. Retinal vascular occlusions especially arterial occlusions are one of the gravest ocular complications reported. This complication may occur in severe cases with cytokine storm or even in mild or asymptomatic patients and presentation can be anytime from few days to weeks after the onset of symptoms. Ophthalmologists should be aware of this new etiology when dealing with patients having features of retinal vascular occlusions and should investigate for the same in this pandemic situation. Although reverse transcriptase polymerase chain reaction is the diagnostic test for COVID-19, serological assays have a role in patients with delayed presentation. We describe the clinical features and multimodal imaging findings in a patient who presented with features of central retinal artery occlusion with cilioretinal artery sparing wherein his ophthalmic condition led to the diagnosis of previously undetected COVID-19 through serology. To the best of our knowledge, this is the first documentation of a case of isolated central retinal artery occlusion leading to a retrospective diagnosis of COVID-19.

Exploring Factors Affecting Health Care Providers' Behaviors for Maintaining Continuity of Care in Kerala, India; A Qualitative Analysis Using the Theoretical Domains Framework.

Introduction: Access to patients' documented medical information is necessary for building the informational continuity across different healthcare providers (HCP), particularly for patients with non-communicable diseases (NCD). Patient-held health records (PHR) such as NCD notebooks have important documented medical information, which can contribute to informational continuity in the outpatient settings for patients with diabetes and hypertension in Kerala. We aimed to use the theoretical domains framework (TDF) to identify the perceived HCP factors influencing informational and management continuity for patients with diabetes and hypertension. Methods: We re-analyzed semi-structured interview data for 17 HCPs with experience in the NCD programme in public health facilities in Kerala from a previous study, using the TDF. The previous study explored patients, carers and HCPs experiences using PHRs such as NCD notebooks in the management of diabetes and hypertension. Interview transcripts were deductively coded based on a coding framework based on the 14 domains of TDF. Specific beliefs were generated from the data grouped into the domains. Results: Data were coded into the 14 domains of TDF and generated 33 specific beliefs regarding maintaining informational and management continuity of care. Seven domains were judged to be acting as facilitators for recording in PHRs and maintaining continuity. The two domains "memory, attention and decision process" and "environmental context and resources" depicted the barriers identified by HCPs for informational continuity of care. Conclusion: In this exploration of recording and communicating patients' medical information in PHRs for patients with diabetes and hypertension, HCPs attributions of sub-optimal recording were used to identify domains that may be targeted for further development of supporting intervention. Overall, nine domains were likely to impact the barriers and facilitators for HCPs in recording in PHRs and communicating; subsequently maintaining informational and management continuity of care. This study showed that many underlying beliefs regarding informational continuity of care were based on HCPs' experiences with patient behaviors. Further research is needed for developing the content and appropriate support interventions for using PHRs to maintain informational continuity.

Systems biology for crop improvement.

In recent years, generation of large-scale data from genome, transcriptome, proteome, metabolome, epigenome, and others, has become routine in several plant species. Most of these datasets in different crop species, however, were studied independently and as a result, full insight could not be gained on the molecular basis of complex traits and biological networks. A systems biology approach involving integration of multiple omics data, modeling, and prediction of the cellular functions is required to understand the flow of biological information that underlies complex traits. In this context, systems biology with multiomics data integration is crucial and allows a holistic understanding of the dynamic system with the different levels of biological organization interacting with external environment for a phenotypic expression. Here, we present recent progress made in the area of various omics studies-integrative and systems biology approaches with a special focus on application to crop improvement. We have also discussed the challenges and opportunities in multiomics data integration, modeling, and understanding of the biology of complex traits underpinning yield and stress tolerance in major cereals and legumes.

Multiomics approach unravels fertility transition in a pigeonpea line for a two-line hybrid system.

Pigeonpea [Cajanus cajan (L.) Millsp.] is a pulse crop cultivated in the semi-arid regions of Asia and Africa. It is a rich source of protein and capable of alleviating malnutrition, improving soil health and the livelihoods of small-holder farmers. Hybrid breeding has provided remarkable improvements for pigeonpea productivity, but owing to a tedious and costly seed production system, an alternative two-line hybrid technology is being explored. In this regard, an environment-sensitive male sterile line has been characterized as a thermosensitive male sterile line in pigeonpea precisely responding to day temperature. The male sterile and fertile anthers from five developmental stages were studied by integrating transcriptomics, proteomics and metabolomics supported by precise phenotyping and scanning electron microscopic study. Spatio-temporal analysis of anther transcriptome and proteome revealed 17 repressed DEGs/DEPs in sterile anthers that play a critical role in normal cell wall morphogenesis and tapetal cell development. The male fertility to sterility transition was mainly due to a perturbation in auxin homeostasis, leading to impaired cell wall modification and sugar transport. Limited nutrient utilization thus leads to microspore starvation in response to moderately elevated day temperature which could be restored with auxin-treatment in the male sterile line. Our findings outline a molecular mechanism that underpins fertility transition responses thereby providing a process-oriented two-line hybrid breeding framework for pigeonpea.

Arachis hypogaea gene expression atlas for fastigiata subspecies of cultivated groundnut to accelerate functional and translational genomics applications.

Spatio-temporal and developmental stage-specific transcriptome analysis plays a crucial role in systems biology-based improvement of any species. In this context, we report here the Arachis hypogaea gene expression atlas (AhGEA) for the world's widest cultivated subsp. fastigiata based on RNA-seq data using 20 diverse tissues across five key developmental stages. Approximately 480 million paired-end filtered reads were generated followed by identification of 81 901 transcripts from an early-maturing, high-yielding, drought-tolerant groundnut variety, ICGV 91114. Further, 57 344 genome-wide transcripts were identified with ≥1 FPKM across different tissues and stages. Our in-depth analysis of the global transcriptome sheds light into complex regulatory networks namely gravitropism and photomorphogenesis, seed development, allergens and oil biosynthesis in groundnut. Importantly, interesting insights into molecular basis of seed development and nodulation have immense potential for translational genomics research. We have also identified a set of stable expressing transcripts across the selected tissues, which could be utilized as internal controls in groundnut functional genomics studies. The AhGEA revealed potential transcripts associated with allergens, which upon appropriate validation could be deployed in the coming years to develop consumer-friendly groundnut varieties. Taken together, the AhGEA touches upon various important and key features of cultivated groundnut and provides a reference for further functional, comparative and translational genomics research for various economically important traits.

Perceived facilitators and barriers of enrolment, participation and adherence to a family based structured lifestyle modification interventions in Kerala, India: A qualitative study.

Background: The objective of the study was to describe participants' and providers' perspectives of barriers and facilitators of enrolment, participation and adherence to a structured lifestyle modification (SLM) interventions as part of the PROLIFIC trial in Kerala, India. Methods: Family members who had been enrolled for 12-months or more in a family-based cardiovascular risk reduction intervention study (PROLIFIC Trial) were purposively sampled and interviewed using a semi-structured guide. The non-physician health workers (NPHWs) delivering the intervention were also interviewed or included in focus groups (FGDs). Thematic analysis was used for data analysis. Results: In total, 56 in-depth interviews and three FGDs were conducted. The descriptive themes emerged were categorised as (a) motivation for enrolment and engagement in the SLM interventions, (b) facilitators of adherence, and (c) reasons for non-adherence. A prior knowledge of familial cardiovascular risk, preventive nature of the programme, and a reputed organisation conducting the intervention study were appealing to the participants. Simple suggestions of healthier alternatives based on existing dietary practices, involvement of the whole family, and the free annual blood tests amplified the adherence. Participants highlighted regular monitoring of risk factors and provision of home-based care by NPHWs as facilitators for adherence. Furthermore, external motivation by NPHWs in setting and tracking short-term health goals were perceived as enablers of adherence. Nonetheless, home makers expressed difficulty in dealing with varied food choices of family members. Young adults in the programme noted that dietary changes were affected by eating out as they wanted to fit in with peers. Conclusions: The findings suggest that a family-based, trained healthcare worker led SLM interventions are acceptable in Kerala. Increasing the number of visits by NPHWs, regular monitoring and tracking of lifestyle goals, and targeting young adults and children for dietary changes may further improve adherence to SLM interventions.

MII RetCam assisted smartphone based fundus imaging for retinopathy of prematurity.

Purpose: The gold standard for evaluating Retinopathy of prematurity (ROP), a potentially blinding disease in preterm babies, is by indirect ophthalmoscopy which is quite subjective. Digital imaging with RetCam, an advanced wide field imaging system is more precise but it is not easily available or affordable. Smartphones are being explored as an alternate cost effective and accessible imaging tool. This is possible because of the good illumination and the built-in high resolution cameras available in modern smartphones. The aim of this study is to illustrate the utility of MII RetCam assisted smartphone based fundus imaging (MSFI) in the documentation and monitoring of ROP. Methods: Single-centre, retrospective observational study of all the preterm babies subjected to MSFI as part of ROP screening from September 2017 to November 2018. iPhone 4S and + 20 Diopter lens attached to the MII RetCam device was used for fundus imaging at baseline and during follow up. The statistical analysis used for the same is the SPSS statistical software. Results: Good quality images of central and peripheral retina could be captured in 33 out of 42 babies (78.57%) with ROP. Serial imaging done in 24 babies with ROP helped in precise monitoring of the disease and planning management. Incidentally detected non-ROP findings were also documented. Unique design of the device enabled imaging by a single examiner. Image database created was useful for academic and counselling purposes. Smaller field images which can cause difficulty in distinguishing the zones is a limitation. Conclusion: MSFI is a potential alternate imaging tool enabling objective documentation and monitoring of ROP in low resource settings.

Tobacco Cessation Among Acute Coronary Syndrome Patients in Kerala, India: Patient and Provider Perspectives.

Tobacco cessation is an important intervention to reduce mortality from ischemic heart disease, the leading cause of death in India. In this study, we explored facilitators, barriers, and cultural context to tobacco cessation among acute coronary syndrome (ACS, or heart attack) patients and providers in a tertiary care institution in the south Indian state of Kerala, with a focus on patient trajectories. Patients who quit tobacco after ACS expressed greater understanding about the link between tobacco and ACS, exerted more willpower at the time of discharge, and held less fatalistic beliefs about their health compared to those who continued tobacco use. The former were motivated by the fear of recurrent ACS, strong advice to quit from providers, and determination to survive and financially provide for their families. Systemic barriers included inadequate training, infrequent prescription of cessation pharmacotherapy, lack of ancillary staff to deliver counseling, and stigma against mental health services.

Intravitreal Bevacizumab for Choroidal Neovascularization Associated with Angioid Streaks: Long-term Results.

PURPOSE: The purpose of the study was to evaluate the long-term efficacy and safety of intravitreal bevacizumab (IVB) in the treatment of choroidal neovascularization (CNV) secondary to angioid streaks (AS). MATERIALS AND METHODS: Noncomparative, interventional retrospective case series involving ten patients (15 eyes) with a minimum follow-up of 25 months following IVB for AS-associated CNV. Demographic and clinical details at baseline and during follow-up were collected from patient records. Detailed clinical examination was followed by fundus fluorescein angiography and optical coherence tomography to confirm CNV. Both primary and recurrent CNVs were treated with monthly injections of IVB till the lesion stabilized. Primary outcome measures were the percentage of patients with stable or improved visual acuity (VA) and with stable or decreased central retinal thickness (CRT) at the last visit. Secondary outcome measure was the incidence of ocular and systemic complications. RESULTS: Recurrence was observed in 11 eyes (73.33%) over a mean follow-up of 57.33 months (range: 25-100). A mean number of injections administered was 5.60. VA improved or stabilized in 73.33% and deteriorated in 26.67% of eyes at the final visit. Mean CRT improved from 324.40 µm at baseline to 265.53 µm at final visit, which was statistically significant. Complications observed were ocular hypertension in one patient and thromboembolic event in another patient. CONCLUSIONS: IVB appears to be a safe and effective option to treat CNV and to preserve vision over a prolonged period. It cannot eliminate the risk of recurrent CNV indicating the need for more effective treatments to arrest this visually debilitating condition.

Genome-Wide Identification, Characterization, and Expression Analysis of Small RNA Biogenesis Purveyors Reveal Their Role in Regulation of Biotic Stress Responses in Three Legume Crops.

Biotic stress in legume crops is one of the major threats to crop yield and productivity. Being sessile organisms, plants have evolved a myriad of mechanisms to combat different stresses imposed on them. One such mechanism, deciphered in the last decade, is small RNA (sRNA) mediated defense in plants. Small RNAs (sRNAs) have emerged as one of the major players in gene expression regulation in plants during developmental stages and under stress conditions. They are known to act both at transcriptional and post-transcriptional levels. Dicer-like (DCL), Argonaute (AGO), and RNA dependent RNA polymerase (RDR) constitute the major components of sRNA biogenesis machinery and are known to play a significant role in combating biotic and abiotic stresses. This study is, therefore, focused on identification and characterization of sRNA biogenesis proteins in three important legume crops, namely chickpea, pigeonpea, and groundnut. Phylogenetic analysis of these proteins between legume species classified them into distinct clades and suggests the evolutionary conservation of these genes across the members of Papillionidoids subfamily. Variable expression of sRNA biogenesis genes in response to the biotic stresses among the three legumes indicate the possible existence of specialized regulatory mechanisms in different legumes. This is the first ever study to understand the role of sRNA biogenesis genes in response to pathogen attacks in the studied legumes.

Gene expression atlas of pigeonpea and its application to gain insights into genes associated with pollen fertility implicated in seed formation.

Pigeonpea (Cajanus cajan) is an important grain legume of the semi-arid tropics, mainly used for its protein rich seeds. To link the genome sequence information with agronomic traits resulting from specific developmental processes, a Cajanus cajan gene expression atlas (CcGEA) was developed using the Asha genotype. Thirty tissues/organs representing developmental stages from germination to senescence were used to generate 590.84 million paired-end RNA-Seq data. The CcGEA revealed a compendium of 28 793 genes with differential, specific, spatio-temporal and constitutive expression during various stages of development in different tissues. As an example to demonstrate the application of the CcGEA, a network of 28 flower-related genes analysed for cis-regulatory elements and splicing variants has been identified. In addition, expression analysis of these candidate genes in male sterile and male fertile genotypes suggested their critical role in normal pollen development leading to seed formation. Gene network analysis also identified two regulatory genes, a pollen-specific SF3 and a sucrose-proton symporter, that could have implications for improvement of agronomic traits such as seed production and yield. In conclusion, the CcGEA provides a valuable resource for pigeonpea to identify candidate genes involved in specific developmental processes and to understand the well-orchestrated growth and developmental process in this resilient crop.

A PROgramme of Lifestyle Intervention in Families for Cardiovascular risk reduction (PROLIFIC Study): design and rationale of a family based randomized controlled trial in individuals with family history of premature coronary heart disease.

BACKGROUND: Recognizing patterns of coronary heart disease (CHD) risk in families helps to identify and target individuals who may have the most to gain from preventive interventions. The overall goal of the study is to test the effectiveness and sustainability of an integrated care model for managing cardiovascular risk in high risk families. The proposed care model targets the structural and environmental conditions that predispose high risk families to development of CHD through the following interventions: 1) screening for cardiovascular risk factors, 2) providing lifestyle interventions 3) providing a framework for linkage to appropriate primary health care facility, and 4) active follow-up of intervention adherence. METHODS: Initially, a formative qualitative research component will gather information on understanding of diseases, barriers to care, specific components of the intervention package and feedback on the intervention. Then a cluster randomized controlled trial involving 740 families comprising 1480 participants will be conducted to determine whether the package of interventions (integrated care model) is effective in reducing or preventing the progression of CHD risk factors and risk factor clustering in families. The sustainability and scalability of this intervention will be assessed through economic (cost-effectiveness analyses) and qualitative evaluation (process outcomes) to estimate value and acceptability. Scalability is informed by cost-effectiveness and acceptability of the integrated cardiovascular risk reduction approach. DISCUSSION: Knowledge generated from this trial has the potential to significantly affect new programmatic policy and clinical guidelines that will lead to improvements in cardiovascular health in India. TRIAL REGISTRATION NUMBER: NCT02771873, registered in May 2016 ( https://clinicaltrials.gov/ct2/show/results/NCT02771873 ).