A culturally informed lower-extremity complication prevention program for people living with diabetes in south India.

BACKGROUND: Diabetes and its complications are increasing in frequency worldwide. Lower-extremity complications carry a high risk for morbidity and mortality, yet are largely preventable through education and self-monitoring. In India, rural areas lack access to education, care, and treatment. Despite existing evidence-based programs to reduce diabetes-related lower-extremity complications in areas with limited resources, uptake and sustainability may be hampered by the lack of translation to the local cultural context. AIMS: To address this gap, this study used the Culturally Informed Healthy Aging nursing process to develop a lower extremity complication prevention program in a rural village. The paper describes the results of a community health needs assessment conducted annually from 2009 to 2014, and subsequent pilot test of an intervention incorporating these results. METHODS: The Culturally Informed Healthy Aging process is a naturalistic, inductive method used to identify and address health needs. Components include community partnership, community assessment, program planning, selection of health priorities, workgroup formation and translation of evidence, and program outcome evaluation. The programming is assessed using process evaluation, which allows for continuous monitoring and program modification. RESULTS: Community assessment revealed a number of values, beliefs, and practices related to foot care and assessment in rural south India. These were incorporated into culturally informed programming and evidence-based protocols were adapted for use in the local context. Programming resulted in increased community capacity for lower extremity complication prevention, accessible population screening, and culturally informed foot care education. DISCUSSION: Strengths, limitations and implications for care in rural India and other areas are discussed.

Implementation of a neonatal transcutaneous bilirubin screening programme in rural India.

BACKGROUND: Universal pre-discharge assessment of risk for neonatal hyperbilirubinaemia is recommended by the American Academy of Pediatrics. A common algorithm is universal transcutaneous bilirubin (TcB) screening, followed by confirmatory total serum bilirubin (TSB) testing for results which cause concern. There is a paucity of data on the feasibility of TcB screening in low-income settings. OBJECTIVES: To evaluate the acceptability and feasibility of implementing universal TcB screening at a resource-limited hospital in rural India, and to determine if it was associated with increased recognition of high-risk hyperbilirubinaemia. METHODS: In December 2012 at Vivekananda Memorial Hospital, Karnataka, India, universal TcB screening at 24-48 hours of life was implemented, with TSB estimated if TcB was >75th percentile for age. The proportion of families that provided consent and the proportion of infants who underwent TcB and TSB testing were calculated. The rates of phototherapy pre- and post-implementation and the rate of high-risk hyperbilirubinaemia (TSB >95th percentile for age) post-implementation among infants ≥ 35 weeks gestation were determined. RESULTS: Parents of 568 of 660 (86%) eligible infants consented to participation. All of these infants were screened with TcB. The proportion who had TSB testing was similar in the pre- (6%) and post-implementation (7%) periods. The rate of phototherapy was not significantly different after implementation (2% vs 3%). Five cases of high-risk hyperbilirubinaemia were identified post-implementation. CONCLUSIONS: The study demonstrates the acceptability and feasibility of universal TcB screening at a resource-limited hospital in rural India. In settings in which early post-discharge follow-up cannot be assured, TcB can play a valuable role in identifying infants who need evaluation.

Burden and predictors of hypertension in India: results of SEEK (Screening and Early Evaluation of Kidney Disease) study.

BACKGROUND: Hypertension (HTN) is one of the major causes of cardiovascular morbidity and mortality. The objective of the study was to investigate the burden and predictors of HTN in India. METHODS: 6120 subjects participated in the Screening and Early Evaluation of Kidney disease (SEEK), a community-based screening program in 53 camps in 13 representative geographic locations in India. Of these, 5929 had recorded blood pressure (BP) measurements. Potential predictors of HTN were collected using a structured questionnaire for SEEK study. RESULTS: HTN was observed in 43.5% of our cohort. After adjusting for center variation (p < 0.0001), predictors of a higher prevalence of HTN were older age ≥ 40 years (p < 0.0001), BMI of ≥ 23 Kg/M2 (p < 0.0004), larger waist circumference (p < 0.0001), working in sedentary occupation (p < 0.0001), having diabetes mellitus (p < 0.0001), having proteinuria (p < 0.0016), and increased serum creatinine (p < 0.0001). High school/some college education (p = 0.0016), versus less than 9th grade education, was related with lower prevalence of HTN. Of note, proteinuria and CKD were observed in 19% and 23.5% of HTN subjects. About half (54%) of the hypertensive subjects were aware of their hypertension status. CONCLUSIONS: HTN was common in this cohort from India. Older age, BMI ≥ 23 Kg/M2, waist circumference, sedentary occupation, education less, diabetes mellitus, presence of proteinuria, and raised serum creatinine were significant predictors of hypertension. Our data suggest that HTN is a major public health problem in India with low awareness, and requires aggressive community-based screening and education to improve health.

Dharma and medical ethics.

Despite the numerous policies, regulations and laws aimed at promoting and ensuring ethical practice in healthcare, ethical misconduct remains rampant. Perhaps something more is needed to encourage a genuine and sustained moral attitude and behaviour. To a casual reader, the regulations on ethics read merely as a list of do's and don'ts and their philosophical foundation is not clear. In actuality, morality is often grounded in philosophy. Traditionally, religious and theistic philosophies drove moral behaviour. However, this is changing due to the current trend of secularism. Hindu philosophies are among the oldest philosophies that are still thriving, and this article explores these philosophies and compares and contrasts them with some of the contemporary ethical theories to assess if they can add value to the field of medical ethics. The main theme of the article is dharma or righteous conduct, the concepts related to it and how these can have a bearing on the development of an ethical attitude and the practice of medical ethics.

Epidemiology and risk factors of chronic kidney disease in India - results from the SEEK (Screening and Early Evaluation of Kidney Disease) study.

BACKGROUND: There is a rising incidence of chronic kidney disease that is likely to pose major problems for both healthcare and the economy in future years. In India, it has been recently estimated that the age-adjusted incidence rate of ESRD to be 229 per million population (pmp), and >100,000 new patients enter renal replacement programs annually. METHODS: We cross-sectionally screened 6120 Indian subjects from 13 academic and private medical centers all over India. We obtained personal and medical history data through a specifically designed questionnaire. Blood and urine samples were collected. RESULTS: The total cohort included in this analysis is 5588 subjects. The mean ± SD age of all participants was 45.22 ± 15.2 years (range 18-98 years) and 55.1% of them were males and 44.9% were females. The overall prevalence of CKD in the SEEK-India cohort was 17.2% with a mean eGFR of 84.27 ± 76.46 versus 116.94 ± 44.65 mL/min/1.73 m2 in non-CKD group while 79.5% in the CKD group had proteinuria. Prevalence of CKD stages 1, 2, 3, 4 and 5 was 7%, 4.3%, 4.3%, 0.8% and 0.8%, respectively. CONCLUSION: The prevalence of CKD was observed to be 17.2% with ~6% have CKD stage 3 or worse. CKD risk factors were similar to those reported in earlier studies.It should be stressed to all primary care physicians taking care of hypertensive and diabetic patients to screen for early kidney damage. Early intervention may retard the progression of kidney disease. Planning for the preventive health policies and allocation of more resources for the treatment of CKD/ESRD patients are imperative in India.

Should the Bt brinjal controversy concern healthcare professionals and bioethicists?

The Genetic Engineering Approval Committee's approval of Bt brinjal, the first genetically modified crop for human consumption in India, has sparked off protests across the country. This article questions the so-called benefits of GM crops and highlights some major concerns. These include: inadequately addressed health and environmental risks, inadequate safety guidelines, a lack of transparency in sharing test data, the implications to seed sovereignty of farmers and the lack of informed choice for consumers. Some concerns about field testing by Mahyco, the developer of Bt-brinjal, and the process of evaluation by GEAC remain unresolved. With inadequate information about the crop's long-term safety, a precautionary approach is advocated before national policy allows commercial release of the seeds. A fair process is also needed in the public consultations being proposed by the minister of state for environment and forests. In addition to issues of procedural justice, a basic ethical question remains: do humans have a right to dominate the land and make expendable those creatures that they deem "undesirable"?