Mortality In India Research Articles

Clinical profile and risk factors of patients presenting with acute myocardial infarction at RIMS, Imphal

Background: Cardiovascular diseases are the leading cause of mortality in India. Ischemic heart disease is a result of an inadequate supply of blood to a portion of the myocardium caused by atherosclerotic disease of an epicardial coronary artery. The increasing incidence of myocardial infarction (MI) and associated mortality is a concern. Aims and Objectives: The aims and objectives of the study were to evaluate the clinical profile and determine the association of risk factors in patients presenting with acute MI. The study highlights the trend of occurrence of acute MI so as appropriate measures can be taken to mitigate the incidence of coronary artery disease (CAD). Materials and Methods: A cross-sectional study was conducted among 100 patients with acute MI admitted to the intensive coronary care unit and medicine wards of a tertiary center in North-East India. The study was carried out for a period of 2 years from September 2019 to August 2021. Results: The mean age of the study population was 63.13±10.47 years, with an age range from 41 to 90 years. The study population had 75% males and 25% females. The most common presenting symptom was chest pain in 96% of patients. Hypertension in 75% of patients was the most common risk factor studied. About 97% of patients had at least one cardinal risk factor for MI. Inferior wall MI in 47% of patients was the most common site of MI. The highest mortality was seen in those who presented with Killip Class IV. Conclusions: Increasing age and male gender predisposed to MI. The association of risk factors such as hypertension, diabetes, obesity, and family history was higher in females. To bring about a reduction in the risk of CAD, emphasis should be laid on the adoption of a healthy lifestyle particularly for those at risk of CAD.

Penalized estimation in parametric frailty model

Frailty model examines the effect of observable and non-observable factors on time to event data. Presence of collinearity produces unstable estimates of parameters. Therefore, this research focus on the penalized estimation of frailty model and proposed the new estimator which is the extension of ridge and principal component estimators. Simulation is run to reveal the performance of proposed estimator. Moreover, the technique is applied on NFHS (National Family Health Survey) data to examine the infant mortality in India.

Air Pollution and Mortality in India: Investigating the Nexus of Ambient and Household Pollution Across Life Stages.

Air pollution in India is a foremost environmental risk factor that affects human health. This study first investigates the geographical distribution of ambient and household air pollution (HAP) and then examines the associated mortality risk. Data on fine particulate matter (PM2.5) concentration has been extracted from the Greenhouse Gas Air Pollution Interactions and Synergies (GAINS) model. HAP, mortality and socio-demographic data were extracted from the National Family and Health Survey-5, India, 2019-2021. Regression models were applied to see the difference in age-group mortality by different pollution parameters. The districts with PM2.5 concentration above the National Ambient Air Quality Standard (NAAQS) level of 40μg/m3 show a higher risk of neonatal (OR-1.86, CI 1.418-2.433), postneonatal (OR-2.04, CI 1.399-2.971), child (OR-2.19, CI 0.999-4.803) and adult death (OR-1.13, CI 1.060-1.208). The absence of a separate kitchen shows a higher probability of neonatal (OR: 1.18, CI 1.074-1.306) and adult death (OR-1.06, CI 1.027-1.088). The interaction between PM2.5 levels above NAAQS and HAP leads toa substantial rise in mortality observed for neonatal (OR 1.19 CI 1.051-1.337), child (OR 1.17 CI 1.054-1.289), and adult (OR 1.13 CI 1.096-1.168) age groups. This study advocates that there is a strong positive association between ambient and HAP and mortality risk. PM2.5 pollution significantly contributes to the mortality risk in all age groups. Children are more vulnerable to HAP than adults. In India, policymakers should focus on reducing the anthropogenic PM2.5 emission at least to reach the NAAQS, which can substantially reduce disease burden and, more precisely, mortality.

Drivers of PM2.5 Episodes and Exceedance in India: A Synthesis From the COALESCE Network

AbstractEmission sources influencing high particulate air pollution levels and related mortality in India have been studied earlier on country‐wide and sub‐national scales. Here, we use novel data sets of emissions (for 2019) and observations created under the Carbonaceous Aerosol Emissions, Source Apportionment, and Climate Impacts network in India (Venkataraman et al., 2020, https://doi.org/10.1175/bams‐d‐19‐0030.1) in WRF‐Chem simulations to evaluate drivers of high PM2.5 levels during episodes and in airsheds with different pollution levels. We identify airsheds in “extreme” (110–140 μg/m3), “severe” (80–110 μg/m3) and “significant” (40–80 μg/m3) exceedance of the Indian annual ambient air quality standard (National Ambient Air Quality Standards [NAAQS]) of 40 μg/m3 for PM2.5. We find that primary organic matter and anthropogenic mineral matter (largely coal fly‐ash) drive high PM2.5 levels, both annually and during high PM2.5 episodes. PM2.5 episodes are driven by organic aerosol in north India (Mohali) in wintertime but are additionally influenced by mineral matter and secondary inorganics in central (Bhopal), south India (Mysuru) and eastern India (Shyamnagar). Across airsheds in exceedance of the NAAQS and during high PM2.5 episodes, primary PM2.5 emissions arise largely from the residential sector (50%–75%). Formal sector emissions (industry, thermal power and transport; 40%–55%) drive airshed and episode scale PM2.5 exceedance in northern and eastern India. Agricultural residue burning emissions predominate (50%–75%) on episode scales, both in northern and central India, but not on annual scales. Interestingly, residential sector emissions strongly influence (60%–90%) airsheds in compliance with the NAAQS (annual mean PM2.5 < 40 μg/m3), implying the need for modern residential energy transitions for the reduction of ambient air pollution across India.

Consensus recommendations for acute trauma care & outcomes in LMICs from the transdisciplinary research, advocacy & implementation network for trauma in India.

Background & objectives Injuries profoundly impact global health, with substantial deaths and disabilities, especially in low- and middle-income countries (LMICs). This paper presents strategic consensus from the Transdisciplinary Research, Advocacy, and Implementation Network for Trauma in India (TRAIN Trauma India) symposium, advocating for enhanced, system-level trauma care to address this challenge. Methods Five working groups conducted separate literature reviews on pre-hospital trauma care, in-hospital trauma resuscitation and training, trauma systems, trauma registries, and India's Towards Improving Trauma Care Outcomes (TITCO) registry. Using a Delphi approach, the TRAIN Trauma India Symposium generated consensus statements and recommendations for interventions to streamline trauma care and reduce preventable trauma mortality in India and LMICs. Experts prioritized interventions based on cost and difficulty. Results An expert panel agreed on four pre-hospital consensus statements, eight hospital resuscitation consensus statements, six system-level consensus statements, and six trauma registry consensus statements. The expert panel recommended six pre-hospital interventions, four hospital resuscitation interventions, nine system-level interventions, and seven trauma registry interventions applicable to the Indian context. Of these, 14 interventions were ranked as low cost/low difficulty, five high cost/low difficulty, five low cost/high difficulty, and three high cost/high difficulty. Interpretation & conclusions This consensus underscores the urgent need for integrated and efficient trauma systems to reduce preventable mortality, emphasizing the importance of comprehensive care that includes community engagement and robust pre-hospital and acute hospital trauma care pathways. It highlights the critical role of inclusive, system-wide approaches, from enhancing pre-hospital care and in-hospital resuscitation to implementing effective trauma registries to improve outcomes and streamline care across contexts.

Economic Impact of Diabetes Care in Kannamanaickanur Village, Udumalpet Taluk, Tirupur District

Diabetes and its complications are a major cause of morbidity and mortality in India, and the prevalence of type 2 diabetes is on the rise. This calls for an assessment of the economic burden of the disease. The research design is exploratory and descriptive. The required information was collected using a structured questionnaire and interview method. The sampling criterion for this study was purposeful sampling. The study sample was composed of 60 diabetes patients from Kannamanaickanur Village and was conducted from January 2023 to March 2023. The prime objective of the study is to find out the Socio-economic profile of the diabetic, to estimate the direct cost, and indirect costs and to suggest the adoption of effective measures for the surveillance, prevention, and control of diabetes, to reduce the economic burden of diabetics. The data were entered in SPSS version 20.0 and percentage analysis was applied to interpret the Socio-economic and clinical profile of the diabetic patients. The Direct cost and indirect costs incurred by diabetic patients are estimated by descriptive statistical tools. The chi-squar. e test is applied to find out the association between the clinical factors and the cost of treating Diabetes. ANOVA is used to analyze the relationship between the age and total cost. The factors influencing the cost of treating Diabetes and the economic burden of Diabetic patients in the Kannamanaickanur Village have been analyzed by multiple regression model. The high out-of-pocket expenditures and income loss due to diabetes are likely to have long-term consequences for households, particularly those with low income and no health insurance.

Role of central endpoint adjudication and challenges in trials on neonatal sepsis—a case of ProSPoNS trial

Despite progress in reducing the infant mortality in India, the neonatal mortality decline has been slower, necessitating concerted efforts to achieve Sustainable Development Goal-3. A promising strategy aiming to prevent neonatal sepsis in high-risk, vulnerable, low birth weight neonates through an innovative intervention includes probiotic supplementation. This article communicates the decision by the ProSPoNS trial investigators to establish a Central Endpoint Adjudication Committee (CEAC) as an addendum to the protocol published in Trials in 2021 for the purpose of clarifying the primary outcome. In the published protocol, the study hypothesis and primary objective are based on “sepsis,” the primary outcome has been specified as sepsis/PSBI, whereas the sample size estimation was performed based on the “physician diagnosed sepsis.” To align all the three above, the investigators meeting, held on 17th–18th August 2023, at MGIMS Sevagram, Wardha, deliberated and unanimously agreed that “physician diagnosed sepsis” is the primary study outcome which includes sepsis/PSBI. The CEAC, chaired by an external subject expert and members including trial statistician, a microbiologist, and all site principal investigators will employ four criteria to determine “physician diagnosed sepsis”: (1) blood culture status, (2) sepsis screen status, (3) PSBI/non-PSBI signs and symptoms, and (4) the clinical course for each sickness event. Importantly, this clarification maintains consistency with the approved study protocol (Protocol No. 5/7/915/2012 version 3.1 dated 14 Feb 2020), emphasizing the commitment to methodological transparency and adherence to predefined standards. The decision to utilize the guidance of a CEAC is recommended as the gold standard in multicentric complex clinical trials to achieve consistency and accuracy in assessment of outcomes.Trial registrationClinical Trial Registry of India (CTRI) CTRI/2019/05/019197. Registered on 16 May 2019.

Regional and socio-demographic variation in laboratory-based predictions of 10-year cardiovascular disease risk among adults in north and south India

ObjectiveCardiovascular disease (CVD) is the leading cause of morbidity and mortality in India. There is no laboratory-based CVD risk data among Indians from different regions and backgrounds. This study estimated laboratory-based 10-year CVD risk across different population sub-groups. MethodsData from UDAY derived from cross-sectional surveys of rural and urban populations of northern (Haryana) and southern (Andhra Pradesh) India were analysed. World Health Organization/International Society of Hypertension laboratory-based equations calculated 10-year CVD risk among participants without CVD history. Wilcoxon rank sum test analyzed average CVD risk across subgroups. Chi-square test compared population proportions in different CVD risk categories. Regression analysis assessed the association between CVD risk and participant characteristics. ResultsThe mean (SD) age of the participants (n = 8448) was 53.2 (9.2) years. Males in Haryana had increased CVD risk compared to those in Andhra Pradesh (p < 0.01). In both states, female gender was shown to have a protective effect on CVD risk (p < 0.01). Age correlated with increased risk (p < 0.01). Education level did not affect CVD risk however employment status may have. Hypertension, diabetes, hyperlipidemia, smoking, and insufficient exercise were associated with increased CVD risk (p < 0.01). Residence (urban versus rural) and wealth index did not largely affect CVD risk. ConclusionMinor differences exist in the distribution of laboratory-based CVD risk across Indian population cohorts. CVD risk was similar in urban wealthy participants and rural poor and working-class communities in northern and southern India. Public health efforts need to target all major segments of the Indian population to curb the CVD epidemic.

Ambient air pollution and daily mortality in ten cities of India: a causal modelling study

The evidence for acute effects of air pollution on mortality in India is scarce, despite the extreme concentrations of air pollution observed. This is the first multi-city study in India that examines the association between short-term exposure to PM2·5 and daily mortality using causal methods that highlight the importance of locally generated air pollution. We applied a time-series analysis to ten cities in India between 2008 and 2019. We assessed city-wide daily PM2·5 concentrations using a novel hybrid nationwide spatiotemporal model and estimated city-specific effects of PM2·5 using a generalised additive Poisson regression model. City-specific results were then meta-analysed. We applied an instrumental variable causal approach (including planetary boundary layer height, wind speed, and atmospheric pressure) to evaluate the causal effect of locally generated air pollution on mortality. We obtained an integrated exposure-response curve through a multivariate meta-regression of the city-specific exposure-response curve and calculated the fraction of deaths attributable to air pollution concentrations exceeding the current WHO 24 h ambient PM2·5 guideline of 15 μg/m3. To explore the shape of the exposure-response curve at lower exposures, we further limited the analyses to days with concentrations lower than the current Indian standard (60 μg/m3). We observed that a 10 μg/m3 increase in 2-day moving average of PM2·5 was associated with 1·4% (95% CI 0·7-2·2) higher daily mortality. In our causal instrumental variable analyses representing the effect of locally generated air pollution, we observed a stronger association with daily mortality (3·6% [2·1-5·0]) than our overall estimate. Our integrated exposure-response curve suggested steeper slopes at lower levels of exposure and an attenuation of the slope at high exposure levels. We observed two times higher risk of death per 10 μg/m3 increase when restricting our analyses to observations below the Indian air quality standard (2·7% [1·7-3·6]). Using the integrated exposure-response curve, we observed that 7·2% (4·2%-10·1%) of all daily deaths were attributed to PM2·5 concentrations higher than the WHO guidelines. Short-term PM2·5 exposure was associated with a high risk of death in India, even at concentrations well below the current Indian PM2·5 standard. These associations were stronger for locally generated air pollutants quantified through causal modelling methods than conventional time-series analysis, further supporting a plausible causal link. Swedish Research Council for Sustainable Development.

District-level epidemiology and sociodemographic determinants of noncommunicable diseases - results the National Family Health Survey −5 (2019–21)

BackgroundNoncommunicable diseases (NCDs) are the leading cause of adult mortality in India. However, the data regarding the prevalence of NCD risk factors at district level is scarce. This study aims to analyse and map NCD risk factors at the state and district levels, exploring sociodemographic influences on these risks in Indian males and females. MethodsWe analyzed National Family Health Survey-5 database and used the prevalence estimates to create choropleth maps, enabling us to examine the geographical variations in NCD risk factors at the district level in India. ResultsDistricts in the Satluj-Yamuna plains, western Rajasthan, and the northeastern regions exhibited clusters with a prevalence of high blood pressure exceeding 30.1 %. Northeastern districts showed over 40 % prevalence of current tobacco use, while high alcohol consumption clusters were observed in the northeastern and Telangana districts. Southern districts showed clusters of both obesity (as measured by BMI) and highest rates of oral, breast, and cervical cancer screening, moreover districts in Tamil Nadu exhibited notable clusters of raised blood glucose prevalence. ConclusionOur analysis revealed variations in the prevalence of NCD risk factors at both the state and district levels. Accordingly, this study ranks districts based on the NCD burden, offering valuable insights to state and district teams to devise targeted measures for the prevention and control of NCDs, particularly in the most heavily affected districts.

Acute Diarrhoea in Children Aged Up to 2 Years Age Group: Assessment of Therapeutic Strategies and Hospital Stay Variance, in Tertiary Care Rural Hospital – An Observational Study

Acute Diarrhoea, it is one of the leading causes of under 5 childrens’ morbidity and mortality in India. It is most common in children especially those between 6 months and 2 years. Antimicrobials are mostly used drug for acute diarrhoeal cases according to many studies but according to WHO antibiotics are not required for all the diarrhoeal cases except few bacterial diarrhoeas. Other way, WHO recommends Zinc with low osmolarity ORS for acute diarrhoea. So, this study was designed for assessing the treatment pattern and its outcome in our setup. Objectives: - To assess the use of antibiotics and Zinc among children under 2 years suffering from acute Diarrhoea by analysing average of use and hospital stay. Materials and Methods: - This observational study includes 76 patients, admitted under Paediatric Department of Mahatma Gandhi Institute of Medical Sciences, in the period of 6 months. All the patients admitted during the study period having acute Diarrhoea with moderate dehydration as per definition of WHO was included in the study. Patients with other existing diseases, bloody diarrhoea and seriously ill were excluded. Data was collected from Paediatric ward and was analysed by using GraphPad software. Results: - Over all among the 76 patients, 25(32.89%) patients received antimicrobials only and 31(40.79%) received Zinc only and11(14.47%) patients received both. Hospital stay difference was not statistically significant in culture negative acute diarrhoea cases with the use of zinc and antimicrobials (p = 0.08) but it was significant in culture positive cases (p = 0.03). Conclusion: - In culture negative acute diarrhoeal cases Zinc was mostly used and hospital stay was not found to be significant with and without antimicrobials. Implication: - Uncomplicated acute diarrhoeal cases may be treated with Zinc alone effectively.

Development of chicken egg yolk antibodies (IgY) against venom of cobra (Naja naja) and krait (Bungarus caeruleus) and a study on its neutralization potential

The Big Four snakes are the leading causes of snakebite mortality in India. Among them, The Indian spectacled cobra (Naja naja) and common krait (Bungarus caeruleus) contribute about one-third of the deaths. The conventional anti-snake venoms (ASV) produced from equine serum are found to be expensive, with a high frequency of clinical side effects, low specificity, and production drawbacks. The current study, therefore, attempted to develop chicken egg yolk immunoglobulins (IgY) as antivenoms against the venoms of cobra and krait venoms. The major pathophysiological properties of the venoms and the efficacy of monovalent ASV IgY were evaluated. The titer of anti-cobra and anti-krait IgY was found to be 1:64000 on the 145th day post-immunization. The results showed that venoms (lethal doses (LD50): cobra:0.375 mg/kg, krait:0.0375 mg/kg of mice) had hemolytic, pro-coagulant, inflammatory, hemorrhagic, and edematic activities that were effectively neutralized by ASV-IgY. 1 mL of monovalent ASV IgY was able to neutralize 0.22 mg of cobra venom and 0.028 mg of krait venom whereas 1 mL of commercial polyvalent antivenom was able to neutralize 0.28 mg of cobra venom and 0.035 mg of krait venom. The study results suggest that using chicken IgY as an monovalent antivenom could effectively treat snakebites.

Development and evaluation of prevention bundle for neonatal healthcare-associated infections: an interventional study

Background Neonatal healthcare-associated infection (HAI) globally is the leading preventable cause of neonatal mortality. Neonatal mortality in India is also very high. Considering that HAIs can be prevented globally, there are disparities in resources; the current study aimed at developing locally feasible and effective prevention bundles for neonatal HAIs. Methods A mixed-method study was conducted at one tertiary care teaching hospital's level IV Neonatal Intensive Care Unit. The study explores the causes of neonatal HAIs, current processes, benchmark practices, gaps in current practices with HAIs, root-cause analysis and system process mapping, and failure mode effect analysis. Observations, interviews, brainstorming activities, and a survey were conducted. Written and audio-video recorded prevention bundle was developed and implemented using a quasi-experimental study design. Results Process standardisation, healthcare worker training, hand hygiene practices, nursing care process and vascular access process were identified as key improvement areas to prevent neonatal HAIs. Out of eighteen identified processes, three processes were standardised. All the healthcare providers were trained at three-time intervals of three months each. After implementing the prevention bundle, there was a significant decline in the rate of HAIs, reducing it from 9.6 to 7.0 per 100 admissions &gt;48 hours. The bacteraemia rate fell from 5.2 per 1000 patient days to 2.6 per 1000 patient days and was statistically significant on a two-tailed student t-test with 95% CI with p-value=0.00073. Conclusions Our developed prevention bundle for neonatal HAIs was significantly effective and reproducible for healthcare workers' training and development. Considering variations in global infection control practices and resources constraint, it is effective to develop a local prevention bundle for neonatal HAIs.

Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study.

While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored. There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes. About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC. Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians. Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.

Air pollution mortality from India’s coal power plants: unit-level estimates for targeted policy

Air pollution from coal-fired electricity generation is an important cause of premature mortality in India. Although pollution-related mortality from the sector has been extensively studied, the relative contribution of individual coal-fired units to the fleet-wide mortality burden remains unclear. Here, we find that emissions from a small number of units drive overall mortality. Units producing just 3.5% of total generation and constituting less than 3% of total capacity result in 25% of annual premature mortality from coal-fired generation. This is a direct consequence of the 200-fold variation that we find in the mortality intensity of electricity generation across units. We use a detailed emissions inventory, a reduced complexity air quality model, and non-linear PM2.5 concentration-response functions to estimate marginal premature mortality for over 500 units operational in 2019. Absolute annual mortality ranges from less than 1 to over 650 deaths/year across units, and the mortality intensity of generation varies from under 0.002 to 0.43 deaths/GWh. Our findings suggest the potential for large social benefits in the form of reduced PM2.5-related premature mortality in India if the highest mortality intensity units are prioritized for the implementation of pollution control technologies or accelerated retirement.

Process evaluation of a complex, multilevel, multicomponent scheme for the prevention and control of non-communicable diseases in Tamil Nadu, India: A mixed-methods protocol

BackgroundNon-communicable diseases (NCDs) are the leading cause of morbidity and mortality in India, necessitating development of multilevel and multicomponent interventions. Makkalai Thedi Maruthuvam (MTM) is a complex multilevel, multicomponent intervention developed and implemented by the south Indian State of Tamil Nadu. The scheme aims to deliver services for preventing and controlling diabetes, and hypertension at doorstep. This paper describes the protocol for planning and conducting the process evaluation of the MTM scheme. Methods and analysisThe process evaluation uses mixed methods (secondary data analysis, key informant interviews, in-depth interviews, conceptual content analysis of documents, facility-based survey and non-participant observation) to evaluate the implementation of the MTM scheme. The broad evaluation questions addressed the fidelity, contexts, mechanisms of impact and challenges encountered by the scheme using the Consolidated Framework for Implementation Research (CFIR) framework. The specific evaluation questions addressed selected inputs and processes identified as critical to implementation by the stakeholders. The CFIR framework will guide the thematic analysis of the qualitative interviews to explore the adaptations and deviations introduced during implementation in various contexts. The quantitative data on the indicators developed for the specific evaluation questions will be cleaned and descriptively analysed.

Consensus Statement from India on the Renal Benefits of ARNi, SGLT-2i, and Bisoprolol in Chronic Kidney Disease.

Chronic kidney disease (CKD) is a major contributor to morbidity and mortality in India. CKD often coexists with heart failure (HF), diabetes, and hypertension. All these comorbidities are risk factors for renal impairment. HF and CKD are pathophysiologically intertwined, and the deterioration of one can worsen the prognosis of the other. There is a need for safe renal pharmacological therapies that target both CKD and HF and are also useful in hypertension and diabetes. Neurohormonal activation achieved through the activation of the sympathetic nervous system (SNS), the renin-angiotensin-aldosterone system (RAAS), and the natriuretic peptide system (NPS) is fundamental in the pathogenesis and progression of CKD and HF. Angiotensin receptor neprilysin inhibitor (ARNi), sodium-glucose cotransporter 2 inhibitors (SGLT-2i), and selective β1-blocker (B1B) bisoprolol suppress this neurohormonal activation. They also have many other cardiorenal benefits across a wide range of CKD patients with or without concomitant HF, diabetes, or hypertension. This consensus statement from India explores the place of ARNi, SGLT-2i, and bisoprolol in the management of CKD patients with or without HF and other comorbidities.

Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India

IntroductionIndia’s progress in reducing maternal and neonatal mortality since the 1990s was faster than the regional average. We systematically analysed how national health policies, services for maternal and newborn health,...

Statistical analysis plan for a cluster randomised trial in Madhya Pradesh, India: community health promotion and medical provision and impact on neonates (CHAMPION2)

BackgroundNeonatal mortality in India has fallen steadily and was estimated to be 24 per 1000 live births in the year 2017. However, neonatal mortality remains high in rural parts of the country. The Community Health Promotion and Medical Provision and Impact On Neonates (CHAMPION2) trial investigates the effect of a complex health intervention on neonatal mortality in the Satna District of Madhya Pradesh.Methods/designThe CHAMPION2 trial forms one part of a cluster-randomised controlled trial with villages (clusters) randomised to receive either a health (CHAMPION2) or education (STRIPES2) intervention. Villages receiving the health intervention are controls for the education intervention and vice versa. The primary outcome is neonatal mortality. The effect of the active intervention on the primary outcome (compared to usual care) will be expressed as a risk ratio, estimated using a generalised estimating equation approach with robust standard errors that take account of clustering at village level. Secondary outcomes include maternal mortality, stillbirths, perinatal deaths, causes of death, health care and knowledge, hospital admissions of enrolled women during pregnancy or in the immediate post-natal care period or of their babies (during the neonatal period), maternal blood transfusions, and the cost effectiveness of the intervention. A total of 196 villages have been randomised and over 34,000 women have been recruited in CHAMPION2.DiscussionThis update to the published trial protocol gives a detailed plan for the statistical analysis of the CHAMPION2 trial.Trial registrationRegistry of India: CTRI/2019/05/019296. Registered on 23 May 2019. https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=MzExOTg=&Enc=&userName=champion2

Heat Stress in India: A Review

Global warming and climate changes have increased the frequency and intensity of heat waves globally as well as in India. The morbidity and mortality of heat stress are under-reported in India. This review was conducted to identify the studies which have reported morbidity and mortality in India and synthesise evidence on the impact of heat stress in the country. Authors identified 373 studies from PubMed and Embase. After removing duplicates and screening for inclusion criteria, 17 articles were selected for the review. Nine articles reported the mortality of heat stress in India, whereas seven articles reported the morbidity. All the studies reported increased mortality due to extreme heat. Eight studies reported excess mortality, which ranged from 5.6% in a study in Varanasi to as high as 43.1 % in Ahmedabad. The studies that have reported morbidity highlight elderly individuals, pregnant women and neonates as the vulnerable population. The discussion focuses on the preventive strategies, heat action plans and primary healthcare reforms needed to manage heat-related illness. Prioritising and focussing on heat-related illness can prevent mortality as well as increase the productivity of the workforce and improve the economy of the country.