Correlation of types of diabetic retinopathy and its psychosocial impact

Background: Diabetic retinopathy affects majority (70% to 90%) of diabetic patients, causes visual impairment which leads to severe psycho-social disruption in life. Our objective was to study the patients of diabetic retinopathy, co-relate between the types of diabetic retinopathy and the extent of psychosocial impairment in these patients.Methods: Data of the diabetic patients attending the Retina Clinic of C.H. Nagri Eye Hospital, Ahmedabad was collected using a pretested questionnaire. It included ocular history, history related to diabetes, data of ocular examination and type of retinopathy (if present). For psycho-social assessment, the patients were asked to fill the validated Gujarati language version of “General Health Questionnaire -28 (GHQ 28).” Selfscoring was done ranging from 0-1-2-3 (lower to higher disability respectively). Analysis of significance was carried out by Mann-Whitney Test using statistical software.Results: Total 308 patients were studied. The subjects were divided into 3 groups: (A) Diabetes mellitus type-2 (DM-2) patients without retinopathy. (B) DM-2 patients having non-proliferative retinopathy (C) DM-2 patients having proliferative retinopathy. According to the accepted scoring pattern of GHQ-28 (cut of point 25), it was observed that 80.26% of patients having non-proliferative retinopathy in both eyes and 93.75% patients having proliferative retinopathy in both eyes were psychosocially impaired. The impairment was found to be more severe in proliferative retinopathy patients as compared to non-proliferative retinopathy patients. (p value NPDR = 35.74). It was also found that in DM-2 patients without retinopathy the average mean score was 25.22 which showed less impairment (p value <0.005).Conclusions: Patients of Diabetic Retinopathy had more psychosocial impairment which shows its significant impact on quality of life and overall health. Psychiatric counselling must be given to the impaired patients to decrease the impact of the disease on the psychosocial aspect of health. It is necessary to decrease the psychosocial suffering along with the control of disease

Always Better Control-Vital Essential Desirable analysis of the drugs used in health centres of Ahmedabad district

Background: The basic principle of inventory control is Always Better Control (ABC) based on cost criteria and Vital Essential Desirable (VED) on criticality. Inequity in drug prioritization and expenses directly affects the health of the community. Study design: Based on ABC-VED matrix, inventory analysis was done. Study area: Community health centre (CHC) - Singarva, two primary health centres (PHC) - Kanbha and Sanathal and two urban health centre (UHC) - Amraiwadi and Sabarmati. Study period: December 2012 to December 2013.Methods: The drugs were first categorized by ABC method and then by VED method. On coupling the two techniques, ABC-VED matrix was made and drugs were classified in to Category I (AV + BV +CV + AE + AD), Category II (BE + CE + BD) and Category III (CD).Results: According to VED analysis large amount of money was spent on D category that is; 35% of annual drug expenditure (ADE) from CHC, 7.6% and 23.4% from both the PHC respectively, 20.1% and 24.7% from both the UHCs. On considering the ABC-VED matrix analysis the ADE spent on Class III was 6.6% among CHC, 1.2% and 1.5% among PHC, 2.6% and 7.2% among the UHC.Conclusion: The ADE used among the ABC-VED Class III should be avoided and the ADE on Class II drugs should be controlled and used judiciously

Assessment of Knowledge of Glaucoma in General Practitioners, Resident Doctors and Interns in Anand District, Gujarat, India

Introduction: Glaucoma has been established as the second most leading cause of blindness after cataract, which is usually irreversible and accounts for 10.1% of total blindness worldwide. Glaucoma has affected 79.6 million people worldwide by 2020. The estimated prevalence of glaucoma in India is 12 million. The Government of India aims to reduce the prevalence of blindness to 0.25/1000 by 2025 and disease burden by one third from current levels. In a developing country, like India, ‘physician of first contact’ may be a general practitioner, resident doctor or intern. Aim: To assess knowledge of glaucoma in general practitioners, resident doctors and interns in Anand district, Gujarat and to identify the level of difference of knowledge in each group and to suggest remedial measures for the same. Materials and Methods: A descriptive semi-structured questionnaire based cross-sectional study was conducted in Pramukhswami Medical College, Karamsad, Gujarat, India, after obtaining ethical clearance from the Institutional Ethics Committee between July 2017 to September 2017. Informed written consent was taken from 240 medical doctors comprising of interns (undergoing compulsory rotatory internship), 1st to 3rd year resident doctors (postgraduate students) working in different wards of all the clinical department and general practitioners practising in radius of 15 kilometers from the main hospital located in Anand district of Gujarat state (80 in each category) and a questionnaire was administered. Participants were inquired about the knowledge of glaucoma, the sneak thief of sight. Residents of Ophthalmology were excluded to avoid bias. Cramer’s V association, Chi-square test and Fisher's-Exact tests were applied for data analysis. Results: Respondents included general practitioners, residents and interns (80:80:80). Glaucoma knowledge was to be higher in residents as compared to interns and general practitioners. About 78.75% residents scored 7 and above out of 10 whereas 61.25% interns and 50% general practitioners obtained the same score. Conclusion: The authors found that knowledge about glaucoma in multi-scale medical practitioners was not uniform and reasonably less than it should be. Resident doctors (fresh graduates and completed compulsory rotatory internship) have better knowledge about various aspects of glaucoma as compared to general practitioners and interns which demands the need for frequent reorientation programme and internship in Ophthalmology guiding about various aspects of disease entities responsible for blindness

SpaText: Spatio-Textual Representation for Controllable Image Generation

Recent text-to-image diffusion models are able to generate convincing results of unprecedented quality. However, it is nearly impossible to control the shapes of different regions/objects or their layout in a fine-grained fashion. Previous attempts to provide such controls were hindered by their reliance on a fixed set of labels. To this end, we present SpaText - a new method for text-to-image generation using open-vocabulary scene control. In addition to a global text prompt that describes the entire scene, the user provides a segmentation map where each region of interest is annotated by a free-form natural language description. Due to lack of large-scale datasets that have a detailed textual description for each region in the image, we choose to leverage the current large-scale text-to-image datasets and base our approach on a novel CLIP-based spatio-textual representation, and show its effectiveness on two state-of-the-art diffusion models: pixel-based and latent-based. In addition, we show how to extend the classifier-free guidance method in diffusion models to the multi-conditional case and present an alternative accelerated inference algorithm. Finally, we offer several automatic evaluation metrics and use them, in addition to FID scores and a user study, to evaluate our method and show that it achieves state-of-the-art results on image generation with free-form textual scene control.Comment: CVPR 2023. Project page available at: https://omriavrahami.com/spatex

Interprofessional Collaboration Led by Health Professional Students: A Case Study of the Inter Health Professional Alliance at Virginia Commonwealth University

Background: Internationally recognized health experts have identified the need for an interdisciplinary approach to meet the healthcare needs of the 21st century, but academic institutions have been slow to take action. In response, eight health professional students at Virginia Commonwealth University developed a student-led organization, the Inter Health Professionals Alliance (IHPA), to foster a collaborative, interdisciplinary environment among health professional students.Methods and Findings: The eight students utilized a participatory action research approach to identify 1) an understanding behind the motivation for developing IHPA and 2) the core benefits of group involvement. Four benefits were identified: the development of knowledge and skills, interprofessional networks, professional competence, and role clarity. The case study demonstrated that students can engage in interdisciplinary collaboration from a student-initiated approach and likely improve the care of future patients. Drawing on personal experiences, IHPA board members outline five pieces of wisdom to aid fellow students in the development of student-led interdisciplinary organizations.Conclusions: With enthusiasm and support, students can transform their educational experiences to meet the healthcare needs of the twenty-first century

Development of a transdiagnostic, low-intensity, psychological intervention for common adolescent mental health problems in Indian secondary schools

Background: The PRIDE programme aims to establish a suite of transdiagnostic psychological interventions organised around a stepped care system in Indian secondary schools. This paper describes the development of a low-intensity, first-line component of the PRIDE model. Method: Contextual and global evidence informed an intervention ‘blueprint’ with problem solving as the primary practice element. Successive iterations were tested and modified across two pilot cohort studies (N=45; N=39). Participants were aged 13–20 years and presenting with elevated mental health symptoms in New Delhi schools. Results: The first iteration of the intervention, based on a guided self-help modality, showed promising outcomes and user satisfaction when delivered by psychologists. However, delivery was not feasible within the intended 6-week schedule, and participants struggled to use materials outside ‘guidance’ sessions. In Pilot 2, a modified counsellor-led problem-solving intervention was implemented by less experienced counsellors over a 3–4 week schedule. Outcomes were maintained, with indications of enhanced feasibility and acceptability. High demand was observed across both pilots, leading to more stringent eligibility criteria and a modified sensitisation plan. Discussion: Findings have shaped a first-line intervention for common adolescent mental health problems in low-resource settings. A forthcoming randomised controlled trial will test its effectiveness

Effectiveness of a brief lay counsellor-delivered, problem-solving intervention for adolescent mental health problems in urban, low-income schools in India: a randomised controlled trial

Background Mental health problems are a leading cause of disability in adolescents worldwide. Problem solving is a well-tested mental health intervention in many populations. We aimed to investigate the effectiveness of a brief, transdiagnostic problem-solving intervention for common adolescent mental health problems when delivered by non-specialist school counsellors in New Delhi, India. Methods This randomised trial was done in six government-run schools (three all-boys schools, two all-girls schools, and one co-educational school) that serve low-income communities. We recruited participants from grades 9 to 12 (ages 12–20 years) by selecting students with persistently elevated mental health symptoms accompanied by distress or functional impairment. Clinical eligibility criteria were assessed by research assistants using the Hindi-language version of the Strengths and Difficulties Questionnaire (SDQ), with reference to locally validated borderline cutoff scores of 19 or greater for boys and 20 or greater for girls on the SDQ Total Difficulties scale, an abnormal score of 2 or more on the SDQ Impact scale, and persistence of more than 1 month on the SDQ Chronicity index. Participants were randomly allocated (1:1) to problem solving delivered through a brief (2–3 week) counsellor-led intervention with supporting printed materials (intervention group), or problem solving delivered via printed booklets alone (control group). Primary outcomes were adolescent-reported mental health symptoms (SDQ Total Difficulties scale) and idiographic psychosocial problems (Youth Top Problems [YTP]) at 6 weeks. Primary analyses were done on an intention-to-treat basis at the 6-week endpoint. The trial is registered with ClinicalTrials.gov, NCT03630471. Findings Participants were enrolled between Aug 20, and Dec 4, 2018. 283 eligible adolescents were referred to the trial, and 251 (89%) of these were enrolled (mean age 15·61 years; 174 [69%] boys). 125 participants were allocated to each group (after accounting for one participant in the intervention group who withdrew consent after randomisation). Primary outcome data were available for 245 (98%) participants. At 6 weeks, the mean YTP scores were 3·52 (SD 2·66) in the intervention group and 4·60 (2·75) in the control group (adjusted mean difference –1·01, 95% CI –1·63 to –0·38; adjusted effect size 0·36, 95% CI 0·11 to 0·61; p=0·0015). The mean SDQ Total Difficulties scores were 17·48 (5·45) in the intervention group and 18·33 (5·45) in the control group (–0·86, –2·14 to 0·41; 0·16, –0·09 to 0·41; p=0·18). We observed no adverse events. Interpretation A brief lay counsellor-delivered problem-solving intervention combined with printed booklets seemed to have a modest effect on psychosocial outcomes among adolescents with diverse mental health problems compared with problem-solving booklets alone. This counsellor-delivered intervention might be a suitable first-line intervention in a stepped care approach, which is being evaluated in ongoing studies

The effectiveness of a low-intensity problem-solving intervention for common adolescent mental health problems in New Delhi, India: protocol for a school-based, individually randomized controlled trial with an embedded stepped-wedge cluster randomized controlled recruitment trial

Background Conduct, anxiety and depressive disorders account for over 75% of the adolescent mental health burden globally. The current protocol will test a low-intensity problem-solving intervention for school-going adolescents with common mental health problems in India. The protocol also tests the effects of a classroom-based sensitization intervention on the demand for counselling services in an embedded recruitment trial. Methods We will conduct a two-arm individually randomized controlled trial in six Government-run secondary schools in New Delhi. The targeted sample is 240 adolescents in grades 9-12 with persistent, elevated mental health symptoms and associated impact. Participants will receive either a brief problem-solving intervention delivered over 3 weeks by lay counsellors (intervention), or enhanced usual care comprised of problem-solving booklets (control). Self-reported adolescent mental health symptoms and idiographic problems will be assessed at 6 weeks (co-primary outcomes) and again at 12 weeks post-randomization. In addition, adolescent-reported impact of mental health difficulties, perceived stress, mental wellbeing and clinical remission, as well as parent-reported adolescent mental health symptoms and impact scores, will be assessed at 6 and 12 weeks post-randomization. We will also complete a parallel process evaluation, including estimations of the costs of delivering the interventions. An embedded recruitment trial will apply a stepped-wedge, cluster (class)-randomized controlled design in 70 classes across the six schools. This will evaluate the added impact of a classroom-based sensitization intervention over school-level recruitment sensitization activities on the primary outcome of referral rate into the host trial (i.e. the proportion of adolescents referred as a function of the total sampling frame in each condition of the embedded recruitment trial). Other outcomes will be the proportion of referrals eligible to participate in the host trial, proportion of self-generated referrals, and severity and pattern of symptoms among referred adolescents in each condition. Power calculations were undertaken separately for each trial. A detailed statistical analysis plan will be developed separately for each trial prior to unblinding. Discussion Both trials were initiated on 20 August 2018. A single research protocol for both trials offers a resource-efficient methodology for testing the effectiveness of linked procedures to enhance uptake and outcomes of a school-based psychological intervention for common adolescent mental health problems

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570