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Railway disasters cause huge loss of life and resources. A triple train collision occurred at 7 PM on 2nd June 2023 at Bahanaga, Balasore, Odisha. It was the third deadliest train accident in India with 288 deaths and more than 900 injured. This study aimed to bring out the experience and capture the emotions of the personnel involved in body management of this major accident. This qualitative questionnaire-based study was done between 13/07/2023 and 29/01/2024, involving 47 personnel (including faculty, residents, staff, and students) who managed the deceased bodies. Six open-ended questions dealing with the experiences of the body management team were analyzed using thematic analysis framework method. Quirkos software was used to generate themes and subthemes. Another six questions about self-reported satisfaction levels of the personnel were graded on a Likert scale of 1 to 5. Qualitative analysis identified six themes and twelve subthemes. It highlighted critical aspects such as lack of training in managing mass tragedies, inadequate flow of essential supplies, emergency preparedness, and defined standard operating procedures (SOP). Excellent teamwork (91.4% of participants expressed high satisfaction with the teamwork) and on-the-spot decision-making were heralded as strengths. The Likert scale showed that 87.2% of participants rated the overall dead body management at 4 or 5. Furthermore, 93.6% (44/47) of participants gave a score 4 or 5 for Tagging and Embalming. Teamwork and proper embalming were identified as the top-rated contributors towards effective body management. Recommendations suggested were mock drills and refresher courses in body management for all stakeholders and psychological support to handle the emotional toll of managing mass tragedy. The identification and embalming of dead bodies are an essential humanitarian service and it helped bereaved families to say a final farewell to their loved ones.

Estrogen-related receptor beta (ERRβ) is downregulated in breast cancer cells and its overexpression in breast cancer patients is positively correlated with an improved prognosis and prolonged relapse-free survival. Here, we unravelled a molecular mechanism for ERRβ downregulation in breast cancer. We found that ERRβ is a key substrate of the SCF complex and that NEDDylation can activate the Cullin subunits of the SCF complex to target ERRβ for degradation in breast cancer. Consistently, using in vitro and in vivo models, we demonstrated that MLN4924, a specific small molecule inhibitor of NEDDylation, can restore ERRβ expression and culminate in a reduction in cell proliferation and migration of breast cancer cells. We also showed that increased ERRβ expression promotes the upregulation of its target genes, including the tumour suppressors p21 Cip1/Waf1 and E-cadherin, involved in cell proliferation and migration arrest at the gene promoter level. Interestingly, this tumour suppressive role of ERRβ does not depend on the expression of ERα in breast cancer. Moreover, our data revealed that the ERRβ recruits the transcription co-activator p300 to its targeted gene promoters to upregulate their expression. Collectively, our work revealed that restoration of ERRβ expression using the NEDDylation inhibitor MLN4924 can be a novel and effective strategy for breast cancer treatment.

ObjectivesEfforts to understand the factors influencing the uptake of reproductive, maternal, newborn, child health and nutrition (RMNCH&N) services in high disease burden low-resource settings have often focused on face-to-face surveys or direct observations of service delivery. Increasing access to mobile phones has led to growing interest in phone surveys as a rapid, low-cost alternatives to face-to-face surveys. We assess determinants of RMNCH&N knowledge among pregnant women with access to phones and examine the reliability of alternative modalities of survey delivery.ParticipantsWomen 5–7 months pregnant with access to a phone.SettingFour districts of Madhya Pradesh, India.DesignCross-sectional surveys administered face-to-face and within 2 weeks, the same surveys were repeated among two random subsamples of the original sample: face-to-face (n=205) and caller-attended telephone interviews (n=375). Bivariate analyses, multivariable linear regression, and prevalence and bias-adjusted kappa scores are presented.ResultsKnowledge scores were low across domains: 52% for maternal nutrition and pregnancy danger signs, 58% for family planning, 47% for essential newborn care, 56% infant and young child feeding, and 58% for infant and young child care. Higher knowledge (≥1 composite score) was associated with older age; higher levels of education and literacy; living in a nuclear family; primary health decision-making; greater attendance in antenatal care and satisfaction with accredited social health activist services. Survey questions had low inter-rater and intermodal reliability (kappa<0.70) with a few exceptions. Questions with the lowest reliability included true/false questions and those with unprompted, multiple response options. Reliability may have been hampered by the sensitivity of the content, lack of privacy, enumerators’ and respondents’ profile differences, rapport, social desirability bias, and/or enumerator’s ability to adequately convey concepts or probe.ConclusionsPhone surveys are a reliable modality for generating population-level estimates data about pregnant women’s knowledge, however, should not be used for individual-level tracking.Trial registration numberNCT03576157.

Kilkari is an outbound service that makes weekly, stage-based, prerecorded calls about reproductive, maternal, neonatal and child health directly to families’ mobile phones, starting from the second trimester of pregnancy and until the child is 1 year old. Since its initiation in 2012–2013, Kilkari has scaled to 13 states across India. In this analysis article, we explored the subscriber’s journey from entry to programme to engagement with calls. Data sources included call data records and household survey data from the 2015 National Family Health Survey. In 2018, of the 13.6 million records received by MOTECH, the technology platform that powers Kilkari, 9.5 million (~70%) were rejected and 4.1 million new subscribers were created. Overall, 21% of pregnant women across 13 states were covered by the programme in 2018, with West Bengal and Himachal Pradesh reaching a coverage of over 50%. Among new subscriptions in 2018, 63% were subscribed during pregnancy and 37% after childbirth. Of these, over 80% were ever reached by Kilkari calls and 39% retained in the programme. The main causes for deactivation of subscribers from the system were low listenership and calls going unanswered for six continuous weeks. Globally, Kilkari is the largest maternal mobile messaging programme of its kind in terms of number of subscribers but the coverage among pregnant women remains low. While call reach appears to be on the higher side, subscriber retention is low; this highlights broader challenges with providing mobile health services at scale across India.

Background The incidence of perineural invasion (PNI) in patients with gastric cancer (GC) is high, and patients with PNI positive disease have a poor prognosis compared to PNI-negative disease. The present study aims to study the incidence and evaluate the impact of PNI on the survival outcome of a cohort of South Asian GC patients. Material and Methods All consecutive patients undergoing curative gastrectomy were included in the study. The incidence of PNI and correlation with different clinico-pathological features and overall survival was performed. Results A total of 59.54% had PNI-positive disease and the median OS of PNI + ve patients was 29.3 months, while it was not reached in PNI-ve patients. The PNI positivity was a significant prognostic factor for overall survival both on univariate and multivariate analysis. On TNM-PNI staging, those with TNM stage I/II patients with PNI + ve disease had similar OS to all stage III patients ( p  = 0.835) and were worse than that of PNI-ve patients ( p  < 0.05). Conclusion The incidence of PNI in gastric cancer is high. The inclusion of PNI with AJCC-TNM staging may better stratify prognostic staging in curatively treated gastric cancer patients.

In 2017, India was home to nearly 20% of maternal and child deaths occurring globally. Accredited social health activists (ASHAs) act as the frontline for health services delivery in India, providing a range of reproductive, maternal, newborn, child health, and nutrition (RMNCH&N) services. Empirical evidence on ASHAs' knowledge is limited, yet is a critical determinant of the quality of health services provided. We assessed the determinants of RMNCH&N knowledge among ASHAs and examined the reliability of alternative modalities of survey delivery, including face-to-face and caller attended telephone interviews (phone surveys) in 4 districts of Madhya Pradesh, India. We carried out face-to-face surveys among a random cross-sectional sample of ASHAs (n = 1,552), and administered a follow-up test-retest survey within 2 weeks of the initial survey to a subsample of ASHAs (n = 173). We interviewed a separate sub-sample of ASHAs 2 weeks of the face-to-face interview over the phone (n = 155). Analyses included bivariate analyses, multivariable linear regression, and prevalence and bias adjusted kappa analyses. The average ASHA knowledge score was 64% and ranged across sub-domains from 71% for essential newborn care, 71% for WASH/ diarrhea, 64% for infant feeding, 61% for family planning, and 60% for maternal health. Leading determinants of knowledge included geographic location, age <30 years of age, education, experience as an ASHA, completion of seven or more client visits weekly, phone ownership and use as a communication tool for work, as well as the ability to navigate interactive voice response prompts (a measure of digital literacy). Efforts to develop a phone survey tool for measuring knowledge suggest that findings on inter-rater and inter-modal reliability were similar. Reliability was higher for shorter, widely known questions, including those about timing of exclusive breastfeeding or number of tetanus shots during pregnancy. Questions with lower reliability included those on sensitive topics such as family planning; questions with multiple response options; or which were difficult for the enumerator to convey. Overall results highlight important gaps in the knowledge of ASHAs. Findings on the reliability of phone surveys led to the development of a tool, which can be widely used for the routine, low cost measurement of ASHA RMNCH&N knowledge in India.

The Kilkari programme is being implemented by the Government of India in 13 states. Designed by BBC Media Action and scaled in collaboration with the Ministry of Health and Family Welfare from January 2016, Kilkari had provided mobile health information to over 10 million subscribers by the time BBC Media Action transitioned the service to the government in April 2019. Despite the reach of Kilkari in terms of the absolute number of subscribers, no longitudinal analysis of subscriber exposure to health information content over time has been conducted, which may underpin effectiveness and changes in health outcomes. In this analysis, we draw from call data records to explore exposure to the Kilkari programme in India for the 2018 cohort of subscribers. We start by assessing the timing of the first successful call answered by subscribers on entry to the programme during pregnancy or postpartum, and then assess call volume, delivery, answering and listening rates over time. Findings suggest that over half of subscribers answer their first call after childbirth, with the remaining starting in the pregnancy period. The system handles upwards of 1.2 million calls per day on average. On average, 50% of calls are picked up on the first call attempt, 76% by the third and 99.5% by the ninth call attempt. Among calls picked up, over 48% were listened to for at least 50% of the total content duration and 43% were listened to for at least 75%. This is the first analysis of its kind of a maternal mobile messaging programme at scale in India. Study analyses suggest that multiple call attempts may be required to reach subscribers. However, once answered, subscribers tend to listen the majority of the call—a figure consistent across states, over time, and by health content area.

Mobile phones are increasingly used to facilitate in-service training for frontline health workers (FLHWs). Mobile learning (mLearning) programmes have the potential to provide FLHWs with high quality, inexpensive, standardised learning at scale, and at the time and location of their choosing. However, further research is needed into FLHW engagement with mLearning content at scale, a factor which could influence knowledge and service delivery. Mobile Academy is an interactive voice response training course for FLHWs in India, which aims to improve interpersonal communication skills and refresh knowledge of preventative reproductive, maternal, neonatal and child health. FLHWs dial in to an audio course consisting of 11 chapters, each with a 4-question true/false quiz, resulting in a cumulative pass/fail score. In this paper, we analyse call data records from the national version of Mobile Academy to explore coverage, user engagement and completion. Over 158 596 Accredited Social Health Activists (ASHAs) initiated the national version, while 111 994 initiated the course on state-based platforms. Together, this represents 41% of the estimated total number of ASHAs registered in the government database across 13 states. Of those who initiated the national version, 81% completed it; and of those, over 99% passed. The initiation and completion rates varied by state, with Rajasthan having the highest initiation rate. Many ASHAs made multiple calls in the afternoons and evenings but called in for longer durations earlier in the day. Findings from this analysis provide important insights into the differential reach and uptake of the programme across states.

BackgroundDirect-to-beneficiary communication mobile programmes are among the few examples of digital health programmes to have scaled widely in low-resource settings. Yet, evidence on their impact at scale is limited. This study aims to assess whether exposure to mobile health information calls during pregnancy and postpartum improved infant feeding and family planning practices.MethodsWe conducted an individually randomised controlled trial in four districts of Madhya Pradesh, India. Study participants included Hindi speaking women 4–7 months pregnant (n=5095) with access to a mobile phone and their husbands (n=3842). Women were randomised to either an intervention group where they received up to 72 Kilkari messages or a control group where they received none. Intention-to-treat (ITT) and instrumental variable (IV) analyses are presented.ResultsAn average of 65% of the 2695 women randomised to receive Kilkari listened to ≥50% of the cumulative content of calls answered. Kilkari was not observed to have a significant impact on the primary outcome of exclusive breast feeding (ITT, relative risk (RR): 1.04, 95% CI 0.88 to 1.23, p=0.64; IV, RR: 1.10, 95% CI 0.67 to 1.81, p=0.71). Across study arms, Kilkari was associated with a 3.7% higher use of modern reversible contraceptives (RR: 1.12, 95% CI 1.03 to 1.21, p=0.007), and a 2.0% lower proportion of men or women sterilised since the birth of the child (RR: 0.85, 95% CI 0.74 to 0.97, p=0.016). Higher reversible method use was driven by increases in condom use and greatest among those women exposed to Kilkari with any male child (9.9% increase), in the poorest socioeconomic strata (15.8% increase), and in disadvantaged castes (12.0% increase). Immunisation at 10 weeks was higher among the children of Kilkari listeners (2.8% higher; RR: 1.03, 95% CI 1.00 to 1.06, p=0.048). Significant differences were not observed for other maternal, newborn and child health outcomes assessed.ConclusionStudy findings provide evidence to date on the effectiveness of the largest mobile health messaging programme in the world.Trial registration numberTrial registration clinicaltrials.gov; ID 90075552, NCT03576157.