"Save Antibiotics, Save lives": an Indian success story of infection control through persuasive diplomacy

Background

Carbapenem resistant Enterobacteriaceae is a worldwide threat, with increasing prevalence in many countries. Restricted usage of higher end antibiotics, especially carbapenem is of great importance in tackling these super bugs. Purpose of this retrospective study was to analyse the impact of antibiotic stewardship activities on the prevalence of carbapenem resistant Enterobacteriaceae in our hospital.

Findings

In the first Quarter of 2009, average usage of carbapenem group of antibiotics was 955 vials a month while in 2010, the usage dropped to 745 vials per month. Carbapenem resistant E.coli rate dropped from 3.7% in 2009 to 1.6% in 2010 and Klebsiella rate reduced from 6% in 2009 to 3.6% in 2010.

Conclusions

Strict antibiotic stewardship strategies in conjunction with good infection control practices are useful in restricting higher end antibiotic usage and reducing the prevalence of carbapenem resistant Enterobacteriaceae.

Transcatheter aortic valve implantation (TAVI) for treatment of aortic valve stenosis: an evidence-based Analysis (part B)

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has become an alternative to surgical aortic valve replacement (sAVR) for patients at high risk for surgery.

OBJECTIVE

To evaluate the safety, effectiveness, and cost-effectiveness of TAVI for treatment of aortic valve stenosis in symptomatic older adults.

REVIEW METHODS

A literature search was performed on September 6, 2011, for studies published from January 1, 2007, to September 6, 2011. A combined decision tree and Markov model was developed to compare costs, life years, and quality-adjusted life-years (QALYs) of all treatment options in their respective patient populations over a 20-year time horizon.

RESULTS

Two studies from the PARTNER trial were identified. The first study compared TAVI to sAVR in patients who were candidates for sAVR. The second study compared TAVI to standard treatment in patients who were not eligible for sAVR. The first study showed that TAVI and sAVR had similar mortality rates at 1 year. The second study showed a significant improvement in patient survival in those undergoing TAVI. However, in both studies, the TAVI group had significantly higher rates of stroke/transient ischemic attack, and major vascular complications. Rates of major bleeding were significantly higher in sAVR group in the first study and significantly higher in TAVI group in the second study. The base-case cost-effectiveness of TAVI was $48,912 per QALY, but the incremental cost-effectiveness ratio ranged from $36,000 to $291,000 per QALY depending on the assumptions made in the longer-term prediction portion of the model (i.e., beyond the follow-up period of the PARTNER trial).

CONCLUSIONS

TAVI improves survival in patients who cannot undergo surgery. For those who are candidates for surgery, TAVI has a mortality rate similar to sAVR, but it is associated with significant adverse effects. TAVI may be cost-effective for patients who cannot undergo surgery, but is not cost-effective for patients who can.

Cost-effectiveness of interventions for chronic obstructive pulmonary disease (COPD) using an Ontario policy model

In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions. After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses. The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html. Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework. Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Long-Term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Home Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model. Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature. For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm. For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx. The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact.

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterized by chronic inflammation throughout the airways, parenchyma, and pulmonary vasculature. The inflammation causes repeated cycles of injury and repair in the airway wall— inflammatory cells release a variety of chemicals and lead to cellular damage. The inflammation process also contributes to the loss of elastic recoil pressure in the lung, thereby reducing the driving pressure for expiratory flow through narrowed and poorly supported airways, in which airflow resistance is significantly increased. Expiratory flow limitation is the pathophysiological hallmark of COPD. Exacerbations of COPD contribute considerably to morbidity and mortality, and impose a burden on the health care system. They are a leading cause of emergency room visits and hospitalizations, particularly in the winter. In Canada, the reported average cost for treating a moderate exacerbation is $641; for a major exacerbation, the cost is $10,086.

OBJECTIVE

The objective of this study was to evaluate the cost-effectiveness and budget impact of the following interventions in moderate to very severe COPD, investigated in the Medical Advisory Secretariat Chronic Obstructive Pulmonary Disease Mega-Analysis Series: smoking cessation programs in moderate COPD in an outpatient setting: – intensive counselling (IC) versus usual care (UC). – nicotine replacement therapy (NRT) versus UC. – IC + NRT versus placebo. – bupropion versus placebo; multidisciplinary care (MDC) teams versus UC in moderate to severe COPD in an outpatient setting; pulmonary rehabilitation (PR) versus UC following acute exacerbations in moderate to severe COPD; long-term oxygen therapy (LTOT) versus UC in severe hypoxemia in COPD in an outpatient setting; ventilation: – noninvasive positive pressure ventilation (NPPV) + usual medical care versus usual medical care in acute respiratory failure due to an acute exacerbation in severe COPD in an inpatient setting. – weaning with NPPV versus weaning with invasive mechanical ventilation in acute respiratory failure due to an acute exacerbation in very severe COPD in an inpatient setting.

METHODS

A cost-utility analysis was conducted using a Markov probabilistic model. The model consists of different health states based on the Global Initiative for Chronic Obstructive Lung Disease COPD severity classification. Patients were assigned different costs and utilities depending on their severity health state during each model cycle. In addition to moving between health states, patients were at risk of acute exacerbations of COPD in each model cycle. During each cycle, patients could have no acute exacerbation, a minor acute exacerbation, or a major exacerbation. For the purposes of the model, a major exacerbation was defined as one that required hospitalization. Patients were assigned different costs and utilities in each model cycle, depending on whether they experienced an exacerbation, and its severity. Starting cohorts reflected the various patient populations from the trials analyzed. Incremental cost-effectiveness ratios (ICERs)—that is, costs per quality-adjusted life-year (QALY)—were estimated for each intervention using clinical parameters and summary estimates of relative risks of (re)hospitalization, as well as mortality and abstinence rates, from the COPD mega-analysis evidence-based analyses. A budget impact analysis was also conducted to project incremental costs already being incurred or resources already in use in Ontario. Using provincial data, medical literature, and expert opinion, health system impacts were calculated for the strategies investigated. All costs are reported in Canadian dollars.

RESULTS

All smoking cessation programs were dominant (i.e., less expensive and more effective overall). Assuming a base case cost of $1,041 and $1,527 per patient for MDC and PR, the ICER was calculated to be $14,123 per QALY and $17,938 per QALY, respectively. When the costs of MDC and PR were varied in a 1-way sensitivity analysis to reflect variation in resource utilization reported in the literature, the ICER increased to $55,322 per QALY and $56,270 per QALY, respectively. Assuming a base case cost of $2,261 per year per patient for LTOT as reported by data from the Ontario provincial program, the ICER was calculated to be $38,993 per QALY. Ventilation strategies were dominant (i.e., cheaper and more effective), as reflected by the clinical evidence of significant in-hospital days avoided in the study group. Ontario currently pays for IC through physician billing (translating to a current burden of $8 million) and bupropion through the Ontario Drug Benefit program (translating to a current burden of almost $2 million). The burden of NRT was projected to be $10 million, with future expenditures of up to $1 million in Years 1 to 3 for incident cases. Ontario currently pays for some chronic disease management programs. Based on the most recent Family Health Team data, the costs of MDC programs to manage COPD were estimated at $85 million in fiscal year 2010, with projected future expenditures of up to $51 million for incident cases, assuming the base case cost of the program. However, this estimate does not accurately reflect the current costs to the province because of lack of report by Family Health Teams, lack of capture of programs outside this model of care by any data set in the province, and because the resource utilization and frequency of visits/follow-up phone calls were based on the findings in the literature rather than the actual Family Health Team COPD management programs in place in Ontario. Therefore, MDC resources being utilized in the province are unknown and difficult to measure. Data on COPD-related hospitalizations were pulled from Ontario administrative data sets and based on consultation with experts. Half of hospitalized patients will access PR resources at least once, and half of these will repeat the therapy, translating to a potential burden of $17 million to $32 million, depending on the cost of the program. These resources are currently being absorbed, but since utilization is not being captured by any data set in the province, it is difficult to quantify and estimate. Provincial programs may be under-resourced, and patients may not be accessing these services effectively. Data from the LTOT provincial program (based on fiscal year 2006 information) suggested that the burden was $65 million, with potential expenditures of up to $0.2 million in Years 1 to 3 for incident cases. From the clinical evidence on ventilation (i.e., reduction in length of stay in hospital), there were potential cost savings to the hospitals of $42 million and $12 million for NPPV and weaning with NPPV, respectively, if the study intervention were adopted. Future cost savings were projected to be up to $4 million and $1 million, respectively, for incident cases.

CONCLUSIONS

Currently, costs for most of these interventions are being absorbed by provider services, the Ontario Drug Benefit Program, the Assistive Devices Program, and the hospital global budget. The most cost-effective intervention for COPD will depend on decision-makers’ willingness to pay. Lack of provincial data sets capturing resource utilization for the various interventions poses a challenge for estimating current burden and future expenditures.

Gabapentin versus nortriptyline in post-herpetic neuralgia patients: a randomized, double-blind clinical trial – The GONIP Trial

BACKGROUND

Gabapentin and nortriptyline have not been compared in a randomized trial in post-herpetic neuralgia (PHN). The present study was, therefore, undertaken to determine their comparative efficacy and tolerability in the treatment of post-herpetic neuralgia.

PATIENTS AND METHODS

The study was a randomized, double-blind, parallel-group trial of 9 weeks duration. Adult PHN patients with history of > 8 weeks of PHN pain after healing of rash, a pain intensity of at least 40 mm on a 100 mm visual analog scale at screening and at randomization, and average pain score of at least 4 on the Likert scale during the baseline week were included in the study. Gabapentin and nortriptyline were given in incremental doses at 2-weekly intervals till a maximum tolerated dose was obtained. The primary efficacy parameter was change in pain score (11-point Likert scale) from baseline to the end of the study period.

RESULTS

70 patients were available for intention-to-treat analysis. The average pain scores on the Likert scale were significantly reduced at the end of study in both the treatment groups with 47.6% and 42.8% reduction in pain scores in nortriptyline and gabapentin groups, respectively. Patients showed significant improvement in sleep scores in both the treatment groups nortriptyline (46.0%) and gabapentin (52.0%). The VAS and the SF-MPQ scores for pain were significantly reduced in both the groups. Gabapentin was, however, better tolerated as compared to nortriptyline.

CONCLUSION

Gabapentin was shown to be equally efficacious but was better tolerated compared to nortriptyline and can be considered a suitable alternative for the treatment of PHN.

Antiviral profile of Nyctanthes arbortristis L. against encephalitis causing viruses

The ethanolic extracts, various fractions and two pure compounds isolated from the plant N. arbortris were tested against Encephalomyocarditis Virus (EMCV) and Semliki Forest Virus (SFV). Pronounced in vitro virus inhibitory activity was observed with the ethanolic and n-butanol fractions as well as with the pure compounds arbortristoside A and arbortristoside C. In addition, ethanolic extracts and n-butanol fraction protected EMCV infected mice to the extent of 40 and 60% respectively against SFV at a daily dose of 125 mg/kg body weight.

Heavy metals in water of the rivers Hooghly and Haldi at Haldia and their impact on fish

The paper deals with the measurement of five heavy metals viz., Cd, Cu, Mn, Pb and Zn in water of the rivers Hooghly and Haldi at Haldia during June 1999 to October 2002. The industrial effluent out fall (OF) at Patikhali, Haldia was also taken as sampling site along with above out fall (AOF) and below out fall (BOF) sites. Most of the metals exhibited their least concentration at the sampling site above the Haldia industrial area of river Hooghly. The average concentrations of the studied metals were Cd 2-14, Cu 5-19, Mn 8-88, Pb 17-41 and Zn 22-37 microg l(-1). Comparison of the data with the Criterion Continuous Concentration (CCC) of USA revealed that Cd, Cu and Pb were the pollutants present at alarming level to disturb the aquatic life process in the zone. The effect was found to reflect on the tissue level aberrations in the residential fishes. The other two metals viz., Mn and Zn were probably less harmful to the aquatic ecosystem. In India, necessity is felt to develop the CCC values, which will be more appropriate for protection of aquatic environment than comparing with drinking water standards.

Nausea and vomiting in pregnancy: results of a survey that identified interventions used by women to alleviate their symptoms

Nausea and vomiting of pregnancy (NVP) affects most pregnant women. There are safe and effective treatments available; however, most women choose to avoid pharmacological therapies and try lifestyle and dietary changes to treat their condition. To date, no attempt has been made to quantify women's experience with a variety of interventions. This study aims to identify factors commonly reported by women that alleviate their symptoms of NVP. Five hundred women with NVP, calling a pregnancy healthline between February 1996 and July 1999, completed a questionnaire where they were asked to rate which of 21 factors helped and to what extent each factor helped to improve their NVP symptoms. For each item, the 'frequency' (percentage of women who indicated that item as an improvement) and 'mean importance' (mean importance score of women who indicated that item as an improvement) were multiplied to give the 'overall impact' score. All 500 women reported that dietary and lifestyle changes helped to improve their NVP symptoms. However, most items were rated low and only 31% of women reported benefit from the use of pharmacological treatment. In conclusion, this study has identified that NVP is a multifaceted condition. Lifestyle changes including validation, supportive counseling and dietary adjustments are important components, that can be used to counsel women with NVP, concomitantly with safe and effective treatment.

A novel method for the evaluation of the severity of nausea and vomiting of pregnancy

The symptomatology of nausea and vomiting of pregnancy (NVP) ranges from mild to very severe. The most advanced method to measure the burden of NVP, the Rhode's scores, incorporates physical signs (length and number of episodes of nausea, number and volume of vomits, and number of retching) with measures of distress caused by these symptoms. However, this system has been validated only for symptoms that occurred in the past 12 h, thus obviating its wide clinical use, and particularly its retrospective use.

OBJECTIVE

To examine whether the severity of the physical symptoms of NVP correlate with the degree of stress caused by them, and to develop simple scores that can be used clinically.

METHODS AND RESULTS

We prospectively scored 283 women with NVP using the Rhode's system. There was excellent and highly significant correlation between the physical symptoms and their degrees of distress. Subsequently, we examined two simple scoring systems, one with three and one with five physical symptoms. Both yielded distribution of severity of NVP not different from the one found with the use of the full Rhode's score.

CONCLUSION

A scoring system based on all five physical symptoms, or only on three (length of nausea, number of episodes of nausea and number of vomits) yielded accurate estimates of severity and changes in severity of NVP. Unlike the Rhode's score, this simple method can be used clinically to evaluate the severity and changes in NVP.

Hypobaric hypoxia and hedonic matrix in rats

This study was carried out to evaluate the effect of continuous exposure to hypobaric hypoxia on the feeding behavior and taste responses of rats, under simulated conditions of a high altitude (HA) of 7,620 m for 21 h a day and consecutively for 18 d, which more closely resembles actual field conditions. Their food, water intake and body weight were recorded daily, and blood sugar was estimated once a week. All the parameters were recorded for a period of 18 d each, before, during, and after exposure to simulated HA. The results show a decrease in daily food and water intake and body weight, and mild hypoglycemia during hypoxic exposure. Single-bottle and two-bottle tests showed a preference for sweet solutions over water, citric acid, sodium chloride, and quinine sulfate during exposure. The two-bottle test showed a preference for glucose over calorically-inert saccharine. The continuous exposure in this study produced qualitatively similar but quantitatively accentuated results as compared to intermittent 6 h exposure contiguously for 21 d. High-altitude stress appears to influence food intake such that sensory cues assume greater significance during feeding behavior.

Cryosurgery in allergic rhinitis

Nasal allergy is a common problem difficult to treat. Most of the chronic patients feel frustration even after completing all conventional modalities of treatment. We have used cryosurgery as an alternative mode of treatment for providing the permanent relief with regards to this disease. Cryosurgery basically freezes and debulks the hypertrophied inferior turbinates as well as the destroys the autonomic innervation, by a cryoprobe at 90°C. This study comprises 104 patients of Allergic Rhinitis. The patients were followed up for an average period of 3-6 months and the response was evaluated in term of relief in three basic clinical presentation namely Rhinorrhoea, Nasal-obstruction and Sneezing. Complete cure was obtained in 40.4% cases, Moderate (significant improvement in two of the features) in 30.87% cases and satisfactory results in 19.27% cases were observed. Only 9.67% cases showed no sign of improvement.This results infer that cryosurgery may be prescribed as an effective method of treatment in patients of Chronic Allergic Rhinitis.

Chaotic motion in an oscillatory boundary layer

The chaotic time oscillations in an incompressible fluid driven into motion by a harmonic time-varying pressure gradient is examined. Special attention is given to centrifugal destabilization of the viscous boundary layer. The basic flow is shown to be linearly unstable. For increasing modulation amplitude, the flow exhibits chaotic oscillations. The energy exchange between subharmonics and superharmonics of the least-stable spanwise wave number is considered. The presence of subharmonic Fourier modes are shown to accelerate the transition to temporally chaotic motion. (c) 1996 American Institute of Physics.

In vitro anti-vaccinia virus activity of some marine plants

Seventy three marine plant extracts were tested in vitro in chick embryo fibroblast cell culture and their anti-vaccinia virus activity was evaluated in terms of reduction in number of plaques by the extracts. Only seven extracts were found to show the activity. Sargassum wightii, a seaweed had the highest activity, reducing 65 per cent of plaques formed by vaccinia virus.

Immunomodulation due to coexposure to styrene and dioctyl phthalate in mice

Pathomorphological and immunological alterations caused by a mixture of styrene and dioctyl phthalate were studied in albino mice following oral administration of 0.02, 0.03, 0.05 x LD50 of the mixture. The chemicals were mixed together proportionate to their respective LD50 values and fed in ground nut oil, 5 d/wk for 4 weeks. Histological examination of spleen revealed considerable depletion of cellular population of lymphoid follicles which corresponded to the dose dependent decrease in splenic mononuclear cell population count. The thymic lobules revealed slight atrophy but accompanied by a significant increase in thymocyte population. Correspondingly few significant histological changes were observed in mesenteric and peripheral lymph nodes. The treatment caused impairment of primary humoral immune response to SRBC (IgM) but there was a significant increase in response of splenocytes to B-cell mitogen LPS. There was a suppression of cutaneous delayed type hypersensitivity and increase in splenic lymphocyte response to T-cell mitogen PHA. Simultaneously, indirect immunity represented by decreased phagocytosis and enhanced metabolic function of reducing NBT by peritoneal exudate cells was observed. The in vitro exposure of vero cells to the mixture caused dose dependent protective effect. The results of present study indicate that subchronic exposure to low doses of mixture of styrene and dioctyl phthalate under certain conditions may modulate some of the immune functions as compared to exposure to either chemicals alone.