The Implementation of RSBY in Chhattisgarh, India: A study of the Durg district

The Rashtriya Swasthya Bima Yojana (RSBY) scheme is a health insurance model currently being implemented by the Indian government. It is a model, however, still in nascent state, subject to tensions and value testing. Very few studies have hitherto assessed the scheme’s implementation and whether the stated objectives of the government initiative are being fulfilled. This short study undertaken in the Durg district of Chhattisgarh reveals that RSBY fails to cover the population living Below the Poverty Line (BPL). Likewise there is discrepancy in the consistency of information and knowledge regarding the scheme among the beneficiaries who are themselves continuing to incur high out-of-pocket expenses. There are thus severe issues in transparency and accountability within the RSBY scheme. Unless the public health delivery system is strengthened and the private sector regulated and indeed monitored, the scheme will not yield the desired results, and the cost of healthcare will further escalate for the poor. In the absence of regulated health services there needs to be more debate, and indeed greater research, on the implementation and the design of RSBY. 

Ultrasonography in infantile hypertrophic pyloric stenosis

Infantile hypertrophic pyloric stenosis (IHPS) is usually seen among the first born male infants. In recent time, ultrasonography has become the investigation of choice and has almost completely replaced the radiographic upper gastrointestinal series for the diagnosis of the disease. Here we report a case of 31 days infant with hypertrophic pyloric stenosis. Our purpose of reporting this case is to show the importance of ultrasonography in diagnosing infantile hypertrophic pyloric stenosis. DOI: http://dx.doi.org/10.3126/jcmsn.v7i1.5978 JCMSN 2011; 7(1): 73-76

Preference for a new prefilled insulin pen compared with the original pen

BACKGROUND

The prevalence of diabetes is increasing in the United States and worldwide. Insulin injection pens are preferred over vial/syringe methods, and are designed to facilitate use, improve adherence, and provide accurate insulin delivery.

OBJECTIVE

This study compares the efficacy, safety profile, and patient preference of the new prefilled insulin pen FT* versus the original insulin pen FP.

METHODS

This randomized, multicenter, open-label, crossover study was conducted in insulin-treated pen-naïve patients with type 1 or type 2 diabetes mellitus (n = 242, mean age 58 years, mean body mass index (BMI) 31.4 kg/m(2), baseline glycosylated hemoglobin [HbA(1c)] 7.3%). Patients were randomized 1:1 to either FT or FP for 12 weeks and then switched to the alternate insulin device for 12 weeks, while the insulin regimen was kept the same. All subjects were on either insulin detemir alone or in combination with insulin aspart treatment during the trial. HbA(1c) was assessed at screening, randomization, cross-over period, and end of trial. The safety profile was evaluated based on adverse events (AEs), adverse device effects (ADEs), and hypoglycemic episodes. Patient-reported outcome (PRO) questionnaires assessed at randomization, crossover period, and end of trial were used to investigate the subjects' preference of the two prefilled devices.

RESULTS

A total of 400 subjects were screened, 242 subjects were randomized and exposed to the prefilled pen devices, and 222 subjects completed the trial. Twenty subjects discontinued the study. Four subjects discontinued due to adverse events. Subject default (withdrawal of consent and loss to follow up) was the most common reason for discontinuation (10 subjects), Glycemic control achieved with FT was comparable to that with FP (FT-FP: difference -0.047 [95% CI -0.127; 0.032%]). The majority of subjects (68%) indicated a preference for the FT device over FP. In addition, the majority of subjects found FT easier to use (64% [144/226]), easier to inject the insulin dose (65% [148/227]) and easier to push for injection (69% [155/226]). The Treatment Related Impact Measure-Diabetes (TRIM-D) ratings of FT were significantly higher for diabetes management facilitation (P < 0.001), and treatment burden (P < 0.001). The safety profiles were comparable for FT and FP.

CONCLUSIONS

FT was found to be comparable to FP with respect to the efficacy and safety profile. Significantly more subjects favored the FT device in terms of ease of use, insulin injection, diabetes management, and overall preference. A limitation of the present study was its open-label design because the pen devices used to administer the insulin were distinctively different and the use of a double-dummy design was precluded by the absence of placebo pen devices. The questionnaires about treatment were related to the use of the device and therefore a blinded study was not possible.

Predictive factors for oligometastatic versus non-oligometastatic involvement of the central nervous system by brain metastases from breast cancer

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Background: To assess rates of oligometastatic (1-3 metastases) versus non-oligometastatic (4 or more) involvement of the central nervous system (CNS) from breast cancer and determine whether rates vary for different breast cancer subtypes.

Methods: We reviewed records of 65 patients with brain metastases from breast cancer. Fisher’s Exact Test compared incidence of oligometastatic versus nonoligometastatic CNS involvement and presence of visceral metastatic disease between groups. Paired Student's t test compared mean age and interval from initial diagnosis to development of brain metastases.

Results: 25 patients (38.5%) developed oligometastatic and 40 (61.5%) developed non-oligometastatic CNS disease. Subtypes predictive of oligometastatic disease included ER+ (p .04) and PR+ (p .008). Subtypes predictive of non-oligometastatic disease included HER2+ (p .05). HER2+ patients trended toward a lower incidence of visceral metastases compared to ER+ or PR+ patients (p .07). Non-oligometastatic and HER2+ patients developed brain metastases sooner after initial diagnosis (p .046 and .03, respectively).

Conclusions: ER+ breast cancer patients are more likely to develop oligometastatic CNS involvement and may be excellent candidates for stereotactic radiosurgery (SRS) alone. HER+ patients are likely to develop non-oligometastatic CNS involvement and may be better treated initially with whole brain radiotherapy (WBRT) even with apparent initial oligometastatic CNS involvement.

Outcome analysis of trapezectomy with and without pyrocarbon interposition to treat primary arthrosis of the trapeziometacarpal joint

We performed a prospective cohort comparative analysis of simple trapezectomy and trapezectomy with pyrocarbon interposition in 38 consecutive patients with trapeziometacarpal joint osteoarthrosis. Patients were assessed preoperatively, at six and 12 months postoperatively using subjective and objective tools. Subjective assessment was performed using the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire and the visual analogue score. Objective assessment was performed with grip strength measurements. At each time interval, statistical differences were sought between the two subgroups. No significant difference between the two subgroups was noted at any time interval on subjective or objective assessment. A significant difference (p < 0.05) was found on comparing the respective preoperative and 12-month subjective scores in both subgroups. Of the pyrocarbon subgroup seven had related complications. We suggest that pyrocarbon interposition does not significantly improve postoperative function, requires a longer operation with a high postoperative risk of pyrocarbon displacement and need for revision surgery.

Analgesic, anti-inflammatory, antipyretic and toxicological evaluation of some newer 3-methyl pyrazolone derivatives

In this paper, we described the pharmacological and toxicological studies of three pyrazolone derivatives namely PYZ1: 4-[4-N dimethylamino benzylidine]-3-methyl pyrazolin-5(4H)-one, PYZ2: 4-[2-chlorobenzylidine]-3-methylpyrazolin-5(4H)-one and PYZ3: 4-[benzylidine]-3-methylpyrazolin-5(4H)-one derivatives. Analgesic, anti-inflammatory and antipyretic studies of 3-methyl pyrazolone derivatives at 400 mg/kg, p.o. have shown significant activity as compared to control. Amongst three pyrazolone derivatives, PYZ2 was found to be more active. Based on the result of pharmacological studies, PYZ2 was selected for toxicological studies. Acute toxicity studies revealed that methyl pyrazolone derivatives are non-toxic in rats up to 5000 mg/kg, p.o. The subacute toxicity study of PYZ2 showed that decrease in Hb content, RBC and WBC count. In biochemical analysis level of blood glucose and bilirubin reduced where as AST, ALT and alkaline phosphatase level elevated. Histopathological studies revealed that there was mild toxicity on liver and kidney at 1000 mg/kg, p.o.

Generic drug approval: a US perspective

OBJECTIVE

Generic drugs are identical or bioequivalent versions of the brand name drugs. They are the economic alternative of the costlier brand name drugs. This article presents a general overview of the procedure and regulatory aspects relating to generic drug approval in the US.

METHODS

A computerized search was conducted to find literature on generic drug approval in the US. The literature was searched using the following key words: generic drug, brand name drug, Hatch-Waxman Act, Medicare Act, NDA, ANDA, CTD and exclusivity.

FINDINGS

The search results were filtered for the literature describing and analyzing the procedure and regulatory provisions for generic drug approval in the US. After the screening total 19 applicable literature remained.

CONCLUSION

In the US standardized procedures for the recognition of generic drugs have been laid down under the Drug Price Competition and Patent Term Restoration Act, 1984 (the Hatch-Waxman Act). Provisions of this Act such as patent challenge, patent term extension and data exclusivity have created profound effects on the approval, sale and distribution of the pharmaceuticals in the US. The Hatch-Waxman Act is an excellent piece of legislation that takes care of the rights of both the brand name and generic drug companies. This article presents only an overview of generic drug approvals and for all practical purposes official resources should be referred.

304 RHYTHMIC BEATING OF HEART MUSCLE GENERATED FROM GOAT EMBRYONIC STEM CELLS

The aim of the present study was to isolate, culture, and characterise goat embryonic stem cell (ESC)-like cells from in vitro fertilized goat embryos. Oocytes were collected from slaughterhouse goat ovaries, and IVF was performed with standard protocol. A total of 60.48% cleavage, 24.01% morulae, 11.35% blastocyst, and 3.4% hatched blastocyst were obtained. Goat ESC-like cells were isolated from individual blastomere cells of early embryos after 2 mg mL–1 of pronase treatment and inner cell mass (ICM) of blastocyst. The ICM were isolated mechanically from 80 expanded blastocysts and 20 hatched blastocysts and enzymatically from 45 expanded blastocysts and 20 hatched blastocysts. The primary colony formation was obtained mechanically from expanded blastocysts (66%) and hatched blastocysts (90%) and enzymatically from expanded blastocysts (30%) and hatched blastocysts (73%). The ICM were cultured on 10 μg mL–1 of mitomycin-C inactivated fetal fibroblast feeder layer and with leukemia inhibitory factor (LIF) without feeder layer. Embryonic stem cells were cultured and characterised by immunofluorescence of surface markers such as alkaline phosphatase, Oct-4, SSEA-1, SSEA-3, SSEA-4 and intracellular molecular markers Oct-4, Sox2, Nanog. The primary colony formation was significantly higher when hatched blastocysts (90%) were used for ICM than when expanded blastocysts (66%), morulae (15%), and single blastomere (10%) were used. Five goat ESC lines were produced, which were maintained undifferentiated on a feeder layer in ESC medium containing LIF up to 5th, 7th, 10th, 20th, and 22nd passages. Three goat ESC lines were also produced in ESC medium containing LIF without feeder layer and maintained undifferentiated up to 5th, 10th, and 12th passages. All the cell lines expressed alkaline phophatase and OCT-4, at 5th, 10th, 15th, and 20th passages. The ESC of passage 20 were used for embryoid body formation for 3 days. The embryoid bodies were cultured to induce differentiation in medium contain activin-A, fibroblast growth factor-2, and BMP-4. The embryoid bodies were analysed with molecular markers such as Gata, BMP4, and Nestin and were found positive. The cardiac tissues were also observed to be positive with cardiac-specific molecular markers such as α actinin, troponin, and α-myosin heavy chain and its histology. The rhythmic beating was found after 30 days of culture, and the beating was still continuing after 42 days. These goat ESC were cryopreserved into LN2 for a long period of time for further use in the future. It could be concluded that goat ESC were maintained undifferentiated up to 22nd passage with feeder layer and 12th passages without feeder layer using LIF only. Cardiomyocyte rhythmic beating of heart muscle was generated from goat ESC. To the best of our knowledge, this is the first time beating has been observed in goat ESC cardiomyocytes in the world. The authors have not found any report on animals such as cattle, buffalo, sheep, and pig, except mouse, monkey, and human being.

305 CONSTRUCTION OF TRANSCRIPTION FACTOR GENES FOR REPROGRAMMING OF ADULT GOAT FIBROBLAST CELLS FOR PRODUCTION OF INDUCED PLURIPOTENT STEM CELLS

Embryonic stem cells (ESC) are derived from the inner cell mass of blastocysts and proliferate extensively while maintaining pluripotency. They can be used for the treatment of juvenile diabetes, Parkinson’s disease, heart failure, and spinal cord injury. However, the use of embryos and tissue rejection remain concerns for ESC transplantation. Reprogramming of somatic cells may be done by different methods such as somatic cell nuclear transfer (Wilmut et al. 1997), fusion of somatic cells (Cowen et al. 2005), treatment with the extract of the pluripotent stem cells (Johnson Rajasingh 2008), and by the stable ectopic expression of defined factors in the somatic cells (Takahashi and Yamanaka 2006). Several transcription factors, including Oct3/4 (Nichols et al. 1998; Niwa et al. 2000), Sox2 (Avilion et al. 2003), and Nanog (Chambers et al. 2003; Mitsui et al. 2003), function in the maintenance of pluripotency in both early embryos and ESC. Takahashi and Yamanaka reported reprogramming the fibroblast cells into stem cells by introducing Oct3/4, Sox2, c-Myc, and Klf4 in mouse embryonic and adult fibroblasts. Yu et al. (2007) demonstrated that four transcription factors (OCT-4, SOX2, NANOG, and LIN28) are sufficient to reprogramme human somatic cells to pluripotent stem cells that exhibit the essential characteristics of ESC. Nakagawa et al. (2008) used three factors (OCT3/4, SOX2, and KLF4) for human iPS cell production from somatic cells. We are trying to reprogramme the adult goat fibroblast cells in induced pluripotent stem cells by using ectopic expression of transcription factors such as Oct-4, Sox2, Nanog, and Lin28. We collected the ovaries from a slaughtered animal from Delhi and collected the oocytes from ovaries. Then after the collection, A and B grade oocytes were selected. Selected oocytes were processed and incubated in in vitro maturation media for 24 h. We collected semen from a male goat, and it was processed and capacitated in sperm TALP. Capacitated sperms were used for IVF of the in vitro matured oocytes in ferTALP. After 12 h sperm were washed from oocytes in embryo developing media (EDM), and oocytes were cultured (in vitro) in EDM. After 24 h cleavage occurred. The cleaved embryos were cultured for 6 to 7 days. At the 7th day, we got blastocysts. From these blastocysts, inner cell mass was isolated enzymatically and cultured to get ESC. The ESC were cultured for 7 passages and used for RNA isolation. The RNA was isolated from these stem cells by the Trizol method. Complementary DNA was prepared by RT-PCR. Using gene-specific primer for Oct-4, Nanog, and Sox2, DNA was amplified. The DNA for the Oct-4, Nanog, and Sox2 genes was cloned in pJET cloning vector and transformed in Top10 E. coli competence cells. After screening, plasmid was isolated and sent for sequencing. Sequences were analysed and the complete open reading frame was created for Oct-4, Nanog, and Sox2.

Nurse case-manager vs multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study

Few outpatients with fractures are treated for osteoporosis in the years following fracture. In a randomized pilot study, we found a nurse case-manager could double rates of osteoporosis testing and treatment compared with a proven efficacious quality improvement strategy directed at patients and physicians (57% vs 28% rates of appropriate care).

INTRODUCTION

Few patients with fractures are treated for osteoporosis. An intervention directed at wrist fracture patients (education) and physicians (guidelines, reminders) tripled osteoporosis treatment rates compared to controls (22% vs 7% within 6 months of fracture). More effective strategies are needed.

METHODS

We undertook a pilot study that compared a nurse case-manager to the multifaceted intervention using a randomized trial design. The case-manager counseled patients, arranged bone mineral density (BMD) tests, and prescribed treatments. We included controls from our first trial who remained untreated for osteoporosis 1-year post-fracture. Primary outcome was bisphosphonate treatment and secondary outcomes were BMD testing, appropriate care (BMD test-treatment if bone mass low), and costs.

RESULTS

Forty six patients untreated 1-year after wrist fracture were randomized to case-manager (n = 21) or multifaceted intervention (n = 25). Median age was 60 years and 68% were female. Six months post-randomization, 9 (43%) case-managed patients were treated with bisphosphonates compared with 3 (12%) multifaceted intervention patients (relative risk [RR] 3.6, 95% confidence intervals [CI] 1.1-11.5, p = 0.019). Case-managed patients were more likely than multifaceted intervention patients to undergo BMD tests (81% vs 52%, RR 1.6, 95%CI 1.1-2.4, p = 0.042) and receive appropriate care (57% vs 28%, RR 2.0, 95%CI 1.0-4.2, p = 0.048). Case-management cost was $44 (CDN) per patient vs $12 for the multifaceted intervention.

CONCLUSIONS

A nurse case-manager substantially increased rates of appropriate testing and treatment for osteoporosis in patients at high-risk of future fracture when compared with a multifaceted quality improvement intervention aimed at patients and physicians. Even with case-management, nearly half of patients did not receive appropriate care.

TRIAL REGISTRY

clinicaltrials.gov identifier: NCT00152321.

Glycaemic variability is associated with coronary artery calcium in men with Type 1 diabetes: the Coronary Artery Calcification in Type 1 Diabetes study

AIMS

We investigated coronary artery calcium in association with glucose levels and variability measured using continuous glucose monitoring in adults with Type 1 diabetes in the Coronary Artery Calcification in Type 1 Diabetes study.

METHODS

Coronary artery calcium was measured by electron beam tomography. The presence of any coronary artery calcium was analysed with respect to glucose levels [mean(T) (mean glucose), % of values < 3.9 mmol/l, > 10 mmol/l and either < 3.9 or > 10 mmol/l] and glycaemic variability [sd(T) (sd of all glucose values); sd(dm) (sd of the daily mean glucose levels) and sd(hh:mm) (glucose sd for a specified time of day, over all days)] using 3-5 days of continuous glucose monitoring from 75 subjects (45 women, 30 men), age 42 ± 9 years (mean ± sd) and diabetes duration of 29 ± 8 years using logistic regression.

RESULTS

We observed significant associations between coronary artery calcium and mean(T) (OR = 4.4, 95% CI 1.1-18.6), % of values > 10 mmol/l (OR = 5.5, 95% CI 1.3-22.6), % of measures < 3.9 or > 10 mmol/l (OR = 5.7, 95% CI 1.3-24.9), sd(T) (OR = 4.7, 95% CI 1.1-19.7), sd(dm) (OR = 6.0, 95% CI 1.2-30.4) and sd(hh:mm) (OR = 4.0, 95% CI 1.1-15.4), among men, but none of these variables were associated with the presence of coronary artery calcium in women.

CONCLUSIONS

We report the novel finding that subclinical atherosclerosis is associated with glucose levels and variability in men with Type 1 diabetes. The relationship of coronary artery calcium and glucose variability in Type 1 diabetes, and potential gender differences in this association, deserve further study.

Maintenance of clinical benefit in Crohn's disease patients after discontinuation of infliximab: long-term follow-up of a single centre cohort

BACKGROUND

Tumour necrosis factor-blockade with infliximab has advanced the treatment of Crohn's disease. While infliximab is efficacious, it remains to be determined whether patients who enter clinical remission with an anti-tumour necrosis factor therapy can have their treatment stopped and retain the state of remission.

AIM

To assess in patients with Crohn's disease who obtained infliximab-induced remission, the proportion who relapsed after infliximab discontinuation.

METHODS

This longitudinal cohort study examined patients from a University-based IBD referral centre. Forty eight patients with Crohn's disease in full clinical remission and who then discontinued infliximab were followed up for up to 7 years. Crohn's disease relapse was defined as an intervention with Crohn's disease medication or surgery.

RESULTS

Kaplan-Meier analysis of the proportion of patients with sustained clinical benefit demonstrated that 50% relapsed within 477 days after infliximab discontinuance. In contrast, 35% of patients remained well, and without clinical relapse, up to the end of the nearly 7-year follow-up.

CONCLUSIONS

In patients with Crohn's disease with an infliximab-induced remission, stopping infliximab results in a predictable relapse in a majority of patients. Nevertheless, a small percentage of patients sustain a long-term remission.