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Haghparast-Bidgoli H, Harris-Fry H, Kumar A, Pradhan R, Mishra NK, Padhan S, Ojha AK, Mishra SN, Fivian E, James P, Ferguson S, Krishnan S, O'Hearn M, Palmer T, Koniz-Booher P, Danton H, Minovi S, Mohanty S, Rath S, Rath S, Nair N, Tripathy P, Prost A, Allen E, Skordis J, Kadiyala S. Economic Evaluation of Nutrition-Sensitive Agricultural Interventions to Increase Maternal and Child Dietary Diversity and Nutritional Status in Rural Odisha, India. J Nutr 2022; 152:2255-2268. [PMID: 35687367 PMCID: PMC9535442 DOI: 10.1093/jn/nxac132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/01/2021] [Accepted: 06/04/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Economic evaluations of nutrition-sensitive agriculture (NSA) interventions are scarce, limiting assessment of their potential affordability and scalability. OBJECTIVES We conducted cost-consequence analyses of 3 participatory video-based interventions of fortnightly women's group meetings using the following platforms: 1) NSA videos; 2) NSA and nutrition-specific videos; or 3) NSA videos with a nutrition-specific participatory learning and action (PLA) cycle. METHODS Interventions were tested in a 32-mo, 4-arm cluster-randomized controlled trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) in the Keonjhar district, Odisha, India. Impacts were evaluated in children aged 0-23 mo and their mothers. We estimated program costs using data collected prospectively from expenditure records of implementing and technical partners and societal costs using expenditure assessment data collected from households with a child aged 0-23 mo and key informant interviews. Costs were adjusted for inflation, discounted, and converted to 2019 US$. RESULTS Total program costs of each intervention ranged from US$272,121 to US$386,907. Program costs per pregnant woman or mother of a child aged 0-23 mo were US$62 for NSA videos, US$84 for NSA and nutrition-specific videos, and US$78 for NSA videos with PLA (societal costs: US$125, US$143, and US$122, respectively). Substantial shares of total costs were attributable to development and delivery of the videos and PLA (52-69%) and quality assurance (25-41%). Relative to control, minimum dietary diversity was higher in the children who underwent the interventions incorporating nutrition-specific videos and PLA (adjusted RRs: 1.19 and 1.27; 95% CIs: 1.03-1.37 and 1.11, 1.46, respectively). Relative to control, minimum dietary diversity in mothers was higher in those who underwent NSA video (1.21 [1.01, 1.45]) and NSA with PLA (1.30 [1.10, 1.53]) interventions. CONCLUSION NSA videos with PLA can increase both maternal and child dietary diversity and have the lowest cost per unit increase in diet diversity. Building on investments made in developing UPAVAN, cost-efficiency at scale could be increased with less intensive monitoring, reduced startup costs, and integration within existing government programs. This trial was registered at clinicaltrials.gov as ISRCTN65922679.
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Affiliation(s)
| | - Helen Harris-Fry
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Naba Kishore Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapada, Odisha, India
| | - Shibananth Padhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapada, Odisha, India
| | | | - Sailendra Narayan Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapada, Odisha, India
| | - Emily Fivian
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Philip James
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Sneha Krishnan
- Jindal School of Environment and Sustainability, OP Jindal Global University and ETCH Consultancy Services, Mumbai, Maharashtra, India
| | - Meghan O'Hearn
- Tufts University Friedman School of Nutrition Science and Policy, Boston, MA, USA
| | - Tom Palmer
- University College London, Institute for Global Health, London, United Kingdom
| | | | - Heather Danton
- SI Research & Training Institute, Inc. Arlington, VA, USA
| | - Sandee Minovi
- SI Research & Training Institute, Inc. Arlington, VA, USA
| | | | | | | | | | | | - Audrey Prost
- University College London, Institute for Global Health, London, United Kingdom
| | - Elizabeth Allen
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jolene Skordis
- University College London, Institute for Global Health, London, United Kingdom
| | - Suneetha Kadiyala
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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Pulkki-Brännström AM, Haghparast-Bidgoli H, Batura N, Colbourn T, Azad K, Banda F, Banda L, Borghi J, Fottrell E, Kim S, Makwenda C, Ojha AK, Prost A, Rosato M, Shaha SK, Sinha R, Costello A, Skordis J. Participatory learning and action cycles with women's groups to prevent neonatal death in low-resource settings: A multi-country comparison of cost-effectiveness and affordability. Health Policy Plan 2021; 35:1280-1289. [PMID: 33085753 PMCID: PMC7886438 DOI: 10.1093/heapol/czaa081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 11/14/2022] Open
Abstract
WHO recommends participatory learning and action cycles with women's groups as a cost-effective strategy to reduce neonatal deaths. Coverage is a determinant of intervention effectiveness, but little is known about why cost-effectiveness estimates vary significantly. This article reanalyses primary cost data from six trials in India, Nepal, Bangladesh and Malawi to describe resource use, explore reasons for differences in costs and cost-effectiveness ratios, and model the cost of scale-up. Primary cost data were collated, and costing methods harmonized. Effectiveness was extracted from a meta-analysis and converted to neonatal life-years saved. Cost-effectiveness ratios were calculated from the provider perspective compared with current practice. Associations between unit costs and cost-effectiveness ratios with coverage, scale and intensity were explored. Scale-up costs and outcomes were modelled using local unit costs and the meta-analysis effect estimate for neonatal mortality. Results were expressed in 2016 international dollars. The average cost was $203 (range: $61-$537) per live birth. Start-up costs were large, and spending on staff was the main cost component. The cost per neonatal life-year saved ranged from $135 to $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women's groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations.
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Affiliation(s)
- Anni-Maria Pulkki-Brännström
- Department of Epidemiology and Global Health, Umeå University, Umeå S-901 87, Sweden.,UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Hassan Haghparast-Bidgoli
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Neha Batura
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Tim Colbourn
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Kishwar Azad
- Perinatal Care Project, Diabetic Association of Bangladesh, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh
| | | | - Lumbani Banda
- Parent and Child Health Initiative (PACHI), Area 14 Plot 171, Lilongwe, Malawi
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Edward Fottrell
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Sungwook Kim
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Charles Makwenda
- Parent and Child Health Initiative (PACHI), Area 14 Plot 171, Lilongwe, Malawi
| | - Amit Kumar Ojha
- Ekjut, Plot no. - 556B, Potka Chakradharpur, West Singhbhum, Pin - 833102, Jharkhand, India
| | - Audrey Prost
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Mikey Rosato
- Women and Children First (UK), United House, North Road, London, N7 9DP, UK
| | - Sanjit Kumer Shaha
- Perinatal Care Project, Diabetic Association of Bangladesh, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh
| | - Rajesh Sinha
- Ekjut, Plot no. - 556B, Potka Chakradharpur, West Singhbhum, Pin - 833102, Jharkhand, India
| | - Anthony Costello
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Jolene Skordis
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
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Pulkki-Brännström AM, Haghparast-Bidgoli H, Batura N, Colbourn T, Azad K, Banda F, Banda L, Borghi J, Fottrell E, Kim S, Makwenda C, Ojha AK, Prost A, Rosato M, Shaha SK, Sinha R, Costello A, Skordis J. Participatory learning and action cycles with women's groups to prevent neonatal death in low-resource settings: A multi-country comparison of cost-effectiveness and affordability. Health Policy Plan 2020; 36:226. [PMID: 33355346 PMCID: PMC7996644 DOI: 10.1093/heapol/czaa164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Haghparast-Bidgoli H, Skordis J, Harris-Fry H, Krishnan S, O'Hearn M, Kumar A, Pradhan R, Mishra NK, Upadhyay A, Pradhan S, Ojha AK, Cunningham S, Rath S, Palmer T, Koniz-Booher P, Kadiyala S. Protocol for the cost-consequence and equity impact analyses of a cluster randomised controlled trial comparing three variants of a nutrition-sensitive agricultural extension intervention to improve maternal and child dietary diversity and nutritional status in rural Odisha, India (UPAVAN trial). Trials 2019; 20:287. [PMID: 31133067 PMCID: PMC6537168 DOI: 10.1186/s13063-019-3388-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 05/02/2019] [Indexed: 11/18/2022] Open
Abstract
Background Undernutrition causes around 3.1 million child deaths annually, around 45% of all child deaths. India has one of the highest proportions of maternal and child undernutrition globally. To accelerate reductions in undernutrition, nutrition-specific interventions need to be coupled with nutrition-sensitive programmes that tackle the underlying causes of undernutrition. This paper describes the planned economic evaluation of the UPAVAN trial, a four-arm, cluster randomised controlled trial that tests the nutritional and agricultural impacts of an innovative agriculture extension platform of women’s groups viewing videos on nutrition-sensitive agriculture practices, coupled with a nutrition-specific behaviour-change intervention of videos on nutrition, and a participatory learning and action approach. Methods The economic evaluation of the UPAVAN interventions will be conducted from a societal perspective, taking into account all costs incurred by the implementing agency (programme costs), community and health care providers, and participants and their households, and all measurable outcomes associated with the interventions. All direct and indirect costs, including time costs and donated goods, will be estimated. The economic evaluation will take the form of a cost-consequence analysis, comparing incremental costs and incremental changes in the outcomes of the interventions, compared with the status quo. Robustness of the results will be assessed through a series of sensitivity analyses. In addition, an analysis of the equity impact of the interventions will be conducted. Discussion Evidence on the cost and cost-effectiveness of nutrition-sensitive agriculture interventions is scarce. This limits understanding of the costs of rolling out or scaling up programs. The findings of this economic evaluation will provide useful information for different multisectoral stakeholders involved in the planning and implementation of nutrition-sensitive agriculture programmes. Trial registration ISRCTN65922679. Registered on 21 December 2016 Electronic supplementary material The online version of this article (10.1186/s13063-019-3388-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Jolene Skordis
- University College London, Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Helen Harris-Fry
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT,, UK
| | - Sneha Krishnan
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT,, UK
| | - Meghan O'Hearn
- Tufts University, Friedman School of Nutrition Science and Policy, 150 Harrison Avenue, Boston, MA, 02111, USA
| | - Abhinav Kumar
- Digital Green, S-26 to 28, 3rd Floor, Green Park Extension Market, New Delhi, 110016, India
| | - Ronali Pradhan
- Digital Green, S-26 to 28, 3rd Floor, Green Park Extension Market, New Delhi, 110016, India
| | - Naba Kishore Mishra
- VARRAT (Voluntary Association for Rural Reconstruction and Appropriate Technology), Boulakani Baradang, Mahakalpara Kendrapad, Odisha, 754224, India
| | - Avinash Upadhyay
- Digital Green, S-26 to 28, 3rd Floor, Green Park Extension Market, New Delhi, 110016, India
| | - Shibananth Pradhan
- VARRAT (Voluntary Association for Rural Reconstruction and Appropriate Technology), Boulakani Baradang, Mahakalpara Kendrapad, Odisha, 754224, India
| | - Amit Kumar Ojha
- Ekjut, 556 B-Ward No 17-Potka, Chakradharpur, Jharkhand, 833102, India
| | - Sarah Cunningham
- Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115,, USA
| | - Shibanand Rath
- Ekjut, 556 B-Ward No 17-Potka, Chakradharpur, Jharkhand, 833102, India
| | - Tom Palmer
- University College London, Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Peggy Koniz-Booher
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, JSI Research and Training Institute, Inc., 1616 Fort Myer Drive 16th Floor, Arlington, VA, 22209, USA
| | - Suneetha Kadiyala
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT,, UK
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Skordis-Worrall J, Sinha R, Kumar Ojha A, Sarangi S, Nair N, Tripathy P, Sachdev HS, Bhattacharyya S, Gope R, Rath S, Rath S, Srivastava A, Batura N, Pulkki-Brännström AM, Costello A, Copas A, Saville N, Prost A, Haghparast-Bidgoli H. Protocol for the economic evaluation of a community-based intervention to improve growth among children under two in rural India (CARING trial). BMJ Open 2016; 6:e012046. [PMID: 27807084 PMCID: PMC5128945 DOI: 10.1136/bmjopen-2016-012046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Undernutrition affects ∼165 million children globally and contributes up to 45% of all child deaths. India has the highest proportion of global undernutrition-related morbidity and mortality. This protocol describes the planned economic evaluation of a community-based intervention to improve growth in children under 2 years of age in two rural districts of eastern India. The intervention is being evaluated through a cluster-randomised controlled trial (cRCT, the CARING trial). METHODS AND ANALYSIS A cost-effectiveness and cost-utility analysis nested within a cRCT will be conducted from a societal perspective, measuring programme, provider, household and societal costs. Programme costs will be collected prospectively from project accounts using a standardised tool. These will be supplemented with time sheets and key informant interviews to inform the allocation of joint costs. Direct and indirect costs incurred by providers will be collected using key informant interviews and time use surveys. Direct and indirect household costs will be collected prospectively, using time use and consumption surveys. Incremental cost-effectiveness ratios (ICERs) will be calculated for the primary outcome measure, that is, cases of stunting prevented, and other outcomes such as cases of wasting prevented, cases of infant mortality averted, life years saved and disability-adjusted life years (DALYs) averted. Sensitivity analyses will be conducted to assess the robustness of results. ETHICS AND DISSEMINATION There is a shortage of robust evidence regarding the cost-effectiveness of strategies to improve early child growth. As this economic evaluation is nested within a large scale, cRCT, it will contribute to understanding the fiscal space for investment in early child growth, and the relative (in)efficiency of prioritising resources to this intervention over others to prevent stunting in this and other comparable contexts. The protocol has all necessary ethical approvals and the findings will be disseminated within academia and the wider policy sphere. TRIAL REGISTRATION NUMBER ISRCTN51505201; pre-results.
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Affiliation(s)
| | | | | | | | | | | | - H S Sachdev
- Sitaram Bhartia Institute of Science and Research, New Delhi, India
| | | | | | | | | | | | - Neha Batura
- University College London, Institute for Global Health, London, UK
| | - Anni-Maria Pulkki-Brännström
- University College London, Institute for Global Health, London, UK
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Anthony Costello
- University College London, Institute for Global Health, London, UK
| | - Andrew Copas
- Department of Infection and Population Health, University College London, London, UK
| | - Naomi Saville
- University College London, Institute for Global Health, London, UK
| | - Audrey Prost
- University College London, Institute for Global Health, London, UK
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Luk AO, Li X, Zhang Y, Guo X, Jia W, Li W, Weng J, Yang W, Chan WB, Ozaki R, Tsang CC, Mukhopadhyay M, Ojha AK, Hong EG, Yoon KH, Sobrepena L, Toledo RM, Duran M, Sheu W, Q Do T, Nguyen TK, Ma RC, Kong AP, Chow CC, Tong PC, So WY, Chan JC. Quality of care in patients with diabetic kidney disease in Asia: The Joint Asia Diabetes Evaluation (JADE) Registry. Diabet Med 2016; 33:1230-9. [PMID: 26511783 DOI: 10.1111/dme.13014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2015] [Indexed: 12/18/2022]
Abstract
AIMS Diabetic kidney disease independently predicts cardiovascular disease and premature death. We examined the burden of chronic kidney disease (CKD, defined as an estimated GFR < 60 ml/min/1.73 m(2) ) and quality of care in a cross-sectional survey of adults (age ≥ 18 years) with Type 2 diabetes across Asia. METHODS The Joint Asia Diabetes Evaluation programme is a disease-management programme implemented using an electronic portal that systematically captures clinical characteristics of all patients enrolled. Between July 2007 and December 2012, data on 28 110 consecutively enrolled patients (China: 3415, Hong Kong: 15 196, India: 3714, Korea: 1651, Philippines: 3364, Vietnam: 692, Taiwan: 78) were analysed. RESULTS In this survey, 15.9% of patients had CKD, 25.0% had microalbuminuria and 12.5% had macroalbuminuria. Patients with CKD were less likely to achieve HbA1c < 53 mmol/mol (7.0%) (36.0% vs. 42.3%) and blood pressure < 130/80 mmHg (20.8% vs. 35.3%), and were more likely to have retinopathy (26.2% vs. 8.7%), sensory neuropathy (29.0% vs. 7.7%), cardiovascular disease (26.6% vs. 8.7%) and self-reported hypoglycaemia (18.9% vs. 8.2%). Despite high frequencies of albuminuria (74.8%) and dyslipidaemia (93.0%) among CKD patients, only 49.0% were using renin-angiotensin system inhibitors and 53.6% were on statins. On logistic regression, old age, male gender, tobacco use, long disease duration, high HbA1c , blood pressure and BMI, and low LDL cholesterol were independently associated with CKD (all P < 0.05). CONCLUSIONS The poor control of risk factors, suboptimal use of organ-protective drugs and high frequencies of hypoglycaemia highlight major treatment gaps in patients with diabetic kidney disease in Asia.
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Affiliation(s)
- A O Luk
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - X Li
- Asia Diabetes Foundation, Prince of Wales Hospital, Hong Kong SAR, China
| | - Y Zhang
- Asia Diabetes Foundation, Prince of Wales Hospital, Hong Kong SAR, China
| | - X Guo
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - W Jia
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - W Li
- Peking Union Medical College Hospital, Beijing, China
| | - J Weng
- The Third Affiliated Hospital of Sun Yat-Sen University, Guangdong, Beijing, China
| | - W Yang
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - W B Chan
- Qualigenics Diabetes Centre, Hong Kong SAR, China
| | - R Ozaki
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - C C Tsang
- Alice Ho Nethersole Hospital, Hong Kong SAR, China
| | | | | | - E G Hong
- Hallym University College of Medicine, Gangwon-do, Korea
| | - K H Yoon
- The Catholic University of Korea, Seocho-gu, Korea
| | - L Sobrepena
- Heart of Jesus Hospital, San Jose City, Philippines
| | - R M Toledo
- Senor Sto. Nino Hospital, Tarlac, Philippines
| | - M Duran
- New Bilibid Prison Hospital, Bureau of Corrections, Muntinlupa, Philippines
| | - W Sheu
- Taichung Veterans General Hospital, Taichung, Taiwan
| | - T Q Do
- Bach Mai Hospital, Hanoi, Vietnam
| | - T K Nguyen
- HCMC University of Pharmaceutical and Medicine, Ho Chi Minh City, Vietnam
| | - R C Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - A P Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - C C Chow
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - P C Tong
- Qualigenics Diabetes Centre, Hong Kong SAR, China
| | - W Y So
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - J C Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Asia Diabetes Foundation, Prince of Wales Hospital, Hong Kong SAR, China
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Affiliation(s)
- Shashi Gandhi
- Department of Microbiology, G. R. Medical College, Gwalior, India E-mail:
| | - A K Ojha
- Department of Medicine, G. R. Medical College, Gwalior, India
| | - K P Ranjan
- Department of Microbiology, G. R. Medical College, Gwalior, India E-mail:
| | - Neelima
- Department of Microbiology, G. R. Medical College, Gwalior, India E-mail:
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Abstract
OBJECTIVES To evaluate the role of pentoxifylline as an adjuvant to operation and routine antibiotic treatment for perforated peritonitis. DESIGN Randomised controlled clinical trial. SETTINGS University hospital, India. SUBJECTS 36 patients with clinically diagnosed and radiologically confirmed perforated peritonitis. 22 (61%) had typhoid enteric perforations, 11 (31%) had duodenal ulcer perforations while 3 (8%) had perforated gastric ulcers. INTERVENTION Laparotomy with closure of perforation and lavage together with routine antibiotic treatment (ciprofloxacin and metronidazole), and random allocation to pentoxifylline 200 mg/day for 3 days in 500 ml of saline over 3-4 hours or saline alone (n = 18 in each group). MAIN OUTCOME MEASURES Hospital stay, APACHE II scores, and the condition of the wound during the postoperative period. RESULTS The baseline characteristics of the two groups were essentially similar. However, their preoperative APACHE II scores differed significantly (mean (SD) 12 (3) in the pentoxifylline group compared with 10 (2) in the saline group; p <0.01). The outcome was better in the pentoxifylline group in terms of significantly reduced hospital stay (median 8, range 6-17, compared with 11, 7-27, p=0.02) improved postoperative APACHE II scores (mean (SD) 8 (2) compared with 9 (2), p=0.02), and reduced incidence of wound infection (6/18 compared with 12/18, p=0.02). CONCLUSION The addition of pentoxifylline to our standard management protocol for patients with perforated peritonitis helped to improve their outcome significantly compared with a placebo-treated group.
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Affiliation(s)
- V K Shukla
- Department of Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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Abstract
Microbial adaptation to environmental stress plays an important role in survival. It is necessary to understand the mechanisms underlying the survival of microbes under stress, as they may eventually aid in the successful control of the growth and persistence of these organisms. During nutrient starvation, Escherichia coli elicits a stringent response to conserve energy. The hallmark of the stringent response is the accumulation of guanosine tetra- (ppGpp) and pentaphosphates (pppGpp), which probably bind RNA polymerase to regulate gene expression at certain promoters. Recently, there has been renewed interest in the stringent responses of other microbes, with a view to correlating it with sporulation, virulence and long-term persistence.
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Affiliation(s)
- D Chatterji
- Molecular Biophysics Unit, Indian Institute of Science, 560012, Bangalore, India.
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Ojha AK, Mukherjee TK, Chatterji D. High intracellular level of guanosine tetraphosphate in Mycobacterium smegmatis changes the morphology of the bacterium. Infect Immun 2000; 68:4084-91. [PMID: 10858225 PMCID: PMC101700 DOI: 10.1128/iai.68.7.4084-4091.2000] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/1999] [Accepted: 03/30/2000] [Indexed: 11/20/2022] Open
Abstract
Almost one-third of the world population today harbors the tubercle bacillus asymptomatically. It is postulated that the morphology and staining pattern of the long-term persistors are different from those of actively growing culture. Interestingly, it has been found that the morphology and staining pattern of the starved in vitro population of mycobacteria is similar to the persistors obtained from the lung lesions. In order to delineate the biochemical characteristics of starved mycobacteria, Mycobacteria smegmatis was grown in 0.2% glucose as a sole carbon source along with an enriched culture in 2% glucose. Accumulation of the stringent factor guanosine tetraphosphate (ppGpp) with a concomitant change in morphology was observed for M. smegmatis under carbon-deprived conditions. In addition, M. smegmatis assumed a coccoid morphology when ppGpp was ectopically produced by overexpressing Escherichia coli relA, even in an enriched medium. The Mycobacterium tuberculosis relA and spoT homologue, when induced in M. smegmatis, also resulted in the overproduction of ppGpp with a change in the bacterium's growth characteristics.
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Affiliation(s)
- A K Ojha
- Centre for Cellular and Molecular Biology, Hyderabad, 500007, India
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