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Haya Yasin,1,2 Subish Palaian,3,4 Pathiyil Ravi Shankar,5 Sridevi Nallamilli6 1Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates; 2Discipline of Pharmaceutical Sciences, School of Pharmaceutical Sciences, University Sains Malaysia, Penang, Malaysia; 3Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates; 4Center of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates; 5IMU Centre for Education, International Medical University, Kuala Lumpur, Malaysia; 6Department of Obstetrics and Gynecology, College of Medical Sciences, Bharatpur, Bagmati Province, NepalCorrespondence: Haya Yasin, Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates, Tel +971557176919, Email Haya.yasin@gmail.com Subish Palaian, Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates, Tel +971551322957, Email subishpalaian@gmail.comIntroduction: Inter-Professional Education (IPE) is an educational engagement between students from two or more professions possibly leading to better collaboration among them in the future workplace. Several organizations have advocated, developed, and updated guidelines for IPE.Objective: This study was aimed at assessing the medical, dental, and pharmacy students’ readiness toward interprofessional education (IPE), and to identify the association between readiness and the demographic profile of students in a university in the United Arab Emirates (UAE).Methods: A cross-sectional questionnaire-based exploratory study involving 215 medical, dental, and pharmacy students at Ajman University, UAE, using convenience sampling. The survey questionnaire (Readiness for Interprofessional Learning Scale, RIPLS) had a total of 19 statements. The first 9 items were related to “teamwork and collaboration”, items 10– 16 were related to “professional identity”, and the remaining three (items 17– 19) were related to “roles and responsibilities”. The individual statements’ median (IQR) scores were calculated and the total scores were compared with the demographic characteristics of the respondents with suitable non-parametric tests at alpha=0.05.Results: Altogether, 215 undergraduate students (medical (n= 35)), pharmacy (n=105), and dental (n=75) responded to the survey. The median (IQR) score for the 19 individual statements was ‘ 5 (4– 5)’ for 12 of the statements. The total scores and domain-specific scores (teamwork and collaboration, professional identity, and roles and responsibilities) according to respondents’ demography showed significant differences only in the case of the educational stream with professional identity score (p=< 0.001), and the total RIPLS score (p=0.024). Further, post hoc pairwise comparison showed a significant difference between medicine-pharmacy (p< 0.001), and dentistry-medicine (p=0.009), for professional identity, and medicine-pharmacy (p=0.020) for the total RIPLS score.Conclusion: A high readiness score among students offers the possibility of conducting IPE modules. A favorable attitude can be considered by curriculum planners while initiating IPE sessions.Keywords: dental, interprofessional education, medical, pharmacy, teamwork, United Arab Emirates

Nisha Jha,1 Pathiyil Ravi Shankar,2 Mohammed Azmi Al-Betar,3 Rupesh Mukhia,4 Kabita Hada,5 Subish Palaian6,7 1Department of Clinical Pharmacology and Therapeutics, KIST Medical College and Teaching Hospital, Lalitpur, Bagmati, Nepal; 2IMU Centre for Education, International Medical University, Kuala Lumpur, Kuala Lumpur Federal Territory, Malaysia; 3Artificial Intelligence Research Center (AIRC), College of Engineering and Information Technology, Ajman University, Ajman, United Arab Emirates; 4Department of Surgery, KIST Medical College, Lalitpur, Bagmati, Nepal; 5Department of General Practice and Emergency Medicine, KIST Medical College, Lalitpur, Bagmati, Nepal; 6Department of Clinical Sciences, College of Pharmacy and Health Sciences Ajman University, Ajman, United Arab Emirates; 7Center of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab EmiratesCorrespondence: Nisha Jha, Department of Clinical Pharmacology and Therapeutics, KIST Medical College and Teaching Hospital, Lalitpur, Bagmati, Nepal, Tel +977 9841602808, Email nishajha32@gmail.com Subish Palaian, Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates, Tel +971 551322957, Email subishpalaian@gmail.comPurpose: Artificial intelligence (AI) is playing an increasingly important role in healthcare and health professions education. This study explored medical students’ and interns’ knowledge of artificial intelligence (AI), perceptions of the role of AI in medicine, and preferences around the teaching of AI competencies.Methods: In this cross-sectional study, the authors used a previously validated Canadian questionnaire and gathered responses from students and interns at KIST Medical College, Nepal. Face validity and reliability of the tool were assessed by administering the questionnaire to 20 alumni as a pilot sample (Cronbach alpha = 0.6). Survey results were analyzed quantitatively (p-value = 0.05).Results: In total 216 students (37% response rate) participated. The median AI knowledge score was 11 (interquartile range 4), and the maximum possible score was 25. The score was higher among final year students (p = 0.006) and among those with additional training in AI (p = 0.040). Over 49% strongly agreed or agreed that AI will reduce the number of jobs for doctors. Many expect AI to impact their specialty choice, felt the Nepalese health-care system is ill-equipped to deal with the challenges of AI, and opined every student of medicine should receive training on AI competencies.Conclusion: The lack of coverage of AI and machine learning in Nepalese medical schools has resulted in students being unaware of AI’s impact on individual patients and the healthcare system. A high perceived willingness among respondents to learn about AI is a positive sign and a strong indicator of futuristic successful curricula changes. Systematic implementation of AI in the Nepalese healthcare system can be a potential tool in addressing health-care challenges related to resource and manpower constraints. Incorporating topics related to AI and machine learning in medical curricula can be a useful first step.Keywords: artificial intelligence, healthcare, machine learning, medical students, Nepal

Nisha Jha,1 Subish Palaian,2,3 Pathiyil Ravi Shankar,4 Sijan Poudyal5 1Department of Pharmacology, KIST Medical College, Lalitpur, Bagmati, Nepal; 2Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates; 3Center of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates; 4IMU Centre for Education, International Medical University, Kuala Lumpur, Malaysia; 5Department of Community Dentistry, KIST Medical College, Lalitpur, Bagmati, NepalCorrespondence: Nisha Jha, Department of Clinical Pharmacology and Therapeutics, KIST Medical College, Imadol, Lalitpur, Bagmati, Nepal, Tel +977 9841 602 808, Email nishajha32@gmail.com Subish Palaian, Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates, Email subishpalaian@gmail.comIntroduction: Health professional education curricula in Nepal do not include interprofessional education (IPE). Though a previous study conducted in Nepal identified positive attitudes among medical and nursing students, so far there are no studies assessing the health professional students’ readiness toward IPE. The aim of the study was to assess the readiness for IPE among medical and dental students.Methods: The present cross-sectional study explored the readiness of conveniently selected first-year medical and dental students towards IPE and compared readiness among subgroups of respondents. The readiness was assessed through an online survey using the standard Readiness for Interprofessional Learning Scale (RIPLS) during June 2021. The nineteen questions in RIPLS were categorized under four domains: teamwork and collaboration (items 1– 9), negative professional identity (items 10– 12), positive professional identity (items 13– 16), and roles and responsibilities (items 17– 19). The individual statements were scored and assessed as per the study objectives. The scores were not normally distributed, so non-parametric tests (Mann–Whitney U-test and Kruskal Wallis test) were used.Results: A total of 83 students (69 medical and 14 dental) students responded. The median total score was 75, IQR 6 with the maximum score being 95. The median (IQR) scores for the domains teamwork and collaboration were 38 (IQR 3), negative professional identity 11 (IQR 2), positive professional identity 16 (IQR 3), roles and responsibilities 10 (3). The scores were different between students aged 20 years and below = 37, and above 20 years = 38; (p =< 0.001) in the negative professional identity domain and the total score (p = 0.001). The scores were also different among those with and without previous learning exposure with other discipline students in the same class (p = 0.046). A high median score of 5 was achieved for 8 out of 19 statements in the questionnaire.Conclusion: The findings showed a high level of readiness for IPE among student respondents. Study findings can be considered as a positive factor for implementing IPE sessions.Keywords: dental, interprofessional education, medical, Nepal, undergraduate students

Sabita Paudel,1 Subish Palaian,2,3 Pathiyil Ravi Shankar,4 Nuwadatta Subedi5 1Department of Pharmacology, Gandaki Medical College, Pokhara, Gandaki, Nepal; 2Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates; 3Center of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates; 4IMU Center for Education, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia; 5Department of Forensic Medicine, Gandaki Medical College, Pokhara, Gandaki, NepalCorrespondence: Sabita PaudelGandaki Medical College, Rithepani, Pokhara, Gandaki, NepalTel +977 61 538595, 550253, 534657Fax +977 61 550254Email drsabitapaudel@gmail.comPurpose: The study was conducted to explore the perception of healthcare workers and staff towards the risk of COVID-19 vaccination and to study vaccine hesitancy amongst them.Methods: A total of 266 healthcare workers working in a medical college in Nepal were studied using a questionnaire consisting of three sections: demographics, experiences and perception of COVID-19, and COVID-19 vaccine safety. Data were analyzed using IBM SPSS version 26. The total perception score was calculated by noting respondent’s agreement with a set of eleven statements using a Likert-type scale. Non-parametric tests (Mann–Whitney U and Kruskal–Wallis) were used for analysis (p< 0.05).Results: Altogether, 13.9% of respondents had been diagnosed COVID-19 positive prior to the survey. Many considered themselves to be at increased risk of contracting COVID-19. Only over one third (38.3%) were willing to be vaccinated. The most common reason for refusal/hesitancy was concern about vaccine safety. The median (interquartile range) total perception score was 36 (4) (maximum possible score=55). The score was significantly higher among those who had been diagnosed COVID positive, those who perceived the pandemic as being moderate or severe and among those willing to be vaccinatedConclusion: Addressing doubts related to vaccine safety and providing more data on the safety of vaccine may be helpful in overcoming hesitancy.Keywords: knowledge score, nonparametric tests, staff, questionnaire

Nisha Jha,1 Pathiyil Ravi Shankar,2 Subish Palaian3 1Department of Clinical Pharmacology and Therapeutics, KIST Medical College, Lalitpur, Nepal; 2IMU Centre for Education, International Medical University, Kuala Lumpur, Malaysia; 3Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab EmiratesCorrespondence: Nisha JhaDepartment of Clinical Pharmacology and Therapeutics, KIST Medical College, Lalitpur, NepalTel +977-9841602808Email nishajha32@gmail.comBackground: Medicines may remain unused and often get expired. Unused medicines can promote self-medication. Unsafe and improper medicine disposal can cause significant environmental harm. Medical and dental students as future prescribers should be aware of the safe disposal of medicines, ecopharmacovigilance and self-medication. The present study examines knowledge and practice about unused and expired medicines and medicine disposal among undergraduate medical and dental students in Nepal.Methods: The study was conducted during September 2020 using an online survey form. First to final year undergraduate students provided their consent and signed an integrity pledge electronically. Age, gender, program of study, year of study, whether staying with family or not, method of financing education, and whether they had used any allopathic medicines during the past 6 months were noted. The total knowledge score among different subgroups was compared. The frequency of responses regarding practice items and the free-text comments were also listed. Statistical analysis was performed using Mann–Whitney test and Kruskal–Wallis test.Results: Altogether 441 of the 668 students (66%) participated. The majority were below 23 years and female. Over 65% had used allopathic medicines during the last 6 months. The median knowledge score was 8 (maximum 10) and was significantly higher among older respondents, females and students in later years of study. Most kept unused medicines at home/hostel till expiry which were disposed of in the household garbage. Over 40% had educated their family members about safe medicine disposal. Knowledge scores were significantly different among subgroups according to respondents’ age, gender and year of study.Conclusion: Respondents were aware of expiry of medicines and knew methods to safely dispose expired medicines. However, they practiced self-medication, stored medications at home and did not practice the safe disposal of medications. Understanding why respondents did not dispose medicines properly is important.Keywords: dental students, ecopharmacovigilance, medicine disposal, medical students, Nepal

Sunil Shrestha,1,2 Asmita Priyadarshini Khatiwada,2 Sudesh Gyawali,3 P Ravi Shankar,4 Subish Palaian5 1Department of Pharmacy, Nepal Cancer Hospital and Research Center Pvt. Ltd, Lalitpur, Nepal; 2Department of Pharmaceutical and Health Service Research, Nepal Health Research and Innovation Foundation, Lalitpur, Nepal; 3In-Charge, Drug Information Center, Manipal Teaching Hospital and Associate Professor, Department of Pharmacology, Manipal College of Medical Sciences, Pokhara, Kaski, Nepal; 4Department of Basic Medical Sciences, Oceania University of Medicine, Apia, Samoa; 5Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab EmiratesCorrespondence: Asmita Priyadarshini KhatiwadaDepartment of Pharmaceutical and Health Service Research, Nepal Health Research and Innovation Foundation, Lalitpur, NepalTel +977-9808291951Email asmita.khatiwada2@gmail.comAbstract: Drug information center (DIC) or Medicine information services provides impartial, well-referenced, critically evaluated, updated information on various aspects of medications to healthcare professionals and consumers. Medicine information services also contribute to the minimization of medication errors by promoting medication education and supporting pharmaceutical services. The main objective of this reflective commentary is to highlight the recent scenario of medicine information services in Nepal, challenges for DIC, how DICs can be strengthened and future perspectives of DIC. The availability of medicine information in various online drug information sites and numerous applications (apps) have made it easier to assess the information in the country such as Nepal. However, the reliability and validity of such information should be considered before dissemination. DIC plays a crucial role in improving drug safety by aiding clinicians in safer use of medications and promoting adverse drug reaction (ADR) reporting in Nepal. Financial support for operating the DIC efficiently is scarce in Nepal resulting in operational problems. The performance of the medicine information services in the country should be evaluated periodically to ensure the good quality of the service. Steps should be taken by the government, private hospitals and regulatory bodies to sustain the already established DIC and to establish additional DICs in the future to provide quality health care service to the community.Keywords: clinical pharmacologists, drug information, drug information center, evidence-based medicines, hospitals, medicine information services, Nepal, pharmacist, pharmacovigilance, pharmacy practice

Objective: To study the impact of educational intervention on the pattern and incidence of potential drug-drug interactions (DDIs). Method: All patients admitted to Internal Medicine wards of Manipal Teaching Hospital during the study period were included. Patient details were collected using a patient profile form and the datum from the filled forms was analyzed using Micromedex electronic database. An intervention was carried out through a presentation during clinical meeting and personal discussion. The target groups for the intervention included doctors and the nurses. Results: Altogether 435 patients during preintervention and 445 during postintervention were studied. The incidence of potential DDIs was 53% (preintervention) and 41% (postintervention) [chi-square =11.27, p=0.001]. The average number of drugs per patient was 8.53 (pre-intervention) and 7.32 (post-intervention) [t=3.493, p=0.001]. Sixty-four percent of the potential DDIs were of ‘Moderate’ type and 58% had a ‘Delayed’ onset in both the phases. Seventy percent of the potential DDIs during the pre-intervention phase and 61% during post-intervention phase had a ‘Good’ documentation status. Pharmacokinetic mechanism accounted for 45% of the potential DDIs during pre-intervention and 36% in the post-intervention phase. Cardiovascular drugs accounted for 36% of the potential DDIs during pre-intervention and 33.2% during post-intervention phase. Furosemide was the high risk drug responsible for DDIs in both phases. The most common potential DDIs observed were between amlodipine and atenolol (4.82%) (preintervention) and frusemide and aspirin (5.20%) (postintervention). Conclusion: There was an association between potential DDIs and age, sex, and polypharmacy.

Abstract Background Self-medication and non-doctor prescribing of drugs is common in developing countries. Complementary and alternative medications, especially herbs, are also commonly used. There are few studies on the use of these medications in Pokhara Valley, Western Nepal. Methods Previously briefed seventh semester medical students, using a semi-structured questionnaire, carried out the study on 142 respondents. Demographic information and information on drugs used for self-medication or prescribed by a non-allopathic doctor were collected. Results Seventy-six respondents (54%) were aged between 20 to 39 years. The majority of the respondents (72 %) stayed within 30 minutes walking distance of a health post/medical store. 59% of these respondents had taken some form of self-medication in the 6-month period preceding the study. The common reasons given for self-medication were mild illness, previous experience of treating a similar illness, and non-availability of health personnel. 70% of respondents were prescribed allopathic drugs by a non-allopathic doctor. The compounder and health assistant were common sources of medicines. Paracetamol and antimicrobials were the drugs most commonly prescribed. A significantly higher proportion of young ( Conclusions Self-medication and non-doctor prescribing are common in the Pokhara valley. In addition to allopathic drugs, herbal remedies were also commonly used for self-medication. Drugs, especially antimicrobials, were not taken for the proper duration. Education to help patients decide on the appropriateness of self-medication is required.

Pemphigus is an autoimmune blistering disorder characterized by the presence of intraepidermal blisters and erosions, primarily affecting the mucosa and/or skin. There are no established Indian guidelines for the management of pemphigus, and Western guidelines cannot be directly applied due to differences in clinicodemographic profiles, comorbidities, and resource limitations. These guidelines aim to provide Indian dermatologists with evidence-based and consensus-driven recommendations for the management of pemphigus vulgaris (PV) and pemphigus foliaceous (PF), taking into account the unique challenges posed by the Indian healthcare setting. The guidelines focus on the comprehensive management of PV and PF, addressing diagnosis, treatment, monitoring, and follow-up. It is intended for dermatologists working in both outpatient and inpatient settings across India. The first draft of the guidelines was prepared by the writing group and then reviewed by 19 national experts in pemphigus management, including inputs from allied specialties. Areas with limited evidence or anticipated variation in recommendations were subjected to rounds of voting, with responses categorized as “strongly agree,” “agree,” “neutral,” “disagree,” or “strongly disagree.” Suggestions were incorporated, and statements were revised until a mean agreement score of 4 or higher was reached across 16 key areas after four voting rounds. These guidelines offer a structured approach to managing pemphigus in India, addressing the need for region-specific recommendations that account for unique challenges such as resource constraints and specific comorbidities in Indian patients. They serve as a valuable resource for dermatologists treating pemphigus in a range of clinical settings.

Abstract Malassezia is a lipophilic commensal yeast that resides mainly on the mammalian skin and is also found to associate with the internal organs. Dysbiosis of Malassezia is related to several diseases and often escapes detection as it is difficult to culture and maintain. Malassezia cell wall differs from other budding yeasts like S. cerevisiae due to the difference in the lipid content and is difficult to transform. In this study, we present a methodology to stain Malassezia's nucleus and perform cell cycle studies. However, staining presents a challenge due to its exceptionally thick cell wall with high lipid content, hindering conventional methods. Our novel methodology addresses this challenge and enables the staining of the Malassezia nucleus with a low background. This would allow researchers to visualize the overall nuclear health specifically nuclear morphology and analyze DNA content, crucial for cell cycle progression. By employing DNA-specific dyes like DAPI or Hoechst, we can observe the nuclear structure, and using PI we can differentiate cells in distinct cell cycle phases using techniques like flow cytometry. This novel staining methodology unlocks the door for in-depth cell cycle analysis in Malassezia which has challenged us through ages being refractory to genetic manipulations, paving the way for a deeper understanding of this commensal fungus and its potential role in human health.

Summary: Background: Treatment delays are significantly associated with advanced stage, poor response to treatment, increased mortality risk, poor health outcomes, increased healthcare expenditures among cancer patients. However, factors associated with these delays have not yet been robustly evaluated. In order to bridge this gap, we determined the delayed time to treatment initiation (TTI) among cancer patients in India, ascertained its determinants, and assessed the trends of delayed TTI. Methods: We analysed data collected from 6695 cancer patients seeking outpatient/daycare treatment, recruited at purposively selected seven healthcare facilities across six states of India. Data on socio-demographic and clinical characteristics including date of cancer diagnosis, date of treatment initiation, cancer site, stage and type of treatment were collected to determine the median TTI and ascertain its determinants among cancer patients in India. Time to treatment initiation was calculated as the duration (days) between diagnosis of cancer (histologically/clinically) and date of initiation of treatment. Multi-variable logistic regression was employed to analyse the relationship between the outcome variable (TTI) and each explanatory variable. A Cox Proportional Hazard (CPH) model was used to conduct time-to-event analysis, and to assess the impact of government-funded health insurance on timely cancer treatment initiation. Findings: The median (IQR) overall TTI was 20 (7–39) days, with a mean of 53.7 days (SD, 192.9). The TTI was higher for those having head and neck cancer (median TTI: 29 days, IQR: 10.5–55.5) and those receiving radiotherapy as initial treatment (27.5 days, IQR: 10–49.5). Younger patients, those educated up to graduation level and males had significantly lower odds of delayed TTI. As compared to patients who were diagnosed between 1995 and 2017, those diagnosed after 2018 had a 36% (26–46%) higher odds of timely initiation of treatment within 30 days. Upon stratifying by enrolment under PMJAY, we found that while the access for timely treatment initiation increased by 33% for those who were not enrolled, vs. 90% among those enrolled under PM-JAY. Overall, this shows significant improvement in timely initiation of cancer treatment as a result of introduction of PM-JAY. Interpretation: The study highlights the positive impact of government-funded health insurance schemes on the timely access to cancer treatment in India. Our study recommends expanding AB PM-JAY cancer packages to include cost-effective treatments, increasing population coverage under screening programs and promoting e-RUPI to reduce financial constraints associated with diagnostic services to address delayed treatment initiation due to unknown cancer stages. Funding: Department of Health Research, Ministry of Health and Family Welfare, New Delhi, India.

Background Accurate estimates of incremental cost (IC) attributable to antimicrobial resistance (AMR) provide information of immense public health importance to the policy makers. Here, we present the IC from patient perspective for treating antimicrobial-resistant pathogens in India.Methods This cohort study was conducted in eight hospitals including government (GH), private (PH) and trust hospitals (TH), considering their ownership, geographical location and categories of cities. This study had a retrospective component, which calculated the direct cost of treating resistant and susceptible blood stream infections caused by selected WHO priority pathogens. The prospective component estimated indirect cost and financial coping strategies for the treatment of AMR. In the retrospective component, 1723 records were included and 170 patients were recruited in the prospective component.Results The median total cost for management of antimicrobial-resistant infections was US$199 (IQR 89, 377) as opposed to US$109 (IQR 55, 229) for susceptible infection in GH. Our study has revealed that the ICs for Enterobacteriaceae (53.9%), Acinetobacter (43.8%) and Staphylococcus (49.7%) at GHs were higher for resistant pathogens. Pharmaceutical cost was the major contributor to IC at GHs (61.5%) and PHs (27.1%). In the prospective component, 46.5% of patients resorted to borrowing money for hospitalisation expenses and the per day median total cost for resistant and sensitive infection was estimated to be US$65 and US$35, respectively.Conclusions The current study concluded that the presence of any critical or high priority pathogens led to an increase in the direct and indirect medical costs. The IC varied with hospital type, length of stay, pathogen, comorbidities and diagnosis. Prospective studies are needed for precise understanding of variations in the costs of treating AMR infections.

Background A digital supportive supervision (DiSS) tool was developed and implemented in Rajasthan, India, to enhance the coverage and quality of maternal health, child health and nutrition (MCHN) services. This study aims to assess the impact and cost-effectiveness of DiSS compared to traditional paper-based supportive supervision.Methods and analysis A quasi-experimental research design incorporating interrupted time series regression analysis will be employed to evaluate the impact of DiSS. Two districts from the high DiSS intensity group, defined as having at least 25% of the MCHN sessions supervised digitally, will be randomly selected as intervention districts. Two comparator districts will be selected from the low DiSS intensity group (less than 25% of MCHN sessions supervised digitally) after matching with intervention districts based on three indicators—female literacy, proportion of population belonging to scheduled caste or tribe and coverage of four antenatal care visits. District-level monthly data on the number of beneficiaries using MCHN services will be obtained from the state’s routine health management information system. Key informants involved in supervising MCHN sessions will also be interviewed to complement the quantitative findings. A mixed micro-costing methodology, incorporating top-down and bottom-up approaches, for assessing the cost of implementing supervision in either scenario. A decision model will estimate long-term health outcomes, in the form of quality-adjusted life years (QALY), in both the intervention and comparator groups. Cost-effectiveness of DiSS will be assessed by computing the incremental cost per QALY gained in the intervention versus comparator group.Ethics and dissemination The study has been approved by the Institute Ethics Committee of the PGIMER, Chandigarh, India (IEC No. IEC-03/2023–2671). The study results will be disseminated at research conferences and published in peer-reviewed journals.

Introduction Patients with chronic kidney disease (CKD) are at increased risk of developing tuberculosis (TB). These patients may also be at higher risk of developing antitubercular treatment (ATT)-associated adverse drug reactions (ADRs). Although dose modification has been recommended, data regarding the impact of impaired kidney function on ATT-associated ADRs is sparse. We studied the incidence and profile of ATT-associated ADRs in patients with CKD and compared them with those with normal kidney function.Methodology This retrospective study analyzed all patients initiated on ATT from January 2016 to August 2019. Patients were grouped into CKD and normal kidney function based on their eGFR. Data on ATT-associated ADRs were collected from medical records. Predictors of ADRs were assessed using univariable and multivariable logistic regression. Additionally, Propensity score matching and analysis were done for CKD and normal kidney function in 1:3 ratio.Results Of 1815 patients on ATT, 75 (4.1%) had CKD. ADRs were more frequent [36/75 (48.0%) vs. 239/1740 (13.7%), p ≤ 0.0001] and more severe [15/46 (32.6%) vs. 43/283 (15.1%), p = 0.010] in CKD than those with normal kidney function. The most common ADRs were hepatobiliary [23/75 (30.6%) vs. 156/1740 (8.9%), p ≤ 0.0001], neuropsychiatric [8/75(10.6%) vs. 21/1740(1.2%), p ≤ 0.0001], renal [4/75(5.3%) vs. 8/1740(0.4%), p = 0.001], and gastrointestinal [5/75(6.6%) vs. 34/1740 (1.9%), p = 0.020]. CKD was an independent predictor for ADRs (OR −4.96, 95% CI: 2.79–8.82; p ≤ 0.0001). The matched cohort showed similar results.Conclusion ATT-associated ADRs were more common and severe in patients with CKD, despite drug dose modifications. Optimal dosing of ATT in CKD needs to be further evaluated.

Extracranial vascular pathology uncommonly causes intracranial subarachnoid hemorrhage (SAH). Among possible lesions are aneurysms at the craniocervical junction arising from a posterior inferior cerebellar artery (PICA) with an extradural origin. We describe a case of a 55-year-old female presenting with a sudden and severe headache. A computed tomography scan revealed a SAH within the fourth ventricle and cervical spinal canal, and a ruptured saccular aneurysm on a PICA with extradural C2-origin. Despite difficult access anatomy, endovascular treatment was feasible and resulted in subtotal initial occlusion and preservation of distal PICA flow. Upon 3-month follow-up, the aneurysm was completely occluded with a patent PICA. The patient’s clinical status remained stable at the 1.5-year follow-up. In conclusion, we present a rare case of an aneurysm originating from a PICA with extradural C2-origin that was treated endovascularly with preservation of the PICA.

Background Ventilator-associated pneumonia (VAP) is the commonest healthcare-associated infection (HAI) in intensive care units (ICU), especially in trauma patients. VAP imposes a significant cost burden on the healthcare ecosystem. However, there are few data from the developing world. Methodology We conducted this study in the trauma ICU (TICU) of PGIMER, Chandigarh, from October 2021 to December 2022. The incidence, incidence density, and average length of stay (ALOS) of both VAP and non-VAP patients were established. The health system cost was assessed using a mixed (top-down and bottom-up) micro-costing approach. We collected data for all the resources (direct and indirect costs) utilized during service delivery and estimated the health system cost per bed per day. Results In this study, 494 patients were admitted to TICU, of which 484 received Mechanical Ventilation (MV) and 47 developed VAP. We included 41 and 44 patients with and without VAP. The VAP incidence rate was 9.7% and the VAP incidence density was 10.79/1000 MV days. The ALOS for VAP patients was 21 days, and for non- VAP patients was 8.2 days. Our study estimated a total health system cost of INR 25,927 per bed per day. The health system cost of treating a VAP patient was INR 544,467 compared to INR 207,416 for a non-VAP patient. Conclusion Treatment of VAP poses substantial costs for the health system and patients. There is a need to focus on preventing VAP, which would eventually reduce the length of stay and the resultant financial impact on the health system and the patient.

Summary: Background: Only limited information exists regarding the epidemiology of Kawasaki disease (KD) in low-income and middle-income countries. The present study provides the incidence of KD during 2015–2019 in Chandigarh, north India. Our centre follows the largest KD cohort in India. Methods: Children with KD at Chandigarh diagnosed during January 2015–December 2019 were enrolled in the study. Annual incidence rates were determined using decadal growth rates of the National Census 2011. We computed the incidence of KD in children aged

IntroductionThe current financing of public-sector district hospitals in India relies on historical budget allocations rather than actual utilization or healthcare needs. We utilized empirical data on healthcare delivery costs to develop the financing framework for these hospitals using a blended payment approach.MethodsThe primary data on cost of delivering services in 27 district hospitals across nine states of India was analysed along with indicators influencing the demand and supply of health services. Payment for outpatient, inpatient, and indirect services was assessed using the risk adjusted global budget, case-based bundled payment, and per-bed-global budget, respectively. Risk adjustment weights were computed by regressing the cost of outpatient care with demand and supply side factors which are likely to influence the utilization or the prices. Budget impact analysis was conducted to assess the fiscal implications of this payment approach, accounting for current care standards and two scenarios: upgrading district hospitals to Indian Public Health Standards (IPHS) or medical colleges.ResultsThe average annual budget for a district hospital in India is estimated at ₹326 million (US$3.35 million), ranging from ₹66 million to ₹2.57 billion (US$0.8–31.13 million). Inpatient care comprises the largest portion (78%) of the budget. Upgrading to IPHS-compliant secondary hospitals or medical colleges would increase average budgets by 131 and 91.5%, respectively.ConclusionImplementing a blended payment approach would align funding with healthcare needs, enhance provider performance, and support ongoing financing reforms aimed at strategic purchasing and universal health coverage.

Summary: Background: The design of health benefits package (HBP), and its associated payment and pricing system, is central to the performance of government-funded health insurance programmes. We evaluated the impact of revision in HBP within India’s Pradhan Mantri Jan Arogya Yojana (PM-JAY) on provider behaviour, manifesting in terms of utilisation of services. Methods: We analysed the data on 1.35 million hospitalisation claims submitted by all the 886 (222 government and 664 private) empanelled hospitals in state of Punjab, from August 2019 to December 2022, to assess the change in utilisation from HBP 1.0 to HBP 2.0. The packages were stratified based on the nature of revision introduced in HBP 2.0, i.e., change in nomenclature, construct, price, or a combination of these. Data from National Health System Cost Database on cost of each of the packages was used to determine the cost-price differential for each package during HBP 1.0 and 2.0 respectively. A dose–response relationship was also evaluated, based on the multiplicity of revision type undertaken, or based on extent of price correction done. Change in the number of monthly claims, and the number of monthly claims per package was computed for each package category using an appropriate seasonal autoregressive integrated moving average (SARIMA) time series model. Findings: Overall, we found that the HBP revision led to a positive impact on utilisation of services. While changes in HBP nomenclature and construct had a positive effect, incorporating price corrections further accentuated the impact. The pricing reforms highly impacted those packages which were originally significantly under-priced. However, we did not find statistically significant dose–response relationship based on extent of price correction. Thirdly, the overall impact of HBP revision was similar in public and private hospitals. Interpretation: Our paper demonstrates the significant positive impact of PM-JAY HBP revisions on utilisation. HBP revisions need to be undertaken with the anticipation of its long-term intended effects. Funding: Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ).

Objective The Indian Government launched Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), the world’s largest health insurance scheme, in 2018. To reform pricing and gather evidence on healthcare costs, a hospital cost-surveillance pilot was initiated among PM-JAY empanelled hospitals. We analysed the process and challenges from both healthcare providers and payer agency’s perspectives and offer recommendations for implementing similar systems in lower- and middle-income countries.Design We employed an open-ended, descriptive and qualitative study design using in-depth interviews (IDI) as the data collection strategy.Settings The interviews were conducted in both virtual and face-to-face modes depending on the convenience of the participants. The IDIs for the National Health Authority (NHA) officials and all providers in Kerala were conducted virtually, while face-to-face interviews were conducted and in Haryana and Chhattisgarh.Participants Staff from 21 hospitals in three states (Haryana, Chhattisgarh and Kerala), including officials from State Health Agency (n=5) and NHA (n=3) were interviewed.Results The findings highlight significant challenges in reporting cost data at the hospital level. These include a shortage of trained staff, leading to difficulties in collecting comprehensive and high-quality data. Additionally, the data collection process is resource-intensive and time-consuming, putting strain on limited capacity. Operational issues with transaction management system, such as speed, user-friendliness and frequent page expirations, also pose obstacles. Finally, current patient records data has gaps, in terms of quantity and quality, to be directly put to use for pricing.Conclusion Accurate cost data is vital for health policy decisions. Capacity building across healthcare levels is needed for precise cost collection. Integration into digital infrastructure is key to avoid burdening providers and ensure quality data capture.

Background Haematological abnormalities following renal transplantation are frequently observed and have a significant effect on survival and graft outcomes. The pattern of haematological abnormalities varies globally. Few studies have been conducted in Asian countries. We aimed to evaluate the patterns of haematological abnormalities in post-transplant recipients in our center during the first year after post-renal transplant and the association of post-transplant anemia with graft function. Methods This single-center retrospective study was conducted on renal transplantation recipients between 2014 and 2019. The study included all patients who received kidney transplants from live/cadaveric donors and had follow-up data collected up to 12 months after the transplant. The outcome studied was the prevalence of haematological abnormalities and the association between post-transplant anemia (PTA) and graft function in post-transplant recipients. Results A total of 106 renal transplant recipients were included in the study. The prevalence of PTA was 98% in the first week, 75% at one month, 35% at three months, 32% at six months, and 27% at 12 months. The other cytopenia cases were leukopenia (43.4%), thrombocytopenia (33.2%), and pancytopenia (15.1%). Post-transplant erythrocytosis was observed in 17.9% of patients. 18 patients with severe PTA in the first week of transplant had significant allograft dysfunction (p=0.04). Patients with and without PTA had similar graft functions at six and 12 months (p=0.50). Conclusions Haematological abnormalities are common in renal transplant recipients. PTA is highly prevalent during the first week and improves over time. Other haematological abnormalities observed were leukopenia, thrombocytopenia, pancytopenia, and post-transplant erythrocytosis. Leucopenia was primarily drug-induced, and thrombocytopenia and pancytopenia were frequently caused by infections in our cohort. Additionally, severe PTA was significantly associated with graft dysfunction in the first week post-transplant, whereas similar graft function was observed at 6 and 12 months post-transplant, irrespective of the presence or absence of PTA.

Introduction: Rapid progression of diabetic kidney disease (DKD) is a significant concern, particularly in developing countries. It remains uncertain whether histopathological parameters, in addition to clinical factors, can predict DKD progression. Objectives: To evaluate renal histopathological and clinical parameters in predicting rapid progression to end-stage kidney disease (ESKD) in type 2 diabetes mellitus (Type 2 DM) patients with biopsy-proven DKD. Patients and Methods: This was an observational retrospective study that included 49 biopsy-proven DKD from January 2018 to December 2022. Those with less than six months of follow-up and CKD stage 5 were excluded. The outcomes studied were rapid progression and progression to ESKD. Patients were categorized into rapid progressors and non-progressors based on the estimated glomerular filtration (eGFR) decline of > or

Endemic fermented vegetables play a crucial role in local cuisine and culture, with traditionally fermented raw green vegetables such as gundruk being a popular practice in North Bengal and Sikkim, India. However, there is a gap in the microbial profiling of these vegetables. This study aimed to explore the diversity of dominant bacterial populations in fermented leafy vegetables using both culture-dependent and culture-independent methods. In addition to isolating bacteria using conventional methods, we conducted phenotypic and biochemical characterization, community DNA isolation, and amplicon sequencing. We also introduced a new approach in bioinformatics analysis: reverse ecology, which analyzes complementation and competition among participant microbes. In conventional culture-dependent techniques, LAB genera such as Lactobacillus, Enterococcus, Leuconostoc, and Pediococcus have been identified as predominant consortia, whereas metagenomic analysis revealed that the microbiome of fermented dried leafy vegetables was mainly composed of Firmicutes, Proteobacteria, Actinobacteria, Bacteroides, and Planctomycetes at the phylum level. Within the Lactobacillaceae family, predominant types included Lactobacillus, Lactococcus, Pediococcus, Leuconostoc, Enterococcus, Vagococcus, Weissella, and Carnobacterium. The microbial metabolism revealed key pathways, such as carbon metabolism, glycolysis, gluconeogenesis, and glyoxylate. Aromatic amino acid degradation, fatty acid metabolism, amino sugar metabolism, nucleotide sugar metabolism, and biosynthesis of nucleotide sugar pathways were also active. The competition index among microbes and human metabolic data was low (0.32–0.44), indicating minimal competition for nutrition. Complementation indices between bacteria and humans were high (0.76–0.88), suggesting a beneficial impact of gundruk microbial populations on human health.

Abstract Background Cancer survivors experience a decrement in health-related quality of life (HRQoL) resulting from the disease as well as adverse effects of therapy. We evaluated the HRQoL of cancer patients, stratified by primary cancer site, stage, treatment response and associated adverse events, along with its determinants. Methods Data were collected from 12,148 patients, sampled from seven purposively chosen leading cancer hospitals in India, to elicit HRQoL using the EuroQol questionnaire comprising of 5-dimensions and 5-levels (EQ-5D-5L). Multiple linear regression was used to determine the association between HRQoL and various socio-demographic as well as clinical characteristics. Results Majority outpatients (78.4%) and inpatients (81.2%) had solid cancers. The disease was found to be more prevalent among outpatients (37.5%) and inpatients (40.5%) aged 45–60 years and females (49.3–58.3%). Most patients were found to be in stage III (40–40.6%) or stage IV (29.4–37.3%) at the time of recruitment. The mean EQ-5D-5 L utility score was significantly higher among outpatients [0.630 (95% CI: 0.623, 0.637)] as compared to inpatients [0.553 (95% CI: 0.539, 0.567)]. The HRQoL decreased with advancing cancer stage among both inpatients and outpatients, respectively [stage IV: (0.516 & 0.557); stage III (0.609 & 0.689); stage II (0.677 & 0.713); stage I (0.638 & 0.748), p value

Abstract Evidence of fungal coexistence in humans points towards fungal adaptation to the host environment, like the skin. The human commensal Malassezia has evolved, especially residing in sebum-rich areas of the mammalian body where it can get the necessary nutrition for its survival. This fungus is primarily responsible for skin diseases like Pityriasis versicolor (PV), characterized by hypo or hyperpigmented skin discoloration and erythematous macules. In this manuscript, we report a 19-year-old healthy female who presented with a one-year history of reddish, hypopigmented, asymptomatic lesions over the chest and a raised erythematous lesion over the face. Upon clinical observation, the patient displayed multiple erythematous macules and erythematous papules over the bilateral malar area of the face, along with multiple hypopigmented scaly macules present on the chest and back. Based on the above clinical findings, a diagnosis of PV and Acne vulgaris (AV) was made. Interestingly, the patient was immunocompetent and didn’t have any comorbidities. Upon isolation of skin scrapings and post-culturing, we found the existence of three fungal genera in the same region of the patient’s body. We further went on to confirm the identity of the particular species and found it to represent Malassezia, Rhodotorula, and Candida. We report how Malassezia, the predominant microbial resident skin fungus, coexists with other fungal members of the skin mycobiome. This study on an applied aspect of microbiology also shows how important it is to identify the fungal organism associated with skin infections so that appropriate therapeutics can be advised to avoid cases of relapse.

Malassezia are lipophilic budding yeasts that thrive on natural lipid sources. They are found on the skin, scalp, and upper back of humans and other warm-blooded animals, due to the high sebaceous gland activity in these regions that support their growth. They generally thrive as commensals and, upon certain not-so-well-defined conditions, transform into pathogenic states, giving rise to dermatological diseases and, at times, systemic infections. The studies for identifying the role of Malassezia in causing disease are severely hampered due to the lack of suitable growth media. Because of the challenges associated with isolation, there have been cases reported of undetectable fungal sepsis and often misdiagnosis for the same reason. The media routinely used for culturing yeast is supplemented with lipids. This study aimed to show that an inexpensive oil supplement like rice bran can support the growth of Malassezia, and SDA media supplemented with rice bran oil gave commendable growth of the budding yeast, better than the traditionally used olive oil-supplemented media. Therefore, rice bran oil can be used as a lipid supplement in the culture medium for the isolation, and maintenance of lipophilic yeasts. Our study again signifies the importance of media in microbiological research and stresses the need to develop better growth substrates for difficult-to-culture organisms like Malassezia and this will aid in molecular taxonomy, species characterization and phylogenetic studies.

First birth interval after marriage is a particularly interesting subject, because it unveils both the social behaviors and fertility patterns. Though, for a woman, who marry at an early age and get sooner childbearing can be the health threat for both mother and child. The objective of this study is to systematically investigate significant predictors associated with time to first birth after marriage. Following the PRISMA guidelines; three database Scopus, PubMed and EMBASE were used to capture relevant articles. A total of 21 articles with the thorough assessment of 326 articles published in English up to 10 January 2024 were included in final review. Thirty-nine significant predictors associated with first birth interval after marriage have been explored. Predictors, such as age at marriage, education, residence, contraceptive, religion, wealth index were observed as some of the major significant predictors. The findings indicate to take care of those factors in order to deal with time to first birth after marriage. Understanding the impact of influential factors can be considered as important reference to formulate appropriate policy to intervene effective program as well as to plan such studies based on primary data with special reference to certain country or region.

Introduction Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world’s largest tax-funded insurance schemes. The present study was conducted to understand the decision-making process around the evolution (and revision) of health benefit packages (HBPs) and reimbursement rates within PM-JAY, with a specific focus on assessing the extent of use of economic evidence and role of various stakeholders in shaping these policy decisions.Methods A mixed-methods study was adopted involving in-depth interviews with seven key stakeholders involved in HBP design and reimbursement rates decisions, and a survey of 80 government staff and other relevant stakeholders engaged in the implementation of PM-JAY. The data gathered were thematically analysed, and a coding framework was developed to explore specific themes. Additionally, publicly available documents were reviewed to ensure a comprehensive understanding of the decision-making processes.Results Findings reveal a progressive transition towards evidence-based practices for policy decisions within PM-JAY. The initial version of HBP relied heavily on key criteria like disease burden, utilisation rates, and out-of-pocket expenditures, along with clinical opinion in shaping decisions around the inclusion of services in the HBP and setting reimbursement rates. Revised HBPs were informed based on evidence from a national-level costing study and broader stakeholder consultations. The use of health economic evidence increased with each additional revision with consideration of health technology assessment (HTA) evidence for some packages and reimbursement rates based on empirical cost evidence in the most recent update. The establishment of the Health Financing and Technology Assessment unit further signifies the use of evidence-based policymaking within PM-JAY. However, challenges persist, notably with regard to staff capacity and understanding of HTA principles, necessitating ongoing education and training initiatives.Conclusion While substantial progress has been made in transitioning towards evidence-based practices within PM-JAY, sustained efforts and political commitment are required for the ongoing systematisation of processes.

Objectives: The existing biomarkers used to promptly identify graft dysfunction after kidney transplantation lack consistency. Neutrophil gelatinase-associated lipocalin (NGAL) appears to be a promising biomarker but its levels measured from serum and urine have demonstrated varying predictive values. Our study aimed to explore the potential of NGAL as a biomarker in predicting graft dysfunction in kidney transplant patients, including live and deceased donor recipients. Methods: A single-centered observational cohort study with live and deceased kidney recipients as participants was conducted between 2018 and 2022 at a tertiary care hospital in Southern India. Serum creatinine levels were monitored daily; creatinine reduction on day two and day seven were calculated. The recipients were categorized based on graft recovery into three groups: delayed graft function (DGF), slow graft function (SGF), or immediate graft function (IGF). Analysis of serum and urine NGAL was conducted two hours after the transplant and their predictive values were evaluated by the area under the curves (AUC) method. Results: Of the 40 participants, 34 (85.0%) received their transplant from live-related donors, while six (15.0%) received kidneys from deceased donors. DGF occurred in four (10.0%) patients, SGF in 12 (30.0%), and 24 (60.0%) patients achieved IGF. Serum NGAL demonstrated higher sensitivity compared to urine NGAL. At a cut-off value of 678 ng/mL (AUC = 0.77), serum NGAL showed 90.0% sensitivity and 53.0% specificity. Urine NGAL had 70.0% sensitivity and 74.0% specificity at a cutoff value of 489 ng/mL (AUC = 0.72). Conclusions: Kidney recipients in SGF and DGF categories had elevated levels of serum and urine NGAL compared to those without IGF. Although serum NGAL showed higher sensitivity than urine NGAL in predicting graft dysfunction, both markers lacked the specificity needed for accurate predictions.

Background: There is mixed evidence on the extent of association between the allocation of public revenue for healthcare and its indicators of need. Objective: In this study, we examined the relationship between allocations through state health financing (SHF) and the Central Government with infant mortality. Materials and Methods: District-wise infant mortality rate (IMR) was computed using National Family Health Survey-4 data. State-wise data for health budgets through SHF and National Health Mission (NHM, a Centrally Sponsored Scheme), were obtained for the year 2015-16. We used a multivariable analysis through generalized linear model method using identity-link function. Results: We found per capita SHF (₹3169) to be more than 12 times that of public health spending per capita through NHM (₹261). IMR was lower in districts with higher SHF allocation, although statistically insignificant. The allocation through NHM was higher in districts with higher IMR, which is statistically significant. Every unit percentage increase in per capita net state domestic product and female literacy led to 0.31% and 0.54% decline, while a 1% increase in under-five diarrhoea prevalence led to 0.17% increase in IMR. Conclusion: The NHM has contributed to enhancing vertical equity in health-care financing. The States' need to be more responsive to the differences in districts while allocating health-care resources. There needs to be a focus on spending on social determinants, which should be the cornerstone for any universal health coverage strategy.

Background: Despite advancement in methods and application of economic evaluations (EEs), there are several uncertainties. Objectives: To assess the impact of alternate methodological and structural assumptions for four key principles of EE, on the results of cost-effectiveness analysis. Materials and Methods: Three previously published model-based EEs were used: (1) Integrated Management of Neonatal and Childhood Illnesses (IMNCIs) intervention; (2) intervention for multiple myeloma, and (3) safety-engineered syringes (SES) intervention. A series of empirical analyses was undertaken to assess the impact of alternate assumptions for discount-rate, time-horizon, study perspective, and health outcome measure, on incremental cost-effectiveness ratio (ICER), and interpretation of cost-effectiveness. Results: Increasing discount rate resulted in an increase in ICERs, for all three case-studies; however, there was no change in the conclusions. Using shorter time-horizons resulted in a significant increase in ICERs, the multiple myeloma intervention remained cost-ineffective, SES intervention became cost-ineffective, whereas IMNCI intervention remained cost-effective, despite a three-fold increase in ICER. On using disability adjusted life years instead of quality adjusted life years, ICERs increased to 0.04, 2 and 4 times for SES, IMNCI and multiple myeloma interventions, respectively. On analyzing results from a societal perspective, a decline in ICERs was observed. The decline was significant for IMNCI where the intervention turned dominant/cost-saving. In the other two case-studies decline in ICERs was modest, 32% for multiple myeloma, and 4% for SES. Conclusion: We observed a significant impact of using alternate assumptions on ICERs which can potentially impact resource-allocation decisions. Our findings provide strong argument in favor of standardization of processes and development of country-specific guidelines for conduct of EE.

Background Globally, there is increasing interest in the use of real-world data (RWD) and real-world evidence (RWE) to inform health technology assessment (HTA) and reimbursement decision-making. Using current practices and case studies shared by eleven health systems in Asia, a non-binding guidance that seeks to align practices for generating and using RWD/RWE for decision-making in Asia was developed by the REAL World Data In ASia for HEalth Technology Assessment in Reimbursement (REALISE) Working Group, addressing a current gap and needs among HTA users and generators.Methods The guidance document was developed over two face-to-face workshops, in addition to an online survey, a face-to-face interview and pragmatic search of literature. The specific focus was on what, where and how to collect RWD/RWE.Results All 11 REALISE member jurisdictions participated in the online survey and the first in-person workshop, 10 participated in the second in-person workshop, and 8 participated in the in-depth face-to-face interviews. The guidance document was iteratively reviewed by all working group members and the International Advisory Panel. There was substantial variation in: (a) sources and types of RWD being used in HTA, and (b) the relative importance and prioritization of RWE being used for policy-making. A list of national-level databases and other sources of RWD available in each country was compiled. A list of useful guidance on data collection, quality assurance and study design were also compiled.Conclusion The REALISE guidance document serves to align the collection of better quality RWD and generation of reliable RWE to ultimately inform HTA in Asia.

Abstract Antioxidant defense mechanisms are important for a parasite to overcome oxidative stress and survive within host macrophage cells. Mitochondrial iron superoxide dismutase A (FeSODA) and trypanothione reductase (TR) are critical enzymes in the antioxidant defense mechanism of Leishmania donovani. FeSODA is responsible for neutralizing reactive oxygen species in mitochondria, while TR is responsible for reducing trypanothione, the molecules that help the parasite fight oxidative stress in Leishmania. In this study, we used multitarget ligands to inhibit both the FeSODA and TR enzymes. We combined structure-based drug design using virtual screening approach to find inhibitors against both the targets. The ZINC15 database of biogenic compounds was utilized to extract drugs-like molecules against leishmaniasis. The compounds were screened by standard precision (SP) and extra precision (XP) docking methods. Two compounds, ZINC000008876351 and ZINC000253403245, were selected based on molecular docking based on the binding affinity for both the targets. The screened molecules ZINC000008876351 and ZINC000253403245 showed strong hydrogen bonding with the target proteins according to the Molecular mechanics with generalised Born and surface area solvation (MM-GBSA) techniques. These two compounds were also experimentally investigated on promastigotes stage of L. donovani. Under in vitro condition, the compounds show inhibitory effects on L. donovani promastigotes with IC50 values of 24.82 ± 0.61 µM for ZINC000008876351 and 7.52 ± 0.17 µM for ZINC000253403245. Thus, the screened compounds seem to have good potential as therapeutic candidates for leishmaniasis.

Hypereosinophilic syndrome with respiratory distress and multiorgan involvement is not so common in children. It is essential to identify this entity based on clinical, laboratory, and imaging features. Corticosteroids should be instituted at the earliest to stabilize the patient and prevent organ damage. Tropical infections are a common secondary cause in children warranting the administration of Diethylcarbamazine. We present a case of an adolescent male in respiratory distress with marked eosinophilia and organs involving the lungs (pulmonary infiltrates with effusion), heart (pericardial effusion), and abdomen (ascites with infiltrates in the liver) which was managed with steroids and anthelmintics. The case highlights the importance of identifying patients with Hypereosinophilic syndrome in pursuing thorough evaluation and commencing therapy.

PURPOSEDenosumab is clinically superior to zoledronic acid (ZA) for preventing and delaying time to first and subsequent skeletal-related events (SREs) among patients with breast cancer (BC) with bone metastases. We evaluated the cost and health benefits of denosumab and ZA (once every 4 weeks and once every 12 weeks) among four different molecular subtypes of BC with bone metastases in India.MATERIALS AND METHODSA Markov model was developed in Microsoft Excel to estimate lifetime health consequences and resulting costs among cohort of 1,000 patients with BC with bone metastasis, for three intervention scenarios, namely denosumab (once every 4 weeks), ZA (once every 4 weeks), and ZA (once every 12 weeks). The health outcomes were measured in terms of SREs averted and quality-adjusted life-years (QALYs) gained. The cost of each intervention scenario was measured using both the health system and the patient's perspectives. Indirect costs because of lost productivity were not included. The future costs and outcomes were discounted at the standard rate of 3%.RESULTSOver a lifetime, the incremental number of SREs averted with use of denosumab once every 4 weeks (compared with ZA once every 4 weeks and once every 12 weeks) among patients with luminal A, luminal B, human epidermal growth factor receptor 2–enriched, and triple negative breast cancer were estimated as 0.39, 0.26, 0.25, and 0.19, respectively. The number of QALYs lived were slightly higher in the denosumab arm (1.45-2.80) compared with ZA once every 4 weeks and once every 12 weeks arms (1.44-2.78). However, denosumab once every 4 weeks was not found to be a cost-effective alternative for either of the four molecular subtypes of breast cancer. ZA once every 12 weeks was found to be a cost-effective option with an average cost-effectiveness ratio ranging between ₹68,254 and ₹73,636.CONCLUSIONZA once every 12 weeks is the cost-effective treatment option for BC with bone metastases in India. The present study findings hold significance for standard treatment guidelines under India’s government-funded health insurance program.

Background The occurrence rate of stage 5 chronic kidney disease (CKD) will be 151 per million population in India in the coming years. Comorbidities like diabetes mellitus and hypertension are the usual triggers of CKD. Hence this study aimed to control the progression of CKD and to note the effectiveness of a structured education program that would help in the prevention of complications related to diabetes and hypertension. Methods This quasi-experimental study was conducted among 88 participants who had hypertension, diabetes mellitus, or both for five or more years. The study objective was to find the effect of a Disease Management Program on delaying progression of CKD in patients with hypertension or diabetes mellitus. The baseline data were obtained from demographic proforma, and the clinical data collected were the blood pressure, serum creatinine, and random blood sugar (RBS) of the participants. The management of hypertension and diabetes mellitus was taught to them. In the fourth and the eighth month, blood pressure and blood sugar were reassessed. At one-year blood pressure, blood sugar, and serum creatinine were tested. Baseline and one-year follow-up blood pressure, blood sugar, and estimated Glomerular Filtration Rate were compared. Descriptive statistics and "Wilcoxon signed-rank test" were used to analyze the data. Results In one year, the mean systolic blood pressure reduced by six mm of Hg and mean blood sugar by 24 mg/dl. The prevalence of CKD stage three and above (< 60 ml/min/m2) was nine (10.22%). The median decline in eGFR was 5 ml/min/m2 (Z= 5.925, P< 0.001). Conclusion The Disease Management Program led to improvements in blood pressure and diabetes control and median progression of CKD was estimated at five ml/min/m2/year.

PURPOSETargeted therapies, such as crizotinib and ceritinib, have shown promising results in treating non–small cell lung cancer (NSCLC) with specific oncogenic drivers like anaplastic lymphoma kinase (ALK), c-ros (ROS1) oncogene, etc. This study aims to assess the cost-effectiveness of these therapies for patients with NSCLC in India.METHODSThe Markov model consisted of three health states: progression-free survival, progressive disease, and death. Lifetime costs and consequences were estimated for three treatment arms: crizotinib, ceritinib, and chemotherapy for patients with ALK- and ROS1-positive NSCLC. Incremental cost per quality-adjusted life-year (QALY) gained with crizotinib and ceritinib was compared to chemotherapy and assessed using a willingness-to-pay threshold of one-time per capita gross domestic product in India.RESULTSThe total lifetime cost per patient for ALK-positive NSCLC was ₹332,456 ($4,054 US dollars [USD]), ₹1,284,100 ($15,659 USD), and ₹2,337,779 ($28,509 USD) in the chemotherapy, crizotinib, and ceritinib arms, respectively. The mean QALYs lived per patient were 1.20, 2.21, and 3.34, respectively. For patients with ROS1-positive NSCLC, the total cost was ₹323,011 ($3,939 USD) and ₹1,763,541 ($21,507 USD) for chemotherapy and crizotinib, with mean QALYs lived per patient of 1.16 and 2.73, respectively. Nearly 92% and 81% reduction in the price of ceritinib and crizotinib is required to make it a cost-effective treatment option for ALK- and ROS1-positive NSCLC, respectively.CONCLUSIONOur study findings suggest that the prices of ceritinib and crizotinib need to be reduced significantly to justify their value for inclusion in India's publicly financed health insurance scheme for treatment of patients with locally advanced/metastatic ALK- and ROS1-positive NSCLC, respectively.

Osseo-muscular presentations of Wilson's Disease (WD) are not common, but have been reported in several studies from different parts of the world. We studied a group of 36 patients who presented with prominent osseo-muscular affection and were ultimately diagnosed with WD. We studied the pattern of osseo-muscular involvement in these patients and also the specific neurologic manifestations that they manifested. We also followed up these patients who were being given optimal dietary and pharmacologic treatment over a period of 2 years to analyze the response of osseo-muscular and neurologic disease to treatment. The results showed that osseo-muscular involvement in WD patients are nonspecific and involve bone demineralization and joint inflammation predominantly. Presence of proximal myopathy with normal creatine phosphokinase level but electrophysiological evidence of myopathy was notable in this study. Neurologic involvement was mainly dystonic and cerebellar with the notable absence of significant tremor. Adequate therapy resulted in salutary improvement or stabilization of both neurologic and osseo-muscular involvement, indicating a possible common toxic effect of excess copper on both neuronal and musculoskeletal tissue. Further studies are required to document the biochemical and toxicologic pathways causing cellular and tissue damage in WD.

BackgroundNonpharmacological interventions, such as personal protective equipment for example, surgical masks and respirators, and maintenance of hand hygiene along with COVID-19 vaccines have been recommended to reduce viral transmission in the community and health care settings. There is evidence from the literature that surgical and N95 masks may reduce the initial degree of exposure to the virus. A limited research that has studied the cost-effective analysis of surgical masks and N95 masks among health care workers in the prevention of COVID-19 in India. The objective of this study was to estimate the cost-effectiveness of N95 and surgical mask compared to wearing no mask in public hospital settings for preventing COVID-19 infection among Health care workers (HCWs) from the health care provider's perspective.MethodsA deterministic baseline model, without any mask use, based on Eikenberry et al was used to form the foundation for parameter estimation and to estimate transmission rates among HCWs. Information on mask efficacy, including the overall filtering efficiency of a mask and clinical efficiency, in terms of either inward efficiency(ei) or outward efficiency(e0), was obtained from published literature. Hospitalized HCWs were assumed to be in one of the disease states i.e., mild, moderate, severe, or critical. A total of 10,000 HCWs was considered as representative of the size of a tertiary care institution HCW population. The utility values for the mild, moderate and severe model health states were sourced from the primary data collection on quality-of-life of HCWs COVID-19 survivors. The utility scores for mild, moderate, and severe COVID-19 conditions were 0.88, 0.738 and 0.58, respectively. The cost of treatment for mild sickness (6,500 INR per day), moderate sickness (10,000 INR per day), severe (require ICU facility without ventilation, 15,000 INR per day), and critical (require ICU facility with ventilation per day, 18,000 INR) per day as per government and private COVID-19 treatment costs and capping were considered. One way sensitivity analyses were performed to identify the model inputs which had the largest impact on model results.ResultsThe use of N95 masks compared to using no mask is cost-saving of $1,454,632 (INR 0.106 billion) per 10,000 HCWs in a year. The use of N95 masks compared to using surgical masks is cost-saving of $63,919 (INR 0.005 billion) per 10,000 HCWs in a year. the use of surgical masks compared to using no mask is cost-saving of $1,390,713 (INR 0.102 billion) per 10,000 HCWs in a year. The uncertainty analysis showed that considering fixed transmission rate (1.7), adoption of mask efficiency as 20%, 50% and 80% reduces the cumulative relative mortality to 41%, 79% and 94% respectively. On considering ei = e0 (99%) for N95 and surgical mask with ei = e0 (90%) the cumulative relative mortality was reduced by 97% and the use of N95 masks compared to using surgical masks is cost-saving of $24,361 (INR 0.002 billion) per 10,000 HCWs in a year.DiscussionBoth considered interventions were dominant compared to no mask based on the model estimates. N95 masks were also dominant compared to surgical masks.

Conclusion: Hypochloremia, but not hyperchloremia, was associated with MAKE30 in this cohort of critically ill patients with sepsis.

ObjectiveThe fundamental disconnect between the actual and the perceived health of an individual raises considerable skepticism on the self-reported health data as it may be confounded by an individual’s socio-economic status. In this light, the present study aims to assess if people with different sociodemographic backgrounds value their health differently.MethodsThe health-state valuation using time-trade off was performed in a cross-sectional survey among a representative sample of 2,311 adults from India. Individuals were selected using a multistage stratified random sampling from five Indian states to elicit their present health-state, and to perform the health-state valuation exercise using computer assisted personal interviewing. A single block of standardized health-states was valued by multiple individuals, each belonging to different socio-demographic group. The difference in the valuation of health was assessed using bivariate analysis. The impact of different sociodemographic factors on the health-state valuation was evaluated using Tobit regression model.ResultsDifferences in the valuation of health were observed among different groups of age, religion, family type, state of residence, substance abuse, presence of ailments at the time of valuation, and number of dependent members in the household. Even after controlling for the severity of the administered health states, factors having a significant association with the valuation of health are age, religion, state of residence, substance abuse, family type, number of dependent members in the household, and presence of chronic or both acute and chronic ailments. Younger individuals place a higher value to their health as compared to their older counterparts. As compared to a healthy individual, a person with ailments rates the same health-state as worse.ConclusionInequalities in self-reported ill-health cannot be attributed to positional objectivity; age, religion, state of residence, substance abuse, family type, dependents, and ailments impact individual health valuation.

Countries pursuing universal health coverage must set priorities to determine which benefits to add to a national health program, but the roles that organizations play are less understood. This article investigates the case of the formation of an organization with a mandate for choice of technology for public health interventions and priorities, the Health Technology Assessment India. First, we narrate a chronology of agenda setting and adoption of national policy for organizational formation drawing on historical documentation, publicly available literature, and lived experiences from coauthors. Next, we conduct a thematic analysis that examines windows of opportunity, enabling factors, barriers and conditions, roles of stakeholders, messaging and framing, and specific administrative and bureaucratic tools that facilitated organization formation. This case study shows that organizational formation relied on the identification of multiple champions with sufficient seniority and political authority across a wide group of organizations, forming a coalition of broad base support, who were keen to advance health technology assessment policy development and organizational placement or formation. The champions in turn could use their roles for policy decisions that used private and public events to raise priority and commitment to the decisions, carefully considered organizational placement and formation, and developed the network of organizations for the generation of technical evidence and capacity building for health technology assessment, strengthened by international networks and organizations with financing, expertise, and policymaker relationships.

The introduction of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) scheme in India was a significant step toward universal health coverage. The PM-JAY scheme has made notable progress since its inception, including increasing the number of people covered and expanding the range of services provided under the health benefit package (HBP). The creation of the Health Financing and Technology Assessment (HeFTA) unit within the National Health Authority (NHA) further enhanced evidence-based decision-making processes. We outline the journey of HeFTA and highlight significant cost savings to the PM-JAY as a result of health technology assessment (HTA). Our paper also discusses the application of HTA evidence for decisions related to inclusions or exclusions in HBP, framing standard treatment guidelines as well as other policies. We recommend that future financing reforms for strategic purchasing should strengthen strategic purchasing arrangements and adopt value-based pricing (VBP). Integrating HTA and VBP is a progressive approach toward health care financing reforms for large government-funded schemes like the PM-JAY.

Background: End-stage renal disease (ESRD) consequences have reached epidemic proportions in India, and disease rates are expected to rise further. Every year, around 0.22 million new patients with renal diseases are diagnosed in India. ESRD poses a significant hurdle to receiving affordable therapy due to the exorbitant charges associated with accessing treatment in corporate hospitals. Objective: To investigate hemodialysis patients' enrolment patterns, utilisation rates, and best practices concerning government and private health insurance schemes in a tertiary care hospital setting. Methods: A multi-centric and prospective cross-sectional study was conducted at tertiary care hospitals. Sources of data collection were patients and family members. The questionnaires included sections related to patient demographics, insurance enrollment details, utilisation patterns, and satisfaction with insurance coverage. Results: Responses were collected from 385 patients undergoing treatment at tertiary care hospitals. The most utilised plans were health cards 107 (29.8%), private schemes 99 (27.6%), Central Government schemes 66 (18.4%), followed by trust 50 (13.9%), society schemes 30 (8.4%), and state schemes 7 (1.9%). The most common Central Government insurance scheme was Employee State Insurance, with 63 (17.5%) of patients enrolled, followed by Ex-servicemen Contributory Health Scheme 2 (0.6%) and Central Government Health Scheme 1 (0.3%). Among those with State Insurance, the Chief Minister Relief Fund Government of Karnataka 3 (0.8%), followed by the Arogya Bhagya Scheme 1 (0.3%). Conclusions: The utilisation rates of insurance benefits were relatively high among hemodialysis patients, demonstrating the significance of insurance coverage in facilitating their healthcare needs.

India envisions achieving universal health coverage to provide its people with access to affordable quality health services. A breakthrough effort in this direction has been the launch of the world’s largest health assurance scheme Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, the implementation of which resides with the National Health Authority. Appropriate provider payment systems and reimbursement rates are an important element for the success of PM-JAY, which in turn relies on robust cost evidence to support pricing decisions. Since the launch of PM-JAY, the health benefits package and provider payment rates have undergone a series of revisions. At the outset, there was a relative lack of cost data. Later revisions relied on health facility costing studies, and now there is an initiative to establish a national hospital costing system relying on provider-generated data. Lessons from PM-JAY experience show that the success of such cost systems to ensure regular and routine generation of evidence is contingent on integrating with existing billing or patient information systems or management information systems, which digitise similar information on resource consumption without any additional data entry effort. Therefore, there is a need to focus on building sustainable mechanisms for setting up systems for generating accurate cost data rather than relying on resource-intensive studies for cost data collection.

Hyperuricemia is a risk factor for the progression of chronic kidney disease (CKD). We compared febuxostat versus allopurinol in the progression of CKD and hyperuricemia in 101 patients with Stage 3–4 CKD treated with febuxostat or allopurinol for at least 6 months for hyperuricemia (>7 mg/dL) between January 2012 and December 2016. Baseline characteristics, serum uric acid (SUA), serum creatinine, and estimated glomerular filtration rate (eGFR) at entry and 6 months were compared. The primary outcome was the decline in eGFR and the secondary outcomes were reductions in SUA and adverse events. Fifty-four were in the febuxostat group and 47 were in the allopurinol group. The baseline characteristics were comparable except for age. The mean dose of febuxostat and allopurinol was 43.70 ± 14.5 mg and 108.51 ± 40 mg, respectively. After 6 months, the median rate of decline in eGFR was 1.2 mL/min/1.73 m2 (IQR: 1.2, 5.5) in the febuxostat group and 3.1 mL/min/1.73 m2 (0.6, 6.2) in the allopurinol group, but this was not statistically significant (P = 0.136). The mean reduction in SUA was significantly better (P = 0.004) in the febuxostat group (3.9 ± 1.7 mg/dL) compared with the allopurinol group (2.1 ± 1.0 mg/dL). Both drugs had no serious adverse events. Febuxostat was better at reducing hyperuricemia than allopurinol, but there was no significant difference in the progression of CKD. Large randomized trials and long-term follow-up are necessary to see whether febuxostat has a favorable effect on the progression of CKD.

Background: A “pay-for-performance” (P4P) intervention model for improved tuberculosis (TB) outcomes, called “Mukti,” has been implemented in an underdeveloped tribal area of central India. The target of this project is to improve nutritional status, quality of life (QoL), and treatment outcomes of 1000 TB patients through four interventions: food baskets, personal counseling, peer-to-peer learning and facilitation for linkage to government schemes. The current study aims to assess the success of this model by evaluating its impact and cost-effectiveness using a quasi-experimental approach. Methods: Data for impact assessment have been collected from 1000 intervention and control patients. Study outcomes such as treatment completion, sputum negativity, weight gain, and health-related QoL will be compared between matched samples. Micro costing approach will be used for assessing the cost of routine TB services provision under the national program and the incremental cost of implementing our interventions. A decision and Markov hybrid model will estimate long-term costs and health outcomes associated with the use of study interventions. Measures of health outcomes will be mortality, morbidity, and disability. Cost-effectiveness will be assessed in terms of incremental cost per quality-adjusted life-years gained and cost per unit increase in patient weight in intervention versus control groups. Results: The evidence generated from the present study in terms of impact and cost-effectiveness estimates will thus help to identify not only the effectiveness of these interventions but also the optimal mode of financing such measures. Our estimates on scale-up costs for these interventions will also help the state and the national government to consider scale-up of such interventions in the entire state or country. Discussion: The study will generate important evidence on the impact of nutritional supplementation and other complementary interventions for TB treatment outcomes delivered through P4P financing models and on the cost of scaling up these to the state and national level in India.