Cost-effectiveness of long-acting reversible contraceptive methods: a review

Long-acting reversible contraception (LARC) methods are proven to be effective in preventing unintended pregnancies. Evidence on cost-effectiveness of these methods will enable policy makers to introduce them in national policies and programs to improve contraceptive access. The aim was to review the studies based on economic evaluations of LARC methods and provide evidence to policy makers to renew their commitment to family planning access. A review of studies on economic evaluations of LARC methods was done. This article uses data from three electronic databases: PubMed, Cochrane and Web of Science to examine whether LARC is cost-effective for clinical trials. The results are presented as a narrative review and summary tables. The literature search yielded 87 studies and 12 studies (five economic evaluations studies from USA) and (five studies from Europe while two studies were from low and middle-income countries) were included. Out of 12 papers, nine had multiple comparators; seven included female sterilization as a comparator, while two studies compared one individual LARC contraceptive method with an individual SARC method. All studies consistently showed that LARCs dominated all SARC (short acting reversible contraceptives) methods. Within LARC, copper IUD, LNG-IUS and implant were more cost-effective than DMPA. After a period of five years, female sterilization turned out to be more cost-effective than LARC methods. LARC methods are cost-effective as compared to SARC methods, especially after 1 year of use. Vasectomy is more cost-effective than LARC methods. Policy makers can consider the findings of this review to aid decision making in contraceptive method introduction or scale-up access

Visceral adiposity index among young girls with PCOS and its association with phenotypes and metabolic risk

Background: Polycystic Ovarian Syndrome (PCOS) is a growing endocrine-metabolic disease in India. Visceral Adiposity Index (VAI) is a surrogate marker of visceral adipose dysfunction and can be used as a useful predictor of unhealthy PCOS phenotypes in low resource settings. No cut-off has been assessed among Indian population.Methods: Secondary data from 106 diagnosed girls with PCOS and 121 controls was analysed to estimate (i) VAI and BMI among different phenotypes (ii) risk of metabolic disorders using VAI among different phenotypes of PCOS and (iii) compare the overall diagnostic performance (for metabolic syndrome) of VAI, BMI and waist circumference.Results: Majority of the girls in the sample considered for analysis were lean PCOS (61%). Mean VAI among PCOS (3.02) was significantly higher than normal controls (2.81). Classic and Mild Phenotypes had high VAI. A unit increase in VAI score was found associated with 5.23 times higher risk of metabolic syndrome (AOR: 5.23, 95% CI: 2.261-12.086). A higher VAI with cut off value of 2.73 could predict risk of metabolic syndrome among PCOS cases, unlike the cutoff among Caucassian population of 1.67. The cut-off for the non- obese group was even higher i.e. 2.81.Conclusions: Given that Indians are genetically more prone to have excess visceral fat the cut-offs for measuring adiposity also needs to be re-defined. The findings of this small sample throws light on the prevalence of visceral adiposity among lean girls with PCOS emphasizing the need to also screen them for metabolic syndrome, educate them about these complications and motivate them to practice healthy lifestyles

A narrative review comparing clinical effectiveness of commonly used uterine balloon tamponade devices for postpartum haemorrhage management in India

 Background: World Health Organisation recommends using Uterine Balloon Tamponade (UBT) for refractory atonic postpartum haemorrhage (PPH) management provided treatment protocols and surgical recourse is possible. Methods: This review collated literature from three electronic databases between January 2010 to December 2019 to compare clinical effectiveness, safety and use related parameters for condom-UBT, Bakri balloon and Every Second Matters (ESM) UBT devices used in India. Results: Thirty-three eligible studies reported effectiveness in managing all PPH causes ranging from 84.2% to 98.3% for condom-UBT and from 65.3% to 94.8% for Bakri-UBT. Three ESM-UBT studies reported PPH survival rates of 94% to 97.4%. Mean UBT effectiveness in controlling atonic PPH was 92.3% for condom-UBT, 84.3% for Bakri-UBT and 97.3% for ESM-UBT. Condom-UBT and Bakri-UBT were comparable across parameters whereas limited ESM-UBT evidence reported success in preventing maternal deaths. Conclusions: For limitations and heterogeneity in methodology and outcome parameters with existing evidence, a robust comparative RCT between UBT devices in India is recommended

COLISTIN RESISTANCE IN CARBAPENEM-RESISTANT KLEBSIELLA PNEUMONIAE STRAINS

Objective: There is an increasing use of colistin consequent to increase in the infections caused by carbapenem-resistant Klebsiella pneumoniae.The present study was conducted to determine the minimum inhibitory concentration (MIC) of colistin and the resistance pattern of colistin in carbapenem-resistant K. pneumoniae (CRKP) strains in our intensive care unit (ICU).Methods: Antibiotic susceptibility testing for other antimicrobial agents was done by Kirby-Bauer disk diffusion method. MIC of colistin was determined by agar dilution method. The results of antibiotic susceptibility testing were interpreted as per Clinical Laboratory Standard Institute guidelines 2016 and MIC of colistin were interpreted as per European Committee on Antimicrobial susceptibility testing. The carbapenem resistance was phenotypically detected by modified hodge test and imipenem/imipenem ethylenediaminetetraacetic acid disk method.Results: Out of 518 K. pneumoniae, 329 were resistant to carbapenems, and 91 isolates showed resistance to colistin. The MIC of colistin ranged between 4 and >512 ug/ml and MIC90 was 16 ug/L and MIC50 was 4 ug/ml. A majority of the colistin-resistant isolates were found in multidisciplinary ICU (85/91).Conclusion: The emergence of colistin-resistant strains is a major problem due to limited treatment options for infections caused by CRKP carbapenemase producing K. pneumoniae. Colistin should not be used alone, combination therapy should be preferred

Hepatic failure, neonatal hemochromatosis and porto-pulmonary hypertension in a newborn with trisomy 21 - a case report

Liver failure in neonates is a rare but often fatal disease. Trisomy 21 is not usually associated with significant infantile liver disease. If present, hepatic dysfunction in an infant with Trisomy 21 is likely to be attributed to transient myeloproliferative disorder with hepatic infiltration by hematopoietic elements and may be associated with secondary hemosiderosis. A less commonly recognized cause of liver failure in neonates with Trisomy 21 is neonatal hemochromatosis (NH); this association has been reported in nine cases of Trisomy 21 in literature. NH is a rare, severe liver disease of intra-uterine onset that is characterized by neonatal liver failure and hepatic and extrahepatic iron accumulation that spares the reticuloendothelial system. NH is the most frequently recognized cause of liver failure in neonates and the commonest indication for neonatal liver transplantation. Although porto-pulmonary hypertension (PPH) has been reported as a complication of liver failure in adults and older children, this has not been reported in neonates with liver failure of any etiology. This is probably due to the rarity of liver failure in newborns, delayed diagnosis and high mortality. The importance of recognizing PPH is that it is reversible with liver transplantation but at the same time increases the risk of post-operative mortality. Therefore, early diagnosis of PPH is critical so that early intervention can improve the chances of successful liver transplantation. We report for the first time the association of liver failure with porto-pulmonary hypertension secondary to NH in an infant with Trisomy 21

Leaf Concentrate Fortification of Antenatal Protein- Calorie Snacks Improves Pregnancy Outcomes

Ready-to-eat (RTE) snacks are routinely distributed to pregnant women in India. These provide protein and calories but are low in micronutrients. We investigated whether RTE snacks fortified with leaf concentrate (LC) could improve pregnancy outcomes, including maternal haemoglobin (Hb) concentrations and infants\u2019 birthweight. This randomized controlled two-arm trial was conducted over 18 months: control (sRTE) group received standard 120 g RTE snack (102 g wheat flour, 18 g soya flour); intervention (lcRTE) group received the same snack fortified with 7 g LC. The study was conducted in Jaipur, Rajasthan, India. One hundred and five pregnant women aged 18-35 years were studied. Among the 105 women randomized to the two arms of the trial, 2 (1.9%) were severely anaemic (Hb 646.0 g/dL); 55 (53.4%) were moderately anaemic (Hb 6.0-8.0 g/ dL); 34 (33.0%) were mildly anaemic (Hb 8.6-10.9 g/dL); and 12 (11.7%) were not anaemic (Hb 6511.0 g/dL). In the final month of pregnancy, 83.0% (39/47) of women in the sRTE group had Hb 648.5 g/dL compared to 37.8% (17/45) in the lcRTE group (p<0.001). After adjustment for age and baseline Hb concentration, the difference in Hb concentrations due to LC fortification was 0.94 g/dL (95% CI 6.8-12.0; p<0.001). Mean live birthweight in the lcRTE group was 2,695 g (SD 325 g) compared to 2,545 g (297 g) in the sRTE group (p=0.02). The lcRTE snacks increased infants\u2019 birthweight by 133.7 g (95% CI 7.3-260.2; p=0.04) compared to sRTE snacks. Leaf concentrate fortification of antenatal protein-calorie snacks in a low-income setting in India protected against declining maternal haemoglobin concentrations and increased infants\u2019 birthweight when compared with unfortified snacks. These findings require replication in a larger trial

Micropropagation of Ilex khasiana, a critically endangered and endemic holly of Northeast India

The paper describes in vitro techniques for mass propagation of IIex khasiana, a rare and critically endangered holly endemic to Khasi Hills Hills of Meghalaya, India. The approach will help conserve I. khasiana and other endangered species

Options for Active Case Detection of Visceral Leishmaniasis in Endemic Districts of India, Nepal and Bangladesh, Comparing Yield, Feasibility and Costs

For the elimination of any infectious disease (i.e., reduction of the burden of a serious public health problem to a minor problem which can be managed by the general health services) the right mix of public health tools has to be identified for the early detection and successful treatment of new cases as well as effective vector control (in the case of vector borne diseases) at affordable costs. The paper provides a powerful example of evidence building for cost-effective early case detection in the visceral leishmaniasis elimination initiative of Bangladesh, India and Nepal. It compares the camp approach (mobile teams testing in chronic fever camps for spleen enlargement and rapid diagnostic tests) with the index case approach (screening for new cases in the neighbourhood of reported visceral leishmaniasis patients) and the incentive based approach (where basic health workers receive an allowance for detecting a new case) using subsequent house-to-house screening for the identification of the real number of un-detected cases. By applying a mix of different study methods and an itinerate research process to identify the most effective, feasible and affordable case detection method, under different environmental conditions, recommendations could be developed which help governments in shaping their visceral leishmaniasis elimination strategy

Challenges in quantifying changes in the global water cycle

Human influences have likely already impacted the large-scale water cycle but natural variability and observational uncertainty are substantial. It is essential to maintain and improve observational capabilities to better characterize changes. Understanding observed changes to the global water cycle is key to predicting future climate changes and their impacts. While many datasets document crucial variables such as precipitation, ocean salinity, runoff, and humidity, most are uncertain for determining long-term changes. In situ networks provide long time-series over land but are sparse in many regions, particularly the tropics. Satellite and reanalysis datasets provide global coverage, but their long-term stability is lacking. However, comparisons of changes among related variables can give insights into the robustness of observed changes. For example, ocean salinity, interpreted with an understanding of ocean processes, can help cross-validate precipitation. Observational evidence for human influences on the water cycle is emerging, but uncertainties resulting from internal variability and observational errors are too large to determine whether the observed and simulated changes are consistent. Improvements to the in situ and satellite observing networks that monitor the changing water cycle are required, yet continued data coverage is threatened by funding reductions. Uncertainty both in the role of anthropogenic aerosols, and due to large climate variability presently limits confidence in attribution of observed changes