Evaluation of prescribing pattern of drugs and compliance to standard treatment guidelines in patients of chronic hepatitis B: a prospective observational study

Background: Hepatitis B is a major global health problem. Chronic hepatitis B is characterized by hepatic inflammation, necrosis and persistence of HbsAg for at least 6 months. Chronic liver disease is more predictably associated with impaired metabolism of drugs than acute liver dysfunction. Prescribing drugs in patients with chronic hepatitis B is challenging because of concerns that the drug may exacerbate the liver disease. There is also the fear that the altered liver state may change metabolism and excretion of the drug. Methods: A cross-sectional prospective study was conducted involving patients diagnosed with chronic hepatitis B at the liver clinic outpatient department (OPD) of AIIMS Bhopal. A total of 102 patients with chronic hepatitis B who met the inclusion criteria were recruited in the study. Results: Out of 102 prescriptions, 492 drugs were prescribed for the 102 patients. Out of 102 patients, 81 patients (81.66%) were on entecavir monotherapy and rest 21 patients (18.34%) were on tenofovir disoproxil fumarate (TDF) monotherapy. Of the 102-prescription issued, 92.15% (94/102) were compliant and 7.85% (8/102) were noncompliant.  Conclusions: Entecavir was the most common antiviral drug prescribed, followed by tenofovir in patients of chronic hepatitis B. Spironolactone plus torasemide combination was the most common fixed dose combination used among study participants. Liver cirrhosis followed by portal hypertension was the most common complication. Majority of prescriptions were compliant with recommendations for pharmacotherapy and safety guidelines in patients of chronic hepatitis B.

Exposure and dose assessment of school children to air pollutants in a tropical coastal-urban area

This study estimates exposure and inhaled dose to air pollutants of children residing in a tropical coastal-urban area in Southeast Brazil. For that, twenty-one children filled their time-activities diaries and wore the passive samplers to monitor NO2. The personal exposure was also estimated using data provided by the combination of WRF-Urban/GEOS-Chem/CMAQ models, and the nearby monitoring station. Indoor/outdoor ratios were used to consider the amount of time spent indoors by children in homes and schools. The model's performance was assessed by comparing the modelled data with concentrations measured by urban monitoring stations. A sensitivity analyses was also performed to evaluate the impact of the model's height on the air pollutant concentrations. The results showed that the mean children's personal exposure to NO2 predicted by the model (22.3 μg/m3) was nearly twice to those measured by the passive samplers (12.3 μg/m3). In contrast, the nearest urban monitoring station did not represent the personal exposure to NO2 (9.3 μg/m3), suggesting a bias in the quantification of previous epidemiological studies. The building effect parameterisation (BEP) together with the lowering of the model height enhanced the air pollutant concentrations and the exposure of children to air pollutants. With the use of the CMAQ model, exposure to O3, PM10, PM2.5, and PM1 was also estimated and revealed that the daily children's personal exposure was 13.4, 38.9, 32.9, and 9.6 μg/m3, respectively. Meanwhile, the potential inhalation daily dose was 570-667 μg for PM2.5, 684-789 μg for PM10, and 163-194 μg for PM1, showing to be favourable to cause adverse health effects. The exposure of children to air pollutants estimated by the numerical model in this work was comparable to other studies found in the literature, showing one of the advantages of using the modelling approach since some air pollutants are poorly spatially represented and/or are not routinely monitored by environmental agencies in many regions

Non-invasive diagnostic tests for Helicobacter pylori infection

BACKGROUND: Helicobacter pylori (H pylori) infection has been implicated in a number of malignancies and non-malignant conditions including peptic ulcers, non-ulcer dyspepsia, recurrent peptic ulcer bleeding, unexplained iron deficiency anaemia, idiopathic thrombocytopaenia purpura, and colorectal adenomas. The confirmatory diagnosis of H pylori is by endoscopic biopsy, followed by histopathological examination using haemotoxylin and eosin (H & E) stain or special stains such as Giemsa stain and Warthin-Starry stain. Special stains are more accurate than H & E stain. There is significant uncertainty about the diagnostic accuracy of non-invasive tests for diagnosis of H pylori. OBJECTIVES: To compare the diagnostic accuracy of urea breath test, serology, and stool antigen test, used alone or in combination, for diagnosis of H pylori infection in symptomatic and asymptomatic people, so that eradication therapy for H pylori can be started. SEARCH METHODS: We searched MEDLINE, Embase, the Science Citation Index and the National Institute for Health Research Health Technology Assessment Database on 4 March 2016. We screened references in the included studies to identify additional studies. We also conducted citation searches of relevant studies, most recently on 4 December 2016. We did not restrict studies by language or publication status, or whether data were collected prospectively or retrospectively. SELECTION CRITERIA: We included diagnostic accuracy studies that evaluated at least one of the index tests (urea breath test using isotopes such as13C or14C, serology and stool antigen test) against the reference standard (histopathological examination using H & E stain, special stains or immunohistochemical stain) in people suspected of having H pylori infection. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the references to identify relevant studies and independently extracted data. We assessed the methodological quality of studies using the QUADAS-2 tool. We performed meta-analysis by using the hierarchical summary receiver operating characteristic (HSROC) model to estimate and compare SROC curves. Where appropriate, we used bivariate or univariate logistic regression models to estimate summary sensitivities and specificities. MAIN RESULTS: We included 101 studies involving 11,003 participants, of which 5839 participants (53.1%) had H pylori infection. The prevalence of H pylori infection in the studies ranged from 15.2% to 94.7%, with a median prevalence of 53.7% (interquartile range 42.0% to 66.5%). Most of the studies (57%) included participants with dyspepsia and 53 studies excluded participants who recently had proton pump inhibitors or antibiotics.There was at least an unclear risk of bias or unclear applicability concern for each study.Of the 101 studies, 15 compared the accuracy of two index tests and two studies compared the accuracy of three index tests. Thirty-four studies (4242 participants) evaluated serology; 29 studies (2988 participants) evaluated stool antigen test; 34 studies (3139 participants) evaluated urea breath test-13C; 21 studies (1810 participants) evaluated urea breath test-14C; and two studies (127 participants) evaluated urea breath test but did not report the isotope used. The thresholds used to define test positivity and the staining techniques used for histopathological examination (reference standard) varied between studies. Due to sparse data for each threshold reported, it was not possible to identify the best threshold for each test.Using data from 99 studies in an indirect test comparison, there was statistical evidence of a difference in diagnostic accuracy between urea breath test-13C, urea breath test-14C, serology and stool antigen test (P = 0.024). The diagnostic odds ratios for urea breath test-13C, urea breath test-14C, serology, and stool antigen test were 153 (95% confidence interval (CI) 73.7 to 316), 105 (95% CI 74.0 to 150), 47.4 (95% CI 25.5 to 88.1) and 45.1 (95% CI 24.2 to 84.1). The sensitivity (95% CI) estimated at a fixed specificity of 0.90 (median from studies across the four tests), was 0.94 (95% CI 0.89 to 0.97) for urea breath test-13C, 0.92 (95% CI 0.89 to 0.94) for urea breath test-14C, 0.84 (95% CI 0.74 to 0.91) for serology, and 0.83 (95% CI 0.73 to 0.90) for stool antigen test. This implies that on average, given a specificity of 0.90 and prevalence of 53.7% (median specificity and prevalence in the studies), out of 1000 people tested for H pylori infection, there will be 46 false positives (people without H pylori infection who will be diagnosed as having H pylori infection). In this hypothetical cohort, urea breath test-13C, urea breath test-14C, serology, and stool antigen test will give 30 (95% CI 15 to 58), 42 (95% CI 30 to 58), 86 (95% CI 50 to 140), and 89 (95% CI 52 to 146) false negatives respectively (people with H pylori infection for whom the diagnosis of H pylori will be missed).Direct comparisons were based on few head-to-head studies. The ratios of diagnostic odds ratios (DORs) were 0.68 (95% CI 0.12 to 3.70; P = 0.56) for urea breath test-13C versus serology (seven studies), and 0.88 (95% CI 0.14 to 5.56; P = 0.84) for urea breath test-13C versus stool antigen test (seven studies). The 95% CIs of these estimates overlap with those of the ratios of DORs from the indirect comparison. Data were limited or unavailable for meta-analysis of other direct comparisons. AUTHORS' CONCLUSIONS: In people without a history of gastrectomy and those who have not recently had antibiotics or proton ,pump inhibitors, urea breath tests had high diagnostic accuracy while serology and stool antigen tests were less accurate for diagnosis of Helicobacter pylori infection.This is based on an indirect test comparison (with potential for bias due to confounding), as evidence from direct comparisons was limited or unavailable. The thresholds used for these tests were highly variable and we were unable to identify specific thresholds that might be useful in clinical practice.We need further comparative studies of high methodological quality to obtain more reliable evidence of relative accuracy between the tests. Such studies should be conducted prospectively in a representative spectrum of participants and clearly reported to ensure low risk of bias. Most importantly, studies should prespecify and clearly report thresholds used, and should avoid inappropriate exclusions

A Comparative Study on the Impact of Portfolio Diversity

The Modern portfolio theory is considered to be one of the most significant approaches for portfolio management. The theory suggests using diversity for optimal investment opportunities and to minimize specific risk. Portfolio diversification reduces the impact of market fluctuations, improves the risk-adjusted returns and provides stability. On the contrary, too much diversification can lead to difficulties in keeping track of the stocks, unwanted tax complications and reduced gains during sudden spikes. Due to these factors, it is necessary to quantify the impact of diversification on portfolios. This paper is aimed at identifying and quantifying the impact of diversity on portfolios. For conducting this research, 2 portfolios have been developed with varying degrees of diversification. Performance indicators such as Beta, Jensen’s Alpha, Sharpe ratio, Sortino ratio, annualized returns, Value at Risk and Conditional Value at risk have been used in this research. The findings of this analysis show that in all aspects, the diversified portfolio outperforms the other. The diversified portfolio provides better returns per unit risk, higher overall returns, considerably lower risk in terms of volatility and lower value at risk. The comparative analysis illustrates that a diverse portfolio is substantially more favourable than an undiversified portfolio. The results of this study can help investors make decisions based on quantitative analytics and not based solely on advice. However, it should be noted that the stocks selected for this research are profitable on their own and additional research can be done for stock selection which has been addressed in concluding section

International Journal of Pharma and Bio Sciences RESEARCH ARTICLE MICROBIOLOGY EVALUATION OF FLUORESCENT STAINING FOR IMPROVEMENT IN DIAGNOSIS OF PULMONARY TUBERCULOSIS IN SPUTUM SMEAR NEGATIVE CASES

Bright field microscopy of sputum after ZN staining is the backbone of revised national tuberculosis control program (RNTCP) for diagnosis of pulmonary tuberculosis. But reduced sensitivity in overburdened RNTCP centers and HIV-TB co-infection necessitates the use of newer modalities to increase the diagnostic yield. A cross sectional prospective analytical study was done from June 2011 to August 2011, to look for increase in sensitivity in diagnosis of pulmonary tuberculosis by examination of sputum smear negative cases by fluorescent microscopy. Two sets of smears were prepared, of which one set of smear was subjected to ZN stain to confirm sputum smear negativity. The second set of slides was stained collectively by fluorescent stain and observed by Labomed binocular LED Microscope with fluorescent attachment. All the data was maintained in Microsoft Office Excel for analysis Four out of 160 (2.50%) enrolled were found out to be positive on reconfirmation and excluded. Out of 156 samples subjected to fluorescent staining, thirteen samples were reported positive by two independent observers. This rise of 8.33 % over routine RNTCP method which was able to diagnose 5.88 % (10/170) cases is highly significant with P<0.017 (χ2=5.686). These 13 additional cases diagnosed constitute 92.85 % increase in case detection when compared to RNTCP method which only detected 14 cases.Fluorescence microscopy is much more effective in diagnosis of paucibacillay cases with ease of identification and less eyestrain. This article can be downloaded from www.ijpbs.ne

Community acquired Roseomonas infection in a pre-existing Tubercular lung lesion

Roseomonas are nonfermenting opportunistic Gram-negative bacilli belonging to the newly established genus of Roseomonas. The clinical experience with the species is limited and is difficult to diagnose because of limited expertise and lack of commercially available identification kits with any of the automated systems. This is a first ever reported case of secondary bacterial infection due to Roseomonas genomospecies 6 in a patient of pulmonary tuberculosis from the Indian subcontinent

Increased sensitivity of sputum microscopy with sodium hypochlorite concentration technique: A practical experience at RNTCP center

Background: In revised national tuberculosis control program (RNTCP), microscopic examination of sputum for AFB plays an important role in the initial diagnosis of tuberculosis. Bacillary concentration after decontamination and liquefaction by 5% sodium hypochlorite is useful in providing increased sensitivity and safety for handling of specimen. Materials and Methods: In this cross-sectional, prospective study, carried out at NKP Salve Institute of Medical Sciences and RC, Nagpur, patients were included according to RNTCP criteria. One set of smears was made according to the RNTCP guidelines while another set was prepared by concentration after decontamination with 5% sodium hypochlorite. Both set of smears were stained according to RNTCP method and were screened by two observers separately to remove observer′s bias and graded according to the RNTCP guidelines. A total of 591 sputum samples from 219 patients were included in the study with 168 males (76.71%) and 51 females (23.28%). Results: A total of 77 samples (13.02%) from 34 patients were positive by routine method whereas by concentration method 119 samples (20.13%) from 49 patients were found positive diagnosing 15 additional patients. This rise of 7.11% in sputum positivity over routine is highly significant (P=0.001021, x2 =10.78) with 44.11% increase in diagnosed cases. Conclusion: There is a statistically significant rise in smear positive cases after concentration with 5% sodium hypochlorite solution. Considering its low cost, decontaminating and liquefaction properties with better sensitivity, this method is safe and can be of vital importance; at least for smear negative cases