One-year clinical outcome of patients with nonvalvular atrial fibrillation: Insights from KERALA-AF registry.

BackgroundWe report patient characteristics, treatment pattern and one-year clinical outcome of nonvalvular atrial fibrillation (NVAF) from Kerala, India. This cohort forms part of Kerala Atrial Fibrillation (KERALA-AF) registry which is an ongoing large prospective study.MethodsKERALA-AF registry collected data of adults with previously or newly diagnosed atrial fibrillation (AF) during April 2016 to April 2017. A total of 3421 patients were recruited from 53 hospitals across Kerala state. We analysed one-year follow-up outcome of 2507 patients with NVAF.ResultsMean age at recruitment was 67.2 years (range 18-98) and 54.8% were males. Main co-morbidities were hypertension (61.2%), hyperlipidaemia (46.2%) and diabetes mellitus (37.2%). Major co-existing diseases were chronic kidney disease (42.1%), coronary artery disease (41.6%), and chronic heart failure (26.4%). Mean CHA2DS2-VASc score was 3.18 (SD ± 1.7) and HAS-BLED score, 1.84 (SD ± 1.3). At baseline, use of oral anticoagulants (OAC) was 38.6% and antiplatelets 32.7%. On one-month follow-up use of OAC increased to 65.8% and antiplatelets to 48.3%. One-year all-cause mortality was 16.48 and hospitalization 20.65 per 100 person years. The main causes of death were cardiovascular (75.0%), stroke (13.1%) and others (11.9%). The major causes of hospitalizations were acute coronary syndrome (35.0%), followed by arrhythmia (29.5%) and heart failure (8.4%).ConclusionsDespite high risk profile of patients in this registry, use of OAC was suboptimal, whereas antiplatelets were used in nearly half of patients. A relatively high rate of annual mortality and hospitalization was observed in patients with NVAF in Kerala AF Registry

Antibiotic consumption and its determinants in India

BACKGROUND: India—one of the most significant antibiotic users in the world with a high burden of antibiotic resistance—does not have a formal antibiotic surveillance system. No formal studies exist on the sub-national differences in antibiotic use in India except for small hospital or community-based studies. Informed by the WHO Global Action Plan, India developed a national action plan; however only two states have state action plans so far. This suggests that it is important to understand existing antibiotic consumption patterns, sub- national differences and trends over time, and the determinants of antibiotic use so that evidence-informed action plans and programs can be developed in India. AIM: To understand the changing landscape of antibiotic use in India and contribute to relevant policy and programmatic interventions that can improve the appropriate use of antibiotics in the country. Specific objectives included examining the use of systemic antibiotic consumption at the national level, analyzing geographical and temporal variations across states between 2011 and 2019, and understanding the determinants of antibiotic consumption. Additionally, we examined Kerala as a case study to understand the use and availability of data in designing, implementing, and monitoring the state antibiotic action plan. METHODOLOGY: First, we conducted a cross-sectional analysis of antibiotic use in 2019 using the WHO Access-Watch-Reserve (AWaRe) and Defined Daily Doses (DDD) matrices at the national level across product type (Fixed-Dose Combinations [FDCs]; and single formulations [SF]), essentiality (listed in the national list of essential medicines [NLEM]; and not listed), and central regulatory approval status (approved and unapproved). Second, we analyzed trends in consumption rates and patterns at the national, state, and groups of states at different levels of health achievements (‘high focus’ [HF]; and ‘non-high focus’ [nHF]) and compared the appropriateness of use between states and state groups. Third, using a cross-sectional, time series (panel) dataset on antibiotic use, per-capita GDP, per-capita government spending on health, girls' tertiary education enrollment ratio, measles vaccination coverage, and lower respiratory tract infection incidence for the period 2011- 2019, we conducted a quasi- experimental fixed-effects analysis to understand the critical determinants of antibiotic use. Finally, we conducted key-informant interviews and document analysis to understand the use of data in policy formulation, implementation, monitoring, and evaluation of the Kerala state action plan. RESULTS: India's per-capita private-sector antibiotic consumption rate was lower than global rates, but the country has a high consumption rate of broad-spectrum antibiotics, FDCs discouraged by WHO, formulations outside NLEM in FDCs, and unapproved formulations. The overall rate increased from 2011 to 2016 and decreased between 2016 and 2019, registering a net decrease of 3.6%. State consumption rates varied widely— with HF states reporting lower rates. The inappropriate use increased over the years, the share of Access antibiotics decreased (13.1%), and the access-to-watch ratio declined (from 0.59 to 0.49). HF and nHF states showed convergence in the share of the Access and the Access-Watch ratio, while they showed divergence in the use of WHO Discouraged FDCs. The most critical independent determinant of antibiotic use was government spending on health—for every US$12.9 increase in per-capita government spending on health, antibiotic use decreased by 461.4 doses per 1000 population per year after adjusting for other factors. Economic progress (increase in per-capita GDP) and social progress (increase in girls' higher education) were also found to reduce antibiotic use independently. The qualitative case study showed that stakeholders understand and express interest in generating and using data for decision- making, and the action plan document mentions some basic monitoring plans. However, a monitoring and evaluation framework is missing, there is a lack of engagement with the private sector, and there is a lack of understanding among key government policymakers on the importance of using data for surveillance and policy implementation. CONCLUSION AND IMPLICATIONS: There is significant and increasing inappropriate antibiotic use in India's private sector, accounting for 85-90% of total antibiotic use. Increased government spending on health is critical in reducing private-sector antibiotic use. The dearth of data on public sector use is a significant challenge in understanding the total consumption rate. Developing a monitoring and evaluation system through stakeholder engagement is necessary for Indian States to inform, monitor, and evaluate effective antibiotic action plans. We need global efforts to improve the science and methods to measure antibiotic use.2023-08-30T00:00:00

Modifiable risk factors of hypertension: A hospital-based case-control study from Kerala, India

Introduction: Hypertension is a major cause of cardiovascular morbidity and mortality in Kerala. Excess dietary salt, low dietary potassium, overweight and obesity, physical inactivity, excess alcohol, smoking, socioeconomic status, psychosocial stressors, and diabetes are considered as modifiable risk factors for hypertension. Objectives: To estimate and compare the distribution of modifiable risk factors among hypertensive (cases) and nonhypertensive (controls) patients and to estimate the effect relationship of risk factors. Materials and Methods: Age- and sex-matched case-control study was conducted in a tertiary care hospital in Kerala using a pretested interviewer-administered structured questionnaire based on the WHO STEPS instrument for chronic disease risk factor surveillance. Bivariate and multiple logistic regression analyses were done. Results: A total of 296 subjects were included in the study. The mean age of study sample was 50.13 years. All modifiable risk factors studied vis-ΰ-vis obesity, lack of physical activity, inadequate fruits and vegetable intake, diabetes, smoking, and alcohol use were significantly different in proportion among cases and controls. Obesity, lack of physical activity, smoking, and diabetes were found to be significant risk factors for hypertension after adjusting for other risk factors. Conclusion: Hypertension is strongly driven by a set of modifiable risk factors. Massive public awareness campaign targeting risk factors is essential in controlling hypertension in Kerala, especially focusing on physical exercise and control of diabetes, obesity, and on quitting smoking