A critical analysis of the COMPASS trial with respect to benefit-risk assessment using the numbers needed to treat: Applicability and relevance in Indian patients with stable cardiovascular disease

The recently published Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial evaluated the hypothesis that rivaroxaban alone or in combination with aspirin would be more effective than aspirin alone for secondary prevention. In India, stable cardiovascular disease occurs in a much younger age group relative to the rest of the world. Our critical analysis of COMPASS trial showed that the younger age group appeared to derive greater benefit from the rivaroxaban + aspirin combination (relative to aspirin alone) as seen with number needed to treat metrics as compared to the older age group.

Demographics of animal bite victims & management practices in a tertiary care institute in Mumbai, Maharashtra, India.

Background & objectives: Rabies is an important public health problem worldwide and more than 55,000 people die annually of the disease. The King Edward Memorial Hospital, Mumbai, is a tertiary referral centre where a rabies clinic runs 24 hours. In view of lack of information about the demographics of the disease in an urban environment the present study was carried out. Methods: Data on 1000 consecutive animal bite victims presenting to the institute in 2010 were collected over a 15 wk period. An electronic database was specially created for capturing information and was modelled on the information available from the WHO expert consultation on rabies, 2005. Economic burden from the patients’ perspective was calculated using both direct and indirect costs. Results: The victims were largely males (771 subjects). The dog was the major biting animal (891, 89.1%).Bites were mainly of Category III (783, 78.3%). One twenty three subjects used indigenous treatments only for local wound care. Of the Category III bites, only 21 of 783 (2.7%) patients were prescribed human rabies immunoglobulin (HRIG) which was primarily for severe bites or bites close to or on the face. A total of 318 patients did not complete the full Essen regime of the vaccine. The median cost to the patient per bite was ` 220 (3.5 USD). Interpretation & conclusions: Our findings showed that the use of HRIG was low with less than 2 per cent of the Category III patients being prescribed it. As vaccine and HRIG continue to remain expensive, the intradermal vaccine, shorter regimes like the Zagreb regime and monoclonal antibodies may offer safer and cost-effective options in the future. Further studies need to be done in different parts of the country.

Use of and satisfaction with complementary and alternative medicine in four chronic diseases: A cross-sectional study from India.

Background. We assessed the extent of use of complementary and alternative medicine (CAM) by patients with four chronic diseases—epilepsy, HIV, rheumatoid arthritis (RA) and diabetes mellitus (DM)—at a tertiary care, teaching hospital of allopathic medicine in India. We also assessed patients’ satisfaction with CAM. Methods. Adults attending the outpatient clinics for epilepsy, HIV, RA and DM who took CAM were recruited over a period of 16 weeks. After obtaining written informed consent, they were administered the ‘Treatment Satisfaction Questionnaire for Medication’ (TSQM)TM to assess satisfaction in domains such as effectiveness, no side-effect, convenience and global satisfaction. Results. Of the 4664 patients screened, 1619 (34.7%) were using CAM and 650 (40%) of them consented to participate. The extent of use of CAM was 63% in patients with DM, 42.7% in RA, 26.2% in HIV and 7.7% in epilepsy. Ayurveda 57.1% (95% CI 53.27–60.89) was the most frequently used CAM. Satisfaction in terms of effectiveness and global satisfaction was highest among patients with HIV (69.4% and 69.2%, respectively) and least among those who had RA (56.6% and 54.1%, respectively). High scores were reported to ‘no side-effect’ domain in all the four diseases. The proportion of physicians who were aware about their patients’ using CAM was 100% in patients with RA, 95% in HIV, 74% in epilepsy and 29% in DM. Conclusion. A large proportion of patients with four chronic diseases reporting to a hospital of allopathic medicine in India were also using CAM and were satisfied with its use. Given the potential interaction of CAM with allopathic medicines, a history of use of CAM should be elicited in clinical practice.

Use of the WOMAC questionnaire in Mumbai and the challenges of translation and cross cultural adaptation.

Patient-reported outcome measures (PROMs) are disease specific questionnaires that are being increasingly used in clinical practice and research. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), is a widely used PROM in patients with hip or knee osteoarthritis. A validated WOMAC was used by us, and significant challenges were faced in administering it as several questions did not have a cultural connect. Functionally equivalent items in the Indian context had then to be used to complete the score.

Frequency and causes for exclusion from randomization of healthy volunteers screened for a phase 1 study in India.

Background. Only a proportion of screened potential participants were actually randomized while conducting a phase 1 study of a humanized rabies monoclonal antibody. We aimed to assess the challenges in defining who is a normal volunteer and the issues that affect volunteer recruitment and thus accrual. Methods. One hundred and fifty-six volunteers were screened and 74 (47.4%) were randomized in a phase 1 study. Data on all participants screened for the study were analysed and reasons for their non-randomization were classified. Results. The reasons for volunteers not being randomized were: (i) deranged laboratory parameters (n=62); (ii) nonlaboratory causes (n=4); and (iii) withdrawal of consent (n=16). A large proportion of screen failures were due to low haemoglobin levels, which led to the protocol being amended midway during the study. An informal interview of those who declined consent showed that they had only wanted to get themselves investigated thoroughly or were interested in getting their HIV status evaluated. Conclusions. Our study shows that <50% participants screened for a phase 1 study in a developing country actually get randomized. The main reason for non-randomization is abnormal laboratory tests. This may help investigators and sponsors to plan protocols better, define normal ranges with acceptable variations based on their own populations a priori and have more pragmatic accrual targets.

Clinical research in India: great expectations?

India is considered as a preferred site for conducting global clinical trials. Existence of a large treatment-naïve population, availability of English-speaking, skilled doctors, plenty of clinical material, and cost-savings are obvious advantages for carrying out clinical research in India. However, challenges exist at various levels. Lack of formal training in bioethics and research methodology, heavy burden of clinical duties and sub-optimal administrative support restrict investigators. Absence of oversight of functioning of ethics committees (ECs) and lack of mechanisms for ensuring quality of ethics review heighten societal concerns about safety of participants. Conducting research on issues not relevant to local needs and failure to ensure post-trial access further enhance society's cynicism. These issues need to be tackled through capacity building, training of investigators and EC members, strengthening of EC functioning and encouraging greater community participation.

Effect of prazosin GITS, atenolol, nifedipine SR, and enalapril on ADP-induced platelet aggregation.

A randomized, observer-blind, parallel-group study was carried out to compare the effect of prazosin GITS, atenolol, nifedipine SR, and enalapril on platelet aggregation, measured at a time expected to coincide with trough plasma levels of these drugs. 24 patients (age-30 to 60 yrs) with uncomplicated mild to moderate hypertension who completed a placebo run-in phase successfully were recruited in this study. They were randomly allocated to one of the 4 treatments: prazosin GITS 2.5 mg OD (Group 1), atenolol 50 mg OD (Group II), nifedipine SR 20 mg BD (Group III), and enalapril 5 mg OD (Group IV). All the drugs were given for 7 days, and blood samples were collected at 0 hr on day 1 (pre-treatment) and day 8 (post-treatment). Based on the dose (incremental concentrations of ADP)--response (% maximum aggregation) curve obtained, 2.5 microM/L of ADP was used to compare % inhibition of platelet aggregation among the 4 groups. We found that prazosin GITS inhibited % maximum aggregation significantly (p = 0.02) at 2.5 microM/L of ADP. Such inhibitory effect was not seen in any of the other groups. The inhibition produced by prazosin GITS differed significantly from the action of the other 3 drugs (p < 0.05). This antiplatelet effect of prazosin GITS bears more clinical relevance in view of the fact that it was seen at a time which is expected to coincide with the trough plasma levels of prazosin.

Cardiac surgery and plasma digoxin levels.

Cardiopulmonary bypass (CPB) can induce several haemodynamic alterations and therefore influence pharmacokinetics of various drugs. In order to assess the effect of CPB on plasma digoxin levels, these were monitored in patients undergoing open heart surgery involving CPB (n = 11), over a 24 hour period, starting just prior to commencement of surgery. For comparison, plasma digoxin was also monitored in a group of patients (n = 10) who underwent cardiac surgery not involving CPB. In 7 of the 11 patients in the CPB group, plasma digoxin levels (ng/ml) were significantly (p < 0.01) lower at the end of 24 hours (0.654 +/- 0.094) than basal levels (1.3114 +/- 0.2498). In contrast, in the non CPB group, 7 of 10 patients showed significantly higher (p < 0.001) plasma levels (ng/ml) at the end of 24 hours (0.477 +/- 0.125) as compared to basal levels (0.26 +/- 0.098). Thus, rather than the type of surgery, it appears that the pre-operative levels of plasma digoxin influence its pharmacokinetics.

The influence of surgical stress on the psychoneuro-endocrine-immune axis.

Stress is known to depress the immune system severely. This study was done to evaluate whether surgical stress influenced polymorphonuclear (PMN) and monocyte functions in association with serum cortisol and the anxiety score as measured on the HARS Rating Scale. We found that surgery (irrespective of whether it was major or minor) significantly depressed PMN and monocyte functions and increased serum cortisol levels. PMN phagocytosis correlated significantly (p < 0.05) with the rise in serum cortisol. In spite of these changes, postoperative clinical recovery was uneventful. No major alterations in the HARS scores were noted pre and post operatively. This study demonstrates that surgical stress depresses the immune system with a concomitant rise in cortisol.

Tinospora cordifolia induces colony stimulating activity in serum.

Tinospora cordifolia (Tc) is an Indian medicinal plant with proven immunomodulatory activity. This study was performed to elucidate its possible mechanism of action. We measured CFU-GM Cotony forming units of the granulocyte-macrophage series in serum of mice treated with Tc. We found that 10 days treatment with Tc (100 mg/ kg/d) induced a significant (p < 0.01) increase in the number of CFU-GM (255 +/- 49.32 vs 38.51 +/- 9.98) This suggests that activation of macrophages by Tc leads to increase in GM-CSF which leads to leucocytosis and improved neutrophil function.

Involvement of prostaglandins in chilli-induced early gastric vascular damage in adult Wistar rat.

OBJECTIVE: To explore the role of prostaglandins in protecting against chilli-induced early gastric vascular damage. METHODS: Early gastric vascular damage was induced in rats by oral administration of 8 mg/Kg chilli extract. The damage was assessed by estimating spectrophotometrically the amount of Evan's blue leaking into gastric tissue and luminal contents 10 min after exposure to chilli. Further groups of rats were pretreated with misoprostol (10, 25 or 50 micrograms/Kg) or dazmegrel (1, 5 or 25 mg) to evaluate their protective effects. RESULTS: Both misoprostol and dazmegrel were able to reduce gastric vascular damage induced by chilli in a dose-dependent fashion. CONCLUSION: Prostaglandins may play a role in protecting against chilli-induced early gastric vascular damage.

A multiple dose comparison of ketorolac tromethamine with ibuprofen for analgesic activity.

This study was done to compare a new analgesic ketorolac with ibuprofen in post-operative and post-laparoscopy pain. A total of 40 patients were recruited for the study of which 20 were post-operative and 20 were post-laparoscopy cases. Medication was given over a period of 48 hours after surgery and a pain score based on subjective symptoms was monitored at fixed intervals after each dose. The analgesic efficacy of ketorolac was found to be comparable to that of ibuprofen and the drug was well tolerated in the doses used without any extra medication being required.

Immunotherapeutic modification of Escherichia coli peritonitis and bacteremia by Tinospora cordifolia.

We present here the protective effects of an Indian medicinal plant Tinospora cordifolia as compared to gentamicin in E. Coli induced peritonitis. Pretreatment with tinospora cordifolia or gentamicin reduced mortality in mice injected with 1 x 10(8) E. coli intraperitoneally from 100% in controls to 17.8% and 11.1% respectively. This was associated with significantly improved bacterial clearance as well as improved phagocytic and intracellular bactericidal capacities of neutrophils in the Tinospora cordifolia treated group. In the gentamicin treated mice although bacterial clearance was rapid, polymorph phagocytosis was depressed. Tinospora cordifolia did not possess in vitro bactericidal activity. The results demonstrate that a "prohost approach" may be beneficial in the therapy of peritonitis.