Ten-year trends of antibiotic prescribing in surgery departments of two private sector hospitals in Central India: a prospective observational study.

BACKGROUND: Inappropriate antibiotic use contributes to the global rise of antibiotic resistance, prominently in low- and middle-income countries, including India. Despite the considerable risk of surgical site infections, there is a lack of antibiotic prescribing guidelines and long-term studies about antibiotic prescribing in surgery departments in India. Therefore, this study aimed to analyse 10 years' antibiotic prescribing trends at surgery departments in two tertiary-care hospitals in Central India. METHODS: Data was prospectively collected from 2008 to 2017 for surgery inpatients in the teaching (TH-15,016) and the non-teaching hospital (NTH-14,499). Antibiotics were classified based on the World Health Organization (WHO) Access Watch Reserve system and analysed against the diagnoses and adherence to the National List of Essential Medicines India (NLEMI) and the WHO Model List of Essential Medicines (WHOMLEM). Total antibiotic use was calculated by DDD/1000 patient days. Time trends of antibiotic prescribing were analysed by polynomial and linear regressions. RESULTS: The most common indications for surgery were inguinal hernia (TH-12%) and calculus of the kidney and ureter (NTH-13%). The most prescribed antibiotics were fluoroquinolones (TH-20%) and 3rd generation cephalosporins (NTH-41%), and as antibiotic prophylaxis, norfloxacin (TH-19%) and ceftriaxone (NTH-24%). Access antibiotics were mostly prescribed (57%) in the TH and Watch antibiotics (66%) in the NTH. Culture and susceptibility tests were seldom done (TH-2%; NTH-1%). Adherence to the NLEMI (TH-80%; NTH-69%) was higher than adherence to the WHOMLEM (TH-77%; NTH-66%). Mean DDD/1000 patient days was two times higher in the NTH than in the TH (185 vs 90). Overall antibiotic prescribing significantly increased in the TH (ß1 =13.7) until 2012, and in the NTH (ß2 =0.96) until 2014, and after that decreased (TH, ß2= -0.01; NTH, ß3= -0.0005). The proportion of Watch antibiotic use significantly increased in both hospitals (TH, ß=0.16; NTH, ß=0.96). CONCLUSION: Total antibiotic use decreased in the last three (NTH) and five years (TH), whereas consumption of Watch antibiotics increased over 10 years in both hospitals. The choice of perioperative antibiotic prophylaxis was often inappropriate and antibiotic prescribing was mostly empirical. The results of this study confirmed the need for antibiotic prescribing guidelines and implementation of antimicrobial stewardship programs.

The development of an integrated environment-human risk approach for the prioritisation of antibiotics for policy decisions.

Environmental contamination with antibiotic residues has caused significant concern. Antibiotics are continually emitted into the environment which potentially threatens environmental and human health, particularly, the risk in the development of antibiotic resistance. A list of priority antibiotics in the environment is essential for eco-pharmacovigilance and policy decisions. This study developed a prioritisation system of antibiotics based on their integrated environmental (resistance and ecotoxicity) and human health (resistance and toxicity) risks, considering various aquatic environmental compartments. Data obtained by conducting a systematic review of the literature of antibiotic residues in various aquatic environmental compartments in China was used as an example. The list of priority antibiotics was created by ranking the antibiotics in descending order, based on the risk scores of their a) overall risk, (b) antibiotic resistance risk to environment, (c) ecotoxicity risk, (d) overall environmental risk, (e) antibiotic resistance risk to human health, (f) toxicity risk to human health and (g) overall human health risk. Ciprofloxacin posed the greatest risk and chloramphenicol posed the least risk. The output from this research can be used to implement eco-pharmacovigilance and to develop targeted policies which would prevent / minimise the environmental and human health risks from antibiotic residues. The use of this list of priority antibiotics will allow for a country / region / setting to (a) optimise the use of antibiotics and their prescribing practices, (b) create effective monitoring and mitigation strategies, (c) minimise the discharge of antibiotic residues and (d) focus research efforts.

A systematic synthesis of expert opinion on effective policies to tackle bacterial resistance worldwide.

Actions that are taken to preserve effective antibacterial agents and eliminate transmission of resistant organisms are crucial to prevent a catastrophic postantibiotic era. In this systematic review, we searched and appraised relevant texts and expert opinions to determine effective strategies to tackle bacterial resistance worldwide. We considered expert opinions, consensus, current discourses, comments, assumptions or assertions and discussion papers published in English. We searched following databases for expert opinion-based literature: MEDLINE, CINAHL, ISI Web of Knowledge, SCOPUS, Cochrane Central Register of Controlled Trials and World Health Organization (WHO). We extracted the textual data from texts using a standardised data extraction tool. Textual pooling was not possible, so the conclusions were presented in a narrative form. Eighteen texts were included in this review. The findings show that, the most repeated policies and strategies include implementing and strengthening bacterial resistance surveillance, developing national guidelines, improving public awareness; enhancing home and everyday life hygiene; improving prescribing patterns, improving laboratories capacity, promoting innovation and research in new drugs and technology and strengthening coordination. This review systematically gathered strategies that were recommended by textual publications. To our knowledge, this was the first systematic review of text and opinion in the field of bacterial resistance. These results can be used by policymakers, hospital managers, and governments, alongside the results of quantitative and qualitative systematic reviews.

To decipher the phytochemical agent and mechanism for Urginea indica mediated green synthesis of Ag nanoparticles and investigation of its antibacterial activity against Methicillin-resistant Staphylococcus aureus.

Globally, Methicillin-Resistant Staphylococcus aureus bacteraemia is one of the commonest bloodstream infections associated with clinical complications and high mortality. Thence, devising effective and targeted biogenic silver based strategies are in great demand. However, limited insights regarding the biosynthesis methodologies impedes the possible scale up and commercial potentials. We, hereby demonstrate the biosynthesis of Ag nanoparticles using the phytochemical agent extracted and purified from bulb extract of Urginea indica. The chemical structure of the phytochemical agent is investigated by various chromatographic and spectroscopic techniques and was found closely relatable to N-ethylacetamide. Ag nanoparticles synthesis by this agent was found to have a strong Surface Plasmon band at 402 nm. X-ray diffraction and transmission electron microscopy further validated the formation of Ag nanoparticles with face-centred cubic structure with a size range of 20-30 nm. The biogenic metal nanoparticles have shown potential antibacterial activity against S. aureus and MRSA (within a range of 10-50 µg/mL). The nanoparticles have also shown promising anti-biofim activity against the above mentioned strains. The nanoparticles were expected to induce ROS mediated bactericidal mechamism. Cell viability and in-vitro infection studies advocate noticeable biocompatibility and future clinical potential of the developed nanoparticles against Staphylococcus infections.

Factors influencing the adsorption of antibiotics onto activated carbon in aqueous media.

Widespread use of antibiotics for treating human and animal ailments has increased their discharge in the environment through excreta. Moreover, unscientific disposal of unused antibiotics has further increased their presence in the environmental matrices. Thus, occurrence of used and/or discarded antibiotics in water resources is becoming a growing concern across the globe. Antibiotics and their residues in the aquatic environment are emerging contaminants which pose a serious threat to the aquatic biota as well as human beings by enhancing antibiotic resistance. Various methods are being adopted for the removal of these contaminants. Adsorption over activated carbon is one such promising method which is environmentally friendly, cost-effective, and efficient. However, there are various factors which affect the overall process efficiency, such as, properties of activated carbon/antibiotics/reaction medium etc. In this article, emphasis has been laid down on evaluating these factors, so that the experimental procedures may be optimized to obtain the highest possible removal efficiency for antibiotics in the aqueous media.

Utility of constructed wetlands for treatment of hospital effluent and antibiotic resistant bacteria in resource limited settings: A case study in Ujjain, India.

Increasing generation of wastewater and its indiscriminate disposal is detrimental to human and animal health. Resource-limited settings often struggle for efficient wastewater treatment systems owing to lack of funds and operational difficulties. Therefore, alternative treatment systems involving low expenditure and simplistic operations are need of the hour. Constructed wetlands are one such alternative that can efficiently remove variety of pollutants from wastewater. In this study, we have assessed the utility of constructed wetlands for treatment of hospital wastewater in Ujjain. An in-house wetland system was designed and constructed using Typha latifolia and Phragmites karka. Results showed that wetland was efficient for removal of various physico-chemical and biological contaminants, namely, biochemical-oxygen-demand (77.1%), chemical-oxygen-demand (64.9%), turbidity (68.3%), suspended-solids (63%), total-phosphorus (58.7%), nitrate-nitrogen (33%), fecal coliforms (96.8%), and total coliforms (95.6%). Paired t test revealed that removal efficiencies for various parameters were significantly different among Phragmites, Typha, and control cells (p ≤ 0.05). Study also depicted that most of the bacterial isolates in inlet wastewater were selectively resistant to antibiotics (ciprofloxacin and sulphamethaxazole) as well and these isolates were also removed. Precisely, Typha was fairly suitable for antibiotic resistant bacteria removal. Thus, constructed wetlands were found to be one of the suitable options for wastewater treatment in resource-limited settings. PRACTITIONER POINTS: Constructed wetlands are one of the suitable options for wastewater treatment in resource limited settings. These systems involve wetland vegetation, soil, and associated microbial assemblages to improve the water quality. Typha and Phragmites were found to be efficient for treating the hospital wastewater. Experiments showed that antibiotic resistant bacteria may also be removed through constructed wetland systems. Easy operation, cost effectiveness, and efficiency are important attributes.

Interventions to optimize the use of antibiotics in China: A scoping review of evidence from humans, animals, and the environment from a One Health perspective.

Objectives: The overuse and misuse of antibiotics has accelerated the rapid emergence of antibiotic resistance. The aim of the study was to review interventions conducted in China to optimize use of antibiotics in humans, animals, and the environment from a One Health perspective. Methods: The literature review for this study was limited to English and Chinese articles published from January 1985 to May 2021. Literature review searches were conducted using Web of Science, Scopus, PubMed and three biomedical databases from China (the Chinese Scientific Journals database, the Wanfang Database, and China National Knowledge Infrastructure). We used Arksey and O'Malley's step-wise methodological framework as the basis for our scoping review. Results: A total of 53 studies met our inclusion criteria, of which 51 (96%) were from human healthcare settings, one from environment health that pertained to rural ponds, and no studies were found that met our criteria on interventions used to improve antibiotic use in animals. For human health, the majority of the research was related to antibiotic intervention programs performed in public institutions, and only one policy assessment study included private institutions. Interventions were classified into four broad categories: 1) Knowledge interventions; 2) decision support; 3) financial incentives; and 4) organizational/management systems. Our findings indicated that combinations of multiple interventions were more effective in promoting the rational use of antibiotics in China. Conclusions: China has made major efforts on improving rational use of antibiotics in the past decades. Most policies or interventions, however, focused mainly on the human health aspect, less effort targeted toward the environment and animal health sectors. For further optimizing use of antibiotics, the cross-disciplinary and coordinated multi-faceted interventions guided by the One Health perspective should be developed and implemented. Meanwhile, the cross-departmental collaborative mechanism leading by the Chinese central government should be further strengthened to play a greater and more active role in fighting against antibiotic resistance wholly.

Antibiotic Use, Incidence and Risk Factors for Orthopedic Surgical Site Infections in a Teaching Hospital in Madhya Pradesh, India.

Orthopedic surgeries contribute to the overall surgical site infection (SSI) events worldwide. In India, SSI rates vary considerably (1.6−38%); however, there is a lack of a national SSI surveillance system. This study aims to identify the SSI incidence, risk factors, antibiotic prescription and susceptibility patterns among operated orthopedic patients in a teaching hospital in India. Data for 1205 patients were collected from 2013 to 2016. SSIs were identified based on the European Centre for Disease Prevention and Control guidelines. The American Society for Anesthesiologists classification system was used to predict patients' operative risk. Univariable and multivariable backward stepwise logistic regressions were performed. Overall, 7.6% of patients developed SSIs over three years. The most common SSIs causative microorganism was Staphylococcus aureus (7%), whose strains were resistant to penicillin (100%), erythromycin (80%), cotrimoxazole (80%), amikacin (60%) and cefoxitin (60%). Amikacin was the most prescribed antibiotic (36%). Male sex (OR 2.64; 95%CI 1.32−5.30), previous hospitalization (OR 2.15; 95%CI 1.25−3.69), antibiotic prescription during hospitalization before perioperative antibiotic prophylaxis (OR 4.19; 95%CI 2.51−7.00) and postoperative length of stay > 15 days (OR 3.30; 95%CI 1.83−5.95) were identified as significant risk factors. Additionally, preoperative shower significantly increased the SSI risk (OR 4.73; 95%CI 2.72−8.22), which is unconfirmed in the literature so far.

'Coming home does not mean that the injury has gone'-exploring the lived experience of socioeconomic and quality of life outcomes in post-discharge trauma patients in urban India.

Trauma results in long-term socioeconomic outcomes that affect quality of life (QOL) after discharge. However, there is limited research on the lived experience of these outcomes and QOL from low - and middle-income countries. The aim of this study was to explore the different socioeconomic and QOL outcomes that trauma patients have experienced during their recovery. We conducted semi-structured qualitative interviews of 21 adult trauma patients between three to eight months after discharge from two tertiary-care public hospitals in Mumbai, India. We performed thematic analysis to identify emerging themes within the range of different experiences of the participants across gender, age, and mechanism of injury. Three themes emerged in the analysis. Recovery is incomplete-even up to eight months post discharge, participants had needs unmet by the healthcare system. Recovery is expensive-participants struggled with a range of direct and indirect costs and had to adopt coping strategies. Recovery is intersocial-post-discharge socioeconomic and QOL outcomes of the participants were shaped by the nature of social support available and their sociodemographic characteristics. Provisioning affordable and accessible rehabilitation services, and linkages with support groups may improve these outcomes. Future research should look at the effect of age and gender on these outcomes.

Antimicrobial stewardship: Attitudes and practices of healthcare providers in selected health facilities in Uganda.

Though antimicrobial stewardship (AMS) programmes are the cornerstone of Uganda's national action plan (NAP) on antimicrobial resistance, there is limited evidence on AMS attitude and practices among healthcare providers in health facilities in Uganda. We determined healthcare providers' AMS attitudes, practices, and associated factors in selected health facilities in Uganda. We conducted a cross-sectional study among nurses, clinical officers, pharmacy technicians, medical officers, pharmacists, and medical specialists in 32 selected health facilities in Uganda. Data were collected once from each healthcare provider in the period from October 2019 to February 2020. Data were collected using an interview-administered questionnaire. AMS attitude and practice were analysed using descriptive statistics, where scores of AMS attitude and practices for healthcare providers were classified into high, fair, and low using a modified Blooms categorisation. Associations of AMS attitude and practice scores were determined using ordinal logistic regression. This study reported estimates of AMS attitude and practices, and odds ratios with 95% confidence intervals were reported. We adjusted for clustering at the health facility level using clustered robust standard errors. A total of 582 healthcare providers in 32 healthcare facilities were recruited into the study. More than half of the respondents (58%,340/582) had a high AMS attitude. Being a female (aOR: 0.66, 95% CI: 0.47-0.92, P < 0.016), having a bachelor's degree (aOR: 1.81, 95% CI: 1.24-2.63, P < 0.002) or master's (aOR: 2.06, 95% CI: 1.13-3.75, P < 0.018) were significant predictors of high AMS attitude. Most (46%, 261/582) healthcare providers had fair AMS practices. Healthcare providers in the western region's health facilities were less likely to have a high AMS practice (aOR: 0.52, 95% CI 0.34-0.79, P < 0.002). In this study, most healthcare providers in health facilities had a high AMS attitude and fair AMS practice.

Measuring socioeconomic outcomes in trauma patients up to one year post-discharge: A systematic review and meta-analysis.

INTRODUCTION: Trauma accounts for nearly one-tenth of the global disability-adjusted life-years, a large proportion of which is seen in low- and middle-income countries (LMICs). Trauma can affect employment opportunities, reduce social participation, be influenced by social support, and significantly reduce the quality of life (QOL) among survivors. Research typically focuses on specific trauma sub-groups. This dispersed knowledge results in limited understanding of these outcomes in trauma patients as a whole across different populations and settings. We aimed to assess and provide a systematic overview of current knowledge about return-to-work (RTW), participation, social support, and QOL in trauma patients up to one year after discharge. METHODS: We undertook a systematic review of the literature published since 2010 on RTW, participation, social support, and QOL in adult trauma populations, up to one year from discharge, utilizing the most commonly used measurement tools from three databases: MEDLINE, EMBASE, and the Cochrane Library. We performed a meta-analysis based on the type of outcome, tool for measurement, and the specific effect measure as well as assessed the methodological quality of the included studies. RESULTS: A total of 43 articles were included. More than one-third (36%) of patients had not returned to work even a year after discharge. Those who did return to work took more than 3 months to do so. Trauma patients reported receiving moderate social support. There were no studies reporting social participation among trauma patients using the inclusion criteria. The QOL scores of the trauma patients did not reach the population norms or pre-injury levels even a year after discharge. Older adults and females tended to have poorer outcomes. Elderly individuals and females were under-represented in the studies. More than three-quarters of the included studies were from high-income countries (HICs) and had higher methodological quality. CONCLUSION: RTW and QOL are affected by trauma even a year after discharge and the social support received was moderate, especially among elderly and female patients. Future studies should move towards building more high-quality evidence from LMICs on long-term socioeconomic outcomes including social support, participation and unpaid work.

Traditional Baduanjin exercise through the eyes of patients with chronic heart failure: A qualitative content analysis study.

Objective: Baduanjin (eight silken movements) is a traditional Chinese exercise that can be used as cardiac rehabilitation therapy for patients with chronic heart failure (CHF) especially when other forms of rehabilitation are scarce or unaffordable. This study explores the experiences of Chinese patients with CHF who undertook Baduanjin exercise at home as part of a pilot trial in Guangzhou, China. Methods: We conducted seven qualitative interviews with participants who had participated in the intervention arm of a pilot randomized controlled trial (RCT) (n = 8). For data collection, we used a semi-structured interview guide with both open-ended, and follow-up questions. We audio recorded the interviews, transcribed them verbatim, and then analyzed them with content analysis. Results: Participants' experiences of doing Baduanjin were classified into three categories: (1) improving practice (2) factors facilitating good exercise adherence, and (3) feeling good. Participants reported that the exercises were easy but that the correct Baduanjin execution and coordination between the mind, movements, and breathing were only achievable through practice. In addition, the training benefits which they perceived were the predominant motivation for patients to keep practicing. Finally, trust in Baduanjin, personal attitudes toward health, flexibility in practice times, as well as social support helped the participants to achieve good adherence to home-based training. Conclusion: This study's findings indicate that Baduanjin could be a cardiac rehabilitation exercise modality for patients with CHF in China, especially in a home-based setting.

Knowledge, Attitudes, Perception and Reported Practices of Healthcare Providers on Antibiotic Use and Resistance in Pregnancy, Childbirth and Children under Two in Lao PDR: A Mixed Methods Study.

BACKGROUND: Overuse and misuse of antibiotics contribute unnecessarily to antibiotic resistance (ABR), and are thereby global health threats. Inappropriate prescriptions of antibiotics during pregnancy, delivery and early childhood are widespread across the world. This study aimed to assess knowledge, attitudes, and reported practices of healthcare providers (HCPs) and to explore their perceptions regarding antibiotic use and ABR related to pregnancy, childbirth, and children under two in Lao PDR. METHODS: This is a mixed methods study with data collection in 2019 via structured interviews among 217 HCPs (medical doctors/assistant doctors, midwives/nurses, pharmacists/assistant pharmacists and drug sellers), who prescribed/dispensed antibiotics in one rural and one urban district in Vientiane province and individual qualitative interviews with 30 HCPs and stakeholders. RESULTS: Of the HCPs, 36% had below average knowledge regarding antibiotic use and ABR, and 67% reported prescribing antibiotics for uncomplicated vaginal delivery. Half of the HCPs did not believe that their prescribing contributed to ABR, and only 9% had participated in antibiotic education. CONCLUSION: A substantial number of HCPs had suboptimal knowledge and prescribed antibiotics unnecessarily, thereby contributing to ABR. Continuous education and regular supervision of HCPs is recommended to improve the use of antibiotics related to pregnancy, childbirth, and young children.

Measuring post-discharge socioeconomic and quality of life outcomes in trauma patients: a scoping review.

PURPOSE: Trauma is a global public health challenge. Measuring post-discharge socioeconomic and quality-of-life outcomes can help better understand and reduce the consequences of trauma. METHODS: We performed a scoping review to map the existing research on post-discharge outcomes for trauma patients, irrespective of the country or setting in which the study was performed. The scoping review was conducted by searching six databases - MEDLINE, EMBASE, the Cochrane Library, Global Index Medicus, BASE, and Web of Science - to identify all articles that report post-discharge socioeconomic or quality of life outcomes in trauma patients from 2009 to 2018. RESULTS: Seven hundred fifty-eight articles were included in this study, extracting 958 outcomes. Most studies (82%) were from high-income countries (HICs). More studies from low- and middle-income countries (LMICs) were cross-sectional (71%) compared with HIC settings (46%). There was a wide variety of different definitions, interpretations, and measurements used by various articles for similar outcomes. Quality of life, return to work, social support, cost, and participation were the main outcomes studied in post-discharge trauma patients. CONCLUSIONS: The wide range of outcomes and outcome measures reported across different types of injuries and settings. This variability can be a barrier when comparing across different types of injuries and settings. Post-discharge trauma studies should move towards building evidence based on standardized measurement of outcomes.

Feasibility and Preliminary Effects of the BESMILE-HF Program on Chronic Heart Failure Patients: A Pilot Randomized Controlled Trial.

Aims: The Baduanjin Eight-Silken-Movements wIth Self-Efficacy building for Heart Failure (BESMILE-HF) program is a contextually adapted cardiac rehabilitation program. It uses a traditional Chinese exercise, Baduanjin, to solve the unmet demand of exercise-based cardiac rehabilitation programs due to their scarcity and unaffordability in China. This pilot study assesses BESMILE-HF's feasibility and preliminary effects. Methods: Eighteen patients with chronic heart failure were included: 8 in a BESMILE-HF group (age: 67 ± 5 years, EF: 40.4 ± 13.6%) and 10 in a control group (age: 70 ± 13 years, EF: 42.9 ± 12.5%). Both received the usual medications, with the intervention group receiving additionally the BESMILE-HF program for 6 weeks. Feasibility was explored by participants' involvement in the intended intervention. Clinical outcome assessments were conducted at baseline and post-intervention, while adverse events were captured throughout the study period. Results: The BESMILE-HF program was well-received by patients, and adherence to the intervention was good. The intervention group completed all required home exercises and total home-practice time was correlated with baseline self-efficacy (r = 0.831, p = 0.011). Moreover, after 6 weeks, self-efficacy increased in the BESMILE-HF group (p = 0.028) and the change was higher than in the control [mean difference (MD): 3.2; 95% confidence interval (CI) 0.6-5.9, p = 0.004]. For the exercise capacity, the control group demonstrated a significant decline in peak oxygen consumption (p =0.018) whereas, the BESMILE-HF group maintained their exercise capacity (p = 0.063). Although the between-group difference was not statistically significance, there was clear clinical improvement in the BESMILE-HF group (1.5 mL/kg/min, 95% CI, -0.3 to 3.2 vs. minimal clinically important difference of 1 mL/kg/min). Throughout the study period, no adverse events related to the intervention were captured. Conclusions: BESMILE-HF is feasible for patients with chronic heart failure in Chinese settings. A larger sample size and a longer follow-up period is needed to confirm its benefit on clinical outcomes. Clinical Trial Registration:ClinicalTrials.gov: NCT03180320.

TaiChi and Qigong for Depressive Symptoms in Patients with Chronic Heart Failure: A Systematic Review with Meta-Analysis.

BACKGROUND: Depression is a debilitating comorbidity of heart failure (HF) that needs assessment and management. Along with mind-body exercise to deal with HF with depression, the use of TaiChi and/or Qigong practices (TQPs) has increased. Therefore, this systematic review assesses the effects of TQPs on depression among patients with HF. METHODS: Randomized controlled trials (RCTs) that examined the effect of TQPs on depression in patients with HF were searched by five databases (PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, CINAHL, and China National Knowledge Infrastructure (CNKI)). With standardized mean difference (SMD) and 95% confidence intervals (95% CI), random-effects meta-analyses of the effect of TQPs on depressive symptoms were performed. RESULTS: Of eight included RCTs, seven (481 patients) provided data for the meta-analysis. The pooling revealed that TQPs contribute to depression remission in HF (SMD -0.66; 95% CI -0.98 to -0.33, P < 0.0001; I 2 = 64%). Its antidepressive effect was not influenced by intervention duration or exercise setting, but rather by ejection fraction subtype, depressive severity, and depression instruments. The beneficial effects were preserved when the study with the largest effect was removed. CONCLUSION: This study suggests that TQPs might be a good strategy for alleviating depressive symptoms in patients with HF. And rigorous-design RCTs, which focus on the identified research gaps, are needed to further establish the therapeutic effects of TQPs for depression in HF.

Effects of improved information and volunteer support on segregation of solid waste at the household level in urban settings in Madhya Pradesh, India (I-MISS): protocol of a cluster randomized controlled trial.

BACKGROUND: Segregation of household waste at the source is an effective and sustainable strategy for management of municipal waste. However, household segregation levels remain insufficient as waste management approaches are mostly top down and lack local support. The realisation and recognition of effective, improved and adequate waste management may be one of the vital drivers for attaining environmental protection and improved health and well-being. The presence of a local level motivator may promote household waste segregation and ultimately pro-environmental behaviour. The present cluster randomized control trial aims to understand if volunteer based information on waste segregation (I-MISS) can effectively promote increased waste segregation practices at the household level when compared with existing routine waste segregation information in an urban Indian setting. METHODS: This paper describes the protocol of an 18 month two-group parallel,cluster randomised controlled trialin the urban setting of Ujjain, Madhya Pradesh, India. Randomization will be conducted at ward level, which is the last administrative unit of the municipality. The study will recruit 425 households in intervention and control groups. Assessments will be performed at baseline (0 months), midline (6 months), end line (12 months) and post intervention (18 months). The primary outcome will be the comparison of change in proportion of households practicing waste segregation and change in proportion of mis-sorted waste across the study period between the intervention and control groups as assessed by pick analysis. Intention to treat analysis will be conducted. Written informed consent will be obtained from all participants. DISCUSSION: The present study is designed to study whether an external motivator, a volunteer selected from the participating community and empowered with adequate training, could disseminate waste segregation information to their community, thus promoting household waste segregation and ultimately pro-environmental behaviour. The study envisages that the volunteers could link waste management service providers and the community, give a local perspective to waste management, and help to change community habits through information, constant communication and feedback. TRIAL REGISTRATION: The study is registered prospectively with Indian Council of Medical Research- Clinical Trial Registry of India ( CTRI/2020/03/024278 ).

Effect and safety of Chinese herbal medicine granules in patients with severe coronavirus disease 2019 in Wuhan, China: a retrospective, single-center study with propensity score matching.

BACKGROUND: Chinese herbal medicine (CHM) has been used for severe illness caused by coronavirus disease 2019 (COVID-19), but its treatment effects and safety are unclear. PURPOSE: This study reviews the effect and safety of CHM granules in the treatment of patients with severe COVID-19. METHODS: We conducteda single-center, retrospective study on patients with severe COVID-19 in a designated hospital in Wuhan from January 15, 2020 to March 30, 2020. The propensity score matching (PSM) was used to assess the effect and safety of the treatment using CHM granules. The ratio of patients who received treatment with CHM granules combined with usual care and those who received usual care alone was 1:1. The primary outcome was the time to clinical improvement within 28 days, defined as the time taken for the patients' health to show improvement by decline of two categories (from the baseline) on a modified six-category ordinal scale, or to be dischargedfrom the hospital before Day 28. RESULTS: Using PSM, 43 patients (45% male) aged 65.6 (57-70) yearsfrom each group were exactly matched. No significant difference was observed in clinical improvement of patients treated with CHM granules compared with those who received usual (p = 0.851). However, the use of CHM granules reduced the 28-day mortality (p = 0.049) and shortened the duration of fever (4 days vs. 7 days, p = 0.002). The differences in the duration of cough and dyspnea and the difference in lung lesion ratio on computerized tomography scans were not significant.Commonly,patients in the CHM group had an increased D-dimer level (p = 0.036). CONCLUSION: Forpatients with severe COVID-19, CHM granules, combined with usual care, showed no improvement beyond usual care alone. However, the use of CHM granules reduced the 28-day mortality rate and the time to fever alleviation. Nevertheless, CHM granules may be associated with high risk of fibrinolysis.