Estimating the potential impact of a health tax on the demand for unhealthy food and beverages and on tax revenue in India.

Foods high in fat, sugar or salt are important contributors to the rising burden of non-communicable diseases globally and in India. Health taxes (HTs) have been used by over 70 countries as an effective tool for reducing consumption of sugar sweetened beverages (SSBs). However, the potential impacts of HTs on consumption and on revenues have not been estimated in India. This paper aims to estimate the potential impact of health taxes on the demand for sugar, SSBs and foods high in fat, sugar or salt (HFSS) in India while exploring its impact on tax revenues. PE of sugar was estimated using Private Final Consumption Expenditure and Consumer Price Index data while price elasticities for SSBs and HFSS were obtained from literature. The reduction in demand was estimated for an additional 10-30% HT added to the current goods and services tax, for varying levels of price elasticities. The results show that for manufacturers of sweets and confectionaries who buy sugar in bulk and assuming a higher price elasticity of -0.70, 20% additional HT (total tax 48%) would result in 13-18% decrease in the demand for sugar used for confectionaries and sweets. For SSBs, HT of 10-30% would result in 7-30% decline in the demand of SSBs. For HFSS food products, 10-30% HT would result in 5-24% decline in the demand for HFSS products. These additional taxes would increase tax revenues for the government by 12-200% across different scenarios. Taxing unhealthy foods is likely to reduce demand, while increasing government revenues for reinvestment back into public health programmes and policies that may reduce obesity and the incidence of non-communicable diseases in India.

Glycocalix[4]arenes and their affinity to a library of galectins: the linker matters.

Galectins are lectins that bind ß-galactosides. They are involved in important extra- and intracellular biological processes such as apoptosis, and regulation of the immune system or the cell cycle. High-affinity ligands of galectins may introduce new therapeutic approaches or become new tools for biomedical research. One way of increasing the low affinity of ß-galactoside ligands to galectins is their multivalent presentation, e.g., using calixarenes. We report on the synthesis of glycocalix[4]arenes in cone, partial cone, 1,2-alternate, and 1,3-alternate conformations carrying a lactosyl ligand on three different linkers. The affinity of the prepared compounds to a library of human galectins was determined using competitive ELISA assay and biolayer interferometry. Structure-affinity relationships regarding the influence of the linker and the core structure were formulated. Substantial differences were found between various linker lengths and the position of the triazole unit. The formation of supramolecular clusters was detected by atomic force microscopy. The present work gives a systematic insight into prospective galectin ligands based on the calix[4]arene core.

Tuning a pyrazoline-based fluorogenic reagent, 3-naphthyl-1-(4-trifluoromethyl)-5-(4-carboxy phenyl)-2-pyrazoline for sensitive precolumn derivatization of aliphatic alcohols and trace analysis by RP-HPLC with fluorescence detection.

A new member of the pyrazoline family, 3-naphthyl-1-(4-trifluoromethyl)-5-(4-carboxy phenyl)-2-pyrazoline has been evaluated as a precolumn derivatization reagent for the analysis of primary alcohols using HPLC. The simultaneous separation of eight alcohol derivatives (C1 -C8 ) within 15 min was achieved on a reverse-phase C8 column with an isocratic elution mode. The derivatives were detected with fluorescence at an emission wavelength of 470 nm when excited at 360 nm. The identification of the corresponding derivatives was carried out by LC-MS/MS and all showed their characteristic parent peak in negative ion mode. The proposed method was validated using normal analytical tools and was found to be excellent. As a preliminary application, our method was used to determine ethanol concentration in alcohol-containing chocolates and cough syrup.

Does the safe childbirth checklist (SCC) program save newborn lives? Evidence from a realistic quasi-experimental study, Rajasthan, India.

BACKGROUND: The WHO Safe Childbirth Checklist (SCC) is a facility-based reminder tool focusing on essential care to improve quality of intrapartum care. We aimed to assess the impact of an intervention package using the SCC tool on facility-based stillbirths (SBs) and very early neonatal deaths (vENDs), in Rajasthan, India. METHODS: Within a quasi-experimental framework, districts were selected as intervention or comparison, matched by annual delivery load. The SCC tool was introduced at all district and sub-district level health facilities in the seven intervention districts, followed by monthly supportive supervision visits. In addition, supply of drugs and equipment were facilitated in all facilities (2013-2015). Facilities in the comparison districts provided routine care. Analysis included only the facilities with a specialized newborn care unit and information on all births was collected from facility registers. The primary outcome was the combined facility-based stillbirths and very early neonatal deaths (within 3-days after birth). We used generalized estimating equation with a Poisson regression model, with time as a linear term and adjusted for facility type in our model to estimate the effect of the intervention. [ClinicalTrials.gov: NCT01994304]. RESULTS: 77,239 births were recorded from 19 intervention facilities and 59,800 births from 15 comparison facilities. The intervention facilities reported 1621 stillbirths and 505 vENDs compared to 1390 stillbirths and 420 vENDs from the comparison facilities (RR 0.89, CI 0.81, 0.97). This translated to 11.16% (p = 0.01) reduction in total mortality (11.39% in stillbirths alone) in the intervention facilities. CONCLUSION: Our results suggest that the SCC program is an effective intervention that could potentially avert 40,000 intrapartum deaths in India annually, most of reduction coming from prevention of stillbirths.

Promoting school climate and health outcomes with the SEHER multi-component secondary school intervention in Bihar, India: a cluster-randomised controlled trial.

BACKGROUND: School environments affect health and academic outcomes. With increasing secondary school retention in low-income and middle-income countries, promoting quality school social environments could offer a scalable opportunity to improve adolescent health and wellbeing. METHODS: We did a cluster-randomised trial to assess the effectiveness of a multi-component whole-school health promotion intervention (SEHER) with integrated economic and process evaluations in grade 9 students (aged 13-14 years) at government-run secondary schools in the Nalanda district of Bihar state, India. Schools were randomly assigned (1:1:1) to three groups: the SEHER intervention delivered by a lay counsellor (the SEHER Mitra [SM] group), the SEHER intervention delivered by a teacher (teacher as SEHER Mitra [TSM] group), and a control group in which only the standard government-run classroom-based life-skills Adolescence Education Program was implemented. The primary outcome was school climate measured with the Beyond Blue School Climate Questionnaire (BBSCQ). Students were assessed at the start of the academic year (June, 2015) and again 8 months later at the end of the academic year (March, 2016) via self-completed questionnaires. This study is registered with ClinicalTrials.gov, number NCT02484014. FINDINGS: Of the 112 eligible schools in the Nalanda district, 75 were randomly selected to participate in the trial. We randomly assigned 25 schools to each of the three groups. One school subsequently dropped out of the TSM group, leaving 24 schools in this group. The baseline survey included a total of 13 035 participants, and the endpoint survey included 14 414 participants. Participants in the SM-delivered intervention schools had substantially higher school climate scores at endpoint survey than those in the control group (BBSCQ baseline-adjusted mean difference [aMD] 7·57 [95% CI 6·11-9·03]; effect size 1·88 [95% CI 1·44-2·32], p<0·0001) and the TSM-delivered intervention (aMD 7·57 [95% CI 6·06-9·08]; effect size 1·88 [95% CI 1·43-2·34], p<0·0001). There was no effect of the TSM-delivered intervention compared with control (aMD -0·009 [95% CI -1·53 to 1·51], effect size 0·00 [95% CI -0·45 to 0·44], p=0·99). Compared with the control group, participants in the SM-delivered intervention schools had moderate to large improvements in the secondary outcomes of depression (aMD -1·23 [95% CI -1·89 to -0·57]), bullying (aMD -0·91 [95% CI -1·15 to -0·66]), violence victimisation (odds ratio [OR] 0·62 [95% CI 0·46-0·84]), violence perpetration (OR 0·68 [95% CI 0·48-0·96]), attitude towards gender equity (aMD 0·41 [95% CI 0·21-0·61]), and knowledge of reproductive and sexual health (aMD 0·29 [95% CI 0·06-0·53]). Similar results for these secondary outcomes were noted for the comparison between SM-delivered intervention schools and TSM-delivered intervention schools (depression: aMD -1·23 [95% CI -1·91 to -0·55]; bullying: aMD -0·83 [95% CI -1·08 to -0·57]; violence victimisation: OR 0·49 [95% CI 0·35-0·67]; violence perpetration: OR 0·49 [95% CI 0·34-0·71]; attitude towards gender equity: aMD 0·23 [95% CI 0·02-0·44]; and knowledge of reproductive and sexual health: aMD 0·22 [95% CI -0·02 to 0·47]). However, no effects on these secondary outcomes were observed for the TSM-delivered intervention schools compared with the control group (depression: aMD -0·03 [95% CI -0·70 to 0·65]; bullying: aMD -0·08 [95% CI -0·34 to 0·18]; violence victimisation: OR 1·27 [95% CI 0·93-1·73]; violence perpetration: OR 1·37 [95% CI 0·95-1·95]; attitude towards gender equity: aMD 0·17 [95% CI -0·09 to 0·38]; and knowledge of reproductive and sexual health: aMD 0·06 [95% CI -0·18 to 0·32]). INTERPRETATION: The multi-component whole-school SEHER health promotion intervention had substantial beneficial effects on school climate and health-related outcomes when delivered by lay counsellors, but no effects when delivered by teachers. Future research should focus on the evaluation of the scaling up of the SEHER intervention in diverse contexts and delivery agents. FUNDING: John D. and Catherine T. MacArthur Foundation, USA and the United Nations Population Fund India Office.

Spectral and theoretical study on complexation of sulfamethoxazole with ß- and HPß-cyclodextrins in binary and ternary systems.

The inclusion complexes of sulfamethoxazole (SMX) with ß-cyclodextrin (ßCD) and (2-hydroxypropyl) ß-cyclodextrin (HPßCD) were prepared. Fluorescence spectroscopy and electrospray mass spectrometry, ESI-MS, were used to investigate and characterize the inclusion complexation of SMX with cyclodextrins in solutions. Whereas in the solid state the complexes were characterized by Fourier transform infrared spectroscopy (FTIR), powder X-ray diffraction (PXRD) and Raman techniques. Enhanced twisted intramolecular charge transfer (TICT), emission as well as local excited (LE) bands were observed upon addition of HPßCD indicate that SMX enters deeper into the cyclodextrins cavity. The stoichiometries and association constants of these complexes have been determined by monitoring the fluorescence data. The effect of presence of ternary components like arginine and cysteine on the complexation efficiency of SMX with cyclodextrins was investigated. Molecular Dynamic simulations were also performed to shed an atomistic insight into the complexation mechanism. The results obtained showed that complexes of SMX with both cyclodextrins are stabilized in aqueous media by strong hydrogen bonding interactions.

Tuning the constrained photophysics of a pyrazoline dye 3-naphthyl-1-phenyl-5-(4-carboxyphenyl)-2-pyrazoline inside the cyclodextrin nanocavities: A detailed insight via experimental and theoretical approach.

The modulation in the photophysics of a pyrazoline dye 3-naphthyl-1-phenyl-5-(4-carboxyphenyl)-2-pyrazoline (NPCP), when it drifts from bulk water into the nanocages of aqueous cyclodextrin solutions was investigated. The intramolecular charge transfer (ICT) fluorescence band intensity was found to increase with a blue shift in the presence of cyclodextrins. The results from 1H NMR and 1HH COSY NMR spectral analysis clearly points out the position of pyrazoline ring inside the cavity and its role in complexation process. A quantitative assessment of the emission intensity data on Benesi-Hildebrand (B-H) equation along with ESI-MS spectra reveals the probable stoichiometry of NPCP-CD complexes. Molecular docking and molecular dynamics studies were conducted for ß/γ cyclodextrin associated inclusion complexes of NPCP. The results obtained by computational studies are in good relation with the data obtained through experimental methods and both ascertain the encapsulation of NPCP into cyclodextrins.

Limited Effectiveness of a Skills and Drills Intervention to Improve Emergency Obstetric and Newborn Care in Karnataka, India: A Proof-of-Concept Study.

OBJECTIVE: The majority of the maternal and perinatal deaths are preventable through improved emergency obstetric and newborn care at facilities. However, the quality of such care in India has significant gaps in terms of provider skills and in their preparedness to handle emergencies. We tested the feasibility, acceptability, and effectiveness of a "skills and drills" intervention, implemented between July 2013 and September 2014, to improve emergency obstetric and newborn care in the state of Karnataka, India. METHODS: Emergency drills through role play, conducted every 2 months, combined with supportive supervision and a 2-day skills refresher session were delivered across 4 sub-district, secondary-level government facilities by an external team of obstetric and pediatric specialists and nurses. We evaluated the intervention through a quasi-experimental design with 4 intervention and 4 comparison facilities, using delivery case sheet reviews, pre- and post-knowledge tests among providers, objective structured clinical examinations (OSCEs), and qualitative in-depth interviews. Primary outcomes consisted of improved diagnosis and management of selected maternal and newborn complications (postpartum hemorrhage, pregnancy-induced hypertension, and birth asphyxia). Secondary outcomes included knowledge and skill levels of providers and acceptability and feasibility of the intervention. RESULTS: Knowledge scores among providers improved significantly in the intervention facilities; in obstetrics, average scores between the pre- and post-test increased from 49% to 57% (P=.006) and in newborn care, scores increased from 48% to 56% (P=.03). Knowledge scores in the comparison facilities were similar but did not improve significantly over time. Skill levels were significantly higher among providers in intervention facilities than comparison facilities (mean objective structured clinical examination scores for obstetric skills: 55% vs. 46%, respectively; for newborn skills: 58% vs. 48%, respectively; P<.001 for both obstetric and newborn), along with their confidence in managing complications. However, this did not result in significant differences in correct diagnosis and management of complications between intervention and comparison facilities. Shortage of trained nurses and doctors along with unavailability of a consistent supply chain was cited by most providers as major health systems barriers affecting provision of care. CONCLUSIONS: Improvements in knowledge, skills, and confidence levels of providers as a result of the skills and drills intervention was not sufficient to translate into improved diagnosis and management of maternal and newborn complications. System-level changes including adequate in-service training may also be necessary to improve maternal and newborn outcomes.

Adoption and Completeness of Documentation Using a Structured Delivery Record in Secondary Care, Subdistrict Government Hospitals of Karnataka State, India.

OBJECTIVE: Poor medical record documentation remains a pervasive problem in hospital delivery rooms, hampering efforts aimed at improving the quality of maternal and neonatal care in resource-limited settings. We evaluated the feasibility and completeness of labor room documentation within a quasi-experimental study aimed at improving emergency preparedness for obstetric and neonatal emergencies in 8 nonteaching, subdistrict, secondary care hospitals of Karnataka state, India. METHODS: We redesigned the existing open-ended case sheet into a structured, delivery record cum job aide adhering to principles of local clinical relevance, parsimony, and computerizability. Skills and emergency drills training along with supportive supervision were introduced in 4 "intervention arm" hospitals while the new delivery records were used in eight intervention and control hospitals. RESULTS: Introduction of the new delivery record was feasible over a "run-in" period of 4 months. About 92% (6103 of 6634) of women in intervention facilities and 80% (6205 of 7756) in control facilities had their delivery records filled in during the 1-year study period. Completeness of delivery record documentation fell into one of two subsets with one set of parameters being documented with minimal inputs (in both intervention and control sites) and another set of parameters requiring more intensive training efforts (and seen more in intervention than in control sites; P < .05). CONCLUSION: Under the stewardship of the local government, it was possible to institute a robust, reliable, and valid medical record documentation system as part of efforts to improve intrapartum and postpartum maternal and newborn care in hospitals.

Estimation of perinatal mortality rate for institutional births in Rajasthan state, India, using capture-recapture technique.

OBJECTIVE: The objective of our investigation was to estimate the perinatal mortality rate among institutional births and to compare the sensitivities of different data collection methods. SETTING: A hospital-based prospective cohort study was undertaken during late-2012 in 21 public sector health facilities of 10 districts of the northern state of Rajasthan, India. PARTICIPANTS: A total of 6872 births were included in this epidemiological study. PRIMARY AND SECONDARY OUTCOME MEASURES: Perinatal mortality rate of institutional births was the primary outcome. Sensitivities of 'active' and passive' data collection methods were the secondary outcome measures. METHODS: All stillbirth data were from routine government records ('passive system'); early neonatal outcome data from government records ('passive') were compared against the method of 'phone-tracking' of outcomes through the community health worker ('active system'). The Lincoln-Petersen formula for capture-recapture method was used to calculate the probable missing number of early neonatal deaths and thereby estimate the institutional perinatal mortality rate. RESULTS: Ratio of births in district:subdistrict facilities was 55:45. The estimated perinatal mortality rate (95% CI) by capture-recapture method was 35.8 (34 to 37) per 1000 births. The sensitivity of the passive system was 87-89% while the sensitivity of the active system was 91%. Three-fourths of perinatal deaths were documented as stillbirths. However, for these reported intrauterine deaths or stillbirths, clinical classification by typologies (term vs preterm; intrapartum vs antepartum; macerated vs fresh; with or without congenital anomalies) was absent in the recording system. CONCLUSIONS: Capture-recapture technique can be used to estimate the institutional perinatal mortality rate and also to assess the level of under-reporting by the 'passive' government reporting system. This can subsequently be used for monitoring of trends and studying the impact of health interventions. Accurate clinical categorisation of perinatal deaths is also recommended for improving quality of care.

Study on the spectral and inclusion properties of a sensitive dye, 3-naphthyl-1-phenyl-5-(5-fluoro-2-nitrophenyl)-2-pyrazoline, in solvents and ß-cyclodextrin.

3-Naphthyl-1-phenyl-5-(5-fluoro-2-nitrophenyl)-2-pyrazoline (NPFP), a fluorogenic probe and its derivative NPFP-Phenylephrine were synthesized and their absorption and fluorescence properties were recorded in solvents of varying polarity. Spectroscopic studies reveal that, the solvatochromic behavior of the compounds depend not only on the polarity but also on the hydrogen-bonding properties of the solvents. The effects of ß-cyclodextrin on the fluorescence properties of both compounds were studied. It was found that there is an enhancement in the fluorescence intensity of labeled drug (NPFP-Phenylephrine) in the presence of ß-cyclodextrin. In the present study, the molecular motions of NPFP-Phenylephrine embedded in a ß-cyclodextrin cavity have been investigated by fluorescence techniques in steady-state and time resolved modes.

Fostering maternal and newborn care in India the Yashoda way: does this improve maternal and newborn care practices during institutional delivery?

BACKGROUND: The Yashoda program, named after a legendary foster-mother in Indian mythology, under the Norway-India Partnership Initiative was launched as a pilot program in 2008 to improve the quality of maternal and neonatal care at facilities in select districts of India. Yashodas were placed mainly at district hospitals, which are high delivery load facilities, to provide support and care to mothers and newborns during their stay at these facilities. This study presents the results from the evaluation of this intervention in two states in India. METHODS: Data collection methods included in-depth interviews with healthcare providers and mothers and a survey of mothers who had recently delivered within a quasi-experimental design. Fifty IDIs were done and 1,652 mothers who had delivered in the past three months were surveyed during 2010 and 2011. RESULTS: A significantly higher proportion of mothers at facilities with Yashodas (55 percent to 97 percent) received counseling on immunization, breastfeeding, family planning, danger signs, and nutrition compared to those in control districts (34 percent to 66 percent). Mothers in intervention facilities were four to five times more likely to receive postnatal checks than mothers in control facilities. Among mothers who underwent cesarean sections, initiation of breastfeeding within five hours was 50 percent higher in intervention facilities. Mothers and families also reported increased support, care and respect at intervention facilities. CONCLUSION: Yashoda as mothers' aide thus seems to be an effective intervention to improve quality of maternal and newborn care in India. Scaling up of this intervention is recommended in district hospitals and other facilities with high volume of deliveries.

Advancing cervical cancer prevention in India: implementation science priorities.

Cervical cancer is the leading cause of cancer mortality in India, accounting for 17% of all cancer deaths among women aged 30 to 69 years. At current incidence rates, the annual burden of new cases in India is projected to increase to 225,000 by 2025, but there are few large-scale, organized cervical cancer prevention programs in the country. We conducted a review of the cervical cancer prevention research literature and programmatic experiences in India to summarize the current state of knowledge and practices and recommend research priorities to address the gap in services. We found that research and programs in India have demonstrated the feasibility and acceptability of cervical cancer prevention efforts and that screening strategies requiring minimal additional human resources and laboratory infrastructure can reduce morbidity and mortality. However, additional evidence generated through implementation science research is needed to ensure that cervical cancer prevention efforts have the desired impact and are cost-effective. Specifically, implementation science research is needed to understand individual- and community-level barriers to screening and diagnostic and treatment services; to improve health care worker performance; to strengthen links among screening, diagnosis, and treatment; and to determine optimal program design, outcomes, and costs. With a quarter of the global burden of cervical cancer in India, there is no better time than now to translate research findings to practice. Implementation science can help ensure that investments in cervical cancer prevention and control result in the greatest impact.

Advancing cervical cancer prevention in India: implementation science priorities.

Cervical cancer is the leading cause of cancer mortality in India, accounting for 17% of all cancer deaths among women aged 30 to 69 years. At current incidence rates, the annual burden of new cases in India is projected to increase to 225,000 by 2025, but there are few large-scale, organized cervical cancer prevention programs in the country. We conducted a review of the cervical cancer prevention research literature and programmatic experiences in India to summarize the current state of knowledge and practices and recommend research priorities to address the gap in services. We found that research and programs in India have demonstrated the feasibility and acceptability of cervical cancer prevention efforts and that screening strategies requiring minimal additional human resources and laboratory infrastructure can reduce morbidity and mortality. However, additional evidence generated through implementation science research is needed to ensure that cervical cancer prevention efforts have the desired impact and are cost-effective. Specifically, implementation science research is needed to understand individual- and community-level barriers to screening and diagnostic and treatment services; to improve health care worker performance; to strengthen links among screening, diagnosis, and treatment; and to determine optimal program design, outcomes, and costs. With a quarter of the global burden of cervical cancer in India, there is no better time than now to translate research findings to practice. Implementation science can help ensure that investments in cervical cancer prevention and control result in the greatest impact.

Investment case for improving maternal and child health: results from four countries.

BACKGROUND: Without addressing the constraints specific to disadvantaged populations, national health policies such as universal health coverage risk increasing equity gaps. Health system constraints often have the greatest impact on disadvantaged populations, resulting in poor access to quality health services among vulnerable groups. METHODS: The Investment Cases in Indonesia, Nepal, Philippines, and the state of Orissa in India were implemented to support evidence-based sub-national planning and budgeting for equitable scale-up of quality MNCH services. The Investment Case framework combines the basic setup of strategic problem solving with a decision-support model. The analysis and identification of strategies to scale-up priority MNCH interventions is conducted by in-country planners and policymakers with facilitation from local and international research partners. RESULTS: Significant variation in scaling-up constraints, strategies, and associated costs were identified between countries and across urban and rural typologies. Community-based strategies have been considered for rural populations served predominantly by public providers, but this analysis suggests that the scaling-up of maternal, newborn, and child health services requires health system interventions focused on 'getting the basics right'. These include upgrading or building facilities, training and redistribution of staff, better supervision, and strengthening the procurement of essential commodities. Some of these strategies involve substantial early capital expenditure in remote and sparsely populated districts. These supply-side strategies are not only the 'best buys', but also the 'required buys' to ensure the quality of health services as coverage increases. By contrast, such public supply strategies may not be the 'best buys' in densely populated urbanised settings, served by a mix of public and private providers. Instead, robust regulatory and supervisory mechanisms are required to improve the accessibility and quality of services delivered by the private sector. They can lead to important maternal mortality reductions at relatively low costs. CONCLUSIONS: National strategies that do not take into consideration the special circumstances of disadvantaged areas risk disempowering local managers and may lead to a "business-as-usual" acceptance of unreachable goals. To effectively guide health service delivery at a local level, national plans should adopt typologies that reflect the different problems and strategies to scale up key MNCH interventions.

A cost-effectiveness analysis of India's 2008 prohibition of smoking in public places in Gujarat.

Tobacco smoking and exposure to secondhand tobacco smoke are associated with disability and premature mortality in low and middle-income countries. The aim of this study was to assess the cost-effectiveness of implementing India's Prohibition of Smoking in Public Places Rules in the state of Gujarat, compared to implementation of a complete smoking ban. Using standard cost-effectiveness analysis methods, the cost of implementing the alternatives was evaluated against the years of life saved and cases of acute myocardial infarction averted by reductions in smoking prevalence and secondhand smoke exposure. After one year, it is estimated that a complete smoking ban in Gujarat would avert 17,000 additional heart attacks and gain 438,000 life years (LY). A complete ban is highly cost-effective when key variables including legislation effectiveness were varied in the sensitivity analyses. Without including medical treatment costs averted, the cost-effectiveness ratio ranges from $2 to $112 per LY gained and $37 to $386 per acute myocardial infarction averted. Implementing a complete smoking ban would be a cost saving alternative to the current partial legislation in terms of reducing tobacco-attributable disease in Gujarat.

Options for active case detection of visceral leishmaniasis in endemic districts of India, Nepal and Bangladesh, comparing yield, feasibility and costs.

BACKGROUND: The VL elimination strategy requires cost-effective tools for case detection and management. This intervention study tests the yield, feasibility and cost of 4 different active case detection (ACD) strategies (camp, index case, incentive and blanket approach) in VL endemic districts of India, Nepal and Bangladesh. METHODOLOGY/PRINCIPAL FINDINGS: First, VL screening (fever more than 14 days, splenomegaly, rK39 test) was performed in camps. This was followed by house to house screening (blanket approach). An analysis of secondary VL cases in the neighborhood of index cases was simulated (index case approach). A second screening round was repeated 4-6 months later. In another sub-district in India and Nepal, health workers received incentives for detecting new VL cases over a 4 month period (incentive approach). This was followed by house screening for undetected cases. A total of 28 new VL cases were identified by blanket approach in the 1(st) screening round, and used as ACD gold standard. Of these, the camp approach identified 22 (sensitivity 78.6%), index case approach identified 12 (sensitivity--42.9%), and incentive approach identified 23 new VL cases out of 29 cases detected by the house screening (sensitivity--79.3%). The effort required to detect a new VL case varied (blanket approach--1092 households, incentive approach--978 households; index case approach--788 households had to be screened). The cost per new case detected varied (camp approach $21 - $661; index case approach $149 - $200; incentive based approach $50 - $543; blanket screening $112 - $629). The 2(nd) screening round yielded 20 new VL cases. Sixty and nine new PKDL cases were detected in the first and second round respectively. CONCLUSIONS/SIGNIFICANCE: ACD in the VL elimination campaign has a high yield of new cases at programme costs which vary according to the screening method chosen. Countries need the right mix of approaches according to the epidemiological profile, affordability and organizational feasibility.

Cardiopulmonary effects of low-dose arginine vasopressin in ovine acute lung injury.

OBJECTIVE: To elucidate the effects of low-dose arginine vasopressin on cardiopulmonary functions and nitrosative stress using an established model of acute lung injury. DESIGN: Prospective, randomized, controlled laboratory experiment. SETTING: Investigational intensive care unit. SUBJECTS: Eighteen chronically instrumented sheep. INTERVENTIONS: Sheep were randomly assigned to a sham group without injury or treatment, an injury group without treatment (40% total body surface area third-degree burn and 48 breaths of cold cotton smoke), or an injured group treated with arginine vasopressin (0.02 IU·min⁻¹) from 1 hr after injury until the end of the 24-hr study period (each n = 6). All sheep were mechanically ventilated and fluid resuscitated using an established protocol. MEASUREMENTS AND MAIN RESULTS: There were no differences among groups at baseline. The injury was characterized by a severe deterioration of cardiopulmonary function (left ventricular stroke work indexes and Pao2/Fio2 ratio; p < .01 each vs. sham). Compared with controls, arginine vasopressin infusion improved myocardial function, as suggested by higher stroke volume indexes and left ventricular stroke work indexes (18-24 hrs and 6-24 hrs, respectively; p < .05 each). In addition to an improved gas exchange (higher Pao2/Fio2 ratios from 6 to 24 hrs, p < .01 each), pulmonary edema (bloodless wet-to-dry-weight ratio; p = .018), bronchial obstruction (p = .01), and pulmonary shunt fraction (12-24 hrs; p ≤ .001 each) were attenuated in arginine vasopressin-treated animals compared with controls. These changes occurred along with reduced nitrosative stress, as indicated by lower plasma levels of nitrate/nitrite (12-24 hrs, p < .01 each), as well as lower myocardial and pulmonary tissue concentrations of 3-nitrotyrosine (p = .041 and p = .042 vs. controls, respectively). At 24 hrs, pulmonary 3-nitrotyrosine concentrations were negatively correlated with Pao2/Fio2 ratio (r = -.882; p < .001) and myocardial 3-nitrotyrosine content with stroke volume indexes (r = -.701; p = .004). CONCLUSIONS: Low-dose arginine vasopressin reduced nitrosative stress and improved cardiopulmonary functions in sheep with acute lung injury secondary to combined burn and smoke inhalation injury.