Effectiveness of blended learning in pharmacy education: An experimental study using clinical research modules.

BACKGROUND &OBJECTIVES: Though there are studies to evaluate the effectiveness of blended learning in pharmacy education, most of them originate from USA and have used previous year students' scores as control. Also there is less research in comparing use of self -regulated learning strategies between blended and other learning strategies. Primary aim was to evaluate the effectiveness of blended learning on knowledge score using clinical research modules. Secondary objective was designed to compare the use of self-regulated learning strategies between blended learning, web-based e-learning and didactic teaching. MATERIALS AND METHODS: A prospective cluster randomized trial was conducted with didactic teaching as control and web-based e-learning and blended learning as interventions. The target population was final year Pharm D students. Outcome was assessed using a validated knowledge questionnaire, a motivated strategies for learning questionnaire and a feedback form. All statistical analyses were carried out using Statistical Package for Social Science (SPSS) Version 20. RESULTS: A total of 241 students from 12 colleges completed the study. Mean knowledge score of students in blended learning group was higher than those in the didactic teaching and web- based e- learning program (64.26±18.19 Vs 56.65±8.73 Vs 52.11±22.06,p<0.001).Frequency of use of learning strategies namely rehearsal, elaboration, organization and critical thinking was statistically significantly higher in the blended learning group compared to those of didactic and web-based e-learning group (p<0.05) But there were no statistically significant difference of motivational orientations between didactic and blended learning group except strategies of extrinsic goal orientation and self-efficacy. Students preferred blended learning (86.5%) over didactic and web-based e-learning. CONCLUSION: Blended learning approach is an effective way to teach clinical research module. Students of blended learning group employed all motivational and learning strategies more often than students of the didactic and web- based e-learning groups except strategies of intrinsic goal orientation, task value, control of learning belief and help seeking.

Effects of immunomodulatory drugs on depressive symptoms: A mega-analysis of randomized, placebo-controlled clinical trials in inflammatory disorders.

Activation of the innate immune system is commonly associated with depression. Immunomodulatory drugs may have efficacy for depressive symptoms that are co-morbidly associated with inflammatory disorders. We report a large-scale re-analysis by standardized procedures (mega-analysis) of patient-level data combined from 18 randomized clinical trials conducted by Janssen or GlaxoSmithKline for one of nine disorders (N = 10,743 participants). Core depressive symptoms (low mood, anhedonia) were measured by the Short Form Survey (SF-36) or the Hospital Anxiety and Depression Scale (HADS), and participants were stratified into high (N = 1921) versus low-depressive strata based on baseline ratings. Placebo-controlled change from baseline after 4-16 weeks of treatment was estimated by the standardized mean difference (SMD) over all trials and for each subgroup of trials targeting one of 7 mechanisms (IL-6, TNF-α, IL-12/23, CD20, COX2, BLγS, p38/MAPK14). Patients in the high depressive stratum showed modest but significant effects on core depressive symptoms (SMD = 0.29, 95% CI [0.12-0.45]) and related SF-36 measures of mental health and vitality. Anti-IL-6 antibodies (SMD = 0.8, 95% CI [0.20-1.41]) and an anti-IL-12/23 antibody (SMD = 0.48, 95% CI [0.26-0.70]) had larger effects on depressive symptoms than other drug classes. Adjustments for physical health outcome marginally attenuated the average treatment effect on depressive symptoms (SMD = 0.20, 95% CI: 0.06-0.35), but more strongly attenuated effects on mental health and vitality. Effects of anti-IL-12/23 remained significant and anti-IL-6 antibodies became a trend after controlling for physical response to treatment. Novel immune-therapeutics can produce antidepressant effects in depressed patients with primary inflammatory disorders that are not entirely explained by treatment-related changes in physical health.

Average annual risk of tuberculous infection in India.

Estimates of the prevalence of tuberculous infection among children 1-9 years of age were available for four defined zones of India from a recently concluded tuberculin survey. These were pooled together and the average annual risk of infection in the country was computed as 1.5%. It was higher in urban areas, at 2.2%, than in rural areas, at 1.3%. The results call for further intensification of tuberculosis control activities, especially in urban areas, greater involvement of private practitioners and information, education and communication (IEC) for high-risk groups, to reduce the diagnostic and treatment delay thereby reducing the transmission of infection in all settings.

The annual risk of tuberculous infection in the eastern zone of India.

SETTING: Rural and urban areas of eight selected districts in the eastern zone of India. OBJECTIVES: To estimate the annual risk of tuberculous infection (ARTI). STUDY DESIGN: A community-based, cross-sectional tuberculin survey was conducted among children aged 1-9 years residing in a sample of rural and urban areas. Stratified two-stage cluster sampling was adopted for selection of rural and urban clusters. A total of 40964 children in 515 clusters underwent tuberculin testing and reading with 1TU PPD RT23 with Tween 80; the maximum transverse diameter of induration was measured about 72 h after the test. RESULTS: A bacille Calmette-Gúerin (BCG) scar was observed in 51.5% of the test-read children. The frequency distribution of tuberculin reaction size among 19332 children without BCG scar was found to be bimodal, with the mode of reactions attributable to infection with tubercle bacilli at 20 mm. The prevalence of infection was estimated as 6.9%. The ARTI computed from the estimated prevalence was 1.3%. Children residing in the urban areas were found to be at a significantly higher risk of infection than those residing in rural areas. CONCLUSION: The high rate of ARTI in the eastern zone of India suggests a need for committed, sustained action in provision of quality tuberculosis control services.

The annual risk of tuberculous infection in Orissa State, India.

SETTING: Rural and urban areas of eight selected districts of Orissa State, India. OBJECTIVES: To estimate the average annual risk of tuberculous infection (ARTI) in the state. DESIGN: A community-based, cross-sectional tuberculin survey was conducted among children aged 1-9 years residing in a sample of rural and urban areas of eight districts of Orissa State. A stratified sampling was adopted for selection of clusters. Highly trained designated tuberculin testers administered 0.1 ml (1 TU) of PPD RT 23 with Tween 80 by the Mantoux method to 10 626 children. Transverse tuberculin reaction sizes were measured about 72 h later by trained designated tuberculin readers. The number of children satisfactorily test-read was 10 191. RESULTS: Based on the frequency distribution of tuberculin reaction sizes, the average ARTI in the state was estimated at 1.7-1.8%. The children residing in urban areas were observed to be at a significantly higher risk of infection than those in rural areas. CONCLUSION: The study in Orissa State suggests high rates of transmission of tuberculous infection and calls to attention the need for intensification of concerted and sustained tuberculosis control efforts.

Can BCG-vaccinated children be included in tuberculin surveys to estimate the annual risk of tuberculous infection in India?

SETTING: Selected villages in three defined zones of India. OBJECTIVES: To compare the estimated prevalence of tuberculous infection among children with and without bacille Calmette-Guérin (BCG) scar. STUDY DESIGN: During a nationwide tuberculin survey, 1-9-year-old children were tuberculin tested using 1TU-PPD RT23 with Tween 80. RESULTS: In the 5-9 year age group, subgroups of tuberculous infected children could be seen as distinct humps among those with or without BCG scar, but not in those aged 1-4 years. In children aged 1-4 years, the estimated prevalence of infection was respectively 3.5%, 3.8% and 3.6% among children without BCG scar, and 4.8%, 4.7% and 4.5% among children with BCG scar in the western, northern and eastern zones. In those aged 5-9 years, the estimated prevalence was respectively 10.4%, 11.0% and 9.1% among children without BCG scar and 11%, 11.9% and 8.7% among children with BCG scar in the three zones. Thus, in children aged 1-4 years, the estimated prevalence among those with BCG scar was considerably higher than in those without BCG scar. This difference was small in those aged 5-9 years. CONCLUSION: Tuberculin surveys may be conducted irrespective of BCG scar status among children aged 5-9 years, when BCG vaccination is given using Danish 1331 strain during infancy under the Expanded Program of Immunization.

Annual risk of tuberculous infection in the northern zone of India.

OBJECTIVE: To estimate the annual risk of infection with tubercle bacilli in the northern zone of India. METHODS: A community-based cross-sectional tuberculin survey was conducted among children aged 1-9 years who lived in a sample of villages and urban blocks of six selected districts in a defined north zone of India. A two-stage cluster sampling method was used to select rural and urban clusters. A total of 48 624 children in 598 clusters were subjected to tuberculin testing with one tuberculin unit (1 TU) of PPD RT23 stabilized with Tween 80. The maximum transverse diameter of induration was measured about 72 hours after the test. FINDINGS: Among the 48 624 test-read children, 22 064 (45.4%) had a bacille Calmette-Gu rin (BCG) scar. On the basis of the frequency distribution of tuberculin reaction size among 25 816 children without a BCG scar, the prevalence of infection with tubercle bacilli was estimated as 10.3%. The annual risk of infection was computed as 1.9%. The proportion of infected children was significantly higher in urban than rural areas. CONCLUSION: The high rate of tuberculous infection in the north zone of India suggests the need for further intensification of tuberculosis control efforts on a sustained and long-term basis.

Annual risk of tuberculous infection in rural areas of Uttar Pradesh, India.

SETTING: Rural areas in Uttar Pradesh, the most populous state in India. OBJECTIVES: 1) To estimate the average annual risk of tuberculous infection (ARI), 2) to study ARI trends with age, and 3) to compare tuberculin reactions among children with and without BCG scar. STUDY DESIGN: A cross-sectional tuberculin survey was conducted among children aged 1-9 years residing in Rae Bareli, Hardoi and Jaunpur districts, Uttar Pradesh. Tuberculin testing was performed using 1TU of PPD RT23 with Tween 80, and indurations were measured 72 hours later. Prevalence of infection was estimated in children without BCG scar based on the cut-off point identified on the frequency distribution of reaction sizes. The ARI was computed from the estimated prevalence. RESULTS: The proportion of children with BCG scar varied from 25% to 31% in the study districts. Using a cut-off of 14 mm among children without BCG scar, the ARI was estimated at 2.3% in Rae Bareli, 1.9% in Hardoi and 1.5% in Jaunpur, and was observed to increase with age. Tuberculin test results among children with BCG scar suggest that they may be included in tuberculin surveys to estimate ARI. CONCLUSION: High rates of transmission of tuberculous infection suggest that tuberculosis control measures need to be intensified.

Annual risk of tuberculous infection in the western zone of India.

SETTING: Rural and urban areas of six selected districts in the western zone of India. OBJECTIVES: To estimate the annual risk of tuberculous infection (ARI). DESIGN: A community-based, cross-sectional tuberculin survey was conducted among children aged 1-9 years residing in a sample of rural and urban areas of six districts in the western zone of India. Stratified two-stage cluster sampling was adopted for selection of rural and urban clusters. A total of 48473 children in 600 clusters underwent tuberculin testing with 1TU PPD RT23 with Tween 80; the induration was measured about 72 h after the test. RESULTS: The BCG scar was observed in 52% of the test-read children. Estimation of the prevalence of infection was based on the frequency distribution of tuberculin reaction size among 22259 children without BCG scar. Reactions > or = 15 mm were considered attributable to infection with tubercle bacilli. The prevalence of infection was estimated to be 9.3%, and the ARI computed from the estimated prevalence was 1.8%. The proportion of infected children was found to be significantly higher in urban than in rural areas. CONCLUSION: The high rate of ARI in the western zone of India calls for further intensification of tuberculosis control efforts.

PPD RT23 for tuberculin surveys in India.

SETTING: Tuberculosis sanatoria and villages in Bangalore district. OBJECTIVES: To study the appropriateness of continuing to use 1TU dilutions prepared by the BCG Laboratory, Guindy, in Chennai, India, from a freeze-dried form of PPD RT23 with Tween 80 received from Statens Serum Institut (SSI), Copenhagen, for tuberculin surveys in India. DESIGN: The responses to dual tuberculin tests were compared among: 1) 63 smear-positive cases using 2TU PPD prepared by the Guindy laboratory (Dilution-G), and 2TU PPD prepared by the SSI (Dilution-S); 2) 124 smear-positive cases using 1TU and 2TU Dilution-G; and 3) 1,338 apparently healthy children using 1TU and 2TU Dilution-G. Test sites were allocated randomly using the double-blind technique. Tuberculin responses obtained during studies conducted in India and in other countries were compared. RESULTS: The differences in sensitivity of tuberculin testing using the different preparations were found to be small and statistically non-significant. Among children, a higher proportion of reaction sizes in 10-14 mm and 15 + mm categories was observed to 2TU compared to 1TU of Dilution-G. This could reflect lower specificity of 2TU in the study area where non-specific sensitivity is highly prevalent. Studies in India and other countries do not suggest any loss in potency of 1TU PPD RT23 with Tween 80. CONCLUSION: 1TU dilutions of PPD RT23 with Tween 80 provided by the BCG Laboratory, Guindy, may continue to be used for tuberculin surveys in India.

Annual risk of tuberculous infection in rural areas of Junagadh district.

Paucity of epidemiological data on tuberculosis in India prompted the National Tuberculosis Institute, Bangalore to embark upon a nation-wide survey to estimate the Annual Risk of Tuberculosis Infection in different parts of the country. The survey in Junagadh district, one of the 26 districts drafted under the nation-wide survey is reported here. The prevalence of infection from the analysis of 3164 children not displaying scars of the BCG vaccination was 4.16% (CI: 3.17-5.14) and from this data the ARI was computed as 0.73% (CI: 0.55-0.91). The inclusion of vaccinated children into the study group yielded similar results. The estimate of the ARI in Junagadh district is lesser than that in several other parts of India which is probably in consonance with its better socio-economic development.