Decreased Length of stay,cost savings and descriptive findings of enhanced patient care resulting from and integrated traumatic brain injury programme

Traumatic brain injury (TBI) has enormous economic consequences. The primary objective was to evaluate the effect of implementation of an integrated TBI programme on patient-care. The research design was a retrospective institutional review for which 1875 patient records were reviewed, healthcare professionals were interviewed, patient care was observed, and a literature review of the prognostic variables for mild, moderate and severe TBI was conducted. The implementation of an integrated TBI programme has reduced the average length of stay from 30.5 to 12 days and resulted in tremendous cost savings of $21.8 million over 6 years. 'Blueprinting' the continuum of TBI patients' care identified the weakest links to be the transfer of patients from the tertiary-care TBI programme to rehabilitation institutions and provision of long-term rehabilitative care due to information asymmetry. This was addressed by the development of comprehensive on-line TBI transfer documents. This study emphasizes the importance of comprehensive neurotrauma programmes.     

Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients

A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar. Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004). We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail.     

Adopting integrated management of childhood illness module at local level in Bangladesh: implications for recurrent costs

This study estimated the recurrent cost implications of adopting Integrated Management of Childhood Illness (IMCI) at the first-level healthcare facilities in Bangladesh. Data on illnesses of children who sought care either from community health workers (CHWs) or from paramedics over a four-month period were collected in a rural community. A total of 5,505 children sought care. About 75% of symptoms mentioned by mothers were directly related to illnesses that are targeted in the IMCI. Cough and fever represented 64% of all reported complaints. Referral of patients to higher facilities varied from 3% for the paramedics to 77% for the CHWs. Had the IMCI module been followed, proportion of children needing referral should have been around 8%. Significant differences were observed between IMCI-recommended drug treatment and current practice followed by the paramedics. Adoption of IMCI should save about US$ 7 million on drugs alone for the whole country. Proper implementation of IMCI will require employment of additional health workers that will cost about US$ 2.7 million. If the current level of healthcare use is assumed, introduction of IMCI in Bangladesh will save over US$ 4 million.     

Knowledge on AIDS among female adolescents in Bangladesh: evidence from the Bangladesh demographic and health survey data

To assess the knowledge on acquired immunodeficiency syndrome (AIDS) among female adolescents in Bangladesh, this study used data extracted from the Bangladesh Demographic and Health Survey (BDHS) 1996-1997. Of 1,446 ever-married women included in the study, most were currently married (96%), Muslims (92%) and from rural areas (91%). Only one in six adolescents had ever heard of AIDS. Of them, 57% reported AIDS as a fatal disease almost always, while only 22% believed that AIDS could be avoided. Multivariate analysis revealed that knowledge on AIDS was strongly and positively associated with education of female adolescents and their husbands and varied significantly across different parts of the country. Knowledge on AIDS was higher among relatively older and urban residents who had access to television or radio and whose husbands were using condom. Strong efforts are needed to improve awareness and to clarify misconceptions about AIDS. Improved access to education, mass-media, and promotion of condom use could prevent AIDS among female adolescents in Bangladesh.     

Determination of aristolochic acid I and II in North American species of Asarum and Aristolochia

Wild ginger, Asarum canadense, which has folk uses as a medicinal and food plant, has been reported to contain aristolochic acid I. Rhizomes of North American species of Aristolochiaceae were surveyed for the presence of aristolochic acids by HPLC. Aristolochic acid I (1) and aristolochic acid II (2) were present in Aristolochia species and Hexastylis; 1 alone was detected in multiple accessions of A. canadense and Asarum caudatum, though not in Asarum wagneri. Concentrations in A. canadense were highly variable, reaching as much as 0.037 percent of dry weight.     

Biologically active steroidal glycosides from Tribulus terrestris

The steroidal saponin constituents obtained from Tribulus terrestris were tested for their antimicrobial and cytotoxic effects. The spirostanol-based steroidal saponins 1-3 exhibited remarkable activity against fungal organisms (Candida albicans and Cryptococcus neoformans) and cancer cell lines [human malignant melanoma (SK-MEL), human oral epidermoid carcinoma (KB), human breast ductal carcinoma (BT-549), and human ovary carcinoma (SK-OV-3)], while none of the compounds possessing the furostanol framework 4-7 showed activity. The most active spirostanol glycoside, compound 3 exhibited a broad range of anticancer activity against cell lines, SK-MEL, KB, BT-549 and SK-OV-3 at IC50s of 6.0, 7.0, 6.0 and 8.2 micrograms/ml, respectively, while compounds 1 and 2 showed selective cytotoxicity against SK-MEL at 6.7 and 9.1 micrograms/ml, respectively. The minimum inhibitory concentrations (MIC) in antifungal bioassay for compounds 1-3 varied from 1.5 to 6.2 micrograms/ml, which prompted to conclude certain structural features are required for these bioactivities.     

Syntheses and reactions of some new 2-arylidene-4-(biphenyl-4-yl)-but-3-en-4-olides with a study of their biological activity

2-Arylidene-4-(biphenyl-4-yl)but-3-en-4-olides also known as 3-arylidene-5-(biphenyl-4-yl)-2(3H)-furanones were prepared from 3-(4-phenyl-benzoyl) propionic acid and aromatic aldehydes. Some of the selected butenolides were reacted with ammonia and benzylamine to give corresponding pyrrolones and N-benzylpyrrolones respectively, which were characterized on the basis of 1H NMR and MS data and elemental analysis results. These compounds were tested for anti-inflammatory and anti-microbial actions. A few compounds were found to have promising anti-inflammatory activity while a fair in number of compounds showed a good anti-fungal activity and a promising antibacterial activity against S. aureus and E. coli.     

Relative sensitivity of the Montgomery-Asberg Depression Rating Scale,the Hamilton Depression rating scale and the Clinical Global Impressions rating scale in antidepressant clinical trials

Although early antidepressant clinical trials simply relied on a clinician's judgment as to whether a depressed patient clinically improved or not, the Hamilton Depression (HAM-D) rating scale has become the 'gold standard' to assess the efficacy of new antidepressants. The alternative Montgomery-Asberg Depression Rating Scale (MADRS) has not achieved general acceptance. However, its ease of use warrants evaluation as to whether it is comparable to HAM-D in its sensitivity in detecting antidepressant-placebo differences in antidepressant clinical trials. A retrospective chart review was performed on the records of 208 depressed adult patients that participated in eight randomized, placebo-controlled, double-blind antidepressant clinical trials at the Northwest Clinical Research Center between 1996 and 2000. We compared the effect sizes of the HAM-D, MADRS and Clinical Impressions Rating Scale (CGI-S for severity and CGI-I for improvement) for patients assigned to placebo or an established antidepressant. The effect size (measured as the mean change in rating with antidepressants minus the mean change for placebo divided by the pooled SD of change, adjusted for age, gender and initial scores) was 0.49 with MADRS, 0.53 with HAM-D, 0.55 with CGI-S and 0.59 with CGI-I. The four rating scales had similar effect sizes regardless of the type of antidepressant evaluated. These data suggest that MADRS is as sensitive an instrument as HAM-D for detecting antidepressant efficacy in clinical trials. Thus, MADRS may be a desirable tool in large-scale, pivotal antidepressant clinical trials.     

Preparation and in vitro characterization of a eutectic based semisolid self-nanoemulsified drug delivery system (SNEDDS) of ubiquinone: mechanism and progress of emulsion formation

The objectives of the present work were, first, to develop a self-nanoemulsified drug delivery system (SNEDDS) based on the eutectic properties of ubiquinone (CoQ10); and second, to study the progress of emulsion formation and drug release mechanisms by turbidimetry and droplet size analysis. Binary phase diagrams of CoQ10 with menthol and essential oils were constructed and used to develop the self-nanoemulsified formulation. Pseudo ternary phase diagram was constructed to identify the efficient self-emulsification region. Release mechanisms of the resultant formulas were quantified using turbidimetry in combination with dissolution studies. Turbidity time profiles revealed three distinctive regions: lag phase, plateau, and the pseudolinear phase. Lag phase was attributed to the liquid crystalline properties of the formula. Plateau turbidity was correlated with droplet size. Laser diffraction analysis revealed an average droplet diameter of 100 nm. Emulsification rate was obtained from the corrected slope of the pseudolinear phase of the profile. Stability of the formula was further evaluated using Fourier transform-infrared (FT-IR) attached to an attenuated total reflectance (ATR) accessory. The present study revealed a eutectic based semisolid self-emulsified delivery system that can overcome the drawbacks of the traditional emulsified systems such as low solubility and irreversible precipitation of the active drug in the vehicle with time.     

Oral delivery of proteins: progress and prognostication

The delivery of proteins has gained momentum with the development of biotechnology sector that provided large-scale availability of therapeutic proteins. The availability is mostly due to the advances in recombinant DNA technology. The low oral bioavailability, however, continues to be a problem for several proteins because of their large molecular size, low permeation through biological membranes, and susceptibility to molecular changes in both biological and physical environments. The demand for effective delivery of proteins by the oral route has brought a tremendous thrust in recent years both in the scope and complexity of drug delivery technology. The important therapeutic proteins and peptides being explored for oral delivery include insulin, calcitonin, interferons, human growth hormone, glucagons, gonadotropin-releasing hormones, enkephalins, vaccines, enzymes, hormone analogs, and enzyme inhibitors. This article reviews the progress in oral delivery of these proteins, provides comments on the strategies to improve their oral bioavailability, and highlights their current market trends.