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Background Epidural analgesia is a popular and effective method of pain relief in labor, but the optimal timing of its administration remains unclear for multiparous women. Some evidence suggests that initiating epidurals very early in labor may be associated with increased interventions. This study aimed to evaluate whether early labor epidural analgesia (initiated before active labor) affects delivery outcomes in multiparous women compared to late epidural or no epidural analgesia. Methodology We conducted a retrospective, single-center, cohort study of term multiparous women (at least 37 weeks of gestation) with singleton, cephalic pregnancies and no prior cesarean delivery, who gave birth between November 1, 2023, and April 30, 2024. Participants were divided into the following three groups based on use of neuraxial analgesia: no neuraxial analgesia (n = 421), early neuraxial analgesia (less than 3 cm of cervical dilation; n = 102), or late neuraxial analgesia (3 cm of dilation or more; n = 145). Primary outcomes were mode of delivery (vaginal versus cesarean), use of oxytocin for labor augmentation, and postpartum hemorrhage of at least 1,000 mL. Secondary outcomes included admission to a neonatal intensive care unit, Apgar scores below 7 at five minutes, and meconium-stained amniotic fluid. Results A total of 668 multiparous women were included. The early neuraxial analgesia group had the highest rates of labor induction (46/102, 45.10%), labor augmentation (41/102, 40.20%), and cesarean delivery (10/102, 9.80%), while the no neuraxial analgesia group had the lowest rates (98/421, 23.28%; 60/421, 14.25%; and 12/421, 2.85%, respectively). Spontaneous vaginal delivery rates were 88/102 (86.27%) for early neuraxial analgesia, 138/145 (95.17%) for late neuraxial analgesia, and 405/421 (96.20%) for no neuraxial analgesia. Postpartum hemorrhage of at least 1,000 mL occurred in 6/102 (5.88%) of the early neuraxial analgesia group, 6/145 (4.14%) of the late neuraxial analgesia group, and 8/421 (1.90%) of those without neuraxial analgesia. Neonatal intensive care unit admissions were slightly higher in the early neuraxial analgesia group (4/102, 3.92%) compared with late neuraxial analgesia (3/145, 2.07%) and no neuraxial analgesia (3/421, 0.71%) groups. Five-minute Apgar scores below 7 remained low in all groups, ranging from 0/102 (0.00%) to 1/145 (0.69%). Conclusions Among multiparous women, initiating epidural analgesia in early labor was associated with higher rates of labor augmentation and operative delivery, whereas late epidural analgesia or no epidural analgesia was linked to fewer interventions. Despite these differences, serious maternal complications and neonatal outcomes remained favorable across all groups. These findings suggest that delaying epidural initiation until active labor may help minimize interventions without compromising maternal or neonatal safety.

ABSTRACT Background: India has become the diabetes capital of the world. Analyzing trends in drug prescribing helps in judging rationality of prescriptions in different settings. This study aimed to assess disease and prescribing trends with a special emphasis on evaluating use of metformin, insulin, fixed dose combinations (FDCs), concomitant medications, pill burden, and costs of drug therapy in diabetes. Materials and Methods: This was a cross-sectional study in which patients of either sex who attended the diabetes clinic at a tertiary care center over 9 months were included consecutively. Basic demographic profile, clinical, and treatment details on the day of visit were collected from the prescription charts. Drug costs for prescriptions were calculated using generic and median brand prices of formulations using a recognized commercial drug directory and generic price list of the government, respectively. Data were analyzed by using Microsoft Excel and Open Epi online software to compare results with published studies. Results: Average age of diabetics was 53.9 ± 11.8 years and disease duration was 8.13 ± 7.78 years in 336 prescriptions analyzed. Dual drug regimens were seen in 32.7% prescriptions, most commonly metformin and sulfonylureas, followed by triple drug regimens (25%) with inhibition of dipeptidyl peptidase IV (DPP IV) inhibitor. Metformin was prescribed in 95% prescriptions (mean dose 1511 ± 559.87 mg) and insulin in 22.6% prescriptions. Angiotensin receptor blocker (ARBs) and statins were the most commonly prescribed concomitant drugs. One FDC per prescription (median) each for diabetes and comorbidities were prescribed. Daily pill burden was 4.59 ± 2.65 pills. The median monthly cost of drug therapy with branded prescribing was INR 870.43 and INR 393.72 with the use of generics. Inferences drawn by comparison with published data showed variable results for different parameters analyzed. Conclusion: Disease pattern was as expected for the region and trends of therapy showed concurrence with rational prescribing. Pill burden and cost of therapy remain high with a significant contribution of comorbidities.

Background Pakistan is facing a growing population of people living with human immunodeficiency (HIV). In this randomized controlled trial, we investigate if a pharmacist-led intervention can increase adherence to antiretroviral therapy (ART) for people living with HIV (PLWH). Methods Adults with HIV, who have been taking ART for more than 3 months were randomly assigned to receive either a pharmacist-led intervention or their usual care. Measures of adherence were collected at 1) baseline 2) just prior to delivery of intervention and 3) 8 weeks later. The primary outcomes were CD4 cell count and self-reported adherence measured with the AIDS Clinical Trial Group (ACTG) questionnaire. Results Post-intervention, the intervention group showed a statistically significant increase in CD4 cell counts as compared to the usual care group ( p  = 0.0054). In addition, adherence improved in the intervention group, with participants being 5.96 times more likely to report having not missed their medication for longer periods of time ( p  = 0.0086) while participants in the intervention group were 7.74 times more likely to report missing their ART less frequently ( p  < 0.0001). Conclusions The findings support the improvement in ART adherence and HIV management. Trial registration The trial is registered with Australian New Zealand Clinical Trials Registry ( ACTRN12618001882213 ). Registered 20 November 2018.

Objectives Sodium-glucose cotransporter-2 (SGLT-2) inhibitors and dipeptidyl peptidase IV (DPP-IV) inhibitors are recommended as preferred add-on oral antidiabetic drugs (OADs) after metformin among type 2 diabetes mellitus (T2DM) patients with atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and chronic kidney disease (CKD). They are generally many folds costlier than other OADs. This is a simulatory analysis to assess the incremental cost escalation and risk reduction with their hypothetical substitution/addition in prescriptions of high-risk patients. Methods A simple simulation of cost-effectiveness analysis was performed using prescriptions of T2DM patients with established cardiovascular (CV) or renal disease or high-risk factors. SGLT-2 and DPP-IV inhibitors with proven benefits/safety were substituted or added in place of other OADs. Increments in treatment costs were calculated, and the anticipated decrease in hazards was extrapolated from cardiovascular outcome trials (CVOTs) and real-world studies. The incremental cost-effectiveness ratios (ICERs) were calculated. Results Prescriptions of 351 patients with a mean age of 58.04 ± 8.67 years were analyzed. The median annual acquisition cost of drug therapy for diabetes per patient was found to be Indian national rupee (INR) 8,964.4 for the original prescriptions when calculated using median retail prices of drugs prescribed for diabetes. Upon substituting one of the SGLT-2 inhibitors for the other OADs in the regimen, the cost increased to INR 12,265 (increase by 36.8%) for dapagliflozin, and INR 26,718 and INR 29,419 (increase by ~200%), respectively, for canagliflozin and empagliflozin. Upon calculating the ICERs, additional cost to prevent one all-cause death with dapagliflozin substitution is INR 660,020-25,384,369; INR 2,223,326 with empagliflozin substitution and INR 8,069,818 with canagliflozin substitution. The ICER for prevention of hospitalization with HF with dapagliflozin substitution is INR 1,320,040-1,435,543; INR 4,010,706 with empagliflozin and INR 5,548,000 with canagliflozin. To prevent a three-point major adverse cardiac event (3P-MACE), INR 2,062,562 would be needed with dapagliflozin substitution, and INR 3,146,861 and INR 3,859,478 with empagliflozin and canagliflozin, respectively. Incremental costs for various outcomes were higher with the addition of SGLT-2 inhibitors and significantly more if substitution with sitagliptin/linagliptin was also done. The numbers needed to treat were calculated too and ranged from 35 to 1,831 for various outcomes and drugs. Conclusion While the recommendations for use of SGLT-2 and DPP-IV inhibitors are adequately backed by evidence from CVOTs and real-world data, the incremental costs per event reduction are quite high for most outcomes in the Indian context. Dapagliflozin, being available as cheaper generic versions, appears to be most effective for most outcomes. Interpretations are subjective in terms of value assigned for preventing a major event.

PurposeChildren in majority world countries (MWC) have high rates of unmet mental health needs, with limited access to specialist resources. Integration of child mental health in existing psychosocial care can improve provision. Through a Train-the-Trainer (ToT) cascade approach, this study aimed to provide a framework for such integration in resource-constrained communities in Karachi, Pakistan and to establish hindering and enabling factors.Design/methodology/approachEight practitioners attended a child mental health ToT program, including training on a five-domain service transformation framework. Trainers co-designed and implemented interventions that integrated child mental health knowledge and skills on each domain. These were attended by 136 end-users (youth, parents, teachers, managers), of whom a sub-sample of 47 stakeholders, as well as the trainers, attended focus groups on their experiences. Data were analysed through a thematic codebook.FindingsEstablished themes reflected common ingredients across all domains/interventions that were deemed important for child mental health care integration. These included child-centric approaches, positive parenting, community mobilization and systemic changes.Originality/valueIntegrated child mental health care informed by the Train-of-Trainer approach can be a useful model for resource-constrained MWC contexts. Integrated interventions should be co-produced with communities.

Background: Evidence has shown the positive impact of pharmacist involvement on the adherence and health outcomes of people living with HIV/AIDS. However, whether such intervention provides value for money remains unclear. This study aims to fill this gap by assessing the cost–effectiveness of pharmacist interventions in HIV care in Pakistan. Methods: A Markov decision analytic model was constructed, considering clinical inputs, utility data, and cost data obtained from a randomized controlled trial and an HIV cohort of Pakistani origin. The analysis was conducted from a healthcare perspective, and the incremental cost–effectiveness ratio (ICER) was calculated and presented for the year 2023. Additionally, a series of sensitivity analyses were performed to assess the robustness of the results. Results: Pharmacist intervention resulted in higher quality-adjusted life years (4.05 vs. 2.93) and likewise higher annual intervention costs than usual care (1979 USD vs. 429 USD) (532,894 PKR vs. 115,518 PKR). This yielded the ICER of 1383 USD/quality-adjusted life years (QALY) (372,406 PKR/QALY), which is well below the willingness-to-pay threshold of 1658 USD (446,456 PKR/QALY) recommended by the World Health Organization Choosing Interventions that are Cost-Effective. Probabilistic sensitivity analysis reported that more than 68% of iterations were below the lower limit of threshold. Sensitivity analysis reported intervention cost is the most important parameter influencing the ICER the most. Conclusion: The study suggests that involving pharmacists in HIV care could be a cost-effective approach. These findings could help shape healthcare policies and plans, possibly making pharmacist interventions a regular part of care for people with HIV in Pakistan.

At present, there are no proven agents for treatment of coronavirus disease (COVID-19). The available evidence has not allowed guidelines to clearly recommend any drugs outside the context of clinical trials. The novel coronavirus SARS-CoV-2 that causes COVID-19 invokes a hyperinflammatory state driven by multiple cells and mediators like interleukin (IL)-1, IL-6, IL-12, and IL-18, tumor necrosis factor alpha (TNFα), etc. Considering the proven role of cytokine dysregulation in causing this hyperinflammation in the lungs with IL-6 being a key driver, particularly in seriously ill COVID-19 patients, it is crucial to further explore selective cytokine blockade with drugs like the IL-6 inhibitors tocilizumab, sarilumab, and siltuximab. These targeted monoclonal antibodies can dampen the downstream IL-6 signaling pathways, which can lead to decreased cell proliferation, differentiation, oxidative stress, exudation, and improve clinical outcomes in patients with evident features of cytokine-driven inflammation like persistent fever, dyspnea and elevated markers. Preliminary evidence has come for tocilizumab from some small studies, and interim analysis of a randomized controlled trial; the latter also being available for sarilumab. International guidelines do include IL-6 inhibitors as one of the options available for severe or critically ill patients. There has been increased interest in evaluating these drugs with a series of clinical trials being registered and conducted in different countries. The level of investigation though perhaps needs to be further intensified as there is a need to focus on therapeutic options that can prove to be ‘life-saving’ as the number of COVID-19 fatalities worldwide keeps increasing alarmingly. IL-6 inhibitors could be one such treatment option, with generation of more evidence and completion of a larger number of systematic studies.

Background The involvement of young people as peer researchers, especially with lived experience, is increasingly considered important in youth mental health research. Yet, there is variation in the understanding of the role, and limited evidence on its implementation across different research systems. This case study focusses on the barriers and enablers of implementing peer researcher roles within and across majority world countries contexts. Methods Based on an international youth mental health project involving different levels of peer researchers and participants from eight countries, peer researchers and a co-ordinating career researcher reflect on lessons regarding enabling and challenging factors. These reflections are captured and integrated by a systematic insight analysis process. Results Building on existing international networks, it was feasible to actively involve peer researchers with lived experience in a multi-country mental health study, who in turn recruited and engaged young participants. Identified challenges include the terminology and definition of the role, cultural differences in mental health concepts, and consistency across countries and sites. Discussion Peer researchers’ role could be strengthened and mainstreamed in the future through ongoing international networks, training, sufficient planning, and active influence throughout the research process. Trial registration : Not applicable. Plain English summary The involvement of young people with lived experience as collaborators (peer researchers) in mental health research has become more prominent in recent years. Yet, there is variation in the understanding of this role and how to involve young people. There is also limited evidence on how this role can be applied across different research systems, especially in majority world countries. We share our experience from a youth mental health project involving peer researchers in eight countries. Peer researchers and the co-ordinating career researcher reflected on lessons regarding enabling and challenging factors. Their reflections highlighted that, overall, it is feasible to successfully involve young people with lived experience in international mental health research. Several challenges were also identified, including terminology, definition of roles, cultural differences in understanding mental health, and consistency across participating countries and sites. According to peer researchers’ reflections, these challenges can be overcome through the establishment of ongoing international networks, training and support, sufficient planning and peer researchers getting involved at all the stages of the research. Lessons from this case study can be of interest to the international research community in strengthening the involvement of young people in mental health research.

Itolizumab is a first-in-class anti-CD6 monoclonal antibody that was initially developed for various cancers and was later developed and approved in India for treatment of moderate to severe chronic plaque psoriasis in 2013. This drug is now being re-purposed for COVID-19. The potential utility of itolizumab in COVID-19, based on its unique mechanism of action in ameliorating cytokine release syndrome (CRS), was proposed first in Cuba with approval of a single-arm clinical trial and expanded access use. Subsequently, a phase II, open-label, randomized, placebo-controlled trial has been conducted in 30 COVID-19 patients in India after receiving regulatory permission. Based on the results, the Indian drug regulatory agency recently approved itolizumab in July 2020 for ‘restricted emergency use’ for the treatment of CRS in moderate to severe acute respiratory distress syndrome (ARDS) due to COVID-19. This has drawn sharp criticism within the scientific community, with the approval being granted on the basis of a relatively small phase II trial, without conduct of a conventional phase III trial, and lacking availability of the claimed supportive real-world evidence in the public domain to date. In a global scenario where finding a successful treatment for COVID-19 is of utmost priority, a biologic agent has been re-purposed and approved with a successfully completed RCT, in a country where cases and mortality due to COVID-19 are growing exponentially. However, instead of welcoming the approval with open arms, many doubts are being raised. This is an issue that needs to be considered and dealt with sensitively, as well as scientifically.

The main purpose of the study is to find out the level of utilization of the library electronic resources and its satisfaction by research scholars and postgraduate students. The research design used for this study is a descriptive one, using survey data and the instrument used was a structured questionnaire administered to the students at Amity University. The study revealed that limited numbers of computers, slow internet speed, inadequate number of titles, lack of technical support, copyright restrictions, information overload, etc. are the major problems preventing students from utilizing the e-resources effectively in the library for their information needs. Recommendations include purchasing more titles and signing copyright agreements to fulfill the requirements apart from providing technical training and support. Internet bandwidth needs to be upgraded for the uninterrupted access. The findings have great implications for increasing visitors and readership subject to fulfillment of recommended upgradations.