Cost analysis of gentamicin-impregnated collagen sponges in preventing sternal wound infection post cardiac surgery.

OBJECTIVE: The use of antibiotic-impregnated sponges (Collatamp) during cardiac surgery is controversial. We analysed the cost-effectiveness of its selective use in patients at high-risk of sternal wound infection (SWI). METHOD: Postoperative costs were analysed in two groups of patients undergoing heart surgery between 2011 and 2013: those with SWI (group 1) and in high-risk patients without SWI (group 2). The potential cost of gentamicin-impregnated collagen sponges (GCS) use in high-risk patients was compared with our current practice. RESULTS: We identified 1,251 patients with at least one recognised risk factor for developing SWI in this period. Of these, 18 developed SWI (incidence 1.4%). The median postoperative cost per patient without SWI was £9,617. The additional cost per patient incurred by SWI was £4,860.75. The annual additional cost for treating patients with SWI was £43,749. With a 50% reduction in SWI, the annual additional cost of treating these patients would be reduced to £21,873. The cost of GCS is £80 per patient. Adding this to £21,873 gives a potential total cost of £71,913 in the treated high-risk cohort. CONCLUSION: In our practice the annual cost of treating SWI in high-risk patients without use of GCS is lower than the annual cost of using GCS in all high-risk patients (£43,749 versus £71,913) if it produces a 50% reduction in SWI. The reduction in the incidence of SWI poses no economic benefit when the cost of the product is factored in.

Health insurance in Singapore: who's not included and why?

INTRODUCTION: Health insurance and the consequent risk pooling are believed to be essential components of a sustainable healthcare financing system. We sought to determine the profile of Singaporeans who had not procured health insurance over and above MediShield, the national government-spearheaded health insurance program and the factors associated with insurance procurement. METHODS: A total of 1,783 respondents were interviewed via telephone and asked to rank their agreement with statements pertaining to healthcare cost, quality and financing on a fivepoint Likert scale. RESULTS: Respondents were representative of the general population in terms of ethnicity and housing type, but lower income households were over-represented. Respondents also had a higher education level compared to the general population. Data on 1,510 respondents, with full information on household (HH) income, education and insurance status, was analysed. HH income below S$1,500 per month (odds ratio [OR] is 5.66, 95 percent confidence interval [CI] is 3.9-8.3, p is less than 0.0001) and a secondary education and below (OR is 2.05, 95 percent CI is 1.5-2.8, p is less than 0.0001) were associated with not procuring insurance over and above MediShield coverage. Respondents with insurance were less likely to agree that healthcare was affordable and that the "3M" framework was sufficient to meet healthcare needs. CONCLUSION: Singaporeans with a lower HH income and a lower education level were less likely to possess health insurance. This may be related to a stronger belief that healthcare is affordable even without insurance. Educational efforts to encourage the more widespread use of health insurance should be targeted toward lower income groups with less formal education and should be complemented by other interventions to address other aspects of insurance procurement considerations.

Performance evaluation of reverse osmosis desalination plants for rural water supply in a developing country--a case study.

Performance evaluation of two reverse osmosis (RO) desalination plants (DSP) at villages: Melasirupodhu (30 m3 day(-1)) and Sikkal (50 m3 day(-1)) in Ramanathpuram district, Tamil Nadu (India) were studied so as to bring out the state-of-art of their operation and maintenance (O&M). Detailed information on plant design and engineering, water quality, plant personnel, and cost of O&M was collected for a period of three years after commissioning of the two plants. Feed water was brackish, the TDS varied in the range of 6500-8500 mg L(-1) at Melasirupodhu and 5300-7100 mg L(-1) at Sikkal villages. The product water quality was observed to be gradually deteriorating as the salt rejection by the membranes decreased with time. The salt rejection was 97-99% at the time of commissioning of the plants, and came down to 89-90% at the end of 3 years of operation. Product water TDS soon after installation of the plants was excellent and within desirable limits of BIS. After three years of operation, few parameters exceeded the desirable limits, however, they were found to be within permissible limits of BIS. The analyses of the data showed that both plants were operated only at 30-36% of the design capacity. Plant shut-down due to inadequate and erratic power supply, and plant break-down and inherent delay in repairs due to lack of adequate infrastructure were found to be the major causes for the low utilization of the plants. Consequently the recurring cost of product water production enhanced to Rs. 25.0/m3 at Melasirupodhu and Rs. 17.5 m(-3) at Sikkal, as against the estimated cost of Rs. 15.0/m3 and Rs. 11.0/m3, respectively, as per the design. Over the years, the energy consumption for the product water output increased reflecting higher operational pressures needed with the aging of the membranes.

Efficacy of isoniazid prophylaxis in patients with systemic lupus erythematosus receiving long term steroid treatment.

OBJECTIVE: To study the efficacy of isoniazid prophylaxis (INHP) in patients with systemic lupus erythematosus (SLE) receiving long term glucocorticosteroid treatment. PATIENTS AND METHODS: Treatment with INHP (5 mg/kg/day, max 300 mg/day) together with pyridoxine 10 mg/day for one year was started in all patients with SLE seen between January 1994 and December 1999 and followed up thereafter. Clinical examination and chest radiography were carried out in all patients before the start of INHP treatment. A liver profile was obtained only if liver toxicity was suspected owing to nausea, loss of appetite, and icterus. Only the data of those patients who completed the INHP treatment or who were withdrawn owing to toxicity have been analysed. This was compared with the results of an earlier study of the incidence of tuberculosis (TB) in patients with SLE not receiving INHP. RESULTS: Ninety seven patients were included, of whom 95 completed one year's treatment with INHP. Treatment was discontinued in two owing to toxicity: hepatitis in one and peripheral neuropathy in one, at eight and 10 months, respectively. One patient developed TB within one month of starting INHP. Seventy patients were followed up further for at least one year (mean 26.4 months, range 12-60 months) after completion of the INHP treatment. During this period one patient developed TB after one month. No deaths due to TB or hepatitis occurred. In comparison with earlier series the incidence of TB decreased from 11% to 2%, a reduction of 82%. The cost of treatment for each case of TB prevented in the first year was 5800 rupees. CONCLUSION: INHP is safe and effective in SLE.

Time budgets of infants for exposure assessment: a methodological study.

The paper presents the application of the microenvironment approach for collection of time budget data to assess exposure of people to indoor air pollution. The aim of the study was to objectively test the hypothesis that exposure to pollutants from combustion of low-grade cooking fuels is a significant risk factor for acute respiratory infection (ARI) in infants (0-12 months). One of the specific objectives of this study was to estimate, in the winter season, the integrated daily exposure of infants and their mothers to respirable suspended particles (RSPs) and carbon monoxide (CO). The daily-integrated exposure was estimated by splitting the day into parts called microenvironments identified by the mobility patterns of the infants and mothers. These were so determined such that the spatial variation in the concentration of pollutants during these microenvironments is believed to be relatively insignificant under the given conditions, based on results of past studies and subjective judgement. The time spent in these microenvironments by the infants and mothers was determined by preparing time budgets. Very little correlation was found between the two methods of measurement (recall method and direct observation using a stopwatch) for the total time spent in cooking or time actually near the stove. It was observed that infants in houses using kerosene were near the stove for a duration that is 68% of the total cooking duration, while for infants in wood-using households this duration is only 44% (on the basis of the recall method, these numbers are 84% and 63% respectively). The infants spent more time in the indoor noncooking microenvironment irrespective of the fuel and slum type.

Reproductive health and empowerment -- a Rajasthan perspective.

PIP: Reproductive health is one of the major issues of current feminist debates. The issue was brought to light because of population control policies which are being enforced through women's bodies and the spread of HIV/AIDS. In this context, women's organizations and activists are trying to focus upon the issue of reproductive health as part of the larger issue of the position of women in families, societies, and states. Policy makers and donor agencies are trying to address the problem as lack of awareness and knowledge of how to use contraceptives. The authors argue in this situation that it is important to study reproductive health relative to the status of women in society. This paper looks at the existing social construct of patriarchy and population control policies in relation to reproductive health. Women and self, the reproductive role of women, preference for male children, family planning decision making, family planning programs and reproductive health, and the Vikalp program in two districts of Rajasthan are discussed.^ieng

Primary causes of perinatal mortality-autopsy study of 134 cases.

PIP: The methodology and results of 134 neonatal autopsies performed over a 2-year period are presented. The causes of perinatal mortality, in descending order, were: 43% by extrinsic perinatal hypoxia; 18% by infection; 12% by respiratory distress syndrome; and 10.5% by congenital abnormlities. These 4 factors accounted for 84% of the total cases. Perinatal mortality is strongly associated with obstetrical factors, respiratory distress syndrome, and prematurity. In addition, iatrogenic infections play a large contributory role in perinatal mortality. Since about 77% of the perinatal deaths occurred in low-birth-weight babies, the reduction of perinatal mortality can be promoted by reducing prematurity rates and by early detection and intervention in cases of intrauterine growth retardation. In addition, adequate and systematic antenatal care is warranted, since none of the participants in this series had received such care. In 10 cases the primary cause of death could not be determined despite complete autopsy. Briefly the methodology entailed collecting autopsy data, and then assigning primary cause of death from a previously prepared and defined list of primary causes of death, after taking into consideration clinical data in each case. Primary causes of death were, according to this methodology: extrinsic perinatal hypoxia, infection, respiratory distress syndrome, congenital anomalies, hematological disorders, idiopathic massive pulmonary hemorrhage, birth trauma, other specific causes, extreme prematurity, intrauterine growth retardation, and unexplained.^ieng