Safety Assessment of Ultra High Dilutions of Camphora officinarum: A Preclinical Investigation.

Background: Camphora officinarum (CO) is a commonly used homeopathic remedy for treating colds, collapse, and recurrent eruptive illnesses. Objective: Due to the non-availability of safety data on CO, the current study intended to determine the oral toxicity of CO in its ethanol-potentized dilutions 6C, 30C, and 200C in Wistar albino rats as per OECD guidelines. Materials and methods: A single oral dose of CO-6C, 30C, and 200C (2000 µl/kg) was administered, and the animals were monitored for behavior and mortality for up to 14 days in an acute toxicity study. In the subacute study, the effects of daily oral administration of CO-6C, 30C, and 200C (200 µl/kg) for 28 days were observed for clinical signs, change in body weight, and mortality. Hematological, biochemical, and histopathological analyses were assessed and organ weights were determined. Results: Results indicate no mortality of CO in its potencies in the acute toxicity study and was found to be safe at 2000 µl/kg dosage in the subacute toxicity study. CO (200 µl/kg/day) did not show any signs of toxicity in the hematological, biochemical, and histopathological analyses, along with organ weights. Conclusion: In conclusion, the findings suggest that CO in potencies of 6C, 30C, and 200C is safe up to a single oral dose of 2000 µl/kg body weight, and the No Observed Adverse Effect Level (NOAEL) was determined to be greater than 200 µl/kg/day.

Assessment of Odontometric and Osteologic Traits for Gender Determination in South Indians: An Original Research.

In forensic, odontologic, genetic, and anthropological aspects, odontometric and osteologic features have long been a valuable source. The goal of this research was to correlate both the osteologic and odontometric characteristics to determine the most accurate approach for determining gender. A retrospective study involving 1000 adults, with equal gender distribution, was carried out utilizing digital panoramic radiography. The archives were searched for radiographic images of the subjects that were procured for the various procedures that ranged from implantations to rehabilitations. The measurement process was carried out with Image-Pro. There was a noticeable gender difference in the mesodistal breadth, which ranged from 17 to 47. Asymmetry of the lower jaw was considerable in both genders, as was gender variance in osseologic characteristics including ramus diameter and gonial angle. The two groups of attributes exhibited a substantial positive predictive value and thus can be used indetermining gender.

Assessment of the Efficacy of TMJ Arthroscopy-Assisted Masseter Nerve Avulsion on Hemimasticatory Spasm: An Original Research.

The goal of this study is to find a cure for the masticatory muscle disease known as hemimasticatory spasm (HMS). This retrospective investigation intends to find a more efficient therapeutic approach for HMS patients by examining the clinical effectiveness of masseteric nerve avulsion performed on HMS using a temporomandibular arthroscope. A clinical study was piloted where the subjects were treated for masseter nerve avulsion by TMJ arthroscopy. The follow-up was done till 2 years, and the subjects were evaluated for the various characteristics like difficulties, masticatory abilities, and various sounds at the joint for the various functions of the joint. The diagnosis was done using the electrophysiological electromyogram (EMG) at the designated time intervals. There was a complete remission in all the subjects. The masseter nerve avulsion was effective since the scores lowered. Within 3 years of the operation, electrophysiological EMG depicted no discharge potential with a high frequency, and the total efficiency when paired with the clinical effectiveness was deemed acceptable. The maximal masseter power between the treated and nontreated sides was comparable. The mastication, on comparing, was also as effective as the normal side; however, lower mastication was noted in the first year. The avulsed nerve tissues lacked any apparent demyelination. Masseteric nerve avulsion with temporomandibular arthroscope assistance provided acceptable and stable total effectiveness for the intervention of the hemimasticatory spasm. While the strength of the muscle of the afflicted side was only marginally reduced, its masticatory effectiveness was optimally preserved.

Assessment of Pain Management After Orthognathic Surgery by the Administration of Montelukast: An Original Research.

Introduction: Opioid may cause undue risk after surgical procedures like orthognathic surgeries. The present study was aimed to determine how the preoperative administration of oral montelukast affected the degree of postoperative discomfort following bimaxillary orthognathic surgery (BOS). Methodology: This study included all skeletal class III subjects scheduled for BOS. The participants were split into placebo and montelukast groups at random. Every patient received a 10-mL serving of apple juice an hour prior to the surgery; however, for the intervention group, a montelukast 10 mg pill was dissolved in the juice. The same surgical team and general anesthetic guidelines were used for all procedures. The visual analog scale (VAS) was used to calculate postoperative pain at designated intervals. The significance level for the statistical analysis was determined using the Statistical Package for the Social Sciences (SPSS) version 23. Results: The control subjects had a higher level of pain at all the intervals than the intended drug test group. Also, the control group needed more analgesics than the test group. There was one observation made that the length of the surgery had an impact on the postoperative pain. Conclusion: Preoperative montelukast medication may be useful in minimizing postoperative discomfort following bimaxillary orthognathic surgery. More research is required for greater relevance.

Assessment of the efficacy of olopatadine 0.1% in the treatment of vernal keratoconjunctivitis in terms of clinical improvement based on total ocular symptom score and ocular surface disease index.

Purpose: The main objective of this study is to explore the efficacy of olopatadine 0.1% treatment in the resolution of symptoms of vernal keratoconjunctivitis (VKC) among the Indian population. Methods: This single-center, prospective cohort study involved 234 patients with VKC. Patients were treated with olopatadine 0.1%, twice daily for a period of 12 weeks and then followed up in 1st week, 4th week, 3rd month, and 6th month. The extent of relief in the symptoms of VKC was measured using total ocular symptom score (TOSS) and ocular surface disease index (OSDI). Results: In the present study, the dropout rate was 5.6%. Total of 136 males and 85 females with a mean age of 37.68 ± 11.35 years completed the study. TOSS score reduced from 58.85 to 5.06 and the OSDI score reduced from 75.41 to 11.2 with statistical significance (P < 0.01) from 1st week to 6th week after olopatadine 0.1% treatment. The data showed relief in subjective symptoms of itching, tearing, and redness, and relief in discomfort in functions related to ocular grittiness, visuals like reading, and environmental like tolerability in dry conditions. Further, olopatadine 0.1% was effective in both males and females, and patients across ages 18-70 years. Conclusion: Based on TOSS and OSDI scores, the findings of this study validate safety and tolerability as revealed by low adverse effects and moderate efficacy of olopatadine 0.1% in reducing VKC symptoms in a broader age group (18-70 years) of both genders.

Assessment of quality of antenatal care services in public sector facilities in India.

OBJECTIVES: We undertook assessment of quality of antenatal care (ANC) services in public sector facilities in the Indian state of Bihar state delivered under the national ANC programme (Pradhan Mantri Surakshit Matritva Abhiyan, PMSMA). SETTING: Three community health centres and one subdistrict hospital each in two randomly selected districts of Bihar. PARTICIPANTS: Pregnant women who sought ANC services under PMSMA irrespective of the pregnancy trimester. PRIMARY AND SECONDARY MEASURES: Quality ANC services were considered if a woman received all of these services in that visit-weight, blood pressure and abdomen check, urine and blood sample taken, and were given iron and folic acid and calcium tablets. The process of ANC service provision was documented. RESULTS: Eight hundred and fourteen (94.5% participation) women participated. Coverage of quality ANC services was 30.4% (95% CI 27.3% to 33.7%) irrespective of pregnancy trimester, and was similar in both districts and ranged 3%-83.1% across the facilities. Quality ANC service coverage was significantly lower for women in the first trimester of pregnancy (6.8%, 95% CI 3.3% to 13.6%) as compared with those in the second (34.4%, 95% CI 29.9% to 39.1%) and third (32.9%, 95% CI 27.9% to 38.3%) trimester of pregnancy. Individually, the coverage of weight and blood pressure check-up, receipt of iron folic acid (IFA) and calcium tablets, and blood sample collection was >85%. The coverage of urine sample collection was 46.3% (95% CI 42.9% to 49.7%) and of abdomen check-up was 62% (95% CI 58.6% to 65.3%). Poor information sharing post check-up was done with the pregnant women. Varied implementation of ANC service provision was seen in the facilities as compared with the PMSMA guidelines, in particular with laboratory diagnostics and doctor consultation. Task shifting from doctors to ANMs was observed in all facilities. CONCLUSIONS: Grossly inadequate quality ANC services under the PMSMA needs urgent attention to improve maternal and neonatal health outcomes.

Markov model- Quantifying outlook towards success of tobacco cessation counseling.

Smoking is still a major public health issue that causes morbidity and mortality all over the world. The percentage of deaths caused by tobacco smoking has escalated from 1.4% in 1990 to 13.3% by 2020. There are numerous evidence-based tobacco control strategies available, and newer ones are always being developed. However, on ceasing the habit, cigarettes users go through a period of withdrawal with an increased percentage of relapse before entering to a more stable condition of sobriety in the long run. In this review, Endnote software was used as resource material to collect literature, which was then carefully arranged in a synchronised way. The Markov model captures the dynamic character of the quitting/relapse process, allowing for more accurate figures of abstinence rate, treatment outcomes and evaluating the performance of newer cessation initiatives during tobacco cessation counselling, as well as suggesting pathways for survivability.

Online viva voce as a formative assessment method in forensic medicine during COVID-19 pandemic.

BACKGROUND: Conducting online classes and assessment during the COVID-19 pandemic is not without challenges. The world of medical education is adapting online training and assessment because of COVID-19 pandemic restrictions. The present study was conducted to assess the students' perception regarding the process, difficulties encountered and perceived effectiveness of online assessment. MATERIALS AND METHODS: Online viva-voce (theory and visual based) was conducted in a government medical college in Karwar, Karnataka, India using videoconferencing application (Google Meet) to 149 second MBBS students as a formative assessment in 2020 over 3 months. Ten students per day joined Google Meet, 10 questions were asked to each student and assessed using a tutor marking system (on-spot). A feedback questionnaire (Google Form) was administered to students who attended online Viva-Voce. Data was analysed using descriptive and inferential statistics (Student's t-test). RESULTS: Out of 149 students, 132 participated and responded to a feedback questionnaire. Majority of the participants (91%) agreed that questions covered all topics kept for viva, 82% of them felt it would be helpful for performance in final examinations. Thirty percent of students faced network issues at their places, 45% felt nervous while facing viva in the presence of other students and 35% of participants preferred online methods over traditional viva voce. Online viva voce can be transparent (90%) and less biased (88%) if done in structured format. CONCLUSION: Online viva-voce may become relevant and effective in medical education assessment with transparent marking system for students' performance.

Implications of the availability and distribution of birth weight on addressing neonatal mortality: population-based assessment from Bihar state of India.

OBJECTIVE: A large proportion of neonatal deaths in India are attributable to low birth weight (LBW). We report population-based distribution and determinants of birth weight in Bihar state, and on the perceptions about birth weight among carers. DESIGN: A cross-sectional household survey in a state representative sample of 6007 live births born in 2018-2019. Mothers provided detailed interviews on sociodemographic characteristics and birth weight, and their perceptions on LBW (birth weight <2500 g). We report on birth weight availability, LBW prevalence, neonatal mortality rate (NMR) by birth weight and perceptions of mothers on LBW implications. SETTING: Bihar state, India. PARTICIPANTS: Women with live birth between October 2018 and September 2019. RESULTS: A total of 5021 (83.5%) live births participated, and 3939 (78.4%) were weighed at birth. LBW prevalence among those with available birth weight was 18.4% (95% CI 17.1 to 19.7). Majority (87.5%) of the live births born at home were not weighed at birth. LBW prevalence decreased and birth weight ≥2500 g increased significantly with increasing wealth index quartile. NMR was significantly higher in live births weighing <1500 g (11.3%; 95% CI 5.1 to 23.1) and 1500-1999 g (8.0%; 95% CI 4.6 to 13.6) than those weighing ≥2500 g (1.3%, 95% CI 0.9 to 1.7). Assuming proportional correspondence of LBW and NMR in live births with and without birth weight, the estimated LBW among those without birth weight was 35.5% (95% CI 33.0 to 38.0) and among all live births irrespective of birth weight availability was 23.0% (95% CI 21.9 to 24.2). 70% of mothers considered LBW to be a sign of sickness, 59.5% perceived it as a risk of developing other illnesses and 8.6% as having an increased probability of death. CONCLUSIONS: Missing birth weight is substantially compromising the planning of interventions to address LBW at the population-level. Variations of LBW by place of delivery and sociodemographic indicators, and the perceptions of carers about LBW can facilitate appropriate actions to address LBW and the associated neonatal mortality.

Design of Resources Allocation in 6G Cybertwin Technology Using the Fuzzy Neuro Model in Healthcare Systems.

In 6G edge communication networks, the machine learning models play a major role in enabling intelligent decision-making in case of optimal resource allocation in case of the healthcare system. However, it causes a bottleneck, in the form of sophisticated memory calculations, between the hidden layers and the cost of communication between the edge devices/edge nodes and the cloud centres, while transmitting the data from the healthcare management system to the cloud centre via edge nodes. In order to reduce these hurdles, it is important to share workloads to further eliminate the problems related to complicated memory calculations and transmission costs. The effort aims mainly to reduce storage costs and cloud computing associated with neural networks as the complexity of the computations increases with increasing numbers of hidden layers. This study modifies federated teaching to function with distributed assignment resource settings as a distributed deep learning model. It improves the capacity to learn from the data and assigns an ideal workload depending on the limited available resources, slow network connection, and more edge devices. Current network status can be sent to the cloud centre by the edge devices and edge nodes autonomously using cybertwin, meaning that local data are often updated to calculate global data. The simulation shows how effective resource management and allocation is better than standard approaches. It is seen from the results that the proposed method achieves higher resource utilization and success rate than existing methods. Index Terms are fuzzy, healthcare, bioinformatics, 6G wireless communication, cybertwin, machine learning, neural network, and edge.

Challenges in microalgal biofuel production: A perspective on techno economic feasibility under biorefinery stratagem.

Rapidly exhausting fossil fuels combined with the ever-increasing demand for energy led to an ongoing search for alternative energy sources to meet the transportation, manufacturing, domestic and other energy demands of the grown population. Microalgae are at the forefront of alternative energy research due to their significant potential as a renewable feedstock for biofuels. However, microalgae platforms have not found a way into industrial-scale bioenergy production due to various technical and economic constraints. The present review provides a detailed overview of the challenges in microalgae production processes for bioenergy purposes with supporting techno-economic assessments related to microalgae cultivation, harvesting and downstream processes required for crude oil or biofuel production. In addition, biorefinery approaches that can valorize the by-products or co-products in microalgae production and enhance the techno-economics of the production process are discussed.

Amplification-free detection of SARS-CoV-2 with CRISPR-Cas13a and mobile phone microscopy.

The December 2019 outbreak of a novel respiratory virus, SARS-CoV-2, has become an ongoing global pandemic due in part to the challenge of identifying symptomatic, asymptomatic, and pre-symptomatic carriers of the virus. CRISPR diagnostics can augment gold-standard PCR-based testing if they can be made rapid, portable, and accurate. Here, we report the development of an amplification-free CRISPR-Cas13a assay for direct detection of SARS-CoV-2 from nasal swab RNA that can be read with a mobile phone microscope. The assay achieved ∼100 copies/µL sensitivity in under 30 min of measurement time and accurately detected pre-extracted RNA from a set of positive clinical samples in under 5 min. We combined crRNAs targeting SARS-CoV-2 RNA to improve sensitivity and specificity and directly quantified viral load using enzyme kinetics. Integrated with a reader device based on a mobile phone, this assay has the potential to enable rapid, low-cost, point-of-care screening for SARS-CoV-2.

The global burden of falls: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017.

BACKGROUND: Falls can lead to severe health loss including death. Past research has shown that falls are an important cause of death and disability worldwide. The Global Burden of Disease Study 2017 (GBD 2017) provides a comprehensive assessment of morbidity and mortality from falls. METHODS: Estimates for mortality, years of life lost (YLLs), incidence, prevalence, years lived with disability (YLDs) and disability-adjusted life years (DALYs) were produced for 195 countries and territories from 1990 to 2017 for all ages using the GBD 2017 framework. Distributions of the bodily injury (eg, hip fracture) were estimated using hospital records. RESULTS: Globally, the age-standardised incidence of falls was 2238 (1990-2532) per 100 000 in 2017, representing a decline of 3.7% (7.4 to 0.3) from 1990 to 2017. Age-standardised prevalence was 5186 (4622-5849) per 100 000 in 2017, representing a decline of 6.5% (7.6 to 5.4) from 1990 to 2017. Age-standardised mortality rate was 9.2 (8.5-9.8) per 100 000 which equated to 695 771 (644 927-741 720) deaths in 2017. Globally, falls resulted in 16 688 088 (15 101 897-17 636 830) YLLs, 19 252 699 (13 725 429-26 140 433) YLDs and 35 940 787 (30 185 695-42 903 289) DALYs across all ages. The most common injury sustained by fall victims is fracture of patella, tibia or fibula, or ankle. Globally, age-specific YLD rates increased with age. CONCLUSIONS: This study shows that the burden of falls is substantial. Investing in further research, fall prevention strategies and access to care is critical.

Mid-upper arm circumference as a substitute of the body mass index for assessment of nutritional status among adult and adolescent females: learning from an impoverished Indian state.

OBJECTIVES: For population-level screening of malnutrition among adults-especially in developing-country settings-the body mass index (BMI) can be impractical because of logistical requirements for weight and height measurement. We analyzed anthropometric data collected from a large-scale nutritional survey on women of rural Bihar to determine the mid-upper arm circumference (MUAC) cutoffs corresponding to standard BMI cutoffs and the predictive accuracies of the determined cutoffs. STUDY DESIGN: It was a cross-sectional study using multistage cluster sampling. METHODS: The current analysis used anthropometric data from a study on dietary practices of rural women (adolescents, lactating mothers, and women in the interpregnancy period). The MUAC (cm) cutoffs corresponding to four standard BMI (kg/m2) values were determined using receiver operating characteristic (ROC) curve analysis. RESULT: We detected a significant positive correlation between BMI and MUAC (r = 0.81, P < 0.0001). In ROC curve analysis, the MUAC cutoffs corresponding to BMI cutoffs of 18.5, 23, 25, and 30 kg/m2 were estimated to be 23.2, 26.0, 27.3, and 30.5 kg/m2, respectively. The predictive accuracy of the determined cutoffs was good, as indicated by the area under the ROC curve for the four different cutoffs-which ranged between 88% and 97%. Other than the cutoff for 'obese' (BMI, 30 kg/m2), the Kappa coefficients for the rest of the MUAC cutoffs showed 'substantial' agreement (>0.6) with their BMI counterparts. CONCLUSION: The results suggest that the cutoffs based on MUAC-a less resource-intensive measure than BMI-can be used for community-based screening of malnutrition among women of Bihar.

Distinct mortality patterns at 0-2 days versus the remaining neonatal period: results from population-based assessment in the Indian state of Bihar.

BACKGROUND: The objectives of this study were to understand the differences in mortality rate, risk factors for mortality, and cause of death distribution in three neonatal age sub-groups (0-2, 3-7, and 8-27 days) and assess the change in mortality rate with previous assessments to inform programmatic decision-making in the Indian state of Bihar, a large state with a high burden of newborn deaths. METHODS: Detailed interviews were conducted in a representative sample of 23,602 live births between January and December 2016 (96.2% participation) in Bihar state. We estimated the neonatal mortality rate (NMR) for the three age sub-groups and explored the association of these deaths with a variety of risk factors using a hierarchical logistic regression model approach. Verbal autopsies were conducted using the PHMRC questionnaire and the cause of death assigned using the SmartVA automated algorithm. Change in NMR from 2011 to 2016 was estimated by comparing it with a previous assessment. RESULTS: The NMR 0-2-day, 3-7-day, and 8-27-day mortality estimates in 2016 were 24.7 (95% CI 21.8-28.0), 13.2 (11.1 to 15.7), 5.8 (4.4 to 7.5), and 5.8 (4.5 to 7.5) per 1000 live births, respectively. A statistically significant reduction of 23.3% (95% CI 9.2% to 37.3) was seen in NMR from 2011 to 2016, driven by a reduction of 35.3% (95% CI 18.4% to 52.2) in 0-2-day mortality. In the final regression model, the highest odds for mortality in 0-2 days were related to the gestation period of ≤ 8 months (OR 16.5, 95% CI 11.9-22.9) followed by obstetric complications, no antiseptic cord care, and delivery at a private health facility or home. The 3-7- and 8-27-day mortality was driven by illness in the neonatal period (OR 10.33, 95% CI 6.31-16.90, and OR 4.88, 95% CI 3.13-7.61, respectively) and pregnancy with multiple foetuses (OR 5.15, 95% CI 2.39-11.10, and OR 11.77, 95% CI 6.43-21.53, respectively). Birth asphyxia (61.1%) and preterm delivery (22.1%) accounted for most of 0-2-day deaths; pneumonia (34.5%), preterm delivery (33.7%), and meningitis/sepsis (20.1%) accounted for the majority of 3-7-day deaths; meningitis/sepsis (30.6%), pneumonia (29.1%), and preterm delivery (26.2%) were the leading causes of death at 8-27 days. CONCLUSIONS: To our knowledge, this is the first study to report a detailed neonatal epidemiology by age sub-groups for a major Indian state, which has highlighted the distinctly different mortality rate, risk factors, and causes of death at 0-2 days versus the rest of the neonatal period. Monitoring mortality at 0-2 and 3-7 days separately in the traditional early neonatal period of 0-7 days would enable more effective programming to reduce neonatal mortality.

Assessment of resistance to rice tungro disease in popular rice varieties in India by introgression of a transgene against Rice tungro bacilliform virus.

Rice crops in South and Southeast Asian countries suffer critical yield losses due to rice tungro disease caused by joint infection with rice tungro bacilliform virus (RTBV) and rice tungro spherical virus (RTSV). Previously, for generating RNA interference-based transgenic resistance against tungro viruses, RTBV ORF IV was used as a transgene to develop RTBV resistance in a popular high-yielding scented rice variety. The transgene from this line was then introgressed into five popular high-yielding but tungro-susceptible rice varieties by marker-assisted backcross breeding with a view to combine the resistant trait with the agronomic traits. The present work includes a resistance assay of the BC3F5 lines of these varieties under glasshouse conditions. Out of a total of 28 lines tested, each consisting of 12 individual plants, eight lines showed significant amelioration in height reduction and 100- to 1000-fold reduction in RTBV titers. The RNAi-mediated resistance was clearly manifested by the presence of virus-derived small RNA (vsRNA) specific for RTBV ORF IV in the transgenic backcrossed lines.

Assessment of knowledge, attitude, and practices and motivation to quit tobacco habits in relation to age and educational status among male tobacco users visiting a Government Dental College Hospital, India.

BACKGROUND: Tobacco use has become an epidemic of modern times. Its use is widespread among young adults and those from lower socioeconomic classes. OBJECTIVE: The objective is to assess knowledge, attitude, and practices (KAP) and motivation to quit tobacco habits in relation to age and educational status among male tobacco users visiting a Government Dental College Hospital, India. MATERIALS AND METHODS: This was a questionnaire survey conducted among 199 male adult smokers visiting the Department of Public Health Dentistry in a Government Dental College in India. Quota sampling was used for recruiting the required number of study participants. Information on KAP related to smoking habits was collected using a predesigned structured questionnaire by two trained and calibrated dentists. Knowledge, attitude toward quitting and their self-confidence toward quitting was compared in relation to age and educational status using Chi-square test. RESULTS: A higher percentage of younger adults aged 18-24 years were interested in quitting the habit (100%) compared to those aged 45-64 years (85.2%). Similarly, a higher percentage of young adults have tried quitting the habit (76.9%) compared to their older counterparts (64.8%) (P < 0.05). Knowledge on ill effects of smoking increased with increasing educational attainment (P < 0.001). People with higher educational attainment had observed the warning sign on packaging (73.7%) compared to those with less than primary education (25.9%) and they also reported that the presence of such warning sign motivated them to think about quitting (54.8% vs. 0%) (P < 0.001). CONCLUSION: Knowledge, positive attitude toward quitting and self-confidence to quit were higher among younger adults and those with secondary education compared to their elder counterparts and those with less than primary education.

Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment: Database Analyses and Systematic Review.

BACKGROUND: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. METHODS: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. RESULTS: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. CONCLUSIONS: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

Decreasing cost of public sector first-line ART services in India from 2007-2008 to 2015-2016.

INTRODUCTION: India has scaled-up antiretroviral treatment (ART) in public sector facilities, but data to understand time trends of average cost of ART are limited. MATERIALS AND METHODS: Cost and output data were collected at all public sector ART centres in undivided Andhra Pradesh (high-HIV burden state) and Rajasthan (low-HIV burden state) in India from fiscal year 2007-2008 to 2012-2013. Average cost per patient for first-line ART, and its relation with scale of services, were assessed. Using data on scale of services, the average cost was estimated up to 2015-2016. Break-even point was estimated from average and marginal cost functions. Costs were adjusted to 2015 constant price. RESULTS: The average cost per patient alive and on ART in 2015-2016 was US$162 in undivided Andhra Pradesh and US$186 in Rajasthan, which was 51.4% and 35.8% lower than in 2007-2008, respectively. Average ART drug cost declined by 27.2% during this period, and was 70.9% and 61.5% of the total ART cost in the two states in 2015-2016. The average cost other than ART drugs declined by 73.1% and 45.7%, with the number of patients served increasing 7 and 14.2 times, respectively. Average cost other than ART drugs had a significant negative relation with scale (R2 = 86.4%-82.8%, p<0.001). Break-even analysis suggested that 47.5% and 58.8% of the ART centres in undivided Andhra Pradesh and Rajasthan, respectively, were functioning below optimal scale in 2015-2016. The estimated total economic cost of first-line ART services provided in the public sector in India in fiscal year 2015-2016 was US$ 151 million; it would be US$ 216.1 million to provide this to all eligible persons in India. CONCLUSION: The average cost of providing first-line ART has declined in India, and further reduction is possible if the optimal scale of services is achieved. These findings can inform resource requirement for the ART programme in India.