Foot and Mouth Disease (FMD) incidence in cattle and buffaloes and its associated farm-level economic costs in endemic India.

The study investigated the important epidemiological parameters and farm-level economic costs of FMD incidence in cattle and buffaloes during 2013-14 to 2015-16 in various states of India. Multistage random sampling procedure was adopted for the primary survey and data was collected through face-to-face personal interview from 18,609 cattle and buffalo rearing farm households from 123 districts across twelve states and one Union Territory. Besides epidemiological parameters, different farm-level direct and indirect loss associated with FMD was assessed at disaggregated level (states) by employing deterministic mathematical models. Highest number of affected villages and disease incidence was observed in non- FMD control programme (FMD-CP) implemented Madhya Pradesh and Assam states, respectively whereas negligible incidence was in FMD-CP implemented Punjab state. The disease incidence was high during 2013-14 and declined during 2014-15 and 2015-16, respectively implied severe incidence scenario (2013-14) succeeded by moderate (2014-15) and mild (2015-16) scenarios. The crossbred and high productive animals were severely affected than local breeds whereas on sexwise and agewise comparison revealed higher incidence in females and adult animals. During severe incidence scenario, milk loss/animal ranged from USD 6.87-47.44, 18.42-125.88, 16.33-91.43, and 27.17-123.62; mortality loss/animal ranged from USD 32.61-804.27, 30.76-577.7, 65.36-502.2, and 188.04-413.7; distress sale loss/animal ranged from USD 3.22-188.63, 64.34-519.3, 214.47-341.8, and 209.11-450.3; and opportunity cost of labour/animal from USD 5.49-54.29, 5.49-67.78; 7.95-31.37 and 9.83-72.38 in indigenous cattle, crossbred cattle, local and improved buffalo, respectively. The estimated draught power loss/animal varied from USD 39.46-142.94 with least being in Madhya Pradesh and highest in Assam states whereas the median treatment cost/animal was USD 9.18 and USD 27.07 in indigenous cattle and upgraded buffaloes, respectively. The total farm-level economic loss projected due to FMD in cattle and buffaloes in India was USD 3159 million (INR 221,110 million), USD 270 million (INR 18,910 million) and USD 152 million (INR 10,610 million), respectively during the severe, moderate and mild incidence scenarios at 2015-16 constant prices. The loss varied across the states, and in severe incidence scenario, the country might lose USD 3.2 billion/year and hence, the bi-annual vaccination schedule need to be strictly implemented in all the states. Besides timely vaccination coverage, managing unabated animal movement, educating and motivating the farmers to vaccinate their animals might reduce the incidence and consequential losses to various stakeholders in endemic states like India.

Current utilization patterns for long-acting insulin analogues including biosimilars among selected Asian countries and the implications for the future.

INTRODUCTION: Prevalence rates for diabetes mellitus continue to rise, which, coupled with increasing costs of complications, has appreciably increased expenditure in recent years. Poor glycaemic control including hypoglycaemia enhances complication rates and associated morbidity, mortality and costs. Consequently, this needs to be addressed. Whilst the majority of patients with diabetes have type-2 diabetes, a considerable number of patients with diabetes require insulin to help control their diabetes. Long-acting insulin analogues were developed to reduce hypoglycaemia associated with insulin and help improve adherence, which can be a concern. However, their considerably higher costs have impacted on their funding and use, especially in countries with affordability issues. Biosimilars can help reduce the costs of long-acting insulin analogues thereby increasing available choices. However, the availability and use of long-acting insulin analogues can be affected by limited price reductions versus originators and limited demand-side initiatives to encourage their use. Consequently, we wanted to assess current utilisation rates for long-acting insulin analogues, especially biosimilars, and the rationale for patterns seen, across multiple Asian countries ranging from Japan (high-income) to Pakistan (lower-income) to inform future strategies. METHODOLOGY: Multiple approaches including assessing utilization and prices of insulins including biosimilars among six Asian countries and comparing the findings especially with other middle-income countries. RESULTS: Typically, there was increasing use of long-acting insulin analogues among the selected Asian countries. This was especially the case enhanced by biosimilars in Bangladesh, India, and Malaysia reflecting their perceived benefits. However, there was limited use in Pakistan due to issues of affordability similar to a number of African countries. The high use of biosimilars in Bangladesh, India and Malaysia was helped by issues of affordability and local production. The limited use of biosimilars in Japan and Korea reflects limited price reductions and demand-side initiatives similar to a number of European countries. CONCLUSIONS: Increasing use of long-acting insulin analogues across countries is welcomed, adding to the range of insulins available, which increasingly includes biosimilars. A number of activities are needed to enhance the use of long-acting insulin analogue biosimilars in Japan, Korea and Pakistan.

The Current Situation Regarding Long-Acting Insulin Analogues Including Biosimilars Among African, Asian, European, and South American Countries; Findings and Implications for the Future.

Background: Diabetes mellitus rates continue to rise, which coupled with increasing costs of associated complications has appreciably increased global expenditure in recent years. The risk of complications are enhanced by poor glycaemic control including hypoglycaemia. Long-acting insulin analogues were developed to reduce hypoglycaemia and improve adherence. Their considerably higher costs though have impacted their funding and use. Biosimilars can help reduce medicine costs. However, their introduction has been affected by a number of factors. These include the originator company dropping its price as well as promoting patented higher strength 300 IU/ml insulin glargine. There can also be concerns with different devices between the manufacturers. Objective: To assess current utilisation rates for insulins, especially long-acting insulin analogues, and the rationale for patterns seen, across multiple countries to inform strategies to enhance future utilisation of long-acting insulin analogue biosimilars to benefit all key stakeholders. Our approach: Multiple approaches including assessing the utilisation, expenditure and prices of insulins, including biosimilar insulin glargine, across multiple continents and countries. Results: There was considerable variation in the use of long-acting insulin analogues as a percentage of all insulins prescribed and dispensed across countries and continents. This ranged from limited use of long-acting insulin analogues among African countries compared to routine funding and use across Europe in view of their perceived benefits. Increasing use was also seen among Asian countries including Bangladesh and India for similar reasons. However, concerns with costs and value limited their use across Africa, Brazil and Pakistan. There was though limited use of biosimilar insulin glargine 100 IU/ml compared with other recent biosimilars especially among European countries and Korea. This was principally driven by small price differences in reality between the originator and biosimilars coupled with increasing use of the patented 300 IU/ml formulation. A number of activities were identified to enhance future biosimilar use. These included only reimbursing biosimilar long-acting insulin analogues, introducing prescribing targets and increasing competition among manufacturers including stimulating local production. Conclusions: There are concerns with the availability and use of insulin glargine biosimilars despite lower costs. This can be addressed by multiple activities.

Prevalence and treatment of neurological and psychiatric disorders among tertiary hospitals in Pakistan; findings and implications.

INTRODUCTION: Mental health and neurological disorders are prevalent in Pakistan. However, there are considerable concerns with their management due to issues of access, availability of trained personnel and stigma alongside paucity of such data. Consequently, there is a need to document current treatment approaches starting with tertiary hospitals in Pakistan where patients with more severe mental and neurological disorders are typically treated. Subsequently, use the findings to help direct future policies and initiatives. METHODS: Multi-centered, cross-sectional, prospective study principally evaluating current medicine usage among patients attending tertiary hospitals in Pakistan with psychiatric and neurological disorders. In addition, possible factors contributing to the prevalence of these disorders in this population to help with future care. All 23 tertiary care hospitals in the ten major Districts in Pakistan were included, which cover 75% of the population. RESULTS: 57,664 patients were evaluated of which 35.3% were females. Both females and males had multiple brain disorders and multiple co-morbidities. Schizophrenia was the most prevalent disorder overall among both females (25.2%) and males (30.4%). A median of six medicines were prescribed per patient, with antipsychotics and antidepressants the most prescribed medicines. Clozapine was the most prescribed medicine in males (12.25%) and females (11.83%) including for psychiatric disorders, with sodium valproate the most prescribed medicine in epilepsy in males (42.44% of all anti-epileptic medicines) as well as females (46.38%). There was a greater prevalence of both disorders among the lower classes. A greater prevalence of schizophrenia was seen in patients abusing alcohol and smokers. The divorce rate was higher among the studied patients and the prevalence of depression was higher among the widowed population. CONCLUSIONS: There were concerns with the quality of prescribing including the extent of polypharmacy as well as possible overuse of clozapine especially in patients with epilepsy, both of which need addressing.

3D Printing of Polyethylene Terephthalate Glycol-Sepiolite Composites with Nanoscale Orientation.

A fused-deposition modeling (FDM) 3D-printed polyethylene terephthalate glycol (PETG)-sepiolite composite showed effective synergetic mechanical reinforcement in tensile testing compared to an injection-molded composite. The results showed that the addition of 3 phr sepiolite improved the tensile strength of 3D-printed PETG samples by 35.4%, while the tensile strength of injection-molded PETG samples was improved by 7.2%. To confirm these phenomena, FDM PETG-sepiolite composites were investigated by small-angle X-ray scattering to correlate the nanostructures of the composites with their mechanical strengths. The small-angle X-ray scattering data and transmission electron microscopy observations demonstrated that needle-shaped sepiolite particles were aligned in the printing direction. This fine oriented nanostructure formed during 3D printing created a synergistic effect that improved the material properties of the composite. These novel PETG-sepiolite composites with enhanced mechanical properties can be promising materials fabricated via FDM 3D printing.

Pharmacotherapeutic interventions for bipolar disorder type II: addressing multiple symptoms and approaches with a particular emphasis on strategies in lower and middle-income countries.

Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middle-income countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed.Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments.Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients' rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.

Fibrothorax in adulthood caused by a cerebrospinal fluid shunt in the treatment of hydrocephalus.

Ventriculopleural shunts have been used as an alternative to ventriculoperitoneal shunts in the treatment of hydrocephalus. Although recurrent pleural effusion is a known complication of this procedure, severe fibrothorax requiring decortication has been described only once, in a case involving a child. The authors report a case of a severe fibrothorax with an entrapped lung presenting in an adult patient.

Serosurveillance of foot and mouth disease in Karnataka state, India: a 3 years study.

A prospective serological investigation was conducted to determine the prevalence and distribution of foot-and-mouth disease (FMD), as well as to monitor the effectiveness of the FMD control programme (FMD-CP) through vaccination in Karnataka, India. Random serum samples were collected every year between May and August before the start of vaccination in 2011, and subsequently following two phases of vaccination in 2012 and 2013. Infection status (seroprevalence) was inferred by subjecting the sera to indirect r3AB3 non-structural protein-ELISA, using kits developed by the Project Directorate on FMD, India. The seromonitoring of FMD-CP was carried out by detecting antibodies deemed to be protective in the pre- and post-vaccinal sera, using liquid-phase blocking-ELISA for structural proteins. The results revealed significant decrease in seroprevalence from 58 to 21 %, providing more definitive data supporting our earlier findings obtained through clinical observations (Hegde et al. in Virusdisease 25:504-509, 2014), and detecting active infection in some of the populations which were considered to be free based on passive surveillance. On the other hand, after four rounds of vaccination, a gradual and significant increase from 4.5 to 59 % of animals carrying antibody levels deemed to be protective was observed against all the three serotypes. The findings of this study could be useful for further strategizing to strengthen the ongoing FMD-CP in Karnataka State, India.

Epidemiology of foot and mouth disease in Karnataka state, India: a retrospective study.

A retrospective study on the epidemiology of foot and- mouth disease (FMD) in Karnataka, India between the years 1977 and 2012-13 based on the data collected through passive and active surveillance was undertaken. A total of 11,159 outbreaks with 0.271 million cases of FMD were recorded from 30 different revenue districts of Karnataka. There was a significant difference between the years for the annual incidence of FMD (P = <0.001, F = 19.10) and also between the months (P = <0.001, F = 4.22). Cattle and buffaloes were the predominant species affected being involved in all of the outbreaks reported. A significant correlation was observed between livestock density and the number of outbreaks reported (r = 0.70, p < 0.02), and number of cases (r = 0.76, p < 0.01) for all the agro-climatic zones. The Central dry zone (n = 2257, 19.89 %) reported the highest number of outbreaks followed by the Northern dry zone (n = 1881, 16.58 %) and the Southern transition zone (n = 1761, 15.52 %), and attack rates were concentrated in the North/Northeastern/Central dry and transition zones. A large majority of the outbreaks were caused by serotype O (64.04 %), followed by Asia 1 (19.87 %) and A (12.27 %). Serotype C was not reported since 1993 in the state. In recent years, serotype O has dominated (82.59 %), with the rest of the outbreaks being almost equally caused by A (9.01 %) and Asia 1 (8.40 %). The study highlights the significance of the O serotype and cattle as the main indicator species in the epidemiology of FMD in Karnataka, India. The findings from this study can be used as baseline epidemiological data for further research to identify endemic and epidemic areas for the development of a sustainable programme for the progressive control of FMD in the state of Karnataka as well as other endemic settings.