ESSENCE: An Implementation Research Program to Scale Up Depression Care in Rural Communities

BACKGROUND

Task sharing may involve training nonspecialist health workers (NSHWs) to deliver brief mental health interventions. This approach is promising for reducing the global mental health treatment gap. However, capacity is limited for training large cadres of frontline workers in low- and middle-income countries, hindering uptake of these interventions at scale.

METHODS

The ESSENCE (enabling translation of science to service to enhance depression care) project in Madhya Pradesh, India, aims to address these challenges through two sequential randomized controlled trials. First, a training trial will evaluate the effectiveness and cost-effectiveness of digital training, compared with conventional face-to-face training, in achieving clinical competency of NSHWs in delivering an intervention for depression. This initial trial will be followed by an implementation trial aimed at evaluating the effectiveness of a remote enhanced implementation support, compared with routine implementation support, in addressing barriers to delivery of depression care in primary care facilities.

RESULTS

This project involved developing and pilot testing a scalable smartphone-based program for training NSHWs to deliver a brief psychological intervention for depression screening. This initial research guided a randomized trial of a digital training approach with NSHWs to evaluate the effectiveness of this approach. This trial will be followed by a cluster-randomized trial to evaluate the effectiveness of remote implementation support in ensuring efficient delivery of depression care in primary care facilities.

NEXT STEPS

Findings from these trials may inform sustainable training and implementation support models to integrate depression care into primary care for scale-up in resource-constrained settings.

Stress Alleviation Methods for community-Based Health ActiVists (SAMBHAV): Development of a digital program for stress reduction for community health workers in rural India

Background

Community health workers (CHWs) face high levels of stress (both professional and personal) and risk of burnout, highlighting the need for efforts to promote their mental health and well-being. This study seeks to develop a digital stress reduction program for CHWs in rural India.

Methods

A stepwise design process was employed to adapt and digitize the evidence-based World Health Organization's Self-Help Plus (SH+) intervention for addressing psychological distress among CHWs in Madhya Pradesh, India. This involved participatory design workshops with CHWs to ensure that the digital stress reduction intervention would be relevant for their needs and the local culture and context. Small groups of CHWs reviewed the adapted program content, allowing the research team to make refinements such as simplifying language, tailoring content to the local setting, and ensuring that program materials are both interesting and relevant. Simultaneously, the research team digitized the content, leveraging a combination of video and graphical content, and uploaded it to the Sangath Learning Management System, a digital platform accessible on a smartphone app.

Results

In total, 18 CHWs contributed to the adaptation of the SH+ content and digital intervention development. Participants commented on finding some terms difficult to follow and recommended simplifying the language and providing detailed explanations. Participants offered positive feedback on the adapted content, expressing that they found the examples covered in the material both relatable and relevant to their own personal experiences at home and in the workplace. By combining participants' insights and comments with feedback from content experts, it was possible to finalize a digital Hindi version of the SH+ intervention for CHWs in rural India.

Conclusions

This study is timely given the continued detrimental impacts of the COVID-19 pandemic, and offers a promising and potentially scalable digital program to alleviate psychological distress among frontline health workers.

Measuring training effectiveness of laboratory biosafety program offered at African Center for Integrated Laboratory Training in 22 President's Emergency Plan for AIDS Relief supported countries (2008-2014)

INTRODUCTION

The African Center for Integrated Laboratory Training (ACILT) in Johannesburg, South Africa offered a laboratory biosafety program to improve laboratory biosafety practices in 22 President's Emergency Plan for AIDS Relief (PEPFAR) supported countries. This manuscript evaluates the transference of newly gained knowledge and skills to the participants' place of employment for HIV and TB diagnostic laboratory programs. It also serves as a follow-on to a previously published manuscript that measured training effectiveness for all courses offered at ACILT.

METHODS

ACILT offered 20 Laboratory Biosafety and Infrastructure courses (2008-2014), also referred as biosafety course/course comprising of 14 core laboratory safety elements to 402 participants from 22 countries. In 2015, participants received 22 e-questions divided into four categories: (1) Safety Policies, (2) Management's Engagement, (3) Safety Programs and (4) Assessments of Safety Practices to determine retrospectively the training effectiveness of biosafety practices in their place of employment 6 months before and after attending their course. We used Kirkpatrick model to assess the transference of knowledge, skills and obstructive factors.

RESULTS

20% (81/402) of the participants completed the e-questionnaire. The overall percentage of positive responses indicating implementation of new safety practices increased from 50% to 84%. Improvement occurred in all four categories after attending the course, with the greatest increases in Safety Policies (67-94%) and Safety Programs (43-91%). Creating a safety committee, allocating resources, and establishing a facility safety policy were important drivers for implementing and maintaining laboratory safety practices. In addition, accredited laboratories and countries with national safety regulations or policies had a higher percentage of improvements. The most reported challenges were inadequate funding and lack of management enforcement.

CONCLUSIONS

PEPFAR and other partners' investments in training institutions, such as ACILT, were effective in building sustainable country ownership to strengthen biosafety practices and were leveraged to combat zoonotic diseases and COVID-19. Although support continues at the national/regional level, a standardized, coordinated and continent-wide sustainable approach to offer a biosafety program-like ACILT is missing. Continuous offerings of biosafety programs similar to ACILT could contribute to sustainable strengthening of laboratory biosafety, QMS and pandemic preparedness.

"We are everyone's ASHAs but who's there for us?" a qualitative exploration of perceptions of work stress and coping among rural frontline workers in Madhya Pradesh, India

OBJECTIVE

More than a million female village-level lay providers called 'Accredited Social Health Activists (ASHAs)', who deliver primary care, face high levels of stress due to work demands and low compensation, within the context of poverty and gender inequality. Evidence on ASHAs has focused on workplace challenges from a system perspective, without sufficient probing into individual-level stress. This study aims to gain perspectives into the experiences of work stress, the related health symptoms, and the responses to stress among ASHAs in India.

METHODS

Focus group discussions (FGDs) conducted with ASHAs in Sehore district, Madhya Pradesh, were audio-recorded and transcribed. Grounded theory was used to generate themes under the various domains of ASHAs' work and domestic life. We identified pathways between the conditions that trigger stressful events, experiences of these events, resulting perceptions, effects on health and wellbeing, and approaches used by ASHAs to respond to stress.

RESULTS

Six FGDs with 59 ASHAs generated the following themes: (a) Facility: Workload, undue pressures, unstructured work; ASHAs' relationships with seniors (e.g., feelings of being disrespected, blamed, or targeted), and low access to physical and administrative resources; (b) Home: Feelings of guilt for putting less time for family/child care; disrespect by the elderly for a poorly incentivised job; (c) Community: Low acceptance by the villagers; caste- and gender-bias; difficult community-level relationships (emotional labour, fear/stigma towards her services); (d) Somatic and psychological symptoms: headache, exhaustion, depressive symptoms (to cite a few); and (e) Responses to stress: Motivation (support from peers, family, a sense of identity/pride, incentives), Individual strengths (e.g., social responsibility), and spiritual recourse mechanisms.

CONCLUSIONS

This study will inform the development of a strengths-based coaching intervention to address work stress among ASHAs. The findings are relevant to building the evidence on alleviation of work stress among female frontline cadres in low-resource settings globally.

Assessing the effect of electronic health information exchange on the completeness and validity of data for measuring viral load testing turnaround time in Nigeria

INTRODUCTION

Implementation of health information exchange has been shown to result in several benefits which includes the improvement in the completeness and timeliness of data for public health program monitoring and surveillance.

OBJECTIVE

The objective of this study was to assess the effect of implementing an electronic health information exchange (HIE) on the quality of data available to measure HIV viral load testing turnaround time (TAT) in Nigeria.

METHODS

We measured viral load data validity and completeness before the implementation of electronic health information exchange, and 6 months after implementation. Records of specimens collected at 30 healthcare facilities and tested in 3 Polymerase Chain Reaction (PCR) labs were analyzed. We define data completeness as the percentage of non-missing values and measured this value by specimens and by data elements in the dataset for calculating TAT. To examine data validity, we classified TAT segments with negative values and date fields that were not in International Organization for Standardization(ISO) standard date format as invalid. Validity was measured by specimens and by each TAT segment. Pearson's chi square was used to assess for improvements in validity and completeness post implementation of HIE.

RESULTS

15,226 records of specimens were analyzed at baseline and 18,022 records of specimens analyzed at endline. Data completeness for all specimens recorded increased significantly from 47% before HIE implementation to 67% six months after implementation (p < 0.01). Data validity also increased from 90% before implementation to 91% after implementation (p < 0.01) CONCLUSION: Our study demonstrated evidence of significant improvement in the quality of data available to measure viral load turnaround time with the implementation of HIE.

Applying Human-Centered Design in Global Mental Health to Improve Reach Among Underserved Populations in the United States and India

INTRODUCTION

Human-centered design (HCD) refers to a diverse suite of interactive processes that engage end users in the development of a desired outcome. We showcase how 2 global mental health research teams applied HCD to develop mobile health tools, each directed at reducing treatment gaps in underserved populations. CASE STUDY 1: Refugees face higher risks for mental health problems, yet these communities face structural and cultural barriers that reduce access to and use of services. To address these challenges, the Research Program on Children and Adversity at the Boston College School of Social Work, in partnership with resettled refugee communities in the northeastern United States, used codesign methodology to digitally adapt delivery of the Family Strengthening Intervention for Refugees-a program designed to improve mental health and family functioning among resettled families. We describe how codesign methods support the development of more feasible, acceptable, and sustainable interventions. CASE STUDY 2: Sangath, an NGO in India focused on mental health services research, in partnership with Harvard Medical School, designed and evaluated a digital training program for community health workers to deliver an evidence-based, brief psychological treatment for depression as part of primary care in Madhya Pradesh, India. We describe how HCD was applied to program development and discuss our approach to scaling up training and capacity-building to deliver evidence-based treatment for depression in primary care.

IMPLICATIONS

HCD involves a variety of techniques that can be flexibly adapted to engage end users in the conceptualization, implementation, scale-up, and sustainment of global mental health interventions. Community solutions generated using HCD offer important benefits for key stakeholders. We encourage widespread adoption of HCD within global mental health policy, research, and practice, especially for addressing mental health disparities with underserved populations.

A qualitative exploration of perceived needs and barriers of individuals with schizophrenia, caregivers and clinicians in using mental health applications in Madhya Pradesh, India

Introduction

About 3.5 million people are living with schizophrenia in India, with most failing to receive minimally adequate care. Digital mental health applications could potentially decrease this treatment gap; however, these applications should be tailored to meet the needs and overcoming barriers of its end-users to ensure their adoption and sustained usage. Few studies in India have explored the perspectives of target stakeholders to understand how digital tools could be viable for supporting care. Therefore, this study explores the perceived needs and barriers of patients with schizophrenia, caregivers and clinicians in using digital mental health applications.

Methods

Focus group discussions (FGDs) were conducted with patients having schizophrenia attending outpatient clinics at a government tertiary hospital, and their caregivers, and mental health clinicians in Bhopal, Madhya Pradesh, India. FGDs were audio-recorded and coded. Framework analysis was employed to guide the analysis, involving deductive and inductive generation of themes, data triangulation and comparison of perspectives between participant groups.

Results

Six FGDs were conducted with individuals with schizophrenia (n ​= ​11), their caregivers (n ​= ​14), and mental health clinicians (n ​= ​19). Four a priori themes were established: a) Prior experiences with health applications; b) Content of a mental health application; c) Involvement of caregivers in mental health application usage and d) Supporting doctors' work through mental health applications. Additionally, two themes were generated inductively: a) Qualities of a mental health application and b) Data privacy and confidentiality.

Conclusion

Exploration of stakeholder perspectives on the content, features, and uses of mental health applications is crucial to yield initial insights about the use of these digital programs in India. This study generated a multitude of suggestions on app functionality and components, which can guide ongoing efforts to develop and deliver digital mental health applications for patients living with schizophrenia in low-resource settings, with limited access to mental health services.

Smartphone digital phenotyping, surveys, and cognitive assessments for global mental health: Initial data and clinical correlations from an international first episode psychosis study

Objective

To examine feasibility and acceptability of smartphone mental health app use for symptom, cognitive, and digital phenotyping monitoring among people with schizophrenia in India and the United States.

Methods

Participants in Boston, USA and Bhopal and Bangalore, India used a smartphone app to monitor symptoms, play cognitive games, access relaxation and psychoeducation resources and for one month, with an initial clinical and cognitive assessment and a one-month follow-up clinical assessment. Engagement with the app was compared between study sites, by clinical symptom severity and by cognitive functioning. Digital phenotyping data collection was also compared between three sites.

Results

By Kruskal-Wallis rank-sum test, we found no difference between app activities completed or digital phenotyping data collected across the three study sites. App use also did not correlate to clinical or cognitive assessment scores. When using the app for symptom monitoring, preliminary findings suggest app-based assessment correlate with standard cognitive and clinical assessments.

Conclusions

Smartphone app for symptom monitoring and digital phenotyping for individuals with schizophrenia appears feasible and acceptable in a global context. Clinical utility of this app for real-time assessments is promising, but further research is necessary to determine the long-term efficacy and generalizability for serious mental illness.

Cross cultural and global uses of a digital mental health app: results of focus groups with clinicians, patients and family members in India and the United States

BACKGROUND

Despite significant advancements in healthcare technology, digital health solutions - especially those for serious mental illnesses - continue to fall short of their potential across both clinical practice and efficacy. The utility and impact of medicine, including digital medicine, hinges on relationships, trust, and engagement, particularly in the field of mental health. This paper details results from Phase 1 of a two-part study that seeks to engage people with schizophrenia, their family members, and clinicians in co-designing a digital mental health platform for use across different cultures and contexts in the United States and India.

METHODS

Each site interviewed a mix of clinicians, patients, and their family members in focus groups (n = 20) of two to six participants. Open-ended questions and discussions inquired about their own smartphone use and, after a demonstration of the mindLAMP platform, specific feedback on the app's utility, design, and functionality.

RESULTS

Our results based on thematic analysis indicate three common themes: increased use and interest in technology during coronavirus disease 2019 (COVID-19), concerns over how data are used and shared, and a desire for concurrent human interaction to support app engagement.

CONCLUSION

People with schizophrenia, their family members, and clinicians are open to integrating technology into treatment to better understand their condition and help inform treatment. However, app engagement is dependent on technology that is complementary - not substitutive - of therapeutic care from a clinician.

Multicentric Hospital-Based Surveillance of Pertussis Amongst Infants Admitted in Tertiary Care Facilities in India

OBJECTIVE

To estimate the disease and economic burden of pertussis amongst hospitalised infants in India.

DESIGN

Multicentric hospital-based surveillance study.

PARTICIPANTS

Hospitalised infants with clinical suspicion of pertussis based on predefined criteria.

OUTCOME MEASURES

Proportion of infants with laboratory-confirmed pertussis, economic burden of pertussis amongst hospitalised infants.

RESULTS

693 clinically suspected infants were recruited of which 32 (4.62%) infants had laboratory-confirmed pertussis. Progressive cough with post-tussive emesis (50%) and pneumonia (34%) were the common clinical presentations; apnea in young infants was significantly associated with pertussis. Infants with pertussis were more likely to be younger (median age 102.5 days vs.157 days) and born preterm (42.9% vs 24.5%). Almost 30% infants with pertussis had not received vaccine for pertussis with 50% of these infants aged less than 2 months. Pertussis was associated with higher costs of hospitalisation, pharmacy and loss of working days by caregivers as compared to non-pertussis cases.

CONCLUSIONS

Younger infants, those born preterm and those inadequately immunised against pertussis are at higher risk of pertussis infection. Timely childhood immunisation and introduction of maternal immunisation for pertussis can help in reducing the disease burden.

Collective insights of public-private partnership impacts and sustainability: A qualitative analysis

The global Coronavirus or COVID-19 pandemic exposed the weakness of healthcare systems including laboratory systems and is a call to action for unprecedented collaboration and partnerships to deal with the global crisis. The United States (U.S.) President’s Emergency Plan for AIDS Relief (PEPFAR) establishes the global HIV/AIDS treatment agenda in alignment with the UNAIDS 90-90-90 treatment targets to achieve epidemic control related to enhanced testing, treatment, and viral suppression. A strategic PEPFAR priority area recognizes that large-scale collective efforts and sharing of resources bear greater potential impact for lasting change than any single organization or entity can achieve alone. An important vehicle utilized within the global public health context is the public-private partnership (PPP) model whereby multiple international organizations forge unified project charters to collectively reach mutually agreed goals. While touted as an ideal mechanism to synthesize resources and maximize gain in numerous applications, little is known from a seasoned stakeholder perspective regarding PPP implementation and sustainability issues. The purpose of this research is to holistically examine perceptions of PPP model sustainability related to inputs and impacts among a collective network of stakeholders experienced with PEPFAR workforce development, laboratory-system strengthening project implementation. Interviews were conducted with frontline stakeholders from public and private sector organizations based in the US and select PEPFAR-supported priority countries. Analysis revealed three dominant themes: PPP impacts, keys of successful collaboration, and logistical challenges and opportunities to enhance sustainability of PPP outcomes in the future.

Digital training for non-specialist health workers to deliver a brief psychological treatment for depression in India: Protocol for a three-arm randomized controlled trial

BACKGROUND

Training non-specialist health workers (NSHWs) at scale is a major barrier to increasing the coverage of depression care in India. This trial will test the effectiveness of two forms of digital training compared to conventional face-to-face training in changing the competence of NSHWs to deliver a brief evidence-based psychological treatment for depression.

METHODS

This protocol is for a three-arm, parallel group randomized controlled trial comparing three ways of training NSHWs to deliver the Healthy Activity Program (HAP), a brief manualized psychotherapy for depression, in primary care. The arms are: digital training (DGT); digital training combined with individualized coaching support (DGT+); and conventional face-to-face training (F2F). The target sample comprises N = 336 government contracted NSHWs in Madhya Pradesh, India. The primary outcome is change of competence to deliver HAP; secondary outcomes include cost-effectiveness of the training programs, change in participants' mental health knowledge, attitudes and behavior, and satisfaction with the training. Assessors blind to participant allocation status will collect outcomes pre- (baseline) and post- (endpoint) training to ascertain differences in outcomes between arms. Training program costs will be collected to calculate incremental costs of achieving one additional unit on the competency measure in the digital compared to face-to-face training programs. Health worker motivation, job satisfaction, and burnout will be collected as exploratory outcome variables.

DISCUSSION

This trial will determine whether digital training is an effective, cost-effective, and scalable approach for building workforce capacity to deliver a brief evidence-based psychological treatment for depression in primary care in a low-resource setting.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04157816.

Leveraging gains from African Center for Integrated Laboratory Training to combat HIV epidemic in sub-Saharan Africa

Background

In sub-Saharan Africa, there is dearth of trained laboratorians and strengthened laboratory systems to provide adequate and quality laboratory services for enhanced HIV control. In response to this challenge, in 2007, the African Centre for Integrated Laboratory Training (ACILT) was established in South Africa with a mission to train staffs from countries with high burdens of diseases in skills needed to strengthen sustainable laboratory systems. This study was undertaken to assess the transference of newly gained knowledge and skills to other laboratory staff, and to identify enabling and obstructive factors to their implementation.

Methods

We used Kirkpatrick model to determine training effectiveness by assessing the transference of newly gained knowledge and skills to participant’s work environment, along with measuring enabling and obstructive factors. In addition to regular course evaluations at ACILT (pre and post training), in 2015 we sent e-questionnaires to 867 participants in 43 countries for course participation between 2008 and 2014. Diagnostics courses included Viral Load, and systems strengthening included strategic planning and Biosafety and Biosecurity. SAS v9.44 and Excel were used to analyze retrospective de-identified data collected at six months pre and post-training.

Results

Of the 867 participants, 203 (23.4%) responded and reported average improvements in accuracy and timeliness in Viral Load programs and to systems strengthening. For Viral Load testing, frequency of corrective action for unsatisfactory proficiency scores improved from 57 to 91%, testing error rates reduced from 12.9% to 4.9%; 88% responders contributed to the first national strategic plan development and 91% developed strategies to mitigate biosafety risks in their institutions. Key enabling factors were team and management support, and key obstructive factors included insufficient resources and staff’s resistance to change.

Conclusions

Training at ACILT had a documented positive impact on strengthening the laboratory capacity and laboratory workforce and substantial cost savings. ACILT’s investment produced a multiplier effect whereby national laboratory systems, personnel and leadership reaped training benefits. This laboratory training centre with a global clientele contributed to improve existing laboratory services, systems and networks for the HIV epidemic and is now being leveraged for COVID-19 testing that has infected 41,332,899 people globally.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06005-8.

Digital Training for Non-Specialist Health Workers to Deliver a Brief Psychological Treatment for Depression in Primary Care in India: Findings from a Randomized Pilot Study

Introduction: Task sharing holds promise for scaling up depression care in countries such as India, yet requires training large numbers of non-specialist health workers. This pilot trial evaluated the feasibility and acceptability of a digital program for training non-specialist health workers to deliver a brief psychological treatment for depression. Methods: Participants were non-specialist health workers recruited from primary care facilities in Sehore, a rural district in Madhya Pradesh, India. A three-arm randomized controlled trial design was used, comparing digital training alone (DGT) to digital training with remote support (DGT+), and conventional face-to-face training. The primary outcome was the feasibility and acceptability of digital training programs. Preliminary effectiveness was explored as changes in competency outcomes, assessed using a self-reported measure covering the specific knowledge and skills required to deliver the brief psychological treatment for depression. Outcomes were collected at pre-training and post-training. Results: Of 42 non-specialist health workers randomized to the training programs, 36 including 10 (72%) in face-to-face, 12 (86%) in DGT, and 14 (100%) in DGT+ arms started the training. Among these participants, 27 (64%) completed the training, with 8 (57%) in face-to-face, 8 (57%) in DGT, and 11 (79%) in DGT+. The addition of remote telephone support appeared to improve completion rates for DGT+ participants. The competency outcome improved across all groups, with no significant between-group differences. However, face-to-face and DGT+ participants showed greater improvement compared to DGT alone. There were numerous technical challenges with the digital training program such as poor connectivity, smartphone app not loading, and difficulty navigating the course content-issues that were further emphasized in follow-up focus group discussions with participants. Feedback and recommendations collected from participants informed further modifications and refinements to the training programs in preparation for a forthcoming large-scale effectiveness trial. Conclusions: This study adds to mounting efforts aimed at leveraging digital technology to increase the availability of evidence-based mental health services in primary care settings in low-resource settings.

Delivering a complex mental health intervention in low-resource settings: lessons from the implementation of the PRIME mental healthcare plan in primary care in Sehore district, Madhya Pradesh, India

BACKGROUND

The PRogramme for Improving Mental health care (PRIME) designed, implemented and evaluated a comprehensive mental healthcare plan (MHCP) for Sehore district, Madhya Pradesh, India.AimsTo provide quantitative measures of outputs related to implementation processes, describe the role of contextual factors that facilitated and impeded implementation processes, and discuss what has been learned from the MHCP implementation.

METHOD

A convergent parallel mixed-methods design was used. The quantitative strand consisted of process data on mental health indicators whereas the qualitative strand consisted of in-depth interviews and focus group discussions with key stakeholders involved in PRIME implementation.

RESULTS

The implementation of the MHCP in Sehore district in Madhya Pradesh, India, demonstrated that it is feasible to establish structures (for example Mann-Kaksha) and operationalise processes to integrate mental health services in a 'real-world' low-resource primary care setting. The key lessons can be summarised as: (a) clear 'process maps' of clinical interventions and implementation steps are helpful in monitoring/tracking the progress; (b) implementation support from an external team, in addition to training of service providers, is essential to provide clinical supervision and address the implementation barriers; (c) the enabling packages of the MHCP play a crucial role in strengthening the health system and improving the context/settings for implementation; and (d) engagement with key community stakeholders and incentives for community health workers are necessary to deliver services at the community-platform level.

CONCLUSIONS

The PRIME implementation model could be used to scale-up mental health services across India and similar low-resource settings.Declaration of interestNone.

Community, facility and individual level impact of integrating mental health screening and treatment into the primary healthcare system in Sehore district, Madhya Pradesh, India

Introduction

Programme for Improving Mental Health Care (PRIME) designed a comprehensive mental healthcare plan (MHCP) for Sehore district, Madhya Pradesh, India. The objective of this paper is to describe the findings of the district-level impact evaluation of the MHCP.

Methods

Repeat community-based CS were conducted to measure change in population-level contact coverage for depression and alcohol use disorders (AUD), repeat FDS were conducted to assess change in detection and initiation of treatment for depression and AUD, and the effect of treatment on patient outcomes was assessed using disorder-specific prospective cohort studies.

Results

PRIME MHCP did not have any impact on contact coverage/treatment seeking for depression (14.8% at the baseline and 10.5% at the follow-up) and AUD (7.7% at the baseline and 7.3% at the follow-up) and had a small impact on detection and initiation of treatment for depression and AUD (9.7% for depression and 17.8% for AUD compared with 0% for both at the baseline) in the health facilities. Patients with depression who received care as part of the MHCP had higher rates of response (52.2% in the treatment group vs 26.9% in the comparison/usual care group), early remission (70.2% in the treatment group vs 44.8% in the comparison/usual care group) and recovery (56.1% in the treatment group vs 28.5% in the comparison/usual care group), but there was no impact of treatment on their functioning.

Conclusions

While dedicated human resources (eg, Case Managers) and dedicated space for mental health clinics (eg, Mann-Kaksha) strengthen the 'formal' healthcare platform, without substantial additional investments in staff, such as Community Health Workers/Accredited Social Health Activists to improve community level processes and provision of community-based continuing care to patients, we are unlikely to see major changes in coverage or clinical outcomes.

Role of public-private partnerships in achieving UNAIDS HIV treatment targets

Background

Despite progress towards achieving UNAIDS 90–90-90 goals, barriers persist in laboratory systems in sub-Saharan Africa (SSA) restricting scale up of early infant diagnosis (EID) and viral load (VL) test monitoring of patients on antiretroviral therapy. If these facilities and system challenges persist, they may undermine recorded gains and appropriate management of patients. The aim of this review is to identify Public Private Partnerships (PPP) in SSA that have resolved systemic barriers within the VL and EID treatment cascade and demonstrated impact in the scale up of VL and EID.

Methods

We queried five HIV and TB laboratory databases from 2007 to 2017 for studies related to laboratory system strengthening and PPP. We identified, screened and included PPPs that demonstrated evidence in alleviating known system level barriers to scale up national VL and EID testing programs. PPPs that improved associated systems from the point of viral load test request to the use of the test result for patient management were deemed eligible.

Results

We identified six PPPs collaborations with multiple activities in select countries that are contributing to address challenges to scale up national viral load programs. One of the six PPPs reached 14.5 million patients in remote communities and transported up to 400,000 specimens in a year. Another PPP enabled an unprecedented 94% of specimens to reach national laboratory through improved sample referral network and enabled a cost savings of 62%. Also PPPs reduced cost of reagents and enabled 300,000 tested infants to be enrolled in care as well as reduced turnaround time of reporting results by 50%.

Conclusions

Our review identified the benefits, enabling factors, and associated challenges for public and private sectors to engage in PPPs. PPP contributions to laboratory systems strengthening are a model and present opportunities that can be leveraged to strengthen systems to achieve the UNAIDS 90–90-90 treatment targets for HIV/AIDS. Despite growing emphasis on engaging the private sector as a critical partner to address global disease burden, PPPs that specifically strengthen laboratories, the cornerstone of public health programs, remain largely untapped.

The effect of VISHRAM, a grass-roots community-based mental health programme, on the treatment gap for depression in rural communities in India: a population-based study

BACKGROUND

VISHRAM was a community-based mental health programme with the goal of addressing the mental health risk factors for suicide in people from 30 villages in the Amravati district in Vidarbha, central India. We aimed to assess whether implementation of VISHRAM was associated with an increase in the proportion of people with depression who sought treatment (contact coverage).

METHODS

A core strategy of VISHRAM was to increase the demand for care by enhancing mental health literacy and to improve the supply of evidence-based interventions for depression and alcohol-use disorders. Intervention for depression was led by community-based workers and non-specialist counsellors and done in collaboration with facility-based general physicians and psychiatrists. From Dec 25, 2013, to March 10, 2014, before VISHRAM was introduced, we did a baseline cross-sectional survey of adults randomly selected from the electoral roll (baseline survey population). The structured interview was administered by field researchers independent of the VISHRAM intervention and included questions about sociodemographic characteristics, health-care service use, depression (measured using the Patient Health Questionnaire [PHQ]-9), and mental health literacy. 18 months after VISHRAM was enacted, we repeated sampling methods to select a separate population of adults (18 month survey population) and administered the same survey. The primary outcome was change in contact coverage with VISHRAM, defined as the difference in the proportion of individuals with depression (PHQ-9 score >9) who sought treatment for symptoms of depression between the baseline and the 18 month survey population. Secondary outcomes were whether the distribution of coverage was equitable, the type of services sought, and mental health literacy.

FINDINGS

1887 participants completed the 18 month survey interview between Sept 18, and Oct 8, 2015. The contact coverage for current depression was six-times higher in the 18 month survey population (27·2%, 95% CI 21·4-33·7) than in the baseline survey population (4·3%, 1·5-7·1). Contact coverage was equitably distributed across sex, education, income, religion, and caste. Most providers consulted for care were general physicians. We observed significant improvements in a range of mental health literacy indicators, for example, conceptualisation of depression as a mental health problem and the intention to seek care for depression.

INTERPRETATION

A grass-roots community-based programme in rural India was associated with substantial increase in equitable contact coverage for depression and improved mental health literacy. It is now crucially important to translate this knowledge into real-world practice by scaling-up this programme through the National Mental Health Programme in India.

FUNDING

Tata Trusts.

Improved Specimen-Referral System and Increased Access to Quality Laboratory Services in Ethiopia: The Role of the Public-Private Partnership

BACKGROUND

Nonstandardized specimen-transport logistics, lack of laboratory personnel to transport specimens, lack of standard specimen containers, and long turnaround time (TAT) hindered access to quality laboratory services. The objective of the Becton, Dickinson, and Company (BD)-US President's Emergency Plan for AIDS Relief (PEPFAR) Public-Private Partnership (PPP) was to support country-specific programs to develop integrated laboratory systems, services, and quality improvement strategies, with an emphasis on strengthening the specimen-referral system (SRS).

METHODS

In 2007, through the Centers for Disease Control and Prevention (CDC), the Ethiopian Public Health Institute (EPHI) joined with the BD-PEPFAR PPP to strengthen laboratory systems. A joint planning and assessment committee identified gaps in the SRS for prioritization and intervention and piloted the system in Addis Ababa and Amhara Region.

RESULTS

The PPP established standardized, streamlined specimen logistics, using the Ethiopian Postal Service Enterprise to support a laboratory network in which 554 facilities referred specimens to 160 laboratories. The PPP supported procuring 400 standard specimen containers and the training of 586 laboratory personnel and 81 postal workers. The average TAT was reduced from 7 days (range, 2-14 days) to 2 days (range, 1-3 days) in Addis Ababa and from 10 days (range, 6-21 days) to 5 days (range, 2-6 days) in Amhara Region.

CONCLUSIONS

This study highlights the feasibility and untapped potential of PPPs to strengthen laboratory systems. This planned and structured approach to improving specimen referral enhanced access to quality laboratory services.

Importance of Public-Private Partnerships: Strengthening Laboratory Medicine Systems and Clinical Practice in Africa

After the launch of the US President's Emergency Plan for AIDS Relief in 2003, it became evident that inadequate laboratory systems and services would severely limit the scale-up of human immunodeficiency virus infection prevention, care, and treatment programs. Thus, the Office of the US Global AIDS Coordinator, Centers for Disease Control and Prevention, and Becton, Dickinson and Company developed a public-private partnership (PPP). Between October 2007 and July 2012, the PPP combined the competencies of the public and private sectors to boost sustainable laboratory systems and develop workforce skills in 4 African countries. Key accomplishments of the initiative include measurable and scalable outcomes to strengthen national capacities to build technical skills, develop sample referral networks, map disease prevalence, support evidence-based health programming, and drive continuous quality improvement in laboratories. This report details lessons learned from our experience and a series of recommendations on how to achieve successful PPPs.

Strengthening the Tuberculosis Specimen Referral Network in Uganda: The Role of Public-Private Partnerships

BACKGROUND

Diagnosis of multidrug-resistant tuberculosis and prompt initiation of effective treatment rely on access to rapid and reliable drug-susceptibility testing. Efficient specimen transport systems and appropriate training on specimen referral contribute to optimal and timely access to tuberculosis diagnostic services.

METHODS

With support and technical assistance from a public-private partnership (PPP) between Becton Dickinson and the US President's Emergency Plan for AIDS Relief, the Uganda National TB Reference Laboratory (NTRL) and National TB and Leprosy Program redesigned the tuberculosis specimen transport network and trained healthcare workers with the goal of improving multidrug-resistant tuberculosis detection.

RESULTS

Between 2008 and 2011, the PPP mapped 93% of health facilities and trained 724 healthcare and postal staff members covering 72% of districts. Strengthening the tuberculosis specimen referral system increased referrals from presumptive multidrug-resistant tuberculosis cases by >10-fold, with 94% of specimens reaching the NTRL within the established target transport time.

CONCLUSIONS

This study demonstrates the potential of PPP collaborations with ministries of health to positively influence patient care by strengthening laboratory systems through increased access to drug-susceptibility testing in Uganda. Ongoing efforts to integrate specimen transport networks will maximize resources and improve patient management.

Challenges in reporting surgical site infections to the national surgical site infection surveillance and suggestions for improvement

INTRODUCTION

Mandatory orthopaedic surgical site infection (SSI) data in England are used as a benchmark to compare infection rates between participating hospitals. According to the national guidelines, trusts are required to submit their data for at least one quarter of the year but they are free to report for all quarters. Owing to this ambiguity, there is a concern about robust reporting across trusts and therefore the accuracy of these data. There is also concern about the accuracy of collection methods. The aim of this five-year retrospective study was to assess the accuracy of SSI reporting at two hospitals in South East England under the same trust.

METHODS

A retrospective review was carried out of five years of electronic medical records, microbiology data and readmission data of all patients who underwent hip and knee replacement surgery at these hospitals. These data were validated with the data submitted to Public Health England (PHE) and any discrepancy between the two was noted.

RESULTS

A significant difference was found in the SSI rates reported by the surveillance staff and our retrospective method.

CONCLUSIONS

Our study confirms the findings of a national survey, which raised concerns about the quality of SSI reporting and the usefulness of PHE SSI data for benchmarking purposes. To our knowledge, there are no previously published studies that have looked at the accuracy of the English orthopaedic SSI surveillance. In the light of our findings, there is an urgent need for external validation studies to identify the extent of the problem in the surveillance scheme. The governing bodies should also issue clear guidelines for reporting SSIs to maintain homogeneity and to present the true incidence of SSI. We suggest some measures that we have instituted to address these inadequacies that have led to significant improvements in reporting at our trust.

Validation of the TRMM Multi Satellite Rainfall Product 3B42 and estimation of scavenging coefficients for (131)I and (137)Cs using TRMM 3B42 rainfall data

The TRMM rainfall product 3B42 is compared with rain gauge observations for Kaiga, India on monthly and seasonal time scales. This comparison is carried out for the years 2004-2007 spanning four monsoon seasons. A good correlation is obtained between the two data sets however; magnitude wise, the cumulative precipitation of the satellite product on monthly and seasonal time scales is deficient by almost 33-40% as compared to the rain gauge data. The satellite product is also compared with APHRODITE's Monsoon Asia data set on the same time scales. This comparison indicates a much better agreement since both these data sets represent an average precipitation over the same area. The scavenging coefficients for (131)I and (137)Cs are estimated using TRMM 3B42, rain gauge and APHRODITE data. The values obtained using TRMM 3B42 rainfall data compare very well with those obtained using rain gauge and APHRODITE data.

Cyclooxygenase-2 inhibition attenuates hypoxic cancer cells induced m2-polarization of macrophages

Tumor-associated macrophages (TAMs), represent a major subpopulation of tumor infiltrating immune cells. These alternatively activated M2-polarized macrophages are well known for their pro-tumor functions. Owing to their established role in potentiating tumor-neovasculogenesis and metastasis, TAMs have emerged as promising target for anti-cancer immunotherapy. One of the key TAMs related phenomenon that is amenable to therapeutic intervention is their phenotype switching into alternatively activated M2-polarized macrophages. Hindering macrophage polarization towards a pro-tumor M2 phenotype, or better still reprogramming the M2 like TAMs towards M1 subtype is being considered a beneficial anti-cancer strategy. Hypoxic tumor milieu has been proposed as one of the most plausible factor governing M2-polarization of macrophages. We recently demonstrated that hypoxic tumor cells imparted a pro—angiogenic M2 skewed phenotype to macrophages. Furthermore, sizeable body of data indicates for participation of cyclooxygenase-2 (COX-2) in macrophage polarization. Concordantly, inhibition of COX-2 is associated with impaired macrophage polarization. Prompted by this in the current study we decided to explore if inhibition of COX-2 activity via chemical inhibitors may prevent hypoxic cancer cell induced M2-polarization of macrophages. We observed that treatment with Flunixin meglumine, an established preferential inhibitor of COX-2 activity markedly inhibited hypoxic cancer cell induced of M2-polarization of macrophages thereby indicating for usage of COX-2 inhibition as possible anti-cancer treatment modality.

Spatial distribution of fallout 137Cs in the coastal marine environment of India

The data on the fallout (137)Cs in the coastal marine environment assume significance in view of massive expansion of nuclear power plants in the Asia-Pacific region and to fulfill the benchmark study required to evaluate the possible impact of the Fukushima radioactive releases in the Asia-Pacific region. Measurements of (137)Cs in sea water, along with salinity and temperature, were carried out at 30 locations covering the coastal area of the Arabian Sea and the Bay of Bengal. For the present study the Indian coastal area is divided in three different regions. The (137)Cs concentration in sea water of the entire Indian coastal region varies from 0.30 to 1.25 Bq m(-3). The data obtained in the present study was compared with the North Indian Ocean data and it was observed that there is a 33% decrease in the Arabian Sea (region I), 50% in the high rainfall coastal area (region II) and 24% in the Bay of Bengal (region III).

Familial hypophosphatemic rickets

Rickets is the failure of mineralization of osteoid and newly formed bones in a child skeleton. It is commonly associated with vitamin D deficiency; however, it can be because of a decrease in the serum phosphate levels leading to inadequate mineralization of cartilage and bone, consequent skeletal deformities, and growth retardation. The hypophosphatemic conditions that interfere in bone mineralization comprise many hereditary or acquired diseases. One of the hereditary types of hypophosphatemic rickets is the familial hypophosphatemic rickets. This rare variety was diagnosed in a 9-year-old patient who had come with a chief complaint of a missing tooth. In the present case, radiographic aspects of oral and systemic manifestations of familial hypophosphatemic rickets are highlighted.

Radiotherapy for Benign Diseases

Radiotherapy mainly involves treatment of patients with malignant tumors. Even with recognition of the risks of late skin injury, carcinogenesis, leukemogenesis, and genetic damage from all ionizing radiation; radiation therapy also continues to be accepted treatment for benign diseases. Before initiation, the quality of irradiation, total dose, overall time, underlying organs at risk, and shielding factors should be considered. Children should be treated with ionizing radiation only in very exceptional cases and after weighing the pros and cons of the therapy. Direct irradiation of skin areas overlying organs that are particularly prone to late effects (e.g. thyroid, eye, gonads, bone marrow and breast) should be avoided. Radiation protection techniques should be used in all instances. The depth of penetration of the x-ray beam should be chosen according to the depth of the pathologic process. Choice of beam energy usually depends on the depth of the target volume; every effort is made to spare normal underlying tissue in superficial lesions. There are a number of other benign conditions that can be treated with radiotherapy; we present a brief overview of some of the commonly encountered conditions.JNMA J Nepal Med Assoc. 2008 Jul-Sep;47(171):151-155.

HIV drug resistance threshold survey using specimens from voluntary counselling and testing sites in Hanoi, Vietnam

Background

In countries where antiretroviral therapy has been available or is being rapidly expanded, the World Health Organization (WHO) recommends surveillance for transmitted HIV drug resistance (HIVDR) by threshold surveillance methods using specimens from antenatal clinics or voluntary counselling and testing (VCT) sites. The aim of this study was to implement the HIVDR threshold survey in VCT sites in Vietnam, where HIV prevalence is high. Estimating transmitted resistance in the infected population will enable the appropriateness of current antiretroviral drug regimens to be assessed and will inform plans for future HIVDR surveillance.

Methods

Consecutive blood specimens were collected from 70 newly diagnosed HIV-positive clients 18–24 years of age at two sites in Hanoi, Vietnam. Informed consent and serum specimens were obtained from each eligible client, with serum frozen at -70°C until shipping to Thailand for resistance testing using the TruGene system.

Results

From February until August 2006, 559 clients were eligible to participate in this survey. Of the 535 clients (95.7%) who agreed to participate, 70 (13%) were HIV-positive and were included in the survey. Of the 70 specimens sent for genotyping, 52 consecutive samples were amplified, 49 of which could be genotyped. Only 1 of 49 genotyped specimens had mutations associated with drug resistance (L74V and Y181C) in the reverse transcriptase gene, indicating that the prevalence of transmitted HIVDR to all drugs and drug classes evaluated was <5%.

Conclusion

The prevalence of transmitted HIVDR was low in Hanoi as determined using threshold surveillance methods. The Ministry of Health plans to repeat this survey methodology in one more province and to confirm these findings by expanded HIVDR surveillance.

HIV drug resistance threshold survey using specimens from voluntary counselling and testing sites in Hanoi, Vietnam

BACKGROUND

In countries where antiretroviral therapy has been available or is being rapidly expanded, the World Health Organization (WHO) recommends surveillance for transmitted HIV drug resistance (HIVDR) by threshold surveillance methods using specimens from antenatal clinics or voluntary counselling and testing (VCT) sites. The aim of this study was to implement the HIVDR threshold survey in VCT sites in Vietnam, where HIV prevalence is high. Estimating transmitted resistance in the infected population will enable the appropriateness of current antiretroviral drug regimens to be assessed and will inform plans for future HIVDR surveillance.

METHODS

Consecutive blood specimens were collected from 70 newly diagnosed HIV-positive clients 18-24 years of age at two sites in Hanoi, Vietnam. Informed consent and serum specimens were obtained from each eligible client, with serum frozen at -70 degrees C until shipping to Thailand for resistance testing using the TruGene system.

RESULTS

From February until August 2006, 559 clients were eligible to participate in this survey. Of the 535 clients (95.7%) who agreed to participate, 70 (13%) were HIV-positive and were included in the survey. Of the 70 specimens sent for genotyping, 52 consecutive samples were amplified, 49 of which could be genotyped. Only 1 of 49 genotyped specimens had mutations associated with drug resistance (L74V and Y181C) in the reverse transcriptase gene, indicating that the prevalence of transmitted HIVDR to all drugs and drug classes evaluated was <5%.

CONCLUSION

The prevalence of transmitted HIVDR was low in Hanoi as determined using threshold surveillance methods. The Ministry of Health plans to repeat this survey methodology in one more province and to confirm these findings by expanded HIVDR surveillance.

Curative interstitial brachytherapy for early stage carcinoma of lip—A case report

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Background: Brachytherapy is potentially useful in the treatment of carcinoma lip. Small cancers of the lip (less than 2 cm) are treated equally well with surgery or radiation therapy with excellent cosmetic and functional results seen in radiation therapy. Methods: We treated an 18-year old male diagnosed as stage 1 carcinoma lip with curative interstitial brachytherapy. Under anaesthesia, three catheters were inserted at 0.5 cm separation through the lesion. Patient was simulated, planned, treated in VARISOURCE (Varian, USA). He received dose of 3 Gy per fraction, two fractions per day at a minimum interval of 6 hours between the two fractions for 6 days. He therefore received a total dose of 36 Gy with High Dose Rate (HDR) Brachytherapy. During treatment, he received hyperalimentaion via naso-gastric tube with intravenous antibiotic prophylaxis. Results: Upper lip swelling occurred in first 12 hours of treatment and remained for 6 days that subsided subsequently. Catheters were removed on 6th day of treatment. Scar formation occurred over the lesion in 1 month’s follow up. In next one month’s follow up, there was no clinical evidence of disease. Cosmetic result was satisfactory. At two months follow, the patient is clinically disease free and has no complaints. Conclusions: Interstiatial brachytherapy is a excellent method for treating early stage carcinoma lips with excellent cosmetic outcome. This kind of treatment is now available in my country at our institution.

No significant financial relationships to disclose.

Tanacetum parthenium and Salix??alba??(Mig-RL??) Combination in??Migraine Prophylaxis

BACKGROUND

Tanacetum parthenium (feverfew) has been used traditionally to treat migraine, and although its mechanism of action is not fully understood, serotonin 5-HT receptor blocking effects have been suggested. T. parthenium and Salix alba (white willow) either alone or in combination (Mig-RL) were recently shown to inhibit binding to 5-HT(2A/2C) receptors; T. parthenium failed to recognise 5-HT(1D) receptors, whereas S. alba or the combination did. It was hypothesised that S. alba in combination with T. parthenium may provide superior migraine prophylactic activity compared with T. parthenium alone.

METHODS

A prospective, open-label study was performed in 12 patients diagnosed with migraine without aura. Twelve weeks' treatment with T. parthenium 300 mg plus S. alba 300 mg (Mig-RL) twice daily was administered to determine the effects of therapy on migraine attack frequency (primary efficacy criterion), intensity and duration (secondary efficacy criteria), and quality of life, together with tolerability for patients.

RESULTS

Attack frequency was reduced by 57.2% at 6 weeks (p < 0.029) and by 61.7% at 12 weeks (p < 0.025) in nine of ten patients, with 70% patients having a reduction of at least 50%. Attack intensity was reduced by 38.7% at 6 weeks (p < 0.005) and by 62.6% at 12 weeks (p < 0.004) in ten of ten patients, with 70% of patients having a reduction of at least 50%. Attack duration decreased by 67.2% at 6 weeks (p < 0.001) and by 76.2% at 12 weeks (p < 0.001) in ten of ten patients. Two patients were excluded for reasons unrelated to treatment. Self-assessed general health, physical performance, memory and anxiety also improved by the end of the study. Mig-RL treatment was well tolerated and no adverse events occurred.

CONCLUSION

The remarkable efficacy of Mig-RL in not only reducing the frequency of migraine attacks but also their pain intensity and duration in this trial warrants further investigation of this therapy in a double-blind, randomised, placebo-controlled investigation involving a larger patient population.

Degradation of xenobiotic compounds by lignin-degrading white-rot fungi: enzymology and mechanisms involved

White-rot fungi (WRF) are ubiquitous in nature with their natural ability to compete and survive. WRF are the only organisms known to have the ability to degrade and mineralize recalcitrant plant polymer lignin. Their potential to degrade second most abundant carbon reserve material lignin on the earth make them important link in global carbon cycle. WRF degrade lignin by its unique ligninolytic enzymatic machinery including lignin peroxidase, manganese peroxidase, laccase, cellobiose dehydrogenase, H2O2-generating enzymes, etc. The ligninolytic enzymes system is non-specific, extracellular and free radical based that allows them to degrade structurally diverse range of xenobiotic compounds. Lignin peroxidase and manganese peroxidase carry out direct and indirect oxidation as well as reduction of xenobiotic compounds. Indirect reactions involved redox mediators such as veratryl alcohol and Mn2+. Reduction reactions are carried out by carboxyl, superoxide and semiquinone radicals, etc. Methylation is used as detoxification mechanism by WRF. Highly oxidized chemicals are reduced by transmembrane redox potential. Degradation of a number of environmental pollutants by ligninolytic system of white rot fungi is described in the present review.

HMG CoA reductase inhibitors (statins) for dialysis patients

BACKGROUND

Cardiovascular disease accounts for more than half the number of deaths among dialysis patients. The role of HMG CoA reductase inhibitors (statins) in the treatment of hyperlipidemia in dialysis patients is unclear and their safety has not been established.

OBJECTIVES

To assess the benefits and harms of statins in peritoneal dialysis (PD) and hemodialysis patients (HD).

SEARCH STRATEGY

We searched MEDLINE (1966-July 2003), EMBASE (1980-July 2003), the Cochrane Central Register of Controlled trials (CENTRAL, in The Cochrane Library - issue 2, 2004), the Cochrane Renal Group's specialized register (April 2004) and handsearched reference lists of textbooks, articles and scientific proceedings.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs comparing statins with placebo, no treatment or other statins in dialysis patients.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model after testing for heterogeneity. The results were expressed as weighted mean difference (WMD) for continuous outcomes and relative risk (RR) for dichotomous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

Six studies involving 357 participants were identified - three studies had both continuous ambulatory peritoneal dialysis (CAPD) and HD participants, two included only HD participants and one study only included CAPD participants. Studies were all of short duration and morbidity and mortality were not assessed. Average total cholesterol decreased significantly with statins compared to placebo in all dialysis patients (WMD -53.70 mg/dL (1.40 mmol/L), 95% CI -66.95 to -40.54). Similarly, average LDL cholesterol decreased significantly with statins in comparison to placebo in all patients (WMD -55.40 mg/dL (1.44 mmol/L), 95% CI -69.90 to -40.90) as did average triglycerides (-33.72 mg/dL (0.37 mmol/L), 95% CI -54.16 to -13.28). There was a significant increase in average HDL cholesterol levels (WMD 4.84 mg/dL (0.13 mmol/L), 95% CI 0.28 to 9.40) with statins compared to placebo in HD but not in CAPD patients. One trial compared statins to the hypolidemic agent probucol and found no significant differences between the two treatment groups.

REVIEWERS' CONCLUSIONS

Statins used for 12 weeks decreased cholesterol levels in dialysis patients similar to the general population. Included studies were of short duration and therefore the efficacy of statins in decreasing the cardiovascular, cerebrovascular events and mortality rates is still unclear. The safety of statins needs to be addressed in the current ongoing clinical trials.