Editor,
The meta-analysis conducted by Yamada et al (2013) has established the
association between baldness and coronary heart disease (CHD). The authors
have concluded that vertex baldness among young men is closely related to
atherosclerosis.
Another factor that deserves mention in this context is smoking. We have
many a times come across patients with severe arterial disease who have
baldness and gray hair and on histo...
Editor,
The meta-analysis conducted by Yamada et al (2013) has established the
association between baldness and coronary heart disease (CHD). The authors
have concluded that vertex baldness among young men is closely related to
atherosclerosis.
Another factor that deserves mention in this context is smoking. We have
many a times come across patients with severe arterial disease who have
baldness and gray hair and on history are found to be smokers or tobacco
users, a practice very common in Indian subcontinent.1, 2 Several studies
have analyzed the association between smoking and androgenetic alopecia
(AGA) and the results are found to be conflicting. Su et al (2007) carried
out a community based survey in Asian men to evaluate the association of
AGA with smoking and found a positive association.3 Smoking status,
current amount of cigarette smoking, and smoking intensity were
statistically significant factors responsible for AGA. Similar results
were found in a cross sectional survey conducted by Mosley and Gibbs.4
Smoking causes hair loss by several mechanisms. Genotoxicants in smoke
affect the microvasculature as well as DNA of the dermal hair papilla.
Smoking induces oxidative stress that leads to release of proinflammatory
cytokines which, in turn, cause inflammation and fibrosis of hair
follicle. Smoking also causes hydroxylation of estradiol thereby inducing
a relative hypoestrogenic state.5
Mosley and Gibbs also found a significant relation between gray hair and
smoking. The relation was consistent for all age groups in both sexes. One
hypothesis proposed for this could be that smoking causes severe disease,
which in turn causes biological aging and hence the graying of hair. The
authors however did not study the dose-response relation. In another study
by Kocaman SA et al, 213 men with suspicion of coronary artery disease
(CAD) were evaluated in terms of age, demographical properties and CVRFs
(cardiovascular risk factors).6 They found that the degree of gray/white
hairs is related to extent of CAD. The authors also suggested that hair
graying is a risk factor for CAD independent of age and other risk
factors.
These studies indicate the need for evaluation of cardiovascular risk
factors, particularly smoking and tobacco habits, in younger men with
vertex baldness, and men and women with premature graying. Such patients
should be encouraged to quit tobacco chewing/smoking to improve their
cardiovascular health. The potential relationship between smoking and
premature graying and baldness should be further investigated and proper
screening test designed to detect patients with asymptomatic CAD.
References
1. Dwivedi S, Jhamb R. Cutaneous markers of cutaneous artery disease.
World J Cardiol 2010; 2(9):1-8.
2. Dwivedi G, Dwivedi S. Betel quid seller syndrome. Occup Environ Med
2010; 67:144.
3. Su LH, Chen TH. Association of androgenetic alopecia with smoking and
its
prevalence among Asian men: a community-based survey. Arch Dermatol. 2007
Nov; 143(11):1401-6.
4. Mosley JG, Gibbs AC. Premature grey hair and hair loss among smokers: a
new opportunity for health education? BMJ. 1996; 313(7072):1616.
5. Tru?eb RM. Molecular mechanisms of androgenetic alopecia. Exp Gerontol.
2002;
37(8-9):981-990.
6. Kocaman SA, ?etin M, Durako?lugil ME, Erdo?an T, ?anga A, ?i?ek Y et
al. The degree of premature hair graying as an independent risk marker for
coronary artery disease: a predictor of biological age rather than
chronological age. Anadolu Kardiyol Derg. 2012 Sep; 12(6):457-63.
While I am pleased with the general research, its significance and
findings in part, it is my humble concern that there may have been a
systematic error in the sampling design. The researchers set out to
measure both attitude towards and compliance with the smoking ban. In
measuring attitudes, the researcher correctly identifies the school
students as the population and randomly picks classes on which the
instrument is...
While I am pleased with the general research, its significance and
findings in part, it is my humble concern that there may have been a
systematic error in the sampling design. The researchers set out to
measure both attitude towards and compliance with the smoking ban. In
measuring attitudes, the researcher correctly identifies the school
students as the population and randomly picks classes on which the
instrument is administered. This is alright, in my estimation. However, in
measuring compliance, the same sampling frame is used. As a result, only
6.4% of occasional smokers and 4.7% of ex-smokers are represented. It is
my opinion that for compliance, purposive sampling would have been used so
as to get a more representative sample of those who needed to comply. To
measure compliance to the smoking ban, the researchers use classes as the
sampling frame rather than just the smoking population at the university.
What confidence can we then have that the tool does indeed give a
representative or accurate picture of compliance levels? On this basis, I
would like to propose that the research did justice to measuring attitudes
towards the ban but may not have accurately portrayed compliance levels to
the ban at the university.
Sir, we read with interest the recent response to our study of
delirium point prevalence from Zieschang and colleagues, Heidelberg,
Germany[1]. Zieschang et al have described a delirium prevalence of 15.6%
in their study population of older hyponatraemic patients and
normonatraemic controls admitted to a step-down facility, and note that
our hospital-wide point prevalence was higher at almost 20%[2].
Sir, we read with interest the recent response to our study of
delirium point prevalence from Zieschang and colleagues, Heidelberg,
Germany[1]. Zieschang et al have described a delirium prevalence of 15.6%
in their study population of older hyponatraemic patients and
normonatraemic controls admitted to a step-down facility, and note that
our hospital-wide point prevalence was higher at almost 20%[2].
Although, both studies describe delirium prevalence, there are some
important methodological differences which may account for the small
difference in prevalence rates. Firstly, the two study populations are not
entirely comparable, as Zieschang et al concede. Our study assessed the
point prevalence of delirium over the course of one day across specialties
in a tertiary-referral acute general hospital (patient mean age 69 years),
whereas the German study cohort consisted only of elderly patients
(patient mean age 82 years) admitted to a post-acute care facility.
Although their population is older, patients admitted to post-acute care
should be, by definition, less unwell than those in an acute hospital, and
hence should have fewer delirium precipitating factors. Interestingly, a
previous study of delirium in post-acute care by Marcantonio et al, showed
prevalence rates of up to 23%[3], which is higher than the figure reported
by Zieschang and colleagues.
Zieschang et al used the Confusion Assessment Method (CAM) rated by
junior physicians as a screening method. Possible and definite cases of
delirium based on this assessment were confirmed by a specialist using DSM
-IV criteria. The sensitivity of the CAM as a screening tool has been
shown in previous studies to be as low as 50% when performed by
inexperienced raters[4]. Hence, it is entirely conceivable that delirium
may have been missed using the CAM method in this study. In our study, the
CAM was performed by experienced and rigorously trained Geriatric Medicine
registrars and was entirely independent of formal DSM-IV delirium
diagnosis. In addition, Zieschang et al do not outline the time delay
between CAM assessment and definitive delirium diagnosis. If the delay was
more than 24 hours, borderline cases may have resolved by that time. All
of these factors could account for the difference in prevalence figures.
Zieschang et al used an abbreviated version of the IQCODE-SF to
screen for prior cognitive status. Using this short screening tool, they
showed that prior cognitive impairment was an independent predictor of
delirium status (OR=17.7; 95%CI 6.8-46.8, p<0.001), which was very much
in keeping with our findings (adjusted OR=15.3; 95%CI 5.2-45.4,
p<0.001), using the 16-item IQCODE-SF. Zieschang et al suggest that
using the question "Compared with five years ago how is this person at
remembering things that have recently happened and how is this person
oriented in time and space?" may be an effective screening tool for
delirium in an older patient population. Although identifying prior
cognitive impairment is important for delirium risk assessment, and so
this question may indicate risk of delirium, this test is unlikely to be
useful as a daily delirium screening tool as it assesses changes over the
previous five years. Screening for delirium ideally should use a test that
indicates acute change from baseline cognitive or behavioural functioning.
It must be highly sensitive, given the consequences of untreated or late-
diagnosed delirium, but also should be specific in order to reduce the
need for unnecessary lengthy formal delirium assessments. Secondary
analysis from our study (manuscript in preparation) indicate that short
attention tests, such as the months of the year backwards or the spatial
span forwards, may be an efficient means of screening for delirium in the
acute hospital.
References
1. Zieschang T, Wolf M, Olster P, Kopf D. Prevalence and Predictors
of Delirium. In: BMJ open.
http://bmjopen.bmj.com/content/3/1/e001772.full/reply - bmjopen_el_6857;
2013.
2. Ryan D, O'Regan N, O Caoimh R, et al. Delirium in an adult acute
hospital population: predictors, prevalence and detection. BMJ Open
2013;3:e001772.
3. Marcantonio ER, Simon SE, Bergmann MA, Jones RN, Murphy KM, Morris JN.
Delirium symptoms in post-acute care: prevalent, persistent, and
associated with poor functional recovery. Journal of the American
Geriatrics Society 2003;51:4-9.
4. Ryan K, Leonard M, Guerin S, Donnelly S, Conroy M, Meagher D.
Validation of the confusion assessment method in the palliative care
setting. Palliative medicine 2009;23:40-5.
Yamada et al. present a fascinating meta-analysis showing that male
pattern baldness is associated with coronary heart disease (CHD).1
Although the association is subject to the inevitable limitations of
observational studies, it is an intriguing observation for which Yamada et
al. provide several potential mechanisms, such as classical coronary risk
factors, hyperinsulinaemia or chronic inflammation causing both baldness...
Yamada et al. present a fascinating meta-analysis showing that male
pattern baldness is associated with coronary heart disease (CHD).1
Although the association is subject to the inevitable limitations of
observational studies, it is an intriguing observation for which Yamada et
al. provide several potential mechanisms, such as classical coronary risk
factors, hyperinsulinaemia or chronic inflammation causing both baldness
and CHD, or perhaps baldness being caused by peripheral sensitivity to
androgens.1 However, Yamada et al. do not explicitly consider the simplest
mechanism, i.e., that the prime cause of male pattern baldness, androgens,
also causes CHD. Although, androgens are generally seen as
cardioprotective,2 no randomized controlled trial has ever shown that
androgens reduce CHD events or mortality. Conversely, randomized
controlled trials of testosterone have been stopped because of adverse,
often cardiovascular, events amongst men given testosterone compared to
placebo.3, 4 Notably, it has also recently come to light that one of the
most effective treatments for CHD, i.e., statins, reduces testosterone.5
Given, it has been definitively demonstrated that lower estrogens among
men than women does not explain the substantially higher rate of CHD among
men than women, perhaps this study might give impetus to consideration of
the alternative hypothesis that higher androgens among men than women is
the explanation, with corresponding implications for the prevention and
treatment of CHD.
Reference List
(1) Yamada T, Hara K, Umematsu H, Kadowaki T. Male pattern baldness
and its association with coronary heart disease: a meta-analysis. BMJ Open
2013;3.
(2) Kelly DM, Jones TH. Testosterone: a vascular hormone in health
and disease. J Endocrinol 2013.
(3) Testosterone treatment of men with alcoholic cirrhosis: a double
-blind study. The Copenhagen Study Group for Liver Diseases. Hepatology
1986;6:807-13.
(4) Basaria S, Coviello AD, Travison TG, Storer TW, Farwell WR,
Jette AM, Eder R, Tennstedt S, Ulloor J, Zhang A, Choong K, Lakshman KM,
Mazer NA, Miciek R, Krasnoff J, Elmi A, Knapp PE, Brooks B, Appleman E,
Aggarwal S, Bhasin G, Hede-Brierley L, Bhatia A, Collins L, LeBrasseur N,
Fiore LD, Bhasin S. Adverse events associated with testosterone
administration. N Engl J Med 2010;363:109-22.
(5) Schooling CM, Au Yeung SL, Freeman G, Cowling BJ. The effect of
statins on testosterone in men and women, a systematic review and meta-
analysis of randomized controlled trials. BMC Med 2013;11:57.
We read the report of this trial with interest. The topic of the
management of comorbid depression in chronic illness is an important one.
We acknowledge the considerable effort involved in mounting a trial such
as the TrueBlue study. However, we also feel it is important to raise
comment on the reported findings, to ensure they are not misinterpreted.
Our comments are:
We read the report of this trial with interest. The topic of the
management of comorbid depression in chronic illness is an important one.
We acknowledge the considerable effort involved in mounting a trial such
as the TrueBlue study. However, we also feel it is important to raise
comment on the reported findings, to ensure they are not misinterpreted.
Our comments are:
First, the trial was not of depressive disorder; participants only
had to have a PHQ-9 score of 5 indicating very mild depressive symptoms
and 50% of the sample had a score less than 10 (an indicator of moderate
depression) 1.
Second, the intervention tested was not 'collaborative care' as it is
usually described. Collaborative care is a multicomponent approach to
delivering care; one component is a case manager but another and
important component is the active involvement of a specialist 2. TrueBlue
was delivered by practice nurses acting as case managers, without
specialist involvement or supervision.
Third, the comparison treatment appears to be usual primary care but
this is not well specified or described making any difference in outcome
between treatments hard to interpret.
Fourth, although the authors claim that the TrueBlue intervention
achieved a better outcome for depression than usual care, we are
unconvinced. The analysis in the trial paper is of a different outcome
(difference in mean scores) from that specified in the protocol (50% drop
in score) 3 and was tested in a subgroup of participating patients (those
scoring more than 10 on the PHQ-9). Even the finding from this analysis,
that TrueBlue was more effective than usual care, is of doubtful clinical
significance with our estimated inter-group difference being less than 2
points on the PHQ-9. We cannot find a report on the pre-specified primary
outcome in the trial report.
Fifth, there is very substantial missing outcome data. In this
cluster randomised trial of the 18 clinics recruited only 11 completed the
study with outcome data on only 289 of 529 participants.
Finally, the authors include, and comment on, many within group
comparisons. The purpose of a randomised trial is to compare treatments in
a way that allows for confounding factors such non-specific effects and
the passage of time; within group comparisons are therefore of limited
value in judging the effectiveness of a treatment.
In summary, whilst depression comorbid with chronic illness is an
important challenge to usual care, and collaborative care is a highly
promising method of addressing this challenge, this trial does not tell us
if it works: the participants did not have depressive disorder, the
intervention was not collaborative care as it is usually described and the
trial, as reported, does not appears to us to provide evaluable findings.
Consequently there remains a need for robustly conducted trials of
collaborative care for patients with clearly defined comorbid depressive
disorder to tell us how useful collaborative care is in addressing the
important problem of comorbid depression.
Yours sincerely,
Professor Michael Sharpe, Dr Jane Walker, Professor Andrew Farmer
University of Oxford, UK
1. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief
depression severity measure. J. Gen. Intern. Med. 2001;16(9):606-13.
2. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative
care for depression: a cumulative meta-analysis and review of longer-term
outcomes. Arch.Intern Med 2006;166(21):2314-21.
3. Morgan M, Dunbar J, Reddy P, Coates M, Leahy R. The TrueBlue study: is
practice nurse-led collaborative care effective in the management of
depression for patients with heart disease or diabetes? BMC Fam. Pract.
2009;10:46.
The point prevalence of delirium in an acute care facility in Ireland
was described with 20% for the 280 patients enrolled in the study.
Prevalence was the highest on the geriatric ward (8/15 patients, 53%) and
in patients >80years of age (24/69 patients, 34.8%) [1].
Delirium prevalence appears to be very high when compared to our own data
set (Clinical trial registration: DRKS00004280). In a case-control-study,
which...
The point prevalence of delirium in an acute care facility in Ireland
was described with 20% for the 280 patients enrolled in the study.
Prevalence was the highest on the geriatric ward (8/15 patients, 53%) and
in patients >80years of age (24/69 patients, 34.8%) [1].
Delirium prevalence appears to be very high when compared to our own data
set (Clinical trial registration: DRKS00004280). In a case-control-study,
which was designed to examine the effect of hyponatremia on delirium in
geriatric patients (manuscript in preparation), delirium prevalence was
substantially lower amounting to 44 of 282 patients (15.6%). Our study
population (mean age 82.3, SD 6.5 years) consisted of hyponatremic
patients (Na <= 130 mmol/l) in a geriatric hospital, who had been
directly admitted or transferred from other hospitals after acute
treatment, and of normonatremic controls matched for age, gender, and main
admission diagnosis. Thus, hospital setting may be an important factor
influencing the prevalence of delirium. All patients were screened with
the German version of the Confusion Assessment Method (CAM) [2] by junior
medical staff. Taking into account the fluctuating nature of delirium they
additionally reviewed the medical chart for delirium, confusion, or
agitation and also questioned the nursing staff. If the CAM was positive
or ambiguous a delirium diagnosis according to DSM-IV criteria was
conducted by a specialist. In the paper by Ryan et al. [1] the CAM was
shown to be less sensitive than diagnosis made by DSM-IV criteria. So we
might have missed cases of delirium.
In order to identify patients with delirium early, risk factors and
predictors may be helpful. Ryan et al. [1] point out that of the 55
patients with delirium 28 (50.9%) probably had pre-existing dementia as
assessed by the Informant Questionnaire on Cognitive Decline in the
Elderly-Short Form (IQCODE-SF) [3]. Prior cognitive impairment was an
independent predictor of delirium (adjusted OR=15.3; 95%CI 5.2-45.4,
p<0.001).
In our study population prior cognitive status was assessed by using an
abbreviated version of the IQCODE covering the past five years. Due to
time constrictions only two questions were applied in the proxy interview:
"Compared with five years ago how is this person at remembering things
that have recently happened?" and "Compared with five years ago how is
this person oriented in time and space?" Of the 44 patients with delirium,
in 32 (84.2%) cases proxies described moderate or severe cognitive decline
over the past five years (11 "a bit worse", 21 "much worse"), in six
patients no cognitive decline was described, and in six patients a proxy
assessment of cognition was missing. When taking this simple question as
indicator of prior cognitive impairment it is an independent predictor of
delirium in logistic regression analysis (OR=17.7; 95%CI 6.8-46.8,
p<0.001), which confirms the results of Ryan et al. [1].
Conclusion: The simple question, "Compared with five years ago how is this
person at remembering things that have recently happened and how is this
person oriented in time and space?", to a proxy of a geriatric patient in
an acute care hospital might be a good predictor of impending delirium.
Further research is needed to confirm this hypothesis.
[1] Ryan DJ, O'Regan NA, O Caoimh R, et al. Delirium in an adult
acute hospital population: predictors, prevalence and detection. BMJ Open
2013;3:e001772. Doi:10.1136/bmjopen-2012-001772
[2] Hestermann U, Backenstrass M, Gekle I, et al. Validation of a German
version of the Confusion Assessment Method for delirium detection in a
sample of acute geriatric patients with a high prevalence of dementia.
Psychopathology 2009;42: 270-276.
[3] Jorm AF. The Informant Questionnaire on Cognitive Decline in the
Elderly (IQCODE): a review. Int Psychogeriatr 2004;16:275-293.
This excellent paper?s conclusions concur my earlier findings on the
effects of cadmium on the urinary proteoglycan excretion (1). It seems
that changes are e.g. related with proteinuria (2) and thus be considered
as markers for more generalized vascular effects as predicted in the
current investigation.
1 Savolainen H. Studies on urinary proteoglycan excretion in
occupational cadmium exp...
This excellent paper?s conclusions concur my earlier findings on the
effects of cadmium on the urinary proteoglycan excretion (1). It seems
that changes are e.g. related with proteinuria (2) and thus be considered
as markers for more generalized vascular effects as predicted in the
current investigation.
1 Savolainen H. Studies on urinary proteoglycan excretion in
occupational cadmium exposure. Pharmacol Toxicol 1994; 75: 113
2 Savolainen H. A sensitive method for the analysis of urinary
proteoglycans. Biochem Int 1992; 28: 475
Data for this article has been deposited in the Dryad digital repository. Please see:
Doshi P, Jefferson T (2013) Data from: Clinical Study Reports of randomized controlled trials - an exploratory review of previously confidential industry reports. Dryad Digital Repository. doi:10.5061/dryad.331f7 http://dx.doi.org/10.5061/dryad.331f7
Data for this article has been deposited in the Dryad digital repository. Please see:
Doshi P, Jefferson T (2013) Data from: Clinical Study Reports of randomized controlled trials - an exploratory review of previously confidential industry reports. Dryad Digital Repository. doi:10.5061/dryad.331f7 http://dx.doi.org/10.5061/dryad.331f7
Peter Doshi
27-Feb-2013
Conflict of Interest:
As declared in the original article (BMJ Open 2013 3:e002496; doi:10.1136/bmjopen-2012-002496).
Pharmaceutical procurement is a specialized professional activity
that requires a lot of knowledge, skill and experience. It is therefore
mandatory that staff involved in key procurement and distribution
positions be well trained and highly motivated, with the capability to
manage the procurement process efficiently.
Pharmaceutical procurement is a complex process, which involves many
steps, agencies and manufacturers. E...
Pharmaceutical procurement is a specialized professional activity
that requires a lot of knowledge, skill and experience. It is therefore
mandatory that staff involved in key procurement and distribution
positions be well trained and highly motivated, with the capability to
manage the procurement process efficiently.
Pharmaceutical procurement is a complex process, which involves many
steps, agencies and manufacturers. Existing government policies, rules and
regulations for procurement as well as institutional structures prove
frequently inadequate and sometimes hinder overall efficiency in
responding to the modern pharmaceutical market1. There are many steps in
the procurement cycle. No matter what model has been adopted to manage the
procurement and distribution system, efficient procedures should be in
place to select the most cost-effective essential drugs to treat commonly
encountered diseases; to quantify the needs; to pre-select potential
suppliers; to manage procurement and delivery; to ensure good product
quality; and also to monitor the performance of suppliers and the
procurement system. Failure in any of these areas leads to lack of access
to appropriate drugs and to waste. In many public supply systems,
breakdowns regularly occur at multiple points in this process. In India,
various organizations follow different operating procedures for effective
pharmaceutical procurement.
Absence of comprehensive documented, systematic and uniform procurement
procedures, guidelines and proper delegation of power become utopian. In
some organizations, purchase manual is either unavailable or available at
an obsolete state. Even some institutions deploy these procurement staff
by having negligible or no training or education leading to procurement
system in jeopardy. Staff becomes vulnerable to audit and vigilance
issues. In West Bengal, there are no Pharmacists in most of the store
purchase section. There are few hospitals in India where a professionally
qualified pharmacist heads medical store or Pharmacy Therapeutic Committee
determines medical pharmacologist and selection of drugs. We are fortunate
to have essential drug list of 348 drugs but it is not in the line of
British National Formulary like database. It is quite a tedious process to
achieve an unbiased conclusion on different types of branded drug, branded
generic drug or the MRP. Non-existence of computerized database, lack of
co-ordination and collaboration lead to failure of rational procurement at
the most competitive price and in a fair, just and transparent manner.
Indian pharmaceutical jungle is flooded with more than 90,000 formulations
with having little control on price regulation. A recent study published
in Indian Journal of Pharmacology shows that there is no remarkable
variation of quality between branded and branded generics in India.
Glimpses of study shown in the following chart:
Trade name of medicine Pharmacological name, strength and dosage form
Manufacturer PTR (1x10) MRP (1x10) Mark-up (retailer)
Alerid tablets (B) Cetirizine HCL 10 mg/tab Cipla INR 27.16 INR
35.31 30
Cetcip tablets (B/G) Cetirizine HCL 10 mg/tab Cipla INR 2.24 INR
25.00 1016
Fludac capsules (B) Fluoxetine HCL 20 mg/cap Cadila INR 29.80 INR
37.26 25
Cadflo capsules (B/G) Fluoxetine HCL 20 mg/cap Cadila INR 6.00 INR
28.00 367
Ciprobid tablets (B) Ciprofloxacin 500 mg/tab Cadila INR 54.84 INR
68.56 27
Ciprodac tablets (B/G) Ciprofloxacin 500 mg/tab Cadila INR 15.00 INR
68.56 357
Lanzol-30 capsule (B) Lansoprazole 30 mg/cap Cipla INR 42.36 INR 53.77
27
Lansec-30capsule (B/G) Lansoprazole 30 mg/cap Cipla INR 15.68 INR
47.25 201
Restyl tablets (B) Alprazolam 0.25 mg/tab Cipla INR 11.85 INR 14.82
25
Tranex tablets (B/G) Alprazolam 0.25 mg/tab Cipla INR 2.20 INR 11.34
415
Branded medicine (B) Branded-generic medicine (B/G), Price to the retailer
(PTR) Maximum Retail Price (MRP)
Findings of the present study indicate that both the branded and
branded-generic versions of the five paired medicines had identical
quality and they fulfilled all the criteria prescribed by the Indian
Pharmacopoeia. Hence, the general notion and doubt regarding the quality
of the branded-generic version of medicines need to be erased conducting
more such studies and publishing them widely. Suitable changes in the drug
price policy may be adopted to lower the prices for branded-generic
versions. Transparency in fixing the MRP by the manufacturer and clear
guidelines for mark-ups at least for branded-generics is required in
pharmaceutical trade. Availability of generics or branded-generics in the
market with lower price tag and assured quality is the need of the hour to
make the medicines affordable3. The government must conduct more and more
promotional events in favour of generic drug, arrange general awareness
programs on quality of generics to increase confidence amongst
prescribers, pharmacists, and consumers.
The corrective measures as follows:
Easy availability of valid Good Manufacturing Practice Certificate (GMP),
approved product list and loan license details for the manufacturers whose
products are produced elsewhere.
A procedure to have knowledge on more number of brands available for the
same medicine
Open access of last purchase rate of different organizations
More stringent provisions in tender documents relating to 'liquidated
damages', 'pre-qualification norms', 'packaging', 'performance security',
'warranty period', 'imposition of penalty for delay in supply, 'remaining
life' and 'bid security', etc.
Updated list of substandard drug in the website of CDSCO(Central Drug
Standard Control Organization/India) and state drug control
Appropriate time-frame at each stage of procurement and accountability of
staff involved in procurement procedure
Central Public Sector Enterprises may be more encouraged to manufacture
all essential drugs at low cost
Enhancement of quantity and quality of approved drug testing labs
Steady flow of government funding towards procurement of drug
Either the allotted fund may be spent in the stipulated year and the
unspent fund may be carried forward to the next year
Increased monitoring on performance of distributors and manufacturers
Decentralization (fragmented drug procurement in different levels-
district, state, central, public sector undertaking etc.) of procurement
Unbiased market information on product availability, comparative pricing,
product quality and supplier performance
Incentive and out of turn career development in procurement section
Increased exposure to latest market situations for tackling different
crisis
Strengthening the existing regulatory system especially for enabling more
detailed and universal classification of drugs and chemicals between
branded generic and generic.
Strengthening the public information system to reach out more consumers
for simple drugs.
When and where needed, pragmatic and rational procurement and
inventory management always ensure choice of right drug in right
quantities, doses and formulations, good quality, safe and efficacious.
All organizations should prepare codified purchase manuals, containing
detailed purchase procedures, guidelines and also proper delegation of
powers, so as to ensure systematic and uniform approach in decision-making
areas pertaining to procurements.
1. Chapter 13: Managing procurement. Management Sciences for Health
(MSH) in collaboration with the World Health Organization, Action
Programme on Essential Drugs. Managing drug supply, second edition. Edited
by J.D. Quick, J. Rankin, R. Laing, R. O'Connor, H.V. Hogerzeil, M.N.G.
Dukes and A. Garnett. Hartford, CT: Kumarian Press; 1997.
2.A comparative evaluation of price and quality of some branded versus
branded-generic medicines of the same manufacturer in India-G.L. Singal,
Arun Nanda, Anita Kotwani, Indian Journal of Pharmacology | April 2011 |
Vol 43 | Issue 2 131
3. Department-related parliamentary standing Committee on health and
family welfare Fifty- ninth report on the functioning of the central drugs
standard control organization (cdsco) (presented to the rajya sabha on 8th
may, 2012) (laid on the table of the lok sabha on 8th may, 2012)
Editor, The meta-analysis conducted by Yamada et al (2013) has established the association between baldness and coronary heart disease (CHD). The authors have concluded that vertex baldness among young men is closely related to atherosclerosis. Another factor that deserves mention in this context is smoking. We have many a times come across patients with severe arterial disease who have baldness and gray hair and on histo...
While I am pleased with the general research, its significance and findings in part, it is my humble concern that there may have been a systematic error in the sampling design. The researchers set out to measure both attitude towards and compliance with the smoking ban. In measuring attitudes, the researcher correctly identifies the school students as the population and randomly picks classes on which the instrument is...
Sir, we read with interest the recent response to our study of delirium point prevalence from Zieschang and colleagues, Heidelberg, Germany[1]. Zieschang et al have described a delirium prevalence of 15.6% in their study population of older hyponatraemic patients and normonatraemic controls admitted to a step-down facility, and note that our hospital-wide point prevalence was higher at almost 20%[2].
Although,...
Yamada et al. present a fascinating meta-analysis showing that male pattern baldness is associated with coronary heart disease (CHD).1 Although the association is subject to the inevitable limitations of observational studies, it is an intriguing observation for which Yamada et al. provide several potential mechanisms, such as classical coronary risk factors, hyperinsulinaemia or chronic inflammation causing both baldness...
We read the report of this trial with interest. The topic of the management of comorbid depression in chronic illness is an important one. We acknowledge the considerable effort involved in mounting a trial such as the TrueBlue study. However, we also feel it is important to raise comment on the reported findings, to ensure they are not misinterpreted. Our comments are:
First, the trial was not of depressive di...
The point prevalence of delirium in an acute care facility in Ireland was described with 20% for the 280 patients enrolled in the study. Prevalence was the highest on the geriatric ward (8/15 patients, 53%) and in patients >80years of age (24/69 patients, 34.8%) [1]. Delirium prevalence appears to be very high when compared to our own data set (Clinical trial registration: DRKS00004280). In a case-control-study, which...
Data deposited in the Dryad repository: http://dx.doi.org/10.5061/dryad.80q86
Conflict of Interest:
None declared
Dear Editor,
This excellent paper?s conclusions concur my earlier findings on the effects of cadmium on the urinary proteoglycan excretion (1). It seems that changes are e.g. related with proteinuria (2) and thus be considered as markers for more generalized vascular effects as predicted in the current investigation.
1 Savolainen H. Studies on urinary proteoglycan excretion in occupational cadmium exp...
Doshi P, Jefferson T (2013) Data from: Clinical Study Reports of randomized controlled trials - an exploratory review of previously confidential industry reports. Dryad Digital Repository. doi:10.5061/dryad.331f7 http://dx.doi.org/10.5061/dryad.331f7
Peter Doshi
27-Fe...
Pharmaceutical procurement is a specialized professional activity that requires a lot of knowledge, skill and experience. It is therefore mandatory that staff involved in key procurement and distribution positions be well trained and highly motivated, with the capability to manage the procurement process efficiently. Pharmaceutical procurement is a complex process, which involves many steps, agencies and manufacturers. E...
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