Paraquat is a bipyridilium herbicide used widely in our country and is a highly toxic compound. A 16-year-old female patient was admitted to the emergency department of our tertiary care hospital in South India with the history of alleged consumption of paraquat poison. Since there is dearth of high quality evidence- based treatment for this poisoning, different treatment modalities have been tried to manage patient's condition. In this case, none of the strategies could work well. Most of the patients reported with paraquat intoxication are from agricultural background; usually such patients cannot afford the treatment expenses. This paper presents a fatal case of acute poisoning with paraquat who succumbed to acute respiratory distress syndrome (ARDS).

Background Oral fingolimod is convenient to use than injectable disease modifying agents (DMAs) in patients with multiple sclerosis (MS). However, the existing literature regarding the comparative adherence trajectories between oral fingolimod and injectable DMAs is limited. Objective To compare the adherence trajectories between oral DMA, fingolimod, and injectable DMAs in patients with MS. Methods A retrospective longitudinal study was conducted using adults (≥18 years) with MS (ICD-9-CM: 340 and a DMA prescription) from the IBM MarketScan Commercial Claims and Encounters Database between 2010 and 2012. Patients were grouped into oral fingolimod or injectable DMA users based on the index DMA among patients with MS. The annual DMA adherence trajectories, based on the proportion of days covered (PDC), were examined using group-based trajectory modeling (GBTM) during the one-year follow-up period after treatment initiation. Multivariable multinomial logistic regression using stabilized inverse probability treatment weights (IPTW) was performed to assess the association between the DMA route of administration (Oral vs Injectable) and the adherence trajectory groups. The balance of covariates between oral and injectable DMAs before and after IPTW was checked against a standardized difference threshold of 0.25. Results The study cohort consisted of 1,700 MS patients who were initiated with oral (15.8%) or injectable (84.2%) DMAs between 2010 and 2012. The adherence rates (PDC≥0.8) in oral fingolimod and injectable DMA users were found to be 64.7% and 50.8%, respectively. The GBTM grouped individuals in the study cohort into three adherence trajectories – rapid discontinuers (23.5%), complete adherers (49.9%), and slow decliners (26.6%). The multinomial logistic regression model with stabilized IPTW revealed that oral fingolimod users had higher odds to be a complete adherer (adjusted odds ratio [AOR]: 2.78, 95% CI: 1.85–4.16) or a slow discontinuer (AOR: 2.62, 95% CI: 1.70–4.05) than injectable DMA users. Conclusions Oral DMA fingolimod was associated with better adherence than injectable DMAs across group-based trajectories. Further research is warranted to evaluate the adherence trajectories with newer oral DMAs introduced in the last decade for MS.

Objectives: MG is a debilitating chronic illness characterized by muscle weakness, potentially life-threatening exacerbations and high costs. We sought to further quantify the humanistic and economic burden by reviewing published evidence. Methods: Using PRISMA guidelines, two systematic literature reviews were conducted, one for quality of life (QOL) and one for economic studies, in key biomedical literature databases, Embase, Ovid Medline and Cochrane. Additionally, only studies published between 2009-2019 were identified. Results: A total of 957 abstracts from the QOL search and 521 from the economic search underwent screening. A total of 81 QOL and 41 economic studies were selected. A variety of QOL tools were used, including SF-36, EQ-5D, HADS, MG-ADL, MG-QOL15, QMG and MGC among others. The only study mapping utility values found a range of 0.94-0.20 across MGFA classifications, indicating a major QOL deterioration related to disease severity. Deterioration was further supported in other studies which found increased levels of chronic fatigue, sleep disturbances and anxiety/depression with MG. Refractory patients experienced significantly worse deteriorations across various scales. Employment status and medication adherence were also negatively affected. Of 41 economic studies, 32 were related to cost/healthcare resource use, while 9 described economic models. The average US cost in 2013 was $98,795 per MG hospitalization and the gross hospitalization cost in the HCUP database had risen more than 13-fold since 2003 totalling $546,834,101. Inpatient, outpatient and home costs were found to account for 27%, 23% and 23% of MG healthcare costs. A US claims database found annual costs to be approximately 4 times higher in refractory vs. non-refractory patients ($109,004 vs. $24,196, p,0.001), possibly related to a higher use of IVig/ PLEX, costly therapies according to economic models. Conclusions: Novel treatment strategies are necessitated to help control rising costs and alleviate the humanistic burden associated with MG, especially in refractory patients.

Objectives: The Kansas City Cardiomyopathy Questionnaire (KCCQ) has been widely used to measure heart failure (HF) patients' perception of their health status, symptoms, physical and social function and quality of life. However, as a disease specific measure, the KCCQ is not designed to estimate health-state utilities, precluding its use in cost-effectiveness research. This study used data from the COAPT trial to map KCCQ scores to the SF-6D utility index. Methods: Data were obtained from the COAPT trial-a prospective, randomized controlled trial of transcatheter mitral valve repair vs. standard care in 614 patients with HF and secondary mitral regurgitation. Patients completed the SF-36 and the KCCQ at baseline and at 1, 6, 12, and 24 months. We calculated SF-6D utility scores and KCCQ overall summary (KCCQ-OS) scores for both the full and short form (KCCQ-12) for each subject. Using mixed linear models with random effects for subjects, we regressed SF-6D utility scores on the KCCQ-OS and the KCCQ-12, testing for age and sex effects. Model fit was evaluated using conditional AIC, R 2 and correlation. Results: Both the KCCQ-OS and the KCCQ-12 score were closely correlated with SF-6D derived health utility (correlation of 0.76 and 0.77 for the KCCQ-OS and KCCQ-12). Model testing revealed a conditional R 2 of 0.71 for the model using the KCCQ-OS and 0.73 for the KCCQ-12. The addition of age and gender to the models had negligible impact on the results. Based on these data, the final mapping equations were 0.44 + 0.0035*(KCCQ-OS) and 0.45 + 0.0034*(KCCQ-12). Conclusions: The KCCQ-OS and the KCCQ-12 are excellent predictors of health state utility in patients with HF, as compared with the SF-6D utility estimates. Further studies are needed to validate these predictive models in other heart failure populations.

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