National Evaluation of HIV Service Resource Allocation in Tanzania.

Using time-driven activity-based costing (TDABC), we examined resource allocation and costs for HIV services throughout Tanzania at patient and facility levels. This national, cross-sectional analysis of 22 health facilities quantified costs and resources associated with 886 patients receiving care for five HIV services: antiretroviral therapy, prevention of mother-to-child transmission, HIV testing and counseling, voluntary medical male circumcision, and pre-exposure prophylaxis. We also documented total provider-patient interaction time, the cost of services with and without inclusion of consumables, and conducted fixed-effects multivariable regression analyses to examine patient- and facility-level correlates of costs and provider-patient time. Findings showed that resources and costs for HIV care varied significantly throughout Tanzania, including as a function of patient- and facility-level characteristics. While some variation may be preferable (e.g., needier patients received more resources), other areas suggested a lack of equity (e.g., wealthier patients received more provider time) and presented opportunities to optimize care delivery protocols.

Superficial temporal artery perforator flaps for reconstruction of intraoral defects.

BACKGROUND: Intraoral defects after tumor resection are often reconstructed with free tissue transfer. However, in patients who are not good candidates for free tissue transfer, regional flaps based on the superficial temporal artery can be utilized. The authors present our technique to reconstruct intraoral defects with the superficial temporal artery perforator (STAP) flap and early outcomes. METHODS: Five patients underwent STAP flaps for defects including the hard palate, buccal sulcus, floor of mouth, and retromolar trigone between 2017 and 2019. The mean defect size was 5.6 × 3.4 cm2 (3 × 3 cm2 - 7 × 4 cm2 ). The mean age was 74 (57-88) and all patients had recurrent cancer. External Doppler, indocyanine green laser angiography, and FLIR thermal imaging were used intra-operatively to identify the best perforators and plan for flap design. RESULTS: The mean flap size was 7.6 × 3.5 cm2 (6 × 3 cm2 - 10 × 5 cm2 ). Four flaps were based off of the posterior branch of the STA, while the fifth was based off of the anterior branch. Two donor sites were closed primarily, and three required skin grafts. One patient experienced partial flap necrosis. There were no complete flap losses and no donor site complications. Average follow up was 14.6 months (9-20 months). All patients maintained preoperative level of speech, mastication, and oral continence. CONCLUSIONS: The STAP flap can be based on the anterior or posterior branch of the superficial temporal artery and is a useful regional flap for intraoral defects after tumor resection.

Smart cascades: using cost analysis to improve HIV care and treatment interventions to achieve global 95-95-95 goals.

Background: HIV programmes are achieving significant scale, even as external financing plateaus. Maximising achievement from identification to viral suppression is key to epidemic control and reaching global 95-95-95 goals. Cost and technical efficiency analyses can help programs understand why losses occur along the cascade, which tactics prevent losses, and additional investments required for cost-efficient solutions.Methodology: The PEPFAR- and USAID-funded Health Policy Plus (HP+) project identified cascade failure points and interventions needed in six countries (Ghana, Indonesia, Kyrgyz Republic, Kenya, Tajikistan, Tanzania). Methods included secondary data analysis and expert interviews. HP+ estimated unit costs and effectiveness of tactics to model future costs and cascade outcomes across scenarios. Conclusions across countries are synthesised for overall best practices.Results: In Ghana, Indonesia, Tajikistan, and the Kyrgyz Republic, HIV identification strategies need to evolve to counter diminishing testing yields. Higher-yield testing modes may have higher costs per person tested, yet lower costs per person identified compared to previous strategies. In Kenya, investments in linkage and retention require additional funding, and will reduce the need for expensive loss-to-follow-up activities. In Tanzania, differentiated antiretroviral therapy can improve patient management while reducing facility-level costs.Conclusion: Results from diverse settings suggest that cost-efficiency analyses aimed at smart cascades will help countries identify and resolve reasons for poor outcomes. The analyses are predicated on contextual exploration of how interventions are linked, and should inform prioritisation and investment strategies. While improving the cascade often has incremental costs, it may be cost-efficient versus the long-term cost of poor outcomes.

HIV treatment support services in Tanzania: a cost and efficiency analysis at facility and community levels.

Differentiated service delivery models provide an opportunity to reduce the cost of HIV treatment while increasing the focus on advanced patients. Also, stable patients who need less attention can visit facilities less frequently, saving time and money and reducing overcrowding. Tanzania needs treatment support services that can improve the quality of life, ensure adherence and result in viral suppression. Treatment support services can be provided through a variety of models, including at the community level, through the facility or through some combination of the two. Understanding the cost of each model is essential for policy-makers who must allocate resources. Data from neighbouring countries suggests that community-level support services can be beneficial to patients, especially in reducing loss to follow-up and death. Though community-based HIV services are available in Tanzania, uncertainty about the costs of these models remain. This study assessed the costs of treatment support services at 27 sites in Tanzania. The cost analysis found that the average unit cost of treatment support services is US$39 per patient per year. The analysis found that community-based models have clear advantages with regard to the number of patients that can be reached with support services. Costing data indicated that community-based models are also less expensive. The lack of data on retention limited any conclusions about whether community-based models are the most effective within the Tanzanian context.

Caring behaviours of student nurses: Effects of pre-registration nursing education.

In an increasing technologised and cost-constrained healthcare environment, the role of pre-registration nursing education in nurturing and developing the professional caring disposition of students is becoming far more critical than before. In view of this growing demand, the aim of this study was to evaluate the impact of Singapore's pre-registration nursing programmes on students' concept of caring. A descriptive quantitative cross-sectional survey collected data using the Caring Behaviour Inventory from first and final year student nurses, nurse lecturers and nurses in practice. The findings based on student surveys indicated a statistically significant reduction in the overall level of caring behaviour in first to final year students. When compared with the findings of lecturers and nurses, less variance to lecturers than to nurses was found amongst the first years' score, and the lowest variance to nurses was demonstrated amongst the final year. A greater reduction was evidenced amongst Singaporean students, which was exaggerated with exposure to pre-enrolled nursing education and magnified with caring job experience. This study indicates more effort is necessary to harness student caring attributes in students' entire educational journey so that expressive caring is not subsumed in the teaching of students to meet demands of complicated contemporary care.

KLF6 allelic loss is associated with tumor recurrence and markedly decreased survival in head and neck squamous cell carcinoma.

The Krüppel-like transcription factor (KLF6) gene is a tumor suppressor gene (TSG) reported to be dysregulated and inactivated through loss of heterozygosity (LOH) and/or somatic mutation in a number of major human cancers. The aim of the present study was to examine KLF6 gene status and expression in head and neck squamous cell carcinomas (HNSCC). A collection of 81 well-characterized oral and oropharyngeal HNSCC samples were analyzed for evidence of KLF6 LOH and mutation and differences in expression patterns between normal and cancerous tissues and these findings were correlated with clinicopathological variables. We also tested the effect of KLF6 inhibition in HNSCC cell lines on proliferation and p21 expression. LOH was found in approximately 30% of cases and was strongly correlated with cancer progression, tumor recurrence and decreased patient survival. Overall, median survival of patients with LOH was less than half (19 vs. 41 months, p=0.036, stratified on stage) than those without loss. Risk of death for patients with LOH was 8 times greater independent of tumor size, nodal status, tobacco smoking or treatment modality (HR 7.89, 95% CI: 1.9-32.4). Subsequent analyses revealed KLF6 mutations in only 2 of 20 samples, but altered subcellular protein localization in 64% of tumors. Targeted stable reduction of KLF6 in HNSCC cell lines increased cellular proliferation while decreasing p21 expression. Taken together, these findings suggest that KLF6 LOH represents a clinically-relevant biomarker predicting patient survival and tumor recurrence and that dysregulation of KLF6 function plays an important role in HNSCC progression.

Internal mammary artery and vein: recipient vessels for free tissue transfer to the head and neck in the vessel-depleted neck.

BACKGROUND: Microvascular free tissue transfer is a standard reconstructive option for postablative defects of the head and neck. However, the success of this surgery requires suitable recipient vessels in the cervical region. This form of reconstruction can be particularly challenging in the vessel-depleted neck. While the internal mammary artery and vein (IMA/V) have been used extensively in breast reconstruction, there are few reports describing their use in head and neck reconstruction. We report the first case series of the use of the internal mammary vessels for head and neck microvascular reconstruction. METHODS: We reviewed 5 cases of free tissue transfers to the head and neck in which extensive prior treatment precluded the use of more traditional recipient vessels in the neck or upper chest. RESULTS: A variety of free flaps were transferred for different reconstructive problems which included: chin/lower lip (n = 2), closure of widely patent tracheoesophageal puncture sites (n = 2), and pharyngoesophageal reconstruction following staged repair of a severe stenosis (n = 1). The radial forearm free flap was transferred in 4 patients and the rectus abdominus free flap in 1 patient. The IMA/V on the right side was prepared in all cases. All free flaps were successfully revascularized without the need for vein grafts and without the need for any microvascular revision procedures. CONCLUSION: The internal mammary artery and vein provide reliable, easily accessible recipient vessels for microvascular reconstruction in the vessel-depleted neck. The selection of free flap donor sites with long donor vessels facilitates the microvascular repair.

Chronic cough as a sign of laryngeal sensory neuropathy: diagnosis and treatment.

Chronic cough is often attributed to reflux, postnasal drip, or asthma. We present 28 patients who had chronic cough or throat-clearing as a manifestation of sensory neuropathy involving the superior or recurrent laryngeal nerve. They had been identified as having sudden-onset cough, laryngospasm, or throat-clearing after viral illness, surgery, or an unknown trigger. Cough and laryngospasm were the most common complaints. Seventy-one percent of the patients had concomitant superior laryngeal nerve or recurrent laryngeal nerve motor neuropathy documented by laryngeal electromyography or videostroboscopy. After a negative workup for reflux, asthma, or postnasal drip, these patients were treated with gabapentin at 100 to 900 mg/d. Symptomatic relief was achieved in 68% of the patients. Sensory neuropathy of the recurrent laryngeal nerve or superior laryngeal nerve should be considered in the workup for chronic cough or larynx irritability. Symptomatic management of patients with cough and laryngospasm due to a suspected sensory neuropathy may include the use of antiseizure medications such as gabapentin.

Oral squamous cell carcinoma: histologic risk assessment, but not margin status, is strongly predictive of local disease-free and overall survival.

To analyze the impact of resection margin status and histologic prognosticators on local recurrence (LR) and overall survival (OS) for patients with oral squamous cell carcinoma (OSCC). This study was both retrospective and prospective in design. Cohort 1 refers to the entire group of 292 patients with OSCC. The slides from the earliest resection specimens from Cohort 1 were examined in an exploratory manner for multiple parameters. Cohort 2 refers to a subset of 203 patients, who did not receive any neoadjuvant therapy and had outcome data. Cohort 3 represents a subset of Cohort 2 (n = 168) wherein the histologic resection margin status could be reconfirmed. Cohort 4 refers a subset of 85 patients with tongue/floor of mouth tumors. Margin status was designated as follows: group 1, clearance of > or =5 mm with intraoperative analysis, no need for supplemental margins (n = 46); group 2, initial margins were measured as <5 mm during intraoperative frozen section; supplemental resection margins were negative on final pathology (n = 73); group 3, the final pathology revealed resection margins <5 mm (n = 30); group 4, the final pathology revealed frankly positive resection margins (n = 19). The endpoints of LR and OS were queried with respect to T stage, tumor site, margin status, and numerous histologic variables, by Cox regression and Kaplan-Meier survival analyses. Tumor stage (T) was significantly associated with LR (P = 0.028). Kaplan-Meier analysis for stage and for intraoral site was significantly associated with LR for T4 tumors. The increased likelihood of LR was higher for T4 OSCC of the buccal mucosa (75%), sinopalate (50%), and gingiva (100%) compared with mobile tongue (27%), and oropharynx (13%) (P = 0.013). Margin status was not associated with LR or OS (Cohort 3). This was so when all tumors were grouped together and when separate analyses were performed by tumor stage and oral subsite. No significance was demonstrated when margin status was examined for patients with similar treatment (surgery alone or surgery with adjuvant RT). However, the administration of adjuvant RT did significantly increase local disease-free survival (P = 0.0027 and P = 0.001 for T1 and T2 SCC, respectively). On exploratory analyses of histologic parameters, worst pattern of invasion was significantly associated with LR (P = 0.015) and OS (P < 0.001). Perineural invasion involving large nerves (>1 mm) was associated with LR (P = 0.005) and OS (P = 0.039). Limited lymphocytic response was also significantly associated with LR (P = 0.005) and OS (P = 0.001). When used as covariates in a multivariate Cox regression model, worst pattern of invasion, perineural invasion, and lymphocytic response were significant and independent predictors of both LR and OS, even when adjusting for margin status. Thus, these factors were used to generate our risk assessment. Our risk assessment classified patients into low-, intermediate-, or high-risk groups, with respect to LR (P = 0.0004) and OS (P < 0.0001). This classification retained significance when examining patients with uniform treatment. In separate analyses for each risk group, we found that administration of adjuvant radiation therapy is associated with increased local disease-free survival for high-risk patients only (P = 0.0296) but not low-risk or intermediate-risk patients. Resection margin status alone is not an independent predictor of LR and cannot be the sole variable in the decision-making process regarding adjuvant radiation therapy. We suggest that the recommendation for adjuvant radiation therapy be based on, not only traditional factors (inadequate margin, perineural invasion, bone invasion) but also histologic risk assessment. If clinicians want to avoid the debilitation of adjuvant radiation therapy, then a 5-mm margin standard may not be effective in the presence of high-risk score.

Use of injectable hydroxyapatite in the secondary setting to restore glottic competence after partial laryngectomy with arytenoidectomy.

Hydroxyapatite cement is a calcium phosphate putty, approved by the US Food and Drug Administration, that solidifies in 20 minutes and gains bone-like stability after 4 to 6 hours. It has been used for craniofacial reconstruction, spinal stabilization, and ossicular reconstruction. This is the first report of use of injectable hydroxyapatite to rebuild soft and hard tissue defects of the larynx after partial laryngeal surgery. Hydroxyapatite was injected in 4 patients to address glottic incompetence after partial laryngectomy. The patients were dependent on tracheotomy and/or gastrostomy tubes. Some had failed prior corrective surgeries. All of the operations were performed endoscopically and gave immediate improvement of glottic incompetence. All 4 patients reported improved symptoms. Three were able to have gastrostomy tubes removed, 1 was decannulated, and 1 had improved voice. In conclusion, hydroxyapatite injection is a technically simple procedure to restore glottic competence that may obviate the need for an open procedure.