Cost of Illness Analysis of Type 2 Diabetes Mellitus: The Findings from a Lower-Middle Income Country.

BACKGROUND: Diabetes is a major chronic illness that negatively influences individuals and society. Therefore, this research aimed to analyze and evaluate the cost associated with diabetes management, specific to the Pakistani Type 2 diabetes population. Research scheme and methods: A survey randomly collected information and data from diabetes patients throughout Pakistan out-patient clinics. Direct and indirect costs were evaluated, and data were analyzed with descriptive and inferential statistics. RESULTS: An overall of 1839 diabetes patients participated in the study. The results have shown that direct and indirect costs are positively associated with the participants' socio-demographic characteristics, except for household income and educational status. The annual total cost of diabetes care was USD 740.1, amongst which the share of the direct cost was USD 646.7, and the indirect cost was USD 93.65. Most direct costs comprised medicine (USD 274.5) and hospitalization (USD 319.7). In contrast, the productivity loss of the patients had the highest contribution to the indirect cost (USD 81.36). CONCLUSION: This study showed that direct costs significantly contributed to diabetes's overall cost in Pakistan and overall diabetes management estimated to be 1.67% (USD 24.42 billion) of the country's total gross domestic product. The expense of medications and hospitalization mostly drove the direct cost. Additionally, patients' loss of productivity contributed significantly to the indirect cost. It is high time for healthcare policymakers to address this huge healthcare burden. It is time to develop a thorough diabetes management plan to be implemented nationwide.

Active Physical Practice Followed by Mental Practice Using BCI-Driven Hand Exoskeleton: A Pilot Trial for Clinical Effectiveness and Usability.

Appropriately combining mental practice (MP) and physical practice (PP) in a poststroke rehabilitation is critical for ensuring a substantially positive rehabilitation outcome. Here, we present a rehabilitation protocol incorporating a separate active PP stage followed by MP stage, using a hand exoskeleton and brain-computer interface (BCI). The PP stage was mediated by a force sensor feedback-based assist-as-needed control strategy, whereas the MP stage provided BCI-based multimodal neurofeedback combining anthropomorphic visual feedback and proprioceptive feedback of the impaired hand extension attempt. A six week long clinical trial was conducted on four hemiparetic stroke patients (screened out of 16) with a left-hand disability. The primary outcome, motor functional recovery, was measured in terms of changes in grip-strength (GS) and action research arm test (ARAT) scores; whereas the secondary outcome, usability of the system was measured in terms of changes in mood, fatigue, and motivation on a visual-analog-scale. A positive rehabilitative outcome was found as the group mean changes from the baseline in the GS and ARAT were +6.38 kg and +5.66 accordingly. The VAS scale measurements also showed betterment in mood ( 1.38), increased motivation (+2.10) and reduced fatigue (0.98) as compared to the baseline. Thus, the proposed neurorehabilitation protocol is found to be promising both in terms of clinical effectiveness and usability.

Assessing adriamycin-induced early cardiotoxicity by estimating left ventricular ejection fraction using technetium-99m multiple-gated acquisition scan and echocardiography.

BACKGROUND: Adriamycin cardiotoxicity begins with the first dose of therapy. The insult may be subclinical initially, but with continued treatment can result in clinical congestive heart failure. Therefore, a study for the detection of early cardiotoxicity of adriamycin by left ventricular ejection fraction (LVEF) estimation using technetium (Tc)-99m multiple-gated acquisition (MUGA) scan and echocardiography (ECHO) was conducted. METHODS: LVEF was assessed in 42 patients with different cancers, advised to receive adriamycin (average received dose = 95.2 ± 6.82 mg/cycle, protocol dose = 65 ± 10 mg/m) in each of six cycles. The percentage of LVEF (%LVEF) was determined as a baseline after every successive cycle, simultaneously, by a Tc-99m MUGA scan (reference method) and ECHO. RESULTS: A significant decline of 12.17 ± 5.01 and 9.26 ± 4.82 (P < 0.001) in %LVEF was noted at the end of adriamycin therapy, estimated by a Tc-99m MUGA scan and ECHO respectively. Thirteen of 42 (31%) and six of 42 (14%) patients developed protocol-defined cardiotoxicity, determined by a Tc-99m MUGA scan and ECHO, respectively. The incidence of cardiotoxicity was 2.4, 2.4, 4.8, 16, and 31.2% at the median cumulative adriamycin dose of 210, 380, 450 , 550 , and 615 mg/m, respectively. CONCLUSION: Subclinical adriamycin cardiotoxicity was detectable from the third cycle and if not detected earlier continued therapy may progress to severe and irreversible cardiotoxicity. A decline of 5% or more of %LVEF instead of 10% should be considered as a significant marker of subclinical cardiotoxicity. A Tc-99m MUGA scan is more sensitive than ECHO for the estimation of subtle changes in %LVEF. Ideally, %LVEF must be determined at baseline and after every cycle, and if not possible then preferably from the third cycle onwards.

Dual phase qualitative and quantitative 99mTc-MIBI scintimammography for predicting response to neoadjuvant chemotherapy in breast cancer.

OBJECTIVE: To determine the role of dual phase 99mTc-MIBI scintimammography in predicting chemotherapeutic response in breast cancer. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Karachi Institute of Radiology and Nuclear Medicine (KIRAN), from September 2004 to March 2005. METHODOLOGY: Female patients with locally advanced breast cancer being planned for the anthracycline-based neoadjuvant chemotherapy were included in this study. All subjects received a 740 MBq bolus intravenous injection of 99mTc-MIBI. Ten minutes and 3 hours post-injection planar images were obtained in prone, lateral and supine positions using double head gamma camera. MIBI washout was scored as follows: >30% as a positive prognostic test (predicting a poor response to chemotherapy) and <30% as negative prognostic test (predicting a good response to chemotherapy). Qualitative analysis of MIBI scans was also performed and categorized as visual wash-out or no visual washout as apparent on the early and delayed images. The criterion for the good and bad response was the reduction of >50% and <50% in the tumour burden respectively. Accuracy analysis, Chi-square test and Wilcoxan sign rank test were applied. RESULTS: There were 32 females (mean age: 46.3 years; median age 46 years; age range 33-65 years). Quantitative dual phase 99mTc-MIBI scintimammography was found to be a good predictor of chemotherapeutic response in breast cancer. These were true positive in 8 patients and true negative in 19 patients with sensitivity (Sens.) 72%, specificity (Spec.) 90%, Positive Predictive Value (PPV) 80%, Negative Predictive Value (NPV) 86.5%, p <0.03. Receiver Operating Characteristics (ROC) curve analysis demonstrates 30% as a cut-off value for the wash-out in quantitative dual phase MIBI for the prediction of the chemotherapeutic response. In comparison, qualitative scintimammography had Sens. 82%, Spec. 53%, PPV 29%, NPV 93% and p <0.38. Statistical difference was found between early and delayed uptake ratios in the responders and non-responders. CONCLUSION: Quantitative dual phase 99mTc-MIBI scintimammography is a simple, reliable, non-invasive and effective tool for predicting the response to neoadjuvant chemotherapy. Furthermore, quantitative assessment is more precise than qualitative (visual wash-out) approach.

Treating difficult or disruptive dialysis patients: practical strategies based on ethical principles.

For more than a decade, dialysis units have had to contend with an increasing number of difficult or disruptive dialysis patients. These individuals present a spectrum of behaviors, ranging from those that harm only themselves to those that physically endanger dialysis staff. Such behaviors can interfere with the ability of the dialysis staff to care for the patient in question and for other patients; in addition, threats or actual physical abuse jeopardize the health and safety of both patients and staff. In this Review, we discuss how the application of ethical principles can assist dialysis staff to balance their ethical obligations to disruptive and difficult patients with those to other patients and staff, and to establish policies and strategies for the treatment of these challenging patients. This approach also allows health-care professionals to identify the limited situations in which involuntary patient discharge from a dialysis unit is ethically justified.

Role of 99mTc-MIBI scintimammography and X-ray mammography in the diagnosis of locoregional recurrence of breast cancer.

OBJECTIVE: To evaluate the utility of Tc- MIBI scintimammography in the loco-regional recurrence of breast cancer and its comparison with mammography. METHODS: The study population comprised of 33 subjects (mean age, 44.9 +/- 14.1 years); evaluated for suspected loco-regional recurrence of breast cancer on clinical examination. All subjects received a 740-1000 MBq bolus IV injection of 99mTc-MIBI preferably in pedal vein. At 5-10 min and 60-90 min post injection planar images were obtained in prone lateral and supine anterior position using double head gamma camera. MIBI uptake was scored as follows: 1: as normal uptake (compared with contralateral side); 2: focal low intense uptake (equivocal); 3: focal high intense uptake (positive). Mammography was performed by two standard views of cranio-caudal and mediolateral oblique in 26 patients. All patients had either excision biopsy or fine needle aspiration cytology (FNAC) for tissue diagnosis. RESULTS: Out of 33 patients, 21 had confirmed as recurrence on hiostopathology/cytology. Scintimammography was found true positive in 18 and true negative in 11 patients. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 85.7%, 91.7%, 94.7%, 78.6% and 87.8% respectively. In comparison, mammography was true positive in 9 and true negative in 6 patients with sensitivity of 52.9%, specificity, 66.7%, PPV 75%, NPV 42.9% and accuracy 57.7%. CONCLUSION: Scintimammography has better diagnostic accuracy than mammography in the detection of loco-regional recurrence of breast cancer.