N0 neck trial: Does intensification of follow-up (Ultrasound + Physical Examination) influence outcomes in early-stage oral cancer?

AIM OF THE STUDY: We previously reported a survival benefit of elective neck dissection (END) over therapeutic neck dissection (TND) in patients with clinically node-negative early-stage oral cancer. We now report the results of the second question in the same study addressing the impact of adding neck ultrasound to physical examination during follow-up on outcomes. METHODS: Patients with lateralized T1/T2 oral squamous cell carcinoma (SCC) were randomized to END or TND and to follow-up with physical-examination plus neck ultrasound (PE+US) versus physical-examination (PE). The primary endpoint was overall survival (OS). RESULTS: Between January 2004 and June 2014, 596 patients were enrolled. This is an intention to treat analysis of 592 analysable patients, of whom 295 were allocated to PE+US and 297 to PE with a median follow-up of 77.47 months (interquartile range (IQR) 54.51-126.48). There was no significant difference (unadjusted hazard ratio [HR], 0.92, 95% CI, 0.71-1.20, p = 0.54) in 5-year OS between PE+US (70.8%, 95% CI, 65.51-76.09) and PE (67.3%, 95% CI, 61.81-72.79). Among 131 patients with neck node relapse as the first event, the median time to relapse detection was 4.85 (IQR 2.33-9.60) and 7.62 (IQR 3.22-9.86) months in PE+US and PE arms, respectively. The N stage in the PE+US arm was N1 33.8%, N2a 7.4%, N2b/c 44.1% and N3 14.7% while in PE was N1 28.6%, N2a 9.5%, N2b/c 39.7%, N3 20.6% and unknown 1.6%. CONCLUSION: Adding neck ultrasound to physical examination during follow-up detects nodal relapses earlier but does not improve overall survival.

Effectiveness of Saccharomyces boulardii CNCM I-745 in Adult Indian Patients with Diarrhoea: A Real-world, Multicentre, Retrospective, Comparative Study.

BACKGROUND: Multiple clinical studies have described the benefits of probiotic Saccharomyces boulardii (S. boulardii) CNCM I-745 against diarrhoea, but the real-world evidence supporting its use is lacking. OBJECTIVE: To evaluate effectiveness of the S. boulardii CNCM I-745 group in a real-world setting. METHODS: This was an electronic medical record (EMR)-based, retrospective, multicentre, comparative study in Indian adult patients presenting with diarrhoea managed between January 2020 and January 2022. Data of patients at the baseline visit, with a follow-up visit within 15 days, and who were administered S. boulardii CNCM I-745 (for the test group) or any other treatment modality excluding probiotics (for the control group) were considered. Effectiveness was evaluated on the basis of number of patients who did not complain of diarrhoea at follow-up. RESULTS: Of 30,385 adult patients with diarrhoea, 270 patients prescribed S. boulardii CNCM I-745 were included, while the control group comprised 1457 patients. The baseline median age of the test group was 47 years (range 19-86 years), while it was 44 years (range 19-100 years) for the control group. The majority of patients in both study groups were females (56.7% in the test and 51.5% in the control group). Median duration between visits was 5 days (range 1-15 days) in both study groups. In all, 77.8% patients (95% CI 72.34-82.59) in the test group did not complain of diarrhoea at follow-up, while the proportion was 15.8% (95% CI 13.95-17.76) in the control group (p < 0.05). Odds ratio (OR) for absence of diarrhoea in the S. boulardii CNCM I-745 group versus the control group was 18.7 (95% CI 13.6-25.7, p < 0.05). For subgroups on concomitant antibiotics, a significant advantage was noted again for the test versus the control group (76.8% versus 18.4%; p < 0.05; OR: 14.7 with 95% CI 8.8-24.4; p < 0.05). CONCLUSION: The effect of S. boulardii CNCM I-745 probiotic in controlling diarrhoea was better than anti-diarrhoeal and/or oral rehydration therapy in real-world clinical practice. The effect was similar even with concomitant antibiotic usage.

Establishing a Pediatric Health Equity, Diversity, and Inclusion Research Review Process.

Equity, diversity, and inclusion (EDI) research is increasing, and there is a need for a more standardized approach for methodological and ethical review of this research. A supplemental review process for EDI-related human subject research protocols was developed and implemented at a pediatric academic medical center (AMC). The goal was to ensure that current EDI research principles are consistently used and that the research aligns with the AMC's declaration on EDI. The EDI Research Review Committee, established in January 2022, reviewed EDI protocols and provided recommendations and requirements for addressing EDI-related components of research studies. To evaluate this review process, the number and type of research protocols were reviewed, and the types of recommendations given to research teams were examined. In total, 78 research protocols were referred for EDI review during the 20-month implementation period from departments and divisions across the AMC. Of these, 67 were given requirements or recommendations to improve the EDI-related aspects of the project, and 11 had already considered a health equity framework and implemented EDI principles. Requirements or recommendations made applied to 1 or more stages of the research process, including design, execution, analysis, and dissemination. An EDI review of human subject research protocols can provide an opportunity to constructively examine and provide feedback on EDI research to ensure that a standardized approach is used based on current literature and practice.

Characteristics of Pediatric Hospital Medicine Fellowship Program Directors.

BACKGROUND AND OBJECTIVES: Rapid growth in pediatric hospital medicine (PHM) fellowships has occurred, yielding many new program directors (PDs). Characteristics of PDs have potential implications on the field. To describe characteristics (demographic, educational) and scholarly interests of PHM fellowship PDs. METHODS: We developed and distributed a 15-question, cross-sectional national survey to the PHM PDs listserv. Questions were pilot tested. The survey was open for 4 weeks with weekly reminders. Responses were summarized using descriptive statistics. RESULTS: Fifty-six current fellowship leaders (40 PDs, 16 associate PDs [APDs]) responded, including at least 1 from 43 of 59 active PHM fellowship programs (73%). Most respondents identified as female (71%) and ≤50 years old (80%). Four (7%, n = 2 PD, 2 APD) leaders identified as underrepresented in medicine. About half (n = 31, 55.4%) completed a fellowship themselves (APDs > PDs; 87.5% vs 42.5%), and 53.5% (n = 30) had advanced nonmedical degrees (eg, Master of Science, Doctor of Philosophy; APDs > PDs; 62% vs 45%). Most leaders (59%, n = 33) chose multiple domains when asked to select a "primary domain of personal scholarship." Education was the most frequently selected (n = 37), followed by quality improvement (n = 29) and then clinical research (n = 19). CONCLUSIONS: This survey confirms a high percentage of women as PHM fellowship leaders and highlights the need to increase diversity. Less than half of senior PDs completed a fellowship in any specialty. Leaders report interest in multiple domains of scholarship; few focus solely on clinical research.

Predictors of Subspecialty Appointment Scheduling and Completion for Patients Referred From a Pediatric Primary Care Clinic.

Failure to complete subspecialty referrals decreases access to subspecialty care and may endanger patient safety. We conducted a retrospective analysis of new patient referrals made to the 14 most common referral departments at Boston Children's Hospital from January 1 to December 31, 2017. The sample included 2031 patient referrals. The mean wait time between referral and appointment date was 39.6 days. In all, 87% of referrals were scheduled and 84% of scheduled appointments attended, thus 73% of the original referrals were completed. In multivariate analysis, younger age, medical complexity, being a non-English speaker, and referral to a surgical subspecialty were associated with a higher likelihood of referral completion. Black and Hispanic/Latino race/ethnicity, living in a Census tract with Social Vulnerability Index (SVI) ≥ 90th percentile, and longer wait times were associated with a lower likelihood of appointment attendance. Future interventions should consider both health care system factors such as appointment wait times and community-level barriers to referral completion.

Clinical and Demographic Characteristics of Patients with Coexistent Hypertension, Type 2 Diabetes Mellitus, and Dyslipidemia: A Retrospective Study from India.

BACKGROUND: Coexisting hypertension, type 2 diabetes mellitus (T2DM), and dyslipidemia (triple disease) can lead to greater risk of cardiovascular morbidity and mortality. The present study sought to comprehend the prevalence, demographic traits, clinical traits, and treatment patterns in Indian patients with these coexisting conditions. METHODS: An electronic medical record (EMR)-based, retrospective, multicenter, cross-sectional study was conducted, and data were collected for patients who were diagnosed with coexistent hypertension, T2DM, and dyslipidemia. Baseline patient variables evaluated were the percentage of patients with triple comorbidity, demographic characteristics, diagnostic laboratory parameters, and treatment pattern details. RESULTS: Data from 4793 centers (clinics) were included, with a total of 6,722,173 patients. Of these, 427,835 (6.36%) patients were found to have coexistent hypertension, T2DM, and dyslipidemia. Most of the patients belonged to the 40-64 year age group (62.10%) and were males (57.00%), while 27.40% patients had a body mass index (BMI) within normal limits, 43.30% patients were pre-obese, and 20.90% patients were class 1 obese. Further, 3402 patients (0.80%) had a recorded history of smoking. Mean glycated hemoglobin (HbA1c) for the patients included in the study was 8.35 ± 1.96 g%. Mean systolic blood pressure (SBP) was 138.81 ± 19.59 mm Hg, while mean diastolic blood pressure (DBP) was 82.17 ± 10.35 mm Hg; 27.60% cases had SBP < 130 mm Hg, while 28.37% cases had DBP < 80 mm Hg. The mean low-density lipoprotein (LDL), total cholesterol, and high-density lipoprotein (HDL) in mg/dl were 98.38 ± 40.39, 174.75 ± 46.73, and 44.5 ± 10.05, respectively. Of the enrolled cases, 55.64% had serum LDL below 100 mg/dl, 72.03% cases had serum cholesterol below 200 mg/dl, and 44.15% males and 71.77% females had serum HDL below the normal prescribed range. The most common monotherapy used for managing hypertension was angiotensin receptor blockers (ARB) (24.80%), followed by beta-blockers (24.30%). The most common combinations administered for management of hypertension were antihypertensives with diuretics (14.30%), followed by ARB plus calcium channel blockers (CCB) (13.30%). For dyslipidemia, the majority of patients (56.60%) received lipid-lowering medication in combination with drugs for other comorbidities. The most common antidiabetic agents prescribed were biguanides (74.60%). CONCLUSIONS: Coexistence of triple disease is not uncommon in the Indian population, with middle-aged patients diagnosed as pre-obese and obese being affected more commonly and receiving treatment for the same. The present study highlights that, though there are medications against the three chronic conditions, the rate of uncontrolled cases of hypertension, T2DM, and dyslipidemia remains high. Coexistence of triple disease increases the risk of cardiovascular and renal complications, which need to be closely monitored and effectively treated.

Effectiveness of Dapagliflozin as Add-On to Metformin with or without Other Oral Antidiabetic Drugs in Type 2 Diabetes Mellitus: A Multicentre, Retrospective, Real-World Database Study.

BACKGROUND: Real-world Indian studies evaluating effectiveness of dapagliflozin as an add-on to other oral antidiabetic drugs (OAD) in patients with type 2 diabetes mellitus (DM) are scarce. METHODS: An electronic medical record (EMR)-based, retrospective, multicentre study was conducted to evaluate the effectiveness of dapagliflozin as add-on therapy in adult patients with inadequately controlled DM on metformin with or without other OAD. Baseline characteristics (visit 1: metformin or metformin plus OAD treatment for at least 30 days) and treatment-related outcomes (visit 2: follow-up) considered between 60 and 140 days after adding/switching dapagliflozin [glycated haemoglobin (HbA1c), body mass index (BMI), systolic blood pressure (SBP) and diastolic blood pressure (DBP)] were analysed. RESULTS: A total of 3616 patients were screened from 478 centres. Most patients had received dapagliflozin (D) + metformin (M) + at least one other OAD [D + M + OAD, n = 2907 (80.4%), 408 followed-up with HbA1c reported], while 709 patients (19.6%, 138 followed-up with HbA1c reported) received dapagliflozin + metformin (D + M). Treatment with dapagliflozin as an add-on therapy resulted in significant change in HbA1c (-1.1 ± 1.44%; p < 0.05 for HbA1c subgroup ≥ 7.5%; -1.6 ± 1.41%; p < 0.05 for HbA1c subgroup ≥ 8%) at visit 2 compared with visit 1. Significant change in body weight (-1.4 ± 3.31 kg; p < 0.05 for HbA1c subgroup ≥ 7.5%; - 1.5 ± 3.22 kg; p < 0.05 for HbA1c subgroup ≥ 8%) was observed at visit 2. Similarly, a significant change in BMI was noted for the HbA1c subgroup ≥ 7.5% (-1.0 ± 8.38 kg/m2). However, the change in BMI in the HbA1c subgroup ≥ 8% was noted to be -1.4 ± 10.4 kg/m2, which was not statistically significant (p = 0.08). In the overall study population, significant change in the SBP (-4.5 ± 14.9 mmHg; p < 0.05 for HbA1c subgroup ≥ 7.5%; -4.5 ± 15.1 mmHg; p < 0.0001 for HbA1c subgroup ≥ 8%) was observed at visit 2 compared with visit 1. On identical lines, significant change in DBP (-1.5 ± 8.94 mmHg; p < 0.05 for HbA1c subgroup ≥ 7.5%; -1.4 ± 8.91 mmHg; p < 0.05 for HbA1c subgroup ≥ 8%) was noted. CONCLUSIONS: Dapagliflozin showed significant improvement in glycemic parameter, BMI and BP when added to metformin, with or without other OADs in a real-world scenario.

Brain Gene Co-Expression Network Analysis Identifies 22q13 Region Genes Associated with Autism, Intellectual Disability, Seizures, Language Impairment, and Hypotonia.

Phelan-McDermid syndrome (PMS) is a rare genetic neurodevelopmental disorder caused by 22q13 region deletions or SHANK3 gene variants. Deletions vary in size and can affect other genes in addition to SHANK3. PMS is characterized by autism spectrum disorder (ASD), intellectual disability (ID), developmental delays, seizures, speech delay, hypotonia, and minor dysmorphic features. It is challenging to determine individual gene contributions due to variability in deletion sizes and clinical features. We implemented a genomic data mining approach for identifying and prioritizing the candidate genes in the 22q13 region for five phenotypes: ASD, ID, seizures, language impairment, and hypotonia. Weighted gene co-expression networks were constructed using the BrainSpan transcriptome dataset of a human brain. Bioinformatic analyses of the co-expression modules allowed us to select specific candidate genes, including EP300, TCF20, RBX1, XPNPEP3, PMM1, SCO2, BRD1, and SHANK3, for the common neurological phenotypes of PMS. The findings help understand the disease mechanisms and may provide novel therapeutic targets for the precise treatment of PMS.

Race, Ethnicity, and Ancestry in Clinical Pathways: A Framework for Evaluation.

Clinical algorithms, or "pathways," promote the delivery of medical care that is consistent and equitable. Race, ethnicity, and/or ancestry terms are sometimes included in these types of guidelines, but it is unclear if this is appropriate for clinical decision-making. At our institution, we developed and applied a structured framework to determine whether race, ethnicity, or ancestry terms identified in our clinical pathways library should be retained, modified, or removed. First, we reviewed all text and associated reference documents for 132 institutionally-developed clinical pathways and identified 8 pathways that included race, ethnicity, or ancestry terms. Five pathways had clear evidence or a change in institutional policy that supported removal of the term. Multispecialty teams conducted additional in-depth evaluation of the 3 remaining pathways (Acute Viral Illness, Hyperbilirubinemia, and Weight Management) by applying the framework. In total, based on these reviews, race, ethnicity, or ancestry terms were removed (n = 6) or modified (n = 2) in all 8 pathways. Application of the framework established several recommended practices, including: (1) define race, ethnicity, and ancestry rigorously; (2) assess the most likely mechanisms underlying epidemiologic associations; (3) consider whether inclusion of the term is likely to mitigate or exacerbate existing inequities; and (4) exercise caution when applying population-level data to individual patient encounters. This process and framework may be useful to other institutional programs and national organizations in evaluating the inclusion of race, ethnicity, and ancestry in clinical guidelines.

Is sleep captured during a standard daytime EEG sufficient to diagnose Electrical Status Epilepticus in Sleep.

Electrical Status epilepticus of sleep (SES) is an EEG pattern where there is significant activation of epileptiform activity in NREM sleep. A spike wave index (SWI) of > 80-85% is often labelled as typical SES. We aimed to explore if sleep during a standard daytime-EEG, as compared an overnight-EEG, was adequate to diagnose ESES. Ten children with daytime and overnight studies suggestive of SES were audited. SWI and Spike Wave Density (SWD) were calculated for 5-minute epochs of wake in the daytime and overnight study, as well daytime-EEG sleep and first and last NREM cycle in the overnight-EEG. SWI in daytime NREM was not significantly different from SWI in the first sleep cycle of the overnight study. SWI in the last sleep cycle was significantly lower than the first sleep cycle in the overnight-EEG. SWD was significantly higher in the first sleep cycle in the overnight-EEG than the daytime sleep and the last NREM cycle. SES may be diagnosed in NREM sleep from a daytime-EEG study. Larger studies are needed to explore the significance of the disparity between SWI and SWD in the first and last NREM cycles in the overnight study.

Assessing the Agreement Between Preoperative Fine-Needle Aspiration Cytology (FNAC) Done for Major Salivary Gland Neoplasm When Reported by Head and Neck Pathologists and Non-head and Neck Pathologists with Its Final Histopathology.

The preoperative FNA is an important investigation in the workup of a salivary gland pathology. A preoperative diagnosis is important to plan management and counsel patients accordingly. In this study, we aimed to assess the agreement between the preoperative FNA and the final histopathology report when reported by a head and neck and a non-head and neck pathologist. All patients with major salivary gland neoplasm having undergone a preoperative FNA before surgery from January 2012 to December 2019 at our hospital were included in the study. Analysis was done to check for concordance between head and neck and non-head and neck pathologists of the preoperative FNA and final histopathology. Three hundred and twenty-five patients were included in the study. The preoperative FNA could identify the tumour as benign or malignant in the majority (n = 228, 70.1%). The agreement between the preoperative FNA, frozen section diagnosis and the reporting of grade in the frozen section and the final HPR was slightly better with the head and neck pathologist (kappa = 0.429, kappa = 0.698 and kappa = 0.257), respectively, than with the non-head and neck pathologist (kappa = 0.387, kappa = 0.519 and kappa = 0.158), all of which was statistically significant (p < 0.001). The diagnosis made with the preoperative FNA and reporting in the frozen section had a fair agreement with the final histopathology when reported by a head and neck pathologist in comparison to a non-head and neck pathologist.

A Mixed-Methods Assessment of Coronavirus Disease of 2019-Era Telehealth Acute Care Visits in the Medical Home.

OBJECTIVES: To compare acute care virtual visits with in-person visits with respect to equity of access, markers of quality and safety, and parent and provider experience, before and during the coronavirus disease 2019 pandemic. STUDY DESIGN: We compared patient demographics, antimicrobial prescribing rates, emergency department (ED) use, and patient-experience scores for virtual visits and in-person care at 2 academic pediatric primary care practices using χ2 testing and interrupted time series analyses. Parent and provider focus groups explored themes related to virtual visit experience and acceptability. RESULTS: We compared virtual acute care visits conducted in March 2020-February 2021 (n = 8868) with in-person acute care visits conducted in February 2019-March 2020 (n = 24 120) and March 2020-February 2021 (n = 6054). There were small differences in patient race/ethnicity across the different cohorts (P < .01). Virtual visits were associated with a 9.6% (-11.5%, -7.8%, P < .001) decrease in all antibiotic prescribing and a 13.2% (-22.1%, -4.4%, P < .01) decrease in antibiotic prescribing for acute respiratory tract infections. Unanticipated visits to the ED did not significantly differ among visit types. Patient experience scores were significantly greater (P < .05) for virtual acute care in overall rating of care and likelihood to recommend. Focus group themes included safety, distractibility, convenience, treatment, and technology. Providers were broadly accepting of virtual care while parental views were more mixed. CONCLUSIONS: Telehealth acute care visits may not have negative effects on quality and safety, as measured by antimicrobial prescribing and unanticipated ED visit rates. Efforts to increase parental acceptance and avoid creating disparities in access to virtual care will be essential to continued success of telehealth acute care visits.

Racial and ethnic disparities in pediatric magnetic resonance imaging missed care opportunities.

BACKGROUND: Imaging missed care opportunities (MCOs), previously referred to as "no shows," impact timely patient diagnosis and treatment and can exacerbate health care disparities. Understanding factors associated with imaging MCOs could help advance pediatric health equity. OBJECTIVE: To assess racial/ethnic differences in pediatric MR imaging MCOs and whether health system and socioeconomic factors, represented by a geography-based Social Vulnerability Index (SVI), influence racial/ethnic differences. MATERIALS AND METHODS: We conducted a retrospective analysis of MR imaging MCOs in patients younger than 21 years at a pediatric academic medical center (2015-2019). MR imaging MCOs were defined as: scheduled but appointment not attended, canceled within 24 h, and canceled but not rescheduled. Mixed effects multivariable logistic regression assessed the association between MCOs and race/ethnicity and community-level social factors, represented by the SVI. RESULTS: Of 68,809 scheduled MRIs, 6,159 (9.0%) were MCOs. A higher proportion of MCOs were among Black/African-American and Hispanic/Latino children. Multivariable analysis demonstrated increased odds of MCOs among Black/African-American (adjusted odds ratio [aOR] 1.9, 95% confidence interval [CI] 1.7-2.3) and Hispanic/Latino (aOR 1.5, 95% CI 1.3-1.7) children compared to White children. The addition of SVI >90th percentile to the adjusted model had no effect on adjusted OR for Black/African-American (aOR 1.9, 95% CI 1.7-2.2) or Hispanic/Latino (aOR 1.5, 95% CI 1.3-1.6) children. Living in a community with SVI >90th percentile was independently associated with MCOs. CONCLUSION: Black/African-American and Hispanic/Latino children were almost twice as likely to experience MCOs, even when controlling for factors associated with MCOs. Independent of race/ethnicity, higher SVI was significantly associated with MCOs. Our study supports that pediatric health care providers must continue to identify systemic barriers to health care access for Black/African-American and Hispanic/Latino children and those from socially vulnerable areas.

Myelin oligodendrocyte glycoprotein antibody-associated bilateral optic neuritis with unilateral prepapillary vitreous hemorrhage.

We present a case of bilateral myelin oligodendrocyte glycoprotein antibody optic neuritis (MOG-ON) with unilateral vitreous hemorrhage in a 6-year-old boy. Multidisciplinary team care, including extensive investigations and prolonged follow-up, excluded alternative causes of vitreous hemorrhage. Early suspicion and diagnosis of MOG-ON led to timely intravenous methylprednisolone treatment, with protracted oral steroid taper, resulting in complete resolution of optic nerve swelling, vitreous hemorrhage, and visual function.

Demographic Profile and Prescribing Patterns of Anti-epileptic Drugs in Indian Epilepsy Patients: Electronic Medical Record-Based Nation-Wide Retrospective Cohort Study.

The aim of this study was to provide real-world data on clinical characteristics, risk factors, and treatment patterns in Indian patients with epilepsy. Electronic medical record (EMR) data of patients diagnosed with epilepsy between January 2001 and December 2019, which included demographics, diagnosis, anti-epileptic drug usage, and underlying risk factors were evaluated. The majority of patients were between the age group of 18 and 55 years (n=3,186), with males accounting for 62% and the remaining 38% being females. Further, the most common comorbidity was hypertension (23.3%, n=1,470), followed by diabetes mellitus (10.8%, n=683) and depression (9.4%, n=597). The most prevalent form of epilepsy was focal epilepsy (n=5,141 81.4%), followed by generalized epilepsy (n=601). Focal epilepsy was most prevalent in males (62%, n=3,167) and most common in the age group of 18-55 years (50.3%, n=2588). Anti-epileptic drug (AED) usage data from 6,318 patients showed that the most commonly prescribed AED alone or in combination for both focal and generalized epilepsy was levetiracetam (41.8%, n= 2645). Data collected from this study are aligned but do not completely agree with the Guidelines for the Management of Epilepsy in India (GEMIND). This affirms treatment initiation with AED monotherapy; however, the treatment choices do not necessarily follow the recommended guidelines to select conventional AEDs, at low strengths, at initiation.

Hirayama disease: the importance of flexion imaging.

Hirayama disease is a rare cervical myelopathy characterised by asymmetrical upper limb weakness and muscle atrophy in the forearm and hand. MRI of the cervical spine plays an essential role in diagnosis, however, the characteristic findings are often only seen when the patient is imaged with the neck in flexion. We present a case of a 15-year-old male who presented with left forearm and hand weakness with muscle wasting. An MRI of the cervical spine with the neck in a neutral position demonstrated atrophy of the spinal cord with intrinsic signal abnormality between C5 and C7. Further imaging with the patient's neck in flexion demonstrated the hallmark features of Hirayama disease. There was anterior displacement of the thecal sac and spinal cord, and an enlarged, crescent-shaped dorsal epidural space which enhanced following i.v. gadolinium administration. The atrophic segment of cord contacted the posterior vertebral bodies when the neck was in full flexion. This case highlights the importance of imaging patients suspected of having this entity with the neck in full flexion in order to make a diagnosis.

Understanding Caregiver Perspectives on an Electronic Consultation and Referral System.

This study examined caregiver impressions of an electronic consultation and referral (ECR) system. Participants included 56 caregivers of primary care patients referred through the ECR system. Semistructured interviews and surveys were conducted between August 2018 and April 2019. Transcripts were coded and themes developed using thematic content analysis. A total of 51% of caregivers stated that they would prefer to see their child's primary care provider (PCP) for a specialty issue if they could receive the same quality of care. All caregivers who received an electronic consult (n = 28) said that they would utilize that process again. Three themes emerged: (1) caregivers expect immediate action prior to or instead of a specialty referral; (2) caregiver preferences for PCP versus specialist are mediated by both child and provider characteristics; (3) caregiver attitudes toward the ECR system are influenced by external considerations and experiences with the system. Results suggest caregivers value enhanced communication and immediate access to specialty input facilitated by the ECR system.

Tobacco and cancer awareness program among school children in rural areas of Ratnagiri district of Maharashtra state in India.

Background: Promoting awareness of tobacco and cancer in the community needs multipronged efforts. We performed a study to evaluate whether we could raise awareness about the harmful effects of tobacco, oral and esophageal cancer among school students by providing them health education. Moreover, we also compared the awareness level in students of age group 12 to ≤14 years with the age group >14 to 18 years. Methods: We conducted an awareness program in the schools of Ratnagiri district of Maharashtra state. Students aged 12-18 years participated in this study. We provided health education to school students using a standard presentation; the presentation was rich in illustrations depicting the harmful effects of tobacco as well as oral and esophageal cancer's signs, symptoms, diagnosis, treatment, and preventive measures. After the health talk, a questionnaire was circulated. The questions were focused on tobacco, signs, and symptoms of the diseases along with early detection, prevention, and treatment of cancer. Results: A total of 1354 students participated in the program. Totally, 567 (41.9%) students were from 6th to 8th grade (Group A, age group 12 to ≤14) and 787 (58.1%) students were from 9th to 12th standards (Group B, age group >14 to 18). Overall scores were high, ranging from 69% to 98%. Group A scored in the range of 69% to 95%, and Group B scored in the range 72%-98% The difference between the two groups was found to be statistically significant (P-value ≤0.05). Conclusion: A standardized health education program helped to raise awareness about the harmful effects of tobacco and cancer amongst school children. Further studies are needed to evaluate whether educating school children has an impact on community understanding of the disease.

Results of sequential swallowing assessments in patients undergoing upfront surgery for oral tongue squamous cell carcinoma.

BACKGROUND: The swallowing outcomes in patients undergoing glossectomy have been inconsistently reported in the literature owing to variable follow up times, different tools for assessment and lack of single institution large scale studies. The aim of our study was to assess the patterns of swallowing outcomes over time and identify factors affecting nasogastric tube dependency at 1-year post-surgery. MATERIALS AND METHODS: This was a retrospective study of treatment naïve patients with oral tongue carcinoma who underwent surgery and attended the speech and swallow clinic between January 2016 and December 2019 at our institute were included in the study. The findings of swallowing assessment by a speech language pathologist at three time points were recorded. RESULTS: A total of 606 patients were found eligible for the study. The median age of the patients was 50 years with the 211 (34.8%) patients having T3/T4 disease. The swallowing outcomes in terms of tube dependence and the spectrum of diet tolerance seem to improve over time with an increasing number of patients switching over to a solid diet by 1 year. A higher defect class (HR = 24.43 [3.48-171.27]) and presence of co-morbidities (HR = 4.17 [1.59-10.92]) were associated with sustained feeding tube dependency status at 1 year. A nomogram was developed based on these findings. CONCLUSION: The swallowing outcomes in terms of tube dependence and the spectrum of diet tolerance seem to improve over time. A higher defect class and presence of co-morbidities were associated with NGT dependency at 1 year.

Retrospective, Observational Study to Determine the Choice of Antihypertensive agent According to Stage of Hypertension, Risk factors and Co-morbidities in Real World Setting in India: A Report of Baseline Data.

BACKGROUND: The present study intended to estimate the comorbidities and risk factors among patients with hypertension in India. Further, the current practice of hypertension management was evaluated and the choice of therapy was assessed based on hypertension grade, risk factors, and comorbidities. METHODS: Electronic medical record data (June 2017-June 2019) of Indian adult hypertensive patients (≥140/90 mmHg) who had two blood pressure (BP) readings were retrospectively analyzed. Demographic characteristics, BP readings, comorbidities, medications and co-medications, and laboratory data were collected at baseline. Grids based on hypertension grade (I, II, and III), demographic factors, risk factors, and comorbidities were created and prescribed antihypertensive drugs (AHDs) in each grid were evaluated. RESULTS: Among 100,075 patients, the proportion of patients in 18-40 year, 40-65 year, and >65 year age groups were 11.4%, 65.1%, and 23.4%, respectively. Proportion of men and women was similar (52.0% vs 47.9%). Proportion of patients with BMI <25 Kg/m2 was 8.1%, 25-29.9 Kg/m2 was 11.9%, and >30 Kg/m2 was 8.8%. Mean BP of patients with hypertension was: grade I (145.05/90.73 mmHg), grade II (160.07/95.64 mmHg), and grade III (180.82/102.76 mmHg). Mean low density lipoprotein (113.26 mg/dL), serum creatinine (2.28 mg/dL), mean HbA1c (8.7%) levels were highest among patients with grade III hypertension. Commonly observed comorbidities were type 2 diabetes mellitus (T2DM: 51.5%), dyslipidemia (36.4%), and chronic kidney disease (CKD: 4.4%). Top concomitant medications included anti-diabetic therapies (34.6%), drugs for dyslipidemia (30.0%), and anti-platelet therapies (6.9%). CONCLUSION: Most prescribed AHD monotherapies were angiotensin receptor II blockers (ARBs) and calcium channel blockers (CCBs) and most prescribed combination therapies were ARBs + diuretics and ARBs + CCBs. Telmisartan and amlodipine+telmisartan for patients with comorbid T2DM or dyslipidemia and metoprolol for those with coronary artery disease were the commonly prescribed AHDs.