A Cost-Effective Novel Surgical Technique of Core Decompression with Bone Marrow Aspiration Concentrate: A Preliminary Cadaveric Study.

Introduction: Core decompression supplemented by stem cell incorporation is an upcoming field of research in avascular necrosis of the femoral head. Plugging the canal to avoid loss of the concentrate injected has been recognized as a crucial step to improve the efficacy of the procedure. We describe a new surgical technique that results in native bone plug formation and eliminates the need for any additional blocker. Methodology: This pilot study was performed on 4 cadaveric proximal femurs. The standard technique was used for core decompression and bone marrow aspirate concentrate (BMAC) injection. Additionally, two more tracts were drilled, superolateral, and inferomedial to the primary tract. Results: No leakage of the radiopaque dye was observed from the entry point of the primary tract, ensuring its complete blockage in all 4 cadaveric proximal femurs. This was confirmed by sectioning the femur specimens which manifested bone plug formation at the confluence of the three tracts. Conclusion: Our technique is a unique and economical method of preventing leakage of BMAC through the entry point in the proximal femoral metaphysis. This may not only benefit patients but can also provide the groundwork for further research in this field.

Assessment and reliability of the World Health Organisation quality of life (WHO QOL-BREF) questionnaire in total hip replacement patients.

BACKGROUND: Several functional scoring tools are available to evaluate the outcomes of total hip replacements (THRs) for diseased or damaged hips. Majority of these scores were devised in western countries and their cross-cultural compatibilities are rarely demonstrated. The World Health Organisation quality of life (WHO QOL-BREF) questionnaire with 4 domains, is one of the best known multilingual instruments for such assessment. Its reliability has never been demonstrated for THRs and the present study was conceptualised for the same. METHODS: THRs done over 6 years were followed up retrospectively. Revision THRs and hemiarthroplasties were excluded. All the cases were done by a single senior arthroplasty surgeon. Clinical examination was done and questionnaires for WHO QOL-BREF and Harris Hip scores were given to the patients. RESULTS: The number of patients included in the study was 96 with 115 operated hips. The average age of these patients was 41.40 years ranging from 17 to 80 years. There was strong male preponderance in our series of patients with 90 THRs. The mean score of domain 1 was 70.8 (SD 21.6), domain 2: 72.4 (SD 18.8), domain 3: 74.7 (SD 16.8) and domain 4: 75.4 (SD 14.8); showed significant functional improvement post THR in domain 2 (P = 0.0001), domain 3 (P = 0.0010) and domain 4(P = 0.0001), when compared to scores of general healthy population. Similarly, the scores were significantly improved in all domains as compared to cohorts of post-operative acetabular and hip fractures. The score was found to be a reliable tool with Cronbach's alpha of 0.912 and strong correlation was present with the standard Harris hip scores (p = 0.000). CONCLUSION: WHO QOL-BREF is a potent tool to assess the quality of life in patients undergoing THRs. It can be used as a single index of measurement and it is simple, reproducible and reliable.

Out-of-pocket expenditure and catastrophic health expenditure for hospitalization due to injuries in public sector hospitals in North India.

BACKGROUND: Injuries are a major public health problem, resulting in high health care demand and economic burden. They result in loss of disability adjusted life years (DALYs) and high out-of-pocket expenditure. However, there is little evidence on the economic burden of injuries in India. We undertook this study to report out-of-pocket expenditure and the prevalence of catastrophic health expenditure for injuries related hospitalizations in public sector hospitals in North India. Further, we also evaluate the determinants of catastrophic health expenditure. METHODS AND ANALYSIS: A prospective observational study was conducted. Participants were recruited from three hospitals for all injury cases. Data were collected via face-to-face baseline interviews and follow-up interviews over the phone at 1, 2, 4 and 12 months post-injury. Prevalence of catastrophic health expenditure (more than 30% of consumption expenditure) and impoverishment (International dollar 1.90) were estimated. RESULTS: Road traffic injuries (57%) were the leading cause of injury. Direct out-of-pocket expenditure for hospitalizations was INR 16,768 (USD 263) while indirect productivity loss was INR 8,164 (USD 128). The prevalence of catastrophic expenditure was 22.2% with 12.2% slipping below poverty line. Prevalence of catastrophic health expenditure and impoverishment was higher and significantly associated with poorest quintile, tertiary care hospital and increased duration of hospitalization (p< 0.001). CONCLUSION: The economic impact of injuries is notably high both in terms of out-of-pocket expenditure and productivity loss. A high proportion of households experienced catastrophic expenditure and impoverishment following an injury, highlighting need for programs to prevent injuries.

Epidemiology of pelvic fractures in adults: Our experience at a tertiary hospital.

PURPOSE: Pelvic fractures are severe injuries and are often associated with multiple system injuries, exacerbating the overall outcome. In India, the incidence of pelvic fractures is on a rise due to suboptimal roads and traffics but related literature regarding the overall epidemiology of these injuries is scarce and scanty. Our aim was to study the epidemiology of patients admitted with pelvic fractures at a level 1 trauma centre in India. METHODS: A 16-month (between September 2015 and December 2016) prospective observational study was carried out on trauma patients with pelvic fractures at a level 1 trauma centre of a tertiary care hospital. Demography of patients, mechanism of injuries and complications were recorded prospectively. RESULTS: We observed 75 patients who presented with pelvic fractures, where 56 were males and 19 were females. Mean age of the study population was 37.57 years. Road traffic accidents were the most common mode of injuries. Lateral compression injuries were the most common pattern. Associated injuries frequently encountered were lower extremities and acetabulum fractures, blunt abdominal trauma, urogenital injuries and head injuries. Out of the 75 patients, 52 were treated surgically and 23 were managed by conservative methods. Associated injuries of the extremities, head, abdomen and urogenital system indicated a longer hospital stay. CONCLUSION: Pelvic fractures, although belong to a relatively rare trauma subset, cause a high morbidity and mortality with considerable burden on the economy. Proper road safety training and driving etiquettes along with its strict implementation in true sense and spirit are the need of the hour.

Cost of Trauma Care in Secondary- and Tertiary-Care Public Sector Hospitals in North India.

BACKGROUND: Several initiatives to provide trauma care, including ambulance services, creation of a network of trauma hospitals and insurance schemes for cashless treatment, are currently being implemented in India. However, lack of information on the cost of trauma care is an impediment to the evidence-based planning for such initiatives. In this study, we aim to bridge this gap in evidence by estimating the unit cost of an outpatient consultation, inpatient bed-day of hospitalization, surgical procedure and diagnostics for providing trauma care through secondary- and tertiary-level hospitals in India. METHODS: We undertook an economic costing of trauma care in a secondary-care district hospital and a tertiary-level teaching and research hospital in North India. Cost analysis was undertaken using a health system perspective, employing a bottom-up costing methodology. Data on all resources-capital or recurrent-on delivery of trauma care during the period of April 2014 to March 2015 were collected. Standardized unit costs were estimated after adjusting for bed occupancy rates. Sensitivity analysis was performed to account for the uncertainties due to differences in prices and other assumptions. RESULTS: The cost of trauma care in the tertiary care hospital was INR 9585 (US$147.4) per day-care consultation; INR 2470 (US$37.7) per bed-day hospitalization (excluding ICU), INR 12,905 (US$198.5) per bed day in ICU and INR 21,499 (US$330.8) per surgery. Similarly, in the secondary-care hospital, the cost of trauma care was INR 482 (US$7.4) per outpatient consultation, INR 791 (US$12.2) per bed day of hospitalization, INR 186 (US$2.9) per minor surgery and INR 6505 (US$100.1) per major surgery. CONCLUSION: The estimates generated can be used for planning and managing trauma care services in India. The findings may also be used for undertaking future research in estimating the cost effectiveness of trauma care services or models of care.

Establishing Evidence-Based Indications for Proton Therapy: An Overview of Current Clinical Trials.

PURPOSE: To review and assess ongoing proton beam therapy (PBT) clinical trials and to identify major gaps. METHODS AND MATERIALS: Active PBT clinical trials were identified from clinicaltrials.gov and the World Health Organization International Clinical Trials Platform Registry. Data on clinical trial disease site, age group, projected patient enrollment, expected start and end dates, study type, and funding source were extracted. RESULTS: A total of 122 active PBT clinical trials were identified, with target enrollment of >42,000 patients worldwide. Ninety-six trials (79%), with a median planned sample size of 68, were classified as interventional studies. Observational studies accounted for 21% of trials but 71% (n=29,852) of planned patient enrollment. The most common PBT clinical trials focus on gastrointestinal tract tumors (21%, n=26), tumors of the central nervous system (15%, n=18), and prostate cancer (12%, n=15). Five active studies (lung, esophagus, head and neck, prostate, breast) will randomize patients between protons and photons, and 3 will randomize patients between protons and carbon ion therapy. CONCLUSIONS: The PBT clinical trial portfolio is expanding rapidly. Although the majority of ongoing studies are interventional, the majority of patients will be accrued to observational studies. Future efforts should focus on strategies to encourage optimal patient enrollment and retention, with an emphasis on randomized, controlled trials, which will require support from third-party payers. Results of ongoing PBT studies should be evaluated in terms of comparative effectiveness, as well as incremental effectiveness and value offered by PBT in comparison with conventional radiation modalities.

Economic Burden of Hospitalization Due to Injuries in North India: A Cohort Study.

There is little documentation of the potential catastrophic effects of injuries on families due to out of pocket (OOP) expenditure for medical care. Patients who were admitted for at least one night in a tertiary care hospital of Chandigarh city due to injury were recruited and were followed-up at 1, 2 and 12 months after discharge to collect information on OOP expenditure. Out of the total 227 patients, 60% (137/227) had sustained road traffic injuries (RTI). The average OOP expenditure per hospitalisation and up to 12 months post discharge was USD 388 (95% CI: 332-441) and USD 1046 (95% CI: 871-1221) respectively. Mean OOP expenditure for RTI and non-RTI cases during hospitalisation was USD 400 (95% CI: 344-456) and USD 369 (95% CI: 313-425) respectively. The prevalence of catastrophic expenditure was 30%, and was significantly higher among those belonging to the lowest income quartile (OR-26.50, 95% CI: 6.70-105.07, p-value: <0.01) and with an inpatient stay greater than 7 days (OR-10.60, 95% CI: 4.21-26.64, p-value: <0.01). High OOP expenditure for treatment of injury puts a significant economic burden on families. Measures aimed at increasing public health spending for prevention of injury and providing financial risk protection are urgently required in India.

Estimation of the economic burden of injury in north India: a prospective cohort study.

BACKGROUND: Injuries are a serious cause of mortality and morbidity worldwide, with trauma being the leading cause of death in the first four decades of life. By contrast with the declining rates of injury seen in high-income countries, low-income and middle-income countries (LMICs) are experiencing an increase in injury rates, largely due to increased motorisation in these countries. In this study, we report the out-of-pocket expenditure and financial risk protection from trauma care in a tertiary care hospital of India. METHODS: Patients who were admitted for at least one night in a tertiary care hospital of Chandigarh during a 1 month period from April 15, 2013, and May 15, 2013, were recruited. Data were collected for the type of injury, out-of-pocket expenditure, and mechanisms undertaken to cope up with the expenditure. Cases were followed up at 1 month, 2 months, and 12 months after discharge to collect information about out-of-pocket expenditure. Prevalence of catastrophic expenditure-ie, if it exceeded 30% of the patient's annual household income-and distress financing-ie, if borrowing (with or without interest) or selling of assets was used to cope with high out-of-pocket expenditure, were assessed among patients recruited. Assuming prevalence of catastrophic expenditure to be 22%, with a precision of 5·5% and 5% alpha error, the sample size was estimated to be 218. FINDINGS: 227 patients were recruited, of whom 155 (68%) were followed up until 12 months. No significant differences were noted based on sociodemographic, injury, and hospitalisation characteristics between the patients who were followed up and those who were lost to follow-up. Average out-of-pocket expenditure per admission to hospital was US$388 (95% CI 332-441) and at 12 months after injury was US$1046 (871-1221). Mean out-of-pocket expenditure for road traffic injury cases at the time of hospitalisation was US$400 (95% CI 344-456) and for non-road traffic injury cases was US$369 (313-425). The prevalence of catastrophic expenditure was 30% (95% CI 26·95-33·05), which was significantly associated with lower income quartile (OR 23·3 [95% CI 5·7-93·9]; p <0·01), inpatient stay greater than 7 days (OR 8·8 [95% CI 3·8-20·6); p<0·01), major surgery (OR 4·9 [95% CI 2·2-10·8]; p<0·01), and occupation as wage labourers (OR 8·1 [95% CI 1·6-39·9]; p=0·01). INTERPRETATION: High private out-of-pocket expenditure for treatment of injury poses major economic burden on families. Measures aimed to increase public health spending for prevention of injury and to provide financial risk protection to those injured deserve urgent priority in India. FUNDING: The George Institute for Global Health, India.