Cost-Conscious Colposcopy: A Single-Institution Review of Biopsy Submission Practices and Outcomes.

OBJECTIVE: Distribution of cervical dysplasia may influence approach for excisional procedures. Separating colposcopy biopsies into multiple specimen cups for pathologic evaluation incurs additional costs. The authors aimed to determine whether the practice of separating biopsy specimens impacts patient outcomes. METHODS: A retrospective review of all colposcopy cases from a single institution was performed. A total of 1,331 cases were reviewed from January 1, 2017, to December 31, 2019. Multibiopsy cohorts were separated by number of specimen cups received by pathology (single or multiple). Cohorts were compared for histology, need for excisional procedure, and final excisional pathology results. Specimen processing fees were acquired from the Department of Pathology ($70/specimen). Statistical analysis performed on MINITAB using Pearson chi-square and Fisher exact tests. RESULTS: Excisional procedures were required by 30.4% (86/283) of multiple specimen submissions compared with 28.2% (154/547) of single specimen cup submissions ( p = .50). There was a higher, although not statistically significant, rate of additional procedures in the multiple specimen cup cohort (8.8 vs 2.9% [ p = .08]). Malignancy diagnosis was equivalent in each cohort. Cost analysis revealed adopting a single specimen cup model would reduce costs up to approximately $30,000/year. CONCLUSIONS: Patient outcomes were not improved by the practice of submitting multiple specimen cups. Given the additional cost associated with separating specimens, the authors recommend during routine colposcopy that all cervical biopsies be sent for evaluation as a single pathology specimen unless a lesion of concern is identified in an area not normally excised during traditional excisional procedures.

A 30-year analysis of National Institutes of Health-funded cardiac transplantation research: Surgeons lead the way.

OBJECTIVES: Obtaining National Institutes of Health funding for heart transplant research is becoming increasingly difficult, especially for surgeons. We sought to determine the impact of National Institutes of Health-funded cardiac transplantation research over the past 30 years. METHODS: National Institutes of Health Research Portfolio Online Reporting Tools Expenditures and Results was queried for R01s using 10 heart transplant-related terms. Principal Investigator, total grant funding amount, number of publications, and citations of manuscripts were collected. A citation-based Grant Impact Metric was assigned to each grant: sum of citations for each manuscript normalized by the funding of the respective grant (per $100K). The department and background degree(s) (MD, PhD, MD/PhD) for each funded Principal Investigator were identified from institutional faculty profiles. RESULTS: A total of 321 cardiac transplantation R01s totaling $723 million and resulting in 6513 publications were analyzed. Surgery departments received more grants and more funding dollars to study cardiac transplantation than any other department (n = 115, $249 million; Medicine: n = 93, $208 million; Pathology: 26, $55 million). Surgeons performed equally well compared with all other Principal Investigators with respect to Grant Impact Metric (15.1 vs 20.6; P = .19) and publications per $1 million (7.5 vs 6.8; P = .75). Finally, all physician-scientists (MDs) have a significantly higher Grant Impact Metric compared with nonclinician researchers (non-MDs) (22.3 vs 16.3; P = .028). CONCLUSIONS: Surgeon-scientists are equally productive and impactful compared with nonsurgeons despite decreasing funding rates at the National Institutes of Health and greater pressure from administrators to increase clinical productivity.

Comprehensive National Institutes of Health funding analysis of academic cardiac surgeons.

OBJECTIVE: To determine trends in National Institutes of Health (NIH) funding for cardiac surgeons, hypothesizing they are at a disadvantage in obtaining funding owing to intensive clinical demands. METHODS: Cardiac surgeons (adult/congenital) currently at the top 141 NIH-funded institutions were identified using institutional websites. The NIH funding history for each cardiac surgeon was queried using the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER). Total grant funding, publications, and type was collected. Academic rank, secondary degrees, and fellowship information was collected from faculty pages. Grant productivity was calculated using a validated grant impact metric. RESULTS: A total of 818 academic cardiac surgeons were identified, of whom 144 obtained 293 NIH grants totaling $458 million and resulting in 6694 publications. We identified strong associations between an institution's overall NIH funding rank and the number of cardiac surgeons, NIH grants to cardiac surgeons, and amount of NIH funding to cardiac surgeons (P < .0001 for all). The majority of NIH funding to cardiac surgeons is concentrated in the top quartile of institutions. Cardiac surgeons had a high conversion rates from K awards (mentored development awards) to R01s (6 of 14; 42.9%). Finally, we demonstrate that the rate of all NIH grants awarded to cardiac surgeons has increased, driven primarily by P and U (collaborative project) grants. CONCLUSIONS: NIH-funded cardiac surgical research has had a significant impact over the last 3 decades. Aspiring cardiac surgeon-scientists may be more successful at top quartile institutions owing to better infrastructure and mentorship.

Objectively-measured physical activity patterns and longitudinal weight category status in a rural setting.

OBJECTIVES: To investigate the relationship between longitudinal weight-change and objectively-measured physical activity (PA) in a rural African setting in 143 adults (≥ 30 years), using data from two cross-sectional surveys, separated by approximately 10 years. Participants were categorised into three weight-change groups (Weight-loss: ≥ 25 kg m-2→ < 25 kg m-2; Weight-gain: < 25 kg m-2→ ≥ 25 kg m-2; Weight-stability: remained < 25 kg m-2 or ≥ 25 kg m-2). Daily ambulation and activity energy expenditure (AEE), measured in the 2005-2007 health survey, was examined across the weight-change groups. Using the daily AEE data, the proportion of those in the weight-change groups, meeting or not meeting two PA guidelines (150- and 420 min week-1), was examined. RESULTS: Weight-change was found in 18.2% of the sample. There was no significant overall body mass change (+ 1.2 kg, p = 0.1616). However, there was significant change in body mass in the weight-gain (+ 15.2 kg) and weight-loss (- 10.8 kg) groups (p ≤ 0.0011). Nearly 90% of those who gained weight met the 150 min week-1 guideline. A significantly greater proportion of the weight-stable group (< 25 kg m-2) met the 420 min week-1 guideline (p < 0.05). Ambulatory level was high irrespective of weight group, although the weight-stable group (< 25 kg m-2) approached 15,000 steps day-1. There was an inconsistent and weak association between PA and weight-change in this group.

Deriving objectively-measured sedentary indices from free-living accelerometry data in rural and urban African settings: a cost effective approach.

OBJECTIVES: To investigate the agreement between two data reduction approaches for detecting sedentary breaks from uni-axial accelerometry data collected in human participants. Free-living, uni-axial accelerometer data (n = 318) were examined for sedentary breaks using two different methods (Healy-Matthews; MAH/UFFE). The data were cleaned and reduced using MAH/UFFE Analyzer software and custom Microsoft Excel macro's, such that the average daily sedentary break number were calculated for each data record, for both methods. RESULTS: The Healy-Matthews and MAH/UFFE average daily break number correlated closely (R2 = 99.9%) and there was high agreement (mean difference: + 0.7 breaks/day; 95% limits of agreement: - 0.06 to + 1.4 breaks/day). A slight bias of approximately + 1 break/day for the MAH/UFFE Analyzer was evident for both the regression and agreement analyses. At a group level there were no statistically or practically significant differences within sample groups between the two methods.

Determinants of body mass index by gender in the Dikgale Health and Demographic Surveillance System site, South Africa.

BACKGROUND: The study was conducted in the Dikgale Health and Demographic Surveillance System (DHDSS) site where we have observed increasing obesity levels, particularly in women, despite evidence of high physical activity (PA) and a relatively low daily energy intake. OBJECTIVE: This study aimed to assess the socio-demographic, behavioural and biological determinants of body mass index (BMI) in adult residents permanently residing in the DHDSS. METHODS: A cross-sectional study was conducted in which socio-demographic, behavioural and biological characteristics from 1143 participants (aged 40-60 years) were collected using a paper questionnaire and standard anthropometric measures. Human immunodeficiency virus (HIV) testing was performed on all participants except those who indicated that they had tested positive. Chi-square and Mann-Whitney tests were used to analyze categorical and continuous variables, respectively, while hierarchical multivariate regression was used to analyze predictors of BMI. RESULTS: The median age of women and men was 51 (46-56) and 50 (45-55) years, respectively. The prevalence of overweight-obesity was 76% in women and 21% in men. A significant negative association of BMI with HIV and smoking and a significant positive association with socio-economic status (SES) was observed in both sexes. In women, BMI was negatively associated with sleep duration (p = 0.015) and age (p = 0.012), but positively associated with sugar-sweetened beverages (SSBs) (p = 0.08). In men, BMI was negatively associated with alcohol use (p = 0.016) and positively associated with being married (p < 0.001). PA was not associated with BMI in either sexes. Full models explained 9.2% and 20% of the variance in BMI in women and men, respectively. CONCLUSION: BMI in DHDSS adults is not associated with physical inactivity but is associated wealth, marital status, sleep, smoking, alcohol use, and HIV status. Future studies should explore the contribution of nutrition, stunting, psycho-social and genetic factors to overweight and obesity in DHDSS.

Prospective evaluation of patient reported swallow function with the Functional Assessment of Cancer Therapy (FACT), MD Anderson Dysphagia Inventory (MDADI) and the Sydney Swallow Questionnaire (SSQ) in head and neck cancer patients.

OBJECTIVES: The Functional Assessment of Cancer Therapy (FACT) instrument is comprised of a group of related and overlapping quality of life (QoL) questionnaires including a core general form, head and neck cancer (HNC)-specific items, and an expert-selected index (FACT-HNSI). Understanding how these relate to more HNC-specific instruments such as the MD Anderson Dysphagia Inventory (MDADI) and Sydney Swallow Questionnaire (SSQ) is vital for guiding their use in clinical trials. MATERIALS AND METHODS: HNC patients concurrently completed MDADI, SSQ, and FACT questionnaires at radiation oncology clinic visits (2015-2016). Spearman correlation coefficients were calculated between each FACT instrument and MDADI or SSQ. Unsupervised k-means cluster analyses were performed to identify clusters of similar QoL responses. Principal component analysis (PCA) identified the degree of variability explained by each instrument. RESULTS: We identified 631 instances (363 patients) where the questionnaires were completed concurrently. Correlations between the various FACT measures and SSQ or MDADI were all significant (p < 0.001), but FACT HNC-specific subscale and FACT-HNSI showed the strongest correlation with MDADI and SSQ. Clustering identified 3 distinct groups of responses when combining instruments either pairwise or three-way. PCA revealed that MDADI and FACT HNC-specific subscale provide similar and likely redundant information. CONCLUSION: FACT HNC-subscale and FACT-HNSI may be preferable over other FACT measures for use in clinical trials where patient-reported swallow function is evaluated. MDADI and FACT provide similar insights into HNC patient QoL while SSQ provides additional, complementary information which could serve to better stratify patients into groups with high, medium, and low QoL outcomes.

Compliance with physical activity guidelines in rural, black South Africans in the Limpopo Province: an energy expenditure approach.

OBJECTIVE: The authors used an energy expenditure-based approach to determine the non-compliance and compliance with public health physical activity (PA) guidelines in rural, black South Africans. METHODS: The authors analysed 7-day objectively measured PA data (NL-2000 pedometer) in 508 females and 267 males. Compliance was defined for the American College of Sports Medicine guideline (ACSM: ≥7.5 to <21 kcal/kg/week and ≥1.5 kcal/kg/day for ≥5 days/week) and the Institute of Medicine guideline (IOM: ≥21 kcal/kg/week and ≥3 kcal/kg/day for 7 days/week). RESULTS: The age- and sex-adjusted prevalence for non-compliance, ACSM compliance and IOM compliance in the sample was 7.8%, 55.0% and 37.2%, respectively. Complying with IOM guidelines required substantially more ambulation (14 522 steps/day) than ACSM guidelines (10 837 steps/day) and non-compliance (6420 steps/day) (p<0.0001). Approximately 95% of IOM-compliant subjects and 51% of ACSM-compliant subjects achieved ≥10 000 steps/day on 4-7 days. Compliance with IOM or ACSM guideline was associated with an 87% (p<0.0001) and a 49% (p=0.0647) reduced risk of obesity, respectively. Partial and full IOM compliance was associated with a significantly reduced risk of obesity (OR=0.58 to 0.16, p<0.04). CONCLUSIONS: The 10 000 steps/day guideline concurs with the ACSM guideline, whereas IOM compliance required higher ambulation levels. Compared with ACSM compliance, IOM compliance was associated with a lower risk of obesity.

Health-related quality of life in depression: a STAR*D report.

BACKGROUND: Although major depressive disorder (MDD) is associated with significant impairments in health-related quality of life (HRQOL), few studies have evaluated HRQOL dysfunction in multiple domains. This report examined the psychological, physical, and social domains in a large sample of outpatients who entered the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. METHODS: The relationship of HRQOL and baseline sociodemographic and clinical features, including depressive severity, was evaluated. We assessed HRQOL with the 12-item Short Form Health Survey, the 5-item Work and Social Adjustment Scale, and the 16-item Quality of Life Enjoyment and Satisfaction Questionnaire. RESULTS: Among 2307 participants, greater depressive symptom severity was associated with poorer HRQOL. After controlling for age and depression severity, lower HRQOL was related independently to being African American or Hispanic, less educated, unemployed, divorced or separated, having public medical insurance, and to having more general medical disorders. We found impairments across all 3 domains, with low correlations between the 3 measures of HRQOL chosen, suggesting that they evaluate different and nonoverlapping aspects of function. CONCLUSION: Sociodemographically disadvantaged patients with greater general medical and depressive illness burden are at greatest risk for poorer quality of life. Distinct impairments are seen in the 3 domains of HRQOL.

A new paradigm for the prediction of antidepressant treatment response.

Current treatment of Major Depressive Disorder utilizes a trial-and-error sequential treatment strategy that results in delays in achieving response and remission for a majority of patients. Protracted ineffective treatment prolongs patient suffering and increases health care costs. In addition, long and unsuccessful antidepressant trials may diminish patient expectations, reinforce negative cognitions, and condition patients not to respond during subsequent antidepressant trials, thus contributing to further treatment resistance. For these reasons, it is critical to identify reliable predictors of antidepressant treatment response that can be used to shorten or eliminate lengthy and ineffective trials. Research on possible endophenotypic as well as genomic predictors has not yet yielded reliable predictors. The most reliable predictors identified thus far are symptomatic and physiologic characteristics of patients that emerge early in the course of treatment. We propose here the term "response endophenotypes" (REs) to describe this class of predictors, defined as latent measurable symptomatic or neurobiologic responses of individual patients that emerge early in the course of treatment, and which carry strong predictive power for individual patient outcomes. Use of REs constitutes a new paradigm in which medication treatment trials that are likely to be ineffective could be stopped within 1 to 2 weeks and other medication more likely to be effective could be started. Data presented here suggest that early changes in symptoms, quantitative electroencephalography, and gene expression could be used to construct effective REs. We posit that this new paradigm could lead to earlier recovery from depressive illness and ultimately produce profound health and economic benefits.

All-cause mortality trends in Dikgale, rural South Africa, 1996-2003.

AIMS: The Dikgale Demographic Surveillance System (DDSS) site, established in 1995, is one of three rural surveillance sites in South Africa. This paper describes detailed mortality patterns of a rural African population in the central region of Limpopo Province. METHODS: These data were based on yearly household visits to collect data on vital events, covering 63, 873 person-years of observation over eight years. RESULTS: Crude mortality was 7.5 per 1,000 person-years (females: 6.9, males: 8.1). Under-1 year and under-5 years mortality was 15.1 and 5.8 per 1,000 person-years, respectively. Life expectancy at birth was 64.3 years (females: 68.1, males: 60.0). For the two four-year periods (1996-9 and 2000-3) under-20 years mortality risk decreased (rate ratio=0.45, 95% CI: 0.25 to 0.80) while 20-49 years mortality risk increased (rate ratio=1.55, 95% CI: 1.10 to 2.20). Multivariate mortality risk for migrants remained relatively constant (0.71, 95% CI: 0.54 to 0.94) across the two four-year periods, but has increased 2.5-fold in all DDSS +50 year-old adults across the two four-year periods. CONCLUSIONS: The DDSS mortality estimates appear to have remained relatively constant while recent mortality estimates for the Agincourt Demographic and Health Surveillance System (ADHSS) site suggest that mortality risk is higher and life expectancy is lower in ADHSS residents. Moreover, DDSS mortality estimates are substantially more favourable compared with provincial and national mortality estimates.

Health in China and India: a cross-country comparison in a context of rapid globalisation.

China and India are similarly huge nations currently experiencing rapid economic growth, urbanisation and widening inequalities between rich and poor. They are dissimilar in terms of their political regimes, policies for population growth and ethnic composition and heterogeneity. This review compares health and health care in China and India within the framework of the epidemiological transition model and against the backdrop of globalisation. We identify similarities and differences in health situation. In general, for both countries, infectious diseases of the past sit alongside emerging infectious diseases and chronic illnesses associated with ageing societies, although the burden of infectious diseases is much higher in India. Whilst globalisation contributes to widening inequalities in health and health care in both countries--particularly with respect to increasing disparities between urban and rural areas and between rich and poor--there is evidence that local circumstances are important, especially with respect to the structure and financing of health care and the implementation of health policy. For example, India has huge problems providing even rudimentary health care to its large population of urban slum dwellers whilst China is struggling to re-establish universal rural health insurance. In terms of funding access to health care, the Chinese state has traditionally supported most costs, whereas private insurance has always played a major role in India, although recent changes in China have seen the burgeoning of private health care payments. China has, arguably, had more success than India in improving population health, although recent reforms have severely impacted upon the ability of the Chinese health care system to operate effectively. Both countries are experiencing a decline in the amount of government funding for health care and this is a major issue that must be addressed.

Exploring China's rural health crisis: processes and policy implications.

China today is experiencing a rural health crisis, one that has uncomfortable echoes of the past. Within China's 'second society' of the peasantry, a resurgence of historical health problems (including vulnerability of the rural poor to epidemics such as schistosomiasis and tuberculosis and high rates of infant and maternal mortality) merge with contemporary concerns over HIV/AIDS, respiratory problems and the threat of Avian Flu to seriously threaten the health and welfare of people in rural areas. This review illustrates and explores the roots of this crisis in terms of key processes of social and environmental change and state health care policy. We argue that this crisis can only be resolved via a fundamental rethink of health provision across China, one that focuses especially on the poorest, most remote parts of the nation (both spatially and socially), and in which the privatisation of health care is more evenly balanced by increased state investment in basic health provision.

Assessment of intraluminal impedance for the detection of pharyngeal bolus flow during swallowing in healthy adults.

Intraluminal impedance, a nonradiological method for assessing bolus flow within the gut, may be suitable for investigating pharyngeal disorders. This study evaluated an impedance technique for the detection of pharyngeal bolus flow during swallowing. Patterns of pharyngoesophageal pressure and impedance were simultaneously recorded with videofluoroscopy in 10 healthy volunteers during swallowing of liquid, semisolid, and solid boluses. The timing of bolus head and tail passage recorded by fluoroscopy was correlated with the timing of impedance drop and recovery at each recording site. Bolus swallowing produced a drop in impedance from baseline followed by a recovery to at least 50% of baseline. The timing of the pharyngeal and esophageal impedance drop correlated with the timing of the arrival of the bolus head. In the pharynx, the timing of impedance recovery was delayed relative to the timing of clearance of the bolus tail. In contrast, in the upper esophageal sphincter (UES) and proximal esophagus, the timing of impedance recovery correlated well with the timing of clearance of the bolus tail. Impedance-based estimates of pharyngoesophageal bolus clearance time correlated with true pharyngoesophageal bolus clearance time. Patterns of intraluminal impedance recorded in the pharynx during bolus swallowing are therefore more complex than those in the esophagus. During swallowing, mucosal contact between the tongue base and posterior pharyngeal wall prolongs the duration of pharyngeal impedance drop, leading to overestimation of bolus tail timing. Therefore, we conclude that intraluminal impedance measurement does not accurately reflect the bolus transit in the pharynx but does accurately reflect bolus transit across the UES and below.

Changing health in China: re-evaluating the epidemiological transition model.

This paper reviews the changing health situation in China, which has shown remarkable improvement in the 50 years since the founding of the People's Republic of China (PRC) in 1949. At first sight this improving health situation follows the classical epidemiological transition model. Just three decades ago health in China was characterised by high rates of infectious disease and early mortality (diseases of poverty) in a mainly peasant society. More recently infectious disease rates have decreased, with corresponding and extended morbidity and mortality associated with an aging population in a rapidly urbanising society. This process has given rise to new health problems, including chronic and degenerative diseases (diseases of affluence). Nonetheless, while there is some validity in the application of the epidemiological transition concept, further analysis demonstrates that China faces a new epidemiological phase, characterised by increasing life expectancy and diseases of affluence coupled with the emergence and re-emergence of infectious diseases. We demonstrate that China's state policy plays a major role in defining the parameters of health in a Chinese context. We conclude that, today, China is faced with a new set of health issues, including the impact of smoking, hypertension, the health effects of environmental pollution and the rise of HIV/AIDS; however, state policy remains vital to the health of China's vast population. The challenge for policy is to maintain health reform whilst tackling the problems associated with rapid urbanisation, widening social and spatial inequalities and the emergence of HIV/AIDS and other infectious diseases.

Quantitative EEG Correlates of Outcome in Older Psychiatric Patients: Part I: Cross-Sectional and Longitudinal Assessment of Patients With Dementia.

Using quantitative electroencephalographic coherence (a measure of synchronized electrical activity between brain regions) the authors examined heterogeneity in clinical presentation and outcome inpatients with dementia. Patients (N = 114) with mild-to-moderate dementia of the Alzheimer's type (DAT) or multi-infarct dementia (MID) were examined for coherence from the left hemisphere. More than 70% diagnostic accuracy in distinguishing between DAT and MID subjects was achieved using coherence measures alone. Also, decreased coherence measured across the Rolandic fissure in the left hemisphere was significantly associated with poorer functional status of subjects at 2-year follow-up, despite similar levels of cognitive impairment at baseline. These findings suggest that coherence is a useful measure for assessment and for prediction of the course of illness inpatients with dementia.