Rush Fracture Liaison Service for capturing "missed opportunities" to treat osteoporosis in patients with fragility fractures.

In spite of being a public health problem of pandemic proportions, osteoporosis continues to be underdiagnosed and undertreated especially in older adults with fragility fractures. Confirmation of this hypothesis resulted in the development of a novel Fracture Liaison Service (Rush FLS). Results of the first 12 months of operation revealed that patients with confirmed fragility fracture do not have a timely diagnosis at fracture occurrence or treatment of their disease. The Rush FLS is an effective fracture liaison model. INTRODUCTION: Determining the prevalence of undiagnosed and untreated osteoporosis in fragility fracture patients, either admitted to an academic tertiary care center or treated and discharged from the center's emergency department to be followed in the endocrinology bone clinic, using an innovative, educational, low-cost, physician-run Fracture Liaison Service (FLS). METHODS: An automated alert was integrated into the electronic medical record at Rush University Medical Center (RUMC), triggered by historical and/or acute fracture(s) in patients 50 years or older, in patients that were either admitted to the hospital or in patients evaluated in the emergency department and discharged to be followed in the endocrinology bone clinic. We report the results of the first 12 months of operation in patients admitted to the hospital. RESULTS: First acute fragility fracture(s) were identified in 36% (80/223), only historical fragility fracture(s) in 28% (63/223) and both acute and historical fragility fracture(s) in 36% (80/223). The cumulative subgroup with historical fragility fractures with/without new fractures included 67% (96/143) without a previous diagnosis of osteoporosis. First acute fragility fracture group included 83.8% (67/80) without a previous diagnosis of osteoporosis. Rush FLS "captured missed opportunities" in 73.1% (163/223) of previously undiagnosed and 77.1% (172/223) of previously untreated osteoporosis patients. Dual-energy x-ray absorptiometry (DXA) prior to FLS consult was confirmed in 30% (67/223). Vitamin D deficiency (25-hydroxy vitamin D < 20 ng/ml) in 41.9% (78/186) including undetectable levels in 16.6% (31/186) and secondary hyperparathyroidism in 43.3% (78/180) were the most common laboratory confirmed secondary etiologies for bone loss. CONCLUSIONS: This study reported undiagnosed, uninvestigated, and untreated osteoporosis in the majority of fragility fracture patients seen by the Rush FLS in the first 12 months of operation.

The kidney allocation system does not appropriately stratify risk of pediatric donor kidneys: Implications for pediatric recipients.

Kidney Allocation System (KAS) was enacted in 2014 to improve graft utility, while facilitating transplantation of highly-sensitized patients and preserving pediatric access to high-quality kidneys. Central to this system is the Kidney Donor Profile Index (KDPI), a metric intended to predict transplant outcomes based on donor characteristics but derived using only adult donors. We posited that KAS had inadvertently altered the profile and quantity of kidneys made available to pediatric recipients. This question arose from our observation that most pediatric donors carry a KDPI over 35 and have therefore been rendered relatively inaccessible to pediatric recipients under KAS. Here we explore early trends in pediatric transplantation following KAS, including: (i) use of pediatric donors, (ii) use of Public Health System (PHS) high infectious risk donors, (iii) wait time, and (iv) living donor transplantation. We note some concerning preliminary changes following KAS implementation, including the allocation of fewer deceased donor pediatric kidneys to children and stagnation in pediatric wait times. Moreover, the poor predictive power of the KDPI for adult donors appears to be even worse when applied to pediatric donors. These early trends warrant further observation and consideration of changes in pediatric kidney allocation if they persist.

A multicenter prospective hospital-based surveillance to estimate the burden of rotavirus gastroenteritis in children less than five years of age in India.

BACKGROUND: Rotavirus is the leading cause of severe, dehydrating diarrhea in children aged <5 years globally, with an estimated 25 million outpatient visits and 2 million hospitalizations attributable to rotavirus infections each year. The aim of this hospital-based surveillance was to summarize the local epidemiological and virological features of rotavirus and to estimate the disease burden in the population under surveillance in India. METHODS: During the 16 months surveillance period from April 2011 through July 2012, a total of 4711 children under the age of 5 years were admitted with acute diarrhea at 12 medical centers attached to medical schools throughout India. Stool samples were randomly collected from 2051 (43.5%) subjects and were analyzed for rotavirus positivity using commercial enzyme immunoassay kit (Premier Rotaclone Qualitative Elisa) at the respective study centers. Rotavirus positive samples were genotyped for VP7 and VP4 by reverse-transcription polymerase chain reaction (RT-PCR) at a central laboratory. RESULTS: During the study period, maximum number of rotavirus related hospitalizations were reported from December 2011 through February 2012. Out of the 2051 stool samples tested for rotavirus, overall 541 (26.4%) samples were positive for rotavirus VP6 antigen in stool. The highest positivity was observed in the month of December, 2011 (52.5%) and lowest in the month of May, 2011 (10.3%). We found that majority of the rotavirus positive cases (69.7%) were in children <24 months of age. The most common genotypes reported were G1 (38%), G2 (18%), G9 (18%), G12 (9%) and mixed strains (17%). CONCLUSIONS: The results of this study confirm the significant burden of acute rotavirus gastroenteritis as a cause of hospitalizations in under five children in India.

Evaluation of nitrate reductase assay for direct detection of drug resistance in Mycobacterium tuberculosis: rapid and inexpensive method for low-resource settings.

The aim of this study was to evaluate a nitrate reductase assay (NRA) for the direct detection of multidrug resistance (MDR) in Mycobacterium tuberculosis from 100 smear-positive sputum samples. The NRA results were compared with the reference proportion method for 100 sputum specimens for which comparable results were available. NRA results were obtained at day 7 for 61 specimens, results for 26 specimens were obtained at day 10, and the results for 13 specimens were obtained at day 14. Thus, 87% of NRA results were obtained in 10 days. NRA is a rapid, accurate, and cost-effective method for the detection of MDR in M. tuberculosis isolates as compared to the proportion method, which is time consuming. Therefore, NRA constitutes a useful tool for detection of tuberculosis drug resistance in low-resource countries with limited laboratory facilities due to its low-cost, ease of performance and lack of requirement of sophisticated equipment.

A multi-period optimization model for energy planning with CO(2) emission consideration.

A novel deterministic multi-period mixed-integer linear programming (MILP) model for the power generation planning of electric systems is described and evaluated in this paper. The model is developed with the objective of determining the optimal mix of energy supply sources and pollutant mitigation options that meet a specified electricity demand and CO(2) emission targets at minimum cost. Several time-dependent parameters are included in the model formulation; they include forecasted energy demand, fuel price variability, construction lead time, conservation initiatives, and increase in fixed operational and maintenance costs over time. The developed model is applied to two case studies. The objective of the case studies is to examine the economical, structural, and environmental effects that would result if the electricity sector was required to reduce its CO(2) emissions to a specified limit.

Radiomodulatory and free-radical scavenging activity of the fractionated aquo-alcoholic extract of the adaptogenic nutraceutical (Rhodiola imbricata)--a comparative in vitro assessment with ascorbate.

OBJECTIVE: Immense interest has been generated in recent years for the development of drugs of herbal origin for the mitigation of deleterious effects of environmental pollutants like ionizing radiation, mainly to protect against radiation leakages resulting from mishaps in nuclear reactors, deliberate use of dirty bombs, etc. METHOD: The radio modifying effects of a fractionated extract of the high-altitude Himalayan plant species Rhodiola imbricata, along with its electron-donation potential, super-oxide ion scavenging (IC50 ≤ 0.025 mg/ml), nitric oxide (NO) scavenging potential (IC(50) = 0.5 mg/ml), and antihemolytic activity were evaluated in the present study. Reducing power, superoxide ion (O(2)(•-)), and nitric oxide scavenging ability of the fractionated extract increased in a dose-dependent manner. Rhodiola imbricata also exhibited antihemolytic potential preventing radiation-induced membrane degeneration of human erythrocytes. CONCLUSION: Thus, it can be stated that Rhodiola imbricata provides protection against gamma radiation via multifarious mechanisms that act in a synergistic manner. Rhodiola imbricata is widely used as a nutraceutical supplement in the trans-Himalayan region nations, and the current study shows that Rhodiola has immense potential for alleviation of biological damage in a radiation environment.

An insight into the grain auger injury problem in Queensland, Australia.

Grain auger-related injuries were studied by examining the injury data obtained from the Queensland worker's compensation database. Close to 60% of 52 claimants were male employees in the 20 to 34 age group. Fingers, hands, and arms were affected in 65% of all cases, and the auger flighting was involved in 60% of claims. The severity of auger-related injuries is reflected in the high average cost of claims and number of working days lost, which were more than double the all-industries values. Injuries involving the auger flighting are three times more costly (in time and money) than the all-industries values. More claims were made during winter and towards the end of summer, with the majority of injuries occurring in the animal industries. Most incidents occurred in the early or middle periods of a working shift. In addition, two focus group meetings were held to gain a broader perspective of the grain auger injury picture in Queensland, Australia. Focus group participants suggested that the operator's state of mind and attitude to safety are important, while the auger's age, type, and shielding were cited as important risk factors. They suggested that older augers are less likely to be adequately shielded, and mobile augers are most likely to be involved in injury events. The information gained from this study is being used to develop strategies to help farmers minimize injuries associated with the use of grain augers.

Medical ethnobotany of the Teribes of Bocas del Toro, Panama.

Ethnomedical uses of 108 medicinal plant species, belonging to 52 families, 89 genera, used by the Teribe Amerindians of Bocas del Toro Province in Panama, along with their socio-cultural practices are reported here. The methods of administration of the herbal remedies, the plant parts used, their families and local names are also documented. The recorded medicinal plants were used mainly for fever, various type of pain and inflammation. The potential value of 26 plants and their traditional uses was elucidated through literature search.

Prevalence and pattern of use of complementary and alternative medicine (CAM) in hypertensive patients of a tertiary care center in India.

OBJECTIVE: To study the prevalence and pattern of use of complementary and alternative medicine (CAM) in patients with essential hypertension. METHOD: 521 consecutive patients visiting the Hypertension Clinic at the Postgraduate Institute of Medical Education and Research, Chandigarh, India, over a 6-month period were interviewed. Information was gathered on the patients' demographics, type(s) of CAM used, sequence of seeking CAM and conventional medicine, sources of recommendation, reasons for opting for CAM and areas of satisfaction and dissatisfaction associated with the use of CAM. Patients were also asked if they had informed their doctor about CAM use. RESULTS: It was observed that 63.9% of patients overall used CAM. Ayurveda was the most commonly used CAM (56.7%), followed by herbal medicines (14.4%). The most commonly cited reason by patients for using CAM was fear of adverse drug reactions of conventional medicines (59.0%). However, more than half of the patients eventually became dissatisfied using CAM. Only 5.4% of CAM users had informed their medical doctors about the use of CAM. CONCLUSION: A significant proportion of patients receiving conventional treatment for hypertension also use CAM therapies. A better understanding of the pattern of CAM use amongst these patients will help dispel prevalent misconceptions concerning CAM and, at the same time, assist conventional practitioners to critically evaluate possible gaps or omissions in their own prescribing habits.

A critical appraisal of evidence-based medicine: some ethical considerations.

Evidence-based medicine (EBM) is a concept that has grown to dominate the medical literature over the last decade. EBM has provoked a variety of criticisms, scientific, philosophical and sociological. However, while its basic conclusion--that we should practise EBM--is ethical, there has been limited ethical analysis of EBM. This paper aims to provide an analysis of EBM from an ethical perspective and identify some of EBM's potential ethical implications. Following a description of what constitutes EBM, this paper will identify and assess some of the basic values and epistemological assumptions of EBM that provide support for the moral duty to practise EBM. It will then examine potential ethical implications that could arise from practising EBM, given the challenges that have been made of EBM's assumptions and claims to authority. This paper will conclude by arguing that practitioners could strengthen the ethics of EBM by embracing a broader definition of evidence and including ethical criteria in the critical appraisal of research studies.

Dimensions of women's autonomy and the influence on maternal health care utilization in a north Indian city.

The dimensions of women's autonomy and their relationship to maternal health care utilization were investigated in a probability sample of 300 women in Varanasi, India. We examined the determinants of women's autonomy in three areas: control over finances, decision-making power, and freedom of movement. After we control for age, education, household structure, and other factors, women with closer ties to natal kin were more likely to have greater autonomy in each of these three areas. Further analyses demonstrated that women with greater freedom of movement obtained higher levels of antenatal care and were more likely to use safe delivery care. The influence of women's autonomy on the use of health care appears to be as important as other known determinants such as education.

Low-cost technology for screening uterine cervical cancer.

We report on an illuminated, low-cost (Rs 1500 (US$ 36)) magnifying device (Magnivisualizer) for detecting precancerous lesions of the uterine cervix. A total of 403 women attending a maternal and child health care clinic who had abnormal vaginal discharge and related symptoms were referred for detailed pelvic examination and visual inspection by means of the device after the application of 5% (v/v) acetic acid. Pap smears were obtained at the same time. The results were compared with those obtained using colposcopy and/or histology. The Magnivisualizer improved the detection rate of early cancerous lesions from 60%, for unaided visual inspection, to 95%. It also permitted detection of 58% of cases of low-grade dysplasia and 83% of cases of high-grade dysplasia; none of these cases were detectable by unaided visual inspection. For low-grade dysplasia the sensitivity of detection by means of the Magnivisualizer was 57.5%, in contrast with 75.3% for cytological examination. However, the two methodologies had similar sensitivities for higher grades of lesions. The specificity of screening with the Magnivisualizer was 94.3%, while that of cytology was 99%. The cost per screening was approximately US$ 0.55 for the Magnivisualizer and US$ 1.10 for cytology.

Lifeboat versus corporate ethic: social and demographic implications of stem and joint families.

We contrast stem and joint family systems, to show how differences in norms of inheritance and residence profoundly influence our values and social constructs. They shape how people evaluate each other and patterns of conflict and cooperation within and between generations. Through this, they influence many fundamental aspects of social organization and behaviour. These influence health outcomes through categorizing people into those whose health is encouraged to prosper or to fail. It also influences a wide range of other outcomes, including strategies of household resource management; migration; ways of exploiting commercial opportunities and the operation of civil society. A number of hypotheses are developed about the nature of these interrelationships, some of which are substantiated empirically and others which can be tested.

Using activity-based costing and theory of constraints to guide continuous improvement in managed care.

Activity-based costing and the theory of constraints have been applied successfully in many manufacturing organizations. Recently, those concepts have been applied in service organizations. This article describes the application of activity-based costing and the theory of constraints in a managed care mental health and substance abuse organization. One of the unique aspects of this particular application was the integration of activity-based costing and the theory of constraints to guide process improvement efforts. This article describes the activity-based costing model and the application of the theory of constraint's focusing steps with an emphasis on unused capacities of activities in the organization.

Physician resource utilization in radiation oncology: a model based on management of carcinoma of the prostate.

PURPOSE: To develop a methodology to estimate the comparative cost of physician time in treating patients with localized prostate cancer, using as an example two-dimensional (2D) vs. three-dimensional (3D) conformal irradiation techniques, and to illustrate how current cost-accounting techniques can be used to quantify the cost of physician time and effort of any treatment. METHODS AND MATERIALS: Activity-based costing, a recent innovation in accounting, widely recommended for estimating and managing the costs of specific activities, was used to derive physician resource utilization costs (actual cost of the physician services and related support services consumed). RESULTS: Patients treated with 3D conformal irradiation consume about 50% more physician time than patients receiving 2D conventional radiation therapy. The average professional reimbursement for the 3D conformal irradiation is only about 26% more than for the 2D treatment. Substantial variations in cost are found depending on the total available physician working hours. In an academic institution, a physician working 40 hours a week would have to spend an average of about 60% of available time on clinical services to break even on a 2D treatment process and over 74% of available time on clinical work to break even on a 3D treatment process. The same physician working 50 hours a week would have to spend an average of about 48% of available time on 2D clinical services and about 60% of available time on 3D clinical work to break even. Current Medicare reimbursement for 3D treatment falls short of actual costs, even if physicians work 100% of a 50-hour week. Medicare reimbursement for 2D barely allows the department to break even for 2D treatments. CONCLUSIONS: Costs based on estimates of resource use can be substantially under- or overestimated. A consistent language (method) is needed to obtain and describe the costs of radiation therapy. The methodology described here can help practitioners and researchers more accurately interpret actual cost information. Future use of such cost-estimation methodologies could provide consistent and comparable costs for negotiations with health care providers and help assess different treatment strategies.