Clinical, humanistic, and economic burden of osteoarthritis among noninstitutionalized adults in the United States.

OBJECTIVE: To estimate the burden of osteoarthritis (OA) among noninstitutionalized adults (≥18 years of age) in the US. DESIGN: Weighted nationally representative data from the 2015 Medical Expenditure Panel Survey were used to estimate OA prevalence in noninstitutionalized adults and compare adults with OA to those without OA for clinical (pain interference with activities [PIA], functional limitations), humanistic (health-related quality-of-life [HRQoL]) and economic outcomes (healthcare costs, wage loss). Productivity/wage loss was estimated among employed working-age adults (18-64 years). Multivariable regression analyses examined the associations between OA and outcomes. RESULTS: In 2015, 10.5% (25.6 million) of noninstitutionalized US adults reported having any OA. Regression analyses indicated that adults with OA were significantly more likely than those without OA to report moderate (adjusted odds ratios [AOR] 1.99; 95% confidence interval [CI] 1.65-2.40] or severe PIA (AOR 2.59; 95% CI 2.21-3.04), any functional limitation (AOR 2.51; 95% CI 2.21-2.85), and poorer HRQoL on the SF-12 version 2 Physical Component Summary score (adjusted beta [standard error] -3.88 [0.357]; P < 0.001). Adjusted incremental annual total healthcare costs and lost wages among adults with OA relative to those without OA were $1778 and $189 per person, respectively, resulting in estimated national excess costs of $45 billion and $1.7 billion, respectively. CONCLUSIONS: OA affects approximately 10% of noninstitutionalized adults in the US, resulting in substantial clinical, humanistic, and economic burdens.

Women's rights in Asia and elsewhere - a fact or an illusion?

More than one-third of the world's population resides in Asia. China and India have the largest population densities and the focus of this article is on these two countries. In the seventeenth century, women were globally treated as inferior and subordinate to men. Women had to listen to their fathers, husbands, and sons, and they could not inherit business or wealth. Starting in the eighteenth century and continuing in the nineteenth century, women's rights became central to political debates in Europe which demanded human rights, leading to the Women's Rights Movement. The Feminist movement began in the twentieth century, which focused on the reproductive rights of women. In the twentieth century, various Declarations have been signed by the United Nations to offer both gender equity and equality to women in the world, but unfortunately many of them have not been put into practice in Asia. In the twenty-first century, the feminist movement is focusing more on women having the power to decide the course of their lives. We still have to overcome challenges of unequal economic opportunity, political empowerment, gender violence, and human trafficking to achieve gender equality in Asia.

Economic burden of primary compared with recurrent Clostridium difficile infection in hospitalized patients: a prospective cohort study.

BACKGROUND: Few studies have investigated the additional healthcare costs of recurrent C. difficile infection (CDI). AIM: To quantify inpatient treatment costs for CDI and length of stay among hospitalized patients with primary CDI only, compared with CDI patients who experienced recurrent CDI. METHODS: This was a prospective, observational cohort study of hospitalized adult patients with primary CDI followed for three months to assess for recurrent CDI episodes. Total and CDI-attributable hospital length of stay (LOS) and hospitalization costs were compared among patients who did or did not experience at least one recurrent CDI episode. FINDINGS: In all, 540 hospitalized patients aged 62±17 years (42% males) with primary CDI were enrolled, of whom 95 patients (18%) experienced 101 recurrent CDI episodes. CDI-attributable median (interquartile range) LOS and costs (in US$) increased from 7 (4-13) days and $13,168 (7,525-24,456) for patients with primary CDI only versus 15 (8-25) days and $28,218 (15,050-47,030) for patients with recurrent CDI (P<0.0001, each). Total hospital median LOS and costs increased from 11 (6-22) days and $20,693 (11,287-41,386) for patients with primary CDI only versus 24 (11-48) days and $45,148 (20,693-82,772) for patients with recurrent CDI (P<0.0001, each). The median cost of pharmacological treatment while hospitalized was $60 (23-200) for patients with primary CDI only (N=445) and $140 (30-260) for patients with recurrent CDI (P=0.0013). CONCLUSION: This study demonstrated that patients with CDI experience a significant healthcare economic burden attributed to CDI. Economic costs and healthcare burden increased significantly for patients with recurrent CDI.

Remote surveillance after colorectal cancer surgery: an effective alternative to standard clinic-based follow-up.

AIM: Most colorectal cancer recurrences are asymptomatic and are detected through routine postoperative clinic surveillance programmes with associated investigations. However, attendance at these clinics has a financial cost and may be associated with an increase in patient anxiety and dissatisfaction. The results of a remote follow-up system developed for selected patients are reported. METHOD: A remote surveillance programme has been in place in our institution for over 9 years. Patients having elective and emergency treatment for colorectal cancer were enrolled. The timeliness of the investigation, detection of local recurrence and distant metastases and overall 5-year survival rates were determined. A cost review and patient satisfaction survey were performed. RESULTS: The programme was suitable for over 900 patients who had received surgery for colorectal cancer between 2004 and 2012, representing some 50% of the total number of patients treated in this period. Of these, 811 (90%) had investigations carried out on time. Five-year survival rates were comparable with national data. Cost-minimization analysis demonstrated a financial saving of 63% and a 75% reduction in clinic appointments. High levels of overall patient satisfaction (97%) were noted with the programme. CONCLUSION: A remote surveillance system after colorectal cancer surgery is a safe and cost-effective alternative to traditional clinic-based follow up and has high patient satisfaction.

An International Menopause Society study of climate, altitude, temperature (IMS-CAT) and vasomotor symptoms in urban Indian regions.

OBJECTIVE: To examine the relationships between climate (season, temperature, humidity), lifestyle, health, mood and beliefs and experience of hot flushes and night sweats amongst mid-aged women living in eight urban Indian centers. METHODS: A total of 717 peri- and postmenopausal women, aged 45-55 years, from urban centers in different regions of India were included. Data were collected during both summer and winter months. Participants completed questionnaires eliciting information about sociodemographics, hot flushes (prevalence, frequency and problem-rating), health and lifestyle (body mass index, diet, exercise, alcohol use), mood (Women's Health Questionnaire) and attributions and beliefs (Menopause Representations Questionnaire). RESULTS: The prevalence of vasomotor symptoms was low, with 34% of the sample reporting hot flushes and/or night sweats. Seasonal variation in temperature was not associated with hot flush prevalence, frequency or problem rating. Hot flush prevalence was mainly associated with higher anxiety and intake of spicy foods, frequency with (older) age and (more) frequent exercise, while hot flushes were more problematic for women who reported poorer general health and more negative beliefs about menopause. CONCLUSIONS: In this study of Indian women, seasonal temperature variation did not appear to influence hot flush reporting. Health, mood, beliefs and lifestyle factors appear to explain some, but not all, of the variance in experience of menopausal symptoms.

Assessment of treatment patterns and patient outcomes before vs after implementation of a severity-based Clostridium difficile infection treatment policy.

BACKGROUND: National guidelines recommend oral vancomycin for severe Clostridium difficile infection (CDI) based on results from recent clinical trials demonstrating improved clinical outcomes. However, real-world data to support these clinical trials are scant. AIM: To compare treatment patterns and patient outcomes of those treated for CDI before and after implementation of a severity-based CDI treatment policy at a tertiary teaching hospital. METHODS: This study evaluated adult patients with a positive C. difficile toxin before and after implementation of a policy where patients with severe CDI given metronidazole were switched to oral vancomycin unless contra-indicated. Patients were stratified according to disease severity using a modified published severity score. Treatment patterns based on CDI severity and rates of refractory CDI were assessed. FINDINGS: In total, 256 patients with CDI (mean age 66 years, standard deviation 17, 52% female) were evaluated (before implementation: N = 144; after implementation: N = 112). Use of oral vancomycin for severe CDI increased significantly from 14% (N = 8) to 91% (N = 48) following implementation of the policy (P < 0.0001). Refractory disease in patients with severe CDI decreased significantly from 37% to 15% following implementation of the policy (P = 0.035). No significant differences were noted among patients with mild to moderate CDI. CONCLUSION: A severity-based CDI treatment policy at a tertiary teaching hospital increased the use of oral vancomycin and was associated with decreased rates of refractory CDI.

Electrophysiologically guided ablation of the pulmonary veins for the curative treatment of atrial fibrillation.

Catheter ablation of triggers that induce paroxysms of atrial fibrillation (AF) is an emerging curative therapy for this most common of supraventricular arrhythmias. In a series of 225 consecutive patients with multidrug resistant AF, 96% of triggering foci originated from one or several pulmonary veins (PV) independent of ambient ectopy or structural heart disease. This article describes an ablation procedure that is guided by activation mapping tailored to each individual PV, including criteria to define an arrhythmogenic PV, the use of provocative manoeuvres, the role of circumferential mapping catheters to provide information on the extent, distribution and activation of PV muscle as well as the monitoring of distal PV potentials (PVP) during ablation. Radiofrequency ablation to eliminate distal PVPs is performed by targeting the proximal PVP during sinus rhythm (right PV) or left atrial pacing (left PV). This end-point predicts a successful outcome more often than acute ectopy suppression. Complete elimination of AF is presently achieved in 70% of the patients, resulting in the elimination of antiarrhythmic treatment and suspension of anticoagulant treatment. It is anticipated that continued technological development will improve and facilitate this technique of curative treatment of AF.

Evaluation of the WHO/UNICEF algorithm for integrated management of childhood illness between the ages of one week to two months.

OBJECTIVE: To evaluate the utility of the WHO/UNICEF algoritham for integrated management of childhood illness (IMCI) between the ages of 1 week to 2 months. DESIGN: Prospective observational. SETTING: The Outpatient Department and Emergency Room of a medical college hospital. METHODS: 129 infants presenting to Outpatient Department (n=70) or Emergency Room (n=59) were assessed and classified as per 'IMCI' algorithm and treatment required was identified. A detailed evaluation with all relevant investigations was also done for these subjects. The final diagnoses made and therapies instituted on this basis served as 'gold standard'. The diagnostic and therapeutic agreement between 'gold standard and the 'IMCI' was computed. RESULTS: More than one illness was present in 97(75.2%) of subjects as per 'gold standard' (mean 2.1). Subjects having any referral criteria as per 'IMCI' algorithm had a greater (p=0.002) co-existence of illnesses (mean 2.3 vs. 1.8 illnesses per child, respectively. IMCI algorithm covered majority (81-84%) of the recorded diagnoses either partly (40-41%) or fully (40-44%). The referral criteria proved quite sensitive (86-87%) in predicting hospitalization but had a lower specificity (53-58%). a total agreement with IMCI was found in 60-66% cases. The mismatch (34-40%) was more commonly of overdiagnosis (21-23%) rather than underdiagnosis (15-21%). The sensitivity of the algorithm to identify serious bacterial infection was high (96.1-96.5%) while the specificity was relatively low (51. 8-59.7%). Upper respiratory infection (URI)emerged as an important cause resulting in unnecessary referrals (13 out of 21 cases). Of the 43 cases identified as diarrhea by the algorithm, 6 had breast fed stools, which do not require any therapy. The 'IMCI' algorithm had a provision for preventive services of immunization and breastfeeding counseling (18% possibility of availing missed opportunities in both). CONCLUSION: There is a sound scientific basis for adopting IMCI approach even in young infants as there is a need to improve the specificity of referral criteria. Two important conditions identified for possible refinement are URI and breast fed stools

Patterns of use of a free nicotine patch program for Medicaid and uninsured patients.

This study assessed the use and effectiveness of a free nicotine patch program among Medicaid and uninsured smokers. Patterns of patch use, associated behaviors with quit attempt, side effects, and self-reported abstinence from smoking for 6 months were evaluated prospectively among patients from five urban family practice offices and a nicotine dependence clinic located in a comprehensive cancer center in Western New York. Results indicated that the majority of participants used the program as intended, and 90% of the participants found the patch useful in their quit attempt. Fourteen percent of participants were abstinent for 6 months or more. We found no support for inappropriate use of transdermal nicotine patches among patients with no health insurance or those on Medicaid. Transdermal nicotine patches are an effective cessation aid for smokers. Given the tall of the consequences of smoking on health costs, barriers to access to effective treatment for smoking cessation among individuals covered by Medicaid for health insurance need to be eliminated.

Palliative radiotherapy--counting the costs of changing practice.

"Working for Patients', the government's review of the National Health Service (NHS) advocates reforms which have led inevitably to pressure for medical specialities to review both the outcomes of their services and the resources used in achieving these outcomes. This paper considers these issues in the context of provision of palliative radiotherapy for patients with incurable cancers and presents the results of a study which evaluated the costs of radiotherapy. In addition to producing some of the first detailed cost estimates for the delivery of radiotherapy, this exercise highlighted the methodological and practical difficulties of undertaking such studies. As increasing pressure to evaluate cancer therapy is a prominent feature of a 'post-NHS Review' world, lessons learnt from this study may also be applicable to the audit of other cancer therapies. Efficient audit practices will, of course, have to evaluate the benefits (in terms of enhancements to length and quality of life) as well as the costs of cancer therapies.

Duplex scanning of the internal carotid artery: an assessment of cerebral blood flow.

Duplex ultrasound scanning (B-mode imaging and pulsed Doppler shift analysis) was used to measure internal carotid artery blood flow (ICBF) in 20 volunteers. The effect of changes in end tidal CO2 on cerebral blood flow was measured. When corrected to a PCO2, of 40 torr (5.32 kPa) internal carotid artery blood flow was 286 +/- 16 ml min-1 (mean +/- s.e.m.). Specific CO2 reactivity (the change in flow per torr change in CO2) was 8.16 +/- 0.69 ml min-1 torr-1 which was equivalent to 2.0 +/- 0.1 per cent of the flow at 40 torr per torr change in CO2 (percentage CO2 reactivity). The mean value and the CO2 reactivity compare favourably with previously reported measurements by other techniques. These data suggest that the non-invasive measurement of internal carotid artery blood flow by Doppler ultrasound scanning is an assessment of cerebral blood flow that can be used to study both normal and pathological changes within the cerebral circulation.

Transcutaneous flow measurements in in-situ bypasses: an assessment of duplex scanning.

Measurement of laminar flow using an ultrasound scanner was shown to have a high degree of correlation with quantified timed flows (r = 0.98, p less than or equal to .001). Sixty-one in-situ bypasses had flow assessed both proximally and distally. Mean fistula flow (proximal-distal flows) for time periods 1-8 weeks, 3 to 8, and 9+ months were 108, 85, and 16mls respectively. Distal bypass flow remained constant despite a significant decrease in fistula flow between the later time periods (p less than or equal to .001) (unpaired t-test). There was no evidence from the study that proximal flow through fistulas of varying resistances adversely affected the distal bypass flow.