Understanding the characteristics of US cancer survivors with informal caregivers.

BACKGROUND: Although informal caregivers such as family and friends provide people with cancer needed physical care and emotional support, little is known about which individuals have access to such caregivers. The purpose of this article is to provide a nationally representative description of the sociodemographic characteristics of cancer survivors who have or had an informal caregiver in the United States. METHODS: Cross-sectional data were taken from the Experiences With Cancer Survivorship Supplement of the Medical Expenditure Panel Survey in 2011, 2016, and 2017. People were cancer survivors from diagnosis until the end of life. The study population consisted of adult survivors of cancer other than nonmelanoma skin cancer who were treated for cancer less than 3 years before the survey and were living in the community (n = 720). The main outcome measure was whether or not the cancer survivor reported having an informal caregiver. RESULTS: In the United States, 55.2% of cancer survivors reported having an informal caregiver during or after their cancer treatment. The relationship of the caregiver to the survivor varied by sex: males were more likely to have a spouse as their caregiver, and females were more likely to have a child as their caregiver. In multivariate analyses, cancer survivors who were female, were married, were of a race/ethnicity other than White, or were in poor health were more likely to have an informal caregiver. CONCLUSIONS: Future research can examine whether those without informal caregivers might need more formal support as they undergo cancer treatment and transition into cancer survivorship.

Medical costs and productivity losses of cancer survivors--United States, 2008-2011.

The number of persons in the United States with a history of cancer has increased from 3 million in 1971 to approximately 13.4 million in 2012, representing 4.6% of the population. Given the advances in early detection and treatment of cancer and the aging of the U.S. population, the number of cancer survivors is projected to increase by >30% during the next decade, to approximately 18 million. Cancer survivors face many challenges with medical care follow-up, managing the long-term and late effects of treatments, monitoring for recurrence, and an increased risk for additional cancers. These survivors also face economic challenges, including limitations in work and daily activities, obtaining health insurance coverage and accessing health care, and increasing medical care costs. To estimate annual medical costs and productivity losses among male and female cancer survivors and persons without a cancer history, CDC, along with other organizations, analyzed data from the 2008-2011 Medical Expenditure Panel Survey (MEPS), sponsored by the Agency for Healthcare Research and Quality. The results indicate that the economic burden of cancer survivorship is substantial among all survivors. For male cancer survivors, during 2008-2011, average annual medical costs and productivity losses resulting from health problems per person and adjusted to 2011 dollars were significantly higher among cancer survivors than among persons without a cancer history, by $4,187 and $1,459, respectively; for females, the estimated annual costs per person were $3,293 and $1,330 higher among cancer survivors than among persons without a cancer history, respectively. These findings suggest the need to develop and evaluate health and employment intervention programs aimed at improving outcomes for cancer survivors and their families.

Health care expenditures for adults with multiple treated chronic conditions: estimates from the Medical Expenditure Panel Survey, 2009.

The objective of this article is to illustrate the usefulness of Medical Expenditure Panel Survey (MEPS) data for examining variations in medical expenditures for people with multiple chronic conditions (MCC). We analyzed 2009 MEPS data to produce estimates of treated prevalence for MCC and associated medical expenditures for adults in the US civilian noninstitutionalized population (sample = 24,870). We also identified the most common dyad and triad combinations of treated conditions. Approximately one-quarter of civilian US adults were treated for MCCs in 2009; 18.3% were treated for 2 to 3 conditions and 7% were treated for 4 or more conditions. The proportion of adults treated for MCC increased with age. White non-Hispanic adults were most likely and Hispanic and Asian adults were least likely to be treated for MCC. Health care expenditures increased as the number of chronic conditions treated increased. Regardless of age or sex, hypertension and hyperlipidemia was the most common dyad among adults treated for MCC; diabetes in conjunction with these 2 conditions was a common triad. MEPS has the capacity to produce national estimates of health care expenditures associated with MCC. MEPS data in conjunction with data from other US Department of Health and Human Services sources provide information that can inform policies addressing the complex issue of MCC.

A Simple Infection Prevention 'Bundle' Including Preoperative Bath With Hair-Wash to Reduce Surgical Site Infection (SSI) Following Elective Caesarean and Gynaecological Surgery in India.

Background: Surgical site infections (SSIs) may be reduced by following SSI prevention measures. We assessed the SSI rate following caesarean section (CS) and gynaecologic surgery after implementing a simple SSI prevention bundle including preoperative bath and hair wash. Methods: The study was carried out in two hospitals in North India (Post Graduate Institute of Medical Education and Research [PGIMER] and Civil Hospital CH) from August 2018 to July 2019. The SSI rate during intervention period (9 months) was compared with baseline rate (3 months). Womens' knowledge about SSI was assessed preoperatively and after counselling, postoperatively. Results: The baseline SSI rate after CS (n = 165) was 11.1% at PGIMER and 8.5% at CH. After gynae surgery (n = 172), it was 13% at PGIMER and 11.5% at CH. During intervention, (CS = 585, gynae surgery = 503), SSI rate was reduced significantly at PGIMER (CS: 11.1% to 3.7%, P = 0.048; gynae surgery: 13% to 7.1%, P = 0.027), but not at CH (CS: 8.5% to 8.2%, P = 0.903; gynae surgery: 11.5% to 11.4%, P = 0.984). Three measures were followed more often at PGIMER than at CH: before CS, bath with hair-wash: 99.3% vs 78.5%, P = 0.00, hair-clipper vs razor: 100% vs 5.1%, P = 0.00 and antibiotic prophylaxis ≤120 min: 100% vs 92.4%, P = 0.00; and before gynae surgery, bath with hair-wash: 93.2% vs 71%, P = 0.00, hair-clipper vs razor: 93.6% vs 1.9%, P = 0.00 and antibiotic prophylaxis ≤120 min: 100% vs 80.8%, P = 0.00. Postoperatively, womens' knowledge about SSI prevention improved significantly at the two sites. Conclusion: The reduction in SSI at PGIMER was attributed to better compliance to SSI prevention measures listed above. Counselling women about simple SSI prevention method like preoperative bath with scalp hair wash increased their knowledge about these significantly.

A reciprocal feedback loop between HIF-1α and HPIP controls phenotypic plasticity in breast cancer cells.

While phenotypic plasticity is a critical factor contributing to tumor heterogeneity, molecular mechanisms underlying this process are largely unknown. Here we report that breast cancer cells display phenotypic diversity in response to hypoxia or normoxia microenvironments by operating a reciprocal positive feedback regulation of HPIP and HIF-1α. We show that under hypoxia, HIF-1α induces HPIP expression that establishes cell survival, and also promotes cell migration/invasion, EMT and metastatic phenotypes in breast cancer cells. Mechanistic studies revealed that HPIP interacts with SRP14, a component of signal recognition particle, and stimulates MMP9 synthesis under hypoxic stress. Whereas, in normoxia, HPIP stabilizes HIF-1α, causing the Warburg effect to support cell growth. Concurrently, mathematical modelling corroborates this reciprocal feedback loop in enabling cell-state transitions in cancer cells. Clinical data indicate that elevated levels of HPIP and HIF-1α correlate with unfavorable prognosis and shorter survival rates in breast cancer subjects. Together, this data shows a reciprocal positive feedback loop between HPIP and HIF-1α that was unknown hitherto. It unveils how the tumor microenvironment influences phenotypic plasticity that has an impact on tumor growth and metastasis and, further signifies considering this pathway as a potential therapeutic target in breast cancer.

Unmasking the great masqueraders: Concurrent isolated large cecal endometrioma and solitary extra-uterine retroperitoneal cellular leiomyoma - A case report with review of literature.

INTRODUCTION: Cecal endometriosis is an infrequent cause of right iliac fossa pain. The extra-uterine retroperitoneal cellular leiomyoma is a rare tumor. The concurrent existence of both these rare conditions is a unique event. PRESENTATION OF CASE: We hereby report the case of a 44-year-old woman who had concurrent large isolated cecal endometrioma, which was diagnosed pre-operatively on imaging to be pelvic endometriosis/hematosalpinx and solitary retroperitoneal cellular leiomyoma, which was incidentally identified. Both the conditions were managed successfully by laparoscopy. DISCUSSION: Cecal endometriosis is difficult to diagnose pre-operatively as there are far commoner clinical conditions that cause similar signs and symptoms. Often it gets mistaken for these conditions and gets diagnosed incidentally 'on table' during surgeries being performed purportedly to treat them. CONCLUSION: Although definitive diagnosis can only be obtained after histopathology, laparoscopy can be considered a standard diagnostic modality for both these conditions.

Giant right atrium in an adult.

Massive right atrial (RA) enlargement is certainly more common in children than in adults, owing to rare congenital anomalies. Indeed, the largest description of such chamber enlargement was noted in a child, where the RA volume was reported to be 900 ml. We now report one of the largest descriptions of the RA in an adult, in absence of tricuspid stenosis and other common adult associations of RA abnormality, such as chronic pulmonary disease, severe mitral valvular pathology with pulmonary hypertension, and pulmonary embolism or infarct. The RA volume was estimated to be well over 500 ml and was notably disproportionate to that of the left atrium and either ventricle.

Missed Opportunities for Depression Screening and Treatment in the United States.

PURPOSE: This study estimates the prevalence of depression assessment in adults age 35 and older and how prevalence varies by sociodemographic characteristics and depressive symptoms. METHODS: We used a nationally representative survey, the Agency for Healthcare Research and Quality's Medical Expenditure Panel Survey, to evaluate if adults 35+ were being assessed for depression by their health care providers in 2014 and 2015. Using multivariate logistic regression, we examined the health and sociodemographic characteristics of patients associated with depression assessment. RESULTS: Approximately 50% of US adults aged 35+ were being assessed for depression (48.6%; 95% CI, 45.5%-51.6%). The following were less likely to be assessed: men compared with women (OR, 0.58; 95% CI, 0.46-0.72), adults 75+ compared with adults 50 to 64 years old (OR, 0.47; 95% CI, 0.32-0.69), the uninsured compared with those with private insurance (OR, 0.30; 95% CI, 0.18-0.51), and adults without recognized depressive symptoms compared with those with recognized symptoms (OR, 0.39; 95% CI, 0.24-0.63). Compared with non-Hispanic whites, the following were less likely to be assessed: Asian (OR, 0.35; 95% CI, 0.19-0.67), Hispanic (OR, 0.47; 95% CI, 0.29-0.75), and African American (OR, 0.42; 95% CI, 0.27-0.67). CONCLUSIONS: Many Americans are not having their depression needs assessed. Certain populations are more likely to be missed, including men, people over 75 years old, minorities, and the uninsured. Additional efforts are needed to determine methods to increase screening recommended by the United States Preventive Services Task Force and to ensure that all Americans have their mental health needs met.

Supporting Children with Disabilities in Low- and Middle- Income Countries: Promoting Inclusive Practice within Community-Based Childcare Centres in Malawi through a Bioecological Systems Perspective.

Given the narrow scope and conceptualisation of inclusion for young children with disabilities in research within low- and middle-income countries (LMICs) contexts, we draw on a bioecological systems perspective to propose the parameters for a broader unit of analysis. This perspective situates human development within a specific cultural context in which family, peers and schooling are regarded as key in responding to young children with disabilities in a given setting. We outline a new bioecological model to illustrate the proximal and distal factors that can influence inclusive early development for children with disabilities within LMICs. To illustrate the relevance of this model to early child development research, we consider its application, as a conceptual framework, with reference to a research study in Malawi. The study was designed to promote greater inclusive practice for young children with disabilities in Community-Based Childcare Centres (CBCCs) with a particular focus on the role of the CBCC volunteer 'caregiver' in rural Malawi. It has significance for educators, service providers and researchers concerned with facilitating inclusive early development across national boundaries and contexts.

L'étroitesse de la portée et de la conceptualisation de l'inclusion de jeunes enfants handicapés dans le corpus de recherche dans les pays à revenu faible et (PRFI) contextes intermédiaire, nous puisons dans une perspective de systèmes bioécologiques pour proposer des paramètres pour une unité d'analyse plus large. Notre perspective situe le développement humain dans un contexte culturel spécifique dans lequel la famille, les pairs et la scolarité sont considérés comme des éléments clés pour apporter une réponse à la question des jeunes enfants handicapés dans un contexte donné. Nous décrivons un nouveau modèle bioécologique pour illustrer les facteurs proximaux et distants qui peuvent influencer le développement des enfants handicapés dans les PRFI pendant leurs premières années. Pour illustrer la pertinence de ce modèle pour la recherche sur le développement des jeunes enfants, nous prenons en considération son application comme cadre conceptuel, en référence à une étude menée au Malawi. L'étude a été conçue aboutir de promouvoir des pratiques plus inclusives pour les enfants handicapés fréquentant des garderies communautaires, en mettant un accent particulier sur le rôle de l'«assistant ¼ bénévole dans les zones rurales du Malawi. Elle est importante pour les éducateurs, les prestataires de services et les chercheurs qui veulent faciliter un développement inclusif des jeunes enfants, au-delà des frontières et contextes nationaux.

Debido al poco alcance y la conceptualización limitada de la inclusión de niños de edad temprana con discapacidades en investigaciones realizadas en el contexto de países de ingresos bajos y medios, utilizamos una perspectiva de sistemas bio-ecológicos, con el fin de proponer parámetros más amplios de análisis. Esta perspectiva sitúa al desarrollo humano dentro de su contexto cultural específico en el cual la familia, los compañeros y la escuela son considerados como factores vitales en la atención a niños de edad temprana con discapacidades. Se describe un modelo bio-ecológico para ilustrar los factores proximales y distales que pueden influenciar el desarrollo temprano en contextos inclusivos para niños con discapacidades en países de ingresos bajos y medios. Con el fin de ilustrar la importancia de este modelo para la investigación del desarrollo infantil temprano, consideramos su aplicación, como marco conceptual, con referencia a una investigación llevada a cabo en Malaui. El estudio se diseñó con el objeto de promover mejores prácticas inclusivas para niños pequeños con discapacidades en Centros Infantiles Comunitarios (CICs) con un enfoque especial en el papel que juega el cuidador voluntario del CIC en zonas rurales de Malaui. Este estudio es relevante para educadores, centros de educación e investigadores interesados en brindar desarrollo temprano inclusivo en diferentes contextos y territorios.

Colorectal tumors within an urban minority population in New York City.

BACKGROUND: Data on gender- and age-specific predisposition to colorectal tumors and colorectal tumor location and stage among the urban minority population in Northeastern United States is limited. OBJECTIVE: To study the age and gender distribution of colorectal tumor type, location, and stage of colorectal tumors among urban minorities. DESIGN: Retrospective analysis of a database of 4,043 consecutive colonoscopies performed over a 2-year period. PARTICIPANTS/MEASUREMENTS: Of study participants, 99% were Hispanic or African American and two-thirds were women. Age, gender, colonoscopy findings, and biopsy results were analyzed in all study subjects. Outcome measures are expressed as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Colonoscopies, 2,394 (63.4%), were performed for cancer screening. Women had higher visit volume adjusted odds to undergo colonoscopy (OR 1.35; CI 1.26-1.44, P < .001). Individuals, 960 (23.7%), had adenomas, and 82 (2.0%) had colorectal cancer. Although cancers were outnumbered by adenomas in the colon proximal to splenic flexure (OR 0.48; CI 0.29-0.80 P = .002), 51% of all abnormalities and 35.4% of cancers were found in this region. Of cancers, 75% belonged to AJCC stage 0 to 2. Men had higher odds for both adenomas and cancers (OR 2.38, CI 2.0-2.82, P < .001). More polyps occurred at a younger age. Of the cancers, 38% were noted among the 50- to 59-year-old subjects. However, the odds of colorectal cancers were higher at age greater than 70 years (OR 1.91; CI 1.09-3.27, P < .05), specifically among men (OR 2.27, 95% CI 1.07-4.65, P < .05). CONCLUSION: Our study of colonoscopies demonstrates lower odds of colonoscopy after adjusting for visit volume and greater predilection for colorectal cancer among urban minority men. Although older individuals were more likely to have colorectal cancer, a high percentage of colorectal tumors were noted at a younger age. These findings emphasize the vital need for preventive health education and improving early access to colorectal screening among urban minority men. A large proportion of colorectal tumors were found proximal to splenic flexure, which supports colonoscopy as the preferred method for colorectal cancer screening in the urban minority population in New York City.

Management of musculoskeletal complications in endstage renal disease: an update.

People treated with prolonged hemodialysis now survive longer and increasingly develop musculoskeletal complications. Significant advances have been made in the management of musculoskeletal manifestations in patients undergoing hemodialysis for endstage renal disease. Noncalcium-based phosphate binders are preferred for the management of hyperphosphatemia. Vitamin D therapy is based on intact parathyroid hormone levels. Newer Vitamin D sterols and calcimimetic agents seem to control secondary hyperparathyroidism without increasing the calcium-phosphorous product. Use of biocompatible dialyzers for hemodialysis may delay articular manifestations of beta-2 microglobulin amyloidosis. Beta-2 microglobulin adsorption columns when used along with hemodialysis may lead to lower beta-2 microglobulin levels and improvement in articular manifestations of beta-2 microglobulin amyloidosis. In this review, we focus on the latest advancements in the management of secondary hyperparathyroidism and beta-2 microglobulin amyloidosis.

The research rotation: competency-based structured and novel approach to research training of internal medicine residents.

BACKGROUND: In the United States, the Accreditation Council of graduate medical education (ACGME) requires all accredited Internal medicine residency training programs to facilitate resident scholarly activities. However, clinical experience and medical education still remain the main focus of graduate medical education in many Internal Medicine (IM) residency-training programs. Left to design the structure, process and outcome evaluation of the ACGME research requirement, residency-training programs are faced with numerous barriers. Many residency programs report having been cited by the ACGME residency review committee in IM for lack of scholarly activity by residents. METHODS: We would like to share our experience at Lincoln Hospital, an affiliate of Weill Medical College Cornell University New York, in designing and implementing a successful structured research curriculum based on ACGME competencies taught during a dedicated "research rotation". RESULTS: Since the inception of the research rotation in 2004, participation of our residents among scholarly activities has substantially increased. Our residents increasingly believe and appreciate that research is an integral component of residency training and essential for practice of medicine. CONCLUSION: Internal medicine residents' outlook in research can be significantly improved using a research curriculum offered through a structured and dedicated research rotation. This is exemplified by the improvement noted in resident satisfaction, their participation in scholarly activities and resident research outcomes since the inception of the research rotation in our internal medicine training program.

Role of l-Arginine in Oligohydramnios.

BACKGROUND: Oligohydramnios is a known obstetric complication which is associated with operative interferences and perinatal morbidity and mortality. l-arginine is a precursor of nitric oxide and may play a role in local vasodilatation. Administration of l-arginine has been suggested to improve amniotic fluid index (AFI) in oligohydramnios. AIMS AND OBJECTIVES: To study the effect of l-arginine in optimizing fetal outcome in cases of oligohydramnios. MATERIALS AND METHODS: A retrospective study was conducted at Dr L H Hiranandani hospital consisting of 100 antenatal patients diagnosed with oligohydramnios [AFI < 8 cm] remote from term. Patients were evaluated for all antenatal risk factors and were started on l-arginine sachets (3 g, 3 sachets a day). The treatment was continued till an adequate improvement in liquor was noted. However, patients were considered for delivery if the liquor remained <5. Further, mean increase in AFI, intervention delivery interval, and neonatal outcome were studied. RESULTS: The mean gestational age at the time of recruitment was 32.3 weeks. The mean AFI noted was 5.421 cm. These patients were delivered at 35 ± 1.1 weeks, and thus, pregnancy could be prolonged by 2.4 ± 1.1 weeks. The mean AFI at the end of therapeutic intervention was 8.753, and thus, an AFI increase of 3.332 cm could be obtained. There was no significant neonatal morbidity in these patients. Significant improvement in liquor volume was obtained in these patients after intervention with l-arginine sachets. CONCLUSION: l-arginine supplementation is promising in improving volume of amniotic fluid in cases of oligohydramnios and prolonging pregnancy by a mean of 2.4 weeks, allowing fetal lung maturation thus benefiting the neonatal outcome.

Hospitalization for heart failure in the presence of a normal left ventricular ejection fraction: results of the New York Heart Failure Registry.

OBJECTIVES: We conducted a prospective multicenter registry in a large metropolitan area to define the clinical characteristics, hospital course, treatment, and factors precipitating decompensation in patients hospitalized for heart failure with a normal ejection fraction (HFNEF). BACKGROUND: The clinical profile of patients hospitalized for HFNEF has been characterized by retrospective analyses of hospital records and state data banks, with few prospective single-center studies. METHODS: Patients hospitalized for heart failure (HF) at 24 medical centers in the New York metropolitan area and found to have a left ventricular (LV) ejection fraction of > or 50% within seven days of admission were included in this registry. Patient demographics, signs and symptoms of HF, coexisting and exacerbating cardiovascular and medical conditions, treatment, laboratory tests, procedures, and hospital outcomes data were collected. Analysis by gender and race was prespecified. RESULTS: Of 619 patients, 73% were women, who were on average four years older than men (72.8 +/- 14.1 years vs. 68.6 +/- 13.8 years, p < 0.001). Black non-Hispanic patients comprised 30% of the study population. They were eight years younger than other patients (66.0 +/- 14.2 years vs. 74 +/- 13.5 years p < 0.001). Co-morbid conditions and their prevalence were: hypertension, 78%; increased LV mass, 82%; diabetes, 46%; and obesity, 46%. Before clinical decompensation that precipitated hospitalization, 86% of patients had chronic symptoms compatible with New York Heart Association functional classes II to IV. Factors precipitating clinical decompensation were identified in 53% of patients. In-hospital mortality was 4.2%. CONCLUSIONS: Patients hospitalized for HFNEF are most often chronically incapacitated elderly women with a history of hypertension and increased LV mass. Reasons for clinical decompensation are identified in only one-half of patients.

The incidence and prognosis of Brugada electrocardiographic pattern in the Manitoba Follow-Up Study.

BACKGROUND: There is a paucity of long-term follow-up data on individuals with asymptomatic Brugada electrocardiographic (ECG) pattern. OBJECTIVES: To investigate the incidence and prognosis of spontaneous Brugada ECG pattern in a prospective cohort. METHODS: The Manitoba Follow-up Study is Canada's longest-running study of cardiovascular disease. Since 1948, a cohort of 3983 healthy aircrew recruits has been followed with routine medical examination, including ECG. Over a 55-year follow-up period, clinical and ECG assessments were performed every three to five years, with yearly contact to monitor vital status. The mean age of the cohort at entry and the average age of the 1375 survivors in 2003 were 31 and 83 years of age, respectively. Brugada ECG pattern was defined as ST-segment elevation in at least one of leads V1 to V3 with a J wave amplitude of at least 2 mm, negative T waves, generally coved ST-T configuration, in the absence of alternative explanations. Serial ECGs of 273 subjects (6.9% of the cohort) with complete right bundle branch block at any time during follow-up were reviewed. Follow-up records pertaining to clinical course were also reviewed. RESULTS: All ECGs (in total 5665) from this cohort were reviewed. Four men had intermittent Brugada ECG pattern (lifetime incidence one per 1000): three men (all 80 years of age or older) were well on last follow-up and one had died of Alzheimer's disease. None of these men had syncope or ventricular arrhythmias documented during follow-up. CONCLUSIONS: The longevity of asymptomatic individuals in this cohort was not affected by spontaneous Brugada ECG pattern.

Mental health services utilization and expenditures associated with cancer survivorship in the United States.

PURPOSE: The aim of this study is to assess mental health services utilization and expenditures associated with cancer history using a nationally representative sample in the US. METHODS: We used data from the 2008-2011 Medical Expenditure Panel Survey and multivariate regression models to assess mental health services use and expenditures among cancer survivors compared to individuals without a cancer history, stratified by age (18-64 and ≥65 years) and time since diagnosis (≤1 vs. >1 year). RESULTS: Among adults aged 18-64, compared with individuals without a cancer history, cancer survivors were more likely to screen positive for current psychological distress and depression regardless of time since diagnosis; survivors diagnosed >1 year ago were more likely to use mental health prescription drugs; those diagnosed within 1 year reported significantly lower annual per capita mental health drug expenditure and out-of-pocket mental health expenditure, while those diagnosed >1 year presented significantly higher annual per capita mental health expenditure. No significant differences in mental health expenditures were found among adults aged 65 or older. CONCLUSIONS: Mental health problems presented higher health and economic burden among younger and longer-term survivors than individuals without a cancer history. This study provides data for monitoring the impact of initiatives to enhance coverage and access for mental health services at the national level. IMPLICATIONS FOR CANCER SURVIVORS: Early detection and appropriate treatment of mental health problems may help improve quality of cancer survivorship.

Healthcare Expenditure Burden Among Non-elderly Cancer Survivors, 2008-2012.

INTRODUCTION: There is increasing concern regarding the financial burden of cancer on patients and their families. This study presents nationally representative estimates of annual out-of-pocket (OOP) burden among non-elderly cancer survivors and assesses the association between high OOP burden and access to care and preventive service utilization. METHODS: Using the 2008-2012 Medical Expenditure Panel Survey, 4,271 cancer survivors and 96,780 individuals without a history of cancer were identified, all aged 18-64 years. High annual OOP burden was defined as spending >20% of annual family income on OOP healthcare costs. Associations between high OOP burden and access to care were evaluated with multivariable logistic regression. Analyses were conducted in 2015. RESULTS: Compared with individuals without a cancer history, cancer survivors were more likely to report a high OOP burden (4.3% vs 3.4%, p=0.009) in adjusted analyses. High OOP burden was more common among cancer survivors who were poor (18.4%), with either public insurance (7.9%) or uninsured (5.7%), and not working (10.2%). Among cancer survivors, high OOP burden was associated with being unable to obtain necessary medical care (19.2% vs 12.5%, p=0.002), delaying necessary medical care (21.6% vs 13.8%, p=0.002), and lower breast cancer screening rates among age-appropriate women (63.2% vs 75.9%, p=0.02). CONCLUSIONS: High OOP burden is more common among adults with a cancer history than those without a cancer history. High OOP burden was associated with being unable to obtain necessary medical care, delaying necessary medical care, and lower breast cancer screening rates among women.

Right ventricular free wall dyskinesis in the setting of left ventricular non compaction: a case report.

BACKGROUND: Left ventricular non compaction is a relatively rare congenital disorder characterized by prominent trabeculations and intertrabecular recesses with the potential for thromboembolism, arrhythmias, and sudden cardiac death as adverse effects. Echocardiography has traditionally been employed as the primary mode of imaging; however, with the advent of cardiac magnetic resonance as a more precise imaging technique, the disorder known as left ventricle non compaction is becoming more broadly defined with increasing recognition of right ventricle (RV) involvement. CASE PRESENTATION: This report describes a 52-year-old Caucasian female with new onset atrial fibrillation with an unusual finding of left ventricular non compaction and right ventricular dysfunction on transthoracic echocardiogram with preserved left ventricular ejection fraction. Cardiac magnetic resonance imaging demonstrated a disproportionately affected right ventricle, with apical free wall dyskinesis. CONCLUSIONS: This case illustrates the unique occurrence of left ventricular non compaction with preserved ejection fraction alongside RV free wall dyskinesis and RV systolic dysfunction. The significance of this is yet unknown given the paucity of existing literature. This report serves to highlight the vast heterogeneity within left ventricular non compaction as we are better able to delineate this disorder using increasingly sophisticated imaging techniques.

Efficacy, user acceptability, tolerability, and cycle control of a combined contraceptive vaginal ring: the Indian perspective.

OBJECTIVE: To assess the contraceptive efficacy, user acceptability, cycle control, and tolerability of a combined contraceptive vaginal ring for up to 13 cycles. MATERIALS AND METHODS: Healthy women coming to the OPD for contraceptive advice were enrolled in this one-year study. Each ring was used for three weeks followed by a one-week ring-free period. RESULTS: A total of 184 women started treatment forming the intent to treat population. Subjects were followed for 13 cycles. Compliance was good with 99 % of cycles in full compliance with specified criteria. In the intent to treat population, no pregnancies occurred giving a Pearl Index of 0. The mean incidence of withdrawal bleeding was 99 % in all cycles. There was 0.16 % incidence of intermenstrual bleeding and 2 % incidence of early withdrawal bleeding. The ring was well tolerated with a low incidence of adverse events. CONCLUSION: The ring is an effective contraceptive that is convenient, well tolerated with excellent cycle control, and highly acceptable to users.

Vanishing left ventricular thrombus in a woman with peripartum cardiomyopathy: a case report.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is a rare cardiac disorder characterized by the development of heart failure in the last month of pregnancy or up to 5 months postpartum in women without other identifiable causes of cardiac failure. The combination of left ventricular (LV) systolic dysfunction and hypercoaguability can cause thromboembolic complications including intra-cardiac thrombi. CASE PRESENTATION: A 25-year-old Caucasian female with PPCM demonstrated multiple thrombi in the LV on transthoracic echocardiography. Following anticoagulation with parenteral heparin, a cardiac MRI four days later demonstrated near resolution of the thrombi. CONCLUSION: We review the presentation, diagnosis and management of LV thrombi in the clinical setting of PPCM.