Informal payments and patients' perceptions of the physician agency problem: Evidence from rural China.

Informal payment for medical services is a common phenomenon in China. Patients make informal payments, in cash or in kind, to physicians in addition to official charges billed for medical services. This paper assesses the associations between patients' perceptions of the physician as an agent for the patient's interests (physician agency problem) and informal payment behavior. Using data of 24,000 and 6700 rural households respectively from the Health Development of Rural China Program database (collected in 2008) and Ningxia data source (collected in 2015), we find that patients' concern about physician agency problems is significantly associated with informal payments. The data shows that patients are more likely to make informal payments when they show low trust towards their physicians. For example, in the surgical cases, among patients who strongly distrusted the physicians, 17.9% (95% confidence interval [CI]:]: 13.5, 22.3) initiated informal payments, compared to 8.0% (95% CI: 5.1, 10.9) who expressed "strong trust" in their physicians. Poor communication was also significantly associated with an increase in the informal payment rate. For example, in the non-surgical setting, among the patients who rated the physicians' explaining skills as "poor," 5.9% (95% CI: 5.0, 6.9) of them made informal payments, significantly higher than the patients who rated "excellent" (of whom 1.8% made informal payments 95% CI, 0.9, 2.7). In this study, we provide an explanation for this finding: patients may initiate informal payments to physicians in order to mitigate the physician agency problem. It suggests that to mitigate informal payments, improving alignment between doctors' incentives and patients' interests would be essential.

Adult Posterior Fossa Anaplastic Ependymoma, Case Series and Literature Review.

OBJECTIVE: Ependymomas are rare central nervous system tumors. The current treatment strategy is gross total tumor removal. Whether adjuvant therapy will be beneficial is controversial. We retrospectively analyzed 3 cases of World Health Organization (WHO) grade III posterior fossa anaplastic ependymomas treated with different treatment modalities. We aimed to identify possible treatment options for infratentorial WHO grade III anaplastic ependymoma in adults. METHODS: We performed a retrospective analysis of 3 patients diagnosed with infratentorial anaplastic ependymomas in our institution from 2016 to 2020. The demographic data were documented. This case series of 3 patients does not meet the Department of Health and Human Services definition of research and does not need Institutional Review Board approval. All patients' informed consents have been obtained. RESULTS: One patient underwent subtotal tumor resection combined with adjuvant radiotherapy and Gamma Knife radiosurgery while the other 2 patients underwent gross total tumor removal combined with Gamma Knife radiosurgery or adjuvant radiotherapy. Tumors recurred in the first patient 20 months later, while the other 2 patents did not develop recurrence. The modified Rankin scale scores of these patients were 1, 0, and 0. All patients are followed up with regular magnetic resonance imaging at our facility. CONCLUSIONS: The strategy for treating WHO grade III anaplastic ependymomas is controversial, but gross total tumor resection remains the key element. Adjuvant stereotactic radiosurgery after tumor removal might be considered if radiotherapy is not an option. The role of chemotherapy is unclear, and the use of chemotherapy should be tailored to individual patients.

Spinal gouty tophus presenting as an epidural mass lesion - A case report.

INTRODUCTION: Gout is a metabolic disease secondary to an increased body pool of urate with hyperuricemia. Gout typically affects the peripheral joints and rarely involves the intra-spinal area. CASE PRESENTATION: A 43-year-old man, who had metabolic syndrome s/p bariatric surgery and gout suffered from severe left low back pain with radiation to the lateral side of his left thigh and anterior side of his left leg for more than 7 days. His L-spine MRI showed an abnormal posterior epidural space occupying lesion at L4-L5 level. For tissue diagnosis and neural structures decompression, he underwent surgical removal of the epidural mass lesion. The surgical specimen showed a picture of gout and he got a good recovery after operation. DISCUSSION: The differential diagnoses of an epidural mass includes synovial cysts, ligament cyst, cystic neuromas, tumors, hematomas and abscesses. Gout in the spinal canal is difficult to diagnosis before surgery because it is rare and its clinical presentation and radiologic findings mimic tumor, abscess, tuberculosis, and degenerative spinal diseases. Patients with spinal gout may present with axial pain and a variety of neurological symptoms. CONCLUSION: Spinal gouty tophus should be considered in the different diagnoses of spinal epidural masses especially in patients with systemic gout. Surgery is needed for final diagnosis. If spinal gouty tophus is highly suspected during the surgery, the specimen should not be preserved with Formalin because birefringent crystals under polarized light is a unique feature for gouty tophus but they dissolve in Formalin.

Comparing quality of primary healthcare between public and private providers in China: study protocol of a cross-sectional study using unannounced standardised patients in seven provinces of China.

INTRODUCTION: The Chinese government has encouraged the development of private sector in delivering healthcare, including primary healthcare (PHC) in the new round of national health reform since 2009. However, the debate about the role of the private sector in achieving universal health coverage continues with poor support from theories and empirical evidence. This study intends to compare the quality of PHC services between the private and public providers in seven provinces in China, using unannounced standardised patients (USPs). METHODS: We are developing and validating 13 USP cases most commonly observed in the PHC setting. Six domains of quality will be assessed by the USP: effectiveness, safety, patient centredness, efficiency, timeliness and equity. The USP will make 2200 visits to 705 public and 521 private PHC institutions across seven provinces, following a multistage clustered sample design. Using each USP-provider encounter as the analytical unit, we will first descriptively compare the raw differences in quality between the private and public providers and then analyse the association of ownership types and quality, using propensity score weighting. ETHICS AND DISSEMINATION: The study was primarily funded by the National Natural Science Foundation of China (#71974211, #71874116 and # 72074163) and was also supported by the China Medical Board (#16-260, #18-300 and #18-301), and have received ethical approval from Sun Yat-sen University (#2019-024). The validated USP tool and the data collected in this study will be freely available for the public after the primary analysis of the study. TRIAL REGISTRATION NUMBER: Chinese Clinical Trial Registry: #ChiCTR2000032773.

Intracranial solitary fibrous tumor/hemangiopericytoma - A case series.

BACKGROUND: Intracranial solitary fibrous tumor/hemangiopericytoma (HPC) is a rare and aggressive tumor. We conducted this retrospective study to investigate the outcome of patients after treatment, the efficacy of postoperative adjuvant radiotherapy, and the factors not conducive to total resection. METHODS: We conducted a retrospective review of the medical records of patients harboring fresh intracranial solitary fibrous tumor/HPC treated from January 2009 to December 2019 in our hospital. We reviewed their clinical presentations, radiologic appearances, tumor size and location, extent of resection, estimate intraoperative blood loss, treatment modalities and results, and duration of follow-up. RESULTS: There were seven consecutive patients (three males and four females). The ages of the patients at the time of diagnosis ranged from 35 to 77 years (mean: 52.86 years). Five patients (71.43%) got tumor bigger than 5 cm in dimension and only 1 patient (14.29%) underwent gross total tumor resection in the first operation without complication. Five patients (71.43%) underwent postoperative adjuvant radiotherapy. Follow-up period ranged from 4.24 to 123.55 months and the median follow-up period was 91.36 months. Three patients had favorable outcome with Glasgow Outcome Scale (GOS) equal to 4; four patients had unfavorable outcome with GOS equal to 2 or 3. No mortality was happened. CONCLUSION: Gross total tumor resection in the initial surgery is very important to achieve a better outcome. Massive intraoperative bleeding and venous sinus or major vessels adjoining are factors not conducive to total resection. Radiotherapy can be administered as adjuvant therapy for cases showing an aggressive phenotype or not treated with gross total resection.

Pituitary spindle cell oncocytoma presented as pituitary apoplexy.

Spindle cell oncocytoma is a rare nonfunctioning neoplasm of the adenohypophysis, and was first described in 2002 by Roncaroli et al. In 2007, spindle cell oncocytoma has been categorized as a separate entity by the World Health Organization (WHO) and is classified as a Grade 1 tumor of the central nervous system. Spindle cell oncocytoma of pituitary gland usually occurs in adults and accounts for 0.1-0.4% of all sellar region tumors. Clinically and radiologically, they are indistinguishable from nonfunctioning pituitary adenomas. From 2002 to 2018, approximately 46 cases of spindle cell oncocytoma of pituitary gland had been reported in the English literature and we would like to report a case of 28-year-old woman presented with pituitary apoplexy proved to be a case of spindle cell oncocytoma of pituitary gland which probably will be the 47th reported case.

Complications of diabetes in China: health system and economic implications.

BACKGROUND: The prevalence of diabetes and diabetic complications increased alarmingly which also brought heavy burden to patients and health system. METHODS: We used mix approaches to summarize evidence from published articles and policy documents on the extent and trends of diabetic complications, potential causes, and awareness and services utilization of diabetes in China. RESULTS: The annual direct medical expense per patient varied among different types of complications and increased dramatically with the number of diabetic complication and patients were exposed to great financial risk. The number of health policies and strategies on diabetes and its complications at the national level is limited. Primary and secondary preventions such as health education and early diagnosis are necessary. CONCLUSIONS: With an increasingly burden of non-communicable diseases such as diabetes and its complications, efforts should be invested in education, early screening mechanism and patient management programs to improve the primary and secondary prevention of diabetes and its complications. An integrated services delivery system centered on primary level is recommended to promote education, early case-detection and screening, patient management, referral and care-coordination between primary, secondary and tertiary health care providers.

Coexistence of intracranial solitary fibrous tumor/hemangiopericytoma and right middle cerebral artery aneurysm.

Intracranial solitary fibrous tumors are rare mesenchymal neoplasms originating in the meninges and constitute a heterogeneous group of rare spindle cell tumors that include benign and malignant neoplasms of which hemangiopericytoma is nowadays considered a cellular phenotypic variant. From literatures, the incidence of coexistence of brain tumors and intracranial aneurysms is ~0.7-5.4%. Meningioma is the most frequent tumor coexisted with intracranial aneurysms, followed by pituitary adenoma, neuroepithelial tumor, and metastatic tumor. We would like to report a case of 74-year-old man harboring a rare intracranial solitary fibrous tumor/hemangiopericytoma and an unruptured aneurysm of the right middle cerebral artery which probably the first report of these combinations in the English literature. Both lesions were treated surgically in one session with favorable outcome. Magnetic resonance angiography should be performed in patients with brain tumor preoperatively not only to visualize neoplastic vascularization but also to pick up incidental aneurysm.

Left orbital roof giant cell tumor of bone: A case report.

BACKGROUND: Giant cell tumor of bone originating from the connective tissue within the bone marrow is benign but locally aggressive lesion. In all, 90% of the cases involve the epiphysis of long bones and less than 2% involve the skull. Giant cell tumors of the skull occur most frequently in the sphenoid and temporal bones, and very rarely in the ethmoid, frontal, parietal, and occipital bones. We would like to share a case of giant cell tumor of bone arising from the left orbital roof with involving ethmoid sinus, which was diagnosed to be a meningioma before surgery. CASE DESCRIPTION: A 32-year-old lady presented to us with the chief complain of left proptosis, diplopia, and left eye soreness without decline of visual acuity for about 2 months. Her orbital magnetic resonance imaging (MRI) disclosed a mass lesion located in the left frontal base, orbital roof, and upper medial orbital region with adjacent dural-tail sign favoring meningioma. She underwent a left supraorbital pterional craniotomy with the gross total removal of tumor and dura reconstruction. Histology examination of the tumor showed a picture of giant cell tumor of bone. Considering giant cell tumor of bone is locally aggressive, postoperative adjuvant therapy with Denosumab was introduced after full explanation. CONCLUSION: Standard treatments of skull-base giant cell tumors have yet to be established due to small number of cases reported in the literature. The standard treatment of giant cell tumor of bone is complete resection of the tumor.

Glioblastoma with Both Oligodendroglioma and Primitive Neuroectodermal Tumor-Like Components in a Case with 9-Year Survival.

INTRODUCTION: Glioblastoma multiforme (GBM), the most common primary malignant brain tumor in adults, is characterized by extensive heterogeneity in its clinicopathological presentation. A primary brain tumor with both astrocytic differentiation and neuronal immunophenotype features is rare. Here, we report a long-term survival patient who presented this rare form of GBM in the disease course. PRESENTATION OF CASE: A 23-year-old woman, presenting with rapidly progressive headache and right-side weakness, was diagnosed with brain tumor over the left basal ganglion. She underwent the first craniectomy for tumor removal, and histopathology revealed classic GBM. Tumor recurrence occurred 8 years later. Another gross total resection was performed and pathology revealed GBM with the oligodendroglioma component (GBM-O). Due to disease progression, she received debulking surgery the following year. The third pathology revealed glioblastoma with primitive neuroectodermal tumor-like component (GBM-PNET). DISCUSSION: GBM-PNETs are collision tumors with both neuronal and glial components. They are rare, and a few case reports have suggested that these tumors are associated with favorable outcomes but a higher risk of cerebrospinal fluid dissemination. CONCLUSION: We report a patient who developed the distinct pathologic variants of classic GBM, GBM-O, and GBM-PNET, throughout the disease course. Young age, aggressive surgical resection, and pathologic and genetic features may have contributed to the long-term survival of the patient.

Intraspinal tumors: analysis of 184 patients treated surgically.

BACKGROUND: Intraspinal tumors are rare central nervous system neoplasms. The reported clinical features of intraspinal tumors have varied in previous studies. We present here the cases of 184 patients with intraspinal tumors treated surgically in our hospital and a review of the literature. METHODS: We conducted a retrospective review of 184 patients with intraspinal tumors who underwent surgical treatment in our institution between 2002 and 2013. Their age, sex, initial presentation, tumor location, level of affected vertebral column, histological diagnosis, and primary origin of the metastatic tumor were reviewed and analyzed. RESULTS: Of these 184 patients, 97 (52.7%) were men and 87 (47.3%) were women. The mean age was 56.3 years (range 7-83 years). A total of 102 (55.4%) had primary tumors, while 82 (44.6%) patients had developed metastatic tumors. The histological diagnosis of the primary tumors included 55 (53.9%) schwannomas, 16 (15.7%) meningiomas, six (5.9%) ependymomas, five (4.9%) neurofibromas, three (2.9%) hemangiomas, two (2.0%) hemagioblastomas, and 15 (14.7%) other tumor types. The most common primary sites of the metastatic tumors were the lung and breast. CONCLUSION: Primary tumors were more numerous than metastastic tumors in our series of patients. For the primary tumors, our study showed a higher proportion of nerve sheath cell tumors (schwannomas and neurofibromas) and fewer meningiomas and neuroepithelial tumors compared with reports from non-Asian countries. In addition, the lung was the most common origin of the metastatic tumors and more than half of these tumors were located at the thoracic spine. Back pain and radicular pain were the most common presentations in patients with intraspinal tumors.

Dyspnea and choking as presenting symptoms in primary medulla oblongata germinoma.

BACKGROUND: The medulla oblongata is the lower half of the brainstem. It contains the cardiac, respiratory, vomiting, and vasomotor centers and deals with autonomic functions such as breathing, heartbeat, and blood pressure. Primary medulla oblongata germinoma is very rare and less than 20 cases have been reported in the English literature. CASE DESCRIPTION: A 22-year-old female without any particular past medical history presented to us in October 2012 with the chief complaint of dyspnea and frequent choking for 1 month. Neurological examination revealed lower cranial nerve palsies and nystagmus. Her brain computed tomography (CT) and brain magnetic resonance imaging (MRI) demonstrated a mass lesion at the dorsal surface of medulla oblongata with extension into the inferior fourth ventricle and foramen magnum. She underwent bilateral suboccipital craniotomy and C1 laminoplasty with the grossly total resection of the tumor. The histological examination of the tumor proved germinoma. Postoperative adjuvant radiotherapy was arranged. The latest brain MRI and whole spine MRI done 1 year after surgery showed neither residual nor recurrent tumor in the whole axis. She is regularly followed-up at our outpatient department and is doing well except having left vocal cord palsy, which occurred before surgery. CONCLUSION: Medulloblastoma, ependymoma, glioma, hemangioblastoma, and cavernous angioma are common intraaxial tumors in the medulla oblongata and fourth ventricle. Intracranial germ cell tumors originate from extragonadal seminal cells and have been found in 0.4-3.4% of patients with primary central nervous system (CNS) tumors in Western countries, while the incidence is reported to be 5-8 times greater in Japan and the Far East. Although germinoma of medulla oblongata is rare and difficult to diagnose preoperatively, it should be included in the differential diagnosis of medulla masses with fourth ventricle extension, especially in Asian population.

Orbital apex syndrome due to aspergillosis with subsequent fatal subarachnoid hemorrhage.

BACKGROUND: Orbital apex syndrome has been described previously as a syndrome involving damage to the oculomotor nerve (III), trochlear nerve (IV), abducens nerve (VI), and ophthalmic branch of the trigeminal nerve (V1), in association with optic nerve dysfunction. It may be caused by inflammatory, infectious, neoplastic, iatrogenic, or vascular processes. CASE DESCRIPTION: A 73-year-old female having hypertension and rheumatoid arthritis stage 4 under long-term corticosteroid therapy presented to us with the right side orbital apex syndrome. Her magnetic resonance imaging (MRI) of orbit showed progression of a lesion at the right orbital apex and adjacent right superior orbital fissure with mild extension to the right posterior ethmoid sinus. She underwent endoscopic endonasal transethmoid approach with the removal of the lesion. The pathology showed a picture of fungal infection and the culture of the specimen proved Aspergillus fumigatus. Her postoperative course was smooth until 5 days after surgery, when she suffered a massive spontaneous subarachnoid hemorrhage resulting from a ruptured aneurysm, which was proven by computed tomography angiography (CTA) of brain. Unfortunately, she expired due to central failure. CONCLUSION: In cases of immunocompromised patients having orbital apex syndrome, fungal infection should be kept in mind. One of the most lethal but rare sequels of CNS fungal infection is intracranial aneurysms. Early diagnosis and radical resection, combined with antifungal medications is the key to save this particular group of patients.

Spontaneous regression of lumbar herniated disc.

Intervertebral disc herniation of the lumbar spine is a common disease presenting with low back pain and involving nerve root radiculopathy. Some neurological symptoms in the majority of patients frequently improve after a period of conservative treatment. This has been regarded as the result of a decrease of pressure exerted from the herniated disc on neighboring neurostructures and a gradual regression of inflammation. Recently, with advances in magnetic resonance imaging, many reports have demonstrated that the herniated disc has the potential for spontaneous regression. Regression coincided with the improvement of associated symptoms. However, the exact regression mechanism remains unclear. Here, we present 2 cases of lumbar intervertebral disc herniation with spontaneous regression. We review the literature and discuss the possible mechanisms, the precipitating factors of spontaneous disc regression and the proper timing of surgical intervention.

Primary vaginal extraosseous Ewing sarcoma/primitive neuroectodermal tumor with cranial metastasis.

Extraosseous Ewing sarcoma is now regarded as a member of the Ewing sarcoma/primitive neuroectodermal tumor (PNET) family. It typically involves the soft tissues of the chest wall, pelvis, paravertebral region, abdominal wall, retroperitoneal region and extremities of children, adolescents and young adults, but it seldom occurs in the female genital tract. We report an extremely rare case of retrospective diagnosis of vaginal extraosseous Ewing sarcoma/PNET which metastasized to the right frontoparietal scalp, skull, and dura. Surgical resection, followed by adjuvant radiotherapy and chemotherapy resulted in a favourable clinical outcome. Both the vaginal and head tumors had similar light microscopic features supporting the diagnosis.

Skull metastasis from uterine leiomyosarcoma: a case report.

Uterine leiomyosarcoma is a rare malignancy whose presenting symptoms usually are not specific for the disease. The clinical presentations include vaginal bleeding, pelvic pain or pressure, and awareness of an abdominal-pelvic mass. The diagnosis should be considered if rapid uterine enlargement occurs, especially in a post-menopausal woman. Local spreading of the tumor could involve the myometrium, pelvic blood vessels and lymphatics, contiguous pelvic structures, and then the abdominal organs, whereas distant metastasis most often involve the lungs. A 63-year-old female presented a rare uterine leiomyosarcoma metastasis to the skull with the manifestions of a bulging mass over her left occipito-parietal region. On admission, neurological examination revealed right hemiplegia. She underwent total resection of the tumor with the reconstruction of the dura, the skull plate and the scalp. Her post-operative course was smooth and the muscle power of her right limbs was improved from grade 1 to grade 3 after the procedure. The histological diagnosis is leiomyosarcoma. Aggressive management of the metastatic skull tumor is recommended in selected patients at least for a betterquality of life.

Huge spinal extradural meningeal cyst in the thoracolumbar spine: a case report of a rare cause of low backpain.

Symptomatic intraspinal extradural meningeal cysts are rare. We present the case of a 17-year-old female with low back pain, progressive numbness, and radiation pain to the flank and lower limbs. Magnetic resonance imaging and computed tomographic myelography revealed a huge intraspinal extradural meningeal cyst extending from T12 to L3 with cord and dural sac compression. The patient underwent surgery to open the cyst and close the connecting dural defect. Pathologic examination of the cyst disclosed non-specific fibrous connective tissue without an inner arachnoid single-cell lining. She achieved complete recovery after the operation. There was no recurrence of the cyst at a 2-year follow-up.

Solitary fibrous tumor of the orbit.

The occurrence of solitary fibrous tumor in the orbit is rare. The following is a report on the case of a 24-year-old man presented with painless, progressive proptosis of the right eye for the duration of 1 year. Computed tomography and magnetic resonance imaging demonstrated a well-circumscribed soft tissue mass with gadolinium enhancement located in the superomedial aspect of the right orbit. The patient underwent complete tumor removal through a right fronto-orbital approach, with a pathological diagnosis of solitary fibrous tumor. Postoperatively, the patient was symptom-free. From review of the literature on orbital solitary fibrous tumor, emphasis should be placed on complete tumor resection and continuous follow-up monitoring of the tumor.