Retrospective Analysis of Dental Implant Failure Rates in Patients with Compromised Health.

Objectives: The goal of the current research was to compare the failure rate of dental implants in medically compromised patients to healthy individuals. Materials and Methods: In this seven years retrospective study, 50 patients from Group A who were medically compromised had 63 implants, while 50 patients from Group B who were healthy had 67 implants. Over 1 mm of bone loss around the implant in the first year and over 0.2 mm of bone loss per year after that were considered failure rates. Result: Two (2.9%) of the dental implants in Group B and 18 (28.6%) in Group A, both failed. The average bone loss around the implant in Group A during the first year was 1.21 mm, compared to 0.3 mm in Group B. Conclusion: Uncontrolled diabetes mellitus group had greater implant failure.

Integrating Xpert MTB/RIF for TB diagnosis in the private sector: evidence from large-scale pilots in Patna and Mumbai, India.

BACKGROUND: Xpert MTB/RIF (Xpert) has been recommended by WHO as the initial diagnostic test for TB and rifampicin-resistance detection. Existing evidence regarding its uptake is limited to public health systems and corresponding resource and infrastructure challenges. It cannot be readily extended to private providers, who treat more than half of India's TB cases and demonstrate complex diagnostic behavior. METHODS: We used routine program data collected from November 2014 to April 2017 from large-scale private sector engagement pilots in Mumbai and Patna. It included diagnostic vouchers issued to approximately 150,000 patients by about 1400 providers, aggregated to 18,890 provider-month observations. We constructed three metrics to capture provider behavior with regards to adoption of Xpert and studied their longitudinal variation: (i) Uptake (ordering of test), (ii) Utilization for TB diagnosis, and (iii) Non-adherence to negative results. We estimated multivariate linear regression models to assess heterogeneity in provider behavior based on providers' prior experience and Xpert testing volumes. RESULTS: Uptake of Xpert increased considerably in both Mumbai (from 36 to 60.4%) and Patna (from 12.2 to 45.1%). However, utilization of Xpert for TB diagnosis and non-adherence to negative Xpert results did not show systematic trends over time. In regression models, cumulative number of Xpert tests ordered was significantly associated with Xpert uptake in Patna and utilization for diagnosis in Mumbai (p-value< 0.01). Uptake of Xpert and its utilization for diagnosis was predicted to be higher in high-volume providers compared to low-volume providers and this gap was predicted to widen over time. CONCLUSIONS: Private sector engagement led to substantial increase in uptake of Xpert, especially among high-volume providers, but did not show strong evidence of Xpert results being integrated with TB diagnosis. Increasing availability and affordability of a technically superior diagnostic tool may not be sufficient to fundamentally change diagnosis and treatment of TB in the private sector. Behavioral interventions, specifically aimed at, integrating Xpert results into clinical decision making of private providers may be required to impact patient-level outcomes.

Field sales force model to increase adoption of a novel tuberculosis diagnostic test among private providers: evidence from India.

BACKGROUND: Impact of novel high-quality tuberculosis (TB) tests such as Xpert MTB/RIF has been limited due to low uptake among private providers in high-burden countries including India. Our objective was to assess the impact of a demand generation intervention comprising field sales force on the uptake of high-quality TB tests by providers and its financial sustainability for private labs in the long run. METHODS: We implemented a demand generation intervention across five Indian cities between October 2014 and June 2016 and compared the change in the quantity of Xpert cartridges ordered by labs in these cities from before (February 2013-September 2014) to after intervention (October 2014-December 2015) to corresponding change in labs in comparable non-intervention cities. We embedded this difference-in-differences estimate within a financial model to calculate the internal rate of return (IRR) if the labs were to invest in an Xpert machine with or without the demand generation intervention. RESULTS: The intervention resulted in an estimated 60 additional Xpert cartridges ordered per lab-month in the intervention group, which yielded an estimated increase of 11 500 tests over the post-intervention period, at an additional cost of US$13.3-US$17.63 per test. Further, we found that investing in this intervention would increase the IRR from 4.8% to 5.5% for hospital labs but yield a negative IRR for standalone labs. CONCLUSIONS: Field sales force model can generate additional demand for Xpert at private labs, but additional strategies may be needed to ensure its financial sustainability.

What would it cost to scale-up private sector engagement efforts for tuberculosis care? Evidence from three pilot programs in India.

BACKGROUND: Private providers dominate health care in India and provide most tuberculosis (TB) care. Yet efforts to engage private providers were viewed as unsustainably expensive. Three private provider engagement pilots were implemented in Patna, Mumbai and Mehsana in 2014 based on the recommendations in the National Strategic Plan for TB Control, 2012-17. These pilots sought to improve diagnosis and treatment of TB and increase case notifications by offering free drugs and diagnostics for patients who sought care among private providers, and monetary incentives for providers in one of the pilots. As these pilots demonstrated much higher levels of effectiveness than previously documented, we sought to understand program implementation costs and predict costs for their national scale-up. METHODS AND FINDINGS: We developed a common cost structure across these three pilots comprising fixed and variable cost components. We conducted a retrospective, activity-based costing analysis using programmatic data and qualitative interviews with the respective program managers. We estimated the average recurring costs per TB case at different levels of program scale for the three pilots. We used these cost estimates to calculate the budget required for a national scale up of such pilots. The average cost per privately-notified TB case for Patna, Mumbai and Mehsana was estimated to be US$95, US$110 and US$50, respectively, in May 2016 when these pilots were estimated to cover 50%, 36% and 100% of the total private TB patients, respectively. For Patna and Mumbai pilots, the average cost per case at full scale, i.e. 100% coverage of private TB patients, was projected to be US$91 and US$101, respectively. In comparison, the national TB program's budget for 2015 averages out to $150 per notified TB case. The total annual additional budget for a national scale up of these pilots was estimated to be US$267 million. CONCLUSIONS: As India seeks to eliminate TB, extensive national engagement of private providers will be required. The cost per privately-notified TB case from these pilots is comparable to that already being spent by the public sector and to the projected cost per privately-notified TB case required to achieve national scale-up of these pilots. With additional funds expected to execute against national TB elimination commitments, the scale-up costs of these operationally viable and effective private provider engagement pilots are likely to be financially viable.

Rare Case of Bilateral Pure Facet Joint Dislocation of Upper Lumbar Spine without Facet Fracture: A Case Report.

INTRODUCTION: Bilateral facetal dislocation without facet fracture, although common in cervical spine, is a very rare entity in lumbar spine with <15 cases reported so far. Such injuries are very unstable involving all the three columns. Neurological insult and visceral affection are commonly associated with bilateral facetal dislocation. CASE REPORT: A 22-year-old gentleman presented with ASIA Aparaplegia following road traffic accident. Radiographs/computed tomography scan revealed pure facetal dislocation L1-L2 with no evidence of facet fracture. The patient also had liver laceration. The patient underwent open instrumented reduction along with left-sidedtransforaminal removal of damaged disc and inter body fusion. The patient improved significantly to ASIA C neurological status at 6-month follow-up. CONCLUSION: Pure facetal dislocation, although rarely seen in lumbar region, is a very unstable injury. Prompt recognition and early intervention facilitate nursing care and neurological recovery. Recognition of associated injuries is also important.

Outcomes of Unstable Subaxial Cervical Spine Fractures Managed by Posteroanterior Stabilization and Fusion.

STUDY DESIGN: Retrospective study. PURPOSE: To evaluate clinical and radiological outcomes of unstable subaxial cervical spine injuries managed by both posterior tension band column stabilization and anterior decompression, stabilization, and fusion. OVERVIEW OF LITERATURE: Unstable subaxial cervical spine injuries often involve disruption of the anterior column and posterior tension band osteoligamentous complex. Such injuries need immediate surgical intervention. Different methods of reduction and surgical approaches have been published in the literature, with lack of consensus on a uniform or standardized method. Controversy still exists regarding stabilization of unstable cervical fractures by anterior or posterior approach alone or combined approaches. METHODS: We retrospectively evaluated 24 patients with post-traumatic unstable subaxial cervical spine injuries with their preoperative clinical details, X-ray, computed tomography, and magnetic resonance imaging of the cervical spine for fracture classification based on the mechanism of injury with status of disc herniation and posterior tension band disruption. All patients were managed by immediate reduction, posterior and anterior stabilization, and fusion in a single session of anesthesia. Data of all patients were analyzed with respect to pre- and postoperative neurological status based on American Spinal Injury Association grading, Visual Analog Scale score, the observation of bony fusion, and implant failure at 1, 3, 6, and 12 months. Data were analyzed using paired t-test. RESULTS: All patients had solid fusion at the desired level with considerable neurological improvement at the 1-year follow-up. CONCLUSIONS: In unstable cervical injuries, stabilization of disrupted posterior tension band increases the stability of anterior plating and fusion. This method of immediate reduction and circumferential stabilization is rapid, safe, and effective and has a low rate of complications.

Inserting pedicle screws in lumbar spondylolisthesis - The easy bone conserving way.

BACKGROUND: Pedicle screw fixation in high grade lumbar listhetic vertebral body has been nightmare for Orthopaedic and spine surgeons. This is because of abnormally positioned listhetic pedicles and non-visualization of pedicle in conventional image intensifier (C-Arm). This results into increased surgical time, more blood loss, radiation exposure and more chances of infection. To overcome this problem, we have devised a new Technique of putting of pedicle screw fixation in listhetic vertebrae. METHODS: Total 20 patients of average age of 42 (25-56) were included during 2010 to 2015. Listhesis was classified according to etiology, Meyerding grading and DeWald modification of Newman criteria used for assessment of severity for spondylolisthesis on standing X-ray lumbosacral spine. Patients satisfying following criteria were considered for surgery. Age more than 20 years, with single involvement of either L4-5/L5-S1, high grade spondylolisthesis (≥ 50% Meyerding grade), unresolving radiculopathy, cauda equina syndrome or pain with and without instability not relieved by 6 months of conservative treatment. According to Meyerding radiographic grading system,10 patients were of type II and 8 of type III and 2 of type IV. Treatment given was pedicle screw fixation, reduction of listhesis vertebra and spinal fusion with our technique. PLT was done in 10 cases and transforaminal lumbar interbody fusion (TLIF) in the other 10 cases. RESULTS: Mean follow up duration was 2 years (range 1.3-3.3 year). The average preoperative LBP VAS of low back pain were 6.7 and average LP VAS for leg pain 5.7. Postoperatively at final follow up there was reduction of LBP VAS to 2.2 and LP VAS to 0.5. There was rapid reduction in their LBP VAS in first two visits at 4 weeks and in LP VAS in first three visits at 8 weeks. The pain-free walking distance improved significantly. The average pre-operative ODI score was 51.4, improved to 18.6 postoperatively. There was no difference in above scores between PLT and TLIF. CONCLUSION: Our surgical technique used for high grade spondylolisthesis is safe, cost-effective, bone-preserving, reliable, and reproducible for high grade Lumber spondylolisthesis.

Synostosis of proximal phalangeal bases for loss of distal metacarpal.

A finger rendered unstable due to loss of metacarpal head can be stabilized by creating a synostosis at the base of the proximal phalanx of the affected finger with the adjacent normal finger. A cortico cancellous graft bridges the two adjacent proximal phalanges at their bases which are temporarily stabilized with an external fixator. The procedure can be done for, recurrence of giant cell tumor of metacarpal and for traumatic metacarpal loss. The procedure and long term follow up of one patient is presented who had giant cell tumor. This option should be considered before offering ray amputation. There is no micro vascular surgery involved, nor is there any donor site morbidity. The graft heals well without any absorption. The affected finger shows excellent function in the long term followup.

Personality changes and the role of counseling in the rehabilitation of patients with laryngeal cancer.

We conducted a study of 65 adults who had undergone laryngectomy for the treatment of laryngeal cancer. Our goal was to identify any abnormal personality traits in these patients and to assess the effect that psychological counseling might have on correcting these abnormalities and thereby improving postoperative voice rehabilitation. A Personality Trait Inventory (PTI) administered to all patients preoperatively identified 47 patients who had abnormal scores for at least three personality traits. These 47 patients were sent for preoperative psychological counseling, and 3 months following surgery, they underwent a follow-up PTI. At the follow-up assessment, 40 of these patients-32 men and 8 women-still registered abnormal scores for at least three traits. Half of the men and half of the women were randomized to receive 12 sessions of individualized psychological counseling over 6 months in addition to standard speech therapy (group I); the other patients received speech therapy only (group II). A follow-up PTI was administered at the completion of psychological counseling and/or speech therapy (postoperative month 9). Statistical analysis of the data was performed with the paired-samples test. Intragroup analysis of the follow-up PTI results revealed that both groups experienced a significant improvement in activity scores (p < 0.001) compared with their previous PTI results and that group I had significantly better scores for two other PTI traits-cyclothymia (mood swings) and depressive tendency (p < 0.05); neither group showed a significant improvement in dominance scores. Intergroup comparisons revealed that group I's activity and depressive tendency scores were significantly better than those of group II; there was no significant difference between the two groups in cyclothymia and dominance scores. Finally, comparison of results by sex, regardless of group, revealed that men had a significantly higher score for dominance and women had significantly higher scores for depressive tendency, emotional instability, introversion, and social desirability. We conclude that a preoperative personality analysis should be carried out in all patients scheduled for laryngectomy to identify those with personality problems that might benefit from psychological counseling. Correction of these problems should help in the physical, mental, vocational, and social rehabilitation of these patients.

Reversible hearing loss associated with high-voltage electric shock.

Hearing loss associated with high-voltage electric shock is a rare entity and minimal information is available in the current literature about this condition. To our knowledge, this article represents the first case report in the literature of improvement in sensorineural hearing loss sustained due to a high-voltage electric shock. A case report of a patient who incurred various otologic problems, including hearing loss and tinnitus, is presented. An improvement in hearing loss and tinnitus was observed in the subsequent follow up after one month. Audiological findings and possible pathophysiology of hearing loss are discussed. We recommend that further studies be done to investigate the incidence, severity and pathophysiology of hearing loss in such cases.