Healthcare Scheme to Overcome Financial Burden Associated with Chemoradiation Therapy in Head and Neck Cancer Patients: A Retrospective Single Centre Study.

Head and neck cancer (HNC) is third highest prevalent cancer among Indian which constitutes about 25-30% of all the cancer in India. Further, out-of-pocket expenditure (OOPE) covers around 67% of total healthcare expenditure and direct medical cost is key factor responsible for raised OOPE in India. Thus, we aimed to quantify total direct medical cost and OOPE associated with HNC management among HNC patients using "Ayushman Bharat Arogya Karnataka scheme" (ABArK scheme). A retrospective study was conducted for the duration of 6 months to collect the data related to total direct medical cost, coverage of "ABArK Scheme" and OOPE of past 2 years of HNC patients. The data of HNC patients above 18 years of age utilizing "ABArK scheme" were included in the study whereas data of patients utilizing other healthcare schemes and incomplete data on target schemes were excluded. A total of 196 patients (54.1%) utilized the "ABArK Scheme" out of 362 HNC patients treated in past 2 years. Among 196 patients, males (76.5%) were predominant over females (23.5%) with the mean age of 53.60 ± 11.58 years. We found that INR 17,370,279 as the total direct medical expenditure for the management of HNC patients of which around 87.465% was covered by "ABArK Scheme" minimizing the OOPE up to INR 3,297,970. Thus, Introduction and implementation of novel healthcare policies like "ABArK Scheme" can counteract financial burden of cancer management by significantly reducing OOPE which could be milestone achievement for the low-middle income countries like India.

Predictive validity of ESSENCE Q screening tool for early detection of neurodevelopmental disorder in children.

INTRODUCTION: Neurodevelopmental disorders (NDD) are a group of conditions that typically manifest early during the child's development with lifelong consequences. Early identification using efficient screening tools can positively modify the natural history of the disorder. ESSENCE Q is a simple questionnaire to detect ESSENCE (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations to reflect the co-existence of NDDs in children less than five years). There are limited studies on the validity of ESSENCE Q in detecting NDDs in young children in India. METHODS: We did a cross-sectional study in a tertiary care hospital to evaluate the validity of ESSENCE Q in detecting neurodevelopmental disorders. We translated the ESSENCE Q and subsequently used it to screen for NDD in 100 children aged 12-60 months. Clinical consensus diagnosis by two experienced experts was taken as the gold standard. RESULTS: 23% were diagnosed as having NDD as per the clinical consensus diagnosis. Around half the children (46%) were "at-risk for NDD" based on the ESSENCE Q scale. We found an optimal cut-off for ESSENCE Q of more than or equal to 4 with a sensitivity of 96%, a specificity of 82%, and a Youden index of 0.77. CONCLUSION: ESSENCE Q has good predictive validity to be used as a quick and easy screening tool to detect NDDs in young children under the age of 5 years.

Neighborhood context and non-small cell lung cancer outcomes in Florida non-elderly patients by race/ethnicity.

OBJECTIVE: The purpose of this study was to investigate the relationship between neighborhood environment and lung cancer outcomes among Florida residents younger than 65 years of age. METHODS AND MATERIALS: This was a retrospective cohort study that included patients diagnosed with non-small cell lung cancer (NSCLC) in Florida from January 2005 to December 2014 (n = 22,750). Multi-level, mixed-effect logistic regression models were used for two outcomes: receipt of treatment and receipt of surgery. Survival analyses, using proportional subdistribution hazard models, were conducted to examine the impact of neighborhood characteristics on risk of death due to lung cancer with adjustment for individual-level variables. Neighborhood exposures of interest were census tract level black and Hispanic segregation combined with economic deprivation. RESULTS: White patients who lived in low black segregation/high deprivation areas had 15 % lower odds of receiving surgery (95 % CI: 0.76-0.93). However, the likelihood of receiving surgery for black patients who lived in high black segregation/low deprivation and high black segregation/high deprivation was lower than for black patients who lived in low black segregation/low deprivation neighborhoods (level 3 AOR = 0.56 [0.38-0.85]; level 4 AOR = 0.69 [0.54-0.88]). Living in suburban and rural areas increased the risk of lung cancer death for white patients by 14 % (95 % CI: 1.05-1.24) and 26 % (95 % CI: 1.08-1.46), respectively. Living in rural areas increased the risk of death for black patients by 54 % r (SHR = 1.54 [1.19-2.0]). Black patients who live in high Hispanic segregation/high deprivation had 36 % increased risk of death compared to black patients who lived in low Hispanic segregation/low deprivation areas. CONCLUSION: This study suggests that when investigating cancer disparities, merely adjusting for race/ethnicity does not provide sufficient explanation to understand survival and treatment variations. Lung cancer outcomes are impacted by neighborhood environments that are formed based on the distribution of race, ethnicity and class.

Association of Antimicrobial Susceptibility and Treatment Outcome in Acne Vulgaris Patients: A Pilot Study.

Purpose Cutibacterium acnes ( C. acnes ) is an emerging pathogen that is highly resistant to antibiotics and is capable of causing persistent infections that are difficult to treat. Methods & Materials Acne vulgaris patients visiting dermatology OPD of our tertiary care hospital during the study period of 2 months were recruited. Skin swabs were collected, and the sample was processed on 5% sheep-blood agar for anaerobic culture by the GasPak method. Isolates were identified by the standard biochemical test. Antimicrobial susceptibility testing was performed for clinically relevant antibiotics by the E-strip method. The clinical response was evaluated after 1-month follow-up to the prescribed antibiotics. Results Minocycline, doxycycline, ceftriaxone, and tetracycline were the most effective antibiotics. Nonsusceptibility to clindamycin and erythromycin were observed in 11.9% and 31% isolates, respectively, with 9.5% isolates being nonsusceptible to both. For none of the antibiotics we found significant difference in the proportion of susceptible and nonsusceptible isolates between mild, moderate, and severe grades of acne vulgaris. For none of the antibiotic regimens, significant difference was observed between nonresponders and responders. Twenty-seven patients received clindamycin and among them 16 of 19 responders and 6 of 8 nonresponders yielded growth of clindamycin-susceptible isolates ( p = 0.57). Conclusion We observed significant prevalence of resistant strains of C. acnes among patients with acne vulgaris. No association was observed between in vitro susceptibility results and treatment outcome.

Stiff Left Atrial Syndrome; Prospects and Possibilities. Retrospective Analysis and Review of the Literature.

OBJECTIVES: Stiff left atrial syndrome is an intriguing clinical phenomena characterized by reduced left atrial compliance, pulmonary venous hypertension and exacerbations of volume overload. We conducted a retrospective review of patients diagnosed with stiff left atrial syndrome at our center. METHODS: All patients admitted to our hospital with volume overload and pulmonary venous hypertension who were diagnosed with stiff left atrial syndrome based on evidence by echocardiogram and right heart catheterization between July 2011 and July 2013 were included in this retrospective review. RESULTS: Twentythree patients (mean age 73 ± 11 years, 39% male and 61% female) were diagnosed with stiff left atrial syndrome at our center. Thirty-five percent had persistent while 39% had permanent atrial fibrillation. Mean duration of atrial fibrillation was 7.6 ± 2.1 years. Forty-three percent of patients had long standing hypertension. There was no mitral regurgitation in 39% of patients while 48% had mild mitral regurgitation. On right heart catheterization, mean right atrial pressure was 12.6±4.8 mm of Hg, mean pulmonary arterial pressure was 33±7.2 mm of Hg, mean pulmonary capillary wedge pressure was 24.8± 4.2mm of Hg while peak V waves were seen at mean of 37.8± 5.3 mm of Hg. Mean left atrial volume index was 49.8±17.1 mL/m 2. After the initial diagnosis with a two year follow- up, there were no readmissions in 65% of patients who were on appropriate diuretic therapy and had regular clinical visits. Frequent readmissions were seen in 35% of patients inspite of appropriate diuretic therapy. All-cause mortality rate was 4.3% at two year follow up. CONCLUSION: In patients with stiff left atrial syndrome, the presence of left atrial dilation, long standing atrial fibrillation and hypertension are the key factors associated with pathogenesis and clinical course. Close follow up and monitoring of volume status is essential to prevent hospital readmissions and improve long term prognosis.

Multidrug resistant tuberculosis in prisons located in former Soviet countries: A systematic review.

BACKGROUND: A systematic literature review was performed to investigate the occurrence of multidrug-resistant tuberculosis (MDR TB) in prisons located in countries formerly part of the Soviet Union. METHODS: A systematic search of published studies reporting MDR TB occurrence in prisons located in former Soviet countries was conducted by probing PubMed and Cumulative Index Nursing and Allied Health Literature for articles that met predetermined inclusion criteria. RESULTS: Seventeen studies were identified for systematic review. Studies were conducted in six different countries. Overall, prevalence of MDR TB among prisoners varied greatly between studies. Our findings suggest a high prevalence of MDR TB in prisons of Post-Soviet states with percentages as high as 16 times more than the worldwide prevalence estimated by the WHO in 2014. CONCLUSION: All studies suggested a high prevalence of MDR TB in prison populations in Post-Soviet states.

Spatial Patterns and Neighborhood Characteristics of Overall Suicide Clusters in Florida From 2001 to 2010.

INTRODUCTION: Although spatial examination of mortality and morbidity is becoming more common in health studies, the investigation of suicide death clusters within the neighborhood context is underutilized. The purpose of this ecological study is to detect high- and low-risk clusters of suicide deaths in Florida and determine which neighborhood characteristics distinguish clusters from non-clusters. METHODS: The scan statistic method was used to detect overall clusters of completed suicides in Florida from 2001 to 2010. Regression analysis was used to investigate the association of neighborhood characteristics with identified clusters. All data synthesis and statistical analyses were conducted in 2015. RESULTS: Twenty-four high-risk and 25 low-risk clusters were identified. The risk of suicide was up to 3.4 times higher in high-risk clusters than in areas outside of clusters (relative risk ranged from 1.36 to 3.44, p≤0.05). Low-risk clusters were associated with 30%-94% decreased risk of suicide (relative risk ranged from 0.06 to 0.70, p≤0.05). Areas with high levels of elderly concentration and household singularity were more likely to be in high-risk clusters, whereas areas with higher economic deprivation and residential density were more likely to be in low-risk clusters. CONCLUSIONS: This study identified general suicide patterns across space in the state of Florida and described the characteristics of those areas.

The Effects of Residential Segregation and Neighborhood Characteristics on Surgery and Survival in Patients with Early-Stage Non-Small Cell Lung Cancer.

BACKGROUND: Although the negative effects of lower socioeconomic status on non-small cell lung cancer (NSCLC) treatment and survival have been widely studied, the impact of residential segregation on prognosis and the receipt of treatment has yet to be determined. METHODS: This is a retrospective, cohort study of NSCLC patients in Georgia (2000-2009; n = 8,322) using data from the Georgia Comprehensive Cancer Registry. The effects of segregation, economic deprivation, and combined segregation/deprivation on the odds of receiving surgery were examined in separate multilevel models. To determine the association for the exposures of interest on the risk of death for different racial groups, separate multilevel survival models were conducted for black and white patients. RESULTS: Living in areas with the highest [AOR = 0.35, 95% confidence interval (CI), 0.19-0.64] and second highest (AOR = 0.37, 95% CI, 0.20-0.68) levels of segregation was associated with decreased odds of receipt of surgery. Black patients living in areas with high residential segregation and high economic deprivation were 31% (95% CI, 1.04-1.66) more likely to die, even after surgery was controlled for. For white patients, economic deprivation was associated with decreased odds of surgery but not survival. Segregation had no effect. CONCLUSION: Our findings suggest how black and white individuals experience segregation and area-level poverty is likely different leading to differences in adverse health outcomes. IMPACT: Identifying neighborhood characteristics impacting health outcomes within different racial groups could help reduce health disparities across racial groups by implementing targeted policies and interventions. Cancer Epidemiol Biomarkers Prev; 25(5); 750-8. ©2016 AACR.

Left Atrial Diastolic Dysfunction And Pulmonary Venous Hypertension In Atrial Fibrillation: Clinical, Hemodynamic And Echocardiographic Characteristics.

BACKGROUND: Left ventricular diastolic dysfunction has been well described; diastolic abnormalities of the LA are less frequently recognized and poorly understood. OBJECTIVE: The purpose of this study was to investigate the clinical, hemodynamic and echocardiographic features of left atrial (LA) diastolic dysfunction. METHODS: Patients with atrial fibrillation (AF), severe LA enlargement, and pulmonary venous hypertension (PVH, Group 1) were compared to patients with pulmonary arterial hypertension (PAH), normal LA size and sinus rhythm (Group 2). All underwent right heart catheterization and transthoracic echo to evaluate hemodynamics and LA function. Mitral regurgitation was evaluated by transesophageal echocardiography. LA diastolic function was measured by comparing filling fraction, pulmonary venous flow and compliance. RESULTS: Right atrial, pulmonary artery systolic and mean pressures were similar. Mean wedge pressure were increased in Group 1, 20.8±2.6 versus 9.7±2.8 mm of Hg (p<0.0001). The most striking hemodynamic difference was large V wave in Group 1 without significant mitral regurgitation. LA filling fraction was abnormal in Group 1, 11.4%±8.5 compared to Group 2, 111.5%±44 (p<0.0001). LA compliance was 0.39±0.27 ml/m2/mmHg in Group 1 versus 6.8±4.54 ml/m2/mmHg in Group 2 (p=0.001). There was a strong negative correlation between the V wave and LA filling fraction (r= 0.756, p<0.001). The ratio of the height of the transmitral E wave divided by the S/D ratio (the LA diastolic dysfunction index) correlated very strongly with the V wave (r=0.907, p<0.001). CONCLUSION: LA diastolic dysfunction is present in some patients with long standing AF and PVH. LA diastolic dysfunction, in addition to left ventricular diastolic dysfunction, may contribute to the syndrome of heart failure with preserved left ventricular systolic function.

Stiff left atrial syndrome after catheter ablation for atrial fibrillation: clinical characterization, prevalence, and predictors.

BACKGROUND: There have been no studies of atrial diastolic function after catheter ablation of atrial fibrillation (AF). We encountered a few patients with symptomatic left atrial (LA) diastolic dysfunction and associated pulmonary hypertension (PH) that developed after catheter ablation for atrial fibrillation. Similar findings were described in patients after cardiac surgery and were referred to as the "stiff left atrial syndrome." OBJECTIVE: The purpose of this study was to prospectively quantify the incidence of patients developing PH associated with diastolic hemodynamic abnormalities of the LA after radiofrequency ablation of AF and to identify the possible predictors. METHODS: Between January 2009 and July 2010, data on 1,380 consecutive patients were prospectively collected. Before ablation and at follow-up, all patients had an echocardiogram to assess for the presence of PH. Patients with no echocardiographic evidence of PH but complaining of unexplained dyspnea with LA diastolic abnormalities were evaluated with right heart catheterization (RHC). Patients were included in the analysis if they developed new or worsening PH postablation with evidence of LA diastolic dysfunction by RHC or direct LA pressure measurement. All patients were evaluated for pulmonary vein stenosis and excluded if this condition was identified. RESULTS: The mean age was 62 ± 11 (75% male), and nonparoxysmal AF was the predominant arrhythmia (71%). New or worsening PH with associated LA diastolic abnormalities was detected in 19 (1.4%) patients after ablation. The prevalence of PH did not differ between AF types (P = .612). Compared with patients who did not develop PH, LA scarring (P <.001), diabetes (P = .026), and obstructive sleep apnea (OSA; P = .006) were more frequently observed among those who developed PH. In a multivariable logistic model, preprocedure LA size ≤45 mm (odds ratio [OR] = 6.13; P = .033), mean LA pressure (OR 1.14; P = .025), severe LA scarring (OR = 4.4; P = .046), diabetes mellitus (OR = 9.5; P = .004), and OSA (OR = 6.2; P = .009) were independently associated with the development of PH postablation. CONCLUSIONS: After radiofrequency catheter ablation of atrial fibrillation (RFCAF), PH with LA diastolic dysfunction or the so-called stiff LA syndrome is a rare but potentially significant complication of AF ablation. Severe LA scarring, LA ≤45 mm, diabetes mellitus, OSA, and high LA pressure are clinical variables that predict the development of this syndrome. The main clinical findings include dyspnea, congestive heart failure, PH, and large V waves on pulmonary capillary wedge pressure (PCWP) or LA pressure tracings in the absence of mitral regurgitation.

Perventricular closure of a large ventricular septal defect in congenitally corrected transposition of the great arteries.

We report the case of a 30 year-old male with congenitally corrected transposition of the great arteries, atrial, and ventricular septal defects (VSD), and pulmonary stenosis. He previously underwent three palliative surgical procedures before undergoing intracardiac repair at age 20 with a left ventricular to pulmonary artery (LV-PA) conduit, VSD closure, and replacement of the systemic atrioventricular valve. A residual VSD was noted postoperatively. He did well for approximately 10 years when he started becoming more breathless with daily activities and was noted to have a resting room air oxygen saturation of 85%. Despite increased diuretic therapy he continued to deteriorate and was ultimately admitted to the hospital in florid right and left heart failure with recurrent atrial fibrillation. Catheterization revealed pulmonary hypertension (pulmonary artery pressure = 80/17 mm Hg), moderate conduit stenosis, severe pulmonic regurgitation, and oxygen saturation of 75%. Calculated shunt fraction (Qp : Qs) was 1.3:1. He was referred for surgical intervention, specifically, LV-PA conduit replacement, oversewing of the pulmonic valve, VSD closure, and pacemaker placement. Intraoperatively, the VSD could not be closed despite multiple attempts through various approaches. Therefore, perventricular VSD closure using two Amplatzer septal occluders (AGA Medical, Golden Valley, MN) was performed in the operating room with the chest open off cardiopulmonary bypass. Following deployment, the residual shunt was small and the inferior vena cava-to-pulmonary artery saturation step-up was only 4%. The left ventricular systolic pressure decreased to one half systemic. This case highlights the utility and efficacy of a hybrid approach in the treatment of complex congenital heart disease.

Sputum color: potential implications for clinical practice.

BACKGROUND: Respiratory infections with sputum production are a major reason for physician visits, diagnostic testing, and antibiotic prescription in the United States. We sought to determine whether the simple characteristic of sputum color provides information that impacts resource utilization such as laboratory testing and prescription of antibiotics. METHODS: Out-patient sputum samples submitted to the microbiology laboratory for routine analysis were assigned to one of 8 color categories (green, yellow-green, rust, yellow, red, cream, white, and clear), based on a key made from paint chip color samples. Subsequent Gram stain and culture results were compared to sputum color. RESULTS: Of 289 consecutive samples, 144 (50%) met standard Gram-stain criteria for being acceptable lower-respiratory-tract specimens. In the acceptable Gram-stain group, 60 samples had a predominant organism on Gram stain, and the culture yielded a consistent result in 42 samples (15% of the 289 total specimens). Yield at each level of analysis differed greatly by color. The yield from sputum colors green, yellow-green, yellow, and rust was much higher than the yield from cream, white, or clear. CONCLUSIONS: If out-patient sputum is cream, white, or clear, the yield from bacteriologic analysis is extremely low. This information can reduce laboratory processing costs and help minimize unnecessary antibiotic prescription.

Desire, envy and punishment: a Matsigenka emotion schema in illness narratives and folk stories.

Accumulating evidence suggests that folktales in some societies are characterized by a culturally constructed underlying emotional structure, or Cultural Emotion Schema. In this paper we argue that Matsigenka illness narratives and folk stories share an underlying emotion schema, in which death and suffering result from conflicts between strong-willed individuals prompting anger and aggression. Analysis of illness narratives collected by Izquierdo in the Matsigenka community of Kamisea in the Peruvian Amazon between 1996 and 1999 reveals a common pattern in which envy and frustration lead to the belief in sorcery as the main cause of illness and death. This pattern contrasts with the typical stories of a previous generation collected by the Johnsons among the Matsigenka of Shimaa and other Matsigenka researchers, where sorcery beliefs were virtually absent. Our argument is that important changes in ecology, community, politics, and religion have led to a systematic rise in feelings of envy and frustration, and that these have increased the likelihood that sorcery accusations will occur. We explore the likelihood that such beliefs increase as egalitarian peoples become more crowded into settlements where they are likely to experience greater inequality, more competition for resources and increased societal and personal stress.

Vertical patellar position in large-breed dogs with clinically normal stifles and large-breed dogs with medial patellar luxation.

OBJECTIVE: To further define vertical patellar position, as measured by the ratio of patellar ligament length to patellar length (L:P), in large-breed dogs with clinically normal stifles and compare that to the L:P of large-breed dogs with medial patellar luxation (MPL). STUDY DESIGN: Retrospective study. SAMPLE POPULATION: Large-breed dogs (n = 50) with clinically normal stifle joints and 30 large-breed dogs with MPL. METHODS: Large-breed dogs with clinically normal stifle joints or MPL were identified and divided into groups (NORM and MPL, respectively). L:P values were determined for each dog by 4 observers from single lateral stifle radiographs. L:P was compared between NORM and MPL groups and 95% confidence intervals (CIs) were calculated. RESULTS: All 4 observers found a significantly higher L:P (more proximally positioned patella) for the MPL group compared with the NORM group. Overall mean (+/-SEM) L:P were: NORM, 1.71+/-0.020 and MPL, 1.87+/-0.025. The 95% CI was determined to be 1.45-1.97 for the NORM group and 1.57-2.17 for the MPL group. CONCLUSIONS: Large-breed dogs with MPL had a significantly more proximal vertical patellar position compared with large-breed dogs with clinically normal stifles. Large-breed dogs with L:P values >1.97 are considered to have patella alta. CLINICAL RELEVANCE: Proximal displacement of the patella within the femoral trochlear groove may play a role in MPL in large-breed dogs.

Left ventricular cardiac tamponade in the setting of cor pulmonale and circumferential pericardial effusion. Case report and review of the literature.

Circumferential pericardial effusion typically results in biventricular tamponade and equalization of intracardiac and pericardial pressure during diastole. However, tamponade may involve the right or left ventricle. While isolated left ventricular cardiac tamponade (LVCT) can occur as a postoperative complication from localized posterior pericardial effusions, circumferential pericardial effusions leading to LVCT are rare. We report a case of a patient with severe pulmonary hypertension, a large nonloculated pericardial effusion, and LVCT, which was probably due to a chronic undifferentiated connective tissue disorder. This case illustrates that when evaluating patients with circumferential pericardial effusions and associated pulmonary hypertension, the typical findings of cardiac tamponade (pulsus paradoxus, right ventricular diastolic compression and hypotension) may be masked. The echocardiogram must be reviewed carefully as it may reveal left ventricular diastolic compression, the hallmark of LVCT, which may significantly compromise left ventricular filling and cardiac output.

Influence of limb positioning and measurement method on the magnitude of the tibial plateau angle.

OBJECTIVE: To evaluate the effect of limb positioning and measurement technique on the magnitude of the radiographically determined tibial plateau angle (R-TPA). STUDY DESIGN: In vitro study, R-TPA was determined by 6 blinded observers and image measurement software. ANIMALS: Five canine cadaver hind limbs. METHODS: The legs were positioned on a custom-made positioning device simulating a radiographic tabletop technique in lateral recumbency. True lateral positioning was defined by superimposition of femoral and tibial condyles on the radiographic projection. Radiographs were taken while the specimens were relocated in a proximal, distal, caudal, and cranial direction with respect to the radiographic beam. For each specimen, 25 different radiographic views were obtained and 6 blinded observers determined the radiographic TPA using 2 different methods. The conventional method used precise anatomic landmarks to determine the tibial plateau. To simulate osteoarthritic changes complicating identification of these landmarks, the tangential method estimated the tibial plateau as the tangent to the central portion of the tibial plateau. After periarticular soft tissue dissection the anatomic tibial plateau angle (A-TPA) was determined. The A-TPA and the R-TPA were compared. RESULTS: The R-TPA significantly decreased as limb position with respect to the X-ray beam changed from cranial proximal to caudal distal. The maximal mean radiographic R-TPA difference was 3.6 degrees with the first and 5.7 degrees with the second method. Regardless of the method used there was no significant difference between A-TPA and R-TPA in the true lateral position. In the peripheral positions, however, significant differences between anatomic and radiographic TPA were seen. CONCLUSIONS: Limb positioning influenced the radiographic appearance of the tibial plateau and the magnitude of the measured TPA. Cranial and proximal positioning of the limb relative to the X-ray beam leads to overestimation whereas caudal and distal positioning leads to underestimation of the TPA. CLINICAL RELEVANCE: True lateral positioning of the tibia defined by superimposition of the femoral and tibial condyles should be used for accurate TPA determination before tibial plateau leveling osteotomy.