High Poverty and Hardship Financing Among Patients with Noncommunicable Diseases in Rural Haiti.

Background: Poverty is a major barrier to healthcare access in low-income countries. The degree of equitable access for noncommunicable disease (NCD) patients is not known in rural Haiti. Objectives: We evaluated the poverty distribution among patients receiving care in an NCD clinic in rural Haiti compared with the community and assessed associations of poverty with sex and distance from the health facility. Methods: We performed a cross-sectional study of patients with NCDs attending a public-sector health center in rural Haiti 2013-2016, and compared poverty among patients with poverty among a weighted community sample from the Haiti 2012 Demographic and Health Survey. We adapted the multidimensional poverty index: people deprived ≥44% of indicators are among the poorest billion people worldwide. We assessed hardship financing: borrowing money or selling belongings to pay for healthcare. We examined the association between facility distance and poverty adjusted for age and sex using linear regression. Results: Of 379 adults, 72% were women and the mean age was 52.5 years. 17.7% had hypertension, 19.3% had diabetes, 3.1% had heart failure, and 33.8% had multiple conditions. Among patients with available data, 197/296 (66.6%) experienced hardship financing. The proportions of people who are among the poorest billion people for women and men were similar (23.3% vs. 20.3%, p > 0.05). Fewer of the clinic patients were among the poorest billion people compared with the community (22.4% vs. 63.1%, p < 0.001). Patients who were most poor were more likely to live closer to the clinic (p = 0.002). Conclusion: Among patients with NCD conditions in rural Haiti, poverty and hardship financing are highly prevalent. However, clinic patients were less poor compared with the community population. These data suggest barriers to care access particularly affect the poorest. Socioeconomic data must be collected at health facilities and during community-level surveillance studies to monitor equitable healthcare access. Highlights: Poverty and hardship financing are highly prevalent among NCD patients in rural Haiti.Patients attending clinic are less poor than expected from the community.People travelling farther to clinic are less poor.Socioeconomic data should be collected to monitor healthcare access equity.

Patterns of Hydrocephalus in Rural Haiti: A Computed Tomography-Based Study.

INTRODUCTION/OBJECTIVE: Hydrocephalus is a common neurosurgical disorder that can lead to significant disability or death if not promptly identified and treated. Data on the burden of hydrocephalus in low-income countries are limited, given a lack of radiologic resources for the diagnosis of this condition. Here, we present an analysis of patterns of hydrocephalus from a large sample of computed tomography (CT) scans of the head performed at a public hospital in rural Haiti, a low-income country in the Caribbean. METHODS: We analyzed reports from 3614 CT scans of the head performed between July 2013 and January 2016 for findings that were consistent with a diagnosis of hydrocephalus (report indicating "hydrocephalus," "ventriculomegaly," or "enlargement of the ventricles"). Extracted data included demographics, study indication, radiologic findings, and reported etiology of hydrocephalus. RESULTS: In total, 119 scans had findings concerning for hydrocephalus (3.5% of all scans, 6.3% of abnormal scans; age range 0-90 years; median age 35.5 years; 49.6% male). Pediatric patients (<18 years of age) accounted for 39% of cases. In total, 113 of 119 (95%) scans had indications for possible neurosurgical intervention. Among these 113 scans, 36 (30%) scans demonstrated communicating hydrocephalus, 66 (55%) scans demonstrated noncommunicating hydrocephalus (primarily due to intraventricular hemorrhage [27 scans, 23%] or brain tumors [24, 20%]), and 11 (9%) scans were indeterminate regarding whether the hydrocephalus was communicating versus noncommunicating. CONCLUSIONS: In a large sample of CTs performed in a rural low-income setting, hydrocephalus was common, predominantly noncommunicating, and often associated with potentially operable intracranial lesions. Data of this nature can inform research, policy, and clinical collaborations that strengthen the neurosurgical capacity of low-income countries.

Head CT findings at a public hospital in rural Haiti.

BACKGROUND: Neuroimaging is often unavailable in low-income countries, creating challenges for precise diagnosis of neurologic disease in individual patients, and impeding acquisition of precise neuroepidemiologic data for program and policy development. METHODS: We analyzed reports from 3614 head CTs performed between July 2013 and January 2016 at Hôpital Universitaire de Mirebalais, a public academic hospital in rural Haiti, extracting patients' age, study indication, and radiologic findings. RESULTS: The most common indications for head CT were headache (27%), trauma (19.9%), abnormal neurological exam (12.2%), and stroke (11.3%). The most common categories of neurologic abnormalities were traumatic (31%), vascular (25.8%), and infectious (12%). Of 291 strokes, 64% were ischemic (median age at diagnosis 60.8years, SD 17.4) and 36% were hemorrhagic (median age 52.0, SD 15.5). In patients undergoing head CT for seizures or epilepsy, 17.5% had evidence of neurocysticercosis. In patients with head trauma, 42.6% had intracranial hemorrhage or fracture. Atrophy was noted on 10% of CTs (median age 57.1; SD 23.8), and was characterized as out of proportion to age in 2% (median age 34.1, SD 15.3). CONCLUSIONS: Median age of stroke patients in this rural low-income population is lower than in high-income countries and proportion of stroke due to intracerebral hemorrhage is higher. Neurocysticercosis is present in nearly one fifth of patients with seizures/epilepsy. These findings can inform policies and programs for prevention and treatment of neurologic disease in low-income settings.

Development of a neurology rotation for internal medicine residents in Haiti.

In many low-income countries where there are few or no neurologists, patients with neurologic diseases are cared for by primary care physicians who receive no formal training in neurology. Here, we report our experience creating a neurology rotation for internal medicine residents in rural Haiti through a collaboration between a public academic medical center in Haiti and a visiting neurologist. We describe the structure of the rotation and the factors that led to its development.

Integrated Genomic Characterization of a Pineal Parenchymal Tumor of Intermediate Differentiation.

BACKGROUND: Pineal parenchymal tumors of intermediate differentiation (PPTIDs) are rare lesions. The differential diagnosis and management strategy for PPTIDs can be challenging because of the variable prognostic and pathologic characteristics of these tumors. METHODS: A 24-year-old man presented with progressive headaches, gait abnormalities, and abulia. Magnetic resonance imaging revealed a large T1-hypointense, T2-isointense, contrast-enhancing, partially cystic mass of the pineal and tectal region. Near-total resection was achieved in a 2-stage operation followed by focal and craniospinal irradiation and adjuvant chemotherapy. RESULTS: Immunohistochemical analysis including use of pineal lineage marker confirmed a diagnosis of PPTID. Targeted exome sequencing showed mutations in TSC1(L388P) and IKZF3(F206C), whereas high-resolution array cytogenetics revealed losses in chromosomes 2, 3, 4, 8, 10, 11, 17, and 20, leading to single-copy loss of PTEN and TP53. CONCLUSIONS: Pineal parenchymal tumors reflect a broad spectrum of malignancy potential and prognoses, which mandate better understanding of the disease mechanism for rational therapeutic strategies. We present a case of PPTID and report several mutations and chromosomal abnormalities previously unrecognized in this tumor subtype. Review of the literature highlights a need for surgical resection followed by adjuvant chemoradiation. Further investigation of these novel variants may improve understanding of the pathogenesis underlying pineal parenchymal tumors.