Estimation of Health Utility and Quality Adjusted Life Years in Bilateral Hand Transplantation: A Time Trade-off Study.

BACKGROUND: Hand transplantation and advances in the field of prostheses have opened new frontiers in the restoration of hand function among bilateral hand amputees (BHA). There is only scarce literature evaluating the health utility (HU) and quality adjusted life years (QALY) gained by bilateral hand composite tissue allotransplantation (CTA) or prosthesis over amputation. The study was focused on BHA restored with prosthesis or CTA. METHODS: The HU of three different health states (HS) namely, BHA, using prosthesis or with CTA and net QALYs gained by hand transplantation or prosthesis over amputation were computed by time trade-off (TTO) method among 236 study participants. RESULTS: Among 236 study participants, medical professional (120), general public (89), BHA (23), and bilateral hand transplant recipients (4) were included. The mean HU by TTO method among the study participants (n = 232) as BHA, using prosthesis or CTA was 0.34 (±0.24), 0.50 (±0.26) and 0.69 (±0.26) respectively. Bilateral hand CTA imparted an expected gain of 12.57 (±11.43) mean QALYs over amputation among the study participants. The subgroup analysis displayed higher mean HU in hand CTA recipient HS along with maximum QALY gained by CTA over amputation. CONCLUSIONS: Bilateral hand CTA HS stands above the other 2 HSs, namely BHA and prosthesis, in terms of the health utility. As demonstrated by QALY gain of 12.57, participants' valuation of health utility is notably higher for CTA with acceptance of lifelong immunosuppressant rather than for a state of uncompromised physical health with a bilateral hand amputation.

Health-Related Quality of Life of Coronary Artery Disease Patients under Secondary Prevention: A Cross-Sectional Survey from South India.

BACKGROUND: Health-related quality of life (HRQOL) is emerging as an important outcome among patients with documented coronary artery disease (CAD). The primary objective of this study was to report the HRQOL of CAD patients under secondary prevention-related treatment and follow-up using the 36-Item Short Form (SF-36) tool. METHODS: This was an analytical cross-sectional survey done in a hospital/clinic setting. We recruited CAD patients 30 to 80 years old with 1 to 6 years of follow-up. Patients self-reported HRQOL using SF-36. RESULTS: We recruited 1206 patients, among whom 879 (72.9%) were male. The mean age of patients was 61.3 (9.6) years. Mean (± standard deviation) scores for physical functioning, role limitations due to physical health, pain, and general health were 66.48 ± 29.41, 78.96 ± 28.01, 80.96 ± 21.15, and 51.49 ± 20.19, respectively. The scores for role limitations due to emotional problems, energy/fatigue, emotional well-being, and social functioning were 76.62 ± 28.0, 66.18 ± 23.92, 76.91 ± 20.47, and 74.49 ± 23.55. In subgroup analysis, age, sex, type of CAD, and treatment showed no significant association with any of the 8 domains of QOL. In addition, hypertension and diabetes showed no significant association with the individual domains of HRQOL. CONCLUSION: Patients with coronary artery disease under secondary prevention-related treatment have suboptimal HRQOL under both physical and mental domains. The role of demographic factors, comorbidities, disease subtypes, and treatment options in modifying HRQOL among patients with CAD appears to be minimal.

Health-related quality of life in Indian children: A community-based cross-sectional survey.

BACKGROUND & OBJECTIVES: There are limited data on health-related quality of life (HRQOL) related to Indian children. The objective of this study was to construct a generic HRQOL reference for children aged 2-18 yr from a community setting. METHODS: The study was a community-based cross-sectional survey. A total of 719 children/adolescents in the age group of 2-18 yr were enrolled using stratified random cluster sampling. A total of 40 clusters (cluster size 18) were selected for the study. The data contained child self-report and parent proxy report from healthy children and their parents/caretakers. The Pediatric Quality of Life Inventory 4.0 (PedsQL4.0) Generic Core Scale was used to collect HRQOL data. Questionnaires were self-administered for parents and children aged 8-18 yr. In the age group of five to seven years, parents assisted the children in filling questionnaires. RESULTS: The mean HRQOL total scores from child self-report and parent proxy report were 87.50±11.10 and 90.10±9.50 respectively, for children aged 2-18 yr. Social functioning had the highest scores and emotional functioning had the lowest scores for the entire sample and subgroups. The mean values for HRQOL in the current study were significantly different from the reference study for both child (87.39 vs. 83.91, P<0.001) and parent proxy reports (90.03 vs. 82.29, P<0.001) when compared between children aged 2-16 yr. INTERPRETATION & CONCLUSIONS: The study provided reference values for HRQOL in healthy children and adolescents from Kerala, India, that appeared to be different from existing international reference. Similar studies need to be done in different parts of India to generate a country-specific HRQOL reference for Indian children.

A Comparison of Treatment Options in Focal Post-Stroke Spasticity of the Upper Extremity: A Prospective Longitudinal Cohort Study from Kerala, India.

Background: Post-stroke 20%-40% of patients develop spasticity which can quadruple total cost of care. This impact can be reduced by affordable treatment options for focal spasticity. Objectives: The primary objective of the study was to compare changes in Passive Range of Movements in patients with focal post-stroke spasticity from pre-treatment to end of 1 month of treatment with anti-spastic agents. The secondary objectives were to measure the changes in Modified Ashworth, and Brunnstrom Recovery Staging during the same period. Materials and Methods: This prospective longitudinal cohort study was conducted in a tertiary level rehabilitation center. One hundred and three adults with post-stroke spasticity participated. The patients received one of the four options: Phenol, Onabotulinum toxin, Bupivacaine and Hyaluronidase.The main outcome measures were the following: Changes in Passive Range of Movement (PRoM), Brunnstrom staging (BRS) and Modified Ashworth Scale (MAS). Result: Post intervention testing at 1 month was done. Each agent significantly improved BRS (1.10, 95% CI 0.8-1.4, P = 0.001) and PRoM (32.28, 95% CI 27.66- 36.89, P = 0.001), while reducing MAS (0.39, 95% CI 0.01-0.77, P = 0.05). In addition, subgroup comparisons were done with phenol as a reference for all three outcome measures. There was a significant difference in the improvement of Brunnstrom staging for Bupivacaine (0.52, 0.094-0.95, 0.02) compared to phenol. Similarly, Hyaluronidase showed better improvement in MAS (0.39, 0.01-0.77, 0.05) compared to Phenol. Conclusion: There was a significant difference in PRoM, MAS and Brunnstrom staging from baseline to end of 1 month long anti-spasticity treatment.

One-year mortality after acute stroke: a prospective cohort study from a comprehensive stroke care centre, Kerala, India.

OBJECTIVES: The primary objective was to report the 1-year all-cause mortality among patients with stroke. The secondary objectives were (1) to report the mortality stratified by type of stroke and sex and (2) to report predictors of 1-year mortality among patients with stroke. DESIGN: A prospective cohort study. SETTING: Institutional-stroke care unit of a tertiary care hospital PARTICIPANTS: Patients who were treated in the study institution during 2016-2020 for acute stroke and were followed up for a period of 1 year after stroke in the same institution. MAIN OUTCOME MEASURES: The main outcome measures were the mortality proportion of any stroke and first ever stroke cohorts at select time points, including in-hospital stay, along with 2 weeks, 2 months, 6 months and 1 year after index stroke. The secondary outcomes were (1) mortality proportions stratified by sex and type of stroke and (2) predictors of 1-year mortality for any stroke and first ever stroke. RESULTS: We recruited a total of 1336 patients. The mean age of participants was 61.6 years (13.5 years). The mortality figures for 2 weeks, 2 months, 6 months and 12 months after discharge were 79 (5.9%), 88 (6.7%), 101 (7.6%) and 114 (8.5%), respectively, in the full cohort. The in-hospital mortality was 45 (3.4%). The adjusted analysis revealed 3 predictors for 1-year mortality after first ever stroke-age, pre-treatment National Institutes of Health Stroke Scale (NIHSS) score and Modified Rankin Scale (mRS) score at baseline. The same for the full cohort had only two predictors-age and pre-treatment NIHSS score. CONCLUSION: Mortality of stroke at 1-year follow-up in the study population is low in comparison to several studies published earlier. The predictors of 1-year mortality after stroke included age, NIHSS score at baseline and mRS score at baseline.

Accuracy of physical examination of cardiovascular system in the diagnosis of common congenital heart diseases in children.

BACKGROUND: It is widely perceived that the value of physical examination in paediatric cardiology has diminished with the increasing availability of echocardiography. The accuracy of physical examination of cardiovascular system in children has not been systematically tested. METHODS: This is a cross-sectional, diagnostic accuracy study from the paediatric cardiology clinic of a tertiary referral hospital in South India. A total of 545 children with 5 common cardiac conditions were included-normal heart, atrial septal defect, patent ductus arteriosus, ventricular septal defect (VSD) and VSD with pulmonic stenosis. Physical examination was documented by a paediatric cardiology fellow and a consultant who were blinded to previous investigations and to each other. The accuracy of physical examination of the fellow and the consultant was determined for each patient group by comparing with echocardiography. Interobserver agreement was calculated using kappa statistics. RESULTS: Physical examination differentiated normal hearts from abnormal with an accuracy of 95.0% for fellows and 96.3% for consultants. For all abnormal hearts, the results for fellows and consultants, respectively, were as follows: sensitivity: 94.3%, 94.9%, specificity: 96.2%, 98.6%, accuracy: 95.0%, 96.3%, positive likelihood ratio: 24.8, 66.4 and negative likelihood ratio: 0.06, 0.05. There was good agreement between fellows and consultant for all patient groups (kappa: 0.72-1), except for large VSD (kappa: 0.232). Younger age and haemodynamically insignificant lesions were associated with incorrect diagnosis. CONCLUSION: This study underscores the utility of clinical examination in initial screening for commonly encountered congenital cardiac conditions even in the current era of echocardiography.

Mapping of head and neck cancer patient concerns inventory scores on to Euroqol-Five Dimensions-Five Levels (EQ-5D-5L) health utility scores.

BACKGROUND: The purpose of this paper is to map the number of concerns on the dimensions in Head and Neck Patient Concerns Inventory (PCI) on to the health utility (HU) index scores on Euroqol-Five Dimensions-Five levels {EQ-5D-5L) . METHODS: This is a cross-sectional survey conducted in patients who have completed their treatment. Four candidate models were considered, three based on ordinary least squares regression (OLS) and one two-parts model. RESULTS: A reduced OLS model based on 'Physical and functional', 'Treatment-related', and 'Psychological, emotional and spiritual well-being' domains was found best on the estimation sample. This was validated externally on a separate sample. CONCLUSIONS: This is the first study that mapped a non-QOL tool to generate HU scores on EQ-5D-5L. The proposed mapping algorithm can estimate the cost-utility in economic evaluation studies when HU scores are not directly available. The algorithm will be best suited for studies in low-middle income countries.

Comparison of intravenous sildenafil with inhaled nitric oxide for acute vasodilator testing in pulmonary arterial hypertension.

Acute vasodilator testing (AVT) identifies acute responders for initiation of calcium channel blockers in pulmonary arterial hypertension (PAH) and operability in congenital heart disease (CHD). We sought to determine the feasibility of intravenous sildenafil (ivS) as an alternative to inhaled nitric oxide (iNO) in AVT. All patients with PAH undergoing cardiac catheterization for AVT (November 2015 to December 2020) were prospectively enrolled. Hemodynamic data were obtained at baseline, with iNO 20 ppm and ivS (0.25 mg/kg for children and 10 mg for adults). We studied 44 patients with a mean age of 20.5 ± 14.4 years (27 [61%] females and 20 [45%] children). There were 17 (38.6%) patients in the CHD group for operability assessment and 27 patients in non-CHD group (idiopathic pulmonary arterial hypertension-16 [36.3%], residual PAH after shunt closure-7 [15.9%], and 2 cases [4.5%] each of familial PAH and portopulmonary hypertension). There was an excellent intraclass correlation for mean pulmonary artery pressures (0.903, 95% confidence interval, CI: 0.809-0.949, p < 0.001), mean aortic pressures (0.745, 95% CI: 0.552-0.858, p < 0.001), pulmonary vascular resistance index (0.920, 95% CI: 0.858-0.956, p < 0.001), systemic vascular resistance (SVR) index (0.828, 95% CI: 0.706-0.902, p < 0.001), and the ratio of pulmonary and SVR indices (0.857, 95% CI: 0.752-0.919, p < 0.001) between the two agents. There were two responders, both in non-CHD group, and were identified by iNO and ivS. The hemodynamic effects of ivS show excellent correlation with iNO and could be a potential alternative agent for identifying acute responders during AVT.

Prevalence of Voice Disorders in School Teachers in a District in South India.

BACKGROUND: Many professions tend to carry inherent risks for the practitioners. In such cases, it becomes mandatory for them to be aware of the risks and counselled about the preventive measures. The inevitable first step, however, is to ascertain the burden of risk. In the case of school teachers, it is known that they are prone to voice disorders of varying hues, at some point of their career. There should be an attempt to find the prevalence in the community. Presently, there is no such data documented from Kerala, a highly literate State in southern India. AIM AND OBJECTIVES: The primary objective of this study was to document the prevalence of subjective dysphonia among the school teacher community. The secondary objective was to compare the prevalence and severity of dysphonia between primary and secondary school teachers. MATERIALS AND METHODS: A cross-sectional study was conducted in 28 schools, using a screening questionnaire, based on similar ones used in other studies. All the schools were in the city of Kochi, the largest and most populous metropolitan area in Kerala. Teachers reporting a current voice complaint at the time of study were administered the validated vernacular version of the voice handicap index questionnaire (VHI 30). The completed questionnaires were collected and statistically analyzed. RESULTS: The screening questionnaire was administered to 702 teachers; 165 were Primary school teachers (Class I-V), 242 Secondary (Class VI-XII), while 279 teachers had to take classes in both sections. The reported prevalence was 45.4% for present difficulty related to their voice, 52.8% for some voice problem in the last 1 year, and 70.1% for problems experienced during the duration of their teaching career. Possible risk factors like age, total years of teaching, hours of daily teaching and number of students taught did not show any significant association with voice problem. CONCLUSIONS: Nearly, half of all the screened school teachers reported a current voice problem, increasing to nearly three-fourths for symptoms during entire career. This is clearly a significant burden which must be addressed at various levels. The secondary school teachers seem to bear a bigger burden in this study.

Compliance of Secondary Prevention Strategies in Coronary Artery Disease Patients with and without Diabetes Mellitus - A Cross-Sectional Analytical Survey from Kerala, India.

CONTEXT: There is limited data related to compliance of secondary prevention strategies for coronary artery diseases (CAD) among patients with and without diabetes. OBJECTIVES: The objective was to compare compliance to secondary prevention strategies for CAD including smoking cessation, weight management, blood pressure (BP) control, Low density lipoprotein (LDL) cholesterol control and adequate physical activity between patients with and without diabetes. SETTINGS AND DESIGN: This is a hospital-based cross-sectional analytical study. METHODS AND MATERIALS: The study questionnaire was used to collect data through interviews of CAD patients. Compliance to secondary prevention strategies was documented using European Society of Cardiology guidelines. STATISTICAL ANALYSIS: We used modified Poisson model to estimate adjusted prevalence ratios (Adj. PR) for estimating compliance. RESULTS: Among 1,206 participants with CAD, 609 (50.5%) had diabetes. The Adj. PR s for three targets - smoking cessation (Adj. PR 1.01, 95% CI 0.97, 1.06, P 0.50), ideal BMI (Adj. PR 0.99, 95% CI 0.92, 1.09, P 0.99) and adequate physical activity (Adj. PR 1.12, 95% CI 0.97, 1.29, P 0.12) showed no significant difference between the groups. There was poor BP control in patients with diabetes compared to those without the same (Adj. PR 0.19, 95% CI 0.15, 0.23, P < 0.0001). LDL cholesterol control was better in patients with diabetes in comparison to those without the same (Adj. PR 1.19, 95% CI 1.08, 1.31, P 0.0005). CONCLUSION: The compliance for secondary prevention of CAD among patients with diabetes is similar to those without diabetes except for poor control of hypertension and better control of LDL cholesterol.