The cost-utility of telemedicine to screen for diabetic retinopathy in India.

PURPOSE: To assess the cost-effectiveness of a telemedicine diabetic retinopathy (DR) screening program in rural Southern India that conducts 1-off screening camps (i.e., screening offered once) in villages and to assess the incremental cost-effectiveness ratios of different screening intervals. DESIGN: A cost-utility analysis using a Markov model. PARTICIPANTS: A hypothetical cohort of 1000 rural diabetic patients aged 40 years who had not been previously screened for DR and who were followed over a 25-year period in Chennai, India. METHODS: We interviewed 249 people with diabetes using the time trade-off method to estimate utility values associated with DR. Patient and provider costs of telemedicine screening and hospital-based DR treatment were estimated through interviews with 100 diabetic patients, sampled when attending screening in rural camps (n = 50) or treatment at the base hospital in Chennai (n = 50), and with program and hospital managers. The sensitivity and specificity of the DR screening test were assessed in comparison with diagnosis using a gold standard method for 346 diabetic patients. Other model parameters were derived from the literature. A Markov model was developed in TreeAge Pro 2009 (TreeAge Software Inc, Williamstown, MA) using these data. MAIN OUTCOME MEASURES: Cost per quality-adjusted life-year (QALY) gained from the current teleophthalmology program of 1-off screening in comparison with no screening program and the cost-utility of this program at different screening intervals. RESULTS: By using the World Health Organization threshold of cost-effectiveness, the current rural teleophthalmology program was cost-effective ($1320 per QALY) compared with no screening from a health provider perspective. Screening intervals of up to a frequency of screening every 2 years also were cost-effective, but annual screening was not (>$3183 per QALY). From a societal perspective, telescreening up to a frequency of once every 5 years was cost-effective, but not more frequently. CONCLUSIONS: From a health provider perspective, a 1-off DR telescreening program is cost-effective compared with no screening in this rural Indian setting. Increasing the frequency of screening up to 2 years also is cost-effective. The results are dependent on the administrative costs of establishing and maintaining screening at regular intervals and on achieving sufficient coverage

Bilateral common iliac vein stent migration

Venous stent migration to the heart is considered to be a rare complication of a common procedure. Therefore, many physicians do not include this complication in their differential diagnosis. We explain why this complication is likely more common than currently thought and why it should be considered as a potential diagnosis. This case describes migration of bilateral iliac vein stents into the right ventricular outflow tract and right interlobar pulmonary artery. We provide multiple imaging modalities demonstrating the migrated stents. We believe radiologists should be cognizant of this complication and consider it as a potential diagnosis. Hopefully, this will create a greater awareness of this life-threatening complication of venous stent placement

What is the recommended approach to asymptomatic patients who develop a reactive PPD?

Clinical evaluation and chest x-ray are recommended for asymptomatic patients with a positive purified protein derivative (PPD) test result, to exclude the slight possibility of active tuberculosis (TB). Patients with radiographic evidence of old (healed) TB infection should also undergo sputum testing (strength of recommendation [SOR]: C, expert opinion). Treatment with isoniazid (INH) monotherapy (300 mg/d) reduces progression of latent tuberculosis to active disease (SOR: A, large randomized controlled trials [RCT]), with 9 months as the optimal treatment length (SOR: B, derivation from RCTs). A 3-month course of combined rifampin (600 mg/d) and INH (300 mg/d) is equivalent in efficacy to INH monotherapy and is associated with similar rates of toxicity (SOR: A, meta-analysis of RCTs), but this regimen is not included in Centers for Disease Control and Prevention recommendations

Ovary-sparing hysterectomy: Is it right for your patient?

Advise patients undergoing hysterectomy for benign conditions that there are benefits to conserving their ovaries. The risk of coronary heart disease (CHD) and death is lower in women whose ovaries are conserved, compared with those who have had them removed. Stength of recommendation: B: A large, high-quality observational study

A RETROSPECTIVE AUDIT OF REFERRALS OF 16-17 YEAR OLDS WITH REFERENCE TO SUBSTANCE ABUSE

Background: Emerge is an innovative Child and Adolescent Mental Health Service that provides support for 16-17 year olds. The team provide a community based multi-disciplinary, open access model, texting young people and travelling to locations convenient to them. There is an enhanced duty system providing a rapid flexible response within working hours. Aims: To examine the referral data as part of the ongoing annual audit cycle and to establish prevalence of alcohol, cigarettes and substance use among young people referred to the service. Method: Data from the case notes was analysed using Statistical Package for Social Science. Demographic details, referrer profession, reason for referral, other services involved and substance use were examined. Results: There were 437 patients referred to Emerge between 1/4/2010 and 31/3/2011, and 387 patients were accepted while 50 were signposted on. Cases were not accepted if they fell outside the age and geographical area, or were not in need of a mental health service. Overall, 24% of young people were reported to consume alcohol, 19% used cannabis and 9% reported using cigarettes. In all categories there were areas where documentation was not complete, and we suggest that these figures are an underestimate. Conclusion: This data has been fed back to the team, a full morning of teaching regarding drugs and alcohol has been delivered. Emerge often works with young people who are marginalised and may be harder to reach, consequently early sessions require neutral and supportive questions, thus if young people do not return after the first appointment, histories may be incomplete. The team will be reflecting on the lessons learned and considering ways to optimise their work

Identity and Access: Gender-Based Preferences and Physician Availability in Primary Care

Patient preferences for physicians may be influenced by shared characteristics such as gender. We analyzed experimental data from a survey of US adults in which respondents were asked to choose between physician profiles that on average varied only by gender. We find that female patients prefer female physicians to male physicians by 51.8 percentage points (95 % CI: 0.470 to 0.566, p \u3c 0.01), and that result holds across Black, White, and Hispanic sub-groups. With no countervailing preference among male patients, this result holds in the overall sample at 26.8 percentage points (95 % CI: 0.228 to 0.307, p \u3c 0.01). We also analyzed data from a simulated patient field experiment concerning access to primary care appointments and find that female physicians, on average, offer appointments 7.1 days later than male physicians (95 % CI: 5.1 to 9.1, p \u3c 0.01), consistent with the finding that female physicians are preferred. Female physicians’ offices appear to favor female patients, offering appointments to them 2.6 days earlier compared to male patients (95 % CI: -5.3 to 0.195, p = 0.07). However, Hispanic female patients were offered 4.2-percentage-points fewer appointments compared to Hispanic males (95 % CI: -0.069 to -0.014, p \u3c 0.01) by female physicians’ offices. Similarly, Black female patients were told that the physician is “not taking new patients” 3.5 percentage points more often (95 % CI: -0.004 to 0.073, p = 0.08) and were offered appointments that were 2.6 minutes shorter compared to Black males (95 % CI: -4.8 to -0.44, p = 0.02). Overall, our analysis suggests that female primary care physicians are in high demand relative to their supply, and that access to scarce female physicians is mediated by race and ethnicity

COMPARISON OF TWO OPTICAL IMAGING SYSTEMS TO REDUCE RADIATION IN ADOLESCENTS WITH SCOLIOSIS

INTRODUCTION Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional (3D) deformity of the spine characterized by abnormal lateral curvature and vertebral rotation affecting 2-3% of adolescents [1]. The current clinical diagnostic and monitoring method consists of full torso X-rays where the Cobb angle, a measure of spinal deviation from the vertical, is used to determine the magnitude of the deformity. Two major limitations are associated with this approach.  First, the routine exposure to radiation has been linked to an increased risk of cancer in scoliotic patients [2]. Second, the Cobb angle is inadequate to fully define the deformity because it is a two-dimensional measure. A holistic approach to define the deformity and reduce radiation exposure is needed. Changes in spinal curvature alter torsal shape making the use of surface topography (ST) a potential alternative to detect and monitor AIS progression in 3D [3] as well as reduce periodic radiation exposure. The majority of recent attempts to validate ST for clinical implementation have used commercial fringe topographic (FT) methods, which are expensive and take prolonged captures. A novel low-cost photogrammetric system that takes instantaneous captures has been developed to remove errors resulting from movement during a capture and increase torso reconstruction accuracy [4]. The effect of the improved accuracy on the ST measures in the new system is not yet understood. The aim of this study was to compare FT and photogrammetric data, thereby providing context for ST measures resulting from the new system. METHODS Models of four AIS (1M, 3F) and four normal (1M, 3F) subjects between the ages of 9-16 were reconstructed via FT (InSpeck Inc, Montreal; now owned by Creaform, Lévis) and photogrammetric methods in order to compare ST measures in three regions, i.e. upper (T7), middle (T12) and lower (L4). Captures from the two systems were taken consecutively while subjects were in a positioning frame to reduce movement artifacts between systems. MeshLab was used to generate meshes from the photogrammetric point clouds. A custom scoliosis code [5] calculated ST measures from meshes between T1 and S1 (Fig 1.). Anatomical landmarks determined each individual’s fixed reference frame. RESULTS A repeated measures multivariate analysis of variability compared 11 distinct ST indices calculated from torsal cross-sections (Fig. 1) [6]. There were two subject groups, normal and scoliosis; two optical methods, FT and photogrammetry; and three analyzed levels, T7, T12 and L4. Statistically significant (SS) differences were found in ST measures between methods (p < 0.001) and spinal levels (p = 0.032). Further tests revealed SS difference in both the normal (p = 0.006) and scoliosis (p = 0.002) groups ST measures from the two methods. DISCUSSION AND CONCLUSIONS The photogrammetry method produced different ST measures from the FT method. Further method comparison includes distorting photogrammetry data until it matches FT data. Increasing sample size will provide SS information on interaction effects and the effects of improved accuracy and repeatability of the novel system vs. InSpeck (accuracy: 0.3 mm vs. 1.29+/- 0.45mm; repeatability: 0.19mm vs. 1.4mm; [4,6]) on ST measures

Study of Protein Arginine Methyltransferase 6 in Medulloblastoma

https://openworks.mdanderson.org/sumexp21/1180/thumbnail.jp