Depression and Anxiety Disorders among Hospitalized Women with Breast Cancer

Purpose

To document the prevalence of depression and anxiety disorders, and their associations with mortality among hospitalized breast cancer patients.

Methods

We examined the associations between breast cancer diagnosis and the diagnoses of anxiety or depression among 4,164 hospitalized breast cancer cases matched with 4,164 non-breast cancer controls using 2006-2009 inpatient data obtained from the Nationwide Inpatient Sample database. Conditional logistic regression models were used to compute odds ratios (ORs) and 95% confidence intervals (CI) for the associations between breast cancer diagnosis and diagnoses of anxiety or depression. We also used binary logistic regression models to examine the association between diagnoses of depression or anxiety, and in-hospital mortality among breast cancer patients.

Results

We observed that breast cancer cases were less likely to have a diagnosis of depression (OR=0.63, 95% CI: 0.52-0.77), and less likely to have a diagnosis of anxiety (OR=0.68, 95% CI: 0.52-0.90) compared with controls. This association remained after controlling for race/ethnicity, residential income, insurance and residential region. Breast cancer patients with a depression diagnosis also had lower mortality (OR=0.69, 95% CI: 0.52-0.89) compared with those without a depression diagnosis, but there was no significant difference in mortality among those with and without anxiety diagnoses.

Conclusion

Diagnoses of depression and anxiety in breast cancer patients were less prevalent than expected based on our analysis of hospitalized breast cancer patients and matched non-breast cancer controls identified in the NIS dataset using ICD-9 diagnostic codes. Results suggest that under-diagnosis of mental health problems may be common among hospitalized women with a primary diagnosis of breast cancer. Future work may fruitfully explore reasons for, and consequences of, inappropriate identification of the mental health needs of breast cancer patients.     

Prognostic Factors in Amyotrophic Lateral Sclerosis: A Population-Based Study

Objective

To determine the prognostic factors associated with survival in amyotrophic lateral sclerosis at diagnosis.

Methods

This retrospective population-based study evaluated 218 patients treated with riluzole between 2005 and 2014 and described their clinical and demographic profiles after the analysis of clinical data and records from the mortality information system in the Federal District, Brazil. Cox multivariate regression analysis was conducted for the parameters found.

Results

The study sample consisted of 132 men and 86 women with a mean age at disease onset of 57.2±12.3 years; 77.6% of them were Caucasian. The mean periods between disease onset and diagnosis were 22.7 months among men and 23.5 months among women, and the mean survival periods were 45.7±47.0 months among men and 39.3±29.8 months among women. In addition, 80.3% patients presented non-bulbar-onset amyotrophic lateral sclerosis, and 19.7% presented bulbar-onset. Cox regression analysis indicated worse prognosis for body mass index (BMI) <25 kg/m² (relative risk [RR]: 3.56, 95% confidence interval [CI]: 1.44–8.86), age >75 years (RR: 12.47, 95% CI: 3.51–44.26), and bulbar-onset (RR: 4.56, 95% CI: 2.06–10.12). Electromyography did not confirm the diagnosis in 55.6% of the suspected cases and in 27.9% of the bulbar-onset cases.

Conclusions

The factors associated with lower survival in amyotrophic lateral sclerosis were age >75 years, BMI <25 kg/m², and bulbar-onset.     

Serum 25-Hydroxyvitamin D Levels and Dry Eye Syndrome: Differential Effects of Vitamin D on Ocular Diseases

Purpose

To investigate associations between serum 25-hydroxyvitamin D levels and dry eye syndrome (DES), and to evaluate the differential effect of vitamin D on ocular diseases including age-related macular disease (AMD), diabetic retinopathy (DR), cataract, and DES.

Methods

A total of 16,396 participants aged >19 years were randomly selected from the Korean National Health and Nutrition Examination Survey. All participants participated in standardized interviews, blood 25-hydroxyvitamin D level evaluations, and comprehensive ophthalmic examinations. DES was defined by a history of clinical diagnosis of dry eyes by a physician. The association between vitamin D and DES was compared to the associations between vitamin D and AMD, DR, cataract, and DES from our previous studies.

Results

The odds of DES non-significantly decreased as the quintiles of serum 25-hydroxyvitamin D levels increased (quintile 5 versus 1, OR = 0.85, 95%CI: 0.55–1.30, P for trend = 0.076) after adjusting for potential confounders including age, sex, hypertension, diabetes, smoking status, and sunlight exposure times. The relative odds of DES (OR = 0.70, 95% CI: 0.30–1.64) and cataract (OR = 0.76, 95% CI: 0.59–0.99) were relatively high, while those of DR (OR = 0.37, 95% CI: 0.18–0.76) and late AMD (OR = 0.32, 95% CI: 0.12–0.81) were lower in men.

Conclusions

The present study does not support an association between serum 25-hydroxyvitamin D levels and DES. The preventive effect of serum 25-hydroxyvitamin D may be more effective for DR and late AMD than it is for cataract and DES.     

Prevalence of Oral and Maxillofacial Trauma in Elders Admitted to a Reference Hospital in Northeastern Brazil

Objective

To know the prevalence and etiology of oral and maxillofacial trauma in elders.

Methods

Analytical quantitative cross-sectional study conducted at a public trauma hospital located in Fortaleza-Ceará, Brazil. The study population comprised patients with trauma who were hospitalized from April to August 2014. Of these patients, patients with oral and maxillofacial trauma were chosen to be included in the research. A questionnaire was administered in order to obtain information on socio-demographics, systemic comorbidities, use of medication, deleterious habits (smoking and alcohol consumption), etiology of oral and maxillofacial trauma and type of pre-hospital care.

Results

Of the 280 elderly hospitalized with trauma, 47 had oral and maxillofacial trauma, with a prevalence of 16.8%. In this group, the age ranged from 60 to 88 years, with a mean age of 72.4 years (SD± 8.38). The elderly were mostly women (55.3%), self-declared pardos (53.2%), who presented with cardiovascular disorders (48.9%), and who received formal pre-hospital care (70.2%). Elderly who were in the 60–69 years age group, spent 6–9 years at school and drank alcohol were 2.64, 3.75, and 1.97, respectively, more likely to suffer oral and maxillofacial trauma. The main causes of trauma were physical aggression, traffic accidents, falls and domestic accidents. All of the physical aggressions resulted in oral and maxillofacial traumas, and the elderly who suffered traffic accidents were four times more likely to have oral and maxillofacial trauma.

Conclusion

The prevalence of 16.8% and the lack of research on oral and maxillofacial traumas in the elderly is worrisome and should be included in the oral health indicators for the elderly population to support the importance of oral health.     

Clinical Impact of Rapid Reduction of Low-Density Lipoprotein Cholesterol Level on Long-Term Outcome of Acute Myocardial Infarction in the Statin Era: Subanalysis of the ALPS-AMI Study

Background

The optimal period to achieve target percent reduction of low-density lipoprotein cholesterol (LDL-C) level for secondary prevention of acute myocardial infarction (AMI) is not well established.

Methods

The Assessment of Lipophilic vs. Hydrophilic Statin Therapy in AMI (ALPS-AMI) study enrolled 508 patients (mean age, 66.0± 11.6 years; 80.6% male) who were hospitalized for AMI and underwent percutaneous coronary intervention (PCI). Of these patients, 81 were excluded because of the absence of LDL-C measurements at 4 weeks after randomization. In the remaining 427 patients, the target LDL-C level reduction of ≥30% was achieved and not reached within 4 weeks after randomization in 204 cases (early reduction group) and 223 cases (late reduction group). The groups were formed prospectively and analyzed with regard to the composite end point (major adverse cardiovascular event [MACE]: all-cause death, myocardial infarction, and stroke) and clinical outcomes.

Results

MACE were significantly more frequent in the late reduction group compared to the early reduction group (9.4% vs. 3.4%, P = 0.013). The incidence of cardiac deaths was also significantly higher in the late reduction group (3.1% vs. 0.5%, P = 0.044). On age-adjusted Cox proportional hazards analysis in statin-naïve patients, percent reduction of LDL-C level during the initial 4 weeks (HR, 0.98; 95% CI: 0.97–0.99, P = 0.042) and baseline LDL-C level (HR, 0.98; 95% CI: 0.97–0.99, P = 0.033) predicted adverse events.

Conclusions

Rapid reduction of LDL-C level is strongly associated with favorable outcome in patients with AMI.     

Caregiver Burden in Patients Receiving Ranibizumab Therapy for Neovascular Age Related Macular Degeneration

Purpose

To assess the caregiver burden and factors determining the burden in patients receiving ranibizumab therapy for neovascular AMD (nAMD).

Methods

This is a cross-sectional questionnaire survey of 250 matched patient caregiver dyads across three large ophthalmic treatment centres in United Kingdom. The primary outcome was the subjective caregiver burden measured using caregiver reaction assessment scale (CRA). Objective caregiver burden was determined by the caregiver tasks and level of care provided. The factors that may predict the caregiver burden such as the patient’s visual acuity of the better eye and vision related quality of life, demographics, satisfaction and support provided by the healthcare and the health status of the dyads were also collected and assessed in a hierarchical regression model.

Results

The mean CRA score was 3.2±0.5, similar to the score reported by caregivers for atrial fibrillation who require regular hospital appointments for monitoring their thromboprophylaxis. Caregiver tasks including accompanying for hospital appointments for eye treatment and patient’s visual acuity in the better eye were the biggest contributors to the caregiver burden hierarchical model explaining 18% and 11% of the variance respectively.

Conclusion

Ranibizumab therapy for nAMD is associated with significant caregiver burden. Both disease impact and treatment frequency contributed to the overall burden.     

The Role of Digital Rectal Examination for Diagnosis of Acute Appendicitis: A Systematic Review and Meta-Analysis

Background

Digital rectal examination (DRE) has been traditionally recommended to evaluate acute appendicitis, although several reports indicate its lack of utility for this diagnosis. No meta-analysis has examined DRE for diagnosis of acute appendicitis.

Objectives

To assess the role of DRE for diagnosis of acute appendicitis.

Data Sources

Cochrane Library, PubMed, and SCOPUS from the earliest available date of indexing through November 23, 2014, with no language restrictions.

Study Selection

Clinical studies assessing DRE as an index test for diagnosis of acute appendicitis.

Data Extraction and Synthesis

Two independent reviewers extracted study data and assessed the quality, using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Bivariate random-effects models were used for the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio (DOR) as point estimates with 95% confidence intervals (CI).

Main Outcomes and Measures

The main outcome measure was the diagnostic performance of DRE for diagnosis of acute appendicitis.

Results

We identified 19 studies with a total of 7511 patients. The pooled sensitivity and specificity were 0.49 (95% CI 0.42–0.56) and 0.61 (95% CI 0.53–0.67), respectively. The positive and negative likelihood ratios were 1.24 (95% CI 0.97–1.58) and 0.85 (95% CI 0.70–1.02), respectively. The DOR was 1.46 (0.95–2.26).

Conclusion and Relevance

Acute appendicitis cannot be ruled in or out through the result of DRE. Reconsideration is needed for the traditional teaching that rectal examination should be performed routinely in all patients with suspected appendicitis.     

Norwegian PUQE (Pregnancy-Unique Quantification of Emesis and Nausea) Identifies Patients with Hyperemesis Gravidarum and Poor Nutritional Intake: A Prospective Cohort Validation Study

Objective

The English questionnaire Pregnancy-Unique Quantification of Emesis and nausea (PUQE) identifies women with severe Hyperemesis Gravidarum. Our aim was to investigate whether scores from the translated Norwegian version; SUKK (SvangerskapsUtløst Kvalme Kvantifisering) was associated with severity of hyperemesis and nutritional intake.

Design

A prospective cohort validation study.

Setting

Hospital cohort of Hyperemesis Gravidarum (HG) patients from western Norway and healthy pregnant women from Bergen, Norway.

Sample

38 women hospitalized due to HG and 31 healthy pregnant controls attending routine antenatal check-up at health centers.

Methods

Data were collected May 2013-January 2014. The study participants answered the Norwegian PUQE-questionnaire (scores ranging from 3 to15) and registered prospectively 24-hours nutritional intake by a food list form.

Main outcome measures

Differences of PUQE-scores, QOL-score and nutritional intake between hyperemesis patients and controls.

Results

Hyperemesis patients had shorter gestational age compared to controls (median 9.7 weeks; 95% CI 8.6-10.6 versus 11.9; 95% CI 10.1-12.9, p=0.004), and larger weight-change from pre-pregnant weight (loss of median 3 kg; 95% CI 3-4 versus gain of 2 kg; 95% CI 0.5-2, p<0.001) otherwise groups were similar regarding pre-pregnant BMI, age, gravidity, and inclusion weight. Compared to controls, hyperemesis patients had significant higher PUQE-score (median 13; 95% CI 11-14 vs. 7; 95% CI 4-8), lower QOL (median score 3; 95% CI 2-4 vs. 6; 95% CI 4.5-8) and lower nutritional intake (energy intake median 990 kcal/24 hours; 95% CI 709-1233 vs. 1652; 95% CI 1558-1880 all p<0.001). PUQE-score was inversely correlated to nutritional intake (-0.5, p<0.001). At discharge PUQE-score had fallen to median 6 (95% CI 5-8) and QOL score risen to 7 (95% CI 6-8) in the HG group, (both p<0.001 compared to admission values).

Conclusion

PUQE-scoring has been validated as a robust indicator of severe hyperemesis gravidarum and insufficient nutritional intake in a Norwegian setting.     

Economic Cost of Campylobacter,Norovirus and Rotavirus Disease in the United Kingdom

Objectives

To estimate the annual cost to patients, the health service and society of infectious intestinal disease (IID) from Campylobacter, norovirus and rotavirus.

Design

Secondary data analysis.

Setting

The United Kingdom population, 2008–9.

Main outcome measures

Cases and frequency of health services usage due to these three pathogens; associated healthcare costs; direct, out-of-pocket expenses; indirect costs to patients and caregivers.

Results

The median estimated costs to patients and the health service at 2008–9 prices were: Campylobacter £50 million (95% CI: £33m–£75m), norovirus £81 million (95% CI: £63m–£106m), rotavirus £25m (95% CI: £18m–£35m). The costs per case were approximately £30 for norovirus and rotavirus, and £85 for Campylobacter. This was mostly borne by patients and caregivers through lost income or out-of-pocket expenditure. The cost of Campylobacter-related Guillain-Barré syndrome hospitalisation was £1.26 million (95% CI: £0.4m–£4.2m).

Conclusions

Norovirus causes greater economic burden than Campylobacter and rotavirus combined. Efforts to control IID must prioritise norovirus. For Campylobacter, estimated costs should be considered in the context of expenditure to control this pathogen in agriculture, food production and retail. Our estimates, prior to routine rotavirus immunisation in the UK, provide a baseline vaccine cost-effectiveness analyses.     

Determinants of Venous Thromboembolism among Hospitalizations of US Adults: A Multilevel Analysis

Background

Venous thromboembolism (VTE) is a significant clinical and public health concern. We evaluated a variety of multilevel factors—demographics, clinical and insurance status, preexisting comorbid conditions, and hospital characteristics—for VTE diagnosis among hospitalizations of US adults.

Methods

We generated adjusted odds ratios with 95% confidence intervals (CIs) and determined sources of outcome variation by conducting multilevel logistic regression analysis of data from the 2011 Nationwide Inpatient Sample that included 6,710,066 hospitalizations of US adults nested within 1,039 hospitals.

Results

Among hospitalizations of adults, age, sex, race or ethnicity, total days of hospital stay, status of health insurance, and operating room procedure were important determinants of VTE diagnosis; each of the following preexisting comorbid conditions—acquired immune deficiency syndrome, anemia, arthritis, congestive heart failure, coagulopathy, hypertension, lymphoma, metastatic cancer, other neurological disorders, obesity, paralysis, pulmonary circulation disorders, renal failure, solid tumor without metastasis, and weight loss—was associated independently with 1.04 (95% CI: 1.02−1.06) to 2.91 (95% CI: 2.81−3.00) times increased likelihood of VTE diagnosis than among hospitalizations of adults without any of these corresponding conditions. The presence of 2 or more of such conditions was associated a 180%−450% increased likelihood of a VTE diagnosis. Hospitalizations of adults who were treated in urban hospitals were associated with a 14%−15% increased likelihood of having a VTE diagnosis than those treated in rural hospitals. Approximately 7.4% of the total variation in VTE diagnosis occurred between hospitals.

Conclusion

The presence of certain comorbidities and hospital contextual factors is associated with significantly elevated likelihood of VTE diagnosis among hospitalizations of adults. The findings of this study underscore the importance of clinical risk assessment and adherence to evidence-based clinical practice guidelines in preventing VTE, as well as the need to evaluate potential contextual factors that might modify the risk of VTE among hospitalized patients.     

A Bundle of Services Increased Ascertainment of Tuberculosis among HIV-Infected Individuals Enrolled in a HIV Cohort in Rural Sub-Saharan Africa

Objectives

To report on trends of tuberculosis ascertainment among HIV patients in a rural HIV cohort in Tanzania, and assessing the impact of a bundle of services implemented in December 2012, consisting of three components:(i)integration of HIV and tuberculosis services; (ii)GeneXpert for tuberculosis diagnosis; and (iii)electronic data collection.

Design

Retrospective cohort study of patients enrolled in the Kilombero Ulanga Antiretroviral Cohort (KIULARCO), Tanzania.)

Methods

HIV patients without prior history of tuberculosis enrolled in the KIULARCO cohort between 2005 and 2013 were included.Cox proportional hazard models were used to estimate rates and predictors of tuberculosis ascertainment

Results

Of 7114 HIV positive patients enrolled, 5123(72%) had no history of tuberculosis. Of these, 66% were female, median age was 38 years, median baseline CD4+ cell count was 243 cells/µl, and 43% had WHO clinical stage 3 or 4. During follow-up, 421 incident tuberculosis cases were notified with an estimated incidence of 3.6 per 100 person-years(p-y)[95% confidence interval(CI)3.26-3.97]. The incidence rate varied over time and increased significantly from 2.96 to 43.98 cases per 100 p-y after the introduction of the bundle of services in December 2012. Four independent predictors of tuberculosis ascertainment were identified:poor clinical condition at baseline (Hazard Ratio (HR) 3.89, 95% CI 2.87-5.28), WHO clinical stage 3 or 4 (HR 2.48, 95% CI 1.88-3.26), being antiretroviralnaïve (HR 2.97, 95% CI 2.25-3.94), and registration in 2013(HR 6.07, 95% CI 4.39-8.38).

Conclusion

The integration of tuberculosis and HIV services together with comprehensive electronic data collection and use of GeneXpert increased dramatically the ascertainment of tuberculosis in this rural African HIV cohort.     

Predictors of Severe Sepsis among Patients Hospitalized for Community-Acquired Pneumonia

Background

Severe sepsis, may be present on hospital arrival in approximately one-third of patients with community-acquired pneumonia (CAP).

Objective

To determine the host characteristics and micro-organisms associated with severe sepsis in patients hospitalized with CAP.

Results

We performed a prospective multicenter cohort study in 13 Spanish hospital, on 4070 hospitalized CAP patients, 1529 of whom (37.6%) presented with severe sepsis. Severe sepsis CAP was independently associated with older age (>65 years), alcohol abuse (OR, 1.31; 95% CI, 1.07–1.61), chronic obstructive pulmonary disease (COPD) (OR, 1.75; 95% CI, 1.50–2.04) and renal disease (OR, 1.57; 95% CI, 1.21–2.03), whereas prior antibiotic treatment was a protective factor (OR, 0.62; 95% CI, 0.52–0.73). Bacteremia (OR, 1.37; 95% CI, 1.05–1.79), S pneumoniae (OR, 1.59; 95% CI, 1.31–1.95) and mixed microbial etiology (OR, 1.65; 95% CI, 1.10–2.49) were associated with severe sepsis CAP.

Conclusions

CAP patients with COPD, renal disease and alcohol abuse, as well as those with CAP due to S pneumonia or mixed micro-organisms are more likely to present to the hospital with severe sepsis.     

Cancer Visibility among Iranian Familial Networks: To What Extent Can We Rely on Family History Reports?

Objective

Patients’ unawareness of their cancer diagnosis (PUAW) and their tendency for non-disclosure (TTND) to relatives leads to a lack of cancer visibility among familial networks. Lack of familial cancer visibility could affect the accuracy of family cancer history (FCH) reports. In this study, we investigated familial cancer visibility and its potential determinants.

Patients and Methods

A sample of patients with a confirmed cancer diagnosis was interviewed. Participants were asked about their number of relatives, number of their relatives who are aware about the cancer diagnosis, and the number of relatives from whom they intended to conceal their diagnosis. PUAW was also assessed. Point estimates and 95% confidence intervals were calculated using the bootstrap technique. Multivariate analyses were conducted using mixed Poisson and logistic regression analyses.

Results

A total of 415 participants with a mean age of 53±15 years and a male to female ratio of 0.53 were enrolled in this study. The rates of PUAW, TTND, and familial cancer visibility in the total sample were 0.20 (95% confidence interval (CI): 0.16, 0.24), 0.16 (95% CI: 0.12, 0.19), and 0.86 (95% CI: 0.83, 0.89), respectively. PUAW (adjusted rate ratio (RR) = 1.32, 95% CI: 1.27, 1.38), TTND (RR = 0.92, 95% CI: 0.91, 0.93), and the patients’ gender (RR = 0.92, 95% CI: 0.82, 0.95) were the most important determinants of familial cancer visibility.

Conclusion

Familial cancer visibility may be a point of concern among the Iranian population. Self-reported cancer histories and FCHs may have low sensitivities (not exceeding 80% and 86%, respectively) in this population. However, these estimates may vary across different societies, because of societal and cultural contexts.     

Epidemiology of Pediatric Ocular Trauma in the Chaoshan Region,China, 2001–2010

Background

Ocular trauma is the leading cause of monocular visual disability and noncongenital unilateral blindness in children. This study describes the epidemiology and medical care associated with nonfatal pediatric (≤17 years of age) eye injury-related hospitalization in the largest industrial base for plastic toy production in China.

Methods

A population-based retrospective study of patients hospitalized for ocular and orbital trauma in the ophthalmology departments of 3 major tertiary hospitals from 1st January 2001 to 31st December 2010 was performed.

Results

The study included 1035 injured eyes from 1018 patients over a 10-year period: 560 (54.1%) eyes exhibited open globe injuries, 402 (38.8%) eyes suffered closed globe injuries, 10 (1.0%) eyes suffered chemical injuries and 8 (0.8%) eyes exhibited thermal injuries, representing an average annual hospitalization rate of 0.37 per 10,000 (95% confidence interval [CI], 0.36–0.38) due to pediatric eye injury in the Chaoshan region. The mean patient age was 9.2±4.4 years with a male-to-female ratio of 3.3∶1 (P = 0.007). Children aged 6 to 11 years accounted for the highest percentage (40.8%, 416/1018) of hospitalization, 56.7% (236/416) of whom were hospitalized for open globe wounds. Injury occurred most frequently at home (73.1%). Open globe wounds cost the single most expensive financial burden (60.8%) of total charges with $998±702 mean charges per hospitalization.

Conclusions

Open globe wounds occurred at home are earmarked for the priorities to prevention strategies. Higher public awareness of protecting primary schoolchildren from home-related eye injuries should be strengthened urgently by legislation or regulation since the traditional industrial mode seems to remain the pattern for the foreseeable future. Further research that provide detailed information on the specific inciting agents of pediatric eye injuries are recommended for facilitating the development and targeting of appropriate injury prevention initiatives.     

Cardiovascular Disease Rates,Outcomes, and Quality of Care in Ontario Métis: A Population-Based Cohort Study

Background

The burden of cardiovascular disease in the Métis, Canada’s fastest growing Aboriginal group, is not well studied. We determined rates of five cardiovascular diseases and associated outcomes in Ontario Métis, compared to the general Ontario population.

Methods

Métis persons were identified using the Métis Nation of Ontario Citizenship Registry. Métis citizens aged 20–105 were linked to Ontario health databases for the period of April 2006 to March 2011. Age- and sex-standardized prevalence and incidence of acute coronary syndromes (ACS), congestive heart failure (CHF), cerebrovascular disease (stroke), atrial fibrillation, and hypertension were compared between the Métis and the general population. Secondary outcome measures included one-year hospitalizations and mortality following the incident cardiovascular diagnosis, as well as quality-of-care measures.

Results

There were 12,550 eligible Métis persons and 10,144,002 in the general population. The adjusted prevalence of each disease was higher (p<0.05) among the Métis compared to the general population: ACS 5.3% vs. 3.0%; CHF 5.1% vs. 3.9%; stroke 1.4% vs. 1.1%; atrial fibrillation 2.1% vs. 1.4%; hypertension 34.9% vs. 29.8%. Incident ACS, stroke, and atrial fibrillation were also higher (p<0.05) among the Métis: ACS 2.4% vs. 1.5%; stroke 0.8% vs. 0.6%; atrial fibrillation 0.6% vs. 0.3%. One-year all-cause and cardiovascular-related mortality were not significantly different. Hospitalizations were higher for Métis persons with CHF (OR 1.93; 95% CI 1.34–2.78) and hypertension (OR 2.27; 95% CI 1.88–2.74). Métis with CHF made more emergency department (ED) visits in the year after diagnosis compared to non-Métis with CHF, while Métis aged ≥65 with ACS were more likely to be on beta-blockers following diagnosis.

Conclusions

The burden of cardiovascular disease was markedly higher in the Métis compared to the general population: prevalence rates for five cardiovascular conditions were 25% to 77% higher. Métis persons with CHF had more frequent hospitalizations and ED visits following their diagnosis.     

Compass: Clinical Evaluation of a New Instrument for the Diagnosis of Glaucoma

Aims

To evaluate Compass, a new instrument for glaucoma screening and diagnosis that combines scanning ophthalmoscopy, automated perimetry, and eye tracking.

Materials and Methods

A total of 320 human subjects (200 normal, 120 with glaucoma) underwent full ophthalmological evaluation and perimetric evaluation using the Humphrey SITA standard 24° test (HFA), and the Compass test that consisted of a full-threshold program on the central 24° with a photograph of the central 30° of the retina. A subgroup of normal subjects and glaucoma patients underwent a second Compass test during the same day in order to study test-retest variability. After exclusion of 30 patients due to protocol rules, a database was created to compare the Compass to the HFA, and to evaluate retinal image quality and fixation stability.

Results

The difference in mean sensitivity between Compass and HFA was -1.02 ± 1.55 dB in normal subjects (p<0.001) and -1.01 ± 2.81 dB in glaucoma (p<0.001). Repeatability SD for the average sensitivity was 1.53 for normal subjects and 1.84 for glaucoma. Test time with the Compass was 634±96 s (607±78 for normals, 678±108 for glaucoma). Compass analysis showed the percentage of fixation within the central 1° was 86.6% in normal subjects, and 79.3% in glaucoma patients. Color image quality was sufficient for diagnostic use in >65% of cases; Image-based diagnosis was in accordance with the initial diagnosis in 85% of the subjects.

Conclusions

Based on preliminary results, Compass showed useful diagnostic characteristics for the study of glaucoma, and combined morphological information with functional data.     

Impairment of Colour Vision in Diabetes with No Retinopathy: Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study (SNDREAMS- II,Report 3)

Purpose

To assess impairment of colour vision in type 2 diabetics with no diabetic retinopathy and elucidate associated risk factors in a population-based cross-sectional study.

Methods

This is part of Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular-genetics Study (SN-DREAMS II) which was conducted between 2007–2010. FM 100 hue-test was performed in 253 subjects with no clinical evidence of diabetic retinopathy. All subjects underwent detailed ophthalmic evaluation including cataract grading using LOCS III and 45° 4-field stereoscopic fundus photography. Various ocular and systemic risk factors for impairment of colour vision (ICV) were assessed in subjects with diabetes but no retinopathy. P value of < 0.05 was considered statistically significant.

Results

The mean age of the study sample was 57.08 ± 9.21 (range: 44–86 years). Gender adjusted prevalence of ICV among subjects with diabetes with no retinopathy was 39.5% (CI: 33.5–45.5). The mean total error score in the study sample was 197.77 ± 100 (range: 19–583). The risk factors for ICV in the study were women OR: 1.79 (1.00–3.18), increased resting heart rate OR: 1.04 (1.01–1.07) and increased intraocular pressure OR: 1.12 (1.00–1.24). Significant protective factor was serum high-density lipoprotein OR: 0.96 (0.93–0.99).

Conclusions

Acquired ICV is an early indicator of neurodegenerative changes in the retina. ICV found in diabetic subjects without retinopathy may be of non-vascular etiology.     

Comparing Tuberculosis Diagnostic Yield in Smear/Culture and Xpert? MTB/RIF-Based Algorithms Using a Non-Randomised Stepped-Wedge Design

Setting

Primary health services in Cape Town, South Africa.

Study Aim

To compare tuberculosis (TB) diagnostic yield in an existing smear/culture-based and a newly introduced Xpert^® MTB/RIF-based algorithm.

Methods

TB diagnostic yield (the proportion of presumptive TB cases with a laboratory diagnosis of TB) was assessed using a non-randomised stepped-wedge design as sites transitioned to the Xpert^® based algorithm. We identified the full sequence of sputum tests recorded in the electronic laboratory database for presumptive TB cases from 60 primary health sites during seven one-month time-points, six months apart. Differences in TB yield and temporal trends were estimated using a binomial regression model.

Results

TB yield was 20.9% (95% CI 19.9% to 22.0%) in the smear/culture-based algorithm compared to 17.9% (95%CI 16.4% to 19.5%) in the Xpert^® based algorithm. There was a decline in TB yield over time with a mean risk difference of -0.9% (95% CI -1.2% to -0.6%) (p<0.001) per time-point. When estimates were adjusted for the temporal trend, TB yield was 19.1% (95% CI 17.6% to 20.5%) in the smear/culture-based algorithm compared to 19.3% (95% CI 17.7% to 20.9%) in the Xpert^® based algorithm with a risk difference of 0.3% (95% CI -1.8% to 2.3%) (p = 0.796). Culture tests were undertaken for 35.5% of smear-negative compared to 17.9% of Xpert^® negative low MDR-TB risk cases and for 82.6% of smear-negative compared to 40.5% of Xpert^® negative high MDR-TB risk cases in respective algorithms.

Conclusion

Introduction of an Xpert^® based algorithm did not produce the expected increase in TB diagnostic yield. Studies are required to assess whether improving adherence to the Xpert^® negative algorithm for HIV-infected individuals will increase yield. In light of the high cost of Xpert^®, a review of its role as a screening test for all presumptive TB cases may be warranted.     

Cost-Effectiveness of Financial Incentives to Promote Adherence to Depot Antipsychotic Medication: Economic Evaluation of a Cluster-Randomised Controlled Trial

Background

Offering a modest financial incentive to people with psychosis can promote adherence to depot antipsychotic medication, but the cost-effectiveness of this approach has not been examined.

Methods

Economic evaluation within a pragmatic cluster-randomised controlled trial. 141 patients under the care of 73 teams (clusters) were randomised to intervention or control; 138 patients with diagnoses of schizophrenia, schizo-affective disorder or bipolar disorder participated. Intervention participants received £15 per depot injection over 12 months, additional to usual acute, mental and community primary health services. The control group received usual health services. Main outcome measures: incremental cost per 20% increase in adherence to depot antipsychotic medication; incremental cost of ‘good’ adherence (defined as taking at least 95% of the prescribed number of depot medications over the intervention period).

Findings

Economic and outcome data for baseline and 12-month follow-up were available for 117 participants. The adjusted difference in adherence between groups was 12.2% (73.4% control vs. 85.6% intervention); the adjusted costs difference was £598 (95% CI -£4 533, £5 730). The extra cost per patient to increase adherence to depot medications by 20% was £982 (95% CI -£8 020, £14 000). The extra cost per patient of achieving ''good'' adherence was £2 950 (CI -£19 400, £27 800). Probability of cost-effectiveness exceeded 97.5% at willingness-to-pay values of £14 000 for a 20% increase in adherence and £27 800 for good adherence.

Interpretation

Offering a modest financial incentive to people with psychosis is cost-effective in promoting adherence to depot antipsychotic medication. Direct healthcare costs (including costs of the financial incentive) are unlikely to be increased by this intervention.

Trial Registration

ISRCTN.com 77769281     

Cataract Surgery Visual Outcomes and Associated Risk Factors in Secondary Level Eye Care Centers of L V Prasad Eye Institute,India

Purpose

To evaluate cataract surgery visual outcomes and associated risk factors in rural secondary level eye care centers of L V Prasad Eye Institute (LVPEI), India.

Methods

The Eye Health pyramid of LVPEI has a network of rural secondary care centres (SCs) and attached vision centres (VCs) that provide high quality comprehensive eye care with permanent infrastructure to the most disadvantaged sections of society. The most common procedure performed at SCs is cataract surgery. We audited the outcome of a random sample of 2,049 cataract surgeries done from October 2009-March 2010 at eight rural SCs. All patients received a comprehensive ophthalmic examination, both before and after surgery. The World Health Organization recommended cataract surgical record was used for data entry. Visual outcomes were measured at discharge, 1–3 weeks and 4–11 weeks follow up visits. Poor outcome was defined as best corrected visual acuity <6/18.

Results

Mean age was 61.8 years (SD: 8.9 years) and 1,133 (55.3%) surgeries were performed on female patients. Pre-existing ocular co-morbidity was present in 165 patients (8.1%). The most common procedure was small incision cataract surgery (SICS) with intraocular lens (IOL) implantation (91.8%). Intraoperative complications were seen in 29 eyes (1.4%). At the 4–11 weeks follow-up visit, based on presenting visual acuity (PVA), 61.8% had a good outcome and based on best-corrected visual acuity (BCVA), 91.7% had a good outcome. Based on PVA and BCVA, those with less than 6/60 were only 2.9% and 1.6% respectively. Using multivariable analysis, poor visual outcomes were significantly higher in patients aged ≥70 (OR 4.63; 95% CI 1.61, 13.30), in females (OR 1.58; 95% CI 1.04, 2.41), those with preoperative comorbidities (odds ratio 4.68; 95% CI 2.90, 7.57), with intraoperative complications (OR 8.01; 95% CI 2.91, 22.04), eyes that underwent no IOL or anterior chamber-IOL (OR 12.63; 95% CI 2.65, 60.25) and those undergoing extracapsular cataract extraction (OR 9.39; 95% CI 1.18, 74.78).

Conclusions

This study demonstrates that quality cataract surgeries can be achieved at rural SCs. The concept of the LVPEI SCs can be applied to other developing countries, allowing rural patients to attain better vision through cataract surgery. Despite improvements in quality of cataract surgery, gender discrimination in terms of outcome continues to be an issue and needs further investigation.