Breaking barriers: assessing the impact of clinical quality improvements on reducing health disparities in hypertension care among Mumbai's urban slums.

The clinical quality improvement initiatives, led by the organisation's Health Equity Working Group (HEWG), aim to support healthcare providers to provide equitable, quality hypertension care worldwide. After coordinating with the India team, we started monitoring the deidentified patient data collected through electronic health records between January and May 2021. After stratifying data by age, sex and residence location, the team found an average of 55.94% of our hypertensive patients control their blood pressure, with an inequity of 11.91% between male and female patients.The objective of this study was to assess the effectiveness of using clinical quality improvement to improve hypertension care in the limited-resourced, mobile healthcare setting in Mumbai slums. We used the model for improvement, developed by Associates in Process Improvement. After 9-month Plan-Do-Study-Act (PDSA) cycles, the average hypertensive patients with controlled blood pressure improved from 55.94% to 89.86% at the endpoint of the initiative. The gender gap reduced significantly from 11.91% to 2.19%. We continued to monitor the blood pressure and found that the average hypertensive patients with controlled blood pressure remained stable at 89.23% and the gender gap slightly increased to 3.14%. Hypertensive patients have 6.43 times higher chance of having controlled blood pressure compared with the preintervention after the 9-month intervention (p<0.001).This paper discusses the efforts to improve hypertension care and reduce health inequities in Mumbai's urban slums. We highlighted the methods used to identify and bridge health inequity gaps and the testing of PDSA cycles to improve care quality and reduce disparities. Our findings have shown that clinical quality improvement initiatives and the PDSA cycle can successfully improve health outcomes and decrease gender disparity in the limited-resource setting.

Assessment of Covid-19 vaccine confidence among healthcare personnel in the safety-net sector in the United States and Puerto Rico.

BACKGROUND: This study aimed to assess COVID-19 vaccine confidence among healthcare personnel in the safety net sector of the United States and Puerto Rico. This study aimed to examine the extent to which increased knowledge and positive attitudes toward COVID-19 vaccine safety and efficacy were associated with healthcare workers' COVID-19 vaccination status and their recommendation of the vaccine to all patients. METHODS: Online survey data were collected from health care workers working in Free and Charitable Clinics across the United States and Federally Qualified Health Centers in Puerto Rico. The survey consisted of 62 questions covering various demographic measures and constructs related to healthcare workers' vaccination status, beliefs, and recommendations for COVID-19 vaccination. Statistical analyses, including multivariate analysis, were conducted to identify the factors associated with the COVID-19 vaccine status and recommendations among healthcare personnel. RESULTS: Among the 2273 respondents, 93% reported being vaccinated against COVID-19. The analysis revealed that respondents who believed that COVID-19 vaccines were efficacious and safe were three times more likely to be vaccinated and twice as likely to recommend them to all their patients. Respondents who believed they had received adequate information about COVID-19 vaccination were 10 times more likely to be vaccinated and four times more likely to recommend it to all their patients. CONCLUSIONS: The study results indicate that healthcare workers' confidence in COVID-19 vaccines is closely tied to their level of knowledge, positive beliefs, and attitudes about vaccine safety and efficacy. The study emphasizes the significance of healthcare workers feeling well informed and confident in their knowledge to recommend the vaccine to their patients. These findings have important implications for the development of strategies to boost COVID-19 vaccine confidence among healthcare workers and increase vaccine uptake among patients.

Types of health service utilization in Mumbai slums: a community-based survey.

OBJECTIVE: Sociodemographic factors play a crucial role in shaping the health-seeking behaviors of individuals residing in slum areas, particularly in their choice of healthcare facilities. Recognizing the importance of strengthening the existing healthcare systems, this research project was undertaken with the primary objective of comprehending the health-seeking behaviors among residents of Mumbai's slum dwellings in India. To achieve this goal, a comprehensive cross-sectional community needs assessment was conducted spanning from October 2018 to January 2019. RESULTS: 432 respondents reported utilizing at least one health facility in the past year. They reported using private hospitals (172), public hospitals (208), Community Health clinics [23], or other healthcare services (29). To gain further insights into the factors influencing these choices, logistic regression analysis was conducted. The analysis revealed that being female was found to be negatively associated with the selection of a general practitioner as a preferred healthcare provider. On the other hand, higher levels of education and income were found to have a positive association with the preference for private hospitals. Conversely, these factors were negatively associated with the choice of government hospitals.

Cost-effectiveness of overactive bladder treatments from a US commercial and payer perspective.

Aim: The cost-effectiveness of treatment options (anticholinergics, ß3-adrenoceptor agonists, onabotulinumtoxinA, sacral nerve stimulation and percutaneous tibial stimulation [the latter two including new rechargeable neurostimulators]) for the management of overactive bladder (OAB) were compared with best supportive care (BSC) using a previously published Markov model. Materials & methods: Cost-effectiveness was evaluated over a 15-year time horizon, and sensitivity analyses were performed using 2- and 5-year horizons. Discontinuation rates, resource utilization, and costs were derived from published sources. Results: Using Medicare and commercial costs over a 15-year time period, onabotulinumtoxinA 100U had incremental cost-effectiveness ratios (ICERs) gained of $39,591/quality-adjusted life-year (QALY) and $42,255/QALY, respectively, versus BSC, which were the lowest ICERs of all assessed treatments. The sensitivity analyses at 2- and 5-year horizons also showed onabotulinumtoxinA to be the most cost-effective of all assessed treatments versus BSC. Conclusion: OnabotulinumtoxinA 100U is currently the most cost-effective treatment for OAB.

Exploring perceived risk for COVID-19 and its role in protective behavior and COVID-19 vaccine hesitancy: a qualitative study after the first wave.

BACKGROUND: The novel coronavirus pandemic (COVID-19) has had severe impacts on morbidity and mortality globally. METHODS: This study was set in rural central Kentucky and included participants recruited from public spaces. Fifteen qualitative interviews about personal experiences during the COVID-19 pandemic were conducted by phone from July 3 to July 24, 2020. Interviews were recorded, transcribed, and coded using a grounded theory approach. RESULTS: Participants who perceived COVID-19 to be a severe risk tended to have personal health concerns and therefore reported taking protective measures for themselves. A slightly smaller proportion of participants reported taking measures to protect others (particularly family). A minority of participants had an ambivalent attitude towards the risk and only took measures if required. COVID-19 vaccine acceptability was low with most participants expressing concerns regarding their need for a vaccine, safety of this vaccine, the value of personal rights, or future vaccine supply. CONCLUSIONS: Most participants perceived some risk of COVID-19 and took steps to prevent infections in themselves and others. Mandates for mask use in certain locations were additionally useful for those who had an ambivalent attitude towards the risk of illness. There was surprisingly little connection between perceiving COVID-19 risk and a desire for the COVID-19 vaccine. In this setting, vaccine acceptability was low, with vaccine concerns outweighing perceived potential benefits. In conclusion, because the risk was often constructed in terms of worries for themselves and others, the framing of health education materials for protective behaviors in these terms may be effective. Furthermore, future COVID-19 vaccine education should address vaccine knowledge and concerns, such as the need for a vaccine and its safety, and emphasize how a vaccination would reduce their chances of severe disease if they were to get sick.

Knowledge, attitudes, and practices of cervical cancer prevention and pap smears in two low-income communities in Lima, Peru.

BACKGROUND: Cervical cancer is a leading cause of death among Peruvian women. Barriers at multiple levels impact effective screening and treatment, including a lack of knowledge about cervical cancer and how regular screening can reduce morbidity and mortality through earlier detection. The aim of this study is to assess knowledge, attitudes, and practices regarding cervical cancer and its prevention in the peri-urban communities of Oasis and Pampas in southern Lima, Peru that can be used to inform future campaigns about cervical cancer prevention. METHODS: A cross-sectional survey that included several open-ended questions was administered to women in Pampas and Oasis between 2015 and 2016 to evaluate the knowledge, attitudes, and practices regarding cervical cancer and Pap smears. RESULTS: In total, 224 women were interviewed. Knowledge about cervical cancer and Pap smears was high, and attitudes were predominantly positive among most participants. Most participants knew how often they should get Pap smears (89.7%), when to begin seeking screening (74.6%), knew the price of a Pap smear (61.9%), and felt Pap smears were important for their health (70.1%). About one third (29.5%) of premenopausal women reported receiving a Pap smear in the last year. However, open ended questions revealed some knowledge gaps around Pap smears, as well as some stigma associated to Human Papilloma Virus (HPV) infection. CONCLUSION: Although knowledge of cervical cancer prevention was generally high and perceptions were positive among women in peri-urban Peruvian communities, our findings revealed there is a need for education on HPV infection prevalence among sexually active individuals to reduce stigma. Future research should focus on exploring experiences with follow-up and treatment associated with abnormal Pap smears, as well as perspectives from health authorities and professionals about barriers in the early detection and treatment process for cervical cancer.

Poly(ethylene glycol) based nanotubes for tuneable drug delivery to glioblastoma multiforme.

Glioblastoma multiforme (GBM) is the most aggressive type of malignant brain tumour, which is associated with a poor two-year survival rate and a high rate of fatal recurrence near the original tumour. Focal/local drug delivery devices hold promise for improving therapeutic outcomes for GBM by increasing drug concentrations locally at the tumour site, or by facilitating the use of potent anti-cancer drugs that are poorly permeable across the blood brain barrier (BBB). For inoperable tumours, stereotactic delivery to the tumour necessitates the development of nanoscale/microscale injectable drug delivery devices. Herein we assess the ability of a novel class of polymer nanotube (based on poly(ethylene glycol) (PEG)) to load doxorubicin (a mainstay breast cancer therapeutic with poor BBB permeability) and release it slowly. The drug loading properties of the PEG nanotubes could be tuned by varying the degree of carboxylic acid functionalisation and hence the capacity of the nanotubes to electrostatically bind and load doxorubicin. 70% of the drug was released over the first seven days followed by sustained drug release for the remaining two weeks tested. Unloaded PEG nanotubes showed no toxicity to any of the cell types analysed, whereas doxorubicin loaded nanotubes decreased GBM cell viability (C6, U-87 and U-251) in a dose dependent manner in 2D in vitro culture. Finally, doxorubicin loaded PEG nanotubes significantly reduced the viability of in vitro 3D GBM models whilst unloaded nanotubes showed no cytotoxicity. Taken together, these findings show that polymer nanotubes could be used to deliver alternative anti-cancer drugs for local therapeutic strategies against brain cancers.

Morphological, molecular and phylogenetic characterisation of Eimeria macyi Wheat, 1975 (Apicomplexa: Eimeriidae) in the eastern red bat Lasiurus borealis (Müller) from Mississippi, USA.

In November 2017, oöcysts of the coccidian Eimeria macyi Wheat, 1975 were isolated from the faeces of a single eastern red bat Lasiurus borealis Müller in Lowndes County, Mississippi, USA. Sporulated oöcysts, morphologically consistent with previous accounts of E. macyi in other chiropterans, were spherical to sub-spherical in shape with a highly mamillated outer wall that appears bi-layered. Oöcysts allowed to sporulate in 2.5% potassium dichromate at ambient temperature (c.23°C) for 7 days were 17-25 × 15-20 (20.7 × 17.9) µm. Micropyle and oöcyst residuum were absent with one to two polar granules scattered among sporocysts. The four ovoid sporocysts were 7-12 × 6-8 (9.9 × 7.1) µm. Stieda bodies were prominent and sub-Stieda bodies were present. Two sporozoites were reflexed within each sporocyst. Nuclear 18S rRNA gene, plastid 23S rRNA gene and mitochondrial cytochrome c oxidase subunit 1 (cox1) gene were sequenced from sporulated oöcysts and compared to other molecular data of Eimeria spp. from rodent and chiropteran hosts. No sequence data in the NCBI database matched E. macyi. Phylogenetic analyses of the sequence data of the 18S rRNA and 23S rRNA genes placed E. macyi within a clade containing Eimeria spp. from rodents and basal to a clade populated by sequences derived from Eimeria spp. of rodents and bats. This account represents a new host record of E. macyi in an eastern red bat and a new geographic locality. Additionally, the cox1 sequence data of Eimeria macyi represents the first mitochondrial sequence of an Eimeria sp. in bats.

Parental Influences on Heavy Episodic Drinking Development in the Transition to Early Adulthood.

PURPOSE: The purpose of this study was to examine how parental relationship quality (communication frequency, time spent together, and closeness) during early adulthood is related to heavy episodic drinking (HED) during this developmental period and whether effects vary according to age, youth sex, or parent sex. METHODS: National data from the Panel Study of Income Dynamics-Transition to Adulthood Study were analyzed. Youth participated in up to four interviews (2005, 2007, 2009, and 2011; n = 1,320-1,489) between ages 18-25 years. At each wave, respondents reported past-year HED and their communication frequency, time spent, and closeness with each parent (items combined into an index). We tested differences in parental effects by age, parent sex, and youth sex using multigroup latent curve models. RESULTS: Paternal relationship quality was negatively associated with HED for both males and females at each age; associations did not vary by respondent age or sex (odds ratio [OR] = .73, 95% confidence interval [CI]: .63-.85). Maternal relationship quality was significantly negatively associated with HED at ages 18-19 years among both sexes equally (OR = .50, 95% CI: .41-.61). Although protective associations continued until the age of 25 years for males, they weakened and became nonsignificant at ages 20-25 years for females (OR = .87, 95% CI: .72-1.04). Findings were robust to inclusion of multiple covariates associated with both parenting and alcohol use. CONCLUSIONS: Having close, communicative parental relationships seems protective against HED in early adulthood, although for females maternal effects appear limited to late adolescence. Programs to improve relationship quality between young adults and their parents may help curb problematic drinking during this vulnerable period.

Perceived Discrimination and Heavy Episodic Drinking Among African-American Youth: Differences by Age and Reason for Discrimination.

PURPOSE: The purpose of this study was to examine whether associations between perceived discrimination and heavy episodic drinking (HED) vary by age and by discrimination type (e.g., racial, age, physical appearance) among African-American youth. METHODS: National data from the Panel Study of Income Dynamics Transition to Adulthood Study were analyzed. Youth participated in up to four interviews (2005, 2007, 2009, 2011; n = 657) between ages 18 and 25 years. Respondents reported past-year engagement in HED (four or more drinks for females, five or more drinks for males) and frequency of discriminatory acts experienced (e.g., receiving poor service, being treated with less courtesy). Categorical latent growth curve models, including perceived discrimination types (racial, age, and physical appearance) as a time-varying predictors of HED, were run. Controls for gender, birth cohort, living arrangement in adolescence, familial wealth, parental alcohol use, and college attendance were explored. RESULTS: The average HED trajectory was curvilinear (increasing followed by flattening), whereas perceived discrimination remained flat with age. In models including controls, odds of HED were significantly higher than average around ages 20-21 years with greater frequency of perceived racial discrimination; associations were not significant at other ages. Discrimination attributed to age or physical appearance was not associated with HED at any age. CONCLUSIONS: Perceived racial discrimination may be a particularly salient risk factor for HED around the ages of transition to legal access to alcohol among African-American youth. Interventions to reduce discrimination or its impact could be targeted before this transition to ameliorate the negative outcomes associated with HED.

The teaching/research trade-off in law: data from the right tail.

BACKGROUND: There is a long scholarly debate on the trade-off between research and teaching in various fields, but relatively little study of the phenomenon in law. This analysis examines the relationship between the two core academic activities at one particular school, the University of Chicago Law School, which is considered one of the most productive in legal academia. METHOD: We measure of scholarly productivity with the total number of publications by each professor for each year, and we approximate performance in teaching with course loads and average scores in student evaluations for each course. In OLS regressions, we estimate scholarly output as a function of teaching loads, faculty characteristics, and other controls. We also estimate teaching evaluation scores as a function of scholarly productivity, fixed effects for years and course subject, and faculty characteristics. RESULT: Net of other factors, we find that, under some specifications, research and teaching are positively correlated. In particular, we find that students' perceptions of teaching quality rises, but at a decreasing rate, with the total amount of scholarship. We also find that certain personal characteristics correlate with productivity. CONCLUSION: The recent debate on the mission of American law schools has hinged on the assumption that a trade-off exists between teaching and research, and this article's analysis, although limited in various ways, casts some doubt on that assumption.

Anatomical and manometric comparison of perineal and transscrotal approaches to artificial urinary sphincter placement.

PURPOSE: We compared cuff sites and assessed anatomical and manometric differences between the transscrotal and perineal approaches to artificial urinary sphincter placement in fresh male cadavers. MATERIALS AND METHODS: Artificial urinary sphincter implantation using perineal and transscrotal incisions was performed in 15 fresh male cadavers. The artificial urinary sphincter cuffs were placed as proximal as possible using each approach. After measuring urethral circumference at each cuff site, an appropriately sized cuff was placed at each location. The 61 to 70 cm H(2)O pressure reservoir and control pump were then connected to the cuffs. Retrograde leak point pressure was assessed sequentially across each cuff. The paired t test was used to compare urethral circumference and retrograde leak point pressure between the 2 approaches. RESULTS: Mean urethral circumference using the perineal and transscrotal approaches was 5.38 (range 3.2 to 7.5) and 3.81 cm (range 3 to 4.5), respectively (p <0.0001, 95% CI of difference 0.99-2.13). Mean retrograde leak point pressure using the perineal and transscrotal approaches was 90.1 and 64.9 cm H(2)O, respectively (p = 0.0002, 95% CI of difference 13.7-33.5). On visual inspection of cuff sites, the perineal approach was more proximal on the urethra than the transscrotal approach. CONCLUSIONS: While the transscrotal approach to artificial urinary sphincter placement has the advantage of technical ease, the anatomical and manometric findings of this cadaver study suggest that the perineal approach offers a more proximal cuff location, more robust urethral size and more effective urethral coaptation than the transscrotal approach.

Presentation and management of a patient with subcutaneous metastatic transitional cell carcinoma of the bladder.

BACKGROUND: A 60-year-old female with a 6-month history of muscle-invasive transitional cell carcinoma of the bladder presented with an enlarging subcutaneous lesion involving her right flank. She had previously undergone radical cystectomy, bilateral pelvic lymphadenectomy and ileal orthotopic neobladder reconstruction. INVESTIGATIONS: Axial fused fluorodeoxyglucose PET-CT of the chest, abdomen and pelvis, fine needle aspiration with direct ultrasound guidance, excisional biopsy and immunohistochemistry. DIAGNOSIS: Subcutaneous and liver metastases of transitional cell carcinoma. MANAGEMENT: Wide local excision of the subcutaneous lesion followed by combination gemcitabine-cisplatin chemotherapy. Gemcitabine was administered at a dose of 1,000 mg/m(2) on days 1, 8, and 15, and cisplatin was administered at a dose of 75 mg/m(2) on day 1; the schedule was repeated every 28 days for three cycles.

Can ischemic preconditioning ameliorate renal ischemia-reperfusion injury in a single-kidney porcine model?

PURPOSE: Ischemic preconditioning (IP) refers to the phenomenon of a brief ischemia-reperfusion event providing resistance to injury from subsequent ischemic periods. We sought to determine the effect of a specific preconditioning regimen on ischemia-reperfusion renal injury in a single-kidney porcine model. MATERIALS AND METHODS: Immediately following right laparoscopic nephrectomy, 12 female pigs had complete left hilar dissections and 1 of 2 interventions: (1) 60 minutes of complete WI (WI; n = 6) or (2) 10 minutes of IP followed by 60 minutes of complete WI (IP; n = 6). IP consisted of 5 minutes of clamping followed by 5 minutes of reperfusion. Serum creatinine (sCr) was obtained preoperatively and on postoperative day (POD) 1, 2, 6, 9, and 14. Mean sCr was compared by group. The left kidney was harvested on POD 14 for blinded histologic review. RESULTS: Mean sCr values were significantly increased at all time points in the WI and IP groups compared with baseline. Peak postoperative sCr was noted on POD 1 in both groups after which there was a downward trend. The WI and IP groups had similar mean sCr values at all time points. The study groups were histologically indistinguishable with no difference in the degree of tissue injury. CONCLUSIONS: A simple intervention which successfully prevents renal warm-ischemic damage would expand the number of surgeons and patients who benefit from laparoscopic NSS. There is no evidence that this preconditioning regimen ameliorated the ischemia-reperfusion injury. Endeavors are ongoing to determine if alternative preconditioning regimens may be beneficial.

Complete androgen insensitivity: the role of the surgeon.

PURPOSE: This is a retrospective series of the surgical management of complete androgen insensitivity at a single institution. MATERIALS AND METHODS: The records of 16 patients 4 to 63 years old with complete androgen insensitivity were extracted from an institutionally approved database. We determined whether each patient underwent vaginoplasty, age at vaginoplasty, vaginal depth before vaginoplasty, age at gonadectomy and whether the patient was sexually active. These data were pooled with those from a prior study at our institution to yield a total of 29 patients. RESULTS: All patients had undergone gonadectomy with no evidence of malignancy in any pathology specimens. Of the 27 patients in whom the date of surgery was known 20 underwent surgery in late adolescence/adulthood, while 7 had the testes removed in childhood. Of the 29 patients 11 (38%) have undergone vaginal reconstruction. Average vaginal depth in postpubertal patients without reconstruction was 6.6 cm (range 1.5 to 10). Preoperative vaginal depth in patients with was between 2 and 4 cm. Ten postpubertal patients have undergone vaginoplasty and 7 (70%) are sexually active. Of the postpubertal patients 15 have not undergone vaginoplasty, of whom 12 (80%) are sexually active. CONCLUSIONS: A delayed approach to gonadectomy and vaginal reconstruction respects patient autonomy and allows a more mature patient to handle the psychological and physical trauma of surgery and rehabilitation. Since we recognize the small number of patients in this series, strict guidelines cannot be proposed.

Simultaneous repair of sigmoid colon conduit fistula and neovagina construction in a patient with bladder exstrophy.

Recurrent urogynecologic complications in women with bladder exstrophy are common and complex given the congenital abnormalities of the bony, connective tissue, and muscular support of the pelvic floor, as well as the length and axis of the vagina. Management of these issues is challenging and often requires unique surgical strategies. We present the case of a distinct, individualized surgical approach to management of several complicated urogynecologic issues in a woman with bladder exstrophy who desired surgical correction of a non-healing fistula, pelvic organ prolapse, and a short vagina.

An initial evaluation of pelvic floor function and quality of life of bladder exstrophy patients after ureterosigmoidostomy.

Classic bladder exstrophy is characterized by displaced pelvic floor musculature and significant skeletal and genitourinary defects. A paucity of data exist evaluating long-term pelvic floor function in exstrophy patients after ureterosigmoidostomy. This study is an initial attempt to evaluate the prevalence of urofecal incontinence, pelvic organ prolapse, and overall quality of life in patients who have had ureterosigmoidostomies. Fifty-two individuals who underwent ureterosigmoidostomy between 1937 and 1990 were identified through the Ureterosigmoidostomy Association and the Johns Hopkins bladder exstrophy database and mailed questionnaires approved by the Institutional Review Board (Johns Hopkins). Data were analyzed with SigmaStat 3.0 (SPSS, Inc., Chicago, IL). Eighty-three percent of the subjects responded, with a mean age of 44.4 years (range, 14-73 years) and mean of 40.9 years (range, 14-65 years) after ureterosigmoidostomy. Prevalence of daily urinary and fecal incontinence was 48% (n = 20) and 26% (n = 11), respectively, whereas the prevalence of weekly combined urofecal incontinence was 63% (n = 27). The incidence of pelvic organ prolapse in this cohort was 48% (n = 20). In these patients, a significant risk of urofecal incontinence and pelvic organ prolapse exists. Long-term follow-up studies are needed to understand the role of pelvic floor musculature in this complex birth defect.