Monetary Burden Research Articles

A mini-update on chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is an inflammatory disorder of the paranasal sinuses and the nasal cavity lasting longer than 12 weeks. This disease is a common clinical syndrome with significant monetary burden due to the high costs of medical visits, diagnostic tests, medications, and surgical therapies. CRS without nasal polyposis (CRSsNP) is the most common subtype of CRS, accounting for about 70% of all patients. Other subtypes include CRS with nasal polyposis (CRSwNP) and allergic fungal rhinosinusitis (AFRS). CRSwNP has the worldwide prevalence of 2% to 4% and is often accompanied by type 2 inflammation and asthma as a comorbid condition. Pediatric chronic sinusitis is distinct from adult chronic sinusitis and is currently considered an infectious process, characterized by persistent inflammation representing an exaggerated immune response to an external stimulus. The medical and surgical management of CRS has been remarkably modified in the past two decades. The aim of this study was to present an update on CRS based on the recent years’ literature.

Data Driven Dominance in Digital Markets: Assessing Indonesian Competition Law in the Digital Age

Digital markets and multi-sided platforms are created by the internet, that are characterized by the use of big data as new market power. Big data enabled dominant and digital-based key players such as Instagram and Facebook/Meta to record and forecast their users’ personal data and spending capacity to increase their economies of scale by tailoring updates to the users’ demand. Therefore, big data becomes an essential market share, and its scarcity determines newer entrants’ ability to enter the market and the existing incumbents’ ability to survive by grappling with fast-paced digital changes. This legal morphology benefits data-driven undertakings to elevate their position in the market and achieve enough independence to influence market behavior. On the other hand, multi-sided platforms refer to where a single undertaking sells different products to different types of consumers on different sides of the platforms that affect each other’s demand due to the cross-group network effect. Undertakings often sell zero-price products to one side while imposing the monetary burden and gaining revenue from the other. This situation triggered legal challenges to the calculation of market share necessary to determine a dominant position that is essentially mathematical based. Furthermore, big data and multi-sided platforms stimulate the rise of novel abusive practices in the digital market. This paper will analyze the Indonesian 1999 competition law’s flexibility to deal with these changes by comparing the existing framework on consumer data protection, big data, and multi-sided platforms management to the European Union competition law.

Perceived Physical, Emotional and Monetary Burden among Caregivers of Thalassemia Patients: An Evidence-based Study from District Gujrat, Pakistan

Thalassemia is among the most challenging hereditary blood disorders with no permanent cure. The patients of thalassemia have to face multidimensional complications that may lead to physical, emotional, social, and monetary burdens, among others, that negatively affect the patients, their families, and especially the caregivers. The caregivers feel the burden owing to the long-standing character of the diseases and the struggling process for curing patients, and the caregivers have to face numerous burdens that lead them towards anxiety, depression, social withdrawal, aggression, poor relationships, lower productivity, and many others. The prime objective of this study is to understand the physical, emotional, and monetary burdens faced by caregivers, and primary data for this quantitative study were collected from caregivers of thalassemia patients of district Gujrat. Researchers applied the purposive sampling technique and a structured questionnaire to approach the study participants. The findings highlighted that the caregivers of thalassemia patients face a large number of physical (continued attachment, tiredness, isolation, lower productivity), emotional (aggression, depression, fear of losing a loved one life), and monetary (visiting health centers, arranging blood donors, travel and transportation, personal obligations) burdens that have significant impacts on their socio-economic, psychological and physical health.

Perspectives on technology: Single-use catheters - evidence and environmental impact.

To explore the data comparing single- vs multi-use catheters for clean intermittent catheterisation (CIC), consider if the widespread use of single-use catheters is warranted given the cost and environmental impact, and put forth ideas for future consideration. A primary literature review was performed in PubMed over the past 50 years. Studies that performed comparative analysis of single- and multi-use catheters were included in our review. All studies that reported on primary data were narratively summarised. A total of 11 studies were identified that reported on primary data comparing single- and multi-use catheters. There was no appreciable evidence suggesting reusable multi-use catheters were inferior to single-use catheters from an infection or usability standpoint. In addition, the environmental and monetary burden of single-use catheters is significant. The intermittent catheter landscape in the USA has a complex past: defined by policy, shaped by industry, yet characterised by a paucity of data demonstrating superiority of single-use over multi-use catheters. We believe that the aversion to reusable catheters by many patients and healthcare professionals is unwarranted, especially given the cost and environmental impact. Moving forward, better comparative data and more sustainable practices are needed.

The Extract of Pinellia Ternata-Induced Apoptosis of Leukemia Cells by Regulating the Expression of Bax, Bcl-2 and Caspase-3 Protein Expression in Mice

The study aims to lessen the monetary burden on patients and society by decreasing the price of proprietary drugs used in leukemia therapy. Flow cytometry, reverse transcription polymerase chain reaction, western blot, and a patient-derived xenograft mouse model were used to confirm the therapeutic effect of Pinellia ternata extract on leukemia. Three types of leukemia cells (K562, HL-60, and C8166 cell lines) were found to undergo early apoptosis (P ≤ .05) after being exposed to P. ternata extract, as measured by flow cytometry. Reverse transcription polymerase chain reaction results showed that P. ternata extract at both middle (300 μg/mL) and high (500 μg/mL) concentrations was able to down-regulate Bcl-2 and upregulate mRNA expression of Bax and caspase-3. In the patient-derived xenograft mouse model formed by BALB/c-nu/nu nude mice, immunohistochemistry indicated that P. ternata extract effectively suppressed the proliferation of leukemia cells. Therefore, P. ternata extract at 300 μg/mL and 500 μg/mL could effectively inhibit myeloid and lymphocytic leukemia cell proliferation and promote leukemia cell apoptosis by regulating Bax/Bcl-2 and caspase-3.

Monetary burden of neurocysticercosis on a hospitalized population in Muli County, China

Neurocysticercosis (NCC) is a potentially life-threatening condition caused by the zoonotic cestode, Taenia solium. Pigs are the typical intermediate hosts for T. solium but humans can become infected and develop NCC upon ingesting parasite eggs that are shed in the feces of an infected person. The objective of this study was to estimate the monetary burden of neurocysticercosis (NCC) on hospitalized patients from Muli County, China. Muli is an agricultural county in Liangshan Prefecture, Sichuan Province, China where pigs are raised and the zoonotic cestode, Taenia solium, is endemic. Demographic and treatment data were collected from the Muli County Health Insurance Department on hospitalized individuals with an NCC diagnosis between 2014 and 2021. These patients represent residents of Muli County that purchased health insurance and received treatment in a public hospital in Sichuan Province. Hospital costs were converted from Chinese renminbi (RMB) to United States dollars (US$) for month and year of hospitalization and adjusted for inflation. Individuals with missing hospital information were excluded from analysis. For indirect costs, annual average salary for Liangshan Prefecture working-age adults was obtained to calculate productivity losses based on number of hospitalization days and travel days to and from the hospital. Transportation costs were evaluated based on estimated bus fare to and from the hospital. Out of 70 patients identified from 2014 to 2021, 68 had complete records, of which 47.1% were male (n = 33) and the median age at first hospitalization was 34 years. Total estimated cost for these patients was US$228,341.98. Direct costs contributed 62.5% (US$142,785.25) and indirect costs were 37.5% (US$85,556.73) of the total cost. The estimated median cost per case was US$2,078.69. Individuals with a single hospitalization (n = 41) cost a median of US$1,572.03 and those with multiple hospitalizations (n = 27) cost a median of US$4,169.95. The median total cost per NCC case was 18.6% of the average wage for a Liangshan Prefecture resident in 2021. While the study was limited to those with insurance coverage, monetary burden on the local population is likely substantial. Public health policies aimed at reducing transmission should be implemented to decrease the economic burden of NCC on this region.

The Ever-Shifting Ground of Pretrial Detention Reform

In the past six decades, pretrial detention systems have undergone waves of reform. Despite these efforts, pretrial jail populations across the country continue to swell. The causes of such growth in jail populations are difficult to pinpoint, but some are more readily apparent: Fear over rising crime rates, judicial reluctance to release accused persons, and monetary burdens associated with release have all contributed to increased detention pretrial across criminal legal systems in the United States. This article examines various pretrial detention reform efforts and highlights the need for greater research in the area.

Societal burden and quality of life in patients with Lisfranc Injuries

BackgroundThe incidence of Lisfranc fractures is rising, along with the incidence of foot fractures in general. These injuries can lead to long-term healthcare use and societal costs. Current economic evaluation studies are scarce in Lisfranc fracture research, and only investigate the healthcare costs. The aim of the present study was to accurately measure the monetary societal burden of disease and quality of life in the first 6 months after the injury in patients with Lisfranc fractures in the Netherlands. Materials and methodsThis study used a prevalence-based, bottom-up approach. Patients were included through thirteen medical centres in the Netherlands. Both stable and unstable injuries were included. The societal perspective was used. The costs were measured at baseline, 12 weeks and 6 months using the iMTA MCQ and PCQ questionnaires. Reference prices were used for valuation. Quality-of-life was measured using the EQ-5D-5 L and VAS scores. Results214 patients were included. The mean age was 45.9 years, and 24.3% of patients had comorbidities. The baseline questionnaires yielded approximately €2023 as the total societal costs in the 3 months prior to injury. The follow-up questionnaires and surgery costs assessment yielded approximately €17,083 as the total costs in the first 6 months after injury. Of these costs, approximately two thirds could be attributed to productivity losses. The EQ-5D-5 L found a mean index value of 0.449 at baseline and an index value of 0.737 at the 6-month follow-up. ConclusionThe total monetary societal costs in the first 6 months after injury are approximately €17,083. Approximately two thirds of these costs can be attributed to productivity losses. These costs appear to be somewhat higher than those found in other studies. However, these studies only included the healthcare costs. Furthermore, the baseline costs indicate relatively low healthcare usage before the injury compared to the average Dutch patient. The mean QoL index was 0.462 at baseline and 0.737 at 6 months, indicating a rise in QoL after treatment as well as a long-lasting impact on QoL. To our knowledge, this is only the first study investigating the societal costs of Lisfranc injuries, so more research is needed.

Financial burden by chronic disease and its associated factors among aged (60+) living in India: An Evidence from 75th‐National Sample Survey (NSS)

AbstractBackgroundSome or more chronic diseases are directly associated with standard of living, socioeconomic status, behavioural, economic support from friends/relatives and loan or monetary generated through the sales of household items/goods. However, financial stability plays an important role in handling the cost of care during hospitalization, transportation and non‐medical expenses, and to avoid further chronic conditions. These costs of care during hospitalization are key contributors among aged (60+) people living in India, especially for those who have no support from other family members or relatives. These monetary costs also vary across various social groups (castes). This study has done to understand the monetary burden due to chronic disease among aged (60+) and its associated factors in India.MethodThis study has utilized social consumption and health data from National Sample Survey, 75th round (2017‐18). The average expenditure per hospitalization case (in‐patient) due to chronic disease in aged (60+) were estimated. Generalised Linear regression modeling (GLRM) was done to understand effect of exposure variables (social group, education, household‐expenditure quintile, major source of finance, nature of treatment) on in‐patient expenses incurred on chronic disease.ResultThis study found that around 61 percent married older people were suffering from chronic morbidity in India. Around 43 percent illiterate older people suffered from any chronic diseases, which was the highest compared to highly educated elderly. The results confirm the significantly higher in‐patient expenses among the people having higher level of education [β = 1.26] compared to lower education. Also, the people belonging to Other backward caste bear significantly higher expenses compared to SC.ConclusionIndian aged (60+) are facing high out of pocket expenses on hospitalization due to chronic disease among. Such costs not only create financial problem but also may affect expenses on other health condition or diseases. Insurance coverage was found very weak in India, especially in rural part, and in people with low education level. Policy makers should focus on such schemes on priority basis to ensure active and health ageing in India.

Government Health Insurance Schemes and Their Benefits to The Indian Population: An Overview

In today’s scenario accelerating cost of health significantly impact the health of people and the populace creating a monetary burden on poor households. One of the key concerns while tackling healthcare disparities is out-of-pocket expenses (OOPE). Providing financial safety and provide universal coverage to the entire populace are the main goal of health schemes. Health policies in India are based on equity prioritising the needs of the poor and underprivileged. Likewise, there is a discrepancy in the consistency of information and knowledge regarding the scheme among the beneficiaries. A review was created to help medical and nursing professionals to gain comprehensive knowledge of various health schemes. We tried to give an overview of various health schemes including Ayushman Bharat Yojana, Aam Aadmi Bima Yojana (AABY), Pradhan Mantri Suraksha Bima Yojana (PMSBY), Rashtriya Swasthya BimaYojana (RSBY), Central Government Health Scheme (CGHS), Employees State Insurance Scheme (ESIC), Employee Health Scheme and various state-level health schemes. include, Yeshasvini Health Insurance Scheme, Mahatma Jyotiba Phule Jan Arogya Yojana, Chief Minister Comprehensive Health Insurance Scheme, Mukhyamantri Amrutum Yojana, Karunya Health Scheme, Awaz Health Insurance Scheme, Telangana State Govt Employees and Journalist Health Scheme, Dr Ysr Aarogyastri Health Care Trust, Mukhyamantri Chiranjeevi Yojana, Rajasthan Government Health Scheme (RGHS), and Aarogya Raksha.

Risk-Reducing Measures for Cancer Prevention.

Cancer, or malignancy, continues to be one of the most serious health problems in the world, leading to death and disability. Unlike in previous years, where new cases of cancer were predominant in developed nations, the number of cases of cancer and the resultant deaths are increasing in low- and middle-income countries. This is partially attributable to the current trend of adopting a Western lifestyle, substantial urbanization, and the rise in infections, such as the human papillomavirus (HPV) and hepatitis B virus (HBV), which together account for over 30% of cancer cases in underdeveloped and developing nations. The deleterious impact of cancer, as cases multiply worldwide, is multi-dimensional. Cancer exerts serious physical, psychological, and monetary burdens, not only on cancer patients but also on their family members, close friends, health care systems, and society at large. Importantly, over half of all cancer types can be prevented globally by mitigating the risk and causative factors as well as prompt adherence to scientifically recommended prevention measures. This review provides various scientifically based and people-centered strategies that every individual could adopt to reduce their risk of developing cancer in the future. It is recommended that, for these cancer prevention strategies to be effective, there should be a strong political will from the governments of individual countries to enact specific laws and implement policies that will significantly reduce sedentary lifestyles and unhealthy eating among the general public. Likewise, HPV and HBV vaccines, as well as cancer screenings, should be made available, affordable, and accessible on a timely basis for those who are eligible to take them. Finally, intensified campaigns and numerous informative and educational programs that promote cancer prevention should be initiated globally.

The understated issue of caregiver anxiety for pediatric surgical hospital admissions: opening the blindfolds

Hospitalization is a nerve-wrecking experience for patients and their families (Lam et al. in Int J Nurs Stud 43:535-545, 2006). The financial burden of hospitalization is the prime perpetrator, however, multiple other factors also contribute significantly to the underlying problem which can be eliminated by efforts of the doctors and other healthcare workers and by modifying the hospital policies (Bassett et al. in J Hosp Med 15:652-658, 2020). We can reduce the number of outpatient visits and switch to telemedicine for rescheduling the cases. The pre-anaesthetic clearance and all the relevant investigations can be done on a single OPD visit thereby reducing the requirement of repeated commutes to the hospital. The free of charge category of the hospital can be extended to the patient requiring prolonged hospital stay or for solid tumor patients who require repeated hospital admissions for chemotherapy. Association with child welfare Non-government organizations (NGO's) can also solve major monetary issues for parents of patients suffering from complex congenital anomalies and solid tumors. The pre-operative NPO period can be shortened to 2-4h, antibiotic use can be completely avoided or minimized in clean elective cases, children living in the same city requiring dressing/catheter removal after a few days (e.g. hypospadias, posterior sagittal anorectoplasty) can be discharged and called for a OPD visit after 5-7days if the parents are willing to take care of the child at home. Patients undergoing minor elective surgeries can be followed up on telemedicine visits only. Parents of patients suffering from complex congenital anomalies should be referred to a clinical psychologist and receive periodic counseling sessions. A child psychologist should also be included in the management of cases which have social stigma attached as bladder exstrophy, anorectal malformations, spina bifida requiring lifelong follow-up and bowel washes or repeated clean intermittent catheterisation. Anxiety assessment questionnaires must be incorporated in the management of chronic patients and high-risk parents must be identified (Tiedeman in J Pediatr Nurs 12:110-119, 1997). We hereby propose adoption of family centric approach during the management of a patient as this may minimize the overall burden of the hospitalization of the family. Hospital admission of a child leads to a myriad responses in the parents. Thus, we conducted a hospital-based cross-sectional study to determine the prevalence of anxiety and depression among the primary caregivers of hospitalized children and the factors causing it. Parents of 228 children admitted in the pediatric surgery ward at a tertiary care hospital were interviewed using the HADS-A and Hamilton Anxiety Questionnaire to assess the prevalence of anxiety and depression during hospital admission. They were also subjected to a questionnaire comprising of 52 questions spread over 5 segments-demographic details, monetary burden, effect on siblings and other family members, practical problems faced, and surgery-specific concerns. Thirty percent of the parents had severe anxiety and 20% developed depression due to the hospitalization of their child. We tested the association of this depression and anxiety against 56 variables in this study. Exorbitant loan amounts (ra -0.449, rd-0.557), repeated commute to the hospital (ra -0.274, rd -0.231), monetary burden (ra -0.193, rd -0.186), repetitive sampling (ra -0.248, rd -0.203), prolonged absence from work (ra -0.440, rd -0.424) were found to be the chief perpetrators of this anxiety and depression. The burden of anxiety and depression in the primary caregivers of pediatric surgical patients is enormous. Identification of the implicating factors is essential. Simple reforms such as reduction in the number of OPD visits, extension of free of charge category, association with non-governmental organizations and involvement of a clinical psychologist can significantly meliorate the hospital journey of both the patients and their parents. (rd-correlation coefficient of for depression, ra-correlation coefficient of for anxiety).

Farmers' attitudes towards agricultural plastics – Management and disposal, awareness and perceptions of the environmental impacts

The amount of plastic waste resulting from agricultural practices is increasing and this trend is expected to continue. Although plastics are essential for certain farming tasks, their impact on the environment is becoming a major issue of concern. Mismanaged larger plastics can disintegrate into microplastics and make their way into soils, surface and groundwater sources. Microplastics are extremely persistent and have the potential to facilitate the transfer of contaminants through the environment, potentially affecting terrestrial and aquatic wildlife. A descriptive survey was conducted on a sample of farmers (n = 430) in Ireland to assess their attitudes on agricultural plastic waste management and their awareness and perceptions of the impacts of microplastics and plastics on the environment. This study found that most farmers (88.2%) are concerned about the amount of plastic waste generated by farming activities. Agricultural plastic disposal methods vary and recycling rates mostly depend on the type of plastic, the cost of recycling and access to facilities. Most farmers view agricultural plastics negatively due to their impact on the environment but also because of the monetary and logistical burdens associated with them. Farmers were relatively aware of microplastics (57.5%), but overall more farmers felt they knew more about plastic pollution than microplastic pollution and these issues in aquatic systems. This was also evident when it came to their perception of the risks plastics pose on the environment with more farmers believing that aquatic environments are at greater risk than the terrestrial environments. Future research efforts must focus on plastic and microplastic pollutions in soils to inform policy-makers and to create greater public awareness. In addition to this, several developments are needed in a collective effort by governments, policy-makers and other stakeholders to reduce plastic and microplastic problems in agriculture.

Potential drug-drug interactions among hospitalised TB patients.

BACKGROUND: Hospitalised TB patients are at heightened risk for developing drug-drug interactions (DDIs) due to overlapping CYP450 enzyme and/or drug transporter biotransformation of anti-TB drugs and co-medications given for treating TB-associated comorbidities. We aimed to compare the occurrence, characterisation and determinants of database identified potential DDIs (pDDIs) associated with first-line anti-TB drugs and other co-medications using a subscription and free access drug information database.METHOD: This was a single-centre retrospective study to assess pDDIs between first-line anti-TB drugs and other medications for comorbidities among hospitalised TB patients using IBM Micromedex® and Drugs.com.RESULTS: On multivariate regression analysis, hospitalised TB patients with comorbidities such as diabetes mellitus, HIV infection and hypertension, longer hospitalisation, and patients administered with more than seven drugs during their hospital stay were associated with increased risk for the occurrence of pDDIs. Significant discrepancies were observed in the detection and severity of pDDIs between IBM Micromedex and Drugs.com.CONCLUSION: We recommend using free access drug information database to a subscription drug information database in drug interaction screening protocols in clinics for enhanced identification of pDDIs and reducing monetary burden in resource-limited settings.

Uses of Health Care System Medical Care Services by Athletes After Injury at the HighSchool Level.

Health care utilization can vary by age group, geographic location, and socioeconomic status (SES). A paucity of information exists regarding the availability and utilization of medical care by injured scholastic athletes. The purpose of this study was to describe and compare injuries and health care service utilization by school SES over an academic year. Injury and health care service data was collected from 1 large school district. Percentage of free and reduced lunch (FRPL) for each school was calculated to stratify schools into high (<50% FRPL) and low (≥50.1% FRPL) SES groups. Incidence proportion and relative risk (RR) with 95% confidence intervals (95% CI) were calculated. About 1756 injuries were reported among over 7000 participating athletes from 14 high schools. Similar injury incidence proportions were reported between high and low SES schools (RR=1.10 [1.00-1.20]). Athletes from low SES schools were twice (RR=2.01 [1.21-3.35]) and over three (RR=3.42 [1.84-6.55]) times more likely to receive emergency and physical therapy care. SES was not associated with the use of physician, imaging, or surgery services. School medical providers and administrators should have ready and provide a list of trusted outside primary care and specialty providers that have experience in sports medicine. They should also enquire and follow up on which outside provider the high school athlete will seek care when referring out to outside providers. Injury incidence was similar between high and low SES schools. However, athletes from low SES high schools were over 2-fold more likely to use emergency department services. Understanding factors influencing health care services choice and usage by student athletes from different socioeconomic backgrounds may assist sport medicine clinicians in identifying barriers and potential solutions in improving time to health restoration, athlete outcomes, and health care monetary burden.

Adapting surgical 'bundles' to prevent surgical site infections in obstetrics and gynecology (Review).

Surgical site infections (SSIs) are a complication in any surgical field and they are responsible for 38% of surgery-related patient deaths. Identifying appropriate prophylaxis and solutions to combat SSIs is of global interest. Several studies and reports on SSI raise awareness of this costly complication, both in terms of physical and mental suffering, and as a monetary burden. Knowing the risk factors and implementing strategies to reduce SSI risk represent an adequate approach to reduce SSI incidence. General risk factors of SSI are applicable in the obstetrics and gynecology field, alongside its specific characteristics, including immunological changes occurring during pregnancy, as well as disturbances of vaginal microbiota. The risk of SSI is determined by patient factors but also by preoperative, intraoperative and postoperative care. 'Bundle' prevention strategies have been smartly adopted and their efficiency has been demonstrated in colorectal surgery, cesarean deliveries and gynecological oncology surgeries. 'Bundle' measures may vary among studies, but they remain important prevention methods, which contribute to decreasing SSIs, which is a favorable outcome, and thus, are increasingly used as a routine practice. Therefore, healthcare personnel should aim for the early identification of risk factors to minimize the risk of SSI. All evidence-based methods for preventing and treating SSIs in all surgical fields should be considered to be integral components in order for the best care to be provided to patients.

Menstrual health and period poverty in Lebanon during economic crisis: A qualitative analysis of the challenges and recommendations

ObjectiveRecently, severe period poverty has had a dramatic spread throughout Lebanon as a result of several crises: the COVID-19 pandemic, the Beirut explosion, and the economic collapse. Period poverty is the lack of access to menstrual hygiene materials, comfortable environments, and adequate education about menstrual health. Due to the great implications of period poverty on Lebanese women's health, our study aims to explore stakeholder's perspective on the Lebanese public health policy regarding menstrual health, the evolving challenges it faces in the context of the current economic collapse, and to suggest recommendations for solutions.MethodsOur study is qualitative in nature, where data collection was done via online semi-structured interviews with stakeholders from the public and private sectors of the Lebanese healthcare system in addition to non-governmental organizations (NGOs) and physicians. Data were then analyzed based on themes and subthemes that emerged from the interviews.ResultsNine stakeholders were interviewed: five from NGOs, two obstetrics and gynecology physicians, and two public sector representatives. The challenges to menstrual health were subcategorized into previously existing and new ones. The consequences of poor menstrual health were tackled on the mental, physical, and social levels. Stakeholders suggested both short-term and long-term recommendations. Short-term recommendations included decreasing the monetary burden by subsidizing menstrual products or via a coupon system. Long-term recommendations included proper education on multiple levels, cooperation between key players in the private and public sectors, and encouragement of local production to ensure future sustainability.ConclusionMenstrual health is a neglected public health issue in Lebanon, causing detrimental effects on girls and women residing in the country. Proper planning and collaboration between the private and public sectors are required to address this human rights issue.

Interleukin-1β in tendon injury enhances reparative gene and protein expression in mesenchymal stem cells.

Tendon injury in the horse carries a high morbidity and monetary burden. Despite appropriate therapy, reinjury is estimated to occur in 50–65% of cases. Although intralesional mesenchymal stem cell (MSC) therapy has improved tissue architecture and reinjury rates, the mechanisms by which they promote repair are still being investigated. Additionally, reevaluating our application of MSCs in tendon injury is necessary given recent evidence that suggests MSCs exposed to inflammation (deemed MSC licensing) have an enhanced reparative effect. However, applying MSC therapy in this context is limited by the inadequate quantification of the temporal cytokine profile in tendon injury, which hinders our ability to administer MSCs into an environment that could potentiate their effect. Therefore, the objectives of this study were to define the temporal cytokine microenvironment in a surgically induced model of equine tendon injury using ultrafiltration probes and subsequently evaluate changes in MSC gene and protein expression following in vitro inflammatory licensing with cytokines of similar concentration as identified in vivo. In our in vivo surgically induced tendon injury model, IL-1β and IL-6 were the predominant pro-inflammatory cytokines present in tendon ultrafiltrate where a discrete peak in cytokine concentration occurred within 48 h following injury. Thereafter, MSCs were licensed in vitro with IL-1β and IL-6 at a concentration identified from the in vivo study; however, only IL-1β induced upregulation of multiple genes beneficial to tendon healing as identified by RNA-sequencing. Specifically, vascular development, ECM synthesis and remodeling, chemokine and growth factor function alteration, and immunomodulation and tissue reparative genes were significantly upregulated. A significant increase in the protein expression of IL-6, VEGF, and PGE2 was confirmed in IL-1β-licensed MSCs compared to naïve MSCs. This study improves our knowledge of the temporal tendon cytokine microenvironment following injury, which could be beneficial for the development and determining optimal timing of administration of regenerative therapies. Furthermore, these data support the need to further study the benefit of MSCs administered within the inflamed tendon microenvironment or exogenously licensed with IL-1β in vitro prior to treatment as licensed MSCs could enhance their therapeutic benefit in the healing tendon.

Presenting Step-Ladder Expansive Cranioplasty as the Next Step After Decompressive Hemicraniectomy: It Is Different!

Context: Decompressive hemicraniectomy (DC) is the final surgical remedy for refractory raised intracranial pressure (ICP). Even with years of experience and profound refination of technique, the procedure has less rewarding results in traumatic brain injury (TBI). Besides, arrangements for bone flap preservation and the necessity of follow-up surgery in the form of cranioplasty bring in unavoidable monetary and logistic burdens to the patients. Step-ladder expansive cranioplasty was conceptualized as an alternative to achieve adequate intracranial volume expansion to help normalize ICP, with immediate reinstitution of the Monro-Kellie doctrine. It is also expected to prevent cerebral cortical pressure injury to the cortex underlying the craniectomy defect. The evolution of this concept, as worked out on different models, the surgical technique, and our experience with this technique are discussed in this article. Evidence Acquisition: Multiple research projects undertaken by our team to build up the concept and acquire data necessary to plan the surgical procedure have been published over last eight years. This review article attempts to evaluate the existing knowledge and our clinical experience so far. Results: Step-ladder expansive cranioplasty allows an assured centrifugal displacement of the inner table and underlying dural bag at craniotomy site by at least 9 mm, thereby achieving a minimum volume expansion of 120 cc for a circular craniectomy defect of 10cm dia. Both of these parameters can be increased as considered necessary by the surgeon. Conclusions: Step-ladder expansive cranioplasty offers an alternative that takes the centripetal pressure exerted by the combination of the tensile strength of the scalp and atmospheric pressure off the brain surface while achieving an assured augmentation of intracranial volume that can be optimized on a case-to-case basis, based on our future understanding of the subject. While it can be a single-stage surgery for those satisfied with the cosmesis, a revision cranioplasty (if required) will be easier, cheaper, and cosmetically superior to the presently popular cranioplasty techniques achieving cover over a craniotomy defect routinely done after DC.

Characteristics of 30-Day All-Cause Hospital Readmissions Among Patients with Acute Pancreatitis and Substance Use.

Previous studies on healthcare resource utilization and 30-day readmission risks among patients with acute pancreatitis (AP) have focused upon opioid and alcohol use. The data on other substance types are lacking. In this study we aim to estimate the 30-day readmission rates, predictors of readmission, impact of readmission on patient outcomes and resulting economic burden among patients with AP and substance use in the USA. This was a retrospective cohort study, based upon data from 2017 National Readmission Database of adult patients with AP and substance use (alcohol in combination, opioid, cannabis, cocaine, sedatives, other stimulants, other hallucinogens, other psychoactive, inhalant and miscellaneous). We estimated the 30-day readmission rates and predictors of 30-day readmission. Among 25,795 eligible patients, most were male, belonged to the lower income quartile, resided in the urban facility and had a Charlson comorbidity score of 0 or 1. The use of a combination of substances was the most common in 17,265 (66.9%) patients followed by only opioids in 4691 (18.2%) patients and only marijuana in 3839 (14.9%) patients. A total of 14.6% patients were readmitted within 30days after discharge for non-elective causes with the highest risk of readmission within the 1st week after discharge with 5.2% readmissions. Among top ten causes of readmission, most of the principal diagnosis were related to AP in 53.1%. Compared to index admission, readmitted patients had significantly higher rates of acute cardiac failure, shock, and higher in-hospital mortality rate. Overall, readmission attributed to an additional 17,801days of hospitalization resulting in a total of $150 million in hospitalization charges and $36 million in hospitalization costs in 2017. On multivariate analysis, chronic pancreatitis, self-discharge against medical advice, treatment at the highest volume centers, higher Charlson comorbidity index, increasing length of stay and severe disease were associated with higher odds of readmission while female gender and private insurance were associated with lower odds. Readmission was associated with higher morbidity and in-hospital mortality among patients with AP and substance use and resulted in a significant monetary burden on the US healthcare system. Several factors identified in this study may be useful for categorizing patients at higher risk of readmission warranting special attention during discharge planning.