Diagnostic and interventional neuroradiology training in the UK: a national trainee survey

AIM

Training structure in neuroradiology can be variable, nationally and internationally. Globally, there is a trend towards standardised training pathways, curricula and targeted competencies. Currently, there is limited understanding of the structure of neuroradiology training in the UK. This survey aims to: [1] identify different contemporary models of neuroradiology training in the UK, [2] compare UK trainees' commitments against national and international standards, and [3] understand whether career expectations match the predicted future demands of neuroradiologists.

MATERIALS AND METHODS

A survey was developed after consultation with BSNR and UKNG representatives. The eligibility criteria included current neuroradiology trainees in the UK with at least 3 months of experience or had recently completed neuroradiology training, but less than 18 months had elapsed since achieving a certificate of completion of training.

RESULTS

A total of 50 trainees responded to the survey; 26 (52%) diagnostic neuroradiologists (DNRs) and 24 (48%) interventional neuroradiologists (INRs) with an overall mean age of 33 years. The mean duration of training at the time of survey was 18 months. The survey details trainee demographics, experience at work, research and teaching commitments and future goals.

CONCLUSION

Most respondents are satisfied with their training and 90% want to remain in the UK after completion of training. There is room for improvement but the future of training and working in neuroradiology seems promising internationally, with ever-evolving techniques and developments.

ADVANCES IN KNOWLEDGE

Advances in knowledge: This study evaluates neuroradiology training in the UK to enhance the training of future neuroradiologists, and safeguard the future of the speciality.

Distribution and Functional Analyses of Mutations in Spike Protein and Phylogenic Diversity of SARS-CoV-2 Variants Emerged during the Year 2021 in India

Introduction

Prolonged COVID-19 pandemic accelerates the emergence and transmissibility of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) variants through the accumulation of adaptive mutations. Particularly, adaptive mutations in spike (S) protein of SARS-CoV-2 leads to increased viral infectivity, severe morbidity and mortality, and immune evasion. This study focuses on the phylodynamic distribution of SARS-CoV-2 variants during the year 2021 in India besides analyzing the functional significance of mutations in S-protein of SARS-CoV-2 variants.

Methods

Whole genome of SARS-CoV-2 sequences (n = 87957) from the various parts of India over the period of January to December 2021 was retrieved from Global Initiative on Sharing All Influenza Data. All the S-protein sequences were subjected to clade analysis, variant calling, protein stability, immune escape potential, structural divergence, Furin cleavage efficiency, and phylogenetic analysis using various in silico tools.

Results

Delta variant belonging to 21A, 21I, and 21J clades was found to be predominant throughout the year 2021 though many variants were also present. A total of 4639 amino acid mutations were found in S-protein. D614G was the most predominant mutation in the S-protein followed by P681R, L452R, T19R, T478K, and D950N. The highest number of mutations was found in the N-terminal domain of S-protein. Mutations in the crucial sites of S-protein impacting pathogenicity, immunogenicity, and fusogenicity were identified. Intralineage diversity analysis showed that certain variants of SARS-CoV-2 possess high diversification.

Conclusions

The study has disclosed the distribution of various variants including the Delta, the predominant variant, in India throughout the year 2021. The study has identified mutations in S-protein of each SARS-CoV-2 variant that can significantly impact the virulence, immune evasion, increased transmissibility, high morbidity, and mortality. In addition, it is found that mutations acquired during each viral replication cycle introduce new sub-lineages as studied by intralineage diversity analysis.

Practice patterns and adherence to society guidelines for suspected choledocholithiasis: A comparison of academic and community settings from a large US healthcare system

Background

The American Society of Gastrointestinal Endoscopy (ASGE) has proposed practice guidelines for evaluating patients with suspected choledocholithiasis. This study aims to assess and compare practice patterns for following ASGE guidelines for choledocholithiasis in a large academic vs. community hospital setting.

Methods

A total of one thousand ER indicated for choledocholithiasis were randomly selected. Patients’ demographics, total bilirubin, imaging studies including magnetic resonance cholangiopancreatography (MRCP), intraoperative cholangiogram (IOC), endoscopic ultrasound (EUS), and ERCP results were retrospectively collected. Patients with prior sphincterotomy were excluded. We examined the following practice deviations from the current ASGE guidelines; (1) ERCP was potentially delayed in high probability cases while awaiting additional imaging studies, (2) ERCP was performed without additional imaging studies in cases of low/intermediate-risk, or (3) ERCP was performed in low/intermediate-risk cases when additional imaging studies were negative.

Results

A total of 640 patients with native papilla who underwent ERCP were included in the final analysis. Overall, the management of 43% (275) of patients was deviated from the applicable ASGE guidelines. Academic and community provider rates of non-adherence were 32 vs. 45%, respectively (p-value: < 0.01). Of 381 high-risk cases, 54.1% had additional imaging before ERCP. (Academic vs. community; 11.7 vs. 88.3%, p-value: < 0.01). In 26.7% (69/258) of low/intermediate risk cases, ERCP was performed without additional studies; academic (14.5%) vs. community (85.5%) (p-value: < 0.01). Finally, in 11.2% (19/170) of patients, ERCP was performed despite intermediate/low probability and negative imaging; academic (26.3%) vs. community (73.7%) (p-value: 0.02).

Conclusion

Our study results show that providers do not adhere to ASGE practice guidelines in 43% of suspected choledocholithiasis cases. The rate of non-adherence was significantly higher in community settings. It could be due to various reasons, including lack/delays for alternate studies (i.e., MRCP, EUS), concern regarding the length of stay, patient preference, or lack of awareness/understanding of the guidelines. Increased availability of alternate imaging and educational strategies may be needed to increase the adoption of practice guidelines across academic and community settings to improve patient outcomes and save healthcare dollars.

Epitope identification and designing a potent multi-epitope vaccine construct against SARS-CoV-2 including the emerging variants

Introduction:

The emergence of a novel coronavirus in China has turned into a SARS-CoV-2 pandemic with high fatality. As vaccines are developed through various strategies, their immunogenic potential may drastically vary and thus pose several challenges in offering immune responses against the virus.

Methods:

In this study, we adopted an immunoinformatics-aided approach for developing a new multi-epitope vaccine construct (MEVC). In silico approach was taken for the identification of B-cell and T-cell epitopes in the Spike protein, for MEVC various cytotoxic T-lymphocyte, helper T-lymphocyte, and B-cell epitopes with the highest affinity for the respective HLA alleles were assembled and joined by linkers.

Results:

The computational data suggest that the MEVC is nontoxic, nonallergenic and thermostable and elicit both humoral and cell-mediated immune responses. Subsequently, the biological activity of MEVC was assessed by bioinformatic tools using the interaction between the vaccine candidate and the innate immune system receptors TLR3 and TLR4. The epitopes of the construct were analyzed with that of the strains belonging to various clades including the emerging variants having multiple unique mutations in S protein.

Conclusions:

Due to the advantageous features, the MEVC can be tested in vitro for more practical validation and the study offers immense scope for developing a potential vaccine candidate against SARS-CoV-2 in view of the public health emergency associated with COVID-19 disease caused by SARS-CoV-2.

Comparing diagnostic accuracy of current practice guidelines in predicting choledocholithiasis: outcomes from a large healthcare system comprising both academic and community settings

BACKGROUND AND AIMS

The American Society for Gastrointestinal Endoscopy (ASGE) 2010 guidelines for suspected choledocholithiasis were recently updated by proposing more specific criteria for selection of high-risk patients to undergo direct ERCP while advocating the use of additional imaging studies for intermediate- and low-risk individuals. We aim to compare the performance and diagnostic accuracy of 2019 versus 2010 ASGE criteria for suspected choledocholithiasis.

METHODS

We performed a retrospective chart review of a prospectively maintained database (2013-2019) of over 10,000 ERCPs performed by 70 gastroenterologists in our 14-hospital system. We randomly selected 744 ERCPs in which the primary indication was suspected choledocholithiasis. Patients with a history of cholecystectomy or prior sphincterotomy were excluded. The same patient cohort was assigned as low, intermediate, or high risk according to the 2010 and 2019 guideline criteria. Overall accuracy of both guidelines was compared against the presence of stones and/or sludge on ERCP.

RESULTS

Of 744 patients who underwent ERCP, 544 patients (73.1%) had definite stones during ERCP and 696 patients (93.5%) had stones and/or sludge during ERCP. When classified according to the 2019 guidelines, fewer patients were high risk (274/744, 36.8%) compared with 2010 guidelines (449/744, 60.4%; P < .001). Within the high-risk group per both guidelines, definitive stone was found during ERCP more frequently in the 2019 guideline cohort (226/274, 82.5%) compared with the 2010 guideline cohort (342/449, 76.2%; P < .001). In our patient cohort, overall specificity of the 2010 guideline was 46.5%, which improved to 76.0% as per 2019 guideline criteria (P < .001). However, no significant change was noted for either positive predictive value or negative predictive value between 2019 and 2010 guidelines.

CONCLUSIONS

The 2019 ASGE guidelines are more specific for detection of choledocholithiasis during ERCP when compared with the 2010 guidelines. However, a large number of patients are categorized as intermediate risk per 2019 guidelines and will require an additional confirmatory imaging study.

Half-Integer Quantized Topological Response in Quasiperiodically Driven Quantum Systems

A spin strongly driven by two harmonic incommensurate drives can pump energy from one drive to the other at a quantized average rate, in close analogy with the quantum Hall effect. The pumping rate is a nonzero integer in the topological regime, while the trivial regime does not pump. The dynamical transition between the regimes is sharp in the zero-frequency limit and is characterized by a Dirac point in a synthetic band structure. We show that the pumping rate is half-integer quantized at the transition and present universal Kibble-Zurek scaling functions for energy transfer processes. Our results adapt ideas from quantum phase transitions, quantum information, and topological band theory to nonequilibrium dynamics, and identify qubit experiments to observe the universal linear and nonlinear response of a Dirac point in synthetic dimensions.

Universal Entanglement of Typical States in Constrained Systems

Constraints play an important role in the entanglement dynamics of many quantum systems. We develop a diagrammatic formalism to exactly evaluate the entanglement spectrum of random pure states in large constrained Hilbert spaces. The resulting spectra may be classified into universal "phases" depending on their singularities. The simplest class of local constraints reveals a nontrivial phase diagram with a Marchenko-Pastur phase which terminates in a critical point with new singularities. We propose a certain quantum defect chain as a microscopic realization of the critical point. The much studied Rydberg-blockaded or Fibonacci chain lies in the Marchenko-Pastur phase with a modified Page correction to the entanglement entropy. Our results predict the entanglement of infinite temperature eigenstates in thermalizing constrained Floquet spin chains, as we confirm numerically.

Prosthetic Mitral Valve Obstruction with Left Atrial Appendage Thrombus: A Therapeutic Dilemma

Valvular obstruction is a rare but life-threatening complication of mechanical prosthetic valves that raises significant challenges in management. We describe a unique case of mechanical mitral valve obstruction with co-existing left atrial appendage (LAA) thrombus. A 48-year-old man with a past medical history of atrial fibrillation and mechanical mitral valve replacement 18 months prior, presented with symptoms of new onset heart failure for 10 days. INR on presentation was sub-therapeutic. Trans-thoracic and trans-esophageal echocardiography revealed prosthetic mitral valve obstruction with mobile, echogenic masses seen on the mechanical valve as well as LAA, suggestive of thrombus. His clinical course rapidly deteriorated and he developed cardiogenic shock. He was deemed to have prohibitive risk for emergent surgical intervention. He received trial of thrombolytic therapy, with partial improvement of hemodynamic parameters and a mild decrease in thrombus burden. He then underwent surgical intervention with a favorable outcome. Intra-operative visualization of the prosthetic valve revealed a combination of pannus and thrombus. Prosthetic valve function should be promptly assessed in patients presenting with heart failure symptoms, as clinical deterioration can be rapid. Acute presentation, history of inadequate anticoagulation and appearance of soft mass on an echocardiogram, are suggestive of thrombus as the etiology of valve obstruction. However, thrombus and pannus are known to frequently co-exist. Emergent surgery is the recommended management strategy in patients with left-sided prosthetic valve thrombosis with the New York Heart Association (NYHA) III or IV symptoms, due to a lower rate of thrombo-embolism, major bleeding, and recurrent prosthetic valve thrombosis when compared with thrombolytic therapy. Slow-infusion, low-dose thrombolytics were recently shown to have favorable outcomes and can be considered when surgery is not available or the patient is deemed to have prohibitive surgical risk.

Dedifferentiated Liposarcoma in a Giant Esophageal Polyp: A Case Report and Review of the Literature

Soft tissue sarcomas represent an extremely rare cause of esophageal masses, and undifferentiated sarcomas are rarer. The proportion of dedifferentiated liposarcomas (DDL) is even lower. The case of a 58-year-old male who complained of dysphagia and was found to have an 18-centimeter long esophageal mass/polyp on esophagogastroduodenoscopy is presented. The lesion was resected endoscopically and a diagnosis of DDL was confirmed by fluorescence in situ hybridization. Due to its rarity, the treatment experience with esophageal DDLs is limited. However, based on our experience, endoscopic resection of the lesion can be considered as the treatment of choice when feasible. We performed a review of the literature to identify and analyze similar reported cases.

P113 Efficacy, safety and long-term durability of endovascular treatment of MCA aneuryms: a review of 161 treated aneurysms

Objectives

The aim of this study was to assess the long-term outcomes of endovascular treatment of MCA aneurysms and identify factors associated with recurrence.

Subjects

161 aneurysms in 147 patients treated between January 2008 and August 2011.

Methods

A retrospective case note review was performed. Aneurysm occlusion was assessed using the Raymond-Roy classification. Clinical outcome was graded using the mRS.

Results

The minimum period of follow up was 65 months, with a maximum follow up period of 120 months. 49% of aneurysms were ruptured at the time of treatment. Morbidity was observed in 15% of the unruptured aneurysms (6% permanent neurological deficit), and in 33% of ruptured aneurysms (15% permanent neurological deficit). 84% of aneurysms were fully occluded following first treatment. Of these, 34% demonstrated angiographic recurrence and 10% required re-intervention. 25% of aneurysms≤7 mm in maximal diameter demonstrated angiographic recurrence, as compared with 50% of aneurysms>7 mm. Aneurysm size >7 mm was associated with a significantly shorter time to recurrence (log rank=9.655, p=0.002).

Conclusions

This is a large series of MCA aneurysms with a long period of follow up. Our results demonstrate that endovascular treatment of MCA aneurysms is associated with a low morbidity and mortality. Given the increasing use of adjunctive devices (stents, web devices) full occlusion of ruptured aneurysms in the acute phase is not necessary, and deliberate staged treatment a reasonable strategy.

Quasiperiodic Quantum Ising Transitions in 1D

Unlike random potentials, quasiperiodic modulation can induce localization-delocalization transitions in one dimension. In this Letter, we analyze the implications of this for symmetry breaking in the quasiperiodically modulated quantum Ising chain. Although weak modulation is irrelevant, strong modulation induces new ferromagnetic and paramagnetic phases which are fully localized and gapless. The quasiperiodic potential and localized excitations lead to quantum criticality that is intermediate to that of the clean and randomly disordered models with exponents of ν=1^{+} (exact) and z≈1.9, Δ_{σ}≈0.16, and Δ_{γ}≈0.63 (up to logarithmic corrections). Technically, the clean Ising transition is destabilized by logarithmic wandering of the local reduced couplings. We conjecture that the wandering coefficient w controls the universality class of the quasiperiodic transition and show its stability to smooth perturbations that preserve the quasiperiodic structure of the model.

Thermal inclusions: how one spin can destroy a many-body localized phase

Many-body localized (MBL) systems lie outside the framework of statistical mechanics, as they fail to equilibrate under their own quantum dynamics. Even basic features of MBL systems, such as their stability to thermal inclusions and the nature of the dynamical transition to thermalizing behaviour, remain poorly understood. We study a simple central spin model to address these questions: a two-level system interacting with strength J with N≫1 localized bits subject to random fields. On increasing J, the system transitions from an MBL to a delocalized phase on the vanishing scale Jc(N)∼1/N, up to logarithmic corrections. In the transition region, the single-site eigenstate entanglement entropies exhibit bimodal distributions, so that localized bits are either 'on' (strongly entangled) or 'off' (weakly entangled) in eigenstates. The clusters of 'on' bits vary significantly between eigenstates of the same sample, which provides evidence for a heterogeneous discontinuous transition out of the localized phase in single-site observables. We obtain these results by perturbative mapping to bond percolation on the hypercube at small J and by numerical exact diagonalization of the full many-body system. Our results support the arguments that the MBL phase is unstable in systems with short-range interactions and quenched randomness in dimensions d that are high but finite.This article is part of the themed issue 'Breakdown of ergodicity in quantum systems: from solids to synthetic matter'.

Clinical characteristics, treatment and 2-year outcomes in Malaysian and Bruneian patients with stable coronary artery within the worldwide CLARIFY registry

INTRODUCTION

The on-going, international, prospective, observational, longitudinal CLARIFY registry is investigating the demographics, clinical profiles, management and outcomes of patients with stable coronary artery disease (CAD). This paper assesses baseline characteristics, treatment, and clinical outcomes at two years' follow-up of Malaysian/Bruneian patients compared with the overall registry population.

METHOD

Between November 2009 and July 2010, outpatients from 45 countries who met the criteria for stable CAD were recruited into the registry. Baseline characteristics were documented at enrolment, and patients were reassessed during their annual visits over a five-year follow-up period. Key outcomes measured were sudden death and cardiovascular (CV) death, non-CV death and CV morbidity.

RESULTS

At baseline, 33,283 patients were available for analysis within the registry; 380 and 27 were Malaysians and Bruneians, respectively. The mean ages of Malaysian/Bruneian patients and the rest of the world (RoW) were 57.83 ±9.98 years and 64.23 ± 10.46 years, respectively (p<0.001). The median body mass index values were 26.6 (24.4-29.6) kg/m² and 27.3 (24.8-30.3) kg/m², respectively (p=0.014). Malaysian/Bruneian patients had lower rates of myocardial infarction (54.55% versus 59.76%, p=0.033) and higher rates of diabetes (43.24% versus 28.99%, p<0.001) and dyslipidaemia (90.42% versus 74.66%, p<0.001) compared with the RoW. Measured clinical outcomes in Malaysian and Bruneian patients at 2-years follow-up were low and generally comparable to the RoW.

CONCLUSION

Malaysian/Bruneian patients with stable CAD tend to be younger with poorer diabetic control compared with the RoW. However, they had similar outcomes as the main registry following two years of treatment.

Acute Retropharyngeal Abscess Masquerading as Meningitis

Retropharyngeal abscess is a potentially serious deep neck space infection occurring more frequently in children than in adults. The clinical picture of RPA is highly variable with paucity of physical findings. Prompt diagnosis of RPA especially in infants is mandatory to prevent potential fatal complications including airway obstruction. The diagnosis of RPA should be based on high index of clinical suspicion with supportive imaging studies like lateral X-ray of neck and CT. We present a case of acute retropharyngeal abscess which was initially misdiagnosed as meningitis and led to airway obstruction. This case is reported to create awareness among emergency physicians, paediatricians and otolaryngologists to have high index of suspicion in diagnosing RPA especially in infants.

Continued Sex-Differences in the Rate and Severity of Knee Injuries among Collegiate Soccer Players: The NCAA Injury Surveillance System, 2004-2009

We extend previous analyses and examined sex-differences in the rate and severity of knee injuries among collegiate soccer players between 2004 and 2009. Data from the National Collegiate Athletic Association Injury Surveillance System (NCAA ISS) were used to calculate injury incidence density (ID) per 1 000 athletic exposures (AE). Multivariable regression modeling then tested the relation between sex and knee injury incidence and severity among all injured soccer players, while controlling for contact, setting, and division level, as well as for the interactions among these variables. The rate of knee injuries was 1.19 per 1 000 AEs in women and 0.91 per 1 000 AEs in men (RR=1.31, 95% Wald CI=[1.16, 1.47]). In the multivariable modeling, women continued to experience significantly higher odds of knee injury compared with men (aOR=1.44, 95% CI=[1.27,1.63]). Also, the adjusted odds of a knee injury that resulted in surgery remained higher in women compared with men (aOR=1.61 (1.00, 2.58), as well as the amount of time lost from participation (beta=0.129; p=0.05). Given the prominence of soccer play in the United States, continued efforts to evaluate and improve knee injury prevention practices and policies may be especially important for female players.

Radiation Dose Reduction in 4D Cerebral CT Angiography by Individualized Estimation of Cerebral Circulation Time

BACKGROUND AND PURPOSE

The novel technique of 4D CTA for dynamic assessment of the intracranial vessels has a greater radiation burden than conventional CTA. Previous descriptions of the technique used a fixed-duration exposure protocol. This study examines the potential for dose reduction by individualizing exposure time to patient physiology by the use of time-enhancement curve techniques as previously applied in CT angiography and venography.

MATERIALS AND METHODS

4D-CTA examinations performed at our institution were retrospectively reviewed. Scan protocols used a test-bolus scan with either a subjective estimate of the main acquisition timing (estimated-duration method) or a quantitative measure (measured-duration method). The estimated-duration method used peak arterial enhancement to determine the start of exposure, with the duration chosen at the radiologist's discretion. The measured-duration method used arterial and venous time-enhancement curves to determine exposure start and duration. Exposure duration, study adequacy, quality score, and maximum venous enhancement were compared among groups.

RESULTS

One hundred fifty-one examinations used the estimated-duration method, and 53 used measured-duration. The measured-duration method used a shorter exposure time (10 versus 15.8 seconds; P < .001). There was no statistically significant difference in the study adequacy rate, subjective quality score, or maximum venous enhancement. The radiation dose was reduced by 51% in the measured-duration method (3021 mGy × cm, 6.9 mSv, versus 1473 mGy × cm, 3.4 mSv). Both methods showed good agreement with DSA (κ = 0.88 for estimated-duration, κ = 1.0 for measured duration).

CONCLUSIONS

Exposure time in 4D-CTA can be reduced with dual time-enhancement curves to match exposure to physiology without degrading study adequacy or quality.

Investigation on the temporal variation and source tracking of faecal bacteria in a forest dominated watershed (Comox Lake), British Columbia, Canada

AIMS

The aims of this study were to investigate the temporal variation in Escherichia coli density and its sources at the drinking water intake of Comox Lake for a period of 3 years (2011-2013).

METHODS AND RESULTS

Density of E. coli was assessed by standard membrane filtration method. Source tracking of E. coli were done by using BOX-A1R-based rep-PCR DNA fingerprinting method. Over the years, the mean E. coli density ranged from nondetectable to 9·8 CFU 100 ml(-1) . The density of E. coli in each of the years did not show any significant difference (P > 0·05); however, a comparatively higher density was observed during the fall. Wildlife was (64·28%, 153/238) identified as the major contributing source of E. coli, followed by human (18·06%, 43/238) and unknown sources (17·64%, 42/238). Although the sources were varied by year and season, over all, the predominant contributing sources were black bear, human, unknown, elk, horse and gull.

CONCLUSIONS

The findings of this investigation identified the multiple animal sources contributing faecal bacteria into the drinking water intake of Comox Lake and their varying temporal occurrence.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results of this study can reliably inform the authorities about the most vulnerable period (season) of faecal bacterial loading and their potential sources in the lake for improving risk assessment and pollution mitigation.

Glucocorticoid usage in giant cell arteritis over six decades (1950 to 2009)

OBJECTIVES

To evaluate the trends in glucocorticoid (GC) therapy in patients with giant cell arteritis (GCA).

METHODS

Using a population-based inception cohort, GC therapy details were collected for all patients with GCA diagnosed between 1950-2009. GC usage for patients diagnosed with GCA between 1980-2009 was compared to those diagnosed between 1950-1979.

RESULTS

The mean starting dose was similar in both time-periods but the mean cumulative dosages at different time points were significantly higher for patients diagnosed between 1980-2009 than in 1950-1979 (at 1-year: 6.3 vs. 4.1g; and at 5 years 10.7 vs. 7.6g, respectively, p<0.001). The median time to permanent discontinuation of GC was 2.6 years for 1980-2009 vs. 1.5 years for 1950-1979 (p=0.004). The risk for GC-associated adverse events was similar in both time periods (p=0.52).

CONCLUSIONS

GCA patients diagnosed in the last three decades were treated with higher cumulative GC doses and were less likely to achieve GC discontinuation. However, their risks for GC-related complications were not significantly higher than their earlier counterparts.

Seasonal dynamics of dissolved metals in surface coastal waters of southwest India

Spatial and temporal variations in concentration of dissolved metals viz. Copper (Cu), Lead (Pb), Chromium (Cr), Nickel (Ni), Zinc (Zn), Cadmium (Cd) and Mercury (Hg) in surface waters of southwest coast of India were studied. Concentrations of metals showed an aberration both temporally and spatially. Seasonal average concentrations of the analyzed metals followed the order Zn > Ni > Cu > Pb > Cd > Cr > Hg. The degree of contamination due to metal was determined by comparison with coastal water quality criteria. It established enrichment of Cu, Zn, Ni and Hg due to anthropogenic influence along southwest coast of India.

Comparative study on production of a-Amylase from Bacillus licheniformis strains

Alpha amylase (α-1, 4-glucan-glucanhydrolase, EC 3.2.1.1), an extracellular enzyme, degrades α, 1–4 glucosidic linkages of starch and related substrates in an endo-fashion producing oligosaccharides including maltose, glucose and alpha limit dextrin (7). The present study deals with the production and comparative study of production of α-amylase from two strains of Bacillus licheniformis, MTCC 2617 and 2618, by using four different substrates, starch, rice, wheat and ragi powder as carbon source by submerged fermentation. The effect of varying pH and incubation temperature, activator, inhibitor, and substrate concentration was investigated on the activity of α-amylase produced by MTCC strain 2618. The results shows that the production of the α-amylase by the B.licheniformis strain MTCC 2618, using four different substrates were found to be maximum (Starch 3.64 IU/ml/minutes, Rice powder 2.93 IU/ml/minutes, Wheat powder 2.67 IU/ml/minutes, Ragi powder 2.36 IU/ml/minutes) on comparing the enzyme production of two strains. It was also observed that the maximum production was found on the 3^rd day (i.e. 72 hr) and characterization of crude enzyme revealed that optimum activity was at pH 7 and 37°C.

Addressing healthcare needs of people living below the poverty line: a rapid assessment of the Andhra Pradesh Health Insurance Scheme

BACKGROUND

Families living below the poverty line in countries which do not have universal healthcare coverage are drawn into indebtedness and bankruptcy. The state of Andhra Pradesh in India established the Rajiv Aarogyasri Community Health Insurance Scheme (RACHIS) in 2007 with the aim of breaking this cycle by improving the access of below the poverty line (BPL) families to secondary and tertiary healthcare. It covered a wide range of surgical and medical treatments for serious illnesses requiring specialist healthcare resources not always available at district-level government hospitals. The impact of this scheme was evaluated by a rapid assessment, commissioned by the government of Andhra Pradesh. The aim of the assessment was to explore the contribution of the scheme to the reduction of catastrophic health expenditure among the poor and to recommend ways by which delivery of the scheme could be improved. We report the findings of this assessment.

METHODS

Two types of data were used for the assessment. Patient data pertaining to 89 699 treatment requests approved by the scheme during its first 18 months were examined. Second, surveys of scheme beneficiaries and providers were undertaken in 6 randomly selected districts of Andhra Pradesh.

RESULTS

This novel scheme was beginning to reach the BPL households in the state and providing access to free secondary and tertiary healthcare to seriously ill poor people.

CONCLUSION

An integrated model encompassing primary, secondary and tertiary care would be of greater benefit to families below the poverty line and more cost-effective for the government. There is considerable potential for the government to build on this successful start and to strengthen equity of access and the quality of care provided by the scheme.

Longitudinal evaluation of health care utilization and costs during the first three years after a new diagnosis of fibromyalgia

OBJECTIVE

To evaluate health care resource utilization and costs 1 year before and 3 years after a fibromyalgia (FM) diagnosis.

METHODS

This retrospective cohort analysis used claims from Humana to identify newly diagnosed FM patients ≥18 years of age based on ≥2 medical claims for ICD-9 CM code 729.1 and 729.0 between June 1, 2002 and March 1, 2005. Prevalence of comorbidities, as well as utilization and costs of pharmacotherapy and health care services were examined for 12 months preceding (pre-diagnosis) and 36 months following (post-diagnosis) the date of first FM diagnosis. These periods were subdivided into 6-month blocks to better observe patterns of change.

RESULTS

We identified 2613 FM patients who had a mean age at diagnosis of 58.5 ± 15.3 years and a mean Charlson Comorbidity Index of 0.48 ± 1.05. Of those, 73% were female. The use and costs of pain-related medications rose from pre-diagnosis and remained stable after the 6-month post-diagnosis period, while the use of non-pain-related medications steadily rose from pre-diagnosis to 3 years post-diagnosis. This increase was concomitant with an increase in the presence of conditions that may account for higher resource utilization. The use of recommended FM therapies (i.e., antidepressants and anticonvulsants) increased post-diagnosis but remained less common than other pain-related therapies. Total resource utilization and costs increased during the period up to 6 months after diagnosis. This increase was followed by a decline (7-12 months post-diagnosis), and plateau, with an increase during the final 6 months of the study period. Total mean per patient costs were $3481 for the 6-month post-diagnosis period, and $3588 for the final 6 months. Limitations include potential errors in coding and recording, and an inability of claims analyses to determine causality between resource utilization and the specific diagnosis of interest.

CONCLUSIONS

An FM diagnosis was associated with increased utilization and pain-related medication cost up to the first 6 months post-diagnosis followed by stabilization over 3 years post-diagnosis. Less use of recommended therapies relative to other therapies suggests that further dissemination of treatment guidelines is needed. An increase in non-pain medications over the observation period accounted for the majority of pharmacy costs. These pharmacy costs may be related to an increasing prevalence of comorbid conditions.