Endoscopic and clinical responses to anti-tubercular therapy can differentiate intestinal tuberculosis from Crohn's disease

BACKGROUND

Differentiation between intestinal tuberculosis and Crohn's disease is difficult and may require therapeutic trial with anti-tubercular therapy in tuberculosis-endemic regions.

AIM

To evaluate the role of therapeutic trial with anti-tubercular therapy in patients with diagnostic confusion between intestinal tuberculosis and Crohn's disease.

METHODS

We performed retrospective-comparative (n = 288: 131 patients who received anti-tubercular therapy before being diagnosed as Crohn's disease and 157 intestinal tuberculosis patients) and prospective-validation study (n = 55 patients with diagnostic confusion of intestinal tuberculosis/Crohn's disease). Outcomes assessed were global symptomatic response and endoscopic mucosal healing.

RESULTS

In the derivation cohort, among those eventually diagnosed as Crohn's disease, global symptomatic response with anti-tubercular therapy was seen in 38% at 3 months and in 37% who completed 6 months of anti-tubercular therapy. Ninety-four per cent of intestinal tuberculosis patients showed global symptomatic response by 3 months. Endoscopic mucosal healing was seen in only 5% of patients with Crohn's disease compared with 100% of intestinal tuberculosis patients. In the validation cohort, all the patients with intestinal tuberculosis had symptomatic response and endoscopic mucosal healing after 6 months of anti-tubercular therapy. Among the patients with an eventual diagnosis of Crohn's disease, symptomatic response was seen in 64% at 2 months and in 31% who completed 6 months of anti-tubercular therapy, none had mucosal healing.

CONCLUSIONS

Disproportionately lower mucosal healing rate despite an overall symptom response with 6 months of anti-tubercular therapy in patients with Crohn's disease suggests a need for repeat colonoscopy for diagnosing Crohn's disease. Patients with intestinal tuberculosis showing significant symptomatic response after 2-3 months of anti-tubercular therapy, suggest that symptom persistence after a therapeutic trial of 3 months of anti-tubercular therapy may indicate the diagnosis of Crohn's disease.

Hepatic venous outflow tract obstruction: treatment outcomes and development of a new prognostic score

BACKGROUND

Results of endovascular interventions in hepatic venous outflow tract obstruction (HVOTO) have been reported from limited studies. Treatment outcomes and prognostic scores need further validation.

AIM

To evaluate treatment outcomes and prognostic scores for hepatic venous outflow tract obstruction in an Indian population.

METHODS

Consecutive patients with hepatic venous outflow tract obstruction diagnosed at a tertiary centre were included. Technical success and clinical response after endovascular interventional therapy were documented. Predictors of survival were assessed with Cox-proportional model. A new score was derived from the factors significant on multivariate analysis and compared with Child-Turcotte-Pugh, model for end-stage liver disease (MELD), Rotterdam prognostic index (PI) and Budd-Chiari syndrome-transjugular intrahepatic portosystemic shunt ( BCS-TIPSS) PI.

RESULTS

Three hundred and thirty-four patients (56.6% males), median age 24 (3-62) years were included. Hepatic vein was the commonest site of block-isolated hepatic vonous block in 48%, combined hepatic venous-inferior vena cava block in 46%. Endovascular interventional therapy was performed in 233/334 (70%) with 90% technical success. Clinical response was complete in 166 (71.2%), partial in 58 (24.9%) and no response in nine (3.9%). Majority of cases with HV block did not require TIPSS and could be treated with angioplasty (with/without stenting). On Cox-proportional multivariate analysis, Child class C and response to intervention were independent predictors of outcome and used to derive the All India Institute of Medical Sciences (AIIMS) hepatic venous outflow tract obstruction score. The 5-year survival was 92% (95% CI, 81-97%) for score ≤3, 79% (95%CI, 63-88%) for score >3 and ≤4, and 39% (95% CI, 21-57%) for score >4. The performance of AIIMS hepatic venous outflow obstruction score was superior to other prognostic indices.

CONCLUSIONS

Advanced Child class and no response to intervention are associated with poor outcomes. The All India Institute of Medical Sciences hepatic venous outflow tract obstruction score predicts survival better than other prognostic scores.

Risk of Anal Cancer in People Living with HIV: Addressing Anal Health in the HIV Primary Care Setting

Anal health and anal cancer are rarely addressed in HIV primary care. We sought to understand factors that impeded or promoted addressing anal health in HIV primary care from providers' perspectives. In this exploratory study, HIV primary care providers from the Mid-South region of the United States participated in brief individual interviews. We analyzed transcribed data to identify barriers and facilitators to addressing anal health. Our study sample included five physicians and four nurse practitioners. The data revealed a number of barriers such as perception of patient embarrassment, provider embarrassment, external issues such as time constraints, demand of other priorities, lack of anal complaints, lack of resources, and gender discordance. Facilitators included awareness, advantageous circumstances, and the patient-provider relationship. Anal health education should be prioritized for HIV primary care providers. Preventive health visits should be considered to mitigate time constraints, demands for other priorities, and unequal gender opportunities.

Activity Engagement: Perspectives from Nursing Home Residents with Dementia

Engagement in social and leisure activities is an indicator of quality of life and well-being in nursing homes. There are few studies in which nursing home residents with dementia self-reported their experiences in activity engagement. This qualitative study describes types of current activity involvement and barriers to activities as perceived by nursing home residents with dementia. Thirty-one residents participated in short, open-ended interviews and six in in-depth interviews. Thematic content analysis showed that participants primarily depended on activities organized by their nursing homes. Few participants engaged in self-directed activities such as walking, visiting other residents and family members, and attending in church services. Many residents felt they had limited opportunities and motivation for activities. They missed past hobbies greatly but could not continue them due to lack of accommodation and limitation in physical function. Environmental factors, along with fixed activity schedule, further prevented them from engaging in activities. Residents with dementia should be invited to participate in activity planning and have necessary assistance and accommodation in order to engage in activities that matter to them. Based on the findings, a checklist for individualizing and evaluating activities for persons with dementia is detailed.

Organizational barriers to receiving quality health care: A qualitative study among lung cancer patients and caregivers

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Background: For lung cancer patients and caregivers, navigating the healthcare system while coping with the complexities of the illness is challenging. We explored organizational barriers to receiving quality healthcare from the perspectives of these stakeholders. Methods: A qualitative study involving 10 focus groups (5 of patients, 5 of caregivers) was conducted. Discussions were guided by a standardized script, recorded for transcription, and analyzed using Dedoose software. Results: 22 patients (10 Males/12 Females; 15 Caucasians and 7 African Americans) and 24 caregivers (6 Males /18 Females; 17 Caucasians and 7 African Americans) shared their experiences. Content analysis showed 5 recurring themes: (1) Insurance Issues: Delays in diagnosis or treatment were reported due to lack of insurance, lag time in insurance approvals and care processing, uncertainty about coverage, and caps for tests and/or office visits. (2) Appointment Scheduling: Participants reported appointment delays and rescheduling, long wait times, cancellations by providers, and inflexibility to accommodate schedules. (3) Provider Communication: Communication was lacking at times in initial diagnosis disclosure, prognosis and treatment preparation, willingness to answer questions in lay terms, and time dedicated to patients during appointments. (4) Patient Education: Participants had inadequate knowledge about lung cancer, treatment options and duration, prognosis, and relied on providers to educate and direct them to credible resources. Many felt confused, frustrated, anxious, or fatalistic. (5) Healthcare System Support: Participants found support within the healthcare system extremely beneficial, when available, for coping with lung cancer, expediting appointments, seeking information, connecting with physicians, and receiving timely diagnosis and treatments. Conclusions: These findings offer valuable insight into lung cancer patients’ and caregivers’ perspectives on organizational barriers to receiving quality care. By identifying these barriers for lung cancer patients and caregivers, better planning and management of effective cancer services can be developed.

Relationship of racial composition and cancer risks from air toxics exposure in Memphis, Tennessee, U.S.A

African Americans in the U.S. often live in poverty and segregated urban neighborhoods, many of which have dense industrial facilities resulting in high exposure to harmful air toxics. This study aims to explore the relationship between racial composition and cancer risks from air toxics exposure in Memphis/Shelby County, Tennessee, U.S.A. Air toxics data were obtained from 2005 National Air Toxics Assessment (NATA), and the demographic data, including racial composition, were extracted from the 2000 United States Census. The association was examined using multivariable geographically weighted regression (GWR) analysis. The risk difference between African American and White concentrated areas was defined as the absolute disparity, and the percent difference as the relative disparity. GWR analyses show that cancer risks increase with respect to increasing percent of African Americans at the census tract level. Individuals in African American concentrated tracts bear 6% more cancer risk burden than in White concentrated tracts. The distribution of major roads causes the largest absolute disparity and the distribution of industrial facilities causes the largest relative disparity. Effective strategies for reduction in environmental disparity should especially target sources of large absolute disparities.

Are We There Yet? Feasibility of Continuous Stress Assessment via Wireless Physiological Sensors

Stress can lead to headaches and fatigue, precipitate addictive behaviors (e.g., smoking, alcohol and drug use), and lead to cardiovascular diseases and cancer. Continuous assessment of stress from sensors can be used for timely delivery of a variety of interventions to reduce or avoid stress. We investigate the feasibility of continuous stress measurement via two field studies using wireless physiological sensors - a four-week study with illicit drug users (n = 40), and a one-week study with daily smokers and social drinkers (n = 30). We find that 11+ hours/day of usable data can be obtained in a 4-week study. Significant learning effect is observed after the first week and data yield is seen to be increasing over time even in the fourth week. We propose a framework to analyze sensor data yield and find that losses in wireless channel is negligible; the main hurdle in further improving data yield is the attachment constraint. We show the feasibility of measuring stress minutes preceding events of interest and observe the sensor-derived stress to be rising prior to self-reported stress and smoking events.

Nicotine dependence among clients receiving publicly funded substance abuse treatment

BACKGROUND

Smoking and nicotine dependence (ND) are prevalent among substance abusers but little is known about characteristics of ND in this population. This information would help identify those most in need of smoking cessation programs. This study evaluated the associations of socio-demographic, tobacco- and substance use-related, and health/mental health factors to ND in adults receiving publicly funded substance abuse treatment in Tennessee.

METHODS

All Tennessee residents who received federal block grant-funded substance abuse treatment during July-December, 2004 were invited to participate in a 6 month post-intake telephone follow-up interview. Socio-demographic characteristics, perceived health and mental health, tobacco use history and patterns, and ND, assessed by the Fagerstrom Test of Nicotine Dependence (FTND), were obtained at follow-up. Alcohol and illicit drug use and smoking status prior to treatment were assessed at intake. This paper analyzes data for 855 clients who were current cigarette smokers at both intake and follow-up.

RESULTS

Sixty three percent of smokers were ND (FTND score ≥ 4). Correlates of ND included older age, poorer self-rated overall health, earlier age of onset of cigarette smoking and substance abuse, fewer smoking quit attempts in past year, single substance use (alcohol or illicit drug, vs. multiple substances) at intake, use of opiates/narcotics and sedatives, and past month self-reported depression.

CONCLUSION

ND was highly prevalent and correlated with specific types and patterns of substance abuse and depression. These results suggest that intensive smoking cessation interventions, involving behavioral support, pharmacotherapy, and mood management, are needed to effectively assist this population.

Mono- versus polydrug abuse patterns among publicly funded clients

To examine patterns of mono- versus polydrug abuse, data were obtained from intake records of 69,891 admissions to publicly funded treatment programs in Tennessee between 1998 and 2004. While descriptive statistics were employed to report frequency and patterns of mono- and polydrug abuse by demographic variables and by study years, bivariate logistic regression was applied to assess the probability of being a mono- or polydrug abuser for a number of demographic variables. The researchers found that during the study period 51.3% of admissions reported monodrug abuse and 48.7% reported polydrug abuse. Alcohol, cocaine, and marijuana were the most commonly abused substances, both alone and in combination. Odds ratio favored polydrug abuse for all but one drug category–other drugs. Gender did not affect drug abuse patterns; however, admissions for African Americans and those living in urban areas exhibited higher probabilities of polydrug abuse. Age group also appeared to affect drug abuse patterns, with higher odds of monodrug abuse among minors and adults over 45 years old. The discernable prevalence of polydrug abuse suggests a need for developing effective prevention strategies and treatment plans specific to polydrug abuse.

Eating and feeding are not the same: caregivers' perceptions of gastrostomy feeding for children with cerebral palsy

Using a semi-structured questionnaire, this descriptive study examined perceptions of feeding and adherence to feeding recommendations for caregivers (26 females; mean age 32y 7mo [SD 9.4y], range 20-59y) of children with cerebral palsy (CP) and a gastrostomy tube (GT). Children in the study (15 females, 11 males; mean age 4y 8mo [SD 3y 11mo], range 8mo-16y) had had a GT in place for at least 1 month and been assessed at Level II (n=2), Level III (n=2), Level IV (n=5), and Level V (n=17) of the Gross Motor Function Classification System. A negative response was reported by 18 caregivers when the GT was recommended; however, 21 caregivers reported improvement in the children following placement. All children received formula through the GT that was adequate for complete nutrition, yet 14 caregivers gave other foods through the GT (e.g. juice, cereal, soup, or table food). Of the 17 children receiving oral feedings, meals were an unpleasant experience for over half. Of the remaining nine children, in spite of a strict nil by mouth recommendation by physicians, five continued to receive some oral feedings. Generally, caregivers perceived GT feeding as 'unnatural'. Understanding these perceptions will help clinicians to develop effective, family-centered, patient-appropriate intervention and adherence strategies for GT-fed children with CP.

Factors associated with client-collateral agreement in substance abuse post-treatment self-reports

This study examined levels of agreement and directionality of disagreement between the post-treatment self-reports of substance abuse clients and their collaterals. The study population comprised 1252 clients with a primary or secondary diagnosis of substance abuse or dependence whose treatment was publicly funded in Tennessee. Client and collateral responses to 13 questions were analyzed for levels of agreement, revealing the following: (a) levels of client-collateral agreement were high, at least 75% agreement on all 13 questions and at least 88% agreement on 10 variables; (b) a Simple Kappa Test confirmed that 11 out of 13 items had moderate to excellent nonchance agreement; (c) there was no consistent trend in directionality, that is, clients neither reported information more positively nor more negatively than their collaterals did; (d) on average, those collaterals who were spouses, parents, and children agreed more with clients compared to other types of collaterals; and (e) those collaterals who saw the clients more frequently and more recently had higher agreement than those who saw the clients less frequently. This research reaffirms that collaterals are a valuable source for verifying the accuracy of clients' self-reports and that this approach continues to hold considerable promise for substance abuse post-treatment assessment.

Emergence of restless legs syndrome during subthalamic stimulation for Parkinson disease

The authors systematically studied the emergence of restless legs syndrome (RLS) after subthalamic nucleus (STN) deep brain stimulation (DBS) for Parkinson disease (PD). Postoperatively, 11 of 195 patients with STN DBS reported new problematic symptoms of RLS. The mean reduction in antiparkinsonian medication was 74%. The mean RLS score at diagnosis was 15 (+/-5.9) of a possible 24 points and after symptomatic drug therapy 4.3 (+/-3.1) points. Reduction of antiparkinsonian medication during STN DBS may unmask symptoms of RLS and complicate therapy of both RLS and PD.

Substance abuse treatment effectiveness of publicly funded clients in Tennessee

The Tennessee Outcomes for Alcohol and Drug Services (TOADS) in collaboration with the Bureau of Alcohol and Drug Abuse Services at the Tennessee Department of Health evaluated the effectiveness of publicly funded substance abuse treatment programs in Tennessee by collecting and analyzing data from clients treated between 1998 and 2000. Using a structured questionnaire, TOADS staff conducted telephone interviews with clients 6 months after their admission to treatment facilities. The sample populations for these follow-up interviews ranged from 1,150 to 1,350 clients over the 3 years, and each year, post-treatment abstinence rates were around 60%, which suggests that treatment in Tennessee has been successful in reducing substance abuse. In addition, the follow-up interview data suggest that treatment also helped drastically reduce both unemployment and arrests among clients. These findings in Tennessee are comparable to treatment outcomes in other states. In addition to the positive effects that treatment has on clients, treatment is also cost-effective for state budgets since treatment reduces many of the burdens substance abuse places on the criminal justice system, the healthcare system, and other state-supported services.

Predictors of substance abuse treatment outcomes in Tennessee

In planning and implementing programs to treat substance abuse, it is important to understand which factors influence post-treatment abstinence. This article identifies and analyzes several variables important in predicting the likelihood of abstinence among substance abuse clients. The data used in this study was collected from 1,350 clients treated for alcohol or drug abuse in residential, halfway house, or outpatient facilities in Tennessee. We analyzed 22 variables as possible treatment outcome predictors by using two statistical procedures: stepwise logistic regression analysis and Quick, Unbiased, Efficient, Statistical Tree (QUEST) analysis, a tree-structured classification algorithm analysis. We found one pretreatment, five in-treatment, and three post-treatment variables to be significant predictors of treatment outcome: previous treatment history, perceived helpfulness of the treatment, simultaneous treatment for mental health, number of days in treatment,completion of treatment, special skills training during treatment, obtaining healthcare services for major physical health problem after treatment, living with someone using alcohol or drugs post treatment, and arrest record since treatment.