Routine diagnosis of intestinal tuberculosis and Crohn's disease in Southern India

AIM:To investigate whether routinely measured clinical variables could aid in differentiating intestinal tuberculosis(ITB)from Crohn’s disease(CD).METHODS:ITB and CD patients were prospectively included at four South Indian medical centres from October 2009 to July 2012.Routine investigations included case history,physical examination,blood biochemistry,ileocolonoscopy and histopathological examination of biopsies.Patients were followed-up after 2 and 6 mo of treatment.The diagnosis of ITB or CD was re-evaluated after 2 mo of antituberculous chemotherapy or immune suppressive therapy respectively,based on improvement in signs,symptoms and laboratory variables.This study was considered to be an exploratory analysis.Clinical,endoscopic and histopathological features recorded at the time of inclusion were subject to univariate analyses.Disease variables with sufficient number of recordings and P<0.05 were entered into logistic regression models,adjusted for known confounders.Finally,we calculated the odds ratios with respective confidence intervals for variables associated with either ITB or CD.RESULTS:This study included 38 ITB and 37 CD patients.Overall,ITB patients had the lowest body mass index(19.6 vs 22.7,P=0.01)and more commonly reported weight loss(73%vs 38%,P<0.01),watery diarrhoea(64%vs 33%,P=0.01)and rural domicile(58%vs 35%,P<0.05).Endoscopy typically showed mucosal nodularity(17/31 vs 2/37,P<0.01)and histopathology more frequently showed granulomas(10/30vs 2/35,P<0.01).The CD patients more frequently reported malaise(87%vs 64%,P=0.03),nausea(84%vs 56%,P=0.01),pain in the right lower abdominal quadrant on examination(90%vs 54%,P<0.01)and urban domicile(65%vs 42%,P<0.05).In CD,endoscopy typically showed involvement of multiple intestinal segments(27/37 vs 9/31,P<0.01).Using logistic regression analysis we found weight loss and nodularity of the mucosa were independently associated with ITB,with adjusted odds ratios of 8.6(95%CI:2.1-35.6)and 18.9(95%CI:3.5-102.8)respectively.Right lower abdominal quadrant pain on examination and involvement of≥3 intestinal segments were independently associated with CD with adjusted odds ratios of 10.1(95%CI:2.0-51.3)and 5.9(95%CI:1.7-20.6),respectively.CONCLUSION:Weight loss and mucosal nodularity were associated with ITB.Abdominal pain and excessive intestinal involvement were associated with CD.ITB and CD were equally common.

Different standards for healthy screenees than patients in routine clinics?

Less than 5%of colorectal adenomas will become malignant,but we do not have sufficient knowledge about their natural course to target removal of these5%only.Thus,95%of polypectomies are a waste of time exposing patients to a small risk of complications.Recently,a new type of polyps,sessile serrated polyps,has attracted attention.Previously considered innocuous,they are now found to have molecular similarities to cancer and some guidelines recommend to have them removed.These lesions are often flat,covered by mucous,not easily seen and situated in the proximal colon where the bowel wall is thinner.Thus,polypectomy carries a higher risk of perforation than predominantly left-sided,stalked adenomas-and we do not know what is gained in terms of cancer prevention.Screening is a neat balance between harms and benefit for presumptively healthy participants not interested in risk exposure to obtain confirmation of being healthy.The situation is quite different for patient worried about symptom.Thus,the standards set for evidence-based practice may be higher for screening than for routine clinics-a mechanism which may benefit patients in the long run.

Re-Assessing Tuberculin Skin Test (TST) for the Diagnosis of Tuberculosis (TB) among African Migrants in Western Europe and USA

Background: Tuberculin skin test (TST)—is widely used for screening tuberculosis TB in migrants from high endemic countries of Africa and Asia. However, the cut-off point for clinical TB and Mtb infection is not well established in TB endemic countries of sub-Saharan Africa. In this study we compared the size of TST induration in smear positive pulmonary TB (PTB) patients, their house-hold contacts and community controls in high endemic setting in Ethiopia. Methods: In a health facility-based cross-sectional study, smear positive PTB patients were recruited. Their household contacts traced, and community controls were recruited from neighbourhoods. Sputum sample collected from patients were examined using smear microscopy. Participants were also tested by TST and QuantiFERON? -TB Gold In–Tube test (QFTGIT). Results: From a total of 224 study participants, skin test induration data were available for 48 PTB patients, 88 household contacts and 75 community controls. All 48 patients, 64 (72.2%) of the household contacts and 35 (46.7%) of the community controls had skin test induration ≥ 10 mm. Moreover, 44 (91.7%) PTB patients, 58 (65.9%) of the household contacts and 26 (34.7%) of the community controls had skin test induration ≥ 15 mm, respectively. The mean size of TST induration was significantly higher in TB patients (18.1mm) compared to that of household contacts (13.6 mm) and community controls (7.9 mm) (pMtb

Favorable lifestyle before diagnosis associated with lower risk of screen-detected advanced colorectal neoplasia

AIM: To investigate the association between adherence to health recommendations and detection of advanced colorectal neoplasia(ACN) in colorectal cancer(CRC) screening.METHODS: A total of 14832 women and men were invited to CRC screening, 6959 in the fecal immunochemical test arm and 7873 in the flexible sigmoidoscopy arm. These were also sent a self-reported lifestyle questionnaire to be completed prior to their first CRC screening. A lifestyle score was created to reflect current adherence to healthy behaviors in regard to smoking, body mass index, physical activity, alcohol consumption and food consumption, and ranged from zero(poorest) to six(best). Odds ratios(ORs) and 95%CIs were calculated using multivariable logistic regression to evaluate the association between the single lifestyle variables and the lifestyle score and the probability of detecting ACN.RESULTS: In all 6315 women and men completed the lifestyle questionnaire, 3323(53%) in the FIT arm and 2992(47%) in the FS arm. This was 89% of those who participated in screening. ACN was diagnosed in 311(5%) participants of which 25(8%) were diagnosed with CRC. For individuals with a lifestyle score of two, three, four, and five-six, the ORs(95%CI) for the probability of ACN detection were 0.82(0.45-1.16), 0.43(0.28-0.73), 0.41(0.23-0.64), and 0.41(0.22-0.73), respectively compared to individuals with a lifestyle score of zero-one. Of the single lifestyle factors, adherence to non-smoking and moderate alcohol intake were associated with a decreased probability of ACN detection compared to being a smoker or having a high alcohol intake 0.53(0.42-0.68) and 0.63(0.43-0.93) respectively.CONCLUSION: Adopted healthy behaviors were inversely associated with the probability of ACN detection. Lifestyle assessment might be useful for risk stratification in CRC screening.

Psychological effects of colorectal cancer screening: Participants vs individuals not invited

AIM To investigate the possible long-term psychological harm of participating in colorectal cancer(CRC)screening in Norway.METHODS In a prospective, randomized trial, 14294 participants(aged 50-74 years) were invited to either flexible sigmoidoscopy(FS) screening, or a faecal immunochemical test(FIT)(1:1). In total, 4422 screening participants(32%) completed the questionnaire, which consisted of the Hospital Anxiety and Depression Scale and the SF-12, a generic health-related quality of life(HRQOL) measurement, when invited to screening and one year after the invitation. A control group of 7650 individuals was invited to complete the questionnaire only, at baseline and one year after, and 1911(25%) completed the questionnaires.RESULTS Receiving a positive or negative screening result and participating in the two different screening modalities did not cause clinically relevant mean changes in anxiety, depression or HRQOL after one year. FS screening, but not FIT, was associated with an increased probability of being an anxiety case(score ≥ 8) at the one-year follow-up(5.6% of FS participants transitioned from being not anxious to anxious, while 3.0% experienced the reverse). This increase was moderately significantly different from the changes in the control group(in which the corresponding numbers were 4.8% and 4.5%, respectively), P = 0.06. CONCLUSION Most individuals do not experience psychological effects of CRC screening participation after one year, while FS participation is associated with increased anxiety for a smaller group.

Clinicopathological features of small T1 colorectal cancers

BACKGROUND Although small colorectal neoplasms(<10 mm)are often easily resected endoscopically and are considered to have less malignant potential compared with large neoplasms(≥10 mm),some are invasive to the submucosa.AIM To clarify the clinicopathological features of small T1 colorectal cancers.METHODS Of 32025 colorectal lesions between April 2001 and March 2018,a total of 1152 T1 colorectal cancers resected endoscopically or surgically were included in this study and were divided into two groups by tumor size:a small group(<10 mm)and a large group(≥10 mm).We compared clinicopathological factors including lymph node metastasis(LNM)between the two groups.RESULTS The incidence of small T1 cancers was 10.1%(116/1152).The percentage of initial endoscopic treatment in small group was significantly higher than in large group(<10 mm 74.1%vs≥10 mm 60.2%,P<0.01).In the surgical resection cohort(n=798),the rate of LNM did not significantly differ between the two groups(small 12.3%vs large 10.9%,P=0.70).In addition,there were also no significant differences between the two groups in pathological factors such as histological grade,vascular invasion,or lymphatic invasion.CONCLUSION Because there was no significant difference in the rate of LNM between small and large T1 colorectal cancers,the requirement for additional surgical resection should be determined according to pathological findings,regardless of tumor size.

A Qualitative Study of Manager Experiences Using the RAFAELA System

Objective: The objective was to explore manager experiences using the RAFAELA system. Background: The RAFAELA system was developed in Finland during the 1990s to create a work situation where patients’ care needs were balanced with personnel resources. The system is used in almost all hospitals in Finland and is implemented in several European countries. However, the system has never been evaluated outside Finland. This study, focusing on the managers’ perspective, represents the second report from a larger Norwegian evaluation project of the RAFAELA system. Methods: An explorative qualitative design was chosen. Data were collected by individual in-depth interviews at a university hospital in Norway during 2012-2013. A total of 10 informants in various management positions were interviewed. The tape-recorded interviews were transcribed verbatim, and the transcripts were analysed using Kvale’s method for content analysis. Results: Four main themes emerged from the qualitative data: making the invisible visible;a common language;a system for prospective planning;and a resource-demanding tool. Conclusions: The study indicated that the RAFAELA system provided useful information about the patients’ care needs and nursing activities. Also the system provided a common reference frame for discussing nursing, staffing and allocation. Although the managers considered the RAFAELA to be time consuming in the implementation phase, they considered the system to be an important tool.

Inoperable severe aortic valve stenosis in geriatric patients: treatment options and mortality rates

Among geriatric patients suffering from severe but inoperable aortic valve stenosis because of high surgical risk and severe co-morbidities,[1] some benefit from trans-aortic valve implantation (TAVI) while others are deemed too frail for TAVI and received medical treatment (MT). This study conducted in frail geriatric patients aimed at describing the patienfs characteristics and the mortality rate associated with the treatment option (MT vs. TAVI) as well as the patient's characteristics associated with one-year mortality.

PM₁₀Emissions from Cooking Fuels in Nigerian Households and Their Impact on Women and Children

A study was carried out on the type of fuels being used by households in Ibadan, a highly populated city in south-west Nigeria. Ekotedo, Agbeni, Bodija and Agbowo communities were selected through stratified random sampling, keeping in view of their socioeconomic background and population density. The study monitored 186 households for the type of fuel used for cooking and measured PM10 and the lung function of the respondents. The study population involved 130 women and 130 children. In addition, a community nurse carried out a physical and clinical examination of both the mothers and the children for respiratory and non-respiratory symptoms. The results showed that 37.7% used firewood, 33.1% used kerosene, 17.7% used charcoal and 11.5% used liquefied natural gas. Firewood use followed by charcoal emitted high PM10 at a level of 1640 μg/m3 and 1159 μg/m3, respectively. Charcoal users showed the lowest lung function values and gas users the highest value. A majority (78.5%) of the respondents complained of having cough during and after cooking. Some of them reported breathing problems, eyes and skin irritations. It is recommended that the communities be advised to switch over from the use of biomass fuels to natural gas so as to sustained the natural resources and again, reduced the health impacts of these cooking fuels on the population.

Pregnancy decisions of married women living with HIV during wide access to antiretroviral therapy in southern Malawi

Availability of antiretroviral therapy and prevention of mother to child transmission of HIV programmes have increased childbearing decisions in people living with HIV. However, pregnancy decisions of married women living with HIV have not been adequately reported in Malawi. In order to provide information to inform the development of antiretroviral and family planning services targeted to the unique needs of women living with HIV, this study explored pregnancy decisions of women living with HIV in rural southern Malawi. Twenty in-depth interviews on married women living with HIV selected purposively were conducted in two antiretroviral clinics of patrilineal Chikhwawa and matrilineal Chiradzulu districts in 2010. With their pregnancy and child rearing experiences, the women who got pregnant after a positive HIV diagnosis decided to never get pregnant again. Their lived experiences of motherhood when living with HIV play a major role in their pregnancy decisions despite free access to antiretroviral therapy, which has improved the quality of their life’s and survival. Societies in Malawi must accept this behavioural change by married women living with HIV and their needs for family planning. Health care workers must be knowledgeable and sensitive about it and assist women living with HIV who are willing to adapt their pregnant decisions based on living experiences.

Depression and Insulin Resistance in Non-Diabetic Subjects: An Intervention Study with Insulin Clamp Technique

Aims: To clarify the relationship between depression and glucose metabolism using sensitive measures of insulin resistance, and to assess if remission of depression results in enhanced insulin sensitivity. Methods: An intervention study to quantify changes in insulin sensitivity before and after treatment of depression was carried out. Twenty six Pakistani women with newly diagnosed depression underwent euglycemic insulin clamp to measure insulin sensitivity at inclusion and again after treatment of depression 6 - 8 weeks later. Twenty-three individuals completed both tests. Results: Significant improvement of insulin sensitivity was observed following the treatment of depression. The improved insulin sensitivity remained statistically significant after controlling for confounding factors. Conclusions: This study establishes a relationship between depression and insulin resistance. It demonstrated that insulin sensitivity can be improved by treating depression.

Tuberculosis Case Notification and Treatment Outcomes in West Gojjam Zone, Northwest Ethiopia: A Five-Year Retrospective Study

Introduction: Tuberculosis (TB) is a major public health concern in Ethiopia. Analysis of TB case notification and treatment outcomes is crucial to understand the TB control program performance. The current study was carried out to assess trends of TB case notifications, treatment success rate and factors associated with unsuccessful treatment outcome among TB patients in West Gojjam Zone of Amhara Region, Ethiopia. Method: A retrospective cohort study was conducted in West Gojjam Zone. Demographic and clinical data were reviewed for all TB patients registered between July 2007 and June 2012 at 30 randomly selected public health facilities of the study zone. In addition, annual case notification reports of the study zone were used to analyze trends in TB case notifications. Logistic regression analysis was used to assess the association between potential predictor variables and unsuccessful treatment outcomes. Results: Tuberculosis case notification for all forms of TB decreased from 203/100,000 population in 2007 to 155/100,000 population in 2012. Among patients whose treatment outcomes were evaluated, 94.4% were successfully treated, 0.3% had treatment failure, 1.5% defaulted and 3.7% died. In multivariate analysis, the odds of unsuccessful treatment outcome was higher among retreatment cases than new cases (adjusted OR, 3.44;95% CI: 1.92, 6.19). HIV co-infected cases were more likely to have unsuccessful treatment outcome compared to HIV negatives (adjusted OR, 2.68;95% CI: 1.92, 3.72). Conclusion: Tuberculosis case notification rates showed a decreasing trend between 2007 and 2012. The treatment success rate exceeded the 90% treatment success rate target as set by the WHO. Special attention is required for patients with high risk of unsuccessful treatment outcome. Therefore, retreatment cases, and HIV positive cases need strict follow up throughout their treatment period.

Why Is Case Management Effective? A Realist Evaluation of Case Management for Frail, Community-Dwelling Older People: Lessons Learned from Belgium

Despite many attempts to evaluate the effectiveness of case management for frail older people, systematic reviews including experimental designs show inconsistent results. Starting from the view that case management is a complex intervention occurring in multilayered realities, we conducted a realist evaluation of case management in Belgium, where this type of intervention is new. Realist approaches are particularly well suited to evaluate complex interventions as they seek to investigate iteratively the literature and empirical data to uncover mid-range theories underpinning the intervention under study. As such, realist evaluations are works in progress which provide tools to describe how, why and for whom an intervention is supposed to work. In this paper, we describe two mid-range theories that can explain why case management can help frail older people to remain at home, through the lens of capacity and social support.

戒烟与复吸影响因素及戒烟者健康状况分析

目的揭示戒烟水平、戒烟与复吸原因、成功戒烟的影响因素及与其健康状况的关系,为在中国提出更有针对性的控烟对策提供参考。方法利用两次具有全国代表性的中国国家卫生服务调查数据,采用分组分析、logistic回归分析、年龄标准化等方法分析戒烟相关指标和影响因素。结果2003年只有6.1%的戒烟率,7.9%的正在吸烟者有戒烟意愿,老年吸烟者、城市地区、高收入者、患有慢性病者或自感健康较差者比较容易戒烟成功,而户中有多名吸烟者、经常饮酒者不易戒烟成功;戒烟者本身健康状况已较差;54%的复吸者报告是因为"控制不住烟瘾",约29%的人是因为社交或社会环境影响而复吸。结论中国吸烟者的戒烟水平和意愿均较低、因病而戒烟表明戒烟太晚太被动;除现有控烟政策外,更有针对性的控烟活动如对年轻吸烟者、农村地区吸烟者、多吸烟者住户和促进未病先戒等活动也是迫切需要的。

Non-invasive home lung impedance monitoring in early post-acute heart failure discharge: Three case reports

BACKGROUND Patients discharged after hospitalization for acute heart failure(AHF) are frequently readmitted due to an incomplete decongestion, which is difficult to assess clinically. Recently, it has been shown that the use of a highly sensitive,non-invasive device measuring lung impedance(LI) reduces hospitalizations for heart failure(HF); it has also been shown that this device reduces the cardiovascular and all-cause mortality of stable HF patients when used in longterm out-patient follow-ups. The aim of these case series is to demonstrate the potential additive role of non-invasive home LI monitoring in the early postdischarge period.CASE SUMMARY We present a case series of three patients who had performed daily LI measurements at home using the edema guard monitor(EGM) during 30 d after an episode of AHF. All patients had a history of chronic ischemic HF with a reduced ejection fraction and were hospitalized for 6–17 d. LI measurements were successfully made at home by patients with the help of their caregivers. The patients were carefully followed up by HF specialists who reacted to the values of LI measurements, blood pressure, heart rate and clinical symptoms. LI reduction was a more frequent trigger to medication adjustments compared to changes in symptoms or vital signs. Besides, LI dynamics closely tracked the use and dose of diuretics.CONCLUSION Our case series suggests non-invasive home LI monitoring with EGM to be a reliable and potentially useful tool for the early detection of congestion or dehydration and thus for the further successful stabilization of a HF patient after a worsening episode.

Medical Acupuncture Modality:Principles, Explanatory Model, and Scientific Developments During 2005-2012

Medical acupuncture is a term given to a pragmatic treatment approach used within the public health services in North Western Europe and other Western countries. Its rationale and methods are derived from, but distinct from, classical traditional Chinese medicine as it is practiced in China and in Europe. The article summarizes 9 principles of the medical acupuncture modality, offers an explanatory model, and reviews international research during 2005 to 2012.

Transcriptome-wide association analysis identified candidate susceptibility genes for nasopharyngeal carcinoma

Dear Editor,Nasopharyngeal carcinoma(NPC)is a common malignancy in East and Southeast Asia,especially in South China.The etiology of NPC has been linked to genetic susceptibility,Epstein-Barr virus(EBV)infection,and environmental factors.Accumulated evidence including multiple genome-wide association studies(GWASs)has revealed robust genetic predisposition of NPC.However,GWAS-identified genetic variants collectively account for only 8.2%of NPC heritability[1].The underlying inherited predisposition is largely undetermined.The strongest genetic signal for NPC consistently hits the human leukocyte antigen(HLA)region on 6p21[2].However,the highly polymorphic nature and complicated long-range linkage disequilibrium(LD)in the HLA region particularly obscure the causal variants driving the association.In addition,most genetic variants located in introns or intergenic regions.The causal genes mediating genetic effects on NPC risk have rarely been ascertained by GWAS alone.

Associations of cerebrospinal fluid amyloidogenic nanoplaques with cytokines in Alzheimer’s disease

Background:The aggregation of amyloidβ(Aβ)is central in the pathogenesis of Alzheimer’s disease(AD).Recently it has been shown that specifically,larger,Thioflavin T-binding Aβaggregates are associated with increased neuroinflammation and cytokine release.This study was aimed to quantify fibrillary amyloid aggregates,so-called nanoplaques,and investigate their relationship with cytokines in the cerebrospinal fluid(CSF).Methods:CSF was collected from 111 patients assessed for cognitive complaints at the Oslo University Hospital Memory Clinic.The patients were grouped based on their amyloid status.The CSF nanoplaque concentration was quantified with the Thioflavin T-fluorescence correlation spectroscopy(ThT-FCS)assay.The levels of nine cytokines(eotaxin-1,granulocyte stimulating factor,interleukin[IL]-6,IL-7,IL-8,monocyte chemoattractant protein-1,gammainduced protein 10,macrophage inflammatory protein[MIP]-1α,and MIP-1β)were quantified with a magnetic bead-based multiplex assay and read on a Luminex IS 200 instrument.Results:There were 49 amyloid-negative and 62 amyloid-positive patients in the cohort;none of the cytokines differed significantly between the amyloid groups.The increased nanoplaque levels were associated with levels of MIP-1βbelow the lower limit of quantification,and with decreased levels of MIP-1αand IL-8.The associations remained significant when adjusted for age,sex,cognitive function,apolipoproteinε4 status and CSF core biomarker levels.Conclusion:The cytokine levels were not associated with amyloid status in this cohort.The nanoplaque levels were negatively associated with MIP-1β,MIP-1αand IL-8,which is in line with recent findings suggesting that the upregulation of some cytokine markers has a protective role and is negatively associated with AD progression.

吸烟致贫及对贫困户卫生服务需要和利用影响的研究

吸烟能导致癌症、心血管疾病及呼吸系统疾病并引发早死，对健康的危害很明确，而吸烟与贫困的关系、与卫生服务需要和利用关系的研究相对较少。减少贫困是社会发展的目标之一，而贫困的产生有各种各样的原因，笔者欲从已引起国际社会关注的吸烟与贫困的关系，阐述吸烟对不同收入人群的直接致贫情况，比较贫困吸烟住户与贫困非吸烟住户在2周患病、应就诊未就诊、

Diabetes mellitus is associated with increased mortality during tuberculosis treatment:a prospective cohort study among tuberculosis patients in SouthEastern Amahra Region,Ethiopia

Background:There is growing evidence suggesting that diabetes mellitus(DM)affects disease presentation and treatment outcome in tuberculosis(TB)patients.This study aimed at investigating the role of DM on clinical presentations and treatment outcomes among newly diagnosed TB patients.Methods:A prospective cohort study was conducted in South-Eastern Amhara Region,Ethiopia from September 2013 till March 2015.Study subjects were consecutively recruited from 44 randomly selected health facilities in the study area.Participants were categorized into two patient groups,namely,patients with TB and DM(TBDM)and TB patients without DM(TBNDM).Findings on clinical presentations and treatment outcomes were compared between the two patient groups.Cox proportional hazard regression analysis was applied to identify factors associated with death.Results:Out of 1314 TB patients enrolled in the study,109(8.3%)had coexisting DM.TBDM comorbidity[adjusted hazard ratio(AHR)3.96;95%confidence interval(C.I.)(1.76–8.89)],and TB coinfection with human immunodeficiency virus(HIV)[AHR 2.59;95%C.I.(1.21–5.59)]were associated with increased death.TBDM and TBNDM patients did not show significant difference in clinical symptoms at baseline and during anti-TB treatment period.However,at the 2nd month of treatment,TBDM patients were more symptomatic compared to patients in the TBNDM group.Conclusions:The study showed that DM is associated with increased death during TB treatment.DM has no association with clinical presentation of TB except at the end of the intensive phase treatment.Routine screening of TB patients for DM is recommended for early diagnosis and treatment of patients with TBDM comorbidity.