Impact analysis of expanding anti-TNF therapy for Crohn’s disease

Aim: To estimate the impact of universal anti-TNF therapy in patients with moderate-to-severe Crohn’s disease. Materials & methods: Developed a population-level Markov model to estimate the impact on health outcomes and medical expenditures of expanding anti-TNF therapy use versus current treatment practices. Results: Reductions in deaths (2600), hip fractures (980), major adverse cardiac events (2700) and patient out-of-pocket medical spending (2%) over 5 years. Total societal costs would be US$22,100 higher per patient per year, primarily due to the high cost of anti-TNF therapy. Conclusion: Expanding anti-TNF therapy use among US adult patients with moderate-to-severe Crohn’s disease would reduce morbidity and mortality, decrease disease-related medical costs and increase treatment costs compared with current practice. Despite the higher costs, this approach could substantially benefit patients.

Stimulation of Synthesis and Lysis of Extracellular Matrix Proteins in Fibrosis Associated with Lymphedema

Background: Fibrotic diseases pose a problem for overall health due to their chronic, progressive nature; the lack of a cure; and the fact that such conditions are largely refractory to current medical and surgical treatment practices. Objective: The aim of the present study was to report the physiological stimulation of synthesis and lysis of extracellular matrix proteins during the treatment of primary lymphedema. Material and Methods: A clinical trial was conducted involving the analysis of changes in type I and III collagen fibers and elastic fibers as well as the thickness of the epidermis and dermis in 10 histological fields. Samples were taken from the skin before and after intensive treatment using the Godoy Method® and adapted to the treatment of fibrosis in a patient with a clinical diagnosis of lower limb lymphedema. Slides were stained with orcein, hematoxylin and eosin, picrosirius red, and Gomori’s reticulin stains. Weibel’s multipoint method was used for the morphometric evaluation. The data were compared using the t-test with a 95% confidence interval. Results: Significant changes were detected in all aspects of interest (thickness of the epidermis and dermis, type I and III collagen fibers, and elastic fibers). Conclusion: The present findings demonstrate the physiological stimulation of synthesis and lysis of the main components of an extracellular matrix, such as type I and III collagen fibers and elastic fibers, as well as a reduction in the thickness of the epidermis and dermis in cases of fibrosis through adequate stimulation of the lymphatic system.

Explanatory models, illness, and treatment experiences of patients with psychosis using the services of traditional and faith healers in three African countries: Similarities and discontinuities

As part of formative studies to design a program of collaborative care for persons with psychosis, we explored personal experience and lay attributions of illness as well as treatment among persons who had recently received care at traditional and faith healers’ (TFHs) facilities in three cultural groups in Sub-Saharan Africa. A purposive sample of 85 individuals in Ibadan (Nigeria), Kumasi (Ghana), and Nairobi (Kenya) were interviewed. Data was inductively explored for themes and analysis was informed by the Framework Method. Across the three sites, illness experiences featured suffering and disability in different life domains. Predominant causal attribution was supernatural, even when biological causation was also acknowledged. Prayer and rituals, steeped in traditional spiritual beliefs, were prominent both in traditional faith healing settings as well as those of Christianity and Islam. Concurrent or consecutive use of TFHs and conventional medical services was common. TFHs provided services that appear to meet the therapeutic goals of their patients even when harmful treatment practices were employed. Cultural and linguistic differences did not obscure the commonality of a core set of beliefs and practices across these three groups. This similarity of core worldviews across diverse cultural settings means that a collaborative approach designed in one cultural group would, with adaptations to reflect differences in context, be applicable in another cultural group. Studies of patients’ experience of illness and care are useful in designing and implementing collaborations between biomedical and TFH services as a way of scaling up services and improving the outcome of psychosis.

Using an Implementation Framework to Survey Outcome Measurement and Treatment Practices in Aphasia

Purpose: Best practices in the field of aphasia rehabilitation increasingly acknowledge a whole-person approach that values interventions aimed at reducing impairments, while also recognizing the impact of aphasia on participation and quality of life. Guided by the Consolidated Framework for Implementation Research (CFIR), this study aimed to examine whether current clinical practices along levels of service provision reflect this whole-person, multifaceted approach. Method: Speech-language pathologists (SLPs) in the United States who provide intervention to people with aphasia across the continuum of care completed this cross-sectional online survey. Current outcome measurement and treatment practices were evaluated within the Living With Aphasia: Framework for Outcome Measurement via multiple-choice and open-text response questions. Data were analyzed descriptively and using ordinal logistic regression models to compare clinical practices along levels of service provision. Results: Data from 90 SLPs revealed that language and cognitive skills are assessed with equal consistency across clinical settings; however, functional communication, participation, and quality of life domains are prioritized in settings providing care to clients within the community. Psychological well-being is rarely assessed within clinical practice along most of the rehabilitation process and prioritized within the university clinic setting when clients are in the chronic stage of recovery. Conclusions: Clinical practices related to a multifaceted approach to aphasia intervention are variable across levels of service provision. Further exploration of barriers and facilitators to multifaceted aphasia care along the domains of the CFIR is needed to provide an informed approach to implementing change.

Caregiver Engagement in Stroke Care: Opportunities and Challenges in Australia and Denmark

Globally, there is a rise in incident cases of stroke, particularly in low- and middle-income countries, due to obesity-related and lifestyle risk factors, including health issues such as high cholesterol, diabetes and hypertension. Since the early 20th century, stroke mortality has declined due to proper management of the risk factors and improved treatment practices. However, despite the decline in mortality, there is an increase in the levels of disability that requires long-term support. In countries such as Australia and Denmark, where most care is provided within the community; family members, generally spouses, assume the role of caregiver, with little to no preparation that affects the quality of care provided to the person living with stroke. While past research has highlighted aspects to improve caregiver preparedness of stroke and its impact on care; health planning, recovery, and public health policies rarely consider these factors, reducing engagement and increasing uncertainty. Hence, there is a need to focus on improving strategies during recovery to promote caregiver engagement. In this study, we, therefore, try to understand the needs of the caregiver in stroke that limit engagement, and processes employed in countries such as Australia and Denmark to provide care for the person with stroke. Based on our understanding of these factors, we highlight the potential opportunities and challenges to promote caregiving engagement in these countries.

Prognostic Enigma of Pancreatic Solid Pseudopapillary Neoplasm: A Single-Center Experience of 63 Patients

Background: Studies investigating prognostic factors of solid pseudopapillary neoplasm (SPN) have been published with conflicting findings.Methods: Retrospective analysis of 63 consecutive cases of SPN in our institution from January 2010 to December 2019 was carried out. The clinicopathological features, treatment practices along with survival associations were collected and analyzed.Results: Fifteen patients (23.8%) were male, and 48 (76.2%) were female, with a median age of 34.0 ± 14.5 years. The larger tumor size was correlated with the more mixed components (p = 0.000) and the higher Ki-67 index (p = 0.042). No recurrence was found in the nine patients whose tumors fulfilled the WHO criteria for malignancy due to the presence of at least perineural invasion (6.4%), angiovascular invasion (2.3%), and/or adjacent organ invasion (6.4%). Microscopic infiltrative growth was detected in 9 (14.3%) tumors, which was correlated significantly with the WHO criteria (p = 0.002), capsule invasion (p = 0.005), and pancreatic parenchyma invasion (p = 0.001), but not with disease-free survival (p = 0.13). CD99 was found to be positively expressed in 88.9% (40/45) of tumors and more likely to have depressed Ki-67 index (p = 0.016). After a median follow-up of 58 months, only two patients (3.2%) had a recurrence after their first operation outside of our hospital. No patient died due to tumor progression.Conclusions: Although survival is favorable with aggressive surgery, it is actually difficult to assess the prognostic factors of resected SPNs. Future investigations into the role of clinicopathological evaluation will unveil the prognostic enigma of pancreatic SPN after resection.

Shackled Bodies, Unchained Minds: Lunatic Asylums in the Bombay Presidency 1793-1921

<p>Lunatic asylums in the Bombay Presidency were characteristically custodial. In 1793, the government sanctioned the building of the first asylum in the Presidency. During the nineteenth century, they built more asylums, adding to their number. However, by the early twentieth century, these asylums remained mere ‘lock-ups’ for those deemed dangerous to society. Lunacy administration, as one superintendent noted, was the veritable Cinderella in the family of colonial institutions. In terms of the public use of asylums by Indians, in 1905 the total patient population of the asylums in the Bombay Presidency stood only at 1203 patients. This was a meagre number compared to the asylum patient population in Britain. The poor admission numbers baffled both the government and the Indian press. This thesis argues that the colonial lunatic asylum did not assimilate into Indian society and therefore remained a failed colonial-medical enterprise. Colonial agencies attributed the poor quality of asylum treatment practices to ‘native apathy’ in matters of mental health, and the low admission numbers to ‘less-brain energy’ of Indians. Eduardo Duran has argued that colonial institutions, because of their lack of cultural competence, inflicted historical traumas on indigenous people; historical traumas affect people on three levels: physical, psychological, and spiritual. The thesis contends that Indian ‘apathy’ was a mere reaction to the historical traumas caused by the asylum system. The thesis accounts for these historical traumas. The first chapter argues that the lunatic asylum contended with two intrinsic characteristics of Indian society - its integrated spiritual-somatic understanding of insanity and its close family ties. The ‘apathy’ of the Indian population towards the asylum system, then, was a reaction to the wounds caused by the colonial undermining of Indian worldviews, medical knowledge, and socio-cultural practices. In the second chapter, the thesis proceeds to examine the colonial-local encounters within the asylum system. These encounters reveal the character of the lunatic asylum as a colonial middle ground. While the government, judiciary and asylum staff executed various forms of control over patients, they failed to achieve colonial hegemony in the lunatic asylums. The third and fourth chapters examine treatment practices and the asylum soundscape as evidence of its failure as a medical institution. Over the nineteenth and twentieth centuries, asylum treatment methods remained largely primitive - revolving around clothing, feeding and keeping patients occupied. Such treatment methods reflected the custodial character of Bombay’s asylum system. The custodial nature was also evident in the asylum soundscape or aural environment. Asylum staff did not succeed in regulating and regimenting the asylum soundscape unlike other asylums around the world because of monetary and spatial constraints. In the final chapter, the thesis proceeds to examine the local community’s understanding of the asylum system. For local communities, the lunatic asylum was a place of ‘insulation, mystery and darkness’ - a perception that kept them away from its use. Extensive archival research in India and Britain, in institutions such as the Maharashtra State Archives, National Archives of India, and British Library, where primary sources such as government proceedings, case notes, asylum general rules, annual reports along with local newspapers and patient letters were collected and analysed in this investigation. Hospital records and photographs, taken at the mental hospitals at Thana and Ratnagiri, corroborated other primary sources. The thesis examines the lunatic asylums in the Bombay Presidency from its establishment in 1793 to 1921, after which the government changed the designation ‘lunatic asylum’ to ‘mental hospital’. The thesis does not aim to examine colonial motivations in establishing the lunatic asylum since colonial agencies had heterogeneous views on the purpose of the asylum. Rather, it assesses the Indian experience as it encountered a colonial medical institution. In analysing the impact of the asylum system, the thesis seeks to explain the aversion of Indian families to the asylum. This aversion is evident in Indian society even today, and so is the custodial character of mental hospitals in Maharashtra. An awareness of the historical traumas associated with such institutions can help mental health practitioners, policy makers and Indian society invent better ways to help people suffering from mental illness.</p>