Search

Background and Aims No consensus exists on defining intestinal ultrasound response, transmural healing, or transmural remission in inflammatory bowel disease, nor clear guidance for optimal timing of assessment during treatment. This systematic review and expert consensus study aimed to define such recommendations, along with key parameters included in response reporting. Methods Electronic databases were searched from inception to July 26, 2021, using pre-defined terms. Studies were eligible if at least two intestinal ultrasound [IUS] assessments at different time points during treatment were reported, along with an appropriate reference standard. The QUADAS-2 tool was used to examine study-level risk of bias. An international panel of experts [n = 18] rated an initial 196 statements [RAND/UCLA process, scale 1–9]. Two videoconferences were conducted, resulting in additional ratings of 149 and 13 statements, respectively. Results Out of 5826 records, 31 full-text articles, 16 abstracts, and one research letter were included; 83% [40/48] of included studies showed a low concern of applicability, and 96% [46/48] had a high risk of bias. A consensus was reached on 41 statements, with clear definitions of IUS treatment response, transmural healing, transmural remission, timing of assessment, and general considerations when using intestinal ultrasound in inflammatory bowel disease. Conclusions Response criteria and time points of response assessment varied between studies, complicating direct comparison of parameter changes and their relation to treatment outcomes. To ensure a unified approach in routine care and clinical trials, we provide recommendations and definitions for key parameters for intestinal ultrasound response, to incorporate into future prospective studies.

Objectives - to study the mortality indicators, their dynamics and structure, in the population of the Orenburg region in the period of 2011-2017. Material and methods. The study was conducted using the data from the territorial authority of statistics in the Orenburg region in the period from 2011 to 2017. The analytical, demographic and statistical methods were implemented for the study of the demographic indicators. Results. Cities and municipal settlements of the Orenburg region with high mortality indicators were included in the second and fourth clusters during the cluster analysis. The first and third clusters included cities and municipal settlements with an average mortality. The most favorable position has the Orenburg area with the lowest mortality rate in the region in 2017 - 8.4%. The dynamics of mortality rates among the male and female population tends to decrease, more pronounced dynamics is in men. Though, the male population is characterized by higher mortality rates in all age groups. The leading position among the causes of death is taken by diseases of the circulatory system (46.3% of the total mortality). The second position is occupied by tumors (17.2%), the third - by external causes (8.4%). Mortality from circulatory system diseases and from external causes has reduced. The dynamics of mortality from tumors does not change significantly. The rank of leading causes of death is not identical in the clusters: in the third and fourth clusters, the other causes occupy the second place in the structure of mortality, while tumors occupy the third. Conclusion. In the Orenburg region, the mortality rate is higher than overage in the Russian Federation by 0.9 per 1000 people. The study revealed significant territorial differences in the mortality rates. In general, the mortality among men in all age groups is higher than the mortality of women. The mortality rate from diseases of the circulatory system plays the leading role in the structure of mortality, but has the tendency for decline. Until 2006, the mortality from external causes ranked the second place, now the second place is taken by death from tumors The mortality from external causes is decreasing; mortality from tumors does not change significantly. The obtained results could be used by local authorities in developing the program of public health protection and assessing its effectiveness.

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P P P P P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

Objective: to evaluate the pharmacokinetics of nadroparin and dalteparin in thrombosis complicating the treatment of children with malignant neoplasms.Materials and methods. The results of 52 pharmacokinetic studies performed in 34 patients with malignant neoplasms, whose treatment was complicated by venous thrombosis, were analyzed. The age of the patients is from 7 to 18 years, he median is 14.5 years. Depending on the value of daily dose and type of heparin administered, the results of pharmacokinetic studies were divided into 6 groups. Dalteparin sodium: during period of chemotherapy induced thrombocytopenia, subcutaneous injection at a dose of 51.0 (40.0-72.0) anti Xa IU/kg every 12 hours - 6 studies; subcutaneous injection every 12 hours at a dose of 100.5 (91.0-141.0) anti Xa IU/kg - 18 observations; long-term continuous administration at a constant rate at a daily dose of 201.0 (180.0-265.0) anti Xa IU/kg - 6 pharmacokinetic observations. Nadroparin calcium: 62.0 (53.0-71.0) anti Xa IU/kg every 12 hours - 6 studies; 93.5 (80.0-117.0) anti Xa IU/kg every 12 hours - 10 observations; subcutaneous injection at a dose of 203.0 (170.0-236.0) anti Xa IU/kg once a day - 6 pharmacokinetic observations.Results. At steady-state, the area under the pharmacokinetic curve (AUC) of dalteparin and nadroparin, regardless of the mode of administration, depended on the maximum specific activity and half-life. No relationship was found for dalteparin between AUC and endogenous creatinine clearance. In contrast to dalteparin, the AUC after administration of na-droparin was closely related to endogenous creatinine clearance. The increase in chronometric indices indirectly reflected the presence of an anticoagulant in the blood, but did not allow an objective assessment of therapeutic effect achievement, recorded by the degree of thrombin generation inhibition.Conclusion. There were no significant advantages of nadroparin compared with dalteparin when using in comparable doses in the case of venous thrombosis, complicated the treatment of children with malignant neoplasms. Subcutaneous administration of 50 % nadroparin calcium daily dose with 12 hours interval is preferred over a single administration of 100 % daily dose every 24 hours. It is mandatory to monitor the administration of low molecular weight heparins in children with oncological diseases in order to make a decision on the adequacy of anticoagulant dose to the therapeutic range.

A meaningful body of literature promotes greater exposure of social work students to educational content concerning substance misuse. This EndNotes piece identifies the rationale for social work pr...

Adherence to evidence-based management is variable in inflammatory bowel disease (IBD), which leads to worse patient outcomes and higher healthcare utilization. Solutions include electronic systems to enhance care, but these have often been limited by lack of clinician design input, poor usability, and low perceived value. A cloud-based IBD-specific clinical management software - 'Crohn's Colitis Care' (CCCare) was developed by Australia and New Zealand Inflammatory Bowel Disease Consortium clinicians and software developers to improve this.CCCare captures patient-reported disease activity and medical assessment, medication monitoring, cancer screening, preventative health, and facilitates communication with the IBD team and referring doctor. De-identified longitudinal data are stored separately in a clinical quality registry for research. CCCare was tested for feasibility and usability in routine clinical settings at two large Australian hospitals. Users' experience was evaluated with System Usability Scale (SUS). Value to clinicians and patients was assessed by qualitative feedback. Security was assessed by penetration testing.Users (Initial evaluation demonstrates CCCare is usable, secure, and valued in clinical use. It is designed to measure outcomes of clinical care, including efficacy, quality, cost, and complications for individuals, and to audit these at hospital and national level.

Objective To examine whether non-medical switching of patients with inflammatory bowel disease (IBD) from originator infliximab to a biosimilar (CT-P13, Inflectra) is safe and clinically non-inferior to continued treatment with originator infliximab. Design Prospective, open label, multicentre, parallel cohort, non-inferiority study in seven Australian hospitals over 48 weeks, May 2017 - October 2019. Participants Adults (18 years or older) with IBD receiving maintenance originator infliximab (Remicade) who had been in steroid-free clinical remission for at least 12 weeks. Intervention Managed program for switching patients in four hospitals from originator to biosimilar infliximab (CT-P13); patients in three other hospitals continued to receive originator infliximab (control). Main outcome measures Clinical disease worsening requiring infliximab dose escalation or change in therapy. Results The switch group included 204 patients, the control group 141 patients with IBD. Ten patients in the control group (7%) and 16 patients switched to CT-P13 (8%) experienced clinical deterioration; the adjusted risk difference (control v switch group) was -1.1 percentage points (95% CI, -6.1 to 8.2 percentage points), within our pre-specified non-inferiority margin of 15 percentage points. Serious adverse events leading to infliximab discontinuation were infrequent in both the switch (six, 3%) and control (six, 4%) groups. Conclusion Switching patients with IBD from originator to biosimilar infliximab is safe and non-inferior to continuing treatment with originator infliximab. Moreover, the introduction of biosimilar infliximab, by increasing market competition, has resulted in substantial cost savings for the Pharmaceutical Benefits Scheme.

BACKGROUND Vedolizumab (VDZ), a humanised monoclonal antibody that selectively inhibits alpha4-beta7 integrins is approved for use in adult moderate to severe ulcerative colitis (UC) patients. AIM To assess the efficacy and safety of VDZ in the real-world management of UC in a large multicenter cohort involving two countries and to identify predictors of achieving remission. METHODS A retrospective review of Australian and Oxford, United Kingdom data for UC patients. Clinical response at 3 mo, endoscopic remission at 6 mo and clinical remission at 3, 6 and 12 mo were assessed. Cox regression models and Kaplan Meier curves were performed to assess the time to remission, time to failure and the covariates influencing them. Safety outcomes were recorded. RESULTS Three hundred and three UC patients from 14 centres in Australia and United Kingdom, [60% n = 182, anti-TNF naïve] were included. The clinical response was 79% at 3 mo with more Australian patients achieving clinical response compared to Oxford (83% vs 70% P = 0.01). Clinical remission for all patients was 56%, 62% and 60% at 3, 6 and 12 mo respectively. Anti-TNF naive patients were more likely to achieve remission than exposed patients at all the time points (3 mo 66% vs 40% P < 0.001, 6 mo 73% vs 46% P < 0.001, 12 mo 66% vs 51% P = 0.03). More Australian patients achieved endoscopic remission at 6 mo compared to Oxford (69% vs 43% P = 0.01). On multi-variate analysis, anti-TNF naïve patients were 1.8 (95%CI: 1.3-2.3) times more likely to achieve remission than anti-TNF exposed (P < 0.001). 32 patients (11%) had colectomy by 12 mo. CONCLUSION VDZ was safe and effective with 60% of UC patients achieving clinical remission at 12 mo and prior anti-TNF exposure influenced this outcome.

The COVID‐19 pandemic, caused by the novel coronavirus SARS‐CoV‐2, has emerged as a public health emergency and challenged healthcare systems globally. In a minority of patients, SARS‐CoV‐2 manifests with a severe acute respiratory illness and currently there are insufficient data regarding the virulence of COVID‐19 in inflammatory bowel disease patients taking immunosuppressive therapy. This review aims to summarise the current literature and provide guidance on the management of inflammatory bowel disease (IBD) patients in the context of the COVID‐19 pandemic in the Australasian setting.

Youth experiencing homelessness face myriad barriers and inequities regarding their reproductive and sexual health and rights. Moreover, homeless youth are often characterized as "disaffiliated" and depicted as difficult to engage in research. This study qualitatively explored homeless youths' attitudes, beliefs, and needs regarding reproductive and sexual health, and sought their perspectives on being involved in research on such topics, which are often thought of as "taboo" or sensitive. Youth were enthusiastic about openly discussing such issues, which they deemed as highly relevant to their daily lives. Youth identified that how they were engaged in such research, and having opportunities for longer-term contributions to such efforts, were both important and exciting to them. Future social work and public health research efforts should seek to further disrupt narratives of homeless youth as "disaffiliated" and difficult to engage, and in doing so, develop more creative, participatory, and youth-led opportunities for including this group in reproductive and sexual health research.

Background and Aims Inflammatory bowel disease [IBD] affects women during their childbearing years. Gastrointestinal ultrasonography [GIUS] accurately identifies disease activity in non-pregnant patients with IBD. The utility of GIUS in pregnancy has not been established. We aimed to determine the feasibility and accuracy of GIUS in the assessment of IBD during pregnancy progression. Methods A multicentre observational study of women with IBD undergoing GIUS during pregnancy. Clinicians assessed the adequacy of bowel views and disease activity in four colonic segments and the terminal ileum. Location[s] in which views were impeded by the uterus were documented. GIUS disease activity [bowel wall thickness >3 mm] was compared with biochemical disease activity [faecal calprotectin >100 μg/g]. Results Ninety patients and 127 GIUS examinations were included [median gestation 19 weeks, range 4–33]. Adequate colonic views were obtained in 116/127 [91%] scans. Adequate ileal views were obtained in 62/67 [93%] scans Conclusions GIUS is a feasible and accurate modality for monitoring IBD in pregnancy. Adequate GIUS views of the colon and terminal ileum can be obtained in the majority of patients up to 20 weeks of gestation. Beyond 20 weeks, GIUS provides good views of the colon but the terminal ileum becomes difficult to assess.

Background and Aim Objective monitoring of disease activity is integral to therapeutic decision‐making in inflammatory bowel disease (IBD). Data are sparse on patients' perspectives of tools used to monitor disease activity in IBD. To evaluate patients' perspectives of gastrointestinal ultrasound (GIUS) performed during routine IBD clinical care, along with its impact on IBD‐specific knowledge. Methods Patients with a formal diagnosis of IBD who underwent GIUS at two tertiary IBD services between March 2017 and January 2019 participated in this prospective study. Participants completed a questionnaire measuring the acceptability, tolerability, and usefulness of GIUS using a visual analogue scale (VAS) from 0 (disagree) to 10 (strongly agree). Comparative acceptability of IBD monitoring tools and the impact of GIUS on IBD‐specific knowledge was measured. Results A total of 121 participants completed the questionnaire, with a mean age of 42 years (range 17–78), 54 (45%) males, and 79 (65%) Crohn's disease patients. In the overall population, GIUS was scored as highly acceptable for monitoring IBD (mean 9.20 ± 1.37) compared to colonoscopy (7.94 ± 2.30), stool sampling (8.17 ± 1.96), blood sampling (8.87 ± 1.62), and imaging (8.67 ± 1.60); P, Gastrointestinal ultrasound (GIUS) is being increasingly used for disease monitoring in inflammatory bowel disease; however, patient perceptions of the different modalities available are sparse. This article evaluates patient perceptions, finding that GIUS was preferred to other modalities, and it was also found to have an impact on disease‐related knowledge.

Objective: Understanding patterns of dangerous and illicit substance use among young parents who are homeless may provide insight into how best to support this highly vulnerable group and t...

ObjectiveFaecal microbiota transplantation (FMT) has proved to be an extremely effective treatment for recurrent Clostridioides difficile infection, and there is interest in its potential application in other gastrointestinal and systemic diseases. However, the recent death and episode of septicaemia following FMT highlights the need for further appraisal and guidelines on donor evaluation, production standards, treatment facilities and acceptable clinical indications.DesignFor these consensus statements, a 24-member multidisciplinary working group voted online and then convened in-person, using a modified Delphi approach to formulate and refine a series of recommendations based on best evidence and expert opinion. Invitations to participate were directed to Australian experts, with an international delegate assisting the development. The following issues regarding the use of FMT in clinical practice were addressed: donor selection and screening, clinical indications, requirements of FMT centres and future directions. Evidence was rated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.ResultsConsensus was reached on 27 statements to provide guidance on best practice in FMT. These include: (1) minimum standards for donor screening with recommended clinical selection criteria, blood and stool testing; (2) accepted routes of administration; (3) clinical indications; (4) minimum standards for FMT production and requirements for treatment facilities acknowledging distinction between single-site centres (eg, hospital-based) and stool banks; and (5) recommendations on future research and product development.ConclusionsThese FMT consensus statements provide comprehensive recommendations around the production and use of FMT in clinical practice with relevance to clinicians, researchers and policy makers.

Objective. The aim of the study was a comparative assessment of urine NGAL (neutrophil gelatinase associated lipocalin) and KIM‑1 (kidney injury molecule‑1) as biomarkers of early detection of tubulointerstitial renal damage in patients with arterial hypertension (HTN) without concomitant diabetes mellitus and kidney disease.Design and methods. The study involved 52 patients of both sexes (17 man and 35 women, mean age 60,2 ± 6,54 years) hospitalized for aggravation of HTN 1–3 degrees, which were divided into 3 groups with glomerular filtration rate (GFR) > 90 ml/min/1,73 m 2 (n = 21), 60–90 ml/min/1,73 m 2 (n = 19) and < 60 ml/min/1,73 m 2 (n = 12). In a separate group, patients with albuminuria in the range 10–29 mg/g urine creatinine were isolated. The comparison group consisted of 15 normotensive individuals (6 men and 9 women, mean age 49,8 ± 9,68 years) with no obvious signs of renal, cardiovascular or other diseases. All patients and controls underwent examination, and albumin, NGAL (Human NGAL ELISA kit) and KIM‑1 (Human KIM‑1 Immunoassay ELISA) levels were assessed in the first morning urine portion.Results. In the group of patients with GFR 67,7 ± 4,92 ml/min/1,73 m 2 (mildly reduced kidney function) and in the group of patients with GFR 55,8 ± 4,44 ml/min/1,73 m 2 (renal dysfunction) urine NGAL level increased by 3,43 (р < 0,05) and 3,92 times (р < 0,05), respectively, as compared with the control group. The urine concentration of KIM‑1 increased by 2,06 times (р < 0,05) was observed only in patients with renal dysfunction. Based on the ROC analysis AUC for the urine NGAL level in patients with mildly reduced kidney function is 0,78 (95 % confidence interval, 95 %CI: 0,70–0,86; p < 0,001), specificity — 89,6 %, sensitivity — 66,7 %. Similar indicators for KIM‑1 are 0,72 (95 % CI: 0,64–0,80; p < 0,001), specificity — 85,3 %, sensitivity — 16,7 %. In the group of patients with mildly reduced kidney function the urine level of NGAL correlated with the HTN severity (r = 0,8944, р < 0,001) and its duration (r = 0,8953, р < 0,001).Conclusions. Urine NGAL as compared with KIM‑1 is a more sensitive biomarker, which indicates tubulointerstitial injury in HTN patients without diabetes mellitus and kidney diseases in the early stage of impairment renal function.

Ulcerative colitis (UC) is a major form of inflammatory bowel disease with increasing global incidence. There is significant phenotypic heterogeneity defined by a range of clinical variables including age of onset and disease extent. Clinical outcomes range from long-term remission on minimal therapy to surgical resection. Close to 70% of UC risk can be attributed to genetics and understanding the genetic mechanisms contributing to this risk and disease heterogeneity is vital for understanding disease pathogenesis and improving patient outcomes through targeted screening and therapies. This study aims to characterise the genetic heterogeneity of UC by identifying genomic risk variants specific to mild and/or severe forms of UC, exploring variations in the effect size of known risk variants and assessing the clinical value of a genetic risk score (GRS). We conducted genome-wide association (GWA) analyses in 287 patients with mild UC, 311 patients with severe UC and 583 age- and gender-matched controls. Odds ratios (OR) for mild vs control, severe vs control and combined mild and severe UC vs control were calculated. Using the combined UC data, two independent loci in the HLA region reached genome-wide significance. An additional genome-wide significant signal on chromosome 1 was identified in severe cases only. OR for known risk loci varied between mild and severe patients and were similar to previously published results. Effect estimates from the most recent UC GWA meta-analysis were used to calculate a GRS for each individual. A higher mean GRS was observed in both mild and severe UC cases compared to controls however, there was no difference between the mean GRS for mild and severe UC. Heterogeneity in effect sizes of UC associated variants between mild and severe disease burden suggests the presence of genetically distinct signatures. While large consortium data are needed to identify genome-wide significant variants, additional risk loci may be identified by targeted recruitment of individuals with a history of severe disease.Author SummaryUlcerative colitis (UC) is a chronic and often debilitating form of inflammatory bowel disease affecting approximately 0.3% of the population in industrialized economies. The disease displays significant clinical heterogeneity including age at presentation, disease severity, and the propensity to develop disease-related complications. Several previous studies have demonstrated the heritability of UC, identifying over 30 loci specific to the disease. The majority of these loci have small to modest effect sizes other than those within the Human Leucocyte Antigen (HLA) region on chromosome 6. Using stringent clinical criteria for defining mild and severe forms of UC in an extremes of phenotype approach, we undertook a genome wide association study in a dataset of 1222 participants to investigate genetic heterogeneity in this disease. We demonstrated substantial differences in genetic associations in severe UC as compared to mild UC. While over 2,000 SNPs achieved genome-wide significance in the severe UC analysis, none reached significance for mild UC. These results were reflected in significant differences in odds ratios. We identified Complement Factor B (CFB) as a potential susceptibility gene for severe UC in the Caucasian population with additional tissue gene expression demonstrating a positive correlation with disease severity.

Background Osteoradionecrosis (ORN) of the mandible is a well-known complication of radiation therapy for head and neck cancer. However, few reports have described hyoid bone ORN and its clinical implications. Methods We describe a retrospective case series of previously irradiated patients who were seen with sudden airway compromise, found to have underlying pathological hyoid fractures secondary to osteoradionecrosis. Results Six patients within postchemoradiation period (3-9 months) for oropharyngeal squamous cell carcinoma were seen with acute-onset dyspnea. Computed topography (CT) imaging was remarkable for severe airway luminal narrowing and pathological hyoid fractures. All six patients required urgent intervention with direct laryngoscopy and tracheostomy. Intraoperatively, five patients were seen with exposed necrotic hyoid bones. Conclusion The hyoid and its associated musculature strongly influence upper airway patency. ORN may compromise its physiological function and leads to acute airway compromise. Hyoid ORN may hold significant and imperative clinical implications in head and neck cancer post-treatment surveillance.

Objectives We sought to review the literature on the access experiences and attitudes toward abortion among youth experiencing homelessness in the United States. Methods We conducted a systematic review of peer‐reviewed literature published from 2001 to 2019. We included qualitative studies involving US participants that focused on access experiences, views, or accounts of unintended pregnancy and/or abortion among youth experiencing homelessness. We excluded studies published before 2001 as that was the year mifepristone medication abortion was made available in the US and we aimed to investigate experiences of access to both medical and surgical abortion options. Results Our thematic analysis of the data resulted in five key themes that characterize the abortion attitudes and access experiences of youth experiencing homelessness: (1) engaging in survival sex and forced sex, (2) balancing relationships and autonomy, (3) availability does not equal access, (4) attempting self-induced abortions using harmful methods, and (5) feeling resilient despite traumatic unplanned pregnancy experiences. Conclusions Youth experiencing homelessness experience barriers to abortion access across the US, including in states with a supportive policy context and publicly funded abortion services. In the absence of accessible services, youth may consider harmful methods of self-induced abortion. Improved services should be designed to offer low-barrier abortion care with the qualities that youth identified as important to them, including privacy and autonomy.

Background and Aim Inflammatory bowel diseases (IBD) are chronic inflammatory conditions of the gut resulting in a significant risk for malnutrition. The reported prevalence of malnutrition in inflammatory disease patients varies from 5.7 to 82.8%. The aim of this study was to measure the prevalence of malnutrition and its association with quality of life (QOL) in a cohort of Australian IBD outpatients. Methods A total of 107 consecutive patients (68 Crohn's disease, 35 ulcerative colitis, 4 indeterminate colitis) were enrolled in this cross‐sectional study. Demographic data were collected, and patients underwent a malnutrition assessment using the patient‐generated subjective global assessment. The RAND 36‐item health survey was used to measure QOL. Results Mild to moderate malnutrition was detected in 17 patients (16%). Malnourished patients were more likely to be underweight (P ≤ 0.01), have active disease (P ≤ 0.01), and have been admitted to hospital in the preceding 12 months (P ≤ 0.05). Malnourished patients had a significantly lower QOL in physical (P ≤ 0.01) and mental (P ≤ 0.01) health components. Patients with active or recently active disease had reduced QOL compared to patients in remission. Malnutrition factors predictive of poor physical health‐related QOL were pain (odds ratio [OR] = 12.8, 95% confidence interval [CI] 2.0–80.4) and unintentional weight loss (OR = 3.1 per kg lost, 95% CI 1.2–7.9). The predictor of poor mental health‐related QOL was early satiety (OR = 7.7, 95% CI 1.7–33.9). Conclusions The malnutrition prevalence for this population was 16%. Malnutrition was associated with being underweight, active disease, and increased number of hospital admissions. Disease activity and malnutrition were associated with poorer QOL., In an outpatient cohort of inflammatory bowel disease patients, we found a malnutrition prevalence of 16%. Malnutrition was associated with being underweight, active disease, and an increased number of hospital admissions and was associated with poorer quality of life.

Objectives To assess the clinical effectiveness of faecal calprotectin (FC) testing for distinguishing between organic gastrointestinal diseases (organic GID), such as inflammatory bowel disease (IBD), and functional gastrointestinal disorders (functional GIDs). Study design Studies that assessed the accuracy of FC testing for differentiating between IBD or organic GID and functional GIDs were reviewed. Articles published in English during January 1998 - June 2018 that compared diagnostic FC testing in primary care and outpatient hospital settings with a reference test and employed the standard enzyme-linked immunosorbent FC assay method with a cut-off of 50 or 100 μg/g faeces were included. Study quality was assessed with QUADAS-2, an evidence-based quality assessment tool for diagnostic accuracy studies. Data sources MEDLINE and EMBASE; reference lists of screened articles. Data synthesis Eighteen relevant studies were identified. For distinguishing patients with organic GID (including IBD) from those with functional GIDs (16 studies), the estimated sensitivity of FC testing was 81% (95% CI, 74-86%), the specificity 81% (95% CI, 71-88%); area under the curve (AUC) was 0.87. For distinguishing IBD from functional GIDs (ten studies), sensitivity was 88% (95% CI, 80-93%), specificity 72% (95% CI, 59-82%), and AUC 0.89. Assuming a population prevalence of organic GID of 1%, the positive predictive value was 4.2%, the negative predictive value 100%. The difference in sensitivity and specificity between FC testing cut-offs of 50 μg/g and 100 μg/g faeces was not statistically significant (P = 0.77). Conclusions FC testing is clinically useful for distinguishing organic GID (including IBD) from functional GIDs, and its incorporation into clinical practice for evaluating patients with lower gastrointestinal symptoms could lead to fewer patients with functional GIDs undergoing colonoscopy, reducing costs for both patients and the health system. Prospero registration CRD4201810507.

OBJECTIVE To determine if reported incidence rates of hemorrhagic cystitis after radiation therapy for prostate cancer are accurate, to investigate the effect of different radiation modalities on the development of hemorrhagic cystitis and to assess its morbidity and treatment. MATERIALS AND METHODS A retrospective chart review was completed of 709 patients at 2 Detroit Medical Center hospitals who underwent radiation therapy for prostate cancer between January 2000 and September 2015. In patients who developed hemorrhagic cystitis, we analyzed the incidence, radiation modality, morbidity, treatment, and complications. RESULTS The incidence rate of hemorrhagic cystitis after radiation for prostate cancer was 11.1%. There was no significant difference between external beam and intensity-modulated radiation therapy and the development of hemorrhagic cystitis (P = .18). Patients developed hemorrhagic cystitis an average of 79.1 months (4-230 months) after radiation. The average number of admissions was 2.5 (1-9) with an average length of stay of 7.6 days (1-42 days). Fifty-two percent of patients required blood transfusion with an average of 4.3 units transfused per patient (1-33U). The most common treatment was cystoscopy with fulguration/clot evacuation in 86% of patients. Complications included urinary tract infection, acute kidney injury, urosepsis, and even death. CONCLUSION The incidence of hemorrhagic cystitis following radiation therapy for prostate cancer is under-reported in the literature. Hemorrhagic cystitis is associated with high morbidity and complications for patients, requiring multiple hospitalizations, blood transfusions, and procedures. Advances in radiation have not significantly reduced the risk of developing hemorrhagic cystitis.

Context Tax-exempt hospitals in the United States are required to report community benefit expenses on their federal tax forms. Two categories of expenses critical to the public health mission of hospitals are the "community health improvement" and "community-building" expense categories. The community health improvement expenses formally qualify as a community benefit, whereas community-building expenses do not. Increasing both types of spending would be consistent with the growing evidence on the effects of social determinants on population health. Objective To identify characteristics associated with the level of community health improvement and community-building expenses reported by tax-exempt hospitals. Design The general acute care hospital is the unit of analysis. We utilize secondary data for all US general acute care hospitals that filed their own Internal Revenue Service Form 990 Schedule H for 2013 (n = 1508). We apply linear regression analysis to an explanatory model with 8 independent variables. Measures The primary dependent variables are percentage of operating expenses devoted to community health improvement and to community building. The independent variables include 4 hospital-level measures, 3 county-level measures, and a measure of state requirements for community benefit. Results The level of community health improvement expenses is positively associated with bed size, system membership, profit margin, and urban location. In states where tax-exempt hospitals are required to demonstrate community benefit to the state, there is lower community health improvement spending. Teaching hospitals also demonstrate lower community health improvement spending. Results for community-building expenses mirror those for community health improvement except that teaching hospital status and per capita income lose significance and hospital competition gains significance in the negative direction. Conclusions Leaders among tax-exempt hospitals in community-related spending are hospitals that are larger, more profitable, members of systems, and located in urban areas and in states that do not have community benefit requirements.

Background Decision support tools may facilitate shared decision-making and improve quality of care. Aim To assess the effectiveness of a decision support tool on improving quality of care in ulcerative colitis. Methods A prospective quality of care intervention was conducted at two Australian hospitals comparing out-patient-based ulcerative colitis care with, and without, a tablet-based decision support tool. This included questions on disease activity management; psychological well-being; and preventive care, with 13 process indicators relevant to each domain. Participants included adult out-patients with mild-to-moderate ulcerative colitis and their clinicians who were divided into two cohorts. The first cohort were followed up immediately after their clinical review to check whether their clinician had discussed the 13 process indicators during the consultation. The second cohort of patients used the decision support tool immediately prior to their consultation which then generated a suggested management plan for the patient and clinician to discuss during the consultation. Management between the 2 cohorts was compared to assess the effectiveness of the decision support tool in improving the primary outcome, defined as the proportion of quality process indicators used for ulcerative colitis care, with and without the decision support tool. Results Thirteen physicians and 100 patients participated. Fifty patients were managed without the decision support tool using standard care (median age 40; 44% male), and 50 patients used the decision support tool (median age 40; 46% male) over a 20-week period. Increase in the median use of process indicators overall was observed following use of the decision support tool (27% vs 100%; P < 0.001). Improvements were seen in psychological well-being management (30% vs 100%; P < 0.001), preventive care (16% vs 100%; P < 0.001) and process indicators related to disease activity management (50% vs 100%; P < 0.001). The decision support tool was found to be usable and acceptable. Shared decision-making was greater in the post-intervention group (mean decision conflict score of 18.0 vs 33.5; P = 0.002). Conclusions The decision support tool substantially improved the quality of the delivery of care. Decision support tools have the potential to minimise errors of omission via a standardised approach to care.

The diagnosis of lobular carcinoma in situ (LCIS) is a strong risk factor for breast cancer. Endocrine therapy (ET) for LCIS has been shown to decrease breast cancer risk substantially. The purpose of this study was to evaluate the trends of ET use for LCIS in two large geographic locations. We identified women, ages 18 through 75, with a microscopic diagnosis of LCIS in California (CA) and New Jersey (NJ) from 2004 to 2014. We evaluated trends in unadjusted ET rates during the study period and used logistic regression to evaluate the relationship between patient, tumor, and treatment characteristics, and ET use. We identified 3,129 patients in CA and 2,965 patients in NJ. The overall use of ET during the study period was 14%. For the combined sample, women in NJ were significantly less likely to utilize ET then their counterparts in CA (OR 0.77, CI 0.66–0.90, NJ vs. CA). In addition, patients in the later year period (OR 1.27, CI 1.01–1.59, 2012–2014 vs. 2004–2005) and women who received an excisional biopsy (OR 2.35, CI 1.74–3.17), were more likely to utilize ET. Uninsured women were less likely to receive ET (OR 0.61, CI 0.44–0.84, non-insured vs. insured status). We observed that an increasing proportion of women are using ET for LCIS management, but geographical differences exist. Health insurance status played an important role in the underutilization of ET. Further research is needed to assess patient outcomes given the variations in management of LCIS.

Objective of the study was to compare blood clotting parameters in lymphoma patients with or without venous thrombosis (VT), as well as to analyze the duration and outcome of anticoagulant therapy in children, adolescents and young adults with lymphoma, whose program treatment was complicated by VT.Materials and methods . The analysis included 28 patients with lymphoma (Hodgkin lymphoma – 5, non-Hodgkin lymphoma – 23), aged from 2 to 25 years (median – 16.0 years), whose program treatment in 2005–2017 was complicated by VT. The case-control study was carried out to compare the parameters of blood coagulation. The control group consisted of 22 patients, aged from 2 to 20 years (median – 15.5 years) with the same diagnosis, age, therapy protocol and phase of treatment who had no thrombotic complications. The comparison group consisted of 35 healthy children aged from 3 to 18 years (median – 14.0 years).Results . There was no difference in majority of blood clotting parameters in lymphoma patients with or without VT. Hyperfibrinogenemia and an increased D-dimers level distinguished patients with lymphoma, regardless of the presence or absence of thrombosis, from healthy children of the same age (рA gene of the factor II takes warfarin continuously for a long time after relapse of VT. Complete recanalization of the thrombosed vessel occurred within the first 3 months in 9 patients, within 4–6 months – in 1, within 7–12 months ‒ in 4. Partial recanalization within 3–12 months was confirmed in 8 patients. Vein obliteration, mainly the internal jugular vein, as the outcome of VT occurred in 6 patients within 4–12 months.Conclusion . Detection of routine blood clotting parameters does not allow identifying patients with thrombosis among children, adolescents and young adults with lymphoma. Fibrinogen and D-dimers levels were significantly higher in lymphoma patients, than in healthy children. Anticoagulant therapy for 3–12 months led to the complete or partial recanalization of VT in 79 % of patients. To detect blood clotting parameters by thrombosis development, as well as to reveal and monitor transient and permanent risk factors are necessary to specify the cause of VT and to determine the appropriate anticoagulant therapy.

Pregnancy rates among youth experiencing homelessness are much higher than those of their housed peers, yet limited research exists on this population’s abortion experiences. This study examined abortion attitudes, experiences, and decision making through individual interviews with 30 female, male, and gender-fluid youth (ages 18-21 years) experiencing homelessness. Respondents indicated that abortions are common in this population. Many youth also reported they either had, and/or knew of others, who had attempted abortions outside of the formal medical system while experiencing homelessness. Most youth noted that self-inductions resulted from not knowing where or how to access abortions safely, and as many feared stigma, judgment, and violence from family members and serious partners in response to obtaining abortions. Most youth reflected inaccurate perceptions regarding abortion cost, accessibility, and legality. Findings should be considered in developing socially contextualized family planning prevention and outreach efforts among this highly vulnerable youth population.

Background The current COVID-19 pandemic, caused by Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), has drastically impacted societies worldwide. Vaccination against SARS-CoV-2 is expected to play a key role in the management of this pandemic. Inflammatory conditions such as inflammatory bowel disease (IBD) often require chronic immunosuppression, which can influence vaccination decisions. Aim This review article aims to describe the most commonly available SARS-CoV-2 vaccination vectors globally, assess the potential benefits and concerns of vaccination in the setting of immunosuppression and provide medical practitioners with guidance regarding SARS-CoV-2 vaccination in patients with IBD. Methods All published Phase 1/2 and/or Phase 3 and 4 studies of SARS-CoV-2 vaccinations were reviewed. IBD international society position papers, safety registry data and media releases from pharmaceutical companies as well as administrative and medicines regulatory bodies were included. General vaccine evidence and recommendations in immunosuppressed patients were reviewed for context. Society position papers regarding special populations, including immunosuppressed, pregnant and breast-feeding individuals were also evaluated. Literature was critically analysed and summarised. Results Vaccination against SARS-CoV-2 is supported in all adult, non-pregnant individuals with IBD without contraindication. There is the potential that vaccine efficacy may be reduced in those who are immunosuppressed; however, medical therapies should not be withheld in order to undertake vaccination. SARS-CoV-2 vaccines are safe, but data specific to immunosuppressed patients remain limited. Conclusions SARS-CoV-2 vaccination is essential from both an individual patient and community perspective and should be encouraged in patients with IBD. Recommendations must be continually updated as real-world and trial-based evidence emerges.

BACKGROUND & AIMS: Higher anti-tumor necrosis factor-α (TNF) drug levels are associated with improved clinical healing of Crohn's perianal fistulas. It is unclear whether this leads to improved healing on radiologic assessment. We aimed to evaluate the association between anti-TNF drug levels and radiologic outcomes in perianal fistulising Crohn's disease. METHODS: A cross-sectional retrospective multicenter study was undertaken. Patients with perianal fistulising Crohn's disease on maintenance infliximab or adalimumab, with drug levels within 6 months of perianal magnetic resonance imaging were included. Patients receiving dose changes or fistula surgery between drug level and imaging were excluded. Radiologic disease activity was scored using the Van Assche Index, with an inflammatory subscore calculated using indices: T2-weighted imaging hyperintensity, collections >3 mm diameter, rectal wall involvement. Primary endpoint was radiologic healing (inflammatory subscore ≤6). Secondary endpoint was radiologic remission (inflammatory subscore =0). RESULTS: Of 193 patients (infliximab, n = 117; adalimumab, n = 76), patients with radiologic healing had higher median drug levels compared with those with active disease (infliximab 6.0 vs 3.9 μg/mL; adalimumab 9.1 vs 6.2 μg/mL; both P < .05). Patients with radiologic remission also had higher median drug levels compared with those with active disease (infliximab 7.4 vs 3.9 μg/mL; P < .05; adalimumab 9.8 vs 6.2 μg/mL; P = .07). There was a significant incremental reduction in median inflammatory subscores with higher anti-TNF drug level tertiles. CONCLUSIONS: Higher anti-TNF drug levels were associated with improved radiologic outcomes on magnetic resonance imaging in perianal fistulising Crohn's disease, with an incremental improvement at higher drug level tertiles for both infliximab and adalimumab.

Introduction: Artificial intelligence (AI) can automate the detection and triage of ICH. ENRICH is a RCT evaluating the efficacy of MIS for ICH. AI ENRICH is a prospective trial operating within and in parallel to the ENRICH trial that utilizes an AI application, Viz RECRUIT and ICH VOLUME to identify and segment ICH to quickly identify potentially eligible subjects. Methods: Non-contrast CT scans performed at 5 participating US hospitals were evaluated specifically for a parenchymal hemorrhage by Viz ICH VOLUME. Participating health care professionals downloaded a phone application that allowed one to be notified for any hemorrhage ≥ 5 mL. Time metrics included the onset of CT scan, phone alert, and user recognition of that alert. Results: Over a combined period of 220 days, 8714 CT scans were evaluated by the Viz ICH VOLUME application. Of these, 257 CT scans were determined to contain an ICH yielding a total of 45 patients that met ENRICH criteria for trial inclusion (30-80 mL). The median time from CT scan to cell phone notification was 2:52 minutes (IQR=0.002) . The median time from cell phone notification to the user viewing the CT scan was 3:00 minutes (IQR=55.5 minutes), which was altered by a few significant delays in recognizing the alert (e.g. coordination of alerts and call schedules). After segregating the 4 weeks after ENRICH restarted on 7/14/20 into 2 week blocks, recognition of an alert within 5 minutes increased from 9% to 61.5% at the first site and 36% to 61.5% at second site - demonstrating the ability of alerts to improve site engagement and active screening for new subjects. Conclusions: In conclusion, Viz ICH VOLUME can screen large numbers of CT scans and send alerts within minutes to medical professionals. Studies relying on radiographic selection criteria may benefit from automated screening, although participating health care providers need to make use of the technology in order to maximize benefit.

Background: Hyperinsulinism (HI) is the most common cause of persistent or recurrent hypoglycemia in infants. Diazoxide is the first-line treatment used to manage infants with hypoglycemia secondary to HI after initial stabilization of blood glucose. Recent changes in definition of and in guidelines for screening for hypoglycemia in neonates led to an increase in the number of infants being treated with diazoxide. Previous studies have noted various side effects of diazoxide. With the increased use of this drug in …

SummaryBackgroundPouchitis is a common complication after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Although antibiotics are the primary therapy for acute pouchitis, a proportion of patients developed chronic antibiotic-dependent pouchitis (CADP) or antibiotic-refractory pouchitis (CARP). The efficacy of second line immunomodulator and biologic therapies for chronic pouchitis remain undefined. We performed a systematic review and metanalysis of published studies to assess their efficacy.MethodThe online EMBASE database was searched for full-text articles describing the treatment of chronic pouchitis meeting our criteria. Post-induction clinical and endoscopic response and remission rates were extracted and combined for meta-analyses. The rate of treatment discontinuation and safety profiles were also assessed.ResultsA total of 21 full-text articles were included in this meta-analysis representing 491 patients. The overall clinical response rate was 49% with clinical remission rate of 34%. The overall endoscopic response and remission rates were 53% and 36% respectively. The safety profile of individual agents was reassuring, but vedolizumab appears to have a more favorable safety profile.ConclusionThis review and meta-analysis identified the effectiveness of vedolizumab and ustekinumab in achieving clinical and endoscopic response in chronic pouchitis, with a reassuring safety profile. There is limited data regarding use of immunomodulators and no conclusion can be drawn. Further studies are required to define the comparative effectiveness of available treatments of CADP or CARP.

Objectives Tumor‐associated autoantibodies (AAbs) in individuals with cancer can precede clinical diagnosis by several months to years. The objective of this study was to determine whether the primary immune response in form of IgM and gut mucosa‐associated IgA can aid IgG AAbs in the detection of early‐stage colorectal cancer (CRC). Methods We developed a novel protein array comprising 492 antigens seropositive in CRC. The array was used to profile IgG, IgM and IgA antibody signatures in 99 CRC patients and 99 sex‐ and age‐matched non‐cancer controls. A receiver operating curve (ROC), Kaplan–Meier survival analysis and univariate and multivariate Cox regression analyses were conducted. Results We identified a panel of 16 multi‐isotype AAbs with a cumulative sensitivity of 91% and specificity of 74% (AUC 0.90, 95% CI: 0.850–0.940) across all CRC stages. IgM and IgG isotypes were conversely associated with disease stage with IgM contributing significantly to improved stage I and II sensitivity of 96% at 78% specificity (AUC 0.928, 95% CI: 0.884–0.973). A single identified IgA AAb reached an overall sensitivity of 5% at 99% specificity (AUC 0.520, 95% CI: 0.440–0.601) balanced across all CRC stages. Kaplan–Meier analysis revealed that se33‐1 (ZNF638) IgG AAbs were associated with reduced 5‐year overall survival (log‐rank test, P = 0.012), whereas cumulative IgM isotype signatures were associated with improved 5‐year overall survival (log‐rank test, P = 0.024). Conclusion IgM AAbs are associated with early‐stage colorectal cancer. Combining IgG, IgM and IgA AAbs is a novel strategy to improve early diagnosis of cancers., Early‐stage detection of colorectal cancer is critical for patient survival. We have conducted a multi‐isotype autoantibody (AAbs) screen using a 492‐feature CRC protein array. Our study shows that IgM AAbs are associated with early‐stage disease and IgA AAbs, although stage‐independent, encompass humoral responses associated with mucosal surfaces. Combining IgG, IgM and IgA AAbs is a novel strategy for early disease detection and improvement of patient outcomes.

Context Nonprofit hospitals in the United States are required to conduct a community health needs assessment (CHNA) every 3 years to identify the most pressing health issues in their community and then develop an implementation strategy for addressing these health issues. CHNA reports must include "evaluation of the impact of any actions that were taken to address the significant health needs identified in the immediately preceding CHNA." Objective To determine whether and how nonprofit hospitals are responding to the requirement to evaluate their implementation strategies addressing their community's priority health needs. Design Using content analysis, we reviewed CHNA reports of all Minnesota nonprofit hospitals (n = 96) since regulations were finalized in December 2014. Setting Nonprofit hospitals in Minnesota. Main outcome measure(s) Reports were coded to determine whether hospitals are responding to the evaluation requirement and the types of evaluation measures (process vs outcome indicators) used to assess hospitals' activities. Results Most of the reports (116 of 136 reports, or 85.3%) include narrative evaluating community benefit programs, showing widespread conformity with the IRS (Internal Revenue Service) mandate. All of the evaluations use process indicators, such as the number of individuals reached. More than half of the evaluations (64 of 116 reports, or 55.2%) also use outcome indicators, with many reporting short- and medium-term changes in health-related knowledge and behaviors. Use of outcome indicators increased substantially in CHNAs in the 2017-2020 period compared with 2015-2016. Conclusions In general, Minnesota hospitals are using program evaluation to assess their community benefit implementation strategies, although the extent to which they evaluate their strategies varies considerably between hospitals. While the use of outcome indicators of impact has increased over time, levels of use suggest the importance of incorporating public health expertise in CHNA work.

Background: The impact of pregnancy on levels of biologic agents in patients with IBD is undefined and time to elimination in vedolizumab-exposed infants is unknown. Aims: To determine the effect of pregnancy on infliximab, adalimumab and vedolizumab levels and to study infant vedolizumab clearance. Methods: In a prospective observational study, maternal drug levels were measured pre-conception, in each trimester, at delivery and postpartum. The association between drug levels and gestation in weeks was assessed using generalised estimating equation modelling. Infant vedolizumab levels were performed at birth (cord blood), 6 weeks and 3 months or until undetectable. Results: We included 50 IBD patients (23 on infliximab, 15 on adalimumab and 12 on vedolizumab) with at least two intrapartum observations, plus 5 patients on vedolizumab with only mother and baby samples at delivery. Modelling showed no change in adalimumab levels, an increase in infliximab levels of 0.16 (95% CI 0.08-0.24) µg/L/week (P < 0.001) and a decrease of 0.18 (95% CI: −0.33 to −0.02) µg/L/week (P = 0.03) for vedolizumab. In 17 mother-baby pairs, median infant vedolizumab levels at birth were lower than maternal levels (P < 0.05) with an infant:maternal ratio of 0.7 (IQR 0.5-0.9). Vedolizumab was undetectable between 15 and 16 weeks of age in all 12 infants completing follow-up testing. Conclusions: During pregnancy, adalimumab levels remain stable, while infliximab levels increase and vedolizumab levels decrease. However, the increments were small suggesting that intrapartum therapeutic drug monitoring and dose adjustment are not indicated. Unlike infliximab and adalimumab, infant vedolizumab levels are lower in cord blood than in mothers and appear to clear rapidly.

This chapter introduces seven commonly misused types of psychoactive substances, beginning with an explanation of what psychoactive means and how these substances might be classified. Mode of administration is introduced as a significant factor, as well. Several important principles of pharmacokinetics (how drugs work), psychopharmacology (tolerance, withdrawal), and polydrug use are presented. The substance types discussed in this chapter include: alcohol, sedative-hypnotics and central nervous system depressants, cannabis, hallucinogens, stimulants, opioids, and inhalants; prescription drug misuse is addressed where relevant. Each substance type is briefly described in terms of what it is, its actions, and some use/misuse statistics. The chapter goal is to provide an orientation for social workers and other professionals to better understand the nature of substances discussed throughout this handbook and which they may encounter in their work with individuals, families, and communities.

Context Many hospitals in the United States are exploring greater investment in community health activities that address upstream causes of poor health. Objective Develop and apply a measure to categorize and estimate the potential impact of hospitals' community health activities on population health and equity. Design, setting, and participants We propose a scale of potential impact on population health and equity, based on the cliff analogy developed by Jones and colleagues. The scale is applied to the 317 activities reported in the community health needs assessment implementation plan reports of 23 health care organizations in the Minneapolis-St Paul, Minnesota, metropolitan area in 2015. Main outcome measure Using a 5-point ordinal scale, we assigned a score of potential impact on population health and equity to each community health activity. Results A majority (50.2%) of health care organizations' community health activities are classified as addressing social determinants of health (level 4 on the 5-point scale), though very few (5.4%) address structural causes of health equity (level 5 on the 5-point scale). Activities that score highest on potential impact fall into the topic categories of "community health and connectedness" and "healthy lifestyles and wellness." Lower-scoring activities focus on sick or at-risk individuals, such as the topic category of "chronic disease prevention, management, and screening." Health care organizations in the Minneapolis-St Paul metropolitan area vary substantially in the potential impact of their aggregated community health activities. Conclusions Hospitals can be significant contributors to investment in upstream community health programs. This article provides a scale that can be used not only by hospitals but by other health care and public health organizations to better align their community health strategies, investments, and partnerships with programming and policies that address the foundational causes of population health and equity within the communities they serve.

Objective. To define the epidemiology of venous thrombosis (VT) in children, adolescents and young adults with lymphomas, to identify the thrombotic risk factors and VT’s prognostic value.Materials and methods. We reviewed the medical records of 513 lymphoma patients (284 with Hodgkin's lymphoma (HL) and 229 with non-Hodgkin lymphoma (NHL)) aged from 0,6 to 26 years (median – 14 years), diagnosed with lymphomas in 2005–2017. Risk thrombotic factors were assessed using binary Cox regression in univariate and multivariate models with calculation of the odds ratio (OR) with 95 % CIs. Results. Twenty-eight of 513 patients (5.5 %, 95 % CI, 4.5–6.5 %) were diagnosed as having VT with a total of 32 thrombotic events. The incidence of VT in NHL patients (23/229, 10.5 %, 95 % CI, 8.5–12.5 %) was higher than in HL patients (5/284, 1.8 %, 95 % CI, 1.0–2.6 %, p 0.05), but had a negative impact on the OS of HL patients (60.0 %, SE 21.9 % (n = 5) versus 94.8 %, SE 1.5 % (n = 279), p

Aim - to identify the most significant risk factors that affect the occurrence of cardiovascular complications in patients with type 2 diabetes and to create the supplement for the risk assessment of cardiovascular complications in patients with type 2 diabetes. Methods of research. The object of the study is adult patients with type 2 diabetes mellitus (n = 60). For the development and analysis of the material, a statistical method is used, a modeling method of constructing the classification trees. Discussion and results. Statistically significant risk factors for cardiovascular complications in type 2 diabetes are a high body mass index, the presence of insulin therapy, the duration of the disease, a high maximum level of systolic blood pressure, high concentrations of LDL, markers of cell damage, and some hemodynamic parameters of myocardial function. A multidimensional model of the risk of complications was developed, which served as an algorithm for the created computer program, their early prognosis and timely carrying out of preventive measures.

Evolution of treatment targets in IBD has increased the need for objective monitoring of disease activity to guide therapeutic strategy. Although mucosal healing is the current target of therapy in IBD, endoscopy is invasive, expensive and unappealing to patients. GI ultrasound (GIUS) represents a non-invasive modality to assess disease activity in IBD. It is accurate, cost-effective and reproducible. GIUS can be performed at the point of care without specific patient preparation so as to facilitate clinical decision-making. As compared with ileocolonoscopy and other imaging modalities (CT and MRI), GIUS is accurate in diagnosing IBD, detecting complications of disease including fistulae, strictures and abscesses, monitoring disease activity and detecting postoperative disease recurrence. International groups increasingly recognise GIUS as a valuable tool with paradigm-changing application in the management of IBD; however, uptake outside parts of continental Europe has been slow and GIUS is underused in many countries. The aim of this review is to present a pragmatic guide to the positioning of GIUS in IBD clinical practice, providing evidence for use, algorithms for integration into practice, training pathways and a strategic implementation framework.

Background: Mindfulness-based cognitive therapy (MBCT) is a promising adjunctive treatment for adolescents and young adults (AYAs) with Inflammatory Bowel Disease (IBD) and comorbid depression. Objectives: This pilot randomised controlled trial (RCT) aimed to evaluate feasibility and efficacy of an adapted MBCT program for AYA, aged 16-29, with IBD. Methods: Sixty-four AYAs were randomly allocated to MBCT (n = 33) or treatment as usual (TAU) (n = 31). Primary outcome measure was the depression score on Depression, Anxiety and Stress Scale. Secondary outcomes included anxiety, stress, IBD-related quality of life, coping, mindfulness, post-traumatic growth, medication adherence, IBD activity, inflammatory markers, microbiome characteristics and brain functional connectivity. Results: Study recruitment rate was 75%, retention rate 70%, and session attendance 92%. Intention to treat analyses revealed that, compared to TAU group, MBCT group had significantly lower depression ( increment = -6.0; 95% CI = -10.8 to -1.2; P = 0.015) and stress ( increment = -5.1; 95%CI = -10.1 to -0.0; P = 0.049), higher active coping ( increment = 1.0;95%CI = 0.1-1.9; P = 0.022), and total mindfulness scores ( increment = 10.9;95%CI = 1.1-20.8; P = 0.030) at 8 weeks (post-therapy), and improved coping by positive reframing ( increment = 1.1;95%CI = 0.0-2.2; P = 0.043) and planning ( increment = 0.9;95%CI = 0.0-1.9; P = 0.045), mindful awareness ( increment = 5.2.;95%CI = 2.0-8.5; P = 0.002) and total mindfulness scores ( increment = 10.8.;95%CI = 0.4-21.1; P = 0.042) at 20 weeks. On per protocol analysis, MBCT group had significantly lower depression ( increment = -6.3; 95%CI = -11.4 to -1.2; P = 0.015), stress ( increment = -6.0; 95% CI = -11.2 to -0.5; P = 0.032), increased active coping ( increment = 0.9;95%CI = 0-1.7; P = 0.05) at 8 weeks, and mindful awareness ( increment = 5.4; 95%CI = 2.1-8.6; P = 0.001) at 20 weeks. Conclusion: In AYAs with IBD, MBCT is feasible and beneficial in improving depression, stress, mindfulness and adaptive coping. It holds promise as an important component of integrated IBD care. Trial registration number ACTRN12617000876392, U1111-1197-7370; Pre-results.

IntroductionPerianal fistulising Crohn’s disease (pfCD) can be somewhat treatment refractory. Higher infliximab trough levels (TLIs) may improve fistula healing rates; however, it remains unclear whether escalating infliximab therapy to meet higher TLI targets using proactive, or routine, therapeutic drug monitoring (TDM) improves outcomes. This randomised controlled trial aimed to assess whether infliximab therapy targeting higher TLIs guided by proactive TDM improves outcomes compared with standard therapy.Methods and analysisPatients with active pfCD will be randomised 1:1 to either the proactive TDM arm or standard dosing arm and followed up for 54 weeks. Patients in the proactive TDM arm will have infliximab dosing optimised to target higher TLIs. The targets will be TLI ≥ 25 µg/mL at week 2, ≥ 20 µg/mL at week 6 and ≥ 10 µg/mL during maintenance therapy. The primary objective will be fistula healing at week 32. Secondary objectives will include fistula healing, fistula closure, radiological fistula healing, patient-reported outcomes and economic costs up to 54 weeks. Patients in the standard dosing arm will receive conventional infliximab dosing not guided by TLIs (5 mg/kg at weeks 0, 2 and 6, and 5 mg/kg 8 weekly thereafter). Patients aged 18–80 years with pfCD with single or multiple externally draining complex perianal fistulas who are relatively naïve to infliximab treatment will be included. Patients with diverting ileostomies or colostomies and pregnant or breast feeding will be excluded. Fifty-eight patients per arm will be required to detect a 25% difference in the primary outcome measure, with 138 patients needed to account for an estimated 6.1% primary non-response rate and 10% dropout rate.Ethics and disseminationResults will be presented in peer-reviewed journals and international conferences. Ethics approval has been granted by the South Western Sydney Local Health District Human Research Ethics Committee in Australia.Trial registration numberAustralian New Zealand Clinical Trials Registry (ACTRN12621000023853); Pre-results.

Phlpp protein phosphatases are abnormally abundant within human osteoarthritic articular chondrocytes and may contribute to the development of osteoarthritis. Mice lacking Phlpp1 were previously shown to be resistant to post-traumatic osteoarthritis. Here a small molecule with therapeutic properties that inhibits Phlpp1 and Phlpp2 was tested for its ability to slow post-traumatic OA in mice and to stimulate anabolic pathways in human articular cartilage from OA joints. PTOA was induced in male C57Bl/6 mice by surgically destabilizing the meniscus. Seven weeks after surgery, mice received a single intra-articular injection of the Phlpp inhibitor NSC117079 or saline. Mechanical allodynia was measured with von Frey assays, mobility was tracked in an open field system, and cartilage damage was assessed histologically. A single intra-articular injection of the Phlpp inhibitor NSC117079 attenuated mechanical allodynia and slowed articular cartilage degradation in joints with a destabilized meniscus. Animals treated with the Phlpp inhibitor 7 weeks after injury maintained normal activity levels, while those in the control group traveled shorter distances and were less active 3 months after the joint injury. NSC117079 also increased production of cartilage extracellular matrix components (glycosaminoglycans and aggrecan) in over 90% of human articular cartilage explants from OA patients and increased phosphorylation of Phlpp1 substrates (AKT2, ERK1/2, and PKC) in human articular chondrocytes. Our results indicate that Phlpp inhibitor NSC117079 is a novel osteoarthritis disease modifying drug candidate that may have palliative affects. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1487-1497, 2018.

INTRODUCTIONA cascade of evidence in recent decades has demonstrated that the root causes for most health outcomes are factors such as one's social support, job status, income, education, and physical environment- often collectively referred to as the social determinants of health (Marmot & Allen, 2014). Representative of this conclusion is the popular county Health Rankings Model of the University of Wisconsin Population Health Institute (2016), which estimates that 40% of health outcome variation is explained by social and economic factors, 30% by health behaviors, 20% by clinical care, and 10% by physical environment. Frieden's Health Impact Pyramid makes a similar point. The Health Impact Pyramid is divided into sectors based on factors that improve health for more people at the lowest unit cost. The base layer of the pyramid is socioeconomic factors. The next layer is "changing the context to make individuals' default decisions healthy." Preventive interventions are next, followed by clinical interventions and, finally, counseling and education (Frieden, 2015, p. 1749). Although the accumulation of evidence in recent years accentuates the need for attention to social determinants of health, the case for attention to the issue has deep historical roots (Lalonde, 1981; McKinlay, 1975).Hospitals and health systems are now in the position of having to decide how much to "move upstream," or invest in programs and partnerships that directly affect the social determinants of health and in which programs to invest. Such decisions are difficult given the long-term and indirect payback from investments in prevention and other upstream activities (Fineberg, 2013) and the historical focus of U.S. hospitals on excellence in individual patient care (White & Griffith, 2016).However, many hospitals and health systems in the United States recently have expanded their investment in population health and in activities that are upstream from clinical care (Health Research & Educational Trust, 2013). HealthPartners in Minneapolis-St. Paul, Minnesota, and Hennepin County Medical Center in the same community, with its Hennepin Health ACO, are two examples (Kindig & Isham, 2014; Sandberg et al., 2014). Kaiser Permanente, Trinity Health, ProMedica, ThedaCare, and Ascension Health are among the many other healthcare delivery organizations reporting new programs aimed at social determinants such as hunger, jobs, and housing (Avis, 2016; Kutscher, 2015). Changes in federal government policy, such as various efforts to reward value-based services, and the Accountable Health Communities Model program of the Centers for Medicare & Medicaid Services (CMS, 2016), are further stimulants to moving upstream in hospital services.The American Hospital Association (AHA) Population Health Survey chronicles the degree to which U.S. hospitals report being aligned with population health goals and investing in upstream programs. In this article, we examine the characteristics of hospitals that are in the forefront of the movement to shift resources into upstream care. We use results of the 2015 AHA Population Health Survey to profile those hospitals and the ways they structure their population health activities.METHODSThe 2015 Population Health Survey was sponsored by the AHA, the Association for Community Health Improvement, and the Public Health Institute. The mail survey was fielded to AHA-registered hospitals between January and May 2015, with a 22% response rate (n = 1,418). Compared to the total population of AHA hospitals, the respondent sample overrepresents hospitals in the Midwest and underrepresents hospitals in the Southeast and Southwest, and overrepresents large hospitals, teaching hospitals, and not-forprofit hospitals. The sample is representative on the characteristics of rural/urban location, critical access status, size category, control (ownership), service type, and system affiliation (Health Research & Educational Trust, 2015). …