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Background In imported falciparum malaria, systemic inflammation with increased capillary permeability can cause life-threatening complications, such as acute pulmonary edema (APO) or adult respiratory distress syndrome (ARDS). This observational study assessed the association of the admission serum albumin level (ALB) and C-reactive protein to albumin ratio (CRP/ALB) with disease severity and these respiratory complications. Methods All adult cases hospitalized during 2001–2015 in the Charité University Hospital, Berlin, with ALB and CRP values measured upon admission, were retrospectively analysed. Results Seventy-six patients were enrolled (26 female, median age: 37 y), 60 with uncomplicated malaria and 16 with severe malaria (SM). SM was associated with lower ALB (p Conclusions Diminished admission ALB levels and elevated CRP/ALB ratios are associated with disease severity and respiratory complications in imported falciparum malaria. These readily and ubiquitously available markers may facilitate early identification of at-risk patients.

Background Janus kinase (JAK) inhibition shows promise for treatment of patients with moderate to severe Crohn’s disease. We aimed to provide mechanistic insights into the JAK1-selective inhibitor upadacitinib through a transcriptomics substudy on biopsies from patients with Crohn's disease from CELEST. Methods Seventy-four patients consented to this optional substudy. Ileal and colonic biopsies were collected during endoscopy at screening and week 12 or 16. RNA isolated from 226 samples was analyzed by RNAseq, with additional qPCR analysis. Additional biopsies from patients with Crohn's disease receiving anti-tumor necrosis factor (anti-TNF; n = 34) and healthy controls (n = 10) were used for qPCR. Single-cell RNAseq public profiles were used to evaluate treatment effects on specific cellular subsets, associations with endoscopic improvement, and indirect comparisons with the anti-TNF-treated cohort. Results In involved areas of mucosa with endoscopic remission after upadacitinib treatment, 1156 and 76 protein-coding genes were significantly regulated (false discovery rate < 0.05) at week 12/16 in colonic and ileal biopsies, respectively (60 overlapped), compared with baseline. Upadacitinib did not significantly affect transcriptomes of noninvolved intestinal areas. CELEST patients (mostly anti-TNF-refractory) showed baseline differences in gene expression compared with a separate cohort of biologic-naïve patients. Notably, upadacitinib reversed overexpression of inflammatory fibroblast and interferon-γ effector signature markers. Conclusions Upadacitinib modulates inflammatory pathways in mucosal lesions of patients with anti-TNF-refractory Crohn's disease, including inflammatory fibroblast and interferon-γ-expressing cytotoxic T cell compartments. This substudy is the first to describe the molecular response to JAK1 inhibition in inflammatory bowel disease and differential effects relative to anti-TNF treatment. (Clinical trial identifier: NCT02365649)

Zusammenfassung Hintergrund Qualitätsindikatoren sind besonders im Notarzteinsatz, der häufig lebensrettenden Charakter hat, von großer Wichtigkeit. Ziel der Studie Das Ziel war, die Übereinstimmung zwischen notärztlicher Verdachtsdiagnose und Krankenhausentlassungsdiagnose und die diagnosebezogene Behandlungsdauer zu ermitteln, um zu prüfen, ob diese als Qualitätsindikatoren herangezogen werden können. Material und Methoden 708 Notarzteinsatzprotokolle des Notarztstandorts Bad Belzig im Zeitraum vom 01.07.2013 bis 30.06.2014 und 01.01.2015 bis 31.12.2015 wurden inkludiert. Die Ermittlung der dÜ (diagnostischen Übereinstimmung) erfolgte durch den Konsens dreier erfahrener Notfallmediziner. Die Behandlungsdauer wurde als Zeitintervall zwischen dem Zeitpunkt des Eintreffens des Notarztes und seiner Abfahrt vom Einsatzort berechnet. Die Behandlungsdauer wurde mittels des Mann-Whitney-U-Tests auf signifikante Unterschiede mit weiteren Variablen getestet. Aus der dÜ und der Behandlungszeit konnte die diagnostische Effizienz im Notarzteinsatz (dEffNA) ermittelt werden. Ergebnisse Die dÜ lag in 69,4% der Fälle vor. Die durchschnittliche Behandlungsdauer alle Einsätze dauerte 21 min. Die dEffNA ergab einen Durchschnittswert für alle Diagnosen von 3,3/min. Der beste Wert für die dEffNA (dEffNA-kurz) unter den 5 untersuchten einsatzbezogenen Entlassungsdiagnosen betrug 13/min für Apoplex und der schlechteste (dEffNA-lang) 1,15/min für hypertensive Entgleisung/Krise. Die Korrektheit der Notarztdiagnose schien unabhängig von der Behandlungsdauer zu sein. Diskussion Die dEffNA, berechnet aus dÜ und Behandlungszeit, kann als Qualitätsindikator in der präklinischen Notfallmedizin herangezogen werden. Mit dessen Hilfe können problematische Behandlungsfälle identifiziert werden.

Der Einfluss des Faktors „Patient“ auf die arztliche Diagnosestellung konnte bereits nachgewiesen werden. Zur praklinischen Diagnosestellung gibt es jedoch diesbezuglich keine Studien. Aus praklinischen Routinedaten konnen objektive Faktoren des Patientenzustands ausgewertet und deren Einfluss auf die Notarztdiagnose untersucht werden. Ziel dieser retrospektiven Pilotstudie war diagnostische Ubereinstimmung (dU) zwischen Notarzt- und Krankenhausentlassungsdiagnose zu ermitteln und den Einfluss der patientenspezifischen Faktoren „GCS“ (Glasgow Coma Scale), „Alter“, „NACA-Score“ (National Advisory Committee for Aeronautics), „Geschlecht“ und „Dauermedikation“ auf die dU zu untersuchen. Die Ermittlung der dU erfolgte durch den Konsens dreier erfahrener Notfallmediziner unter Verwendung der ICD-10-Kodierung. Die dU wurde bezuglich der 5 patientenspezifischen Faktoren zunachst univariat und anschliesend mittels multipler logistischer Regression auf signifikante Ergebnisse getestet. Weiterhin wurden die Korrelationskoeffizienten der kategorialen und nichtnormalverteilten Variablen und ein Goodness-of-Fit-Test (mittels Hosmer-Lemeshow-Test) berechnet. Eine dU bestand in 24 % (n = 138) nicht, sie bestand mindestens teilweise in 76 % (n = 442). Die untersuchten patientenspezifischen Faktoren zeigten keinen Einfluss auf die notarztliche Diagnosestellung. Der GCS-Summenwert des Patienten, sein Alter, der NACA-Score des Patienten, sein Geschlecht und seine Medikation scheinen keinen Einfluss auf die Qualitat der Notarztdiagnose zu haben. Andere Studien erbrachten einen Anteil von etwa 90 % korrekter Notarztdiagnosen, der als Benchmark dienen kann. Weitere Untersuchungen zu den Ursachen und Verbesserungspotenzial bei diagnostischer Ungenauigkeit sind erforderlich.

Background Due to the unique pathophysiology with progressive mircocirculatory obstruction and simultaneously increased vascular permeability, overhydration can be rapidly harmful in patients with falciparum malaria. The outcome in all 558 cases hospitalised during 2001–2015 in the Charité University Hospital, Berlin, was favourable, independent of the antimalarial used. Here, the fluid management strategy in the most severely affected subgroup is examined. Methods All fluids in 32 patients requiring treatment on intensive care units (ICUs) for >48 h were retrospectively quantified. All malaria-specific complications were followed up over the whole ICU stay. Results Strong linear relationships between fluid intake and positive balances reflecting dehydration and increased vascular permeability were evident over the whole stay. With 2.2 (range: 0.7–6.9), 1.8 (0.6–6.1) and 1.3 (0.3–5.0) mL/kg/h on day 1, day 2 and over the remaining ICU stay, respectively, median fluid volumes remained below the actual WHO recommendations. No evidence for deterioration of any malaria-specific complication under such restrictive fluid management was found. The key prognostic parameter metabolic acidosis improved significantly over 48 h (p=0.02). All patients survived to discharge. Conclusions These results suggest that in the face of markedly increased vascular permeability, a restrictive fluid management strategy is clinically safe in adults with severe imported falciparum malaria.

Arturo Ortiz-Álvarez,1 Mónica A Delgado-Ramírez,1 Montserrat Cuevas-Zúñiga,1 Teresa Hernández-Carrera,1 David Moncada Barrón,2 Daniel Aguilar Zapata,1 Rafael R Valdez Vázquez,1 Juan Pablo Ramírez-Hinojosa,1 Ana Patricia Rodríguez-Zulueta1 1Department of Infectious Disease, Hospital General Dr. Manuel GEA González, Mexico City, Mexico; 2Microbiology Laboratory, Hospital General Dr. Manuel GEA González, Mexico City, Mexico Introduction: Outpatient parenteral antimicrobial therapy is a safe, effective, and convenient way of administering antimicrobials for a wide variety of infections. So far there are no reports on the efficacy of outpatient antimicrobial therapy in Mexico. Our objective was to determine the outcomes, safety, and cost of outpatient ertapenem therapy (OET) in our hospital. Patients and methods: A case series of 99 patients that received intravenous OET was conducted. The primary outcomes were clinical cure, relapse, and recurrence of infection. Results: Of the 99 patients who received OET the most common diagnosis was urinary tract infection in 56%. Extended-spectrum-β-lactamase-producing Enterobacteriaceae caused 67% of infections in our population. Ninety-seven percent of the patients were cured at the completion of OET. One patient presented relapse 12 days after the end of OET; two patients presented recurrence, one with skin and soft tissue infection and one with pyelonephritis at days 35 and 34, respectively, after the end of OET. Three patients were readmitted after OET, one with an episode of phlebitis, one with recurrence, and one with relapse. A case of non-Clostridium difficile-associated diarrhea was observed. The intravascular line complications observed during OET were phlebitis in two patients. Conclusion: In our hospital, the OET was found to be effective, safe, and cost-saving when compared to inpatient care. Keywords: OPAT, ESBL, ertapenem

Este artículo se encuentra disponible en la página web de la revista en la siguiente URL: https://www.tandfonline.com/doi/full/10.1080/09712119.2017.1337017 Tendon injuries are the most frequent musculoskeletal problems, constituting 30–50% of all sport-related lesions. Efficient handling of early stage tendon injury and healing can accelerate tendon repair as well as improve the quality of newly formed tendons. Plasma rich in growth factors (PRGF) is an autologous biological therapy that has been proposed to treat tendon injuries. To elucidate the effect of this treatment on the early stage of tendon healing, 14 sheep were used to perform the present study. The right Achilles tendon was surgically severed and repaired with sutures. Seven animals were treated with PRGF and the other seven with saline solution after surgical tendon reconstruction. Tendons were ultrasound-guide infiltrated 1 week after the induced injury. Two weeks later, the sheep were euthanized and histochemical and immunohistochemical analyses were performed. The tendons with PRGF showed reduced infiltration of inflammatory cells compared to those treated with saline solution. Analysis of the blood vessels, morphometric data of fibroblast nuclei, and collagen fibres in the extracellular matrix did not show statistical differences between groups. These findings suggest the important role that PRGF therapy plays in the modulation of inflammatory response in Achilles tendon injuries, leading to acceleration of the tendon healing process, shortening the convalescence period.

Objective To determine the effects of two dexmedetomidine continuous rate infusions on the minimum infusion rate of alfaxalone for total intravenous anaesthesia (TIVA), and subsequent haemodynamic and recovery effects in Greyhounds undergoing laparoscopic ovariohysterectomy. Study design Prospective, randomized and blinded clinical study. Animals Twenty-four female Greyhounds. Methods Dogs were premedicated with dexmedetomidine 3 μg kg−1 and methadone 0.3 mg kg−1 intramuscularly. Anaesthesia was induced with IV alfaxalone to effect and maintained with a TIVA mixture of alfaxalone in combination with two different doses of dexmedetomidine (0.5 μg kg−1 hour−1 or 1 μg kg−1 hour−1; groups DEX0.5 and DEX1, respectively). The alfaxalone starting dose rate was 0.07 mg kg−1 minute−1 and was adjusted (± 0.02 mg kg−1 minute−1) every 5 minutes to maintain a suitable depth of anaesthesia. A rescue alfaxalone bolus (0.5 mg kg−1 IV) was administered if dogs moved or swallowed. The number of rescue boluses was recorded. Heart rate, arterial blood pressure and arterial blood gas were monitored. Qualities of sedation, induction and recovery were scored. Differences between groups were tested for statistical significance using a Student’s t test or Mann–Whitney U test as appropriate. Results There were no differences between groups in sedation, induction and recovery quality, the median (range) induction dose of alfaxalone [DEX0.5: 2.2 (1.9–2.5) mg kg−1; DEX1: 1.8 (1.2–2.9) mg kg−1], total dose of alfaxalone rescue boluses [DEX0.5: 21.0 (12.5–38.8) mg; DEX1: 22.5 (15.5–30.6) mg] or rate of alfaxalone (DEX0.5: 0.12 ± 0.04 mg kg−1 minute−1; DEX1: 0.12 ± 0.03 mg kg−1 minute−1). Conclusions and clinical relevance Co-administration of dexmedetomidine 1 μg kg−1 hour−1 failed to reduce the dose rate of alfaxalone compared with dexmedetomidine 0.5 μg kg−1 hour−1 in Greyhounds undergoing laparoscopic ovariohysterectomy. The authors recommend an alfaxalone starting dose rate of 0.1 mg kg−1 minute−1. Recovery quality was good in the majority of dogs.

Background Increasing numbers of aging individuals with chronic co-morbidities travel to regions where falciparum malaria is endemic. Non-communicable diseases are now leading risk factors for death in such countries. Thus, the influence of chronic diseases on the outcome of falciparum malaria is an issue of major importance. Aim of the present study was to assess whether non-communicable diseases increase the risk for severe imported falciparum malaria. Methods A retrospective observational study of all adult cases with imported falciparum malaria hospitalized between 2001 and 2015 in the tertiary care Charité University Hospital, Berlin, was performed. Results A total of 536 adult patients (median age 37 years; 31.3% female) were enrolled. Of these, 329 (61.4%) originated from endemic countries, 207 patients (38.6%) from non-endemic regions. Criteria for severe malaria were fulfilled in 68 (12.7%) cases. With older age, lack of previous malaria episodes, being a tourist, and delayed presentation, well-characterized risk factors were associated with severe malaria in univariate analysis. After adjustment for these potential confounders hypertension (adjusted odds ratio aOR, 3.06 95% confidence interval, CI 1.34–7.02), cardiovascular diseases (aOR, 8.20 95% CI 2.30–29.22), and dyslipidaemia (aOR, 6.08 95% CI 1.13–32.88) were individual diseases associated with severe disease in multivariable logistic regression. Hypertension proved an independent risk factor among individuals of endemic (aOR, 4.83, 95% CI 1.44–16.22) as well as of non-endemic origin (aOR, 3.60 95% CI 1.05–12.35). Conclusions In imported falciparum malaria hypertension and its related diseases are risk factors for severe disease.

The aim of the study was to ascertain the influence of knowledge and interventions in sexual and reproductive health and contraception practices among adolescent street girls from Kinshasa, Democratic Republic of the Congo.A cross-sectional study was carried out among street girls between 12 and 21 years of age. A standardised questionnaire was used, encompassing socio-demographic data and knowledge and practices regarding sexual and reproductive health. A network analysis was carried out.The study comprised 293 street girls. The mean age was 17.1 years (range 12-21 years) and the mean time spent living on the streets was 3.9 years (range 0-15 years). Commercial sex was reported by 78.5% (95% confidence interval [CI] 73.3%, 83.2%) as the main source of their income. During their last sexual intercourse, 44.0% (95%CI 38.1%, 50.4%) had not used a condom; 29.3% (95%CI 23.3%, 35.9%) had used hormonal contraception. Previous pregnancy was reported by 62.5% (95%CI 56.7%, 68.3%) and current pregnancy by 12.3% (95%CI 8.8%, 17.2%); 24.5% of previous pregnancies ended in voluntary termination, with a higher rate among the youngest street girls (12-15 years, 50.0%; p = 0.01). Time spent living on the streets was independently associated with pregnancy (odds ratio 1.2; 95%CI 1.1, 1.4). Practices and outcomes (previous or current pregnancy) were poorly correlated with knowledge about sexual and reproductive health. The network analysis confirmed the poor influence of exposure to intervention activities on sexual and reproductive health practices and outcomes, but did confirm a centrality effect of knowledge about HIV/AIDS.Street girls in Kinshasa are extremely vulnerable with regard to their sexual and reproductive health, especially the youngest street girls. Behavioural and biomedical interventions have had limited influence. Structural and societal changes are necessary to positively impact street girls' sexual and reproductive health. Knowledge about HIV/AIDS than about risk of pregnancy had a greater influence on sexual and reproductive health practices.

Background The clinical presentation of SARS-CoV-2 disease ranges from asymptomatic respiratory infection to acute respiratory distress syndrome. Risk factors upon hospital admission associated with the need for invasive mechanical ventilation are not well documented. Methods 185 hospitalized patients with confirmed COVID-19 were enrolled in this study, and they were classified as patients who required invasive mechanical ventilation and patients who did not require it. Comorbidities such as diabetes, high blood pressure, obesity, chronic lung disease and immunodeficiency were recorded. Laboratory studies were requested upon admission such as C-reactive protein, leukocyte and lymphocyte levels, D-dimer, troponin, serum ferritin and procalcitonin. Results Of the patients who entered the study, 65 patients (35%) required invasive mechanical ventilation (IMV), while 120 (65%) did not require advanced airway management. Of the patients with invasive mechanical ventilation, age > 65 years, male sex, obesity (BMI > 30) and high blood pressure were the most frequent characteristics, presenting the latter two in 26% and 27% respectively. Regarding laboratory studies, the parameters most associated with the requirement for mechanical ventilation were a D-dimer (> 1000) and troponin (> 1), with 26% and 18%, respectively. Conclusion This study showed the high proportion of obesity, hypertension and advanced age among patients who required invasive mechanical ventilation associated with SARS-CoV2 infection. The presence of elevated D-dimer and troponin on admission are associated with more severe presentations and a requirement for invasive mechanical ventilation. Disclosures All Authors: No reported disclosures

Hip problems are common in ballet dancers, and it is likely that dancers' perceived quality of life is impaired by their presence. There are no instruments to detect functional impairments related to hip injuries in young, athletic populations. The aim of this study was to evaluate the impact of hip related problems on the quality of life in professional ballet dancers. Thirty-seven professional ballet dancers, ages 18 to 33, completed a post-hire health screening prior to the start of their company's season. Participants completed the Hip Disability and Osteoarthritis Outcome Score (HOOS) questionnaire, which assesses level of disability due to a hip problem, and answered additional questions regarding the presence of pain with ballet-specific movements. Subjects were also asked to self-report current or prior history of hip problems or injuries. Dancers with a self-reported history of a hip problem (8 of 37, 21.6%) recorded relatively low HOOS sub-scores (indicative of enhanced disability) for pain and quality of life. The remaining sub-scores-for symptoms, activities of daily living (ADLs), and sports-were not significantly different from those of dancers who were problem-free. Dancers with a history of hip problem were also more likely to report hip pain with two or more dance movements. The impact of hip problems on the quality of life in professional ballet dancers tends to persist despite a lack of significant effect on the ability to perform ADLs or sports-related tasks. Therefore, the self-reported presence of a hip problem should be viewed as a risk factor for decreased quality of life in this population.

Sinopulmonary aspergillosis represents a diverse collection of allergic, invasive, and chronic sinus and respiratory conditions. These diseases can affect patients with and without immune impairment and in some cases may be life-threatening. Areas covered: We review the diagnosis, classification, and therapeutic options available to treat sinopulmonary aspergillosis and look ahead to emerging diagnostic and therapeutic options that may soon play an important role in clinical practice. Expert commentary: Histopathology and tissue culture remain the gold standard for the diagnosis of invasive sinopulmonary aspergillosis, but several new molecular detection methods have recently emerged, including various PCR-based platforms, MALDI-TOF, and lateral flow assays. We examine these methodologies as well as the barriers associated with the standardization, validation, and implementation. We also explore the pipeline of antifungal agents in development to treat sinopulmonary aspergillosis.

bioRxiv preprint, During organ development, the progenitor state is transient, and depends on specific combinations of transcription factors and extracellular signals. Not surprisingly, abnormal maintenance of progenitor transcription factors may lead to tissue overgrowth, and the concurrence of signals from the local environment is often critical to trigger this overgrowth. Therefore, identifying specific combinations of transcription factors/signals promoting -or opposing- proliferation in progenitors is essential to understand normal development and disease. We have investigated this issue using the Drosophila eye as model. Transcription factors hth and tsh are transiently expressed in eye progenitors causing the expansion of the progenitor pool. However, if their co-expression is maintained experimentally, cell proliferation continues and differentiation is halted. Here we show that Hth+Tsh-induced tissue overgrowth requires the BMP2 Dpp and the abnormal hyperactivation of its pathway. Rather than using autocrine Dpp expression, Hth+Tsh cells increase their avidity for Dpp, produced locally, by upregulating extracellular matrix components. During normal development, Dpp represses hth and tsh ensuring that the progenitor state is transient. However, cells in which Hth+Tsh expression is forcibly maintained use Dpp to enhance their proliferation., Grants BFU2012-34324 and BFU2015-66040 (Spanish Ministry for Economy and Competitiveness (MINECO) co-funded by FEDER) to FC, and grants BFU2014-55738-REDT and BFU2014-57703-REDC, in which FC is participant. MN was a FCT, Portugal PhD fellow (SFRH/BD/69222/2010).

To evaluate asthma symptom frequency, severity, and control among children with asthma and to evaluate the impact on social functioning and sleep impairment.Using a cross-sectional design, adult caregivers of children aged 6-12 years with moderate to severe asthma (severity based on National Asthma Education and Prevention Program guidelines) were surveyed about the child's symptoms, treatment, activity limitation, and sleep impairment. Asthma was categorized as uncontrolled if the caregiver reported any of the following of the child: experienced2 days/week with symptoms, were awakened at night by symptoms during the preceding 4 weeks, had activity limited by a health problem, or used short-acting beta-agonist for rescue5 times/week. Asthma not meeting any of these criteria was categorized as controlled. Social functioning and sleep impairment were assessed using questions adapted from the SleepLearnPlay instrument. Children with uncontrolled and controlled asthma were compared using t tests for continuous variables and Fisher's exact test for categorical variables. Multiple comparison adjustment using the Bonferroni procedure was made for social functioning and sleep impairment measures.A total of 473 caregivers completed the survey; 360 were caregivers of children with uncontrolled asthma and 113 of children with controlled asthma. Compared with controlled asthma, a greater proportion of children with uncontrolled asthma showed avoidance across all nine social activities assessed. Children with uncontrolled asthma were significantly more likely to wake up at night with symptoms (p.0001) and use a rescue inhaler at night (p.0001), experience difficulty waking up in the morning (p = .0001) and getting out of bed (p = .0039), and be overly tired all day (p.0001).Uncontrolled asthma impacted functioning and sleep of children to a significantly greater degree than well-controlled asthma. Proper treatment and disease management to improve symptom control can reduce this impact on the lives of children.

Background Results of a national survey of asthmatic children that evaluated management goals established in 2004 by the National Asthma Education and Prevention Program (NAEPP) indicated that asthma symptom control fell short on nearly every goal. Methods An Internet-based survey was administered to adult caregivers of children aged 6-12 years with moderate to severe asthma. Asthma was categorized as uncontrolled when the caregiver reported pre-specified criteria for daytime symptoms, nighttime awakening, activity limitation, or rescue medication based on the NAEPP guidelines. Children's health-related quality of life (HRQOL) and caregivers' quality of life (QOL) were assessed using the Child Health Questionnaire Parent Form 28 (CHQ-PF28) and caregiver's work productivity using a modified Work Productivity and Activity Impairment Questionnaire. Children with uncontrolled vs. controlled asthma were compared. Results 360 caregivers of children with uncontrolled asthma and 113 of children with controlled asthma completed the survey. Children with uncontrolled asthma had significantly lower CHQ-PF28 physical (mean 38.1 vs 49.8, uncontrolled vs controlled, respectively) and psychosocial (48.2 vs 53.8) summary measure scores. They were more likely to miss school (5.5 vs 2.2 days), arrive late or leave early (26.7 vs 7.1%), miss school-related activities (40.6 vs 6.2%), use a rescue inhaler at school (64.2 vs 31.0%), and visit the health office or school nurse (22.5 vs 8.8%). Caregivers of children with uncontrolled asthma reported significantly greater work and activity impairment and lower QOL for emotional, time-related and family activities. Conclusions Poorly controlled asthma symptoms impair HRQOL of children, QOL of their caregivers, and productivity of both. Proper treatment and management to improve symptom control may reduce humanistic and economic burdens on asthmatic children and their caregivers.

Objective Qualitative research among patients with systemic lupus erythematosus (SLE) can identify aspects of the disease relevant to clinical research and practice. A phenomenological, mixed-method approach was used to investigate these disease-driven health issues. Methods A convenience sample of patients with SLE from Los Angeles County, California was recruited from a private, community-based rheumatology practice for participation in focus groups and interviews. Semistructured discussions explored disease manifestations and impact. A self-administered questionnaire evaluated the occurrence and importance of disease issues previously identified from literature. Patient health issues were identified through convergence using 1) qualitative analysis of focus group transcripts and 2) quantitative analysis of the questionnaire. Patients were also asked about their ability to accurately recall disease experiences. Results Focus group participants (n = 23) had a mean age of 43 years and a mean disease duration of 8 years; 19 (83%) were women and 14 (61%) were white. The most frequent health issues identified by focus group transcript analysis were pain (83%), fatigue (61%), work or school impairment (48%), skin manifestations (43%), and skin sensitivity (43%). Questionnaire findings were similar: the most frequent health issues were inability to do previous activities (87%), fatigue (87%), pain (87%), and work or school impairment (83%). Most interviewed patients (7 of 10) reported an ability to accurately recall disease issues between 24 hours and 7 days. Conclusion SLE patients reported signs and symptoms that could significantly impact their functioning in daily life. Treatments that substantially improve these disease manifestations would offer considerable benefit to patients, treating physicians, and general society.

This study evaluated the effects of excessive sleepiness (ES) on health status, daily functioning, and work productivity.From a survey performed in June to July 2006, people with or without ES in two groups (1758 with obstructive sleep apnea, depression, narcolepsy, multiple sclerosis, or shift work; 1977 without these conditions) were assessed on the Work Productivity and the Activity Impairment Scale, Short Form-12, Medical Outcomes study 6-item Cognitive Function Scale, and the Toronto Hospital Alertness Test.ES in both groups was associated with highly significant impairments in health status, daily activities, and work productivity for all measures (P0.0001), except for absenteeism (P = 0.0400 for group A, P = 0.8360 for group B).ES may have an incremental negative impact measurable above that of obstructive sleep apnea, multiple sclerosis, narcolepsy, depression, or shift work.

The extent to which proton pump inhibitors (PPIs) can offset direct medical costs by reducing symptoms related to gastroesophageal reflux disease (GERD) in order to improve work productivity is not well understood. This study aimed to evaluate the economic impact of treating GERD with PPIs versus no treatment, from an employer's perspective.An economic model was developed to simulate symptom reduction and breakthrough symptoms as well as associated costs over 1 year among a population of 100,000 with a 20% GERD prevalence rate. Medical costs, including GERD-related office visits, hospitalisations and procedures, were delineated by symptom severity. Indirect costs represented the monetised work productivity loss. PPI treatment costs $2/day (standard dose).The GERD burden was substantial ($62,500,000). Treatment yielded $32,600,000 in savings ($1,630 saved/patient/year), mostly from reducing indirect costs. Treatment produced greater savings among nighttime GERD patients throughout the PPI cost range ($1-$5/day). Savings dropped if the price of standard doses of PPI exceeded $3.92/day for the treatment of daytime GERD patients.

An association between non-alcoholic fatty liver disease (NAFLD) and cardiovascular disease (CVD) has been recently suggested. Indeed, different studies have demonstrated that NAFLD patients present increased subclinical atherosclerosis compared to non-steatosic individuals, and are supported by the few follow-up studies revealing that CVD is the second most common cause of death in NAFLD patients. However, the nature of the relationship NAFLD/CVD is still under debate.

This review assessed the use of electronic medical record (EMR) systems in outcomes research. We systematically searched PubMed to identify articles published from January 2000 to January 2007 involving EMR use for outpatient-based outcomes research in the United States. EMR-based outcomes research studies ( n = 126) have increased sixfold since 2000. Although chronic conditions were most common, EMRs were also used to study less common diseases, highlighting the EMRs’ flexibility to examine large cohorts as well as identify patients with rare diseases. Traditional multi-variate modeling techniques were the most commonly used technique to address confounding and potential selection bias. Data validation was a component in a quarter of studies, and many evaluated the EMR’s ability to achieve similar results previously achieved using other data sources. Investigators using EMR data should aim for consistent terminology, focus on adequately describing their methods, and consider appropriate statistical methods to control for confounding and treatment-selection bias.

Nighttime gastrointestinal reflux disease (GERD) prevalence and severity estimates vary substantially across studies. We assessed nighttime GERD (NTG) prevalence and symptom frequency and severity through a web survey of US adults, using the GERD Symptom and Medication Questionnaire (GERD-SMQ), a validated symptom questionnaire. NTG was based on episodes of nighttime heartburn per week and time of occurrence. Symptom severity and impact were assessed and compared for GERD cases with and without NTG. GERD prevalence among respondents (n = 2,603) was 27%. Forty-five percent of symptomatic GERD respondents had NTG. Among respondents with both daytime and nighttime symptoms, 51% reported that nighttime symptoms were more bothersome. NTG respondents reported greater disease severity compared with those without (P

Men who have sex with men (MSM) represent the largest group with HIV in the U.S. (CDC 2005). Interventions for prevention with HIV-infected MSM are urgently needed, and integrating prevention into HIV care represents one opportunity for this advancement. This article describes the development and results of initial pilot testing of a behavioral intervention to reduce HIV sexual risk transmission behavior for HIV-infected MSM that is integrated into HIV care. To illustrate our intervention development process, we describe the setting and population (HIV-infected MSM patients at Fenway Community Health in Boston) for the project, the initial conceptualization of the project including its guiding conceptual model (information, motivation, and behavioral skills model, IMB: Fisher and Fischer 1993), the iterative process of attaining and integrating input from stakeholders, the use of peer interventionists, the open phase pilot and participant input, an overview of the intervention content, and, finally, lessons learned. The result of this process is an example of an intervention developed with strong input from the community and other stakeholders, which is ready for further testing in a randomized controlled trial.

Objectives: Hospital administrative data were analyzed to assess treatment patterns, in-hospital mortality, rates of hemorrhagic events and thrombus propagation, utilization of health care resources, and hospital costs associated with various treatments during inpatient care for venous thromboembolism (VTE). Study Design: Data from inpatient records were collected for deep venous thrombosis (DVT) and pulmonary embolism (PE) encounters at 132 US hospitals between January 1999 and December 2000. Patients receiving the most frequently employed treatments were compared with respect to demographics, related procedures and diagnostics, length of stay, adverse events, in-hospital mortality, and hospital costs. Results: A total of 953 primary DVT and 3933 primary PE admissions were identified. Most admissions involved treatment with unfractionated heparin and vitamin K antagonist (UFH/VKA, 64.2% of admissions), followed by UFH with VKA and low-molecular-weight heparin (UFH/LMWH/VKA, 14.4%), and LMWH/VKA (12.9%). Compared with those treated with UFH/VKA, patients treated with LMWH/VKA experienced higher anticoagulant costs ($540 vs. $106), but lower total hospital costs ($5198 vs. $5977) and shorter lengths of stay (4.4 vs. 5.7 days for those without PE and 5.7 vs. 6.7 days for those with PE). Conclusions: UFH/VKA was the most common regimen used to treat VTE. In spite of its higher medication cost, however, treatment with LMWH/VKA was associated with significantly shorter hospital stays and lower total hospitalization costs, compared with UFH/VKA.

Some studies have shown that currently available protease inhibitors (PIs) are associated with an increased risk of cardiovascular disease. We have systematically reviewed the published literature and conference abstracts for studies evaluating cardiovascular risk factors and events in patients receiving highly active antiretroviral therapy, with and without PIs. The majority of studies showed that the use of PIs was associated with increased levels of total cholesterol (36 [75%] of 48 studies), triglycerides (35 [73%] of 48 studies), and low-density lipoprotein (12 [100%] of 12 studies). PI use was often associated with morphological signs of cardiovascular disease, such as increased carotid intima thickness or atherosclerotic lesions (7 [88%] of 8 studies). Finally, 2 (67%) of 3 long-term observational studies that met our inclusion criteria demonstrated an association between use of PIs and subsequent myocardial infarction. The benefits of the currently available PIs should be balanced against the long-term risk of cardiovascular disease.

Purpose: To assess the agreement between 3- vs 12-month Rome II IBS symptom criteria and to assess the agreement between the Rome criteria and self-report of a previous medical diagnosis of irritable bowel syndrome (IBS) in an employed U.S. population.

Impairments in worker productivity and health-related quality of life among employees with irritable bowel syndrome: does bowel habit predominance make a difference?