Endoscopic balloon catheter dilatation via retrograde or static technique is safe and effective for cricopharyngeal dysfunction.

AIM: To evaluate the safety and efficacy of upper esophageal sphincter (UES) dilatation for cricopharyngeal (CP) dysfunction. To determine if: (1) indication for dilatation; or (2) technique of dilatation correlated with symptom improvement. METHODS: All balloon dilatations performed at our institution from over a 3-year period were retrospectively analyzed for demographics, indication and dilatation site. All dilatations involving the UES underwent further review to determine efficacy, complications, and factors that predict success. Dilatation technique was separated into static (stationary balloon distention) and retrograde (brusque pull-back of a fully distended balloon across the UES). RESULTS: Four hundred and eighty-eight dilatations were reviewed. Thirty-one patients were identified who underwent UES dilatation. Median age was 63 years (range 27-81) and 55% of patients were male. Indications included dysphagia (28 patients), globus sensation with evidence of UES dysfunction (2 patients) and obstruction to echocardiography probe with cricopharyngeal (CP) bar (1 patient). There was evidence of concurrent oropharyngeal dysfunction in 16 patients (52%) and a small Zenker's diverticula (≤ 2 cm) in 7 patients (23%). Dilator size ranged from 15 mm to 20 mm. Of the 31 patients, 11 had dilatation of other esophageal segments concurrently with UES dilatation and 20 had UES dilatation alone. Follow-up was available for 24 patients for a median of 2.5 mo (interquartile range 1-10 mo), of whom 19 reported symptomatic improvement (79%). For patients undergoing UES dilatation alone, follow-up was available for 15 patients, 12 of whom reported improvement (80%). Nineteen patients underwent retrograde dilatation (84% response) while 5 patients had static dilatation (60% response); however, there was no significant difference in symptom improvement between the techniques (P = 0.5). Successful symptom resolution was also not significantly affected by dilator size, oropharyngeal dysfunction, Zenker's diverticulum, age or gender (P > 0.05). The only complication noted was uvular edema and a shallow ulcer after static dilatation in one patient, which resolved spontaneously and did not require hospital admission. CONCLUSION: UES dilatation with a through-the-scope balloon by either static or retrograde technique is safe and effective for the treatment of dysphagia due to CP dysfunction. To our knowledge, this is the first study evaluating retrograde balloon dilatation of the UES.

Hispanics and inflammatory bowel disease.

BACKGROUND: Historically, inflammatory bowel disease (IBD) was considered a disease, which predominately affects whites. As such, the majority of research in IBD has been conducted in this population. However, more research on this suggests that IBD affects other ethnic groups. Rapidly shifting demographics in the United States necessitates a better understanding of how IBD may affect Hispanics. We reviewed the current literature on IBD in Hispanics. METHODS: A PubMed search was conducted using keywords inflammatory bowel disease, Ulcerative Colitis, Crohn's disease, Hispanics, Latinos, ethnicity, to identify existing literature with a focus on adult populations. Non-English language articles were excluded. RESULTS: The existing data and literature on Hispanic patients with IBD remains sparse. Limited studies on prevalence suggest IBD may be more common in Hispanics in the United States compared with those in Latin America. Conflicting data exist as to whether Hispanics patients with IBD are more likely to have ulcerative colitis compared with Crohn's disease. One study explored difference in IBD between foreign-born and U.S.-born Hispanics and found that ulcerative colitis was more common only in foreign-born Hispanics, whereas within 1 generation, U.S.-born Hispanics resemble their non-Hispanic white counterparts about development of Crohn's disease. Such a rapid change in the proportion of ulcerative colitis and Crohn's disease points strongly to environmental factors driving the change in proportion of disease subtypes. Additionally, a trend towards less use of biologic and immunomodulators in Hispanics was noted in several studies. CONCLUSIONS: Additional research is needed to better understand how diversity within the Hispanic population (U.S.-born and foreign-born) may be driving difference in disease manifestations. More investigations should focus on determining the cause of a potential disparity in the use of biologic and immunomodulators in Hispanics.

Fecal Microbiota Transplantation: A Review of Emerging Indications Beyond Relapsing Clostridium difficile Toxin Colitis.

The symbiotic relationship between gut microbiota and humans has been forged over many millennia. This relationship has evolved to establish an intimate partnership that we are only beginning to understand. Gut microbiota were once considered pathogenic, but the concept of gut microbiota and their influence in human health is undergoing a major paradigm shift, as there is mounting evidence of their impact in the homeostasis of intestinal development, metabolic activities, and the immune system. The disruption of microbiota has been associated with many gastrointestinal and nongastrointestinal diseases, and the reconstitution of balanced microbiota has been postulated as a potential therapeutic strategy. Fecal microbiota transplantation (FMT), a unique method to reestablish a sustained balance in the disrupted microbiota of diseased intestine, has demonstrated great success in the treatment of recurrent Clostridium difficile infection and has gained increasing acceptance in clinical use. The possibility of dysfunctional micro-biota playing a causative role in other gastrointestinal and nongas-trointestinal diseases, therefore, has also been raised, and there are an increasing number of studies supporting this hypothesis. FMT is emerging as a feasible therapeutic option for several diseases; however, its efficacy remains in question, given the lack of clinical trial data. Altering microbiota with FMT holds great promise, but much research is needed to further define FMT's therapeutic role and optimize the microbiota delivery system.

Religious coping and hospital admissions among adults with sickle cell disease.

Although a well-established literature implicates religiosity as a central element of the African American experience, little is known about how individuals from this group utilize religion to cope with specific health-related stressors. The present study examined the relation between religious coping and hospital admissions among a cohort of 95 adults with sickle cell disease-a genetic blood disorder that, in the United States, primarily affects people of African ancestry. Multiple regression analyses indicated that positive religious coping uniquely accounted for variance in hospital admissions after adjusting for other demographic and diagnostic variables. Specifically, greater endorsement of positive religious coping was associated with significantly fewer hospital admissions (ß = -.29, P < .05). These results indicate a need for further investigation of the roles that religion and spirituality play in adjustment to sickle cell disease and their influence on health care utilization patterns and health outcomes.

Examining the characteristics and beliefs of hydroxyurea users and nonusers among adults with sickle cell disease.

The attitudes of patients with sickle cell disease (SCD) toward the use of hydroxyurea (HU) therapy may contribute to the underutilization of HU in the United States, yet our understanding of these attitudes is limited. We examined the attitudes and beliefs of 94 adult SCD patients, comparing those who never used HU (n 5 37), formerly used HU (n 5 23), and were currently using HU (n 5 34). Seventy percent of current HU users reported some level of improvement from the drug ("average" or "very much") and 80% reported little or no trouble from side effects. Fifty-seven percent of former users reported taking HU for less than 6 months, with "doctor"s recommendation," or "not liking the way it made me feel" given as the most commonly reported reasons for stopping HU. Fifty percent of the never users reported receiving no information about HU from any source, and 85% of the never users thought that they would receive no improvement if they were to take HU. A deeper understanding of patient perspectives toward HU utilization is required as part of multipronged efforts to combat its underutilization in the treatment of SCD.

Problematic hospital experiences among adult patients with sickle cell disease.

BACKGROUND: Adults with sickle cell disease (SCD) have often reported difficulties obtaining care during vaso-occlusive crisis (VOC) in qualitative studies. METHODS: We measured the experiences of 45 SCD patients who received in-hospital care for VOC using the Picker Patient Experience Questionnaire (PPE-15), and used the one sample binomial test to compare with national norms. RESULTS: Most SCD patients reported that they were insufficiently involved in decisions (86%), staff gave conflicting information (64%), it wasn't easy to find someone to discuss concerns (61%), doctors' answers to questions were not clear (58%), nurses' answers to questions were not clear (56%), doctors did not always discuss fears and anxieties (53%), and nurses did not always discuss fears and anxieties (52%). A greater percentage of SCD patients than the U.S. sample in 9 of 12 areas reported problems. CONCLUSIONS: Further research is needed to determine the consequences of and potential interventions to improve these poor experiences.

The association of provider communication with trust among adults with sickle cell disease.

BACKGROUND: Adults with sickle cell disease often report poor interpersonal healthcare experiences, including poor communication with providers. However, the effect of these experiences on patient trust is unknown. OBJECTIVE: To determine the association between patient ratings of the previous quality of provider communication and current trust in the medical profession among adults with sickle cell disease. RESEARCH DESIGN: Cross-sectional survey. PARTICIPANTS: A total of 95 adults with sickle cell disease. MEASUREMENTS: The four-item Provider Communication Subscale from the Consumer Assessment of Healthcare Plans and Systems Survey; The five-item Wake Forest Trust in the Medical Profession Scale. MAIN RESULTS: Better ratings of previous provider communication were significantly associated with higher levels of trust toward the medical profession. A 10% increase in provider communication rating was associated with a 3.76% increase in trust scores (p < 0.001, 95% CI [1.76%, 5.76%]), adjusting for patient-level demographic, clinical, and attitudinal characteristics. CONCLUSIONS: Poorer patient ratings of provider communication are associated with lower trust toward the medical profession among adults with sickle cell disease. Future research should examine the impact of low trust in the medical profession on clinical outcomes in this population of patients.

Health care provider attitudes toward patients with acute vaso-occlusive crisis due to sickle cell disease: development of a scale.

OBJECTIVE: Patients with sickle cell disease (SCD) often perceive negative provider attitudes, which may affect the quality of patient-provider communication and care during vaso-occlusive crises (VOCs). This study investigated the validity and reliability of a scale to measure provider attitudes toward patients with acute VOC. METHODS: Using a cohort of adults with VOC (September 2006 to June 2007), we administered a 10-item provider questionnaire within 72 h of patient encounters. After factor analysis, we created a 7-item Positive Provider Attitudes toward Sickle Cell Patients Scale (PASS); higher scores indicate more positive attitudes. We assessed internal consistency and evidence of construct validity, exploring bivariate relationships between provider or patient characteristics and the PASS score using multilevel modeling. RESULTS: We collected 121 surveys from 84 health care providers for 47 patients. Patients averaged 30.3 years in age, and 60% were women. Among providers, 79% were nurses, and 70% worked in inpatient settings. PASS scores averaged 24.1 (S.D. 6.7), ranged 7-35, and had high internal consistency (Cronbach's alpha=0.91). As hypothesized, inpatient vs. emergency department providers (Delta=4.65, p<0.001) and nurses vs. other providers (Delta=0.95, p<0.001) had higher PASS scores. Higher patient educational attainment (Delta per year=2.74, p<0.001) and employment (Delta=5.62, p=0.001) were associated with higher PASS scores. More frequent hospitalizations (Delta per episode=-0.52, p<0.001) and prior disputes with staff (Delta=-7.53, p=0.002) were associated with lower PASS scores. CONCLUSION: Our findings provide preliminary evidence for the reliability and construct validity of the PASS score in measuring provider attitudes toward patients with VOC. PRACTICE IMPLICATIONS: Future studies should examine the validity of PASS in other cohorts of patients with SCD and their providers. With further evidence, PASS may prove useful for investigating the impact of provider attitudes on the quality of communication and care provided to these patients.