The Influence of Health-Seeking Behaviors on the Health Literacy of Adolescents With Sickle Cell Disease.

Background: Health literacy may influence the transition from pediatric care to adult care in adolescents with sickle cell disease (SCD). It is postulated that one influencing factor of health literacy in adolescents with SCD is health-seeking behavior. The purpose of this study was twofold: (1) to explore health-seeking behaviors of adolescents with SCD and (2) to determine if there are significant differences in health literacy levels of adolescents with SCD based upon health-seeking behaviors. Methods: This was a cross-sectional, descriptive study evaluating health-seeking behaviors and health literacy in 110 Black and non-Hispanic adolescents with SCD. Convenience sampling was utilized for recruitment. The inclusion criteria were a diagnosis of one of the four primary genotypes of SCD and age of 10-19 years. Health literacy was evaluated using the Newest Vital Sign (NVS). Frequencies and percentages were calculated for all variables. Independent Samples t-tests were conducted to evaluate differences in health literacy scores based upon differing health-seeking behaviors. Results: The mean age of participants was 14.8 years (SD = 2.2). The mean NVS score was 2.7 (SD = 1.6). The two most common responses to "where do you go FIRST for health information?" were the Internet (29.6%; n = 40) and health care providers (27.4%; n = 37). There was no statistical difference in NVS scores between adolescents using the Internet versus health care providers as their first source of health information (t[75] = - .12; p = .22). Discussion: Knowledge of health-seeking behaviors and health literacy in adolescents with SCD gives insight into the design and evaluation of future interventions to improve health and health literacy in this population.

Rethink Vape: Development and evaluation of a risk communication campaign to prevent youth E-cigarette use.

INTRODUCTION: E-cigarettes are now the most common form of tobacco use among adolescents, and use is associated with increased risk of initiation of cigarette smoking. This project used a community-engaged research process to develop and pilot a risk communication campaign to prevent youth vaping. METHOD: The research team worked with a 36-member Teen Advisory Council and a 19-member Expert Panel. Together, the team employed survey (N = 674) and focus group (N = 82) methodologies, and hired a marketing company to partner on development of the campaign. Campaign concepts were developed, eliminated, and/or modified through an iterative process of feedback and refinement. The final campaign included video ads (https://bit.ly/2QMR8gH) a microsite (rethinkvape.org), and social media sites (@rethinkvape). The campaign communicated three messages to teens: what's in the vapor, health risks, and connections to big tobacco. Prior to launch of the campaign, a randomized controlled 2 (time) × 2 (group) online experiment was conducted to evaluate the campaign (N = 268). RESULTS: Repeated measures mixed analyses of variance indicated that vaping knowledge, perceptions of risk, and anti-vape intentions significantly increased among teens viewing the Rethink Vape Materials compared to their own baseline, while control participants did not change. Following evaluation, the team launched a 6-week online media campaign with a teen-targeted geo-fence radius to deliver 3,838,465 impressions, 770,443 completed video views, and 18,316 clicks in mobile app, Snapchat, YouTube, and Spotify platforms. The majority of placements exceeded industry standards, with mobile pre-roll and Snapchat as top performers. CONCLUSIONS: The e-cigarette campaign showed promising signs of effectiveness and scalability.

Maintenance rituximab after autologous stem cell transplantation in patients with mantle cell lymphoma.

BACKGROUND: High-dose therapy and autologous stem cell transplantation (ASCT) improves outcomes for patients with mantle cell lymphoma (MCL), but relapse ultimately occurs in most patients. Recently presented interim results from a phase III prospective trial suggest maintenance rituximab (MR) after ASCT for MCL improves progression-free survival (PFS). The maturation of these data and any benefit of MR on overall survival (OS) remain to be defined. PATIENTS AND METHODS: In this retrospective study, we examined a cohort of consecutive patients with MCL that underwent ASCT for MCL at our center and evaluated their outcomes according to whether they received MR after ASCT (n = 50) or did not (n = 107). MR was treated as a time-dependent covariate to account for variation in timing of its initiation. RESULTS: MR was associated with an improved PFS [hazard ratio (HR) 0.44; confidence interval (CI) (0.24-0.80), P = 0.007] and overall survival (OS; HR 0.46; CI 0.23-0.93, P = 0.03) following a multivariate adjustment for confounding factors with a median follow-up of ∼5 years. Grade 4 neutropenia was increased (34% versus 18%, P = 0.04) in the MR group, but no effect on the rate of mortality unrelated to relapse was observed. CONCLUSIONS: These data support that MR after ASCT for MCL confers a benefit in PFS and additionally suggest it may improve OS. General application of this strategy will require confirmation of benefit in prospective randomized trials.

Utilization of stored autologous PBSCs to support second autologous transplantation in multiple myeloma patients in the era of novel agent therapy.

Outcomes in multiple myeloma (MM) have improved significantly with novel agent therapy and autologous stem cell transplantation (ASCT). ASCTs are typically planned as either tandem or a single transplant with additional stored PBSCs available for a second salvage transplant. To accommodate these strategies, many centers routinely collect and store adequate PBSCs for two ASCTs. We analyzed the cost associated with this practice by determining the expenses of PBSC collection, cryopreservation and storage, and the ultimate use of additional cryopreserved PBSCs in patients who had undergone at least one ASCT. There were 889 MM patients transplanted between 1993 and 2011 at our center. Most (N=726) had residual PBSCs in storage after their first ASCT (ASCT1). Only 135 patients underwent a second ASCT within a median of 14 months after ASCT1. The percentage of patients receiving a second ASCT declined over time. The resources required to collect and store unused PBSCs added up to 336 extra patient days of apheresis and 41 587 extra patient months of cryopreservation, translating into an average extra cost per patient of US$4981.12. A reconsideration of conventional PBSC collection and storage practices would save significant cost for the majority of MM patients who never undergo a second ASCT.

Guidelines for designing a digestive disease endoscopy unit: report of the World Endoscopy Organization.

A dedicated digestive disease endoscopy unit is structurally and functionally differentiating rapidly as a result of increasing diagnostic and therapeutic possibilities in the last 10-20 years. Publications with practical details are scarce, imposing a challenge in the construction of such a unit. The lack of authoritative information about endoscopy unit design means that architects produce their own design with or without consulting endoscopists working in such a unit. A working group of the World Endoscopy Organization discussed and outlined a practical approach fordesign and construction of a modern endoscopy unit. Designing the layout is extremely important, necessitating thoughtful planning to provide comfort to the endoscopy staff and patients, and efficient data archiving and transmission during endoscopic services.

Efficacy and safety of hematopoietic stem cell remobilization with plerixafor+G-CSF in adult patients with germ cell tumors.

Autologous hematopoietic SCT (auto-HSCT) can be curative for patients with germ cell tumors. Poor stem cell mobilization jeopardizes the ability to deliver this therapy. Herein, we describe a retrospective study examining safety and efficacy of plerixafor in combination with G-CSF for patients with germ cell tumors who had previously failed stem cell collection. Overall, 21 patients with germ cell tumors and previous mobilization failure were remobilized with G-CSF (10 µg/kg SC) and plerixafor (0.24 mg/kg SC) beginning the evening of day 4 of G-CSF treatment. Dosing of G-CSF and plerixafor was repeated until collection of ≥ 2 × 10(6) CD34+ cells/kg. Remobilization resulted in a median yield of 3.2 × 10(6) CD34+ cells/kg. A total of 17 (81%) patients collected ≥ 2 × 10(6) and 9 (43%) patients collected ≥ 4 × 10(6) CD34+ cells/kg in a median of 2 (range 1-3) and 3 (range 1-4) days, respectively. In all, 16 (76%) patients proceeded to transplant; 8 (38%) received tandem transplants. There were no serious adverse events. In summary, the majority of patients with germ cell tumors who failed prior mobilization with growth factors ± chemotherapy were remobilized with plerixafor plus G-CSF facilitating at least one auto-HSCT. Use of plerixafor plus G-CSF can increase access of this potentially life-saving procedure to patients with high-risk germ cell tumors.

Cranial pseudotumour in haemophilia.

Intracranial pseudotumour has rarely been reported in haemophilia. We present the fourth case describing this complication.

Yield of colonoscopy in patients with nonacute rectal bleeding: a multicenter database study of 1766 patients.

OBJECTIVE: There are few data to guide the choice between colonoscopy and flexible sigmoidoscopy in patients with nonacute rectal bleeding, especially in younger age groups. Our aim was to determine the yield of colonoscopy for significant proximal large bowel disease in the absence of significant distal disease, with special reference to young patients. METHODS: This was a retrospective study of data collected prospectively in 1766 patients (median age 57 yr, 711 women). The endoscopic database (GI-Trac) contained 152 discrete fields for data input. Multiple logistic regression analysis was performed to identify variables independently associated with the presence of isolated significant proximal disease. RESULTS: Young patients had a higher percentage of normal examinations than did older patients. The incidence of diverticular disease, small polyps, large polyps, and cancer rose with increasing age. No patient aged <40 yr had an isolated proximal cancer, but 7% had other significant isolated proximal disease. There was no overall association between age and significant proximal disease in the absence of significant distal disease (p = 0.66). The only variable associated with isolated proximal disease was anemia (odds ratio = 1.81; 95% CI = 1.11-2.93; p = 0.02). CONCLUSION: The yield of colonoscopy (beyond the range of sigmoidoscopy) for neoplasia is low in patients aged <40 yr, but other significant disease may be missed if age is the only criterion determining colonoscopy use.

Age and alarm symptoms do not predict endoscopic findings among patients with dyspepsia: a multicentre database study.

INTRODUCTION: Symptoms of dyspepsia are common but most patients do not have major upper gastrointestinal pathology. Endoscopy is recommended for dyspeptic patients over the age of 45, or those with certain "alarm" symptoms. We have evaluated the effectiveness of age and "alarm" symptoms for predicting major endoscopic findings in six practising endoscopy centres. METHODS: Clinical variables of consecutive patients with dyspepsia symptoms undergoing upper endoscopy examinations were recorded using a common endoscopy database. Patients who had no previous upper endoscopy or barium radiography were included. Stepwise multivariate logistic regression was used to identify predictors of endoscopic findings. The accuracy of these for predicting endoscopic findings was evaluated with receiver operating characteristic analysis. The sensitivity and specificity of age thresholds from 30 to 70 years were evaluated. RESULTS: Major pathology (tumour, ulcer, or stricture) was found at endoscopy in 787/3815 (21%) patients with dyspepsia. Age, male sex, bleeding, and anaemia were found to be significant but weak independent predictors of endoscopic findings. A multivariate prediction rule based on these factors had poor predictive accuracy (c statistic=0.62). Using a simplified prediction rule of age > or =45 years or the presence of any "alarm" symptom, sensitivity was 87% and specificity was 26%. Increasing or decreasing the age cut off did not significantly improve the predictive accuracy. CONCLUSIONS: Age and the presence of "alarm" symptoms are not effective predictors of endoscopic findings among patients with dyspepsia. Better clinical prediction strategies are needed to identify patients with significant upper gastrointestinal pathology.

Colonic mucosal concentrations of folate are accurately predicted by blood measurements of folate status among individuals ingesting physiologic quantities of folate.

Folate status is inversely related to the risk of colorectal cancer. Whether conventional blood measurements of folate status accurately reflect folate concentrations in the colorectal mucosa has been a controversial topic. This is an important issue because accurate measures of folate status in the colorectal mucosa are important for ascertaining the risk of colorectal cancer in epidemiological studies and for determining the effects of folate supplementation in clinical trials. We examined whether conventional blood measurements of folate and a more sensitive, inverse indicator of systemic folate status, serum homocysteine, accurately reflect folate concentrations in human colonic mucosa obtained by endoscopic biopsy. Study subjects (n = 20) were participants in a randomized trial that investigated the effect of folate supplementation (5 mg daily for 1 year) on provisional molecular markers of colon cancer. Blood samples and biopsies of normal rectosigmoid mucosa were obtained at baseline, at 6 months, and at 1 year. Serum, RBC, and colonic mucosal folate and serum homocysteine concentrations were determined. Colonic mucosal folate concentrations correlated directly with serum folate concentrators at each time point (r = 0.572-0.845; P < 0.015) and with RBC folate concentrations at 6 months and 1 year (r = 0.747-0.771; P < 0.001). Colonic mucosal folate concentrations correlated inversely with serum homocysteine concentrations at each time point (r = -0.622-0.666; P < 0.008). Systemic measures of folate status did not correlate with colonic mucosal folate concentrations among individuals receiving supplemental folate. Our observations indicate that colonic mucosal concentrations of folate may be predicted accurately by blood measurements of folate status only among individuals not ingesting supraphysiological quantities of folate.

Effects of folate supplementation on two provisional molecular markers of colon cancer: a prospective, randomized trial.

OBJECTIVES: Dietary folate intake is inversely associated with the risk of colorectal cancer. This study investigated the effect of folate supplementation on genomic DNA methylation and DNA strand breaks in exons 5-8 of the p53 gene of the colonic mucosa, two provisional biomarkers of colon cancer. METHODS: Twenty subjects with adenomas were randomized to receive either folate (5 mg/day) or placebo for 1 yr after polypectomy. At baseline, 6 months and 1 yr, systemic and colonic measures of folate status were determined, as were the biomarkers mentioned earlier. RESULTS: Folate supplementation increased serum, red blood cell and colonic mucosal folate concentrations (p < 0.02). Folate supplementation also increased the extent of genomic DNA methylation at 6 months and 1 yr (p = 0.001), whereas placebo administration was associated with an increase in the extent of genomic DNA methylation only at 1 yr. Similarly, folate supplementation decreased the extent of p53 strand breaks in exons 5-8 at 6 months and 1 yr (p < 0.02), whereas placebo administration was associated with a decrease in the extent of p53 strand breaks only at 1 yr. CONCLUSIONS: Both of these provisional biomarkers of colon cancer underwent accelerated improvement at 6 months with folate supplementation. However, these markers also improved with placebo at 1 yr. Therefore, potential confounding factors that seem to modulate these biomarkers need to be identified and corrected in order for these markers to serve as suitable surrogate endpoints in folate chemoprevention trials.

Is prophylactic ciprofloxacin effective in delaying biliary stent blockage?

BACKGROUND: Late stent blockage is a major complication of endoscopic stent insertion for malignant obstructive jaundice. Stents block as a result of bacterial infection and biofilm formation. We report a randomized but unblinded study using an animal model to evaluate the effect of prophylactic ciprofloxacin, which selectively suppresses gram-negative bacteria, in an attempt to prolong stent patency. METHOD: Ten adult cats underwent surgical implantation of 5F polyethylene stents through common bile duct strictures created around the choledochotomy, with the tip of the stent left in the duodenum. Five animals received intravenous ciprofloxacin perioperatively and were then maintained on oral ciprofloxacin 25 mg twice daily. Control cats were not given antibiotics. The animals were sacrificed when signs of biliary obstruction or cholangitis persisted for more than 3 days or at the end of the 16-week study period. Stents were removed and examined for patency. In addition, the stents were cultured to recover the adherent bacteria. RESULTS: All control animals developed stent blockage within 4 weeks. Two ciprofloxacin-treated cats developed stent blockage at 21 and 42 days, respectively, whereas the other 3 cats had patent stents for the entire study period. There was a significant difference between the median stent patency of 112 days for the ciprofloxacin group versus 16 days for the control group (p < 0.02). Bacteriologic cultures showed that the bile and blocked stents from the control group had predominantly gram-negative bacteria, whereas the bile and stents of the ciprofloxacin group had gram-positive and anaerobic bacteria, with an absence of gram-negative bacteria (p < 0.01). CONCLUSION: Ciprofloxacin prophylaxis eliminates gram-negative bacterial infection in bile and minimizes sludge formation and may have a potential benefit in delaying stent blockage.

In vitro evaluation of antibiotic prophylaxis in the prevention of biliary stent blockage.

BACKGROUND: Bacterial adherence and biofilm formation are important factors in the blockage of biliary stents. Clinical studies with oral antibiotic prophylaxis to prevent stent blockage have produced conflicting results. The aim of this study was to evaluate the in vitro effect of single antibiotic (ciprofloxacin, ceftazidime, or ampicillin) treatment on adherence of Escherichia coli and Enterococcus to plastic stents. METHODS: Selected clinical isolates of E coli and Enterococcus were perfused through a modified Robbins device containing segments of polyethylene stents. The stents were removed daily and the number of bacteria attached was measured. The effect of antibiotic treatment on bacterial adherence was tested by the perfusion of individual antibiotics into separate modified Robbins devices using a side-arm adaptor and the results were compared with saline controls. RESULTS: Compared with the saline controls, ciprofloxacin and ceftazidime caused a 10- to 100-fold reduction in the number of E coli attached to the stents, whereas ampicillin had no effect on adherence of E coli. Ampicillin caused a 5- to 10-fold reduction in Enterococcus adherence but there was no change with ceftazidime. Sustained reduction in E coli adherence was observed with prolonged ciprofloxacin perfusion. CONCLUSION: Timely treatment with appropriate antibiotics reduced bacterial adherence in vitro and may be potentially beneficial in the prevention of stent blockage.

Is there a synergistic effect between mixed bacterial infection in biofilm formation on biliary stents?

BACKGROUND: Biliary sludge which forms as a result of bacterial adherence and biofilm formation in the biliary system is a recognized cause of blockage of plastic stents. Bacteriological cultures of sludge have revealed a mixed infection with gram-positive and gram-negative bacteria. Animal studies have shown that prophylactic ciprofloxacin, which selectively suppress gram-negative bacteria, results in prolonged stent patency despite colonization of the stents by gram-positive bacteria. METHODS: We tested a possible synergistic effect between gram-negative and gram-positive bacteria in adherence and biofilm formation on plastic stents. Clinical isolates of Escherichia coli and Enterococcus were cultured in separate chemostats to achieve a steady growth. Adherence of the two bacteria on plastic stent surface were tested separately by perfusing infected bile with the respective bacteria through different modified Robbins devices containing 10F polyethylene stent pieces up to 4 days. In a second experiment, Enterococcus was perfused through stent pieces precolonized with E. coli for 24 hours. The stent pieces were then removed daily and analyzed by bacteriologic culture and scanning electron microscopy for bacterial adherence and biofilm formation. RESULTS: Gram-negative E. coli were more adherent than gram-positive Enterococcus. Precolonization with E. coli facilitates subsequent attachment of Enterococcus. CONCLUSIONS: We concluded that there is a synergistic effect between gram-positive and gram-negative bacteria in adherence and biofilm formation.

Management of occluded biliary Wallstents.

BACKGROUND: Wallstents (Schneider Stent, Inc., USA) used for the palliation of malignant biliary strictures, although associated with prolonged patency, can occlude. There is no consensus regarding the optimal management of Wallstent occlusion. AIMS: To evaluate the efficacy of different endoscopic methods for managing biliary Wallstent occlusion. METHODS: A multicentre retrospective study of patients managed for a biliary Wallstent occlusion. RESULTS: Data were available for 38 patients with 44 Wallstent occlusions, all of which had initial endoscopic management. Twenty four patients had died and 14 were alive after a median follow up of 231 (30-1095) days following Wallstent occlusion. Occlusions were managed by insertion of another Wallstent in 19, insertion of a plastic stent in 20, and mechanical cleaning in five. Endoscopic management was successful in 43 (98%). Following management of the occlusion, bilirubin decreased from 6.0 (0.5-34.3) to 2.1 (0.2-27.7) mg/100 ml (p < 0.05). No complications occurred. The median duration of second stent patency was 75 days (95% confidence interval 43 to 107) after insertion of another Wallstent, 90 days (71 to 109) after insertion of a plastic stent, and 34 days (30 to 38) after mechanical cleaning (NS). The respective median survivals were 70 days (22-118), 98 days (54-142), and 34 days (30-380) (NS). Incremental cost effective analysis showed that plastic stent insertion is the most cost effective option. CONCLUSION: Although all three methods are equally effective in managing an occluded Wallstent, the most cost effective method appears to be plastic stent insertion.