Short bowel syndrome with intestinal failure in adults.

ABSTRACT: Short bowel syndrome is a rare condition that can lead to intestinal failure. It occurs as a congenital condition or due to massive small bowel resection. This article provides an overview of this condition in adult patients, including diagnosis and treatment in inpatient and outpatient settings.

Predictors of and barriers to receipt of advance premium tax credits.

OBJECTIVES: The Advance Premium Tax Credit (APTC) is designed to remedy lack of health insurance due to cost; however, approximately 30 million Americans remain without health insurance and millions of households leave billions in tax credits unclaimed each year. A prerequisite of APTC is to file one's taxes; however, few studies have examined tax filing and APTC jointly. This study examined the relationship between tax filing and applying for APTC, as well as perceived barriers to and sociodemographic characteristics associated with applying for the APTC. STUDY DESIGN: Descriptive study. METHODS: Researchers surveyed 372 Marketplace-insured members who were eligible for APTC. RESULTS: Most of the sample filed personal taxes in 2019 and planned to file taxes in 2020, yet only 23% applied for the APTC in 2019, and 26.3% were planning to apply in 2020. Most commonly, respondents were not going to apply because they believed they were not eligible (53.5%), they did not know about the APTC (15.8%), and they did not know whether they were eligible (9.9%). Logistic regression modeling found that employment, income, and race were significantly associated with applying for the APTC. CONCLUSIONS: Barriers to applying for the APTC were unrelated to tax filing and were specific to a lack of knowledge about the APTC and eligibility. These results indicate the need to build knowledge and awareness of the APTC and eligibility and to target groups least likely to apply. Implications and future directions are discussed.

Impact of number versus location of metastases on survival in stage IV M1b non-small cell lung cancer.

BACKGROUND: To assess the impact of location versus number of extra-pulmonary metastatic sites (EPMS) on survival in stage IV non-small cell lung cancer (NSCLC). METHODS AND MATERIALS: Retrospective analysis was conducted on patients diagnosed during 1999-2013 with stage IV, M1b (AJCC 7th edition) NSCLC using the large, institutional Glans-Look Database, which contains patient demographic, clinical, pathological, treatment, and outcome information. We assessed the impact of location and number of EPMS and identified correlates of overall survival using the Kaplan-Meier method and Cox regression. RESULTS: We identified a total of 2065 NSCLC patients with EPMS. Median age was 67 (IQR 58-75) years, 52% were men, and 78% were current or former smokers. 60% had one EPMS, and 40% had two or more EPMS. Among those with only one EPMS, most frequent organ involvement included bone (40%), brain (32%), and liver (13%). Median overall survival (mOS) was worst in those with liver metastasis and best in those with adrenal metastasis (2.0 vs. 5.2 months, p = 0.015). However, outcomes based on site of organ involvement were not significantly different in multivariable analysis. Compared to patients with one EPMS, individuals with two or more EPMS experienced worse outcomes (mOS ≤ 2.9 vs. 3.9 months, p < 0.001), and were associated with worse prognosis in Cox regression analysis (HR 1.5, 95% CI 1.3-1.7, p < 0.001). CONCLUSIONS: Number rather than location of EPMS is a prognostic factor in patients with stage IV M1b NSCLC. This information is relevant for accurate prognostication, stratification of participants in future clinical trials, and timely and appropriate advanced care planning.

Prevalence of Skin Tears in Elderly Patients: A Retrospective Chart Review of Incidence Reports in 6 Long-term Care Facilities.

The incidence and prevalence of skin tears in long-term care (LTC) facilities has not been well established. To ascertain the point prevalence of reported skin tears, a retrospective review of incident reports was performed in 6 LTC facilities in western Pennsylvania from November 1, 2016 through December 31, 2016. Report data, including resident age; gender; mobility limitations; skin tear location, number, and cause (if known); occurrence time (7 am to 3 pm, 3 pm to 11 pm, or 11 pm to 7 am nursing shift); and history of previous skin tears, were abstracted. All data were entered into a statistical analysis program and analyzed using descriptive statistics. Period prevalence was used to determine prevalence rate; an independent t test was used to compare the presence of skin tears between genders. Differences between location and cause of skin tears were evaluated using a multinomial test of related proportions. A test of proportions was used to evaluate skin tear occurrence time (nursing shift) differences. The overall point prevalence rate was 9% (N = 1253 residents) ranging from 6 to 28 skin tears per facility. The average age of residents with a skin tear (n = 119) was 83.5 years. The majority (111, 93%) had mobility limitations. Falls accounted for 38 skin tears (31.9%), followed by propelling in a wheelchair (18, 15.1%; X2 =7.14; P = .008). Forearm skin tears (37, 31.1%) occurred significantly more frequently than lower leg skin tears (19, 16%; P = .016). Significantly more skin tears occurred during the 7 am to 3 pm shift (47, 39.5%) and 3 pm to 11 pm shift (49, 41.2%) than during the 11 pm to 7 am shift (23, 19.3%; X2 = 5.78; P <.01). The results of this study confirm skin tears are a significant problem among elderly residents in LTC, especially because the reported rate is likely lower than the actual rate. Research to further elucidate the incidence and prevalence of skin tears and associated risk factors is needed to help develop evidence-based risk assessment, classification systems, treatment guidelines, and preventive measures.

Factors affecting patient adherence to recommended measures for prevention of recurrent venous ulcers.

PURPOSE: The purpose of the study was to describe patients' adherence to clinical recommendations for preventing recurrent venous leg ulcers (VLUs). DESIGN: A cross-sectional study design was used for data collection. SUBJECTS AND SETTING: The target population comprised patients discharged from 7 wound clinics with a healed VLU within 1 to 24 months prior to treatment for a recurrent VLU. Six of the wound clinics used for data collection were based in hospital outpatient departments and 1 were community based. Seventy-one patients participated in the study; 59% were male. Participants' mean age was 67 +/- 14 years (mean 6 SD). METHODS: Participants completed a confidential anonymous questionnaire administered by wound care clinicians at each site. The 27-item questionnaire was developed by the investigators. Items on the questionnaire addressed multiple issues relevant to VLU recurrence, including compliance with compression stockings, leg elevation, and changes in medical condition. Items on the questionnaire also addressed satisfaction with education about prevention of VLU recurrence and subject demographics. RESULTS: The majority of the patients (73%) reported wearing their stockings every day and elevating their legs (87%) as instructed. Sixteen respondents (25%) reported a weight gain since their last visit to the clinic; 9 reported weight gain varying from 10 to 50 pounds. Most of the patients (90%) were satisfied that they received sufficient information at discharge to care for their legs. CONCLUSION: Seventy-three percent of patients with recurrent VLUs stated that they were adhering to recommendations for regular use of compression stockings in order to prevent recurrence. However, significant weight gain was reported by 25% of respondents. These findings suggest that prevention of weight gain should be examined as a possible intervention to prevent VLU recurrence in future studies.

A retrospective descriptive study of nursing home residents with heel eschar or blisters.

Pressure ulcers on heels are a serious problem in nursing home patients and can lead to complications. Current clinical guidelines recommend leaving dry heel eschar intact, but the evidence for this recommendation is largely based on expert opinion and not always followed. To examine outcomes of heel pressure ulcers in nursing home patients, a retrospective study was conducted by reviewing the charts of patients in 15 different nursing homes who had a heel eschar or a heel blister during a period of 50 months. In all facilities, standard protocol of care consisted of offloading the area and keeping eschar and blisters dry and debriding only if the eschar or blister became loose. A total of 263 heel wounds were identified. Of those, 179 (68%) had eschar and 84 (32%) were blisters. Almost half of all patients (41%) were lost to follow-up. All but one (amputation related to pain from ischemia) of the remaining wounds (n = 154) healed. Ninety-four of the 95 wounds with eschar and 57 of 57 wounds with blisters healed after an average of 11 (SD 9.44) weeks for wounds with eschar and 6 (SD 4.75) weeks for blister-covered wounds. These results suggest practitioners can follow current clinical guidelines for the management of these wounds until further research comparing different protocols of care has been conducted.

Properties of proxy-derived modified Rankin Scale assessment.

BACKGROUND: Cognitive or communication issues may preclude direct modified Rankin Scale interview, necessitating interview with a suitable surrogate. The clinimetric properties of this proxy modified Rankin Scale assessment have not been described. AIMS: To describe reliability of proxy-derived modified Rankin Scale and compare with traditional direct patient interview. METHODS: Researchers assessed consenting stroke inpatients and their proxies using a nonstructured modified Rankin Scale approach. Paired interviewers (trained in modified Rankin Scale) performed independent and blinded modified Rankin Scale assessment of patients and appropriate proxies. Interobserver variability and agreement between patient and proxy modified Rankin Scale were described using kappa statistics (k, 95% confidence interval) and percentage agreement. RESULTS: Ninety-seven stroke survivors were assessed. Proxies were family members (n = 29), nurses (n = 50), or physiotherapists (n = 25). Median modified Rankin Scale from both patient and proxies was 3 [interquartile range (IQR): 2-4]. Reliability for patient modified Rankin Scale interview was weighted kappa = 0·70 (95% confidence interval: 0·30-1·00). Reliability for proxy modified Rankin Scale weighted kappa = 0·62 (95% confidence interval: 0·34-0·90). Subgroup analysis of various proxy information sources were as follows: family weighted kappa = 0·61; nurse weighted kappa = 0·58; therapist weighted kappa = 0·58. There was disagreement between patient-derived modified Rankin Scale and corresponding proxy modified Rankin Scale weighted kappa = 0·64 (95% CI: 0·42-0·86). CONCLUSIONS: There is potential for substantial interobserver variability in proxy modified Rankin Scale and validity of certain proxy assessments is questionable. Direct modified Rankin Scale interview is preferred.

Face off: searching for truth and beauty in the clinical encounter. Based on the memoir, autobiography of a face by Lucy Grealy.

Based on Lucy Grealy's memoir, Autobiography of a Face, this article explores the relationship between gender and illness in our culture, as well as the paradox of "intimacy without intimacy" in the clinical encounter. Included is a brief review of how authenticity, vulnerability, and mutual recognition of suffering can foster the kind of empathic doctor-patient relationship that Lucy Grealy sorely needed, but never received. As she says at the end of her memoir, "All those years I'd handed my ugliness over to people, and seen only the different ways it was reflected back to me."

Phase I clinical trial of an adenovirus/prostate-specific antigen vaccine for prostate cancer: safety and immunologic results.

PURPOSE: We performed a phase I clinical trial of adenovirus/prostate-specific antigen (PSA) vaccine in men with measurable metastatic hormone-refractory disease. EXPERIMENTAL DESIGN: Men with measurable metastatic disease received one vaccine injection. Toxicity, immune responses, changes in PSA doubling times, and patient survival were assessed. Thirty-two patients with hormone-refractory metastatic prostate cancer were treated with a single s.c. vaccine injection at one of three dose levels, either as an aqueous solution or suspended in a Gelfoam matrix. All patients returned for physical and clinical chemistry examinations at regular intervals up to 12 months after injections. RESULTS: The vaccine was deemed safe at all doses in both administration forms. There were no serious vaccine-related adverse events; the most prevalent were localized erythema/ecchymoses and cold/flu-like symptoms. Anti-PSA antibodies were produced by 34% of patients and anti-PSA T-cell responses were produced by 68%. PSA doubling time was increased in 48%, whereas 55% survived longer than predicted by the Halabi nomogram. CONCLUSIONS: The adenovirus/PSA vaccine was proven safe with no serious vaccine-related adverse events. The majority of vaccinated patients produced anti-PSA T-cell responses and over half survived longer than predicted by nomogram. Although the latter data are only derived from a small number of patients in this phase I trial, they are encouraging enough to pursue further studies.

Defining the chromatin signature of inducible genes in T cells.

BACKGROUND: Specific chromatin characteristics, especially the modification status of the core histone proteins, are associated with active and inactive genes. There is growing evidence that genes that respond to environmental or developmental signals may possess distinct chromatin marks. Using a T cell model and both genome-wide and gene-focused approaches, we examined the chromatin characteristics of genes that respond to T cell activation. RESULTS: To facilitate comparison of genes with similar basal expression levels, we used expression-profiling data to bin genes according to their basal expression levels. We found that inducible genes in the lower basal expression bins, especially rapidly induced primary response genes, were more likely than their non-responsive counterparts to display the histone modifications of active genes, have RNA polymerase II (Pol II) at their promoters and show evidence of ongoing basal elongation. There was little or no evidence for the presence of active chromatin marks in the absence of promoter Pol II on these inducible genes. In addition, we identified a subgroup of genes with active promoter chromatin marks and promoter Pol II but no evidence of elongation. Following T cell activation, we find little evidence for a major shift in the active chromatin signature around inducible gene promoters but many genes recruit more Pol II and show increased evidence of elongation. CONCLUSIONS: These results suggest that the majority of inducible genes are primed for activation by having an active chromatin signature and promoter Pol II with or without ongoing elongation.

Oligodeoxynucleotide CpG 7909 delivered as intravenous infusion demonstrates immunologic modulation in patients with previously treated non-Hodgkin lymphoma.

Oligodeoxynucleotides containing CpG motifs (CpG ODN) can alter various immune cell subsets important in antibody therapy of malignancy. We undertook a phase I trial of CPG 7909 (also known as PF-3512676) in patients with previously treated lymphoma with the primary objective of evaluating safety across a range of doses, and secondary objectives of evaluating immunomodulatory effects and clinical effects. Twenty-three patients with previously treated non-Hodgkin lymphoma received up to 3 weekly 2-hour intravenous (IV) infusions of CPG ODN 7909 at dose levels 0.01 to 0.64 mg/kg. Evaluation of immunologic parameters and clinical endpoints occurred for 6 weeks. Infusion-related toxicity included grade 1 nausea, hypotension, and IV catheter discomfort. Serious adverse hematologic events observed more than once included anemia (2=Gr3, 2=Gr4), thrombocytopenia (4=Gr3), and neutropenia (2=Gr3), and were largely judged owing to progressive disease. Immunologic observations included: (1) The mean ratio of NK-cell concentrations compared with pretreatment at day 2 was 1.44 (95% CI=0.94-1.94) and at day 42 was 1.53 (95% CI=1.14-1.91); (2) NK activity generally increased in subjects; and (3) Antibody-dependent cellular cytotoxicity activity increased in select cohorts. No clinical responses were documented radiographically at day 42. Two subjects demonstrated late response. We conclude CpG 7909 can be safely given as a 2-hour IV infusion to patients with previously treated non-Hodgkin lymphoma at doses that have immunomodulatory effects.

Neutropenia and febrile neutropenia in patients with Hodgkin's lymphoma treated with doxorubicin (Adriamycin), bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy.

When uncomplicated neutropenia during doxorubicin (Adriamycin), bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy for the treatment of Hodgkin's lymphoma is encountered, it is unclear whether or not treatment should be modified. In the present study, we determined the incidence of neutropenia, febrile neutropenia, and the relationship of febrile neutropenia to grade III/IV neutropenia and dose modification, in a large university patient population. We reviewed the charts of patients diagnosed with Hodgkin's lymphoma between 1 January 1990 and 31 December 2002 who were treated with ABVD chemotherapy, and seen at the University of Iowa with complete diagnosis, staging, and treatment dosing records. Adequate data was available on 894 treatments in 81 patients with Hodgkin's lymphoma treated with ABVD chemotherapy. Grade III/IV neutropenia was present on the scheduled day of treatment in 187 (20.9%) treatments in 64 (79%) patients. Grade III/IV neutropenia was most common at cycle 1 day 15. Febrile neutropenia developed nine times in eight patients, and eight episodes of febrile neutropenia developed when the treatment-day absolute neutrophil count (ANC) > or =1000. Dose delay of >4 days and/or dose reduction to <80% of original doxorubicin dose following grade III/IV neutropenia occurred in 29 of 187 treatments, with no episodes of febrile neutropenia. With grade III/IV neutropenia on the day of therapy, 158 treatments were administered without dose reduction or dose delay with one subsequent episode of febrile neutropenia. Neutropenia during ABVD is common, and dose modification for uncomplicated neutropenia on the day of treatment may not reduce the risk of febrile neutropenia. It may be possible to maintain dose intensity in the face of uncomplicated neutropenia during ABVD therapy.

99mTc-depreotide tumour uptake in patients with non-Hodgkin's lymphoma.

BACKGROUND: 99mTc-depreotide (NeoTect) is a synthetic somatostatin analogue, which binds to somatostatin receptor (SSTR) subtypes 2, 3 and 5. Imaging patients with non-Hodgkin's lymphoma (NHL) using the somatostatin analogue In-pentetreotide (Octreoscan) has demonstrated the feasibility of identifying lymphoma sites with this class of peptide radiopharmaceutical. SSTR peptides can be labelled with beta emitters and, if sufficient tumour uptake relative to normal organs can be demonstrated, therapeutic applications can be considered. METHODS: In this prospective Institutional Review Board (IRB)-approved study, patients with NHL and a recent computed tomography (CT) examination were eligible. Whole-body and selected single-photon emission computed tomography (SPECT) imaging was performed 1 h after intravenous injection of 99mTc-depreotide. Images were compared with CT scan findings. The radioactivity concentration of 99mTc-depreotide in abdominal/pelvic tumour sites, together with normal organs, was determined and expressed as the percentage of injected activity per gram of tissue (%IA x g). RESULTS: Paired CT and 99mTc-depreotide images for three patients with indolent and six with aggressive NHL revealed abnormal 99mTc-depreotide uptake corresponding to the tumour seen on CT in seven of these patients. In three of the patients, all known tumour sites were detected on 99mTc-depreotide images. The mean %IA x g for nine abdominal/pelvic tumour foci from four patients was found to be 0.004% (range, 0.001-0.007%). The mean tumour to bone marrow activity concentration ratio in these four patients was found to be 0.94 (range, 0.33-1.40), whereas the tumour to kidney ratio was 0.53 (range, 0.16-0.80). CONCLUSIONS: Levels of 99mTc-depreotide in tumour suggest at least the possibility of potential therapy with beta emitter-labelled SSTR peptides; however, depreotide itself appears not to be a suitable candidate as a targeting agent due to the relatively high bone marrow concentration.