Inflammatory Bowel Disease Infusion Therapy Adherence in a Rural Pediatric Population.

INTRODUCTION: Biologic therapy is often used in patients with inflammatory bowel disease (IBD), which includes Crohn's Disease (CD) and ulcerative colitis (UC). While biologic therapy improves outcomes, it is dependent on strict compliance for optimal benefit. Limited information is available to describe IBD infusion therapy compliance and adherence barriers in a rural, geographically dispersed pediatric population. METHODS: Parents/guardians and patients (aged 0-21 years) with a diagnosis of IBD and scheduled biologic therapy infusions were offered a survey consisting of a mix of multiple-choice and open-ended questions. Surveys were offered via in-person paper format or telephone. RESULTS: Of the 27 pediatric patients completing the survey, the mean age was 14 years old (SD 3.7 years) with 19 patients having CD and eight patients with UC. The results showed that more than half of the patients (59%) had to reschedule, miss, or delayed their infusion therapy at least once. Therapy compliance was maintained as patients were able to reschedule a new appointment within two weeks. The most common reasons for missing appointments were forgetfulness and school conflicts. Patients wanting to maintain health and avoid flare-ups were reported as key drivers for therapy. CONCLUSION: Pediatric patients in rural and geographically disperse areas continue to have long commutes and other barriers to IBD specialty care. Forgetfulness and school activities were reported as barriers to biological therapy adherence. Protective factors including knowledge of therapy health benefits, parental involvement, and staff support can help maintain high adherence rates in this population.

[Gallstone ileus: a diagnostic and therapeutic challenge. Presentation of a clinical case]. / Íleo biliar: un reto diagnóstico y terapéutico. Presentación de un caso clínico.

Background: Gallstone ileus represents 4% of the causes of bowel obstruction in general population, but it increases to 25% in patients above 65 years of age. Gallstone ileus does not present with unique symptoms, making diagnosis difficult. It has a high mortality (12 to 27%) due to associated comorbidities and diagnostic delay. The aim of this case report is to communicate the importance of prompt diagnosis and surgical management of gallstone ileus. Clinical case: It is presented the clinical case of a 67-year-old female patient with a history of long-standing diabetes mellitus without medical control, without previous surgical history, who began suffering 2 days prior to admission to the emergency room with signs and symptoms of intestinal occlusion. She was given medical management without improvement and diagnostic delay of mechanical intestinal occlusion that was surgically intervened 7 days after the onset of clinical symptoms, finding gallstone ileus in the exploratory laparotomy, with satisfactory resolution of the pathology despite the diagnostic delay. Conclusions: Gallstone ileus is a difficult clinical entity to diagnose and therefore requires a high index of suspicion. The aim of gallstone ileus treatment is to release the obstruction, which is done through enterolithotomy. It is the recommended technique for gallstone ileus management because of its lower morbidity and mortality, compared with the other techniques.

Introducción: el íleo biliar representa el 4% de las causas de obstrucción intestinal en la población en general, pero incrementa a un 25% en los pacientes de más de 65 años. No presenta síntomas únicos, lo cual hace difícil su diagnóstico. Tiene una alta mortalidad (entre 12 y 27%) debido a las comorbilidades asociadas y al retraso diagnóstico. El objetivo de este caso clínico es comunicar la importancia del diagnóstico oportuno y el manejo quirúrgico del íleo biliar. Caso clínico: se presenta el caso clínico de una paciente de 67 años con antecedente de diabetes mellitus de larga evolución sin control médico, sin antecedentes quirúrgicos previos, cuyo padecimiento comenzó dos días antes de su ingreso a urgencias con signos y síntomas de oclusión intestinal. Se le dio manejo médico sin mejoría y hubo retraso diagnóstico de oclusión intestinal mecánica, la cual fue intervenida quirúrgicamente siete días después del inicio del cuadro clínico. En la laparotomía exploradora se encontró un íleo biliar, con resolución satisfactoria de la patología a pesar del retraso diagnóstico. Conclusiones: el íleo biliar es una entidad clínica de difícil diagnóstico que requiere un alto índice de sospecha. El objetivo del tratamiento del íleo biliar es liberar la obstrucción por medio de la enterolitotomía. Comparada con las otras técnicas, esta es la técnica recomendada para el manejo del íleo biliar, debido a su menor morbimortalidad.

Individual Differences in Hemispheric Emotional Valence by Computerized Test Correlate with Lateralized Differences in Nucleus Accumbens, Hippocampal and Amygdala Volumes.

Purpose: Conventional theories of hemispheric emotional valence (HEV) postulate fixed hemispheric differences in emotional processing. Schiffer's dual brain psychology proposes that there are prominent individual differences with a substantial subset showing a reversed laterality pattern. He further proposed that hemispheric differences were more akin to differences in personality than in emotional processing. This theory is supported by findings that unilateral treatments, such as transcranial magnetic stimulation, are effective if they accurately target individual differences in laterality. The aim of this paper was to assess if a computer test of hemispheric emotional valence (CTHEV) could effectively identify individual differences in HEV and to ascertain if these individual differences were associated with underlying differences in brain structure and connectivity. Patients and Methods: The CTHEV was administered to 50 (18 male/32 female) right-handed participants, aged 18-19 years, enrolled in a study assessing the neurobiological effects of childhood maltreatment. Based on a literature review, we determined whether CTHEV correlated with lateralized volumes of the nucleus accumbens, amygdala, hippocampus, and subgenual anterior cingulate as well as volume of the corpus callosum. Results: CTHEV scores correlated with laterality indices of the nucleus accumbens (p = 0.00016), amygdala (p = 0.0138) and hippocampus (p = 0.031). A positive left hemispheric valence was associated with a larger left-sided nucleus accumbens and hippocampus and a smaller left amygdala. We identified four eigenvector network centrality DTI measures that predict CTHEV, most notably the left amygdala, and found that CTHEV results correlated with total and segment-specific corpus callosal volumes. Conclusion: Individual differences in HEV can be readily assessed by computer test and correlate with differences in brain structure and connectivity that could provide a mechanistic understanding. These findings provide further support for a revised understanding of HEV and provide a tool that could be used to guide lateralized brain treatments.

Pneumomediastinum and Pneumorrhachis Associated With Cannabinoid Hyperemesis Syndrome.

More complications continue to be reported with the increasing use of marijuana (MJ) in the United States, including the increasing prevalence of Cannabinoid Hyperemesis Syndrome (CHS). To our knowledge, based on a thorough review of the literature, we present the third case of CHS with associated pneumomediastinum (PM) and the first case of pneumorrhachis (PR) in a young healthy patient. The main objective of this paper is to heighten awareness of CHS and its potential complications. A brief discussion of a focused history is essential for diagnosis, proper evaluation, and treatment.

Landfill Leachate from an Urban Solid Waste Storage System Produces Genotoxicity and Cytotoxicity in Pre-Adolescent and Young Adults Rats.

Landfill leachate is a complex mixture of organic and inorganic molecules, as well as environmental pollutants that can cause harm to ecosystems and living beings. The micronucleus test in peripheral blood erythrocytes was used to evaluate the genotoxic and cytotoxic effects of exposure to a landfill leachate from an outdoor solid waste storage system on Wistar strain rats at different developmental stages, pre-adolescents and young adults, and the heavy metal content of the leachate was determined by atomic absorption spectrometry. Contents of arsenic, cadmium, chromium, mercury, and lead in the landfill leachate were outside the allowable international standards, and the exposure to the landfill leachate caused genotoxic and cytotoxic effects on Wistar rats, where the pre-adolescent animals were more susceptible to the toxics contained in the landfill leachate than young adults. Heavy metals contained in landfill leachate, individually or synergically with other molecules can be responsible for clastogenic and cytotoxic effects that can be harmful to humans and ecosystems.

Clinical experience using intranasal ketamine in the longitudinal treatment of juvenile bipolar disorder with fear of harm phenotype.

OBJECTIVES: Fear of Harm (FOH) is a pediatric onset phenotype of bipolar disorder (BD) characterized by BD plus treatment resistance, separation anxiety, aggressive obsessions, parasomnias, and thermal dysregulation. Intranasal ketamine (InK) in 12 youths with BD-FOH produced marked improvement during a two-week trial. Here we report on the open effectiveness and safety of InK in maintenance treatment of BD-FOH from the private practice of one author. METHODS: As part of a chart review, patients 18 years or older and parents of younger children responded to a clinical effectiveness and safety survey. Effectiveness was assessed from analysis of responses to 49 questions on symptomatology plus qualitative content analyses of written reports and chart review. Adverse events (AEs) were analyzed by frequency, duration and severity. Peak InK doses ranged from 20 to 360mg per administration. RESULTS: Surveys were completed on 45 patients treated with InK for 3 months to 6.5 years. Almost all patients were "much" to "very much" improved clinically and in ratings of social function and academic performance. Significant reductions were reported in all symptom categories. There were 13 reports of persistent AEs, none of which resulted in discontinuation. Acute emergence reactions were sporadically observed in up to 75%, but were mild and of brief duration. LIMITATIONS: Retrospective review from a single practice without placebo control with potential for response and recall bias. CONCLUSIONS: InK every 3-4 days at sub-anesthetic doses appeared to be a beneficial and well-tolerated treatment. Use of InK may be considered as a tertiary alternative in treatment refractory cases. Randomized control trials are warranted.

Music Intervention With Reminiscence Therapy and Reality Orientation for Elderly People With Alzheimer Disease Living in a Nursing Home: A Pilot Study.

The purpose of this study was to investigate the effect of an 8-week nursing intervention consisting of 2 weekly sessions of music and reminiscence therapy together with the application of reality orientation techniques. Our expectation at the onset of the study was that listening to music that was familiar and connected with the memory of past events would, due to the music's emotional impact, stimulate memory associations, leading, in turn, to a positive effect on depression and anxiety in people living with dementia. We carried out a pre-/posttest intervention design with a sample of 19 patients divided into 2 groups-a 10-patient control group and a 9-patient intervention group-in a nursing home in Spain. Goldberg tests for depression and anxiety have been assessed at baseline and postintervention in both groups. Our results confirm the valuable effect of music therapy and reminiscence therapy together with reality orientation techniques on depression in patients with mild Alzheimer disease. Our study may constitute an important starting point for further research on nursing interventions based on the provision of music and/or reminiscence therapy together with reality orientation techniques that is implemented on a daily basis in nursing homes.

Does sleep disruption mediate the effects of childhood maltreatment on brain structure?

Background: Childhood maltreatment is associated with alterations in morphology of stress susceptible brain regions. Maltreatment is also known to markedly increase risk for psychopathology and to have an enduring disruptive effect on sleep. Objective: To determine whether abnormalities in sleep continuity have effects on brain morphometry and to evaluate the extent to which sleep impairments mediate the effects of maltreatment on brain structure. Method: Maltreatment and Abuse Chronology of Exposure (MACE) scale ratings, actigraph-assessed sleep and 3T MRI were obtained on N = 37 18-19-year-old participants recruited from the community (N = 34 with neuroimaging). Results: Fourteen participants had no history of maltreatment while N = 23 were exposed, on average, to 4.7 types of maltreatment. Multiplicity of maltreatment was strongly associated with reduced sleep efficiency, increased wake after sleep onset time and number/duration of awakenings, which were independent of effects of maltreatment on depression and anxiety. The most important predictors of impaired sleep were exposure to parental non-verbal emotional abuse at 9-10 years of age. Reduced sleep efficiency correlated with reduced grey matter volume in hippocampus including CA1 subfield, molecular layer and dentate gyrus as well as inferior frontal gyrus and insula. Sleep mediated 39-46% of the effects of maltreatment on volume of hippocampal structures and inferior frontal gyrus. Conclusions: Actigraph-assessed sleep is disrupted in maltreated late teens and mediates a significant portion of the effects of maltreatment on hippocampal volume. Studies are needed to assess whether efforts to enhance sleep in maltreated children can pre-empt or ameliorate neurobiological consequences of maltreatment.

Objetivo: determinar si las anomalías en la continuidad del sueño tienen efectos sobre la morfometría cerebral y evaluar en qué medida las alteraciones del sueño intervienen en los efectos del maltrato sobre la estructura del cerebro. Método: Se obtuvieron las puntuaciones de la Escala de cronología de la exposición al maltrato y al abuso (MACE, por sus siglas en inglés), sueño evaluado por actigraph y 3T MRI en N = 37 participantes de 18-19 años reclutados en la comunidad (N = 34 con neuroimagen). Resultados: Catorce participantes no tenían antecedentes de malos tratos mientras que N = 23 habían estado expuestos, de media, a 4.7 tipos de maltrato. La multiplicidad de los malos tratos se asoció fuertemente con una menor eficiencia del sueño, tiempo mayor de vigilia después de la hora de inicio del sueño y el número / duración de despertares, que fueron independientes de los efectos del maltrato sobre la depresión y la ansiedad. Los predictores más importantes de problemas de sueño fueron la exposición al abuso emocional no verbal de los padres a los 9-10 años de edad. La reducción de la eficiencia del sueño se correlacionó con la reducción del volumen de la materia gris en el hipocampo, incluido el subcampo CA1, la capa molecular y la circunvolución dentada, así como la circunvolución frontal inferior y la ínsula. El sueño mediaba en el 39-46% de los efectos del maltrato sobre el volumen de las estructuras del hipocampo y la circunvolución frontal inferior. Conclusiones: el sueño evaluado por Actigraph se ve alterado en adolescentes mayores maltratados y media en una parte importante de los efectos del maltrato sobre el volumen del hipocampo. Se necesitan estudios para evaluar si los esfuerzos para mejorar el sueño en los niños maltratados pueden adelantar o mejorar las consecuencias neurobiológicas del maltrato.