Treatment of new-onset ulcerative colitis and ulcerative proctitis: a retrospective study.

BACKGROUND: Although guidelines recommend use of oral 5-aminosalicylates (5-ASAs) as first-line therapy in patients with mild to moderate ulcerative colitis (UC) and ulcerative proctitis (UP) and steroids with or without 5-ASAs in those more severely ill, little is known about how UC and UP are actually treated. AIM: To document treatment of new-onset UC and UP in routine clinical practice. METHODS: Using a large US health insurance database, we identified all persons with new-onset UC or UP between 1 January 2005 and 31 December 2007, based on: (i) initial receipt of an oral 5-ASA, mesalazine (mesalamine) suppository, 5-ASA enema, steroid, antimetabolite, budesonide or TNF inhibitor; (ii) sigmoidoscopy/colonoscopy in prior 30 days resulting in a new diagnosis of UC or UP and (iii) no prior encounters for Crohn's disease. We examined patterns of pharmacotherapy over 1 year. RESULTS: We identified 1516 UC patients and 636 UP patients who met study entry criteria. In UC, initial therapies most frequently used were oral 5-ASAs (53% of patients), oral 5-ASAs and systemic steroids (12%), systemic steroids (8%) and mesalazine suppositories (6%); in UP, mesalazine suppositories (42%) and oral 5-ASAs (19%) were most often used, followed by combination therapy (14%), mesalazine enema (11%) and rectal steroids (10%). Few patients received maintenance therapy, and there was limited use of antimetabolites and biological agents. CONCLUSIONS: Oral 5-ASAs and systemic steroids are the mainstay of treatment in patients with new-onset ulcerative colitis; in those with new-onset ulcerative proctitis, it is mesalazine suppositories. Care of these patients appears consistent with treatment guidelines.

Prognostic factors for disability claim duration due to musculoskeletal symptoms among self-employed persons.

BACKGROUND: Employees and self-employed persons have, among others, different personal characteristics and different working conditions, which may influence the prognosis of sick leave and the duration of a disability claim. The purpose of the current study is to identify prognostic factors for the duration of a disability claim due to non-specific musculoskeletal disorders (MSD) among self-employed persons in the Netherlands. METHODS: The study population consisted of 276 self-employed persons, who all had a disability claim episode due to MSD with at least 75% work disability. The study was a cohort study with a follow-up period of 12 months. At baseline, participants filled in a questionnaire with possible individual, work-related and disease-related prognostic factors. RESULTS: The following prognostic factors significantly increased claim duration: age > 40 years (Hazard Ratio 0.54), no similar symptoms in the past (HR 0.46), having long-lasting symptoms of more than six months (HR 0.60), self-predicted return to work within more than one month or never (HR 0.24) and job dissatisfaction (HR 0.54). CONCLUSIONS: The prognostic factors we found indicate that for self-employed persons, the duration of a disability claim not only depends on the (history of) impairment of the insured, but also on age, self-predicted return to work and job satisfaction.

Differences in muscle load between computer and non-computer work among office workers.

Introduction of more non-computer tasks has been suggested to increase exposure variation and thus reduce musculoskeletal complaints (MSC) in computer-intensive office work. This study investigated whether muscle activity did, indeed, differ between computer and non-computer activities. Whole-day logs of input device use in 30 office workers were used to identify computer and non-computer work, using a range of classification thresholds (non-computer thresholds (NCTs)). Exposure during these activities was assessed by bilateral electromyography recordings from the upper trapezius and lower arm. Contrasts in muscle activity between computer and non-computer work were distinct but small, even at the individualised, optimal NCT. Using an average group-based NCT resulted in less contrast, even in smaller subgroups defined by job function or MSC. Thus, computer activity logs should be used cautiously as proxies of biomechanical exposure. Conventional non-computer tasks may have a limited potential to increase variation in muscle activity during computer-intensive office work.

The effects of pause software on the temporal characteristics of computer use.

The study investigated the natural work-pause pattern of computer users and the possible effects of imposing pause regimes on this pattern. Hereto, the precise timing of computer events was recorded across a large number of days. It was found that the distribution of the pause durations was extremely skewed and that pauses with twice the duration are twice less likely to occur. The effects of imposing pause regimes were studied by performing a simulation of commercially available pause software. It was found that depending on the duration of the introduced pause, the software added 25-57% of the pauses taken naturally. Analysis of the timing of the introduced pauses revealed that a large number of spontaneous pauses were taken close to the inserted pause. Considering the disappointing results of studies investigating the effects of introducing (active) pauses during computer work, this study has cast doubt on the usefulness of introducing short duration pauses.

Communication patterns between caregivers and their spouses with Alzheimer's disease: a case study.

The purpose of this study was to examine the style of communication that takes place between couples in their home environment in relationship to the abilities to the spouse with Alzheimer's disease (AD) and the amount of stress and burden experienced by the caregiver. Three styles of communication emerged: parallel, questioning, and direct. Caregivers engaging in parallel communications reported greater stress and time burden than any other caregivers. Nurses need to be observant of the communication patterns that exist between caregivers and their spouses with AD and help caregivers develop successful communicative strategies that enhance interactions with their spouses.

A multidimensional evaluation of a nursing information-literacy program.

The goal of an information-literacy program is to develop student skills in locating, evaluating, and applying information for use in critical thinking and problem solving. This paper describes a multidimensional evaluation process for determining nursing students' growth in cognitive and affective domains. Results indicate improvement in student skills as a result of a nursing information-literacy program. Multidimensional evaluation produces a well-rounded picture of student progress based on formal measurement as well as informal feedback. Developing new educational programs can be a time-consuming challenge. It is important, when expending so much effort, to ensure that the goals of the new program are achieved and benefits to students demonstrated. A multidimensional approach to evaluation can help to accomplish those ends. In 1988, The University of Northern Colorado School of Nursing began working with a librarian to integrate an information-literacy component, entitled Pathways to Information Literacy, into the curriculum. This article describes the program and discusses how a multidimensional evaluation process was used to assess program effectiveness. The evaluation process not only helped to measure the effectiveness of the program but also allowed the instructors to use several different approaches to evaluation.

Communicating with persons with Alzheimer's disease: experiences of family and formal caregivers.

The purpose of this exploratory study was to examine and compare communication processes used by family members and formal caregivers to manage behavioral problems such as fearfulness, agitation, and wandering, that commonly occur when caring for persons with Alzheimer's Disease (AD). Two groups of caregivers of persons with AD (formal and family) comprised the sample for the study. Two themes emerged from the focus group interviews: environmental adjustments and reassurance. Results suggest that interventions must be individualized. Enhancing the caregiver's skills to manage disruptive behavior may prolong his or her ability to provide in-home care for the family member with AD.

Effectiveness of current technology in the diagnosis and management of lower gastrointestinal hemorrhage.

Lower gastrointestinal hemorrhage is a common clinical problem for which multiple diagnostic tests and therapeutic interventions have been developed but no optimal approach has been established. We reviewed 107 consecutive patients admitted to the Massachusetts General Hospital for management of acute lower gastrointestinal hemorrhage to determine the effectiveness of diagnostic and management technologies, with particular attention to urgent colonoscopy. Colonoscopy yielded a diagnosis in 90% of patients, provided the opportunity for successful therapy in 9 of 13 patients (69%), and shortened hospital stay. Angiography performed after a scan positive for bleeding was often diagnostic, and angiography provided the means for successful therapy in 5 of 10 patients (50%). Barium enema and sigmoidoscopy had lower clinical yields. Although roles exist for other technologies, colonoscopy is the most convenient and effective first test in the evaluation of patients with significant lower gastrointestinal hemorrhage. Diagnostic yield, therapeutic opportunity, and cost effectiveness are maximized in early studies.

Occult gastrointestinal bleeding.

Occult gastrointestinal bleeding is loss of blood into the digestive tract that is not apparent to the patient or physician by physical examination. It is detected by examination of the stool for chemical evidence of blood by laboratory techniques or by the observation of iron deficiency. The presence of occult blood is important because it may indicate otherwise asymptomatic gastrointestinal neoplasia, assist with the evaluation of gastrointestinal symptoms in the absence of visible bleeding, and point toward a digestive tract source of blood loss in the patient with iron-deficiency anemia.

Ultraviolet laser-induced fluorescence of colonic polyps.

Ultraviolet laser-induced fluorescence was examined in vivo to determine whether the technique can reliably distinguish between hyperplastic and adenomatous polyps of the colon. Spectra from 86 normal colonic sites, 35 hyperplastic polyps, and 49 adenomatous polyps were recorded in vivo. Polyp type was independently determined by two senior pathologists who were unaware of the fluorescence measurement. A multivariate linear regression analysis was used to differentiate spectra from hyperplastic and adenomatous polyps and resulted in a sensitivity, specificity, predictive value positive, and predictive value negative for identifying adenomatous polyps of 86%, 80%, 86%, and 80%, respectively. These values were not significantly different from the accuracy of routine clinical pathology. Thus, ultraviolet laser-induced fluorescence appears to show promise as a means for distinguishing tissue types. However, further experience is needed before its routine clinical use can be recommended. Significant changes in the fluorescence spectra occurred postmortem, suggesting that future studies of laser-induced fluorescence of colonic tissue must use data acquired in vivo.

Ultraviolet laser-induced fluorescence of colonic tissue: basic biology and diagnostic potential.

Laser-induced fluorescence (LIF) of colonic tissue was examined both in vitro and in vivo to assess the ability of the technique to distinguish neoplastic from hyperplastic and normal tissue and to relate the LIF spectra to specific constituents of the colon. Spectra from 86 normal colonic sites, 35 hyperplastic polyps, 49 adenomatous polyps, and 7 adenocarcinomas were recorded both in vivo and in vitro. With 337-nm excitation, the fluorescence spectra all had peaks at 390 and 460 nm, believed to arise from collagen and NADH, and a minimum at 425 nm, consistent with absorption attributable to hemoglobin. The spectra of colonic tissue recorded both in vivo and in vitro are different, primarily in the NADH fluorescence component, which decays exponentially with time after resection. When normal colonic tissue is compared to hyperplastic or adenomatous polyps, the predominant changes in the fluorescence spectra are a decrease in collagen fluorescence and a slight increase in hemoglobin reabsorption. A multivariate linear regression (MVLR) analysis was used to distinguish neoplastic tissue from non-neoplastic tissue with a sensitivity, specificity, predictive value positive, and predictive value negative toward neoplastic tissue of 80%, 92%, 82%, and 91%, respectively. When the MVLR technique was used to distinguish neoplastic polyps from non-neoplastic polyps, values of 86%, 77%, 86%, and 77% respectively, were obtained. The data suggest that the LIF measurements sense changes in polyp morphology, rather than changes in fluorophores specific to polyps, and it is this change in morphology that leads indirectly to discrimination of polyps.

Focus group: implications for program evaluation of mental health services.

The focus group is a qualitative research method that involves group interaction based on a selected topic. It generally involves eight to 12 individuals who discuss a particular topic under the direction of a moderator who promotes interaction and guides the discussion on the topic of interest. This paper presents theoretical perspectives and a review of focus group methodology applied in related disciplines. A research project, which applied the focus group methodology, is described to illustrate important principles in utilizing this qualitative research technique. Information related to preparation for focus group sessions, structure, setting, participants, principles related to conducting the session and analysis are presented. The relevance of this methodology for research and practice in mental health also is discussed.

Practice patterns and costs of hospitalization for upper gastrointestinal hemorrhage.

We conducted an observational study at three hospitals in Boston to examine the patterns of practice and the costs involved in the medical management of noncirrhotic, upper gastrointestinal bleeding. A total of 111 patients were identified and studied: 42 from hospital 1, 38 from hospital 2, and 31 from hospital 3. There were no significant differences in the management of the patients, except for the more frequent use of upper gastrointestinal radiography at hospital 3 and the more frequent use of cimetidine at hospital 2. Only a small percentage (3-7%) of patients required surgery, and overall mortality (0-8%) was low. The average cost of hospitalization, determined by using the New England Medical Center cost model, was calculated for direct costs ($3,180). The majority of costs incurred were for hospital bed or intensive care unit stay (63%) and transfusion of blood products (14%), with costs for physicians' services (9%), endoscopy (2%), and upper gastrointestinal radiography (1%) accounting for only a small percentage. This study demonstrates remarkable similarity in practice patterns and resource utilization at three different hospitals and provides data on the actual costs involved in hospitalization for noncirrhotic, upper gastrointestinal hemorrhage.

The risks and benefits of an Rx-to-OTC switch. The case of over-the-counter H2-blockers.

In recent years, many new over-the-counter (OTC) medications have resulted from the granting of OTC status by the U.S. Food and Drug Administration to drug entities that previously were available only by prescription (Rx). While the benefits to consumers of Rx-to-OTC switches may be substantial, they also involve some degree of risk, as usage typically expands and physician supervision diminishes. This study explores the potential utility of techniques of decision analysis in evaluating the balance of these benefits and risks. Histamine H2 receptor antagonists (H2-blockers), which are currently available only by prescription, are presented as a case study and were examined to determine how OTC availability of these agents would alter the patterns, effectiveness, and risks of self-treatment for acid-peptic disorders. Currently, about 5.7 million persons experience an episode of dyspepsia during any given quarter, of whom 3.5 million self-medicate with antacids. Study results indicate that OTC availability of H2-blockers would: 1) increase the proportion of persons with dyspepsia who self-medicate from 61.8% currently to 64.1%; 2) increase the proportion of persons who experience complete relief of their symptoms while self-medicating from 37.9% currently to 43.2%; 3) result in 14 additional cases of serious hematologic disorders and an additional 22,000 instances of minor side effects per quarter, but cause the overall rate of side effects among persons who self-medicate to decline; 4) cause an additional 300 persons per quarter with gastric cancer to self-medicate before seeking professional care, but cause no change in the median time between onset of symptoms and the decision to seek such care; and 5) decrease by 277,000 the number of persons per quarter who seek professional care for dyspepsia. On balance, results suggest that OTC H2-blockers may be a relatively safe and effective means of self-care for acid-peptic disorders, and may substantially reduce the number of patient encounters with the medical care system for minor gastrointestinal complaints. This study also illustrates the potential utility of the techniques of decision analysis to the formulation of drug regulatory policy.

A need for social support. The chronically mentally ill institutionalized elderly.

Now that nursing homes are playing a major role in community care of psychiatric patients, they must be evaluated for the extent to which they offer and provide opportunities for social reintegration. Reality orientation and therapeutic milieu are the interventions used most often with elderly institutionalized chronically mentally ill patients. Attention that the elderly chronically mentally ill patients receive in reality orientation or in therapeutic milieu is probably more beneficial than the treatment itself.

Medical management of gallstones: a cost-effectiveness analysis.

OBJECTIVE: Ursodeoxycholic acid (ursodiol) is an oral dissolution agent recently approved by the Food and Drug Administration for treatment of cholelithiasis. The authors conducted a cost-effectiveness analysis comparing ursodiol with elective cholecystectomy and expectant management for men and women of ages 50 and 70 with typical chronic biliary symptoms. DESIGN: Using published literature and national cost data, the authors performed a decision analysis in which the outcome measures were life expectancy, quality-adjusted life expectancy, and expected lifetime treatment cost. PATIENTS: The analysis applies to patients with symptoms of biliary colic, noncalcified gallstones less than 20 mm in diameter, and functioning oral cholecystograms, who are candidates for elective cholecystectomy. Excluded were patients with acute cholecystitis or known or suspected common bile duct stones. RESULTS: Ursodiol is both clinically advantageous and less expensive than surgery for symptomatic men aged 64 or more, and for symptomatic women aged 69 or more. At ages younger than these, the clinical advantage of surgery is small and could be nullified if ursodiol were targeted at patients for whom dissolution is most likely to be effective, based on evidence of stone size and composition. Expected lifetime costs of ursodiol range from $300-400 more than surgery for 50-year-olds to $700-1,000 less than surgery for 70-year-olds. Ursodiol is the preferred choice for patients throughout this age range who are at significantly elevated risk of operative mortality. CONCLUSION: Ursodiol is a clinically advantageous and cost-effective alternative to elective cholecystectomy, especially for older and high-risk patients.

The diagnostic value of upper gastrointestinal radiography.

We reviewed the indications for and results of 788 consecutive upper gastrointestinal radiographs (UGIs) performed for ambulatory patients. Sixty-three percent of tests were ordered for the evaluation of abdominal pain, dyspepsia, or esophageal reflux. Of these tests, only 4.8% yielded results of major clinical importance to patient management. The yield for patients greater than 50 years of age was greater than for patients less than 50, 6.9 versus 3.0% (p = 0.04). There was a significant increase in yield with increasing age (chi trend = 11.6, p less than 0.001). Among patients with an indication of esophageal reflux alone (n = 62), there were no patients younger than age 60 with a test result that would significantly affect therapy or outcome. Among patients evaluated for fecal occult blood or weight loss (n = 120), 11.7% of tests ordered showed a finding of major clinical importance. In this group, the yield was higher in those greater than or equal to 50 years of age than in those less than 50, 14.7 versus 6.7%, (p = 0.2). These results indicate that UGIs ordered to evaluate pain or symptoms of esophageal reflux in the absence of bleeding or weight loss rarely yield results that significantly influence therapy. Such patients may be best served by an initial trial of empiric therapy or some other test. The UGI has greatest value when indications for it include bleeding or weight loss.

Nonsurgical treatment of cholelithiasis. An analysis of clinical opportunity.

This article examines the potential impact of recently developed nonsurgical treatments for gallstones on patient care and resource utilization. Using epidemiological and efficacy data from the literature and current patient selection criteria, the authors evaluate UDCA, extracorporeal shock-wave lithotripsy, and direct instillation of methyltertbutyl ether in terms of short-term clinical results, health policy, and economic implications.