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risk management [keywords]
- Hepatitis B and human immunodeficiency virus co-infection. [REVIEW]
- World J Gastroenterol 2014 Dec 14; 20(46):17360-17367.
Hepatitis B and human immunodeficiency virus (HBV and HIV) infection share transmission patterns and risk factors, which explains high prevalence of chronic HBV infection in HIV infected patients. The natural course of HBV disease is altered by the HIV infection with less chance to clear acute HBV infection, faster progression to cirrhosis and higher risk of liver-related death in HIV-HBV co-infected patients than in HBV mono-infected ones. HIV infected patients with chronic hepatitis B should be counseled for liver damage and surveillance of chronic hepatitis B should be performed to screen early hepatocellular carcinoma. Noninvasive tools are now available to evaluate liver fibrosis. Isolated hepatitis B core antibodies (anti-HBc) are a good predictive marker of occult HBV infection. Still the prevalence and significance of occult HBV infection is controversial, but its screening may be important in the management of antiretroviral therapy. Vaccination against HBV infection is recommended in non-immune HIV patients. The optimal treatment for almost all HIV-HBV co-infected patients should contain tenofovir plus lamivudine or emtricitabine and treatment should not be stopped to avoid HBV reactivation. Long term tenofovir therapy may lead to significant decline in hepatitis B surface Antigen. The emergence of resistant HBV strains may compromise the HBV therapy and vaccine therapy.
- Anti-tumour necrosis factor agent and liver injury: Literature review, recommendations for management. [REVIEW]
- World J Gastroenterol 2014 Dec 14; 20(46):17352-17359.
Abnormalities in liver function tests, including transient and self-limiting hypertransaminasemia, cholestatic disease and hepatitis, can develop during treatment with anti-tumour-necrosis-factor (TNF) therapy. The optimal management of liver injury related to anti-TNF therapy is still a matter of debate. Although some authors recommend discontinuing treatment in case of both a rise of alanine aminotransferase more than 5 times the upper limit of normal, or the occurrence of jaundice, there are no standard guidelines for the management of anti-TNF-related liver injury. Bibliographical searches were performed in PubMed, using the following key words: inflammatory bowel disease (IBD); TNF inhibitors; hypertransaminasemia; drug-related liver injury; infliximab. According to published data, elevation of transaminases in patients with IBD treated with anti-TNF is a common finding, but resolution appears to be the usual outcome. Anti-TNF agents seem to be safe with a low risk of causing severe drug-related liver injury. According to our centre experience, we found that hypertransaminasemia was a common, mainly self-limiting finding in our IBD cohort and was not correlated to infliximab treatment on both univariate and multivariate analyses. An algorithm for the management of liver impairment occurring during anti-TNF treatment is also proposed and this highlights the need of a multidisciplinary approach and suggests liver biopsy as a key-point in the management decision in case of severe rise of transaminases. However, hepatic injury is generally self-limiting and drug withdrawal seems to be an exception.
- Multicenter Outbreak of Infections by Saprochaete clavata, an Unrecognized Opportunistic Fungal Pathogen. [JOURNAL ARTICLE]
- MBio 2014; 5(6)
Rapidly fatal cases of invasive fungal infections due to a fungus later identified as Saprochaete clavata were reported in France in May 2012. The objectives of this study were to determine the clonal relatedness of the isolates and to investigate possible sources of contamination. A nationwide alert was launched to collect cases. Molecular identification methods, whole-genome sequencing (WGS), and clone-specific genotyping were used to analyze recent and historical isolates, and a case-case study was performed. Isolates from thirty cases (26 fungemias, 22 associated deaths at day 30) were collected between September 2011 and October 2012. Eighteen cases occurred within 8 weeks (outbreak) in 10 health care facilities, suggesting a common source of contamination, with potential secondary cases. Phylogenetic analysis identified one clade (clade A), which accounted for 16/18 outbreak cases. Results of microbiological investigations of environmental, drug, or food sources were negative. Analysis of exposures pointed to a medical device used for storage and infusion of blood products, but no fungal contamination was detected in the unused devices. Molecular identification of isolates from previous studies demonstrated that S. clavata can be found in dairy products and has already been involved in monocentric outbreaks in hematology wards. The possibility that S. clavata may transmit through contaminated medical devices or can be associated with dairy products as seen in previous European outbreaks is highly relevant for the management of future outbreaks due to this newly recognized pathogen. This report also underlines further the potential of WGS for investigation of outbreaks due to uncommon fungal pathogens.Several cases of rapidly fatal infections due to the fungus Saprochaete clavata were reported in France within a short period of time in three health care facilities, suggesting a common source of contamination. A nationwide alert collected 30 cases over 1 year, including an outbreak of 18 cases over 8 weeks. Whole-genome sequencing (WGS) was used to analyze recent and historical isolates and to design a clade-specific genotyping method that uncovered a clone associated with the outbreak, thus allowing a case-case study to analyze the risk factors associated with infection by the clone. The possibility that S. clavata may transmit through contaminated medical devices or can be associated with dairy products as seen in previous European outbreaks is highly relevant for the management of future outbreaks due to this newly recognized pathogen.
- Late rectal toxicity after low-dose-rate brachytherapy: Incidence, predictors, and management of side effects. [REVIEW]
- Brachytherapy 2014 Dec 13.
As clinical outcomes for patients with clinically localized prostate cancer continue to improve, patients and physicians are increasing making treatment decisions based on concerns regarding long-term morbidity. A primary concern is late radiation proctitis, a clinical entity embodied by various signs and symptoms, ranging from diarrhea to rectal fistulas. Here, we present a comprehensive literature review examining the clinical manifestations and pathophysiology of late radiation proctitis after low-dose-rate brachytherapy (BT), as well as its incidence and predictors. The long-term risks of rectal bleeding after BT are on the order of 5-7%, whereas the risks of severe ulceration or fistula are on the order of 0.6%. The most robust predictor appears to be the volume of rectum receiving the prescription dose. In certain situations (e.g., salvage setting, for patients with increased radiosensitivity, and following aggressive biopsy after BT), the risk of these severe toxicities may be increased by up to 10-fold. A variety of excellent management options exist for rectal bleeding, with endoscopic methods being the most commonly used.
- Psychoeducation to facilitate return to work in individuals on sick leave and at risk of having a mental disorder: protocol of a randomised controlled trial. [JOURNAL ARTICLE]
- BMC Public Health 2014 Dec 17; 14(1):1288.
Sickness absence due to poor mental health is a common problem in many Western countries. To facilitate return to work, it may be important to identify individuals on sick leave and at risk of having a mental disorder and subsequently to offer appropriate treatment. Psychoeducation alone has not previously been used as a return to work intervention, but may be a promising tool to facilitate return to work. Therefore, the aim of the study is to evaluate the effectiveness of psychoeducation designed specifically to facilitate return to work for individuals on sick leave and at risk of having a mental disorder. The psychoeducation was a supplement to the various standard offers provided by the job centres.Methods/design: The study is a randomised controlled trial, in which individuals on sick leave either receive psychoeducation and standard case management or standard case management alone. Participants were individuals with mental health symptoms, who had been on sick leave from part-time or full-time work or unemployment for about 4-8 weeks. The psychoeducational intervention was group-based and the course consisted of 2 hour sessions once a week for 6 weeks. The course was given by psychiatric nurses, a psychologist, a social worker, a physiotherapist and a person who had previously been on sick leave due to mental health problems. The sessions focused on stress and work life, and the purpose was to provide individuals on sick leave the skills to understand and improve their mental functioning.The primary outcome is the duration of sickness absence measured by register data. Secondary outcomes include psychological symptoms, mental health-related quality of life, and locus of control. These outcomes are measured by questionnaires at the start of the intervention and at 3 and 6 months follow-up.On the basis of this trial, the effect of psychoeducation for individuals on sick leave and at risk of having a mental disorder will be studied. The results will contribute to the continuing research on sickness absence and mental health. It will primarily show whether psychoeducation can lead to faster and sustainable return to work.Trial Registration: Clinical Trial.gov NCT01637363. Registered 6 July 2012.
- Effect of concentrates restriction on feed consumption, diet digestibility, and nitrogen utilization in captive Asian elephants (Elephas maximus). [JOURNAL ARTICLE]
- Zoo Biol 2014 Dec 16.
In order to study the effect of concentrates restriction on feed consumption, diet digestibility, and utilization of nitrogen in captive Asian elephants (Elephas maximus), two feeding trials were conducted on three juveniles, four sub-adults, and three adults. During trial I, the conventional zoo diets of juveniles, sub-adults, and adult contained 22, 17, and 16% of concentrates on dry matter (DM) basis, respectively. During trial II, the amount of concentrate was reduced by 50%. A digestion trial of five days collection period was conducted during each period. The animals ate more roughages when concentrates were restricted. Intake of DM (g/kg BW(0.75) /day) was highest in sub-adults, followed by juveniles and adults. Apparent digestibility of crude protein (CP), neutral detergent soluble (NDS), and supply of digestible energy (DE) was highest in juveniles, followed by sub-adults and adults. Based upon the estimated metabolic fecal nitrogen (MFN) and calculated endogenous urinary nitrogen (EUN) and dermal losses, minimum dietary CP required to meet maintenance requirement was estimated to be 6.12, 6.05, and 5.97% in juveniles, sub-adults, and adults, respectively. Restriction of concentrates resulted in decreased (P < 0.05) digestibility of DM and GE, but the diet still supplied adequate amounts of DE and CP to fulfill estimated requirements of energy and protein during the period of experimentation. Thus, the concentrates portion of the diets of captive Asian elephants should be fed in a restricted way so as to reduce the intake of excessive calories and the potential risk of obesity. Zoo Biol. 9999:1-11, 2014. © 2014 Wiley Periodicals, Inc.
- [Mass poisoning events.] [JOURNAL ARTICLE]
- Med Klin Intensivmed Notfmed 2014 Dec 18.
Mass poisoning events are rare and different in some respects from other mass casualties, especially with regard to diagnosis and triage.Based on the description of important historical events and experiences of poison control centers, an overview is provided for different types of mass poisoning events as well as guidelines for specific medical management.The review is based on a literature search and case reports notified to the Giftinformationszentrum-Nord Poisons Center.Toxicological risk assessment is based on identification of all relevant agents, evaluation of their toxic hazards (toxicity), and evaluation of the exposure (dose and pathway) for all persons exposed. This risk assessment constitutes the basis of medical diagnosis and management. In cases of suspicion of poisoning or poisonings caused by illegal drugs, risk assessment may be difficult due to the lack of important data needed for risk assessment. Mass poisonings caused by ethanol or contaminated food are well understood, with therapy being mainly symptomatic. However, in rare poisonings by other agents, a specific antidote treatment may be important. Thus, adequate antidote supplies must be available for these events.As hardly any medical professional has personal practical knowledge of mass poisoning casualties, such events are unique experiences. Thorough preparation and intensive cooperation with poison control centers and-if applicable-public health authorities may be important for best practice event management.
- Modeling for waste management associated with environmental-impact abatement under uncertainty. [JOURNAL ARTICLE]
- Environ Sci Pollut Res Int 2014 Dec 17.
Municipal solid waste (MSW) treatment can generate significant amounts of pollutants, and thus pose a risk on human health. Besides, in MSW management, various uncertainties exist in the related costs, impact factors, and objectives, which can affect the optimization processes and the decision schemes generated. In this study, a life cycle assessment-based interval-parameter programming (LCA-IPP) method is developed for MSW management associated with environmental-impact abatement under uncertainty. The LCA-IPP can effectively examine the environmental consequences based on a number of environmental impact categories (i.e., greenhouse gas equivalent, acid gas emissions, and respiratory inorganics), through analyzing each life cycle stage and/or major contributing process related to various MSW management activities. It can also tackle uncertainties existed in the related costs, impact factors, and objectives and expressed as interval numbers. Then, the LCA-IPP method is applied to MSW management for the City of Beijing, the capital of China, where energy consumptions and six environmental parameters [i.e., CO2, CO, CH4, NOX, SO2, inhalable particle (PM10)] are used as systematic tool to quantify environmental releases in entire life cycle stage of waste collection, transportation, treatment, and disposal of. Results associated with system cost, environmental impact, and the related policy implication are generated and analyzed. Results can help identify desired alternatives for managing MSW flows, which has advantages in providing compromised schemes under an integrated consideration of economic efficiency and environmental impact under uncertainty.
- How to evaluate population management? Transforming the Care Continuum Alliance population health guide toward a broadly applicable analytical framework. [JOURNAL ARTICLE]
- Health Policy 2014 Dec 10.
Many countries face the persistent twin challenge of providing high-quality care while keeping health systems affordable and accessible. As a result, the interest for more efficient strategies to stimulate population health is increasing. A possible successful strategy is population management (PM). PM strives to address health needs for the population at-risk and the chronically ill at all points along the health continuum by integrating services across health care, prevention, social care and welfare. The Care Continuum Alliance (CCA) population health guide, which recently changed their name in Population Health Alliance (PHA) provides a useful instrument for implementing and evaluating such innovative approaches. This framework is developed for PM specifically and describes the core elements of the PM-concept on the basis of six subsequent interrelated steps. The aim of this article is to transform the CCA framework into an analytical framework. Quantitative methods are refined and we operationalized a set of indicators to measure the impact of PM in terms of the Triple Aim (population health, quality of care and cost per capita). Additionally, we added a qualitative part to gain insight into the implementation process of PM. This resulted in a broadly applicable analytical framework based on a mixed-methods approach. In the coming years, the analytical framework will be applied within the Dutch Monitor Population Management to derive transferable 'lessons learned' and to methodologically underpin the concept of PM.
- Carbohydrates and obesity: from evidence to policy in the UK. [JOURNAL ARTICLE]
- Proc Nutr Soc 2014 Dec 17.:1-6.
Carbohydrates provide the major source of energy in the diet and hence the type and amount of carbohydrate consumed is an important consideration for weight control. Recent risk assessments have shown that there is no consistent association between the proportions of energy consumed as carbohydrate and body weight and reinforce the dominance of total energy intake as the primary determinant of body weight. However, they have highlighted evidence that different types of carbohydrate have specific effects on the risk of obesity. Short-term experimental studies suggest that some types of dietary fibre may be linked to increased satiation and cohort studies are supportive of an association between low intakes of fibre-rich, whole-grain foods and weight gain. But these observations are not supported by evidence of effects on body weight in randomised controlled trials, suggesting that high-fibre or whole-grain intake may simply be a marker of a broader dietary pattern. Recent attention has focused on the growing evidence of a positive association between the intake of free sugars and weight gain and particularly the risks linked to consumption of sugar-sweetened beverages (SSB). Given the high population-level intake of free sugars the challenge is to identify actions that will successfully reduce consumption to contribute to reductions in the prevalence of obesity. The present paper considers the range of policy options available, using the Nuffield ladder of intervention to provide a framework for risk management, with a focus on the consumption of SSB. Current policy interventions are largely based around consumer education and encouragement to industry to renovate products to reduce the sugar content of food and drinks and/or reduce portion size, but dietary change has been slow. Further measures, including the use of specific incentives/disincentives may be needed to change consumption patterns, some of which may infringe personal or commercial freedom. For these policies to be implemented will require sustained efforts to create a climate in which such interventions are acceptable or even welcomed by society as an appropriate protection against obesity and other diet-related ill-health.