[A comparison study of cognitive-behavioral therapy alone versus combination with tapered hypnotic agents in patients with chronic insomnia].

Objective: To investigate the efficacy of cognitive-behavioral therapy for insomnia (CBT-i) or combination with tapered hypnotic agents. Methods: Seventy-five patients were randomized into either CBT-i group (n=37) or combination group (n=38). The duration of treatment lasted for 8 weeks. The efficacy was evaluated by Pittsburgh sleep quality index (PSQI), Beck depression index (BDI) , Beck anxiety inventory (BAI) and sleep diary variables at baseline, middle and end of treatment. Results: (1)Compared with the results at baseline, the total scores of PSQI,BDI and BAI in both groups significantly decreased at the end of treatment: CBT-i group, PSQI (4.7±2.5) vs. (12.9±3.5); BDI (3.2±4.4) vs. (9.7±6.4); BAI (4.2±5.6) vs. (10.7±8.1); and combination group, PSQI (5.8±2.8) vs. (13.9±3.1); BDI (4.5±4.8) vs. (13.8±8.7); BAI (4.4±4.0) vs. (14.1±6.3) (all P<0.01). (2) Compared with the results at baseline, subjective sleep quality (SQ), sleep onset latency (SOL), sleep efficiency (SE), sleep disturbance (SD) and used sleep medication (USM) in PSQI in combination group significantly decreased at week 4 and 8 (all P<0.05) . The total sleep time (TST) and daytime dysfunction (DF) in PSQI significantly decreased at week 8 (both P<0.05) . (3) Compared with combination group, improvement of SOL and SE in CBT-i group was superior (both P=0.01). Conclusions: CBT-i for chronic insomnia is effective in both CBT-i alone and combination with tapered hypnotic agents. CBT-i group is superior in improving SOL and SE. Combination regimen in our study can significantly reduce the doses of medication.

Real-world costs of ischemic stroke by discharge status.

OBJECTIVE: The objective of this study was to estimate the acute healthcare costs of ischemic stroke during hospitalization and the quarterly all-cause healthcare costs for the first year after discharge by discharge status. METHODS: Adult patients with a hospitalization with a diagnosis of ischemic stroke (ICD-9-CM: 434.xx or 436.xx) between 1 January 2006 and 31 March 2015 were identified from a large US commercial claims database. Patients were classified into three cohorts based on their discharge status from the first stroke hospitalization, i.e. dead at discharge, discharged with disability, or discharged without disability. Third-party (medical and pharmacy) and out-of-pocket costs were adjusted to 2015 USD. RESULTS: A total of 7919 patients dead at discharge, 45,695 patients discharged with disability, and 153,778 patients discharged without disability were included in this analysis. The overall average age was 59.7 years and 52.3% were male. During hospitalization, mean total costs (third-party and out-of-pocket) were $68,370 for patients dead at discharge, $73,903 for patients discharged with disability, and $24,448 for patients discharged without disability (p < .001 for each pairwise comparison); mean third-party costs were $63,605 for patients dead at discharge, $67,861 for patients discharged with disability and $19,267 for patients discharged without disability (p < .001 for each pairwise comparison). During the first year after discharge, mean total costs for patients discharged with disability vs. without disability were $46,850 vs. $30,132 (p < .001). Mean third-party costs for patients discharged with disability vs. without disability were $19,116 vs. $10,976 during the first quarter after discharge, $10,236 vs. $6926 during the second quarter, $8241 vs. $5810 during the third quarter, and $6875 vs. $5292 during the fourth quarter (p < .001 for each quarter). CONCLUSION: The results demonstrated the high economic burden of ischemic stroke, especially among patients discharged with disability with the highest costs incurred during the inpatient stays.

Hospital-acquired hepatitis a: report of an outbreak.

A nosocomial outbreak of hepatitis A occurred after hospitalization of a 21-month-old girl with amebic liver abscess and unsuspected, anicteric hepatitis A. The index patient, who had an acute diarrheal illness prior to enzyme elevations, seroconverted from IgM hepatitis A antibody to IgG hepatitis A antibody. Of the 103 hospital personnel with known or potential exposure, three physicians (2.9%) contracted clinical hepatitis A, 27 to 29 days after their initial contact with the source patient. A fourth physician developed subclinical infection. Two of the three clinical cases occurred in two of the three primary care physicians of the source patient. Hepatitis A should be considered in any patient with acute, unexplained liver enzyme abnormalities. Diarrhea occurring in a fecally incontinent child incubating hepatitis A may increase the risk of transmission.

The CHOICE trial: adalimumab demonstrates safety, fistula healing, improved quality of life and increased work productivity in patients with Crohn's disease who failed prior infliximab therapy.

BACKGROUND: Adalimumab induces and maintains remission in adults with Crohn's disease. AIM: To evaluate safety, fistula healing, quality of life and work productivity in adalimumab-treated patients who failed infliximab, including primary nonresponders. METHODS: After a ≥8-week infliximab washout, patients with moderate-to-severe Crohn's disease received open-label adalimumab as induction (160/80 mg at weeks 0/2) and maintenance (40 mg every other week) therapies. At/after 8 weeks, patients with flare/nonresponse could receive weekly therapy. Minimum study duration was 8 weeks, continuing until the commercial availability of adalimumab for Crohn's disease. RESULTS: Of 673 patients enrolled, 17% were infliximab primary nonresponders and 83% were initial responders. Three percent of patients had serious infections (mainly abscesses). Complete fistula healing was achieved by 34/88 (39%) patients with baseline fistulas. Improvements in quality of life and work productivity were sustained from week 4 to week 24 for all patients, as well as the subgroup of primary nonresponders. CONCLUSIONS: Blinded clinical trials have shown adalimumab to be both an effective first-line therapy for anti-TNF-naïve patients and an important treatment option for infliximab-refractory or -intolerant patients. This trial presents open-label experience to support further the safety and effectiveness of adalimumab in patients who failed infliximab therapy, including primary nonresponders (NCT00338650).

An unusual cause of chylothorax after Norwood stage one reconstruction.

We report an unusual cause of prolonged chylothorax drainage after Norwood stage one reconstruction. This 1-month-old girl's chylous drainage was refractory to medical treatment. Echocardiography revealed thrombosis of the superior vena cava. Upon sternotomy to remove the thrombus, we were surprised to find the ePTFE (expanded polytetrafluoroethylene) tube previously used for selective cerebral perfusion compressing the innominate vein and the pericardium-based aortic arch. We performed a superior vena cava thrombectomy and shortened the ePTFE tube. Her chylothorax subsided gradually. We suggest that external compression of the venous drainage system should be considered in patients with prolonged chylothorax drainage. Once medical treatment fails, early surgical exploration may be helpful to stop the chylothorax.

Management of diastolic heart failure--a practical review of pathophysiology and treatment trial data.

The lack of large randomised controlled trials to guide therapy in diastolic heart failure causes some difficulties for evidence-based medicine practising clinicians. Traditionally, treatments for systolic heart failure have been highjacked for diastolic heart failure without much proof of benefit. However, recent studies have began to provide some evidence base for our practice. Betablockers and angiotensin receptor antagonists have recently been shown to reduce hospitalisation in large randomised controlled trials. Diuretic based antihypertensive regimes have been shown to reduce heart failure by 50%. Left ventricular hypertrophy regression is likely to be a good surrogate endpoint for diastolic heart failure, although definitive proof for this is not yet available. Angiotensin receptor antagonists, ACEI, calcium channel blockers, diuretics and aldosterone blockers have all been shown to cause left ventricular hypertrophy regression. We recommend these drugs to achieve strict blood pressure control together with dietary and lifestyle modification for the treatment of diastolic heart failure. We emphasise the importance of rate control, as diastolic heart-failure patients tolerate tachycardia poorly. We further argue that the pathophysiology of diastolic heart failure is part of systolic heart failure and the two should not be thought of as separate entities. Therefore, our traditional practice of using systolic heart failure treatments for diastolic heart failure is theoretically sound and should not cause us undue anxiety.