Value redefined for inflammatory bowel disease patients: a choice-based conjoint analysis of patients' preferences.

PURPOSE: Value-based healthcare is an upcoming field. The core idea is to evaluate care based on achieved outcomes divided by the costs. Unfortunately, the optimal way to evaluate outcomes is ill-defined. In this study, we aim to develop a single, preference based, outcome metric, which can be used to quantify overall health value in inflammatory bowel disease (IBD). METHODS: IBD patients filled out a choice-based conjoint (CBC) questionnaire in which patients chose preferable outcome scenarios with different levels of disease control (DC), quality of life (QoL), and productivity (Pr). A CBC analysis was performed to estimate the relative value of DC, QoL, and Pr. A patient-centered composite score was developed which was weighted based on the stated preferences. RESULTS: We included 210 IBD patients. Large differences in stated preferences were observed. Increases from low to intermediate outcome levels were valued more than increases from intermediate to high outcome levels. Overall, QoL was more important to patients than DC or Pr. Individual outcome scores were calculated based on the stated preferences. This score was significantly different from a score not weighted based on patient preferences in patients with active disease. CONCLUSIONS: We showed the feasibility of creating a single outcome metric in IBD which incorporates patients' values using a CBC. Because this metric changes significantly when weighted according to patients' values, we propose that success in healthcare should be measured accordingly.

Salmonella Subcutaneous Abscess: A Rare Complication Post Salmonella Gastroenteritis.

Salmonella is a gram-negative bacilli bacterium that can infect and colonize humans, causing a wide range of clinical manifestations. The most common manifestation is gastroenteritis, usually after ingestion of undercooked and ill-prepared food, particularly in developing countries. Indonesia is among those reported to have a high incidence of Salmonella infection. Uncommonly, extraintestinal manifestations can affect distant body sites, either during or after the episode of bacteremia. This case report presents a rare case of a healthy 19-year-old female who developed an atypical chest wall abscess colonized by Salmonella in the context of experiencing gastroenteritis three weeks prior on her return from Bali, Indonesia. This case highlights the indolent course associated with a Salmonella chest wall abscess with a discussion of the current literature and management.

A Rare Case of Metastatic Hepatocellular Carcinoma to the Hard Palate.

Extrahepatic metastasis of hepatocellular carcinoma (HCC) to the head and neck is unusual, especially the oral cavity/maxillofacial region. Metastatic HCC to the hard palate, however, is particularly rare. The most common site of HCC metastasis is the lung, followed by lymph nodes, bone, and adrenal gland. Importantly, oral cavity metastatic HCC may be misdiagnosed as a primary malignancy, such as a salivary gland carcinoma. In this article, we describe a young woman with metastatic HCC to the hard palate that was initially diagnosed as an acinic cell carcinoma.

Assessment of the microbiome during bacteriophage therapy in combination with systemic antibiotics to treat a case of staphylococcal device infection.

BACKGROUND: Infectious bacterial diseases exhibiting increasing resistance to antibiotics are a serious global health issue. Bacteriophage therapy is an anti-microbial alternative to treat patients with serious bacterial infections. However, the impacts to the host microbiome in response to clinical use of phage therapy are not well understood. RESULTS: Our paper demonstrates a largely unchanged microbiota profile during 4 weeks of phage therapy when added to systemic antibiotics in a single patient with Staphylococcus aureus device infection. Metabolomic analyses suggest potential indirect cascading ecological impacts to the host (skin) microbiome. We did not detect genomes of the three phages used to treat the patient in metagenomic samples taken from saliva, stool, and skin; however, phages were detected using endpoint-PCR in patient serum. CONCLUSION: Results from our proof-of-principal study supports the use of bacteriophages as a microbiome-sparing approach to treat bacterial infections. Video abstract.

Firefighters' and Emergency Medical Service Personnel's Knowledge and Training on Radiation Exposures and Safety: Results from a Survey.

Little is known about first responders' knowledge of radiation exposure and the training they receive regarding radiological events. Firefighters and emergency medical services (EMS) personnel were surveyed in July 2018 to February 2019 regarding their knowledge of radiation exposure and the radiological event training they had received. Knowledge was assessed using 15 true-false questions. Five types of radiological event training were assessed. A Mann-Whitney test assessed differences in training received by occupation. A linear regression identified predictors of knowledge scores. A total of 433 individuals completed the survey (response rate = 82.9%). Knowledge scores ranged from 5 to 13, with an average of 8.6. Predictors of knowledge included having received more training on radiological transportation incidents or improvised nuclear devices, and being a firefighter. About a quarter (23.6%, n = 102) had not received any of the 5 types of radiological event training. Firefighters received more training than EMS personnel except on nuclear reactor incidents. Only 14% had participated in a radiological event exercise. First responders' knowledge of radiation exposure and prevention measures is low, and many have received either no or very little training on radiological events. The lack of radiation exposure knowledge and radiological event training received, as identified in this study, could result in increased mortality rates. First responder agencies should provide additional radiological event training and exercise opportunities.

Influence of boric acid on energy metabolism and stress tolerance of Candida albicans.

Boron presents at physiological pH in the form of boric acid (BA), a molecule that has both positive and negative effects on biological processes. In medicine, BA is used as a topical treatment for vaginal yeast infections by Candida species because of its well-documented but poorly understood effect on inhibition of growth in general and of invasive, hyphal growth in particular. The present study examines the influence of BA on carbohydrate energy metabolism of this common human pathogen. Starting from previous findings about an inhibition of key NAD-dependent enzymes by BA in vitro, we confirmed that such an inhibition occurs in permeabilized C. albicans cells. Cultures growing even with moderate concentrations of BA experience mitochondrial failure, increase ethanol production from glucose and decrease the deposition of carbohydrate stores in the form of glycogen. Cells growing on the non-fermentable, FAD-generating carbon source lactate have a higher BA tolerance, which suggests that the toxicity of BA is rooted in an inhibition of NAD-dependent reactions and the increased production of ethanol. Boric acid exposure sensitizes C. albicans selectively to the toxic effects of ethanol. This additive effect suggests that the endogenously produced ethanol increases the load on ethanol resistance mechanisms. Lastly, combination studies showed no interactions of BA with common antifungal drugs, meaning that addition of BA to topical formulations can provide an additive antifungal effect regardless of the chosen active ingredient.

A comprehensive review of the treatment of Merkel cell carcinoma.

Merkel cell carcinoma (MCC) is an uncommon but malignant cutaneous neuroendocrine carcinoma with a high incidence of local recurrence, regional lymph node metastases, and subsequent distant metastases. The etiology of MCC remains unknown. It usually occurs in sun-exposed areas in elderly people, many of whom have a history of other synchronous or metachronous sun-associated skin lesions. The outcome for most patients with MCC is generally poor. Surgery is the mainstay of treatment. The role of adjuvant therapy has been debated. However, data from recent development support a multimodality approach, including surgical excision of primary tumor with adequate margins and sentinel lymph node dissection followed by postoperative radiotherapy in most cases, as current choice of practice with better locoregional control and disease-free survival. Patients with regional nodal involvement or advanced disease should undergo nodal dissection followed by adjuvant radiotherapy and, perhaps, systemic platinum-based chemotherapy in most cases.

Characterization of laryngopharyngeal reflux in patients with premalignant or early carcinomas of the larynx.

BACKGROUND: An association between laryngopharyngeal reflux (LPR) and laryngeal carcinoma has been suggested, but remains unproven. The current pilot study was performed to determine the incidence of LPR among patients with early laryngeal carcinomas or dysplasia and to examine the associations between levels of LPR and histologic stage, smoking status, the symptom of heartburn, and body position during reflux episodes. METHODS: Behavioral and 24 hour pH monitoring data were prospectively acquired and analyzed for 40 previously untreated adults with dysplasia, T1 or T2 laryngeal carcinomas. RESULTS: Eighty-five percent of patients had LPR. No significant association was shown between the level of LPR and histologic stage or smoking status. Heartburn did not predict LPR. The incidence of LPR in the upright body position was 91%, compared with 9% in the supine position, among patients with LPR. CONCLUSIONS: When compared to available normative data, the current findings show a high incidence of LPR in patients with premalignant and early laryngeal cancer. These findings highlight the need for a matched-control study evaluating LPR as a potential predisposing factor for laryngeal carcinoma.