The impact of health on economic growth: A narrative literature review.

The nexus between health and economic growth is a dynamic and complex relationship. This article reviews the empirical evidence that has sought to assess the causal impact of health on growth, understood as growth in GDP per capita, and focusing on cross-country and selected single country studies. The review largely provides evidence in favour of a positive effect of population health on economic growth. However, the multitude of the factors at play and the possible bidirectional relationship between health and growth pose a challenge for the quantification of the effect and for the relative importance of the underlying mechanisms. There is notable heterogeneity between studies in the magnitude and, in some cases, even in the sign of the effect. The evidence suggests that the health-growth relationship may depend on three main factors: the sample composition (i.e. a country's demographic stage or GDP per capita); the health dimension considered (e.g. health improvements at different life stages may affect productivity differently); and the model specification (e.g. whether or not initial life expectancy is controlled for in the analysis or the quality of the instrument). These findings advocate for a policy approach that integrates health considerations into economic strategies and emphasizes intersectoral collaboration to maximize the economic returns from improved health outcomes.

Infliximab for treatment of steroid-refractory ulcerative colitis.

BACKGROUND: Success achieved in two subtypes of Crohn's disease has persuaded a few investigators to experiment the monoclonal anti-tumour necrosis factor antibody infliximab in the treatment of ulcerative colitis. So far, however, the results (achieved in some 30 steroid-refractory patients included in two independent full-papers) indicate a rate of initial response of 50% and of remission of 25%. AIMS: To analyse data of an open trial conducted on consecutive steroid-refractory severely ill patients admitted to our referral Unit. PATIENTS AND METHODS: In 9 months, infliximab was given to 8 patients (4 male, 4 female aged 20-60 years) with uncontrolled ulcerative colitis of whom 6 were non-responders to parenteral steroids. All received the first infliximab dose as an intravenous infusion of 5 mg/kg. RESULTS: Of the 8, 4 (50%) did not respond to the first injection and were submitted to urgent colectomy; the other four responded clinically. Two have maintained clinical remission for 7 months, without the need for steroids; both have received daily azathioprine at 2 mg/kg, and only one has received two further infliximab injections. Of the other two, one received a second injection at week 5, despite this relapsed, and underwent elective colectomy at that time; the other relapsed at 6 months and showed a partial response to a repeat infliximab infusion. Thus, the rate of sustained response is 2/8 (25%) in this study. CONCLUSION: These results, achieved in an open uncontrolled fashion, seem to reflect those of other independent studies. In our opinion, these findings warrant an in-depth reappraisal of the indication to use infliximab as rescue treatment for refractory ulcerative colitis.

An audit of the immunosuppressive management of ulcerative colitis. A retrospective chart review from a referral Day-Hospital of Gastro-enterology.

BACKGROUND: Ulcerative colitis is a chronic inflammatory disease of the colon thought to be caused by an abnormal T-cell response to lumenal antigens. In the last 10 years immunosuppressives have been proposed to treat its severe forms including cyclosporin and azathioprine. METHODS: An analysis of 72 patients treated for severe ulcerative colitis between 1991 and 2001 at our Day Hospital permitted an audit of the efficacy of this two-drug regime. RESULTS: Overall, the percentages of patients avoiding colectomy immediately, at 1 year, and on ending the study were 68, 47 and 36%, respectively. Thirty-five (81%) of the 43 colectomies, performed as a restorative procedure, clustered in the first year after disease presentation. The risk of colectomy was significantly reduced in the subset treated with azathioprine. Of the 25 long-term responder patients avoiding colectomy, to-date 16 (64%) had at least a relapse at the median time of 17.5 months; all but 1 episodes were managed on an out-patient basis. The types and frequencies of observed side-effects were within the known therapeutic profile of the two drugs. CONCLUSIONS: A two-drug regime of cyclosporin and azathioprine can avoid colectomy for 1 year in slightly less than 50% of a cohort of severe ulcerative colitis patients and permits an acceptable long-term response in slightly less than 40%. An accurate evaluation of this policy needs to be balanced with other options, including most recently refined techniques of colectomy.

Long-term efficacy of oral microemulsion cyclosporin for refractory ulcerative colitis.

AIM: The 60% bioavailable oral microemulsion formulation of cyclosporin (NEORAL ), has replaced the intravenous route to treat both organ transplant and immune-based disease. Its use for steroid-refractory ulcerative colitis (a recognized indication for intravenous cyclosporin) has been scanty. METHODS: Twenty-three consecutive patients (14 male/9 female, universal colitis 14/23) entered a 3-month course of NEORAL (initially dosed at 5 mg/kg/day) because of steroid-refractoriness (14 cases) and steroid-dependence (9 cases). Responders (at least showing a 50% reduction of a clinical activity score) were continued on azathioprine. The initial steroid dose was tapered on commencing NEORAL; patients requiring steroid resumption or increase in the follow-up were defined as relapsers. RESULTS: The target trough concentration of 200 ng/ml of whole blood was achieved without major titration in all but 1 patient. There were 7 non-responders (30%). Of the 16 responders (70%), 2 have not relapsed; the remaining 14 relapsed at the median time of 9.5 months (1.5-60) with 10 (71%) showing only 1 relapse. Five patients were colectomized 12 months after NEORAL (1.5-24), leaving 11 of the initial 23 (47%) with their colon. Of the 16, all but 1 had azathioprine; the median daily steroid needs fell from 32 to 5 mg. CONCLUSION: The rates of acute and chronic response of 70% and 47% achieved by NEORAL in this indication duplicate the figures achieved by the traditional schedules of cyclosporin administration.

[Possibility of radiology in the study of defection disorders]. / Possibilità della radiologia nello studio dei disturbi della defecazione.

Chronic constipation and defecation disorders are a very common disease, but the diagnosis is often unsatisfactory and therefore therapy is mostly inadequate. The purpose of this paper is to demonstrate the contribution of radiological procedures and mainly of the defecography, in improving and determining the diagnosis itself. Many normal and pathological cases are reviewed, described and demonstrated by radiological patterns. Finally, a correct protocol of different procedures, radiological and not, for morphological and functional study of large bowel and pelvis floor is stressed.

[Long-term effects of gastric resection on the inferior esophageal sphincter]. / Effetti a distanza della resezione gastrica sullo sfintere esofageo inferiore.

The manometric profile of the oesophagogastric junction has been studied in patients subjected one year earlier to partial gastric resection. A reduction in maximum basal pressure (--49.8%) and length of the lower oesophageal sphincter (--35.45%) were noted. These figures agree with what was observed one month after operation in a previous study. It is concluded that gastric resection lead to a non-transitory reduction in sphincter function.

Continuously infused cyclosporine at low dose is sufficient to avoid emergency colectomy in acute attacks of ulcerative colitis without the need for high-dose steroids.

A dosage of 4 mg/kg/day intravenous cyclosporine as an adjunct to high-dosage hydrocortisone has been recommended to avoid colectomy in acute steroid-resistant ulcerative colitis. In treating eight such patients, four of whom presented with toxic megacolon, we immediately tapered the steroid dosage and infused a lower dosage of only 2 mg/kg cyclosporine for 15 days to fit a therapeutic range of 60-240 ng/ml, as previously designed for a kidney transplant program. Seven of the eight (87.5%), including three with megacolon, went into remission and started the chronic phase of treatment; the eighth patient underwent colectomy. Of the seven, one died on day 3 of the chronic phase because of pulmonary embolism while in clinical remission, and another discontinued treatment. The other five (62.5%) remain in remission on 6 mg/kg oral cyclosporine, or have already switched from cyclosporine to azathioprine. Two episodes of reversible nephrotoxicity appeared in the chronic phase only. These results emphasize the efficacy and safety of cyclosporine in acute ulcerative colitis, but there is still a need for further dose-response and drug association relationship studies.

Severe steroid-unresponsive ulcerative colitis: outcomes of restorative proctocolectomy in patients undergoing cyclosporin treatment.

PURPOSE: The recent introduction of the immune suppressor cyclosporin for treatment of steroid-refractory ulcerative colitis has required surgeons to perform a colectomy in those patients who eventually fail this rescue treatment, thus raising questions as to the safety of surgery as performed in patients with a heavily manipulated immune system. To assess the rates of mortality and morbidity in this setting, we studied a cohort of consecutive patients who had surgery after failing cyclosporin for refractory ulcerative colitis at our center. METHODS: Between January 1991 and December 1996, 25 patients with ulcerative colitis underwent restorative proctocolectomy performed in three steps (21 patients) and in two steps (4 patients). Seventeen of the 25 patients (68 percent) were initial nonresponders to a dose of 2 mg/kg/day of intravenous cyclosporin and underwent surgery immediately, the remaining 8 (32 percent) relapsed as outpatients on oral cyclosporin and were readmitted for surgery. RESULTS: There was no operative mortality. Nine patients of the 25 developed postoperative (early) complications (36 percent). The three-step operation subset had a 28 percent complication rate, the two-step 75 percent. Three patients needed reoperation. A total of 11 patients (44 percent) reported with late complications: two patients required surgical treatment, one for obstruction and one for pouch-perianal fistula. Three cases of pouchitis were recorded. No patient required pouch removal. CONCLUSION: Given the absence of postoperative mortality and a low overall complication rate, restorative proctocolectomy can safely be performed in patients who fail rescue treatment with a dose of 2 mg/kg of cyclosporin for steroid-refractory ulcerative colitis. Corollary evidence in this article hints but does not prove that the three-step procedure is safer than the two-step operation.

Pudendal neuropathy in diabetic patients with faecal incontinence.

To investigate the pathophysiology of faecal incontinence in diabetes mellitus, two groups of diabetic patients were studied: 14 subjects (7 females and 7 males, mean age 57 +/- 9 years) with faecal incontinence (Group A) and 15 subjects (6 females and 9 males, mean age 54.7 +/- 8 years) without faecal incontinence but affected by somatic peripheral neuropathy. A third group (C) of 10 healthy volunteers was used as controls. All subjects underwent electroneurographic evaluation of peripheral neuropathy, pudendal nerve terminal motor latency, anorectal manometry and rectal sensitivity tests. All the patients of group A had somatic peripheral neuropathy. Maximum squeeze pressure was lower in A compared to C (P < 0.025) and sustained for a shorter period in A compared with B (P < 0.0005) and C (P < 0.0005). All rectal sensitivity thresholds were higher in A compared with B and C. Pudendal Nerve Terminal Motor Latency was prolonged in 93% of patients studied in group A and in 73% of patients in group B (A vs B P < 0.005), with a significant difference in comparison with C: A vs C P < 0.0005, B vs C P < 0.005. Our findings suggest that somatic neuropathy plays an important role in faecal incontinence in diabetic patients, combined with sensation threshold impairment as a feature of an autonomic involvement.

Emergency colonoscopy.

Different diagnostic techniques for massive active lower gastrointestinal hemorrhage are reviewed. According to data in the literature and personal experience in 409 emergency endoscopic examinations of the large bowel, emergency colonoscopy is a valuable diagnostic tool in cases of massive colorectal bleeding.