Trends In Treatment Outcomes Research Articles

Re-evaluating the merits of decentralization as a core strategy for effective delivery of drug-resistant tuberculosis care in Pakistan.

Decentralized, person-centred models of care delivery for drug-resistant tuberculosis (DR-TB) continue to be under-resourced in high-burden TB countries. The implementation of such models—made increasingly urgent by the COVID-19 pandemic—are key to addressing gaps in DR-TB care. We abstracted data of rifampicin-resistant (RR)/multidrug-resistant tuberculosis (MDR-TB) patients initiated on treatment at 11 facilities between 2010 and 2017 in Sindh and Balochistan provinces of Pakistan. We analysed trends in treatment outcomes relating to programme expansion to peri-urban and rural areas and estimated driving distance from patient residence to treatment facility. Among the 5586 RR/MDR-TB patients in the analysis, overall treatment success decreased from 82% to 66% between 2010 and 2017, as the programme expanded. The adjusted risk ratio for unfavourable outcomes was 1.013 (95% confidence interval 1.005–1.021) for every 20 km of driving distance. Our analysis suggests that expanding DR-TB care to centralized hubs added to increased unfavourable outcomes for people accessing care in peri-urban and rural districts. We propose that as enrolments increase, expanding DR-TB services close to or within affected communities is essential.

OP19 Disease course and treatment outcomes of early resected Crohn’s Disease patients: A Danish nationwide cohort study from 1997 to 2015

Abstract Background Limited resective surgery is used as a primary therapeutic option in patients with Crohn’s disease (CD) who present with severe symptoms or fibrostenotic complications. Recent studies suggest that surgery represents a valid alternative of biological therapy in subgroups of CD patients.1 However, only few studies have described the disease course in early resected CD patients regardless of disease location. This study aimed to investigate disease course in all early resected CD patients. Methods Using the Danish National Patient Registry (NPR), we identified 9739 patients who were diagnosed with CD between January 1st, 1997 and December 31st, 2015. Of those, 499 patients underwent a major abdominal surgery within 30 days before or after their diagnosis. Data on re-operation, hospitalization and medication use were retrieved from the NPR and the National Prescription Registry. Trends in treatment outcomes over time were assessed using Chi-square test, Kaplan Meier survival analysis and log-rank test. Results Overall, 217 (43.5%) patients had an initial ileocecal resection, 154 (30.9%) had a colonic resection and 112 (22.4%) had a small bowel resection and 16(3.2%) patients without classification of surgery. The cumulative risk of reoperation was 16.4% at five years after the initial surgery. Five-year risk of hospitalization and need for medical therapy was 66.1% and 61.7% (Figure 1). Among 326 (65.3%) patients who received medical therapy during follow-up, 216 (66.3%) were treated with an immunomodulator and 62 (19.0%) with a biological drug. There was no difference in the risk of re-operation (p=0.11), hospitalization (p=0.70) or medication use (p=0.37) in relation to the anatomic location of the initial surgery. When comparing patients diagnosed before and after 2005, five-year risk of hospitalization decreased from 76.9% to 56.1% (p<0.001, Figure 2), while five-year risk of medication use decreased from 65.9% to 58.5% (p=0.01, Figure 2). In contrast, five-year risk of re-operation showed an increasing, but insignificant trend from 13.7% to 18.6% (p=0.18). Conclusion The risk of re-operation and hospitalization after the initial surgery in this cohort of early resected CD patients are lower when compared to other CD cohorts. Furthermore, hospitalization risk and need for medical therapy decreased over time. Reference

Sociodemographic and clinical characteristics in child and youth mental health; comparison of routine outcome measurements of an Australian and Dutch outpatient cohort.

Although of great value to understand the treatment results for mental health problems obtained in clinical practice, studies using naturalistic data from children and adolescents seeking clinical care because of complex mental health problems are limited. Cross-national comparison of naturalistic outcomes in this population is seldomly done. Although careful consideration is needed, such comparisons are likely to contribute to an open dialogue about cross-national differences and may stimulate service improvement. The aim of this observational study is to investigate clinical characteristics and outcomes in naturalistic cohorts of specialized child and adolescent mental health outpatient care in two different countries. Routinely collected data from 2013 to 2018 of 2715 outpatients in the Greater Area of Brisbane, Australia (CYMHS) and 1158 outpatients in Leiden, the Netherlands (LUMC-Curium) were analysed. Demographics, clinical characteristics and severity of problems at start and end of treatment were described, using Children's Global Assessment Scale (CGAS), Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) and the parental Strength and Difficulties Questionnaire (SDQ-P). Routine outcome measures (CGAS, HoNOSCA, SDQ-P) showed moderate to severe mental health problems at start of treatment, which improved significantly over time in both cohorts. Effect sizes ranged between 0.73-0.90 (CYMHS) and 0.57-0.76 (LUMC-Curium). While internalizing problems (mood disorder, anxiety disorder and stress-related disorder) were more prevalent at CYMHS, externalizing developmental problems (ADHD, autism) prevailed at LUMC-Curium. Comorbidity (>1 diagnosis on ICD10/DSM-IV) was relatively similar: 45% at CYMHS and 39 % at LUMC-Curium. In both countries, improvement of functioning was lowest for conduct disorder and highest for somatoform/conversion disorders and obsessive-compulsive disorders (OCD). Overall, 20-40% showed clinically significant improvement (shift from clinical-range at start to a non-clinical-range at the end of treatment), but nearly half of patients still experienced significant symptoms at discharge. This large-scale outcome study showed both cohorts from Australia and the Netherlands improve during the course of treatment on clinician- and parent-reported measures. Although samples were situated within different contexts and differed in patient profiles, they showed similar trends in improvement per diagnostic group. While 20-40% showed clinically significant change, many patients experienced residual symptoms reflecting increased risk for negative outcome into adulthood. We emphasize cross-national comparison of naturalistic outcomes faces challenges, although it can similarly reveal trends in treatment outcome providing direction for future research: what factors determine discharge from specialized services; and how to improve current treatments in this severely affected population.

Trends in treatment outcomes for retractile testis in Japanese boys: A single-center study.

To investigate the natural course of retractile testis by analyzing its prevalence and outcomes. This retrospective study included 215 boys in whom retractile testis was diagnosed after reviewing the medical history and physical examinations of the patients. Orchiopexy was performed once the testis became undescended. We investigated the trends in the prevalence and outcomes of retractile testis and compared clinical factors between cases that resolved spontaneously and those that required orchiopexy. Of 215 boys, 145 were finally evaluated. The mean age at diagnosis was 2years, and 100 boys were aged ≤2years when they were hospitalized. Seventy-three boys were referred to our institution through health examinations as babies. The condition improved spontaneously in 89 boys, while 43 boys underwent orchiopexy, and 13 boys remained under follow-up. The follow-up period between diagnosis and resolution was significantly longer in the spontaneous resolution group than in the surgical intervention group (P=0.011). Bilateral retractile testis improved spontaneously in significantly more boys compared to unilateral retractile testis (P=0.0010). Spontaneous resolution was observed in boys of all ages, but those diagnosed at ≤3years of age had a significantly higher rate of spontaneous resolution compared to those who were diagnosed at >3years of age (P=0.0019). Our findings suggest that retractile testis cannot be affirmed as a variant of normal testis. Performing examinations at a young age is critical for preventing misdiagnosis, screening failures, and unnecessary surgery.

Trends in treatment outcomes of hydrocele in Japanese children: A single-institute experience.

To investigate trends in treatment outcomes of surgical intervention versus observation for pediatric hydrocele. This retrospective study included 175 patients diagnosed with hydrocele at our institution. Hydrocele was diagnosed based on medical history, physical examination and ultrasonography findings. The treatment for these patients was divided into two options: surgical intervention or careful follow up; the outcomes were investigated. The median age at diagnosis was 3months, and a total of 11 patients (6%) were premature at birth. Hydrocele was diagnosed on the right side, the left side and bilaterally in 106 (61%), 46 (26%) and 23 (13%) patients, respectively. A total of 136 patients showed spontaneous improvement at the median 7months after diagnosis, and 54 patients underwent surgical intervention. The rate of spontaneous resolution deceased with age, but spontaneous resolution was observed in patients aged >2years. Our findings suggest that spontaneous resolution can be observed in patients aged >2years, and surgical intervention can be carried out effectively and safely. Infant hydrocele should be followed up carefully for at least 1year without surgical intervention since diagnosis. Investigation of the optimal timing of and appropriate reason for surgical intervention can lead to better management and outcomes in patients with hydrocele. Further research is warranted to support the current clinical practice.

Trends in Treatment Outcome and Critical Predictors of Mortality for Congenital Diaphragmatic Hernia in a Single Center

Objective: To review trends in treatment outcomes, to determine risk factors for mortality, and to present a cut-off values of observed/expected lung to head ratio (O/E LHR) predicting mortality in infants with congenital diaphragmatic hernia (CDH). Methods: A retrospective study of infants with CDH treated in the neonatal intensive care unit at tertiary medical center over 27 years (1989 to 2016) was done. We analyzed the factors associated with mortality and based on significant factors in predicting the mortality, the best cut-off value of O/E LHR was sought. Results: A total of 264 patients were included for the study. The mean gestational age and birth weight were 38.0±2.2 weeks and 2,934.2±578.2 g, respectively. Seventy nine patients (29.9%) died. The range of yearly mortality rate varied from 0 to 67%. Prenatal, neonatal, and surgical factors associated to mortality included time of prenatal diagnosis, polyhydramnios, O/E LHR, associated major congenital anomalies (cardiac, gastrointestinal or chromosomal anomalies), gestational age, birth weight, Apgar scores, initial pH and pCO2, and number of herniated organs. Among 62 fetuses whose O/E LHR were available, O/E LHR and major congenital anomalies were independent risk factors for mortality (area under curve=0.918), fetuses with O/E LHR <44% without congenital anomalies showed predicted mortality of 72% and fetuses with O/E LHR ≥44% without congenital anomalies showed expected mortality of 7%. Conclusion: The mortality of Infants with CDH has not improved despite advance of neonatal care. The O/E LHR and the presence of major congenital anomalies could be used adjunctively when counseling parents about the prognosis.

A Decade of Combination Antiretroviral Treatment in Asia: The TREAT Asia HIV Observational Database Cohort.

Asian countries have seen the expansion of combination antiretroviral therapy (cART) over the past decade. The TREAT Asia HIV Observational Database (TAHOD) was established in 2003 comprising 23 urban referral sites in 13 countries across the region. We examined trends in treatment outcomes in patients who initiated cART between 2003 and 2013. Time of cART initiation was grouped into three periods: 2003-2005, 2006-2009, and 2010-2013. We analyzed trends in undetectable viral load (VL; defined as VL <400 copies/ml), CD4 changes from pre-cART levels, and overall survival. Of 6,521 patients included, the overall median CD4 count at cART initiation was 120 cells/μl (interquartile range: 38-218). Despite an increase over time, pre-cART CD4 counts remained <200 cells/μl. Adjusted analyses showed undetectable VL was more likely when starting cART in later years [2006-2009: odds ratio (OR) = 1.76, 95% confidence interval (CI) (1.45, 2.15); and 2010-2013: OR = 3.04, 95% CI (2.33, 3.97), all p < .001, compared to 2003-2005], and survival was improved [2006-2009: subdistribution hazard ratio (SHR) = 0.41, 95% CI (0.27, 0.61), 2010-2013: SHR = 0.29, 95% CI (0.17, 0.49), all p < .001, compared to 2003-2005]. No differences in CD4 response was observed over time. Age and CD4 levels prior to cART initiation were associated with all three treatment outcomes, with older age and higher CD4 counts being associated with undetectable VL. Survival and VL response on cART have improved over the past decade in TAHOD, although CD4 count at cART initiation remained low. Greater effort should be made to facilitate earlier HIV diagnosis and linkage to care and treatment, to achieve greater improvements in treatment outcomes.

Current Trends in Treatment Outcomes of Orbital Cellulitis in a Tertiary Hospital in Southern Nigeria.

Background:Orbital cellulitis refers to the inflammation or infection of the soft tissues of the orbit located behind the orbital septum.Aim:To determine the current trends in the outcomes following the management of orbital cellulitis in a tertiary hospital in Southern Nigeria.Patients and Methods:A retrospective review of medical records of patients with orbital cellulitis from January 2008 to December 2014 was conducted. The age, sex, duration of symptoms, predisposing factors, clinical findings, laboratory/radiological investigations, treatment provided, complications, and follow-up were recorded. Results were analyzed with SPSS Version 21 program.Results:Forty-two patients were seen made of 17 (40.5%) males and 25 (59.5%) females with a mean age of 18.2 ± 18.7 years of which children <16 years constituted 24 (57.1%) of cases. Orbital cellulitis was a unilateral occurrence in 38 (90.5%) patients. Trauma and sinusitis were the common predisposing causes in 20 (47.6%) and 6 (14.3%) patients, respectively. The most common complaint was eye swelling 36 (52.9%). Most patients had visual acuities of >6/18 at presentation, 38 (82.6%) and at discharge, 39 (84.8%). The mean duration of presenting complaints was 15.5 ± 31.6 days. Patients who presented early were less likely to develop complications, P = 0.003. The most common complication was exposure keratopathy in 8 (44.4%) eyes. The only surgical intervention performed was incision and drainage of abscess in 3 (7.1%) eyes. No patient came for follow-up.Conclusion:Prompt institution of effective antibiotics and management of complications that may arise improves prognosis of orbital cellulitis.

Temporal trends in treatment outcomes for HIV-1 and HIV-2-infected adults enrolled in Côte d'Ivoire's national antiretroviral therapy program.

BackgroundIn Côte d'Ivoire during 2004–2007, numbers of ART enrollees increased from <5,000 to 36,943. Trends in nationally representative ART program outcomes have not yet been reported.Methodology/Principal FindingsWe conducted a retrospective chart review to assess trends in patient characteristics and attrition [death or loss to follow-up (LTFU)] over time, among a nationally representative sample of 3,682 adults (≥15 years) initiating ART during 2004–2007 at 34 health facilities. Among ART enrollees during 2004–2007, median age was 36, the proportion female was 67%, the proportion HIV-2-infected or dually HIV-1&2 reactive was 5%, and median baseline CD4+ T-cell (CD4) count was 135 cells/µL. Comparing cohorts initiating ART in 2004 with cohorts initiating ART in 2007, median baseline weight declined from 55 kg to 52 kg (p = 0.008) and the proportion weighing <45 kg increased from 17% to 22% (p = 0.014). During 2004–2007, pharmacy-based estimates of the percentage of new ART enrollees ≥95% adherent to ART declined from 74% to 60% (p = 0.026), and twelve-month retention declined from 86% to 69%, due to increases in 12-month mortality from 2%–4% and LTFU from 12%–28%. In univariate analysis, year of ART initiation was associated with increasing rates of both LTFU and mortality. Controlling for baseline CD4, weight, adherence, and other risk factors, year of ART initiation was still strongly associated with LTFU but not mortality. In multivariate analysis, weight <45 kg and adherence <95% remained strong predictors of LTFU and mortality.ConclusionsDuring 2004–2007, increasing prevalence among ART enrollees of measured mortality risk factors, including weight <45 kg and ART adherence <95%, might explain increases in mortality over time. However, the association between later calendar year and increasing LTFU is not explained by risk factors evaluated in this analysis. Undocumented transfers, political instability, and patient dissatisfaction with crowded facilities might explain increasing LTFU.

Trends in treatment outcome of smear-positive pulmonary tuberculosis in Southeastern Nigeria, 1999 - 2008

Background: the Directly Observed Treatment Short Course (DOTS) strategy was introduced into the tuberculosis control programme of Ebonyi, Southeastern, Nigeria in 1996. The impact of the programme on the treatment outcomes for smear-positive tuberculosis has not been assessed ever since. We assessed the trends in treatment outcome for new smear-positive pulmonary tuberculosis between 1999 and 2008. Methods: we conducted a retrospective analysis of the Ebonyi state Ministry of Health quarterly smear-positive tuberculosis statistical returns. Patients were treated and treatment outcome categories computed according to the WHO/National Tuberculosis Control Programme’s guidelines. Chi-square for trends was used to determine significance. Results: the number of smear-positive cases who registered for treatment fell from 1 361 patients in 1999 to 977 in 2008 (Trend χ2=349; P&lt;0.001). The follow-up smear results at month two were not available for 16% of the patients in 1999; this unavailability decreased to 1.7% in 2008. The negative conversion rate at month two increased from 77.5% in 1999 to 95.9% in 2008 (Trend χ2=16.5; P&lt;0.001). Treatment success rose from 74.9% in 1999 to 88.7% in 2008 (Trend χ2=12.8; P&lt;0.001), whilst default rate declined from 12% to 4.3% (Trend χ2=55.6; P&lt;0.001). Though decreasing (Trend χ2=4.64; P=0.031), the annual death rate remained at around 5% during the study period. Conclusions: monitoring, supervision and home visits have improved, and our DOTS programme has achieved an 85% treatment success and declining default rates. However, with the current low case notification and high mortality rates, alternative mechanisms are needed to achieve global stop-TB targets in the State.

Cognitive treatments of sentence processing disorders: What have we learned?

Several cognitive neuropsychological studies describing treatments of sentence processing disorders have been reported in recent years. We review the outcome of 10 studies that describe treatment outcomes for 17 aphasic patients. Although the studies used different approaches to intervention, they shared the goal of improving reversible sentence comprehension, and they targeted a hypothesised deficit of “thematic mapping”. Several trends in treatment outcomes were observed. In most cases, there was strong evidence that the treatments induced a change in the pattern of sentence processing. Moreover, the outcomes indicated that impaired reversible sentence comprehension can arise from a range of impairments, only some of which directly implicate structural and/or lexical deficits assumed to be the source of poor thematic mapping abilities. Patterns of post-therapy generalisation within and across processing modalities appeared to be related, among other things, to the therapy approach and to the selection of treatment materials. These findings are discussed with regard to the theoretical implications of sentence processing treatment data.

Study of a diagnostic profile of the borderline syndrome in childhood and trends in treatment outcome.

Bemporad et al. recently outlined a profile of the Borderline Syndrome in Childhood seen in 24 patients. A comparison of 70 previously diagnosed borderline children with two control groups significantly distinguished the borderlines on Bemporad's criteria and supported his observation of high frequencies of child abuse and family disorganization.