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Can adjuncts to bowel preparation for colonoscopy improve patient experience and result in superior bowel cleanliness? A systematic review and meta-analysis (2020)

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Type of publication:
Systematic Review

Author(s):
Kamran, Umair; *Abbasi, Abdullah; Tahir, Imran; Hodson, James; Siau, Keith

Citation:
United European gastroenterology journal; 2020 Dec; 8(10):1217-1227.

Abstract:
BACKGROUND Bowel preparation for colonoscopy is often poorly tolerated due to poor palatability and adverse effects. This can negatively impact on the patient experience and on the quality of bowel preparation. This systematic review and meta-analysis was carried out to assess whether adjuncts to bowel preparation affected palatability, tolerability and quality of bowel preparation (bowel cleanliness).METHODS A systematic search strategy was conducted on PubMed, MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews to identify studies evaluating adjunct use for colonoscopic bowel preparation. Studies comparing different regimens and volumes were excluded. Specific outcomes studied included palatability (taste), willingness to repeat bowel preparation, gastrointestinal adverse events and the quality of bowel preparation. Data across studies were pooled using a random-effects model and heterogeneity assessed using I2-statistics.RESULTS Of 467 studies screened, six were included for analysis (all single-blind randomised trials; n = 1187 patients). Adjuncts comprised citrus reticulata peel, orange juice, menthol candy drops, simethicone, Coke Zero and sugar-free chewing gum. Overall, adjunct use was associated with improved palatability (mean difference 0.62, 95% confidence interval 0.29-0.96, p < 0.001) on a scale of 0-5, acceptability of taste (odds ratio 2.75, 95% confidence interval: 1.52-4.95, p < 0.001) and willingness to repeat bowel preparation (odds ratio 2.92, 95% confidence interval: 1.97-4.35, p < 0.001). Patients in the adjunct group reported lower rates of bloating (odds ratio 0.48, 95% confidence interval: 0.29-0.77, p = 0.003) and vomiting (odds ratio 0.47, 95% confidence interval 0.27-0.81, p = 0.007), but no difference in nausea (p = 0.10) or abdominal pain (p = 0.62). Adjunct use resulted in superior bowel cleanliness (odds ratio 2.52, 95% confidence interval: 1.31-4.85, p = 0.006). Heterogeneity varied across outcomes, ranging from 0% (vomiting) to 81% (palatability), without evidence of publication bias. The overall quality of evidence was rated moderate.CONCLUSION In this meta-analysis, the use of adjuncts was associated with better palatability, less vomiting and bloating, willingness to repeat bowel preparation and superior quality of bowel preparation. The addition of adjuncts to bowel preparation may improve outcomes of colonoscopy and the overall patient experience.

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Progesterone to prevent miscarriage in women with early pregnancy bleeding: the PRISM RCT (2020)

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Type of publication:
Randomised controlled trial

Author(s):
Coomarasamy A.; Harb H.M.; Devall A.J.; Williams H.M.; Gallos I.D.; Ewer A.; Cheed V.; Roberts T.E.; Ogwulu C.B.; Middleton L.J.; Goranitis I.; Eapen A.; Daniels J.P.; Ahmed A.; Hinshaw K.; Bender-Atik R.; Bhatia K.; Bottomley C.; Kriedt K.; Jurkovic D.; Brewin J.; Choudhary M.; Crosfill F.; Deb S.; Duncan W.C.; Norman J.E.; Horne A.W.; Holland T.; Izzat F.; Johns J.; Ross J.; Lumsden M.-A.; Manda P.; Nunes N.; Overton C.E.; Quenby S.; Rao S.; Shahid A.; *Underwood M. ; Vaithilingham N.; Watkins L.; Wykes C.

Citation:
Health Technology Assessment (Winchester, England); Jun 2020; vol. 24 (no. 33); p. 1-70

Abstract:
BACKGROUND: Progesterone is essential for a healthy pregnancy. Several small trials have suggested that progesterone therapy may rescue a pregnancy in women with early pregnancy bleeding, which is a symptom that is strongly associated with miscarriage. OBJECTIVE(S): (1) To assess the effects of vaginal micronised progesterone in women with vaginal bleeding in the first 12 weeks of pregnancy. (2) To evaluate the cost-effectiveness of progesterone in women with early pregnancy bleeding. DESIGN: A multicentre, double-blind, placebo-controlled, randomised trial of progesterone in women with early pregnancy vaginal bleeding. SETTING: A total of 48 hospitals in the UK. PARTICIPANTS: Women aged 16-39 years with early pregnancy bleeding. INTERVENTIONS: Women aged 16-39 years were randomly assigned to receive twice-daily vaginal suppositories containing either 400mg of progesterone or a matched placebo from presentation to 16 weeks of gestation. MAIN OUTCOME MEASURES: The primary outcome was live birth at >=34 weeks. In addition, a within-trial cost-effectiveness analysis was conducted from an NHS and NHS/Personal Social Services perspective. RESULT(S): A total of 4153 women from 48 hospitals in the UK received either progesterone (n=2079) or placebo (n=2074). The follow-up rate for the primary outcome was 97.2% (4038 out of 4153 participants). The live birth rate was 75% (1513 out of 2025 participants) in the progesterone group and 72% (1459 out of 2013 participants) in the placebo group (relative rate 1.03, 95% confidence interval 1.00 to 1.07; p=0.08). A significant subgroup effect (interaction test p=0.007) was identified for prespecified subgroups by the number of previous miscarriages: none (74% in the progesterone group vs. 75% in the placebo group; relative rate 0.99, 95% confidence interval 0.95 to 1.04; p=0.72); one or two (76% in the progesterone group vs. 72% in the placebo group; relative rate 1.05, 95% confidence interval 1.00 to 1.12; p=0.07); and three or more (72% in the progesterone group vs. 57% in the placebo group; relative rate 1.28, 95% confidence interval 1.08 to 1.51; p=0.004). A significant post hoc subgroup effect (interaction test p=0.01) was identified in the subgroup of participants with early pregnancy bleeding and any number of previous miscarriage(s) (75% in the progesterone group vs. 70% in the placebo group; relative rate 1.09, 95% confidence interval 1.03 to 1.15; p=0.003). There were no significant differences in the rate of adverse events between the groups. The results of the health economics analysis show that progesterone was more costly than placebo (7655 vs. 7572), with a mean cost difference of 83 (adjusted mean difference 76, 95% confidence interval -559 to 711) between the two arms. Thus, the incremental cost-effectiveness ratio of progesterone compared with placebo was estimated as 3305 per additional live birth at >=34 weeks of gestation. CONCLUSION(S): Progesterone therapy in the first trimester of pregnancy did not result in a significantly higher rate of live births among women with threatened miscarriage overall, but an important subgroup effect was identified. A conclusion on the cost-effectiveness of the PRISM trial would depend on the amount that society is willing to pay to increase the chances of an additional live birth at >=34 weeks. For future work, we plan to conduct an individual participant data meta-analysis using all existing data sets. TRIAL REGISTRATION: Current Controlled Trials ISRCTN14163439, EudraCT 2014-002348-42 and Integrated Research Application System (IRAS) 158326. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 33. See the NIHR Journals Library website for further project information.

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The importance of skin biopsies: Sweet syndrome as a differential for 'acute painful red rash' in a patient with normal neutrophils and polymyalgia rheumatica on glucocorticoids (2020)

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Type of publication:
Journal article

Author(s):
Rajakulenthiran T.G.; Amarasena R.; Silva S.S.C.; *Singh R.; *Kelly S.

Citation:
Clinical Medicine, Journal of the Royal College of Physicians of London; Mar 2020; vol. 20, p. S25

Abstract:

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Metabolic stone screening - can education improve adherence to national guidelines? (2020)

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Type of publication:
Journal article

Author(s):
Ravindraanandan M.; *Jayawardena P.

Citation:
Journal of Endoluminal Endourology; Jan 2020; vol. 3 (no. 1)

Abstract:
Nephrolithiasis is a common urological disease affecting approximately 13% of the global population. Identifying a preventable cause during follow-up for stone formation is a necessary factor in reducing recurrence. The majority of kidney stones are comprised of calcium, with oxalate and phosphate compounds accounting for approximately 80% of stone formers. Serum analysis can be used to identify the levels of calcium in the blood, excluding metabolic causes for stones. Current NICE guidelines recommend performing a metabolic screen during an acute admission. Adherence to these guidelines from clinicians can be poor. We aim to see whether education can improve serum metabolic requests from clinicians in the UK. Method A case-control study was performed in a single rural district general hospital in the UK. Patients who presented with renal colic were analyzed retrospectively for four months, looking at serum metabolic screen requests. Two months of education was then delivered to acute departments, with a further prospective study performed following this for six months. Outcomes were then compared between both groups to see if there was an improvement in serum requests following the delivery of local education. Results A total of 124 patients were included in our study. 50 patients were analyzed in cohort A over a 4-month period. Complete serum analysis was performed on 22% (n=11) of patients. Incomplete serum analysis was performed on 58% (n-29) of patients with uric acid being missed on all of them. 10 patients had no metabolic serum analysis performed at all, with 1 patient having a previous history of stones. A total of 74 patients were analyzed in cohort B over a 6-month period. This was following the 2 months of departmental education given by urologists. Complete serum analysis was performed on 24% (n=18) of patients. Incomplete serum analysis was performed on 55% (n=41) of patients with uric acid being missed from all of them. The remaining 21% of patients (n=15) had no metabolic serum screen performed at all. There was no significant difference seen between both cohorts after comparing metabolic serum requests before and after department education for 2 months (p=0.7287). Conclusion Improving adherence to clinical guidelines for metabolic screening has proved difficult with departmental teaching alone, with very little improvement achieved. Nevertheless, formal face-to-face education is advocated to reinforce knowledge in junior doctors managing renal stones.

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The Prevalence of Thyroid Dysfunction and Autoimmunity in Women With History of Miscarriage or Subfertility (2020)

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Type of publication:
Journal article

Author(s):
Rima K Dhillon-Smith, Aurelio Tobias, Paul P Smith, Lee J Middleton, Kirandeep K Sunner, Krystyna Baker, Samantha Farrell-Carver, Ruth Bender-Atik, Rina Agrawal, Kalsang Bhatia, Justin J Chu, Edmond Edi-Osagie, Ayman Ewies, Tarek Ghobara, Pratima Gupta, Davor Jurkovic, Yacoub Khalaf, Khashia Mulbagal, Natalie Nunes, Caroline Overton, Siobhan Quenby, Raj Rai, Nick Raine-Fenning, Lynne Robinson, Jackie Ross, Andrew Sizer, Rachel Small, *Martyn Underwood , Mark D Kilby, Jane Daniels, Shakila Thangaratinam, Shiao Chan, Kristien Boelaert, Arri Coomarasamy

Citation:
The Journal of Clinical Endocrinology & Metabolism, Volume 105, Issue 8, August 2020

Abstract:
Objective: To describe the prevalence of and factors associated with different thyroid dysfunction phenotypes in women who are asymptomatic preconception.
Design: Observational cohort study.
Setting: A total of 49 hospitals across the United Kingdom between 2011 and 2016.
Participants: Women aged 16 to 41 years with history of miscarriage or subfertility trying for a pregnancy.
Methods: Prevalences and 95% confidence intervals (CIs) were estimated using the binomial exact method. Multivariate logistic regression analyses were conducted to identify risk factors for thyroid disease.
Intervention: None.
Main Outcome Measure: Rates of thyroid dysfunction.
Results: Thyroid function and thyroid peroxidase antibody (TPOAb) data were available for 19213 and 19237 women, respectively. The prevalence of abnormal thyroid function was 4.8% (95% CI, 4.5-5.1); euthyroidism was defined as levels of thyroid-stimulating hormone (TSH) of 0.44 to 4.50 mIU/L and free thyroxine (fT4) of 10 to 21 pmol/L. Overt hypothyroidism (TSH > 4.50 mIU/L, fT4 < 10 pmol/L) was present in 0.2% of women (95% CI, 0.1-0.3) and overt hyperthyroidism (TSH < 0.44 mIU/L, fT4 > 21 pmol/L) was present in 0.3% (95% CI, 0.2-0.3). The prevalence of subclinical hypothyroidism (SCH) using an upper TSH concentration of 4.50 mIU/L was 2.4% (95% CI, 2.1-2.6). Lowering the upper TSH to 2.50 mIU/L resulted in higher rates of SCH, 19.9% (95% CI, 19.3-20.5). Multiple regression analyses showed increased odds of SCH (TSH > 4.50 mIU/L) with body mass index (BMI) ≥ 35.0 kg/m2 (adjusted odds ratio [aOR] 1.71; 95% CI, 1.13-2.57; P = 0.01) and Asian ethnicity (aOR 1.76; 95% CI, 1.31-2.37; P < 0.001), and increased odds of SCH (TSH ≥ 2.50 mIU/L) with subfertility (aOR 1.16; 95% CI, 1.04-1.29; P = 0.008). TPOAb positivity was prevalent in 9.5% of women (95% CI, 9.1-9.9).
Conclusions: The prevalence of undiagnosed overt thyroid disease is low. SCH and TPOAb are common, particularly in women with higher BMI or of Asian ethnicity. A TSH cutoff of 2.50 mIU/L to define SCH results in a significant proportion of women potentially requiring levothyroxine treatment.

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Unscheduled Emergency Department Revisits in a Tertiary Care Hospital – A Quality Improvement Study (2020)

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Type of publication:
Journal article

Author(s):
Mohammed Nazim Kt, Nithyanand M, *Dodiy Herman, Sourabh M Prakash, Shahana Sherin, *Benita Florence

Citation:
Indian Journal of Clinical Practice, Vol. 30, No. 10, p. 931-933, March 2020

Abstract:
Patients who revisit the emergency department (ED) within 72 hours constitute an integral key performance indicator of quality emergency care. The number of patient footfalls to the ED in a tertiary care hospital in a rural area of a district in India from December 1, 2018 to May 31, 2019 was 7,808 and the average re-attendances recorded during that period was 0.32%. With increase in the number of healthcare setups, rising standards of the healthcare industry and increase in the expectations of the population visiting hospitals, ED re-attendance within 72 hours has been considered as an important key performance indicator of emergency patient care. The early ED revisit rate at this tertiary care hospital for 6 months was found to be only 0.32% (at an average of 4 cases per month). This is less when compared to many other international hospitals where it ranges from 1.5% to 2.5%. Since readmissions cause unnecessary overcrowding in ED, it would be best if each hospital evaluated their rate of readmission and its causes, and then tried to address the problems found. This can be effective in better management of ED, reduction of treatment costs, increasing patient satisfaction and prevention of ED overcrowding.

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Lessons of the month 1: A case of rhombencephalitis as a rare complication of acute COVID-19 infection (2020)

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Type of publication:
Journal article

Author(s):
*Po Fung Wong, *Sam Craik, *Piers Newman, *Annabel Makan, *Koottalai Srinivasan, *Emma Crawford, *Devapriya Dev, *Harmesh Moudgil and *Nawaid Ahmad

Citation:
Clinical Medicine 2020 Vol 20, No 3, p. 293-294

Abstract:
A 40-year-old man developed acute brainstem dysfunction 3 days after hospital admission with symptoms of the novel SARS-CoV-2 infection (COVID-19). Magnetic resonance imaging showed changes in keeping with inflammation of the brainstem and the upper cervical cord, leading to a diagnosis of rhombencephalitis. No other cause explained the patient’s abnormal neurological findings. He was managed conservatively with rapid spontaneous improvement in some of his neurological signs and was discharged home with continued neurology follow up.

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No difference in strength and clinical outcome between early and late repair after Achilles tendon rupture (2020)

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Type of publication:
Journal article

Author(s):
*Carmont, Michael R; Zellers, Jennifer A; Brorsson, Annelie; Silbernagel, Karin Grävare; Karlsson, Jón; Nilsson-Helander, Katarina

Citation:
Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the ESSKA; May 2020; vol. 28 (no. 5); p. 1587-1594

Abstract:
PURPOSE This retrospective study aimed to determine the patient-reported and functional outcome of patients with delayed presentation, who had received no treatment until 14 days following injury of Achilles tendon rupture repaired with minimally invasive surgery and were compared with a group of sex- and age-matched patients presenting acutely. Based on the outcomes following delayed presentation reported in the literature, it was hypothesized that outcomes would be inferior for self-reported outcome, tendon elongation, heel-rise performance, ability to return to play, and complication rates than for acutely managed patients.
METHODS Repair was performed through an incision large enough to permit mobilisation of the tendon ends, core suture repair consisting of a modified Bunnell suture proximally and a Kessler suture distally and circumferential running suture augmentation.
RESULTS Nine patients presented 21.8 (14.9) days (range 14-42 days) after rupture. The rate of delayed presentation was estimated to be 1 in 10. At 12 months following repair, patients with delayed treatment had median (range) ATRS score of 90 (69-99) compared with 94 (75-100) in patients treated acutely presenting 0.66 (1.7) (0-5) days. There were no significant differences between groups: ATRA [mean (SD) delayed: – 6.9° (5.5), acute: – 6° (4.7)], heel-rise height index [delayed: 79% (20), acute: 74% (14)], or heel-rise repetition index [delayed: 77% (20), acute: 71% (20)]. In the delayed presentation group, two patients had wound infection and one iatrogenic sural nerve injury.
CONCLUSIONS Patients presenting more than 2 weeks after Achilles tendon rupture may be successfully treated with minimally invasive repair. LEVEL OF EVIDENCE III.

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Global longitudinal strain detects trastuzumab induced cardiotoxicity early in a clinical population (2020)

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Type of publication:
Conference abstract

Author(s):
*Grylls, J., *Ellis, C., *Ingram, T., *Lee, E.

Citation:
European Heart Journal – Cardiovascular Imaging 2020; Volume 21, Issue Supplement 1

Abstract:
Background: Trastuzumab is highly effective in the treatment of breast cancer, and is often used as an adjuvant therapy. Due to its potential cardiotoxicity, serial monitoring of cardiac function is vital. Ejection fraction (EF) by two-dimensional echocardiography is routinely used but has limitations in measurement variability. Myocardial deformation imaging, in particular Global Longitudinal Strain (GLS), can detect pre-clinical myocardial dysfunction. However, its use is not yet adopted into routine clinical practice.
Aims: Our aim was to ascertain if a clinically significant reduction in GLS (≥11% from baseline) occurred before the onset of EF reduction, in patients who developed cardiotoxicity whilst receiving trastuzumab.
Methods: Between January 2014 and January 2019, 235 consecutive patients received trastuzumab and underwent serial echocardiography at 3 monthly intervals at our institute. Cardiotoxicity is defined as a ≥10% EF reduction from baseline or an EF <50%. Women who developed cardiotoxicity as defined by this change in EF were retrospectively studied.Two-dimensional speckle tracking was used to derive peak longitudinal strain in each myocardial segment from the apical four-, three- and two-chamber view images. GLS was taken as the average value of all these segments. The median time to ≥11% GLS reduction and ≥10% EF reduction or EF <50% was compared.
Results: Thirteen women (mean age 53 ± 9.5 years) developed cardiotoxicity. EF was 61.8 ± 4.4% at baseline and 45.7 ± 7.5% following therapy (p = 0.00). A ≥11% reduction in GLS from baseline was observed in all patients: GLS -20.2 ± 1.5% and -15.6 ± 2.1%, p = 0.00. The median time to cardiotoxicity as defined by EF and GLS was 6 months and 3 months, respectively (p = 0.031), as shown in Table 1. Repeatability analysis showed both EF and GLS measurements in our cohort have good measurement reproducibility. Inter-observer intraclass correlation (ICC) for EF and GLS were 0.912 and 0.913, respectively. Intra-observer ICC for EF and GLS were 0.925 and 0.900, respectively.
Conclusion: Cardiotoxicity developed in a significant portion (6%) of our patients receiving trastuzumab. As a reduction in GLS was detectable early and preceded that of EF by 3 months, this may represent a therapeutic window for initiation of cardio-protective medication, if and when the use of GLS is incorporated into routine practice for cardiotoxicity surveillance.

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