ADEPT - Abnormal Doppler Enteral Prescription Trial

<p>Abstract</p> <p>Background</p> <p>Pregnancies complicated by abnormal umbilical artery Doppler blood flow patterns often result in the baby being born both preterm and growth-restricted. These babies are at high risk of milk intolerance and necrotising enterocolitis, as well as post-natal growth failure, and there is no clinical consensus about how best to feed them. Policies of both early milk feeding and late milk feeding are widely used. This randomised controlled trial aims to determine whether a policy of early initiation of milk feeds is beneficial compared with late initiation. Optimising neonatal feeding for this group of babies may have long-term health implications and if either of these policies is shown to be beneficial it can be immediately adopted into clinical practice.</p> <p>Methods and Design</p> <p>Babies with gestational age below 35 weeks, and with birth weight below 10th centile for gestational age, will be randomly allocated to an "early" or "late" enteral feeding regimen, commencing milk feeds on day 2 and day 6 after birth, respectively. Feeds will be gradually increased over 9-13 days (depending on gestational age) using a schedule derived from those used in hospitals in the Eastern and South Western Regions of England, based on surveys of feeding practice. Primary outcome measures are time to establish full enteral feeding and necrotising enterocolitis; secondary outcomes include sepsis and growth. The target sample size is 400 babies. This sample size is large enough to detect a clinically meaningful difference of 3 days in time to establish full enteral feeds between the two feeding policies, with 90% power and a 5% 2-sided significance level. Initial recruitment period was 24 months, subsequently extended to 38 months.</p> <p>Discussion</p> <p>There is limited evidence from randomised controlled trials on which to base decisions regarding feeding policy in high risk preterm infants. This multicentre trial will help to guide clinical practice and may also provide pointers for future research.</p> <p>Trial registration</p> <p>Current Controlled Trials ISRCTN: 87351483</p

Towards precision medicine: defining and characterizing adipose tissue dysfunction to identify early immunometabolic risk in symptom-free adults from the GEMM family study

Interactions between macrophages and adipocytes are early molecular factors influencing adipose tissue (AT) dysfunction, resulting in high leptin, low adiponectin circulating levels and low-grade metaflammation, leading to insulin resistance (IR) with increased cardiovascular risk. We report the characterization of AT dysfunction through measurements of the adiponectin/leptin ratio (ALR), the adipo-insulin resistance index (Adipo-IRi), fasting/postprandial (F/P) immunometabolic phenotyping and direct F/P differential gene expression in AT biopsies obtained from symptom-free adults from the GEMM family study. AT dysfunction was evaluated through associations of the ALR with F/P insulin-glucose axis, lipid-lipoprotein metabolism, and inflammatory markers. A relevant pattern of negative associations between decreased ALR and markers of systemic low-grade metaflammation, HOMA, and postprandial cardiovascular risk hyperinsulinemic, triglyceride and GLP-1 curves was found. We also analysed their plasma non-coding microRNAs and shotgun lipidomics profiles finding trends that may reflect a pattern of adipose tissue dysfunction in the fed and fasted state. Direct gene differential expression data showed initial patterns of AT molecular signatures of key immunometabolic genes involved in AT expansion, angiogenic remodelling and immune cell migration. These data reinforce the central, early role of AT dysfunction at the molecular and systemic level in the pathogenesis of IR and immunometabolic disorders

Bowel management for the treatment of pediatric fecal incontinence

Fecal incontinence is a devastating underestimated problem, affecting a large number of individuals all over the world. Most of the available literature relates to the management of adults. The treatments proposed are not uniformly successful and have little application in the pediatric population. This paper presents the experience of 30 years, implementing a bowel management program, for the treatment of fecal incontinence in over 700 pediatric patients, with a success rate of 95%. The main characteristics of the program include the identification of the characteristics of the colon of each patient; finding the specific type of enema that will clean that colon and the radiological monitoring of the process

Consenso mexicano sobre detección y tratamiento del cáncer gástrico incipiente

El cáncer gástrico representa una de las neoplasias más frecuentes en el aparato digestivo y en la mayoría de los casos es el resultado de la progresión de lesiones premalignas. La detección oportuna de estas lesiones es relevante ya que un tratamiento oportuno brinda la posibilidad de curación. En nuestro país no existía un consenso respecto a la detección temprana del cáncer gástrico, por lo que la Asociación Mexicana de Gastroenterología reunió aun grupo de expertos y realizó el Consenso sobre detección y tratamiento del cáncer gástricoincipiente (CGI) para establecer recomendaciones de utilidad para la comunidad médica. Eneste consenso se utilizó la metodología Delphi y se emitieron 38 recomendaciones al respectodel CGI. El consenso define el CGI como aquel que al momento del diagnóstico se encuentralimitado a la mucosa y a la submucosa, independientemente de metástasis en ganglios linfáticos.En México, como otras partes del mundo, los factores asociados al CGI incluyen la infección porHelicobacter pylori, los antecedentes familiares, el tabaquismo y los factores dietéticos. Para eldiagnóstico se recomienda utilizar cromoendoscopia, magnificación y equipos con luz mejorada.Un diagnóstico histopatológico preciso es invaluable para tomar de decisiones terapéuticas. Eltratamiento endoscópico del CGI, ya sea disección o resección de la mucosa, debe ser preferidoal manejo quirúrgico cuando se puedan obtener resultados semejantes en términos de curaciónoncológica. La vigilancia endoscópica se deberá de individualizar

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p&lt;0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p&lt;0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

A framework for understanding shared substrates of airway protection

Deficits of airway protection can have deleterious effects to health and quality of life. Effective airway protection requires a continuum of behaviors including swallowing and cough. Swallowing prevents material from entering the airway and coughing ejects endogenous material from the airway. There is significant overlap between the control mechanisms for swallowing and cough. In this review we will present the existing literature to support a novel framework for understanding shared substrates of airway protection. This framework was originally adapted from Eccles' model of cough28 (2009) by Hegland, et al.42 (2012). It will serve to provide a basis from which to develop future studies and test specific hypotheses that advance our field and ultimately improve outcomes for people with airway protective deficits

Comparison of paper-and-pencil vs. computerized administration of the Leistungsprufsystem (LPS)

The increasing use of computerized diagnostic procedures inevitably questions the equivalence of conventional paper-and-pencil versions and corresponding computer transpositions. To investigate the equivalence of the computerized version of the Leistungsprufsystem (LPS), as implemented in the Hogrefe Testsystem, and the conventional paper-and-pencil version, 131 participants, were tested applying a counter-balanced design with repeated measures. Heterogeneous results of the paper-and-pencil and the compterized version clearly show that one cannot proceed on the assumption that both versions are equivalent, and the results, emphasize the necessity of systematic I equivalence checks. An additionally performed investigation of retest reliability-of the computerized LPS version resulted in reliability coefficients ranging from r(n) = 0.55 to r(n) = 0.94 for a 2-week retest interval. Potential reasons for the non-equivalence of both LPS versions are discussed

Colour vision classification – comparing CAD and CIE 143:2001 International recommendations for colour vision requirements in transport

Purpose To evaluate the colour vision severity classification standard ‘CIE 143:2001 International recommendations for colour vision requirements in transport’ (CIE 143:2001), which has become out of date because of the lack of commercial availability of required colour vision tests. Methods One‐hundred‐five subjects had colour vision tested and colour vision severity classified according to a modified CIE 143:2001 algorithm that included pseudoisochromatic plates (Ishihara's test and Hardy Rand Rittler (HRR) 4th edition), Optec 900 lantern and Farnsworth D‐15. Subject's results and colour vision severity classification were compared to performance and colour vision severity classification on the computerized ‘Colour Assessment and Diagnosis’ (CAD) test. Results According to CIE 143:2001, using Ishihara’s test, Optec lantern and Farnsworth D 15, 11 subjects (10%) were category I (normal), 16 (15%) were category II (mild), 48 (46%) were category III (poor), and 30 (29%) were category IV (severe). Classified by CAD score, 10 (10%) were category I, 11 (10%) were category II, 41 (39%) were category III, and 43 (41%) were category IV. The correlation between the two estimates of the severity of colour vision loss (i.e. CIE 143:2001 and CAD) was high, with a Kendall’s Tau test of 0.81 (τ = 0.81 p < 0.001). A suggested CIE 143:2001 classification including new CAD score limits improves the classification correlation to 0.90 (τ = 0.90 p < 0.001) for all diagnoses. Conclusion The colour vision severity classification standard ‘CIE 143:2001 International recommendations for colour vision requirements in transport’, has not implemented new diagnostic tools with better accuracy. We propose three possible revisions to the CIE 143:2001 algorithm, based on the availability of CAD: (1) Replacing the current CIE 143:2001 algorithm using new CAD threshold limits, (2) Use of CAD as a secondary test to Ishihara's test and HRR or (3) Revising the current CIE 143:2001 algorithm using Ishihara's test, HRR, Optec 900 and FD15