7 research outputs found
The pandemic response: The role of virtual mock OSCEs as a learning resource for medical students
Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries
Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely
A Newfoundland cohort of familial and sporadic idiopathic pulmonary fibrosis patients: clinical and genetic features
Background: Idiopathic pulmonary fibrosis (IPF) is an adult-onset Idiopathic Interstitial Pneumonia (IIP) usually
diagnosed between age 50 to 70 years. Individuals with Familial Pulmonary Fibrosis (FPF) have at least one affected
first or second-degree relative and account for 0.5-20% of cases.
Methods: We ascertained and collected DNA samples from a large population-based cohort of IPF patients from
Newfoundland, Canada. For each proband, a family history was documented and medical records were reviewed.
Each proband was classified as familial (28 patients) or sporadic (50 patients) and all 78 probands were screened for
variants in four highly penetrant, adult-onset PF genes (SFTPC, SFTPA2, TERT, TERC).
Results: Seventy-eight IPF probands were enrolled of whom 28 (35.9%) had a positive family history. These 28
familial patients led to the recruitment of an additional 49 affected relatives (total of 77 FPF patients). By age
60 years, 42% of the familial cohort had been diagnosed with PF compared with only 16% of the sporadic patient
collection (Ï2 = 8.77, p = 0.003). Mean age of diagnosis in the familial group was significantly younger than the
sporadic group (61.4 years vs. 66.6 yrs, p = 0.012) with a wider age range of diagnosis (19â92 years compared with
47â82 years). Thirty-three of 77 (42.8%) FPF patients had a tissue diagnosis and all but five had usual interstitial
pneumonia histology. Compared with other published case series, the familial IIP histologies were more
homogeneous. Three of 28 familial probands (10.7%) and none of the 50 sporadic probands had pathogenic
variants in the four genes tested. All three familial probands had mutations in TERT. Other phenotypes associated
with telomerase deficiency were present in these families including cirrhosis, bone marrow hypoplasia and
premature graying. Telomere length assays were performed on mutation carriers from two families and confirmed
telomere-related deficiency.
Conclusion: The proportion of familial cases in our cohort is higher than any previously reported estimate and we
suggest that this is due to the fact that Newfoundland cohort is ethnically homogeneous and drawn from a
founder population. In our patient collection, diagnosis with IPF prior to age 45 years predicted familial disease. In
two of the three TERT mutation families, the pedigree appearance is consistent with genetic anticipation. In the
other 25 FPF families negative for mutations in known PF genes, we did not identify other telomerase associated
medical problems (bone marrow dysfunction, cirrhosis) and we hypothesize that there are novel PF genes
segregating in our population
Rifaximin for prevention and treatment of hepatic encephalopathy in people with cirrhosis
Background:
Hepatic encephalopathy describes the spectrum of neuropsychiatric changes that may complicate the course of cirrhosis and detrimentally affect outcomes. Ammonia plays a key role in its development. Rifaximin is a nonâabsorbable antibiotic that inhibits ureaseâproducing bacteria and reduces absorption of dietary and bacterial ammonia.//
Objectives:
To evaluate the beneficial and harmful effects of rifaximin versus placebo, no intervention, or nonâabsorbable disaccharides for: (i) the prevention of hepatic encephalopathy, and (ii) the treatment of minimal and overt hepatic encephalopathy, in people with cirrhosis, both when used alone and when combined with a nonâabsorbable disaccharide.//
Search methods:
We searched the Cochrane HepatoâBiliary Group Clinical Trials Register, CENTRAL, MEDLINE, Embase, three other databases, the reference lists of identified papers, and relevant conference proceedings. We wrote to authors and pharmaceutical companies for information on other published, unpublished, or ongoing trials. Searches were performed to January 2023.//
Selection criteria:
We included randomised clinical trials assessing prevention or treatment of hepatic encephalopathy with rifaximin alone, or with a nonâabsorbable disaccharide, versus placebo/no intervention, or a nonâabsorbable disaccharide alone.//
Data collection and analysis:
Six authors independently searched for studies, extracted data, and validated findings. We assessed the design, bias risk, and participant/intervention characteristics of the included studies. We assessed mortality, serious adverse events, healthârelated quality of life, hepatic encephalopathy, nonâserious adverse events, blood ammonia, Number Connection TestâA, and length of hospital stay.//
Main results:
We included 41 trials involving 4545 people with, or at risk for, developing hepatic encephalopathy. We excluded 89 trials and identified 13 ongoing studies. Some trials involved participants with more than one type of hepatic encephalopathy or more than one treatment comparison. Hepatic encephalopathy was classed as acute (13 trials), chronic (7 trials), or minimal (8 trials), or else participants were considered at risk for its development (13 trials). The control groups received placebo (12 trials), no/standard treatment (1 trial), or a nonâabsorbable disaccharide (14 trials). Eighteen trials assessed rifaximin plus a nonâabsorbable disaccharide versus a nonâabsorbable disaccharide alone. We classified 11 trials as at high risk of overall bias for mortality and 28 for nonâmortality outcomes, mainly due to lack of blinding, incomplete outcome data, and selective reporting.//
Compared to placebo/no intervention, rifaximin likely has no overall effect on mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.50 to 1.38; P = 48, I2 = 0%; 13 trials, 1007 participants; moderateâcertainty evidence), and there may be no overall effect when compared to nonâabsorbable disaccharides (RR 0.99, 95% CI 0.49 to 1.97; P = 0.97, I2 = 0%; 10 trials, 786 participants; lowâcertainty evidence). However, there is likely a reduction in the overall risk of mortality when comparing rifaximin plus a nonâabsorbable disaccharide to a nonâabsorbable disaccharide alone (RR 0.69, 95% CI 0.55 to 0.86; number needed to treat for an additional beneficial outcome (NNTB) = 22; P = 0.001, I2 = 0%; 14 trials, 1946 participants; moderateâcertainty evidence).//
There is likely no effect on the overall risk of serious adverse events when comparing rifaximin to placebo/no intervention (RR 1.05, 95% CI 0.83 to 1.32; P = 68, I2 = 0%; 9 trials, 801 participants; moderateâcertainty evidence) and there may be no overall effect when compared to nonâabsorbable disaccharides (RR 0.97, 95% CI 0.66 to 1.40; P = 85, I2 = 0%; 8 trials, 681 participants; lowâcertainty evidence). However, there was very lowâcertainty evidence that use of rifaximin plus a nonâabsorbable disaccharide may be associated with a lower risk of serious adverse events than use of a nonâabsorbable disaccharide alone (RR 0.66, 95% CI 0.45 to 0.98; P = 0.04, I2 = 60%; 7 trials, 1076 participants).//
Rifaximin likely results in an overall effect on healthârelated quality of life when compared to placebo/no intervention (mean difference (MD) â1.43, 95% CI â2.87 to 0.02; P = 0.05, I2 = 81%; 4 trials, 214 participants; moderateâcertainty evidence), and may benefit healthârelated quality of life in people with minimal hepatic encephalopathy (MD â2.07, 95% CI â2.79 to â1.35; P < 0.001, I2 = 0%; 3 trials, 176 participants). The overall effect on healthârelated quality of life when comparing rifaximin to nonâabsorbable disaccharides is very uncertain (MD â0.33, 95% CI â1.65 to 0.98; P = 0.62, I2 = 0%; 2 trials, 249 participants; very lowâcertainty evidence). None of the combined rifaximin/nonâabsorbable disaccharide trials reported on this outcome.//
There is likely an overall beneficial effect on hepatic encephalopathy when comparing rifaximin to placebo/no intervention (RR 0.56, 95% CI 0.42 to 0.77; NNTB = 5; P < 0.001, I2 = 68%; 13 trials, 1009 participants; moderateâcertainty evidence). This effect may be more marked in people with minimal hepatic encephalopathy (RR 0.40, 95% CI 0.31 to 0.52; NNTB = 3; P < 0.001, I2 = 10%; 6 trials, 364 participants) and in prevention trials (RR 0.71, 95% CI 0.56 to 0.91; NNTB = 10; P = 0.007, I2 = 36%; 4 trials, 474 participants). There may be little overall effect on hepatic encephalopathy when comparing rifaximin to nonâabsorbable disaccharides (RR 0.85, 95% CI 0.69 to 1.05; P = 0.13, I2 = 0%; 13 trials, 921 participants; lowâcertainty evidence). However, there may be an overall beneficial effect on hepatic encephalopathy when comparing rifaximin plus a nonâabsorbable disaccharide to a nonâabsorbable disaccharide alone (RR 0.58, 95% CI 0.48 to 0.71; NNTB = 5; P < 0.001, I2 = 62%; 17 trials, 2332 participants; lowâcertainty evidence)
Barrettâs esophagus and cardiac intestinal metaplasia: Two conditions within the same spectrum
BACKGROUND: Immunostaining for cytokeratin 7 (CK7) and cytokeratin 20 (CK20) has a characteristic pattern in Barrettâs esophagus (BE), but reports regarding its sensitivity and specificity are inconsistent. Intestinal metaplasia of the gastric cardia (CIM) is histologically similar to BE, but with no abnormal endoscopic findings.
OBJECTIVES: To evaluate the sensitivity and specificity of a semi-quantitative CK7/CK20 immunostaining pattern for the diagnosis of BE, and to further elucidate the pathogenesis of CIM.
METHODS: Tissues were examined by hematoxylin and eosin and periodic acid schiff/alcian blue stains, and then were immunostained with CK7 and CK20 antibodies. Correlations with other clinical parameters were statistically analyzed.
RESULTS: When values were revised based on follow-up data and auxiliary testing, all BE cases (100%) displayed the characteristic BE CK7/CK20 immunostaining pattern, compared with 66% of CIM cases. In the subgroup of patients who were endoscopically and immunohistochemistry-positive but histologically negative, all patients except for one had documented BE when clinical history, auxiliary testing and follow-up were evaluated. There were no statistically significant differences between BE and CIM regarding Helicobacter pylori infection or the type of metaplasia (complete versus incomplete). The sensitivity of the CK7/CK20 pattern reached 100% in the subgroup of CIM patients with a history of acid reflux. Of 26 cases of CIM where follow-up was available, four cases (15%) progressed to BE, and one developed dysplasia. All four cases showed the BE pattern of CK7/CK20 staining and were negative for H pylori infection.
CONCLUSIONS: A semiquantitative CK7/CK20 pattern can be used to confirm BE even in the absence of histological evidence. The subgroup of CIM with acid reflux may develop into BE and may need closer follow-up
A review of the international early recommendations for departments organization and cancer management priorities during the global COVID-19 pandemic: applicability in low- and middle-income countries
Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a new virus that has never been identified in humans before. COVID-19 caused at the time of writing of this article, 2.5 million cases of infections in 193 countries with 165,000 deaths, including two-third in Europe. In this context, Oncology Departments of the affected countries had to adapt quickly their health system care and establish new organizations and priorities. Thus, numerous recommendations and therapeutic options have been reported to optimize therapy delivery to patients with chronic disease and cancer. Obviously, while these cancer care recommendations are immediately applicable in Europe, they may not be applicable in certain emerging and low- and middle-income countries (LMICs). In this review, we aimed to summarize these international guidelines in accordance with cancer types, making a synthesis for daily practice to protect patients, staff and tailor anti-cancer therapy delivery taking into account patients/tumour criteria and tools availability. Thus, we will discuss their applicability in the LMICs with different organizations, limited means and different constraints
The Mediterranean region under climate change
This book has been published by Allenvi (French National Alliance for Environmental Research) to coincide with the 22nd Conference of Parties to the United Nations Framework Convention on Climate Change (COP22) in Marrakesh. It is the outcome of work by academic researchers on both sides of the Mediterranean and provides a remarkable scientific review of the mechanisms of climate change and its impacts on the environment, the economy, health and Mediterranean societies. It will also be valuable in developing responses that draw on âscientific evidenceâ to address the issues of adaptation, resource conservation, solutions and risk prevention. Reflecting the full complexity of the Mediterranean environment, the book is a major scientific contribution to the climate issue, where various scientific considerations converge to break down the boundaries between disciplines