Antinuclear antibody testing in obstetric patients

Objectives. To assess possible associations between the presence of antinuclear antibodies (ANAs) and pregnancy outcome in order to determine the significance of this test in obstetric practice.Methods. A case-control study was performed on 408 patients admitted to an obstetric high care unit and on whom ANA testing was consecutively performed. The study group consisted of 46 patients who tested positive for ANAs and a control group of 92 patients who tested negative for ANAs. In addition to demographic data, indications for admission and pregnancy outcome were compared between the two groups.                                Results. Of the 46 patients with a positive ANA result, 28 had an antinuclear pattern, 13 an anticytoplasmic pattern and 5 an antinuclear and an anticytoplasmic pattern. No significant differences were observed between the two groups (ANApositive and negative) with regard to demographic data, indication for admission, clinical and laboratory data, and pregnancy outcome. The patients were also tested for anticardiolipin antibodies, and significantly more patients with severe pre-eclampsia tested positive (24% versus 4.7%, p = 0.01). No difference in HIV status and presence of autoantibodies was found between the two groups.Conclusion. The presence of ANAs was not associated with adverse pregnancy outcome. Therefore routine patient testing for ANAs in an obstetric high-care unit is not recommended

The confidential enquiry into maternal deaths in South Africa : a case study

The Confidential Enquiry into Maternal Deaths (CEMD) in South Africa has been operational for 15 years. This case study describes the process of notification and independent assessment of maternal deaths, predominantly in facilities. In the earlier years of the Enquiry, institutional maternal mortality ratio increased and was 176.2 per 100 000 live births in the 2008–10 triennium; thereafter it decreased to 146.7 in the 2011/12 period. The slow progress was due to the significant contribution of HIV/AIDs to maternal mortality and challenges in implementing the recommendations that were devised from the findings of the Enquiry. Nevertheless, the CEMD process has been maintained and strengthened so it is currently able to perform routine maternal death surveillance at both national and district levels, identify deficiencies within the health system, generate reports and also provide early warning about alarming trends such as the increasing numbers of deaths due to caesarean-section-associated haemorrhage.http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1471-05282015-09-30hj201

Randomised controlled trial of transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND Study)

Cellular mechanisms in basic and clinical gastroenterology and hepatolog

Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial

Background Infected necrosis complicates 10% of all acute pancreatitis episodes and is associated with 15–20% mortality. The current standard treatment for infected necrotizing pancreatitis is the step-up approach (catheter drainage, followed, if necessary, by minimally invasive necrosectomy). Catheter drainage is preferably postponed until the stage of walled-off necrosis, which usually takes 4 weeks. This delay stems from the time when open necrosectomy was the standard. It is unclear whether such delay is needed for catheter drainage or whether earlier intervention could actually be beneficial in the current step-up approach. The POINTER trial investigates if immediate catheter drainage in patients with infected necrotizing pancreatitis is superior to the current practice of postponed intervention. Methods POINTER is a randomized controlled multicenter superiority trial. All patients with necrotizing pancreatitis are screened for eligibility. In total, 104 adult patients with (suspected) infected necrotizing pancreatitis will be randomized to immediate (within 24 h) catheter drainage or current standard care involving postponed catheter drainage. Necrosectomy, if necessary, is preferably postponed until the stage of walled-off necrosis, in both treatment arms. The primary outcome is the Comprehensive Complication Index (CCI), which covers all complications between randomization and 6-month follow up. Secondary outcomes include mortality, complications, number of (repeat) interventions, hospital and intensive care unit (ICU) lengths of stay, quality-adjusted life years (QALYs) and direct and indirect costs. Standard follow-up is at 3 and 6 months after randomization. Discussion The POINTER trial investigates if immediate catheter drainage in infected necrotizing pancreatitis reduces the composite endpoint of complications, as compared with the current standard treatment strategy involving delay of intervention until the stage of walled-off necrosis

Diastolic blood pressure drop after standing as a clinical sign for increased mortality in older falls clinic patients.

Item does not contain fulltextBACKGROUND: Orthostatic hypotension, postprandial hypotension, and carotid sinus hypersensitivity are hypotensive syndromes with high prevalence in older people. However, their pathophysiology and prognostic significance remain largely unknown. METHODS: In a retrospective cohort study of 313 consecutive patients visiting our falls outpatient clinic, we examined the clustering of orthostatic hypotension, postprandial hypotension, and carotid sinus hypersensitivity in the same patients, which might reflect a shared similar pathophysiology. The value of hypotensive syndrome presence and the degree of blood pressure decline as prognostic indicators for mortality were assessed using Cox proportional hazards analyses. RESULTS: In 313 patients (mean age 78.7 +/- 8.0 years), 168 of 309 (54%), 175 of 302 (58%), and 143 of 272 (53%) were diagnosed with orthostatic hypotension, postprandial hypotension, and sinus carotid hypersensitivity, respectively. There was no clustering of the hypotensive syndromes. During a median follow-up of 23.0 months, 58 (19%) patients died. Orthostatic hypotension, but not postprandial hypotension or carotid sinus hypersensitivity, predicted mortality [hazard ratio 1.97; 95% confidence interval (CI) 1.11-3.47]. After adjusting for age, comorbidity and other baseline characteristics, this relationship was no longer significant. However, orthostatic hypotension with severe diastolic blood pressure decline of at least 20 mmHg remained a powerful independent predictor of mortality (hazard ratio 2.50; 95% CI 1.20-5.22). CONCLUSIONS: In falls clinic patients, hypotensive syndromes did not cluster and did not independently predict mortality. However, orthostatic hypotension with severe diastolic blood pressure decline was a powerful independent predictor of mortality and might be used prognostically as an easily available cardiovascular sign of increased mortality risk.1 juni 201

Clip placement to prevent delayed bleeding after colonic endoscopic mucosal resection (CLIPPER): study protocol for a randomized controlled trial

Contains fulltext : 230390.pdf (publisher's version ) (Open Access

A Study on Design and Development for Javelin

Contains fulltext : 172389.pdf (publisher's version ) (Open Access)BACKGROUND: Acute pancreatitis is mostly caused by gallstones or sludge. Early decompression of the biliary tree by endoscopic retrograde cholangiography (ERC) with sphincterotomy may improve outcome in these patients. Whereas current guidelines recommend early ERC in patients with concomitant cholangitis, early ERC is not recommended in patients with mild biliary pancreatitis. Evidence on the role of routine early ERC with endoscopic sphincterotomy in patients without cholangitis but with biliary pancreatitis at high risk for complications is lacking. We hypothesize that early ERC with sphincterotomy improves outcome in these patients. METHODS/DESIGN: The APEC trial is a randomized controlled, parallel group, superiority multicenter trial. Within 24 hours after presentation to the emergency department, patients with biliary pancreatitis without cholangitis and at high risk for complications, based on an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 8 or greater, Modified Glasgow score of 3 or greater, or serum C-reactive protein above 150 mg/L, will be randomized. In 27 hospitals of the Dutch Pancreatitis Study Group, 232 patients will be allocated to early ERC with sphincterotomy or to conservative treatment. The primary endpoint is a composite of major complications (that is, organ failure, pancreatic necrosis, pneumonia, bacteremia, cholangitis, pancreatic endocrine, or exocrine insufficiency) or death within 180 days after randomization. Secondary endpoints include ERC-related complications, infected necrotizing pancreatitis, length of hospital stay and an economical evaluation. DISCUSSION: The APEC trial investigates whether an early ERC with sphincterotomy reduces the composite endpoint of major complications or death compared with conservative treatment in patients with biliary pancreatitis at high risk of complications. TRIAL REGISTRATION: Current Controlled Trials ISRCTN97372133 (date registration: 17-12-2012)

Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC):a multicentre randomised controlled trial

Background It remains unclear whether urgent endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy improves the outcome of patients with gallstone pancreatitis without concomitant cholangitis. We did a randomised trial to compare urgent ERCP with sphincterotomy versus conservative treatment in patients with predicted severe acute gallstone pancreatitis.Methods In this multicentre, parallel-group, assessor-masked, randomised controlled superiority trial, patients with predicted severe (Acute Physiology and Chronic Health Evaluation II score >= 8, Imrie score >= 3, or C-reactive protein concentration >150 mg/L) gallstone pancreatitis without cholangitis were assessed for eligibility in 26 hospitals in the Netherlands. Patients were randomly assigned (1:1) by a web-based randomisation module with randomly varying block sizes to urgent ERCP with sphincterotomy (within 24 h after hospital presentation) or conservative treatment. The primary endpoint was a composite of mortality or major complications (new-onset persistent organ failure, cholangitis, bacteraemia, pneumonia, pancreatic necrosis, or pancreatic insufficiency) within 6 months of randomisation. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN97372133.Findings Between Feb 28, 2013, and March 1, 2017, 232 patients were randomly assigned to urgent ERCP with sphincterotomy (n=118) or conservative treatment (n=114). One patient from each group was excluded from the final analysis because of cholangitis (urgent ERCP group) and chronic pancreatitis (conservative treatment group) at admission. The primary endpoint occurred in 45 (38%) of 117 patients in the urgent ERCP group and in 50 (44%) of 113 patients in the conservative treatment group (risk ratio [RR] 0.87, 95% CI 0.64-1.18; p=0.37). No relevant differences in the individual components of the primary endpoint were recorded between groups, apart from the occurrence of cholangitis (two [2%] of 117 in the urgent ERCP group vs 11 [10%] of 113 in the conservative treatment group; RR 0.18, 95% CI 0.04-0.78; p=0.010). Adverse events were reported in 87 (74%) of 118 patients in the urgent ERCP group versus 91 (80%) of 114 patients in the conservative treatment group.Interpretation In patients with predicted severe gallstone pancreatitis but without cholangitis, urgent ERCP with sphincterotomy did not reduce the composite endpoint of major complications or mortality, compared with conservative treatment. Our findings support a conservative strategy in patients with predicted severe acute gallstone pancreatitis with an ERCP indicated only in patients with cholangitis or persistent cholestasis