Dietary modifications for infantile colic

Infantile colic can be defined as periods of inconsolable, unexplained, and incessant crying in a seemingly healthy infant that, quite understandably, leads to exhausted, frustrated, and concerned parents seeking to comfort their child (Landgren 2010). The prevalence of excessive crying varies according to the definition used although, most often, it peaks during the second month of life,with a prevalence of 1.5%to 11.9%(Reijneveld 2001).Traditionally, the definition of the condition was based on the rule of three (Wessel 1954): that is, unexplained episodes of paroxysmal crying for more than three hours per day, for three days per week, for at least three weeks. More recently a new definition has been proposed. It refers to a clinical condition of fussing and crying for at least one week in an otherwise healthy infant (Hyman 2006). Colic can be graded as mild, moderate, or severe, though there is no consensus for this classification. Colic can affect up to 10% to 30% of infants worldwide (Clifford 2002; Rosen 2007)

Clinical Evidence: a useful tool for promoting evidence-based practice?

Background: Research has shown that many healthcare professionals have problems with guidelines as they would prefer to be given all relevent information relevent to decision-making rather than being told what they should do. This study assesses doctors' judgement of the validity, relevance, clarity and usability of the Italian translation of Clinical Evidence (CE) after its free distribution launched by the Italian Ministry of Health. Methods: Opinions elicited using a standardised questionnaire delivered either by mail or during educational or professional meetings. Results: Twenty percent (n = 1350) doctors participated the study. Most of them found CE's content valid, useful and relevant for their clinical practice, and said CE can foster communications among clinicians, particularly among GPs and specialists. Hospital doctors (63%) more often than GPs (48%) read the detailed presentation of individual chapters. Twenty-nine percent said CE brought changes in their clinical practice. Doctors appreciated CE's nature of an evidence-based information compendium and would have not preferred a collection of practice guidelines. Conclusions: Overall, the pilot initiative launched by the Italian Ministry of Health seems to have been well received and to support the subsequent decision to make the Italian edition of Clinical Evidence concise available to all doctors practising in the country. Local implementation initiatives should be warranted to favour doctor's use of CE

Pain-relieving agents for infantile colic

Background: Infantile colic is a common disorder in the first months of life, affecting somewhere between 4% and 28% of infants worldwide, depending on geography and definitions used. Although it is self limiting and resolves by four months of age, colic is perceived by parents as a problem that requires action. Pain-relieving agents, such as drugs, sugars and herbal remedies, have been suggested as interventions to reduce crying episodes and severity of symptoms. Objectives: To assess the effectiveness and safety of pain-relieving agents for reducing colic in infants younger than four months of age. Search methods: We searched the following databases in March 2015 and again in May 2016: CENTRAL, Ovid MEDLINE, Embase and PsycINFO, along with 11 other databases. We also searched two trial registers, four thesis repositories and the reference lists of relevant studies to identify unpublished and ongoing studies. Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs evaluating the effects of pain-relieving agents given to infants with colic. Data collection and analysis: We used the standard methodological procedures of The Cochrane Collaboration. Main results: We included 18 RCTs involving 1014 infants. All studies were small and at high risk of bias, often presenting major shortcomings across multiple design factors (e.g. selection, performance, attrition, lack of washout period). Three studies compared simethicone with placebo, and one with Mentha piperita; four studies compared herbal agents with placebo; two compared sucrose or glucose with placebo; five compared dicyclomine with placebo; and two compared cimetropium - one against placebo and the other at two different dosages. One multiple-arm study compared sucrose and herbal tea versus no treatment. Simethicone. Comparison with placebo revealed no difference in daily hours of crying reported for simethicone at the end of treatment in one small, low-quality study involving 27 infants. A meta-analysis of data from two cross-over studies comparing simethicone with placebo showed no difference in the number of of infants who responded positively to treatment (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.73 to 1.23; 110 infants, low-quality evidence). One small study (30 participants) compared simethicone with Mentha piperita and found no difference in crying duration, number of crying episodes or number of responders. Herbal agents. We found low-quality evidence suggesting that herbal agents reduce the duration of crying compared with placebo (mean difference (MD) 1.33, 95% CI 0.71 to 1.96; three studies, 279 infants), with different magnitude of benefit noted across studies (I2 = 96%). We found moderate-quality evidence indicating that herbal agents increase response over placebo (RR 2.05, 95% CI 1.56 to 2.70; three studies, 277 infants). Sucrose. One very low-quality study involving 35 infants reported that sucrose reduced hours spent crying compared with placebo (MD 1.72, 95% CI 1.38 to 2.06). Dicyclomine. We could consider only one of the five studies of dicyclomine (48 infants) for the primary comparison. In this study, more of the infants given dicyclomine responded than than those given placebo (RR 2.50, 95% CI 1.17 to 5.34). Cimetropium bromide. Data from one very low-quality study comparing cimetropium bromide with placebo showed reduced crying duration among infants treated with cimetropium bromide (MD -30.20 minutes per crisis, 95% CI -39.51 to -20.89; 86 infants). The same study reported that cimetropium increased the number of responders (RR 2.29, 95% CI 1.44 to 3.64). No serious adverse events were reported for all of the agents considered, with the exception of dicyclomine, for which two of five studies reported relevant adverse effects (longer sleep 4%, wide-eyed state 4%, drowsiness 13%). Authors' conclusions: At the present time, evidence of the effectiveness of pain-relieving agents for the treatment of infantile colic is sparse and prone to bias. The few available studies included small sample sizes, and most had serious limitations. Benefits, when reported, were inconsistent. We found no evidence to support the use of simethicone as a pain-relieving agent for infantile colic. Available evidence shows that herbal agents, sugar, dicyclomine and cimetropium bromide cannot be recommended for infants with colic. Investigators must conduct RCTs using standardised measures that allow comparisons among pain-relieving agents and pooling of results across studies. Parents, who most often provide the intervention and assess the outcome, should always be blinded

Time from adenosine di-phosphate receptor antagonist discontinuation to coronary bypass surgery in patients with acute coronary syndrome: meta-analysis and meta-regression

BACKGROUND: Adenosine di-phosphate receptor antagonists (ADPRAs) blunt hemostasis for several days after administration. This effect, aimed at preventing cardiac ischemic complications particularly in patients with acute coronary syndromes (ACS), may increase perioperative bleeding in the case of cardiac surgery. Practice Guidelines recommend withholding ADPRAs for at least 5days prior to surgery, though with a weak base of evidence. The purpose of this study was to systematically review observational and experimental studies of early or late preoperative discontinuation of ADPRAs prior to coronary artery bypass grafting (CABG) for patients with ACS. METHODS: MEDLINE, EMBASE, the Cochrane Library databases up to December 2011; and reference lists. Observational and experimental studies that compared early ADPRA discontinuation with late discontinuation, or no discontinuation, in patients with ACS undergoing CABG. RESULTS: There were 19 studies, including 14,046 participants, 395 deaths and 309 reoperations due to bleeding. ADPRA late discontinuation up to CABG was associated with an increased risk of postoperative mortality (OR 1.46, 95% confidence interval (CI) 1.10 to 1.93) and reoperations due to bleeding (OR 2.18; 95% CI 1.47 to 2.62). Between-study heterogeneity was low. Meta-analysis limited to high quality or prospective studies gave consistent results. In most instances, the 95% prediction intervals for summary risk estimates confirmed the risk across study groups. CONCLUSIONS: ADPRA late discontinuation prior to CABG is associated with an increased risk of death and reoperations due to bleeding in patients with ACS. The confidence in the estimates of risk for late discontinuation is moderate to high

Acepromazione, detomidine and morphine: “the wooden horse” evaluation of standing sedation protocols in the equine patients undergoing bone scintigraphy

In equine practice standing sedation has became increasingly popular. Many protocols have been investigated permitting to restrain patients avoiding general anaesthesia and the risk associated by increasing the threshold to all external stimuli and partially providing analgesia (Muir W. 1981; Dodman N. 1980). The target of standing sedation protocols during diagnostic imaging procedures is to reduce all the reaction of the patients to external stimuli, and to diminish physiological movements. No studies have been published establishing a standard protocol, and the decision of which protocol use is based on anaesthetist preferences and not on evidence-based medicine.The aim of the study is to evaluate two sedative protocols, focusing not only on the lack of response to stimuli and the reduction of physiological movements but also on the immobility of the patient that is mandatory for diagnostic imaging procedures.Thirteen horses referred to perform bone scintigraphy were enrolled in the study. Patients were randomly divided in two groups; both groups received same dose of acepromazine (0.003 mg/kg) and detomidine (10 \uf06d/kg), MOR group received morphine (0.25 mg/kg), the BTF group received butorphanol (0.01 mg/kg). During the procedure to evaluate the horse sedation a simple descriptive scale (Taylor P. et al. 2014) was used; respiratory and hearth rate were recorded and if needed adjunctive boluses of detomidine were administrated. To evaluate the reduction of voluntary and involuntary movements the parameter chosen was the number of retake necessary to obtain an image with excellent diagnostic quality. This parameter was evaluated each time by the same radiologist that was unaware of which protocol was administered. Statistical analysis with T-Test was performed.Heart rate resulted not statistically different (MOR=27.1\ub12,4;BTF 26.8\ub13.7); respiratory rate in the MOR group resulted statistically diminished (MOR=9.9\ub12.3; BTF 13.4\ub13.1). The sedation score was statistically higher in the MOR group (MOR= 1.6\ub10.5; BTF 1.0\ub10.3) and moreover in the total body examinations. The total dose of detomidine used in the two groups resulted non statistically different (MOR=23.7; BTF 23.2). The total number of retake did not result statistically significant even if the clinical difference was relevant (MOR=7.1; BTF=16.2), but the number of retake for each region investigated resulted statistically diminished in the MOR group (MOR=0.4\ub10.5; BTF 0.8\ub10.8). The results of this study demonstrate the supremacy of the MOR sedation protocol to perform bone scintigraphy in horses. Further studies are recommended to evaluate the administration of detomidine constant rate infusion to maintain a required sedation degree. The \u201cWooden Ho se\u201d could by applied in ot e diagnostic imaging tec niques suc as CT o MRI and also for various standing surgeries. Other parameters that could be considered are the duration of the exams and also the number of urinations of the patient during the exam to evaluate operators exposure to radiations

Community pharmacists and stress at the counter : Qualitative exploratory initial italian research

Objectives: Community pharmacists are the most accessible healthcare professionals. They interact with a large number of patients who often show emotional concern. Their stressful and complex role is widely acknowledged, nonetheless research on their personal life is practically non-existent. Thus, we set out to qualitatively explore the emotional perceptions of pharmacists. Methods: Twenty experienced pharmacists were interviewed by a psychologist and a pharmacist. Data were analysed using an interpretative phenomenological analysis and coded using NVivo qualitative data analysis software. Key findings: Interviewed pharmacists admitted to different types of difficulties, mostly arising from a series of small, standalone episodes. Their stories describe intrinsic difficulties with their practice, rather than personal experiences. This study reveals the complexity of a community pharmacists' role - divided into health and hygiene advice, counselling and empathic relationships, and entrepreneurship. An important obstacle is the integration and concomitant implementation of these components. Endogenous factors such as personal experiences, personality and academic background, and exogenous factors such as social status of the patient population, legal and administrative issues and location, all affect pharmacists' ability to cope with their role. Conclusions: Improving health care can be obtained by incorporating community pharmacists into the healthcare team. Technical training is important in order to improve relationship skills and personal coping strategies. Further studies are recommended to provide a simple tool for measuring aspects of the personal and emotional aspects (inner life) of a community pharmacist