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How do we define therapy-resistant Constipation in Children 4-18 years old? A systematic review with meta-narrative synthesis Data extraction
Get PDFBackground
Therapy resistant constipation often is a frustrating clinical entity recognised by the persistence of infrequent and painful bowel movements fecal incontinence and abdominal pain despite intensive treatment. It is important to clearly define therapy resistant constipation before children are subjected to invasive diagnostic and therapeutic procedures.
Aim
To conduct a systematic review determining how pediatric interventional studies define therapy resistant constipation.
Method
We searched CENTRAL, MEDLINE, Embase, WHO ICTR and ClinicalTrials.gov. Studies that included patients with therapy resistant constipation were identified. Data were extracted on criteria used for defining therapy resistant constipation and reported using meta-narrative approach highlighting areas of convergence and divergence in the findings.
Results
A total of 1553 abstracts were screened in duplicate, and 47 studies were included in the review. There were at least 7 definitions used in the paediatric literature to define medically resistant constipation. The term intractable was used in 24 articles and 21 used the term refractory to describe therapy resistant constipation. Out of them only 14 articles have attempted to provide an explicit definition including a predefined time and prior therapy. There were 10 studies without a clear definition for therapy resistant constipation. The duration before being diagnosed as therapy resistant constipation varied from 1 months to 2 years among studies. Seven studies employed the Rome criteria (Rome III or Rome IV) to characterising constipation, while 5 adopted the Rome III and European and North American paediatric societies definition of paediatric gastroenterology, hepatology and nutrition guideline of management of constipation in children.
Conclusion
The current literature has no explicit definition for therapy resistant constipation in children. There is a need for a detailed consensus definition to ensure consistency of future research and to avoid unnecessary, and maybe even harmful, invasive diagnostic and therapeutic interventions
An Evaluation of the ARG UK Prison-based ‘Improving the well-being of offenders and their families by re-connecting them with the natural world’ project funded by the HMPPS Innovation Grant Scheme
Get PDFTreatments for intractable constipation in childhood
No full textBackground
Constipation that is prolonged and does not resolve with conventional therapeutic measures is called intractable constipation. The treatment of intractable constipation is challenging, involving pharmacological or non‐pharmacological therapies, as well as surgical approaches. Unresolved constipation can negatively impact quality of life, with additional implications for health systems. Consequently, there is an urgent need to identify treatments that are efficacious and safe.
Objectives
To evaluate the efficacy and safety of treatments used for intractable constipation in children.
Search methods
We searched CENTRAL, MEDLINE, Embase, and two trials registers up to 23 June 2023. We also searched reference lists of included studies for relevant studies.
Selection criteria
We included randomised controlled trials (RCTs) comparing any pharmacological, non‐pharmacological, or surgical treatment to placebo or another active comparator, in participants aged between 0 and 18 years with functional constipation who had not responded to conventional medical therapy.
Data collection and analysis
We used standard Cochrane methods. Our primary outcomes were symptom resolution, frequency of defecation, treatment success, and adverse events; secondary outcomes were stool consistency, painful defecation, quality of life, faecal incontinence frequency, abdominal pain, hospital admission for disimpaction, and school absence. We used GRADE to assess the certainty of evidence for each primary outcome.
Main results
This review included 10 RCTs with 1278 children who had intractable constipation. We assessed one study as at low risk of bias across all domains. There were serious concerns about risk of bias in six studies.
One study compared the injection of 160 units botulinum toxin A (n = 44) to unspecified oral stool softeners (n = 44). We are very uncertain whether botulinum toxin A injection improves treatment success (risk ratio (RR) 37.00, 95% confidence interval (CI) 5.31 to 257.94; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Frequency of defecation was reported only for the botulinum toxin A injection group (mean interval of 2.6 days). The study reported no data for the other primary outcomes.
One study compared erythromycin estolate (n = 6) to placebo (n = 8). The only primary outcome reported was adverse events, which were 0 in both groups. The evidence is of very low certainty due to concerns with risk of bias and serious imprecision.
One study compared 12 or 24 μg oral lubiprostone (n = 404) twice a day to placebo (n = 202) over 12 weeks. There may be little to no difference in treatment success (RR 1.29, 95% CI 0.87 to 1.92; low certainty evidence). We also found that lubiprostone probably results in little to no difference in adverse events (RR 1.05, 95% CI 0.91 to 1.21; moderate certainty evidence). The study reported no data for the other primary outcomes.
One study compared three‐weekly rectal sodium dioctyl sulfosuccinate and sorbitol enemas (n = 51) to 0.5 g/kg/day polyethylene glycol laxatives (n = 51) over a 52‐week period. We are very uncertain whether rectal sodium dioctyl sulfosuccinate and sorbitol enemas improve treatment success (RR 1.33, 95% CI 0.83 to 2.14; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Results of defecation frequency per week was reported only as modelled means using a linear mixed model. The study reported no data for the other primary outcomes.
One study compared biofeedback therapy (n = 12) to no intervention (n = 12). We are very uncertain whether biofeedback therapy improves symptom resolution (RR 2.50, 95% CI 1.08 to 5.79; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). The study reported no data for the other primary outcomes.
One study compared 20 minutes of intrarectal electromotive botulinum toxin A using 2800 Hz frequency and botulinum toxin A dose 10 international units/kg (n = 30) to 10 international units/kg botulinum toxin A injection (n = 30). We are very uncertain whether intrarectal electromotive botulinum toxin A improves symptom resolution (RR 0.96, 95% CI 0.76 to 1.22; very low certainty evidence) or if it increases the frequency of defecation (mean difference (MD) 0.00, 95% CI −1.87 to 1.87; very low certainty evidence). We are also very uncertain whether intrarectal electromotive botulinum toxin A has an improved safety profile (RR 0.20, 95% CI 0.01 to 4.00; very low certainty evidence). The evidence for these results is of very low certainty due to serious concerns with risk of bias and imprecision. The study did not report data on treatment success.
One study compared the injection of 60 units botulinum toxin A (n = 21) to myectomy of the internal anal sphincter (n = 21). We are very uncertain whether botulinum toxin A injection improves treatment success (RR 1.00, 95% CI 0.75 to 1.34; very low certainty evidence). No adverse events were recorded. The study reported no data for the other primary outcomes.
One study compared 0.04 mg/kg oral prucalopride (n = 107) once daily to placebo (n = 108) over eight weeks. Oral prucalopride probably results in little or no difference in defecation frequency (MD 0.50, 95% CI −0.06 to 1.06; moderate certainty evidence); treatment success (RR 0.96, 95% CI 0.53 to 1.72; moderate certainty evidence); and adverse events (RR 1.15, 95% CI 0.94 to 1.39; moderate certainty evidence). The study did not report data on symptom resolution.
One study compared transcutaneous electrical stimulation to sham stimulation, and another study compared dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. These studies did not report any of our predefined primary outcomes.
Authors' conclusions
We identified low to moderate certainty evidence that oral lubiprostone may result in little to no difference in treatment success and adverse events compared to placebo. Based on moderate certainty evidence, there is probably little or no difference between oral prucalopride and placebo in defecation frequency, treatment success, or adverse events. For all other comparisons, the certainty of the evidence for our predefined primary outcomes is very low due to serious concerns with study limitations and imprecision. Consequently, no robust conclusions could be drawn
Pitt Ford's Problem-Based Learning in Endodontology
No full textPitt Ford’s Problem-Based Learning in Endodontology, 2nd Edition, is an essential reference for Endodontology, enriched with the latest research and clinical evidence. Employing a problem-based approach, it consolidates readers’ knowledge and diagnostic skills. Prepared by an international team of clinical academics, this edition reflects the latest advances in the field.
Encouraging self-directed learning, the authors present diverse clinical cases covering topics such as non-odontogenic pain, pulp preservation, endodontic treatment, restoration, regenerative endodontic procedures, and trauma. Each section is accompanied by images as well as further reading recommendations.
A touchstone to key areas concerning the dental pulp and the root canal system, Pitt Ford’s Problem-Based Learning in Endodontology is a valuable resource for dental students, residents, and clinicians seeking the latest techniques and procedures in Endodontology
Nonlinear interaction in composites using physics informed neural networks
Get PDFModelling of composites requires the consideration of various components that work together and interact in a linear and nonlinear way. Linear and nonlinear modelling in view of demanding needs, like representative volume element calculations within numerical homogenization and the advent of new tools, like physics informed neural networks, are reviewed in this article. In particular, a concept is proposed towards the implementation of a unilateral contact mechanics law within physics-informed neural networks. The theoretical framework and related applications are presented. Results indicate that the proposed deep learning approach can further be applied towards solving contact mechanics problems, considering the mechanical interactions between the constituents of composites
Older Adults' Perspectives on Robotic Technology: A Conceptual Framework
No full textThis study explores older adults' perceptions of anthropomorphized assistive robots, particularly in the context of increasing care needs for this demographic. Utilizing a virtual reality environment, participants interacted with four distinct anthropomorphized assistive robots. The preliminary findings, presented as a conceptual framework, reveal a diverse spectrum of roles these devices assume in older adults' lives. These roles are categorized based on relationship tolerance and the degree of autonomy perceived by users. Notably, participants displayed a preference for devices embodying pet-like qualities, aligning with their desire for familiarity and comfort. By delving into these nuanced roles, this study contributes to our theoretical understanding while simultaneously providing invaluable design criteria for technology catering to the unique preferences and needs of this demographic
Entrepreneurial Learning in Diaspora Family Business Case Studies: A Family Entrepreneurial Team(s) Theoretical Perspective
No full textThe aim of this chapter is to offer theoretical perspectives for case studies, to extend our understanding of diaspora entrepreneurship as a learning process in the diaspora family business context. To do so, we first highlight the use of the social theory Situated Learning and its branches Communities of Practice and Legitimate Peripheral Participation. Second, to encourage those scholars in the field of diaspora family business and diaspora entrepreneurship, to research beyond the individual diaspora entrepreneur and to consider the joint practices and participation of those family and non-family members who compose Family Entrepreneurial Teams (FETs), while exploring further the links associated with entrepreneurial learning and the collective
Understanding and Improving the Effectiveness of Sketch Facial Composites
Get PDFConstructing a facial composite sketch by a forensic artist is one of the oldest, yet least researched methods of facilitating an eyewitness’s memory for an offender’s face and depicting it based on their recall and instructions. While a lot is known about how faces are processed in relation to computerised composites systems such as E-FIT and newer holistic systems, little is known of the mechanisms of sketch composites and their effectiveness. There are two main ways of constructing a sketch composite; by using reference materials (e.g., pictures of facial features or hairstyles) as recognition aids to support recall or not using them and for the witness to rely on the developing sketch as a comparison point for their mental image of the face. How long an offender is seen is one of the key factors in the storage and retrieval of the memory of them and it is important to explore the role of reference materials (or not) when encoding duration has been short or longer. Experiments 1, 2 and 3 examined these two factors in a 2 x 2 study design. Overall, it was found that longer encoding (30 sec – 60 sec) led to more effective composites (resembled the target better/were more identifiable) than short encoding (5 sec). No overall benefit for the use of reference materials was found, however, it is indicated that they improve the composites after short encoding. Recall is a vital part in sketch composite construction, which can be enhanced in a composite interview with specific mnemonics and instructions. One of the most effective ones is mentally reinstating the context of the situation where encoding of the offender occurred by thinking about any cues from the environment, sounds, smells and one’s emotions and moods. A more detailed version of this is to also verbally describe it to the interviewer, which has been found to be effective with computerised systems. It was hypothesised that sketches would also be improved. Two experiments manipulating context were conducted, which found some conflicting results. In one experiment, the detailed context reinstatement impaired the composite quality while another experiment found a benefit for sketch composites not using any reference materials. These results indicate that sketch composites can be improved by providing witnesses with visual cues during construction and using memory enhancement techniques
Patients’ and health professionals’ research priorities for chronic pain associated with inflammatory bowel disease: a co-produced sequential mixed methods Delphi consensus study
Get PDFObjective
Chronic pain in IBD is common and detrimental for quality of life. Recent Cochrane reviews identified a multitude of RCT interventions, but the certainty in the findings is low or very low. We set out to reach a patient and professional co-produced Delphi consensus on treatment priorities, key outcomes, and propose a model for understanding our findings.
Methods
An online survey was co-produced with CCUK and sent to patients and healthcare professionals in two phases, for prioritisastion of treatments andoutcome measures. Phase three consisted of four online group interview, where patients and healthcare professionals discussed the rationale of their choices. Transcripts were combined with the free text data from the Delphi surveys and analysed through a three-phase qualitative technique.
Results
The phase 1 survey was completed by 128 participants (73 patients, 3 carers and 53 health professionals). Diet was the top priority for both patients (n=26/73, 36.1%) and health care professionals (n=29/52, 56.9%). Phase 2 was completed by 68 participants. FODMAP diet, stress management therapy, and relaxation therapy were the top 3 consensus priorities. Phase 3 group interviews were attended by 13 patients and 5 healthcare professionals. Key themes included: The patient as an individual, beliefs and experiences, disease activity influencing therapy choice, accessibility barriers, and quality of life.
Conclusion
Low FODMAP diet, followed by psychological therapies were the highest rated research priorities for healthcare professionals and patients. Funding bodies and researchers should consider these findings, alongside the model for understanding our findings, when making research decisions
Intelligent Management System for Driverless Vehicles
Get PDFThis research addresses concerns related to driverless vehicles by proposing the development of an Intelligent Management System (IMS). Emphasised in 'The Pathway to Driverless Cars Summary report and action plan' by the UK Department of Transport, key areas for improvement lie in vehicle reliability, maintenance, and passenger safety. The study targets compliance with Society of Automotive Engineers (SAE) Level 5 automation, concentrating on fully autonomous vehicles to enhance commuter satisfaction and overall vehicle performance. Despite advancements, challenges such as on-road safety and integration persist.
The research unfolds through a two-stage development process aimed at achieving an Intelligent Management System for Driverless Vehicles (IMSDV). The initial stage, described in chapter 3 involves the creation of a 'Single Seat Driverless Pod' as a test apparatus, simulating various features found in existing driverless vehicles. This includes the development of mechanical steering components and a control system incorporating electronic hardware, sensors, actuators, controllers, wireless remote access, and software. The subsequent phase, described in chapter 4 focuses on autonomous navigation using Google Maps, intelligent motion control, localisation, and tracking algorithms within the driverless pod.
The latter chapters of the thesis present the investigation of possible improvements in steering system components. A novel encapsulated vehicle wheel condition monitoring system, integrating the Internet of Things (IoT), is proposed to enhance maintainability, reliability, and passenger safety for driverless vehicles.
Testing and validation are conducted in two segments. The driverless pod undergoes initial testing to validate its features and generate data for further sub-system development. Separately, the IoT-based monitoring system undergoes individual testing. The final step involves integrating the IoT capabilities into the driverless pod, testing the sub-system, and capturing relevant data.
The thesis outlines the research scope, emphasising significant contributions, with a particular focus on the monitoring system for steering components in driverless vehicles, employing embedded IoT technology. This augmentation, alongside other original contribution, is strategically poised to enhance the maintainability, reliability, and safety of driverless vehicles at SAE Level 5. The concluding chapter succinctly revisits these distinctive contributions and additionally provides recommendations for advancing intelligent management systems for driverless vehicles