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Pruritus and Patient Reported Outcomes in Non-Dialysis CKD.
No full textBACKGROUND AND OBJECTIVES
Among patients on hemodialysis, pruritus has been associated with poorer mental and physical quality of life, sleep quality, depression, and mortality. We evaluated patients with nondialysis CKD to describe the prevalence of pruritus, identify associated factors, and investigate associations with patient-reported outcomes.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS
Using cross-sectional data from patient questionnaires in the CKD Outcomes and Practice Patterns Study (CKDopps), we asked patients with CKD stages 3-5 (nondialysis) from the United States, Brazil, and France to identify how much they were bothered by pruritus. Response options ranged from "not at all" to "extremely." Log-Poisson regression, yielding prevalence ratios, was used to evaluate associations of moderate-to-extreme pruritus with patient characteristics, CKD stage, self-reported depression symptoms, and restless sleep. Mixed linear regression was used to examine associations between pruritus and physical and mental component summary scores, with lower scores indicating poorer quality of life.
RESULTS
Of the 5658 CKDopps patients enrolled in the United States, Brazil, and France, 3780 (67%) answered the pruritus question. The prevalence of moderate-to-extreme pruritus was 24%, and more likely in older patients, women, and those with stage 5 CKD, lung disease, diabetes, and physician-diagnosed depression. In adjusted models, patients with moderate pruritus had physical and mental component summary scores 3.5 (95% confidence interval [95% CI], -4.6 to -2.3) and 2.3 (95% CI, -3.2 to -1.5) points lower, respectively, than patients without pruritus, and they also had a higher adjusted prevalence of patient-reported depression (prevalence ratio, 1.83; 95% CI, 1.58 to 2.11) and restless sleep (prevalence ratio, 1.69; 95% CI, 1.49 to 1.91) compared with patients without pruritus. These patient-reported outcomes were progressively worse with increasing severity of pruritus.
CONCLUSIONS
Our findings demonstrate high prevalence of pruritus in nondialysis CKD, as well as strong associations of pruritus with poor health-related quality of life, self-reported depression symptoms, and self-reported poor sleep
Low intake of vitamins B, C, E and folate from dietary sources may lead to a higher risk of developing frailty in older adults.
No full text
Development of a group structured education programme to support safe exercise in people with Type 1 diabetes: the EXTOD education programme.
No full textAIM
To develop a structured education programme for individuals with Type 1 diabetes who are engaging in regular exercise.
METHOD
A multidisciplinary team of experts in supporting exercise and physical activity for people with Type 1 diabetes, alongside researchers with experience of developing self-management education, developed an exercise programme using the Medical Research Council framework. The programme was informed by a review of the evidence relating to Type 1 diabetes and exercise, the behaviour change literature (including the behaviour change taxonomy), and qualitative interviews with stakeholders. The programme and supporting resources were refined using an iterative process of testing, delivery and collecting feedback from participants and the wider development team.
RESULTS
The outcome of the intervention development was the design of a feasible and acceptable intervention for people with Type 1 diabetes to support safe exercise. The pilot allowed refinement of the intervention prior to testing in a two-site feasibility randomized controlled trial. Key findings from the pilot informed minor restructuring of the timetable (timings and order) and adaptation of supporting educational materials (participant handbook and teaching materials).
CONCLUSION
The 'EXercise in people with Type One Diabetes' (EXTOD) education programme has been developed using robust methodology for the generation of educational interventions. It now needs testing in a randomized controlled trial. This article is protected by copyright. All rights reserved
Primary care implications of the British Thoracic Society Guidelines for bronchiectasis in adults 2019.
No full textThe British Thoracic Society (BTS) Guidelines for Bronchiectasis in adults were published in January 2019, and comprise recommendations for treatment from primary to tertiary care. Here, we outline the practical implications of these guidelines for primary care practitioners. A diagnosis of bronchiectasis should be considered when a patient presents with a recurrent or persistent (>8 weeks) productive cough. A definitive diagnosis is made by using thin-section chest computed tomography (CT). Once diagnosed, patients should be initially assessed by a specialist respiratory team and a shared management plan formulated with the patient, the specialist and primary care teams. The cornerstone of primary care management is physiotherapy to improve airway sputum clearance and maximise exercise capacity, with prompt treatment of acute exacerbations with antibiotics
Three-dimensional endoscopy: The future of nasoendoscopic training.
No full textOBJECTIVES/HYPOTHESIS
Three-dimensional (3D) endoscopy is an emerging tool in surgery that provides real-time depth perception. Its benefits have been investigated in surgical training, but the current literature lacks significant objective outcome data. We aimed to objectively compare the efficacy of two-dimensional (2D) versus 3D high-definition endoscopes in novice users.
STUDY DESIGN
Prospective, randomized crossover study.
METHODS
Ninety-two novice medical students who used both 2D and 3D endoscopes to complete two validated tasks in a box trainer participated in the study. Time taken and error rates were measured, and subjective data were collected.
RESULTS
Wilcoxon tests showed 3D technology was significantly faster than 2D (78 vs. 95 seconds, P = .004), and errors per task were significantly lower (3 vs. 5, P < .001). Sixty-nine percent of participants preferred the 3D endoscope.
CONCLUSIONS
3D high-definition endoscopy could be instrumental in training the next generation of endoscopic surgeons. Further research is required in a clinical setting.
LEVEL OF EVIDENCE
2b Laryngoscope, 129:1280-1285, 2019
(Doctor…My child keeps falling over) unexpected MRI findings in children with history of frequent falls and dizziness: a case series.
No full textFrequent falls and dizziness are common complaints in children. These symptoms can be caused by wide range of underlying pathologies including peripheral vestibular deficits, cardiac disease, central lesions, motor skills delay and psychogenic disorders. We report three paediatric cases who presented with complaints of repeated falls and imbalance. MRI scan revealed underlying brain lesions (frontal lobe arteriovenous malformation, exophytic brain stem glioma and cerebellomedullary angle arachnoid cyst with cerebellar tonsillar ectopia). By reporting these cases, we would like to emphasise the importance of a thorough assessment of children with similar symptoms by detailed clinical history, physical examination and maintaining low threshold for investigations, including radiological imaging. Taking in consideration, the wide range of differential diagnosis, the challenge of obtaining detailed history and difficulty of performing reliable physical examination in this age group. Management of underlying disorders can be medical, surgical or just observational
Objective quantification of vitreous haze on optical coherence tomography scans: no evidence for relationship between uveitis and inflammation in multiple sclerosis.
No full textBACKGROUND
Occurrence of intermediate uveitis, which is characterized by the presence of vitreous haze (VH), in patients with multiple sclerosis (MS) may be a sign of coexistent inflammatory central nervous system (CNS) disease activity. Using an automated algorithm to quantify VH on optical coherence tomography (OCT) scans, we aimed to investigate whether VH in MS patients is associated with signs of inflammatory CNS disease activity.
METHODS
VH was quantified on OCT macular volume scans of 290 MS patients and 85 healthy controls (HCs). The relationship between VH and clinical, retinal OCT and MRI parameters of inflammatory disease activity was investigated using generalized estimating equations.
RESULTS
Mean VH scores did not differ between patients and HCs (p=0.629). Six patients (2.1%) showed values higher than the highest of the controls. VH scores did not differ between the different disease types or between eyes with and without a history of optic neuritis (p=0.132). VH was not associated with inner nuclear layer volume on OCT (p=0.233), cerebral T2 lesion load on MRI (p=0.416) or the development of new relapses (p=0.205).
CONCLUSION
In this study OCT-based automated VH estimation did not detect increased vitreous inflammation in MS patients compared to HCs, and did not find an association with CNS inflammatory burden. This article is protected by copyright. All rights reserved
Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) Study: a WSES observational study.
No full textBackground
Timing and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted.
Methods
This worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018.
Results
A total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47 years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6 days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80 years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate ≥ 22 breaths/min, systolic blood pressure 4 mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8.
Conclusions
The simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality
Long term tapering versus standard prednisolone treatment for first episode of childhood nephrotic syndrome: phase III randomised controlled trial and economic evaluation.
No full textOBJECTIVE
To determine whether extending initial prednisolone treatment from eight to 16 weeks in children with idiopathic steroid sensitive nephrotic syndrome improves the pattern of disease relapse.
DESIGN
Double blind, parallel group, phase III randomised placebo controlled trial, including a cost effectiveness analysis.
SETTING
125 UK National Health Service district general hospitals and tertiary paediatric nephrology centres.
PARTICIPANTS
237 children aged 1-14 years with a first episode of steroid sensitive nephrotic syndrome.
INTERVENTIONS
Children were randomised to receive an extended 16 week course of prednisolone (total dose 3150 mg/m) or a standard eight week course of prednisolone (total dose 2240 mg/m). The drug was supplied as 5 mg tablets alongside matching placebo so that participants in both groups received the same number of tablets at any time point in the study. A minimisation algorithm ensured balanced treatment allocation by ethnicity (South Asian, white, or other) and age (5 years or less, 6 years or more).
MAIN OUTCOME MEASURES
The primary outcome measure was time to first relapse over a minimum follow-up of 24 months. Secondary outcome measures were relapse rate, incidence of frequently relapsing nephrotic syndrome and steroid dependent nephrotic syndrome, use of alternative immunosuppressive treatment, rates of adverse events, behavioural change using the Achenbach child behaviour checklist, quality adjusted life years, and cost effectiveness from a healthcare perspective. Analysis was by intention to treat.
RESULTS
No significant difference was found in time to first relapse (hazard ratio 0.87, 95% confidence interval 0.65 to 1.17, log rank P=0.28) or in the incidence of frequently relapsing nephrotic syndrome (extended course 60/114 (53%) standard course 55/109 (50%), P=0.75), steroid dependent nephrotic syndrome (48/114 (42%) 48/109 (44%), P=0.77), or requirement for alternative immunosuppressive treatment (62/114 (54%) 61/109 (56%), P=0.81). Total prednisolone dose after completion of the trial drug was 6674 mg for the extended course versus 5475 mg for the standard course (P=0.07). There were no statistically significant differences in serious adverse event rates (extended course 19/114 (17%) standard course 27/109 (25%), P=0.13) or adverse event rates, with the exception of behaviour, which was poorer in the standard course group. Scores on the Achenbach child behaviour checklist did not, however, differ. Extended course treatment was associated with a mean increase in generic quality of life (0.0162 additional quality adjusted life years, 95% confidence interval -0.005 to 0.037) and cost savings (difference -£1673 ($2160; €1930), 95% confidence interval -£3455 to £109).
CONCLUSIONS
Clinical outcomes did not improve when the initial course of prednisolone treatment was extended from eight to 16 weeks in UK children with steroid sensitive nephrotic syndrome. However, evidence was found of a short term health economic benefit through reduced resource use and increased quality of life.
TRIAL REGISTRATION
ISRCTN16645249; EudraCT 2010-022489-29