Using clinical cases to guide healthcare

Evidence-based practice(EBP)has been the gold standard in healthcare for nearly three centuries and aims to assist physicians in providing the safest and most effective healthcare for their patients.The well-established hierarchy of evidence lists systematic reviews and meta-analyses at the top however these methodologies are not always appropriate or possible and in these instances case-control studies,case series and case reports are utilised to support EBP.Case-control studies allow simultaneous study of multiple risk factors and can be performed rapidly and relatively cheaply.A recent example was during the Coronavirus pandemic where case-control studies were used to assess the efficacy of personal protective equipment for healthcare workers.Case series and case reports also play a role in EBP and are particularly useful to study rare diseases such as inflammatory bowel disease in transgender and gender non-conforming individuals.They are also vital in generating and disseminating early signals and encouraging further research.Whilst these methodologies have weaknesses,particularly with regards to bias and loss of patient confidentiality for rare pathologies,they have an important part to play in EBP and when appropriately utilised can significantly impact upon clinical practice.

Emerging role of colorectal mucus in gastroenterology diagnostics

Colonoscopy is currently the gold standard for diagnosis of inflammatory bowel disease(IBD)and colorectal cancer(CRC).This has the obvious drawback of being invasive as well as carrying a small risk.The most widely used non-invasive approaches include the use of faecal calprotectin in the case of IBD and fecal immunochemical test in the case of CRC.However,the necessity of stool collection limits their acceptability for some patients.Over the recent years,there has been emerging data looking at the role of non-invasively obtained colorectal mucus as a screening and diagnostic tool in IBD and CRC.It has been shown that the mucus rich material obtained by self-sampling of anal surface following defecation,can be used to measure various biomarkers that can aid in diagnosis of these conditions.

Roux-en-Y gastric bypass or sleeve gastrectomy for obstructive sleep apnea:A systematic review and meta-analysis

Objective:Bariatric surgery has been shown to be an effective method of treatment for obstructive sleep apnea(OSA)with long-term benefits,however,the mechanisms of action and the optimum operative procedure remains unclear.The aim of this systemic review was to compare the efficacy of laparoscopic sleeve gastrectomy(LSG)and Roux-en-Y gastric bypass(RYGB)in resolving OSA.Methods:A comprehensive search of MEDLINE,Pubmed,Embase,and OVID was performed.Studies that reported OSA resolution in obese patients with BMI>30 kg/m2 were included in the study.RCTs,comparative prospective and matched cohort studies comparing RYGB with LSG were considered for this study.Results:Five studies(309 participants)were included:4 cohort studies and 1 RCT;all with low risk of bias.At 12 months follow-up,there was a trend towards improved resolution of OSA with LSG(OR 0.47,95%CI[0.20 to 1.06];p=0.07)when compared to RYGB.In contrast,there was a trend to poorer weight loss in the LSG group(SMD 3.83,95%CI[-1.82 to 9.48];p=0.18).Similarly,at 36 months follow-up,there was a trend towards better resolution of OSA with LSG(OR 0.52,95%CI[0.16 to 1.71];p=0.28)and a significantly poorer weight loss in LSG when compared to RYGB(SMD 8.25,95%CI[2.91 to 13.58];p=0.002).Conclusion:Despite poorer weight loss following LSG,there is a trend towards increased resolution of sleep apnea post-LSG.These findings suggest the possibility of weight loss independent factors causing OSA resolution,which should be further investigated.Registration:PROSPERO:CRD42018090367.

Associations with pancreatic exocrine insufficiency:An United Kingdom single-centre study

BACKGROUND Pancreatic exocrine insufficiency(PEI)is said to be associated with numerous conditions both within and outside the gastrointestinal(GI)system.The majority of research has been concerned with conditions that reduce the volume of functioning pancreatic tissue or prevent adequate drainage to the small bowel,such as chronic pancreatitis,cystic fibrosis,pancreatic cancer and pancreatic resection.However,the evidence base supporting an association with extrapancreatic conditions,such as coeliac disease,diabetes mellitus and congestive cardiac failure,is heterogeneous.AIM To strengthen the evidence base by studying all previously reported associations with PEI in a large cohort of outpatients.METHODS A single-centre retrospective study was performed.General gastroenterology outpatients tested for PEI with faecal elastase-1(FE1)were identified and information retrieved from the electronic patient record.PEI was defined as FE1<200μg/g.Patients already taking pancreatic enzyme replacement therapy were excluded.Multiple imputation was used to handle missing data.Univariable logistic regression was used to study which presenting symptoms predicted PEI.Multivariable logistic regression was used to explore the relationship between all previously reported associations and PEI.RESULTS Of 1027 patients were included.182 patients(17.7%)were diagnosed with PEI.Steatorrhoea[odds ratios(OR):2.51,95%confidence intervals(CI):1.58-3.98]and weight loss(OR:1.49,95%CI:1.08-2.06)were the only presenting symptoms that predicted PEI.Chronic pancreatitis(OR:7.98,95%CI:3.95-16.15),pancreatic cancer(OR:6.58,95%CI:1.67-25.98),upper GI surgery(OR:2.62,95%CI:1.32-5.19),type 2 diabetes(OR:1.84,95%CI:1.18-2.87),proton pump inhibitor therapy(OR:1.87,95%CI:1.25-2.80)and Asian ethnicity(OR:2.11,95%CI:1.30-3.42)were significantly associated with PEI in the multivariable analysis.None of the other historically reported associations with PEI were significant after adjustment for the other variables included in our multivariable analysis.CONCLUSION PEI is common in patients with chronic pancreatitis,pancreatic cancer,upper GI surgery and type 2 diabetes.Proton pump inhibitor therapy may also be associated with PEI or a false positive FE1.

Optical imaging technology in colonoscopy:Is there a role for photometric stereo?

Colonoscopy screening for the detection and removal of colonic adenomas is central to efforts to reduce the morbidity and mortality of colorectal cancer.However,up to a third of adenomas may be missed at colonoscopy,and the majority of post-colonoscopy colorectal cancers are thought to arise from these.Adenomas have three-dimensional surface topographic features that differentiate them from adjacent normal mucosa.However,these topographic features are not enhanced by white light colonoscopy,and the endoscopist must infer these from two-dimensional cues.This may contribute to the number of missed lesions.A variety of optical imaging technologies have been developed commercially to enhance surface topography.However,existing techniques enhance surface topography indirectly,and in two dimensions,and the evidence does not wholly support their use in routine clinical practice.In this narrative review,co-authored by gastroenterologists and engineers,we summarise the evidence for the impact of established optical imaging technologies on adenoma detection rate,and review the development of photometric stereo(PS)for colonoscopy.PS is a machine vision technique able to capture a dense array of surface normals to render three-dimensional reconstructions of surface topography.This imaging technique has several potential clinical applications in colonoscopy,including adenoma detection,polyp classification,and facilitating polypectomy,an inherently three-dimensional task.However,the development of PS for colonoscopy is at an early stage.We consider the progress that has been made with PS to date and identify the obstacles that need to be overcome prior to clinical application.

Tubularized incised plateurethroplasty and grafted tubularized incised plate urethroplasty: systematic review, metaanalysis and trial sequential analysis

Background Hypospadias is one of the most common genital birth defects.There are around 300 various techniques available for the repair of hypospadias.This study aims to compare the reported outcomes of Tubularized incised plate urethroplasty(TIP)and Grafted TIP(GTIP)repair in children undergoing primary hypospadiasrepair.Methods This meta-analysisadhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines,and we framed our research question using the population,intervention,control and outcomes format.We conducted comprehensive electronic searches across various databases,employing a Boolean search strategy with predefined search terms.Only randomized controlled trials(RCTs)were included for quantitative analysis.Results Totally,10 RCTs met our inclusion criteria for quantitative analysis.The results indicated that urethrocutaneous fistula,glans dehiscence,and stricture rates were comparable between the two groups.The incidence of meatal stenosis was found to be significantly lower in the GTIP group with a relative risk(RR)of 0.32(95%confidence interval(Cl)0.15 to 0.67).Conclusion The coucomes UCF,glans dehiscence,and stricture rates were comparable between the two groups.Notably,the incidence of meatal stenosis was found to be significantly lower in the grafted TIP group.In terms of operative time,our quantitative synthesis demonstrated that the TIP group had a shorter operative time than the GTIP group with significant heterogeneity.

照顾者虐待老年人行为评估及影响因素的研究进展

随着老年人数增长,长期照护负担加重,老年人虐待事件发生率逐渐上升,已引起广泛关注。本文大量查阅国内外文献,汇集各国照顾者虐待老年人的行为评估工具,并分析照顾者虐待老年人相关影响因素,以指导我国研制本土化评估工具,预警老年人虐待事件发生可能性,制定有效可行的干预措施,将预防的关口前移,营造和谐照护氛围,提高老年人生存质量。

Gastrointestinal tuberculosis:Diagnostic approaches for this uncommon pathology

A case report entitled“Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction”recently published in the World Journal of Clinical Cases presented a rare cause of gastric outlet obstruction and highlighted the atypical manner in which gastrointestinal tuberculosis(TB)can present.The literature with regards to this rare pathology is limited to case reports and case series with the largest being published using data from between 2003 and 2013.However,since then the diagnostic tools available have significantly changed with more modern and increasingly accurate tests now available.This editorial reviews the current state of the art with regards to diagnosis in gastrointestinal TB.

Research surveys and their evolution:Past,current and future uses in healthcare

Research surveys are believed to have originated in antiquity with evidence of them being performed in ancient Egypt and Greece.In the past century,their use has grown significantly and they are now one of the most frequently employed research methods including in the field of healthcare.Modern validation techniques and processes have allowed researchers to broaden the scope of qualitative data they can gather through these surveys such as an individual’s views on service quality to nationwide surveys that are undertaken regularly to follow healthcare trends.This article focuses on the evolution and current utility of research surveys,different methodologies employed in their creation,the advantages and disadvantages of different forms and their future use in healthcare research.We also review the role artificial intelligence and the importance of increased patient participation in the development of these surveys in order to obtain more accurate and clinically relevant data.

Role of diet in the management of inflammatory bowel disease

Many studies have looked at connections between diet,etiology,signs and symptoms associated with inflammatory bowel disease(IBD).Although these connections are apparent to clinicians,they are difficult to prove qualitatively or quantitatively.Enteral feeding and polymeric diets are equally effective at bringing about remission in Crohn's disease(CD).Parenteral feeding is also effective,although none of these methods is as effective as corticosteroid therapy.However,enteral feeding is preferred in the pediatric population because linear growth is more adequately maintained via this route.Exclusion diets in patients brought into remission using an elemental diet have been shown to maintain remission for longer periods.Studies that aim to isolate culpable food groups have shown that individuals react differently on exposure to or exclusion of various foods.The commonly identifi ed food sensitivities are cereals,milk,eggs,vegetables and citrus fruits.Studies that have looked at gut mucosal antigen behavior have shown higher rectal blood flow,in response to specifi c food antigens,in those with CD over healthy subjects.Exclusion of sugar shows little evidence of amelioration in CD.Omega 3 fatty acids show promise in the treatment of IBD but await larger randomized controlled trials.Patients frequently notice that specifi c foods cause aggravation of their symptoms.Whilst it has been diffi cult to pinpoint specifi c foods,with advances in the laboratory tests and food supplements available,the aim is to prolong remission in these patients using dietary measures,and reduce the need for pharmacotherapy and surgical intervention.

中国利福喷丁在香港临床研究期间的生物利用度

背景:利福喷丁在香港的临床研究。目的:评价研究中所使用的中国利福喷丁的生物利用度。设计:通过微生物学试验测定给予四批药物的287名病人血清标本中利福喷丁的含量结果:从40名病人中随机分配给西方或中国的利福喷丁所获得的首批曲线区域图对比显示:中国利福喷丁生物利用度是西方药物的74％。第二批药的生物利用度发现是西方的66％,最后二批利福喷丁的剂量由计划的600mg增至750mg或短时增至900mg,则血清中浓度同西方药获得的相类似,在每批药使用期间生物利用度没有变化。结论:通过比较开始二批和最后二批试验的结果将估价利福喷丁剂量对疗效和毒性的作用。

Mycobacterium avium subspecies paratuberculosis in the causation of Crohn's disease

Mycobacterium avium subspecies paratuberculosis(MAP),originally called Johne’s bacillus was firstdescribed from Germany in 1895 as the cause of achronic inflammatory disease of the intestine in acow.As the 20th century progressed,clinical andsub-clinical MAP infection in farm animals inWestern Europe appeared to become moreprevalent.Among the early reviews available

链霉素的早期杀菌活性

背景:观察研究Cape城市Tygerburgy医院诊治的新诊涂阳肺结核病人对链霉素的早期治疗效应。 目的:测定标准的早期杀菌活性(EBA)即收集链霉素治疗的头2天内16小时的痰标本,观察活菌数的下降情况。 设计:病人随机分组接受按对数间隔的不同剂量的链霉素(7.5mg、15mg、或30mg/kg)。采用标准生物学方法与以往所进行的对巴龙霉素的估算(7.5mg及15mg/kg)的EBA进行比较。 结果:30mg/kg SM治疗的EBA为0.133显著高于0(p=0.0009),而15mg/kg及7.5mg/kg的EBA各为0.043及-0.025,则与无显著差异。EBA=0.2587±0.02527 log_(10)剂量的线性回归公式可获显著的坡度(p=0.007)。而巴龙霉素估计为1.745,强于SM,而95％CI为(0.6-28.6),表明不可能认为巴龙霉素比SM有力。 结论:链霉素低的EBA是与剂量相关的,SM在空洞内杀菌活性与临床研究结果一致。如系SM耐药菌株,巴龙霉素可能成为选用的氨基糖苷类药物。

动力性左室梗阻:终末期肾脏疾病患者心绞痛的潜在原因

背景:终末期肾脏疾病(ESRD)患者常有不能单纯以冠状动脉疾病(CAD)解释的心绞痛。其症状常由收缩和舒张功能障碍、心律失常和微血管病变引起。本研究提出肾衰竭患者心绞痛的另一种可能原因,即动力性左室梗阻(LVO)。方法:对125例拟实施肾脏移植的患者行多巴酚丁胺负荷超声心动图(DSE)及冠状动脉造影。LVO定义为LV流出道压力阶差峰值】50mmHg。

常规免疫的时间选择及其后的花粉病的发病危险

Background: Suggestions that immunisation influences allergic disease risk, ei ther positively (pertussis) or negatively (BCG)-are of concern for vaccination policy. Aims: To determine whether DTP, MMR, and BCG vaccination in infancy infl uenced hay fever risk. Methods: Case-control study of 7098 hay fever cases and controls, within two primary care databases. One control per case was matched fo r practice, age, and sex. Odds ratios (OR)were derived using conditional logisti c regression. Results: Compared to those completing in month 5 (base group) (39. 3%), DTP unvaccinated children (4.3%) had a similar risk of hay fever (OR = 0. 94, 95%Cl 0.73 to 1.23). However, those completing after 12months (4.2%) had a reduced risk (OR = 0.60, 95%Cl 0.45 to 0.76) compared to the base group. Compa red to those vaccinated in month 14 (base group) (29.5%), MMR unvaccinated chil dren (2.3%) had an OR of 0.79 (95%Cl 0.58 to 1.08). Completion of MMR after tw o years was associated with reduced hay fever risk (OR = 0.62, 95%Cl 0.48 to 0. 80) compared to the base group. The effects of late immunisation with DTP and MM R were independent. Those vaccinated with BCG by age 2 (2.4%) had an odds ratio of 1.28 (95%Cl 0.96 to 1.70). Adjustment for consulting behaviour, social fact ors, or sibship size did not alter these associations. Conclusions: Immunisation against DTP or MMR does not increase the risk of hay fever. The lower confidenc e limit for BCG vaccination contradicts the hypothesised protective effect. The reduced risk of hay fever among children immunised late may be explained by a th ird factor causing both postponement and reduced risk such as intercurrent febri le illnesses.

细菌性阴道病的自然病史与妊娠期中间菌群和口服克林霉素的作用

OBJECTIVE: We sought to describe the natural history of abnormal vaginal flora in pregnancy and estimate the efficacy of oral clindamycin in eradicating it and preventing relapse. METHODS: This was a subanalysis of a randomized trial of oral clindamycin for abnormal vaginal flora in pregnancy. All 494 enrolled women were asked to provide a vaginal smear 2 weeks after treatment and every second participant to provide further smears at 20, 24, 28, 32, and 36 weeks of gestation. We used Nugent score of Gram-stained smears to assess the cure rate among the clindamycin group and the rate of spontaneous resolution among the placebo group. RESULTS: Posttreatment smears were available for 462 women (231 in each of the clindamycin and placebo arms). The prevalence of abnormal flora posttreatment was 10%(22 of 231) in the clindamycin group compared with 93%(214 of 231) in the placebo group (P < .001). Two hundred nineteen women obtained 4 weekly smears; slides for 84 women were lost, and results were available for 135 women (69 clindamycin, 66 placebo). In the clindamycin group, the prevalence of abnormal flora was 15%at 20 weeks of gestation and 17%at 36 weeks of gestation compared with 69%at 20 weeks of gestation and 43%at 36 weeks of gestation in the placebo group. CONCLUSION: Oral clindamycin eradicated abnormal flora in 90%of treated pregnant women and maintained a normal flora in two thirds of women throughout pregnancy. Almost one third of untreated women in our study had spontaneous resolution of abnormal flora by 20 weeks of gestation. Because previous research has shown that spontaneous resolution does not modify the risk of preterm birth, early screening is essential.

高危人群妊娠早期静脉导管、鼻骨检查和唐氏综合征的关系

OBJECTIVE: Assessing the role of fetal ductus venosus and nasal bones evalua ti on in first-trimester screening for Down syndrome. METHODS: This was a prospect ive cohort study in a tertiary referral fetal medicine unit involving 628 consec utive fetuses undergoing chorionic villus sampling. The indication for chorionic villus sampling was an increased risk (more than 1:300) for trisomy 21 based on maternal age and nuchal translucency screening in 313 cases (54.7%), increased maternal age in 195 (34.1%), and other in 64 (11.2%). Immediately before chor ionic villus sampling, an ultrasound examination was performed. The pattern of b lood flow in the ductus venosus and the presence or absence of the nasal bones w as noted. RESULTS: A satisfactory examination of both ductus venosus and nasal b ones was possible in 572 fetuses. Of these, 497 (86.9%) had a normal karyotype, and 47 (8.2%) were affected with Down syndrome. The likelihood ratio for triso my 21 was 7.05 (95%confidence interval 4.27-11.64) in the case of abnormal duc tus venosus flow and 6.42 (95%confidence interval 3.86-10.67) in the case of a bsent nasal bones. CONCLUSION: In addition to increased fetal nuchal translucenc y, Down syndrome is significantly associated with first-trimester abnormal flow velocity patterns in the ductus venosus and hypoplasia of the nasal bones.

子宫动脉血流波形的纵向变异与出生体重

OBJECTIVE: To investigate the relationship between the timing of disappearance of high-resistance uterine artery waveforms between the first and second trimester of pregnancy and birth weight. METHODS: Uterine artery Doppler recordings were obtained in a cohort of singleton pregnancies at 11-14 weeks of gestation and subsequently at 18-23 weeks. At each examination, the presence or absence of an early diastolic notch was recorded for each side. An abnormal pattern of blood flow was defined as the presence of bilateral notches. Cases complicated by preeclampsia or preterm delivery were excluded. RESULTS: Four hundred eleven pregnancies showed absent or unilateral uterine artery notches at the 11-14-week scan (group 1). All these cases maintained a low-resistance uterine blood flow pattern at the second-trimester scan. Of the 251 pregnancies with bilateral notches at the 11-14-week scan, 222 subsequently displayed a low-resistance blood flow at 18-23 weeks (group 2) whereas only 29 maintained bilateral notches (group 3). The mean birth weight was higher in group 1 (3,452 g) than in groups 2 (3,310 g) and 3 (3,224 g). This difference was confirmed after adjusting for confounding variables. Small-for-gestational-age fetuses were more common in groups 2 (14.9%) and 3 (14%) compared with group 1 (6.8%, P < .001). During the study period, severe preterm preeclampsia was observed in 6 cases only. CONCLUSION: The longitudinal variation in uterine artery blood flow pattern has a statistically significant correlation with birth weight, likely reflecting the timing and degree of trophoblastic invasion of the maternal vessels.

被动吸烟与冠心病和脑卒中风险的关系:通过测量cotinine的前瞻性研究

Objective: To examine the associations between a biomarker of overall p assive exposure to tobacco smoke (serum cotinine concentration) and risk of coronary he art disease and stroke. Design: Prospective population based study in general pr actice (the British regional heart study). Participants 4729 men in 18 towns who provided baseline blood samples (for cotinine assay) and a detailed smoking his tory in 1978-80. Main outcome measure: Major coronary heart disease and stroke events (fatal and non-fatal) during 20 years of follow up. Results: 2105 men wh o said they did not smoke and who had cotinine concentrations < 14.1 ng/ml were divided into four equal sized groups on the basis of cotinine concentrations. Re lative hazards (95%confidence intervals) for coronary heart disease in the seco nd (0.8-1.4 ng/ml), third (1.5-2.7 ng/ml), and fourth (2.8-14.0 ng/ml) quarte rs of cotinine concentration compared with the first (≤0.7 ng/ml) were 1.45 (1. 01 to 2.08), 1.49 (1.03 to 2.14), and 1.57 (1.08 to 2.28), respectively, after a djustment for established risk factors for coronary heart disease. Hazard ratios (for cotinine 0.8-14.0 v ≤0.7 ng/ml) were particularly increased during the f irst (3.73, 1.32 to 10.58) and second five year follow up periods (1.95, 1.09 to 3.48) compared with later periods. There was no consistent association between cotinine concentration and risk of stroke. Conclusion: Studies based on reports of smoking in a partner alone seem to underestimate the risks of exposure to pas sive smoking. Further prospective studies relating biomarkers of passive smoking to risk of coronary heart disease are needed.

皮内注射肉毒杆菌A毒素治疗腋下多汗症

Axillary hyperhydrosis in children and teenagers may be severe enough to affect social development. Current treatments range from aluminum chloride compounds to surgical removal of sweat glands and sympathectomy. Intradermal injection of botulinum A toxin has recently been found to be a safe and effective alternative in the adult population. Use in children has so far not been documented. We hereby report a case illustrating the use of botulinum A toxin in a 14- year-old girl with disabling axillary hyperhydrosis.