Comparison of P-POSSUM and O-POSSUM in predicting mortality after oesophagogastric resections

Background

P‐POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and morbidity) predicts mortality and morbidity in general surgical patients providing an adjunct to surgical audit. O‐POSSUM was designed specifically to predict mortality and morbidity in patients undergoing oesophagogastric surgery.

Aim

To compare P‐POSSUM and O‐POSSUM in predicting surgical mortality in patients undergoing elective oesophagogastric cancer resections.

Methods

Elective oesophagogastric cancer resections in a district general hospital from 1990 to 2002 were scored by P‐POSSUM and O‐POSSUM methods. Observed mortality rates were compared to predicted mortality rates in six risk groups for each model using the Hosmer–Lemeshow goodness‐of‐fit test. The power to discriminate between patients who died and those who survived was assessed using the area under the receiver–operator characteristic (ROC) curve.

Results

313 patients underwent oesophagogastric resections. 32 died within 30 days (10.2%). P‐POSSUM predicted 36 deaths (χ² = 15.19, df = 6, p = 0.019, Hosmer–Lemeshow goodness‐of‐fit test), giving a standardised mortality ratio (SMR) of 0.89. O‐POSSUM predicted 49 deaths (χ² = 16.51, df = 6, p = 0.011), giving an SMR of 0.65. The area under the ROC curve was 0.68 (95% confidence interval 0.59 to 0.76) for P‐POSSUM and 0.61 (95% confidence interval 0.50 to 0.72) for O‐POSSUM.

Conclusion

Neither model accurately predicted the risk of postoperative death. P‐POSSUM provided a better fit to observed results than O‐POSSUM, which overpredicted total mortality. P‐POSSUM also had superior discriminatory power.Oesophagogastric cancers continue to be a major cause of cancer mortality. Scotland currently has one of the highest incidences of oesophageal cancers in Europe and within the UK.¹ Surgical resection continues to be the mainstay for treatment of oesophagogastric cancers. Postoperative mortality following oesophagogastric resections is significant and varies between 1.4–23%.^2,3 In the UK, mortality for oesophagogastric cancer is higher than in the rest of Europe.⁴ In Scotland, patients with oesophagogastric cancers have a poor prognosis in comparison with other European countries.¹ Postoperative mortality has continued to decline over the last decade mainly due to improved case selection, specialised provision of services and multidisciplinary involvement.Preoperative risk assessment and informed consent play a vital role in the management of oesophagogastric cancers. It is essential for both the patient and surgeon to have an assessment preoperatively of the probability of success of a major surgical procedure. This should take into account the surgeon''s performance, hospital performance, physiological status of the patient, and multidisciplinary involvement including interventional radiologists. This will enable a fully informed consent to be obtained from the patient. In addition this will identify patients who are at high risk from the operative procedure. In this group, preventive measures can be instituted and postoperative complications may be predicted to enable early recognition and institution of appropriate treatment, which may result in a better outcome.Predicting postoperative mortality and risk assessment before surgery continues to be a challenge. Over the last decade the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM),⁵ and its modifications such as P‐POSSUM^6,7 have been used in general surgery and allied specialities to predict postoperative mortality with varying degree of success. POSSUM and P‐POSSUM both use a four grade, 12 factor Physiological Score and a six factor Operative Severity Score to predict operative mortality. These scoring systems, when used appropriately, can be useful in providing an estimation of postoperative mortality for an individual patient.⁷O‐POSSUM was derived to provide a dedicated scoring system to predict postoperative mortality specifically for oesophageal and gastric surgery.⁸ This system was based on the methods used by POSSUM and P‐POSSUM, the primary end point being in‐hospital mortality. In O‐POSSUM, the risk factors were selected on the basis of their clinical relevance. Operative blood loss and number of procedures, which describe structure and process of care, were excluded from multivariate analysis.The aim of our study was to compare the predictive accuracy of P‐POSSUM and O‐POSSUM in patients undergoing elective oseophagogastric resections for cancer.     

Views of patients with heart failure about their role in the decision to start implantable cardioverter defibrillator treatment: prescription rather than participation

Background

There is a shortage of reports on what potential recipients of implantable cardioverter–defibrillators (ICDs) need to be informed about and what role they can and want to play in the decision‐making process when it comes to whether or not to implant an ICD.

Aims

To explore how patients with heart failure and previous episodes of malignant arrhythmia experience and view their role in the decision to initiate ICD treatment.

Patients and methods

A qualitative content analysis of semistructured interviews was used. The study population consisted of 31 outpatients with moderate heart failure at the time of their first ICD implantation.

Setting

The study was performed at Sahlgrenska University Hospital, Göteborg, Sweden.

Results

None of the respondents had discussed the alternative option of receiving treatment with anti‐arrhythmic drugs, the estimated risk of a fatal arrhythmia, or the expected time of survival from heart failure in itself. Even so, very little criticism was directed at the lack of information or the lack of participation in the decision‐making process. The respondents felt that they had to rely on the doctors'' recommendation when it comes to such a complex and important decision. None of them regretted implantation of the ICD.

Conclusions

The respondents were confronted by a matter of fact. They needed an ICD and were given an offer they could not refuse, simply because life was precious to them. Being able to give well‐informed consent seemed to be a matter of less importance for them.Treatment with automatic implantable cardioverter–defibrillators (ICDs) has been shown to be more effective than medical treatment in preventing sudden cardiac death among patients who have survived life‐threatening ventricular arrhythmias (ventricular tachycardia/fibrillation).¹ As a result, international guidelines recommend the ICD as the treatment of choice for these patients.^2,3,4 The risk of fatal arrhythmias recurring in the absence of a clear reversible cause ranges from 30% to 50% at the 2‐year follow‐up.⁴Approximately one‐third of the patients who receive an ICD experience heart failure.¹ Chronic heart failure is a common syndrome caused by reduced cardiac function that leads to the failure of the heart to pump blood. This in turn gives rise to disabling symptoms including breathlessness and fatigue. Depending on the degree of impaired exercise tolerance in daily life, the patients are classified according to the New York Heart Association (NYHA) in one of four classes (I–IV). This is a serious condition with high mortality. Approximately half the patients who develop severe heart failure corresponding to NYHA class IV will die within a year. Even in the milder or moderate stages of heart failure, the 5‐year mortality is almost 50%. However, it is difficult to estimate the short‐term prognosis due to various clinical courses. About one‐third of the patients will die suddenly and unexpectedly, one‐third will die suddenly in conjunction with a period of deterioration or a myocardial infarction, and one‐third will die following a progressive deterioration in heart failure symptoms.^3,5Patients with reduced ventricular function (ejection fraction <35–40%) and advanced heart failure (NYHA⩾ III) obtain the greatest benefit from ICD treatment in terms of survival.¹ In one study, mortality was reduced by 29% in patients treated with ICDs over a period of 3 years compared with those who received the best medical treatment for the prevention of arrhythmias (anti‐arrhythmics).⁶ Alternately, it could be said that though the device would save these patients from a sudden, dramatic, painless and somewhat premature death due to arrhythmia, thereby leading to a limited prolongation of life, the price that is paid for this effect could also be a more painful end, due to symptoms of progressive heart failure and the potential negative effects related to the treatment itself.     

Doctor's views on disclosing or withholding information on low risks of complication

Background

More and more quantitative information is becoming available about the risks of complications arising from medical treatment. In everyday practice, this raises the question whether each and every risk, however low, should be disclosed to patients. What could be good reasons for doing or not doing so? This will increasingly become a dilemma for practitioners.

Objective

To report doctors'' views on whether to disclose or withhold information on low risks of complications.

Methods

In a qualitative study design, 37 respondents (gastroenterologists and gynaecologists or obstetricians) were included. Focus group interviews were held with 22 respondents and individual in‐depth interviews with 15.

Results

Doctors have doubts about disclosing or withholding information on complication risk, especially in a risk range of 1 in 200 to 1 in 10 000. Their considerations on whether to disclose or to withhold information depend on a complicated mix of patient and doctor‐associated reasons; on medical and personal considerations; and on the kind and purpose of intervention.

Discussion

Even though the degree of a risk is important in a doctor''s considerations, the severity of the possible complications and patients'' wishes and competencies have an important role as well. Respondents said that low risks should always be communicated when there are alternatives for the intervention or when the patient may prevent or mitigate the risk. When the appropriateness of disclosing risks is doubtful, doctors should always tell their patients that no intervention is without risk, give them the opportunity to gather all the information they need or want, and enable them to detect a complication at an early stage.The concept of risk has become an important guiding concept in medicine. The “risk epidemic”, as some call it,¹ confronts doctors with new questions about what risks they should discuss with their patients.There are large differences in legal standards for what should be disclosed to patients. For instance, UK and German law take as a standard “what a reasonable doctor would disclose”. Both the USA and The Netherlands (Medical Treatment Agreement Act (Wet op de geneeskundige behandelingovereenkomst)) describe the doctor''s duty to inform in terms of what Beauchamp and Childress² call a “reasonable patient” standard: what a reasonable patient would need or want to know to be able to give informed consent.When the complication risk is high and consequences may be severe, it is obvious that doctors have to inform their patients. But in cases of low or negligible risk, doctors have doubts about disclosing information because it is not clear what a reasonable patient would need or want to know. There may also be a danger of information overkill, threatening instead of strengthening patient autonomy. The ethical question here is, What should doctors do when it is unclear whether a reasonable patient would want to have particular risk information?A large amount of literature is available on how to disclose both low and high risks; for instance, the BMJ issue of September 2003 contains a highly informative special section on this problem.³ Risks, when disclosed, may be improperly and incorrectly perceived by both patients and doctors^4,5,6,7 and patients may have only a poor memory of what is disclosed by the doctor.^4,7,8,9 Nevertheless, patients generally seem to appreciate communication on the risks involved.¹⁰We will not deal with the issue of how to communicate. Instead, we will take up the problem raised by the philosopher Onora O''Neill,¹¹ who argued that the preoccupation with informed consent has led us to disregard forms of shaping autonomy that rely less heavily on giving exhaustive information, and that the question is not only how we should inform about risk but also to what extent.We explored the views, motives and practices of doctors on the question of what complication risks doctors should inform their patients about.     

Quality of life and alteration in comorbidity following laparoscopic adjustable gastric banding

Objectives

Obesity is an increasing problem in the UK and bariatric surgery is likely to increase in volume in the future. While substantial weight loss is the primary outcome following bariatric surgery, the effect on obesity‐related morbidity, mortality and quality of life (QOL) is equally important. This study reports on weight loss, QOL, and health outcomes following laparoscopic adjustable gastric banding (LAGB) in a low volume bariatric centre (<20 cases/year) and presents the first assessment of factors relating to the QOL which has been produced from a UK based surgical practice.

Study design

Questionnaire based study of patients who had LAGB. Each patients'' initial body mass index (BMI), QOL, and comorbidities were recorded. Change in these parameters was measured including excess weight loss, and output from both the Moorehead–Ardelt QOL questionnaire, and the Bariatric Analysis and Reporting Outcome System (BAROS).

Results

Eighty‐one patients (14 males, 67 females) answered the questionnaire. More than 50% excess weight loss was recorded in 52/81 patients (64%). Sixty‐four patients (79%) reported improvement in their QOL including self‐esteem, physical activity, social involvement, and ability to work. Seventy‐one patients had initial obesity related comorbidity. In 61 of these patients (86%) their comorbidities resolved or improved. Minor port site related complications were recorded in nine patients while two patients had removal of the band because of infection.

Conclusion

LAGB is a safe method of bariatric surgery. It can achieve satisfactory weight loss with significant improvement in QOL and comorbidity.Laparoscopic adjustable gastric banding (LAGB) is a minimally invasive bariatric procedure that has been widely used since its introduction in 1993.¹ Its popularity is in part due to the relative safety of the technique compared to other bariatric procedures. It involves minimal dissection around the gastro‐oesophageal junction without the need for any surgical reconfiguration of normal anatomy.^2,3 Furthermore, as a restrictive bariatric procedure it avoids the risks of malabsorption and can be adjusted according to the progress of the patient.⁴Reduction in weight is the most commonly reported outcome measure following a bariatric procedure.⁵ However, the effect of weight loss on obesity‐related morbidity, mortality and quality of life (QOL) following the bariatric procedure are all important measures to report.^6,7 Oria and Moorehead addressed these outcome measures when they introduced the Bariatric Analysis and Reporting Outcome System (BAROS) in 1998⁶ that has been used and validated in subsequent trials.^7,8 These measures are the primary goal of obesity treatment, and therefore the most relevant health outcomes for assessing treatment effects.Previous studies that reported on these measures were usually from specialised high volume bariatric centres.^7,9 This may explain the limited number of reports from the UK where bariatric surgery is usually integrated into surgical practice within relatively smaller volume centres. However, with the increasing demand on bariatric surgery, reports from such low volume centres are of crucial importance as they may provide guidance on whether to emphasise the low volume bariatric surgical practice or to move forward towards a larger scale and more specialised centres of bariatric excellence.This study reports on the outcome of morbidly obese patients who had LAGB in a low volume bariatric centre (<20 cases/year) in terms of QOL, change in comorbidities and weight loss. It also allows definition of the relationship between the quantity of weight lost and the degree of improvement in health outcomes.     

Effects of comorbidity and hospital care on 6-month mortality in patients with elevated cardiac troponin T

Objective

To examine the effects of comorbidity and hospital care on mortality in patients with elevated cardiac troponin T.

Design

Observational study.

Setting

A large university hospital with on‐site diagnostic cardiac catheter laboratory.

Patients

All hospitalised patients with elevated cardiac troponin T level (⩾0.01 μg/l) over an 8‐week period.

Main outcome measures

6‐month all‐cause mortality.

Results

Among 313 patients with elevated cardiac troponin T, 195 had acute coronary syndrome and 118 had other conditions. Multivariate analysis showed that among patients with acute coronary syndrome, increasing comorbidity score (odds ratio (OR) 1.23 per point increase, 95% confidence interval (CI) 1.00 to 1.51; p = 0.048), age (OR 1.08 per year, 95% CI 1.04 to 1.13; p<0.001), raised troponin T level (OR 2.22 per 10‐fold increase, 95% CI 1.27 to 3.89; p = 0.005), and ST depression (OR 3.12, 95% CI 1.38 to 7.03; p = 0.006) were independent adverse predictors, while cardiologist care (OR 0.22, 95% CI 0.09 to 0.51; p<0.001) was associated with a better survival. Increasing troponin T level (OR 3.33 per 10‐fold increase, 95% CI 1.24 to 8.91; p = 0.017) was found to predict a worse prognosis among patients without acute coronary syndrome, and cardiologist care did not affect outcome in this group. Among hospital survivors with acute coronary syndrome, increasing comorbidity score, age and a lack of cardiologist care were independently associated with lesser use of effective medications.

Conclusions

Comorbidity was associated with a higher 6‐month mortality in patients having acute coronary syndrome, and lesser use of effective medicines among hospital survivors. Cardiologist care was associated with better 6‐month survival in patients with acute coronary syndrome, but not in those without acute coronary syndrome.Prognostic indices including the original Charlson''s comorbidity index¹ have shown that comorbidity was important in determining the short and long term outcome in patients with various medical conditions, including those with acute myocardial infarction.^2,3,4,5 Among patients admitted to hospital with suspected acute coronary syndrome, an abnormally raised cardiac troponin level can be found in patients with, and also without, acute coronary syndrome.^6,7 An increasing cardiac troponin level was associated with increasing mortality in patients with acute coronary syndrome,⁸ and also those without acute coronary syndrome.⁹ Despite the availability of international management guidelines, care provided for patients with acute coronary syndrome varied in hospitals with or without interventional facilities, and was affected by whether patients received cardiologist care.¹⁰ We examine the effects of comorbid diseases, including a validated comorbidity index,¹¹ and hospital care on the 6‐month outcome among patients with elevated cardiac troponin T, caused by acute coronary syndrome and other conditions.     

Comparison of clinical and electrodiagnostic features in B12 deficiency neurological syndromes with and without antiparietal cell antibodies

Background and aims

This study was undertaken to compare the clinical and electrodiagnostic (Edx) features in autoimmune and nutritional vitamin B12 deficiency neurological syndromes.

Methods

Consecutive patients with vitamin B12 deficiency neurological syndromes were evaluated and blood counts, red blood cell indices, serum chemistry, thyroid function, HIV serology, antiparietal cell antibody (APCA), serum B12, bone marrow and spinal MRI assessed. EDx studies included nerve conduction, tibial somatosensory (SEP) and motor evoked potential (MEP) to the tibialis anterior, and visual evoked potential (VEP). The results were compared between APCA positive and negative groups.

Results

57 patients aged 17–80 years (mean 45.3) were studied; 48 were vegetarians. The presenting clinical syndromes were myeloneuropathy in 25, myelopathy in 14, myeloneuroencephalopathy in 13, myeloencephalopathy in four and behavioural abnormality only in one patient. Spinal MRI in 47 patients revealed posterior spinal cord hyperintensity in 21 and cord atrophy in six. Nerve conduction was abnormal in 15%, MEP in 56.6%, SEP in 87.3% and VEP in 63.6% of patients. At 3 months, 31 patients had complete, 11 partial and three poor recovery. APCA was positive in 49% of patients. There was no difference in clinical, MRI or Edx findings or outcome between the APCA positive and negative groups.

Conclusion

APCA was positive in 49% of patients with B12 deficiency neurological syndrome but their clinical, MRI and Edx changes were not different from the APCA negative group. Neurological manifestations may be caused by B12 deficiency itself rather than the underlying cause.Vitamin B12 deficiency is common in vegetarians, especially in Hindus and Jains who exclude animal protein from their diet for religious or social reasons. Lower levels of serum B12 have been reported in vegetarians compared with non‐vegetarians in India.¹ Vitamin B12 deficiency can also occur as a result of autoimmune diseases, parasitic diseases, drugs, gastrointestinal surgery, malabsorption and genetic defects, such as transcobalamin II polymorphism.² Pernicious anaemia is an autoimmune disorder in which the gastric mucosa is atrophic, with loss of parietal cells resulting in intrinsic factor deficiency. In the absence of intrinsic factor, less than 1% of dietary vitamin B12 is absorbed. In the nervous system, vitamin B12 acts as a coenzyme in the methyl melonyl CoA mutase reaction which is necessary for myelin synthesis. Vitamin B12 deficiency therefore results in defective myelin synthesis leading to diverse central and peripheral nervous system dysfunctions. Pernicious anaemia may be associated with a number of autoimmune disorders, such as myxoedema, thyrotoxicosis, Hashimoto''s thyroiditis, Addison''s disease and vitiligo. Untreated vitamin B12 deficiency due to autoimmune or nutritional causes results in macrocytic anaemia, subacute combined degeneration of the spinal cord, encephalopathy and neuropathy in various combinations and permutations.^3,4,5,6The different causes of B12 deficiency (that is, nutritional deficiency or autoimmunity) may have different clinical, laboratory and prognostic features because of the effect of autoimmune conditions or the effect of the associated antineuronal autoantibodies. A Medline search using the key words “pernicious anaemia”, “antiparietal cell antibody”, “nutritional deficiency” and “subacute combined degeneration” did not reveal any study comparing the clinical, laboratory findings and prognosis of vitamin B12 deficiency of autoimmune or nutritional aetiology. We have prospectively evaluated patients with B12 deficiency neurological syndrome and compared their clinical, radiological and electrodiagnostic (Edx) findings, and outcome, in terms of the presence or absence of antiparietal cell antibodies (APCA).     

Histopathological features of breast cancer in Al-Madinah region of Saudi Arabia

Objectives:

To observe the frequency of breast cancer among Saudi patients and to highlight the age variations and features of advanced cancer.

Methods:

A retrospective study of breast cancer biopsies from all Saudi patients performed between January 2006 and December 2013 in King Fahad Hospital, Al-Madinah, Kingdom of Saudi Arabia. All the available demographic and tumor related data was analyzed.

Results:

Of 1005 breast tissues reviewed, 982 specimens were from female, and 23 from male patients. In females, 398 specimens (40.5%) were diagnosed as malignant. Invasive ductal carcinoma (IDC) (85.2%) was most common, followed by ductal carcinoma in situ (8%), and invasive lobular carcinoma (2.7%). The mean age of Saudi females with IDC was 46.9 years. Approximately 48.7% IDC were Grade III tumors. A tumor size >2.5 cm was found in 61.1% patients, whereas axillary nodal metastasis was present in 57.1% and lymphovascular invasion in 64.1% who underwent axillary nodal dissection. In males, 4 specimens (17.4%) were malignant (all IDC).

Conclusion:

Our finding are consistent with previous reports of breast cancer being diagnosed in younger age group, in advanced stages, and with features of aggressive behavior; which signals the urgency for implementation of breast screening programs.Breast cancer (BC) is the second most common cancer in the world, and most frequent cancer among women with an estimated 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers).1 As reported by GLOBOCAN,1 in both, the less developed (883,000 cases) and the more developed regions (794,000 cases), it is the most common cancer in women. The American Cancer Society estimated 232,340 new cases of invasive BC in women, and approximately 2,240 new cases among men in the US during 2013.2 In the United Kingdom (UK), BC mortality is however, the second to lung cancer, accounting for 11,684 deaths in 2011.3 In the Kingdom of Saudi Arabia (KSA), BC is most prevalent cancer in Saudi females as reported in Saudi Tumour Registry Report 2012.4 In 2008, previous study3 from Jeddah, KSA compared the cancer statistics for the KSA and USA; with the aim to study the future cancer burden in Saudi Arabia. They concluded that the cancer rates demonstrate a considerable increase and enormous demands on healthcare resources, in the future.5 Al Diab et al,6 reported 80 articles on BC from KSA. They concluded that it is most common in the Central region of KSA, and least common in the Northern region, with Eastern, Western, and Southern regions falling in the middle.6 In our present, hospital based, retrospective study, we cited and compared similar recent studies from around the world; such as from India,7,8 Nigeria,9 Pakistan,10 and Yemen.11 The KSA medical literature also has a number of similar relevant hospital based studies available for comparison.12-15 There is however, only one article in the local literature for hospital-based cancer data for Al-Madinah, which was carried out almost 20 years back.16 Although there has been some very recent hospital-based research publications from Al-Madinah; these articles have reported general disease patterns and cancers in many different organs such as large bowel,17,18 prostate,19 lymph nodes,20 and thyroid,21 but no data is available for this common and important disease, namely BC. We will be investigating this important problem of BC in the rapidly growing and advancing region of Al-Madinah; based on the histopathology diagnosis of biopsies and mastectomies/axillary dissections performed in the local population; and compare our data with previous international and national studies.     

Increased prevalence of gastrointestinal symptoms in patients with allergic disease

Background

Children with allergic diseases such as asthma and atopic dermatitis experience increased gastrointestinal symptoms. Further, physiological and histological abnormalities of the gastrointestinal tract in patients with allergic diseases have been reported. It is not certain whether adult patients experience increased gastrointestinal symptoms.

Methods

A retrospective, case–control study of 7235 adult (⩾20 years old) primary care patients was conducted. A general practitioner diagnosis of irritable bowel syndrome was used to serve as a marker of lower gastrointestinal symptoms. The prevalence of lower gastrointestinal symptoms was calculated in patients with asthma or allergic rhinitis and compared with that in patients with other chronic diseases (insulin‐dependent diabetes mellitus, osteoarthritis and rheumatoid arthritis) and with the remaining population.

Results

Gastrointestinal symptoms were significantly more common in patients with asthma (9.9%) as compared with patients with chronic diseases (4.9%; odds ratio (OR) 2.13, 95% confidence interval (CI) 1.39 to 2.56; p<0.002) or the remaining non‐asthmatic population (5.5%; OR 1.89, 95% CI 1.39 to 2.56; p<0.001). Gastrointestinal symptoms were also significantly more common in patients with allergic rhinitis (7.9%) as compared with patients with chronic diseases (4.9%; OR 1.66, 95% CI 1.02 to 2.7; p<0.05) and the remaining population (5.5%; OR 1.47, 95% CI 1.04 to 2.1; p<0.02). This phenomenon was independent of age, sex and inhaled asthma therapy in the case of patients with asthma.

Conclusions

Our findings support the hypothesis that lower gastrointestinal symptoms are more common in patients with allergic diseases such as asthma and allergic rhinitis.Lower gastrointestinal symptoms such as diarrhoea and abdominal pain are common in children with allergic diseases such as asthma¹ and atopic dermatitis.² Although food allergies and rare organic gastrointestinal diseases such as eosinophilic gastroenteropathy are associated with atopic disease, it is unlikely that they alone would account for such symptoms. Histological abnormalities of the gastrointestinal tract in patients with allergic airway diseases have also been reported. Small bowel biopsy specimens from patients with asthma and allergic rhinitis show features in common with the inflammatory reaction observed in the airways, with accumulation of eosinophils, T cells, mast cells, macrophages and increased expression of proallergic cytokines, such as interleukin (IL)4 and IL5.^3,4 Accumulation of eosinophils in the oesophageal mucosa has also been reported in patients with allergic rhinitis and asthma compared with controls.⁵ It is yet to be established whether these microscopic inflammatory changes influence gastrointestinal function. Interestingly, absorption studies with chromium 51‐labelled EDTA suggest a permeability defect of the gastrointestinal tract in patients with asthma.⁶We hypothesised that lower gastrointestinal symptoms would be more prevalent in patients with asthma and allergic rhinitis. We conducted a retrospective, case–control study of community‐based patients by evaluating computerised records of patients from a large primary healthcare centre in the UK. This strategy allowed us to identify large numbers of patients with asthma and allergic rhinitis through specific diagnostic codes (James Read codes). We used a general practitioner diagnosis of irritable bowel syndrome (IBS) to serve as a marker for lower gastrointestinal symptoms. IBS has no specific features, and, typically, diagnosis depends on the presence of lower gastrointestinal tract symptoms in the absence of organic bowel disorders. Although criteria‐based definitions of IBS have been developed,^7,8 it was not deemed necessary to use them strictly in this study, as we were simply using the diagnostic label to indicate the presence of lower gastrointestinal symptoms without an obvious organic cause.     

Community-acquired pneumonia: doctors do not follow national guidelines

Objectives

Appropriate assessment of community‐acquired pneumonia (CAP) allows accurate severity scoring and hence optimal management, leading to reduced morbidity and mortality. British Thoracic Society (BTS) guidelines provide an appropriate score. Adherence to BTS guidelines was assessed in our medical assessment unit (MAU) in 2001/2 and again in 2005/6, 3 years after introducing an educational programme.

Methods

A retrospective case‐note study, comparing diagnosis, documentation of severity, management and outcome of CAP during admission to MAU during 3 months of each winter in 2001/2 and 2005/6.

Results

In 2001/2, 65/165 patients were wrongly coded as CAP and 100 were included in the study. In 2005/6 43/130 were excluded and 87 enrolled. In 2005/6, 87% did not receive a severity score, a significant increase from 48% in 2001/2 (p<0.0001). Parenteral antibiotics were given to 79% of patients in 2001/2 and 77% in 2005/6, and third generation cephalosporins were given to 63% in 2001/2 and 54% in 2005/6 (p = NS). In 2001, 15 different antibiotic regimens were prescribed, increasing to 19 in 2005/6.

Conclusions

Coding remains poor. Adherence to CAP management guidelines was poor and has significantly worsened. Educational programmes, alone, do not improve adherence. Restriction of antibiotic prescribing should be considered.Community‐acquired pneumonia (CAP) accounted for almost 100 000 (2%) of acute hospital admissions in the UK in the financial year 2004/5,^1,2 and is associated with significant morbidity, mortality and expenditure.³ The appropriate assessment of patients with CAP allows accurate classification of severity of disease and optimal management.⁴ Early identification of severity significantly improves prognosis. Furthermore, CAP patients can avoid unnecessary admission and inappropriate antibiotic prescribing.⁵National guidelines for the assessment of severity of CAP and its management have been produced in many countries. In the UK, the British Thoracic Society (BTS) initially described guidelines for the management of CAP in 1993⁶ and updated these in 2001³ and again in 2004,⁷ with particular reference to severity scoring. Lim et al validated a prognostic score for mortality in CAP patients in 2003.⁸ This included the previous “CURB” score of Confusion, raised Urea, increased Respiratory rate and hypotension (BP) to which they added age over 65 to produce the CURB‐65 score. Scoring of 0 or 1 for each of the 5 points produced a prognostic index of outcome with a score of 0 suggesting a 30 day mortality risk of 0.7% and a score of 5 predicting a 57% mortality risk. Severe CAP was classified as a score of ⩾3. This score is simpler to use and more clinically useful than the more complex scoring system proposed by the Infectious Diseases Society of America.^9,10,11 Implementation and maintained adherence to these guidelines is necessary to realise the benefits in morbidity, mortality and cost reduction.^12,13Historically, adherence to guidelines has been poor, resulting in inappropriate management which may affect both morbidity and mortality.^14,15 Misuse or over‐use of antibiotics can result in antibiotic‐associated diarrhoea or colonisation with antibiotic resistant organisms, increased hospital stay and increased costs.^16,17,18In 2001/2, a retrospective study showed that adherence to the guidelines was poor in the acute medical assessment unit (MAU) of the Royal Liverpool University Hospital.¹⁹ We present the further findings of 2005/6 alongside these, after the introduction of an educational programme.     

Screening for Addison's disease in patients with type 1 diabetes mellitus and recurrent hypoglycaemia

Background

Addison''s disease may present with recurrent hypoglycaemia in subjects with type 1 diabetes mellitus. There are no data, however, on the prevalence of Addison''s disease presenting with recurrent hypoglycaemia in patients with diabetes mellitus.

Methods

Three year retrospective study of diabetic patients with “unexplained” recurrent hypoglycaemia investigated with a short Synacthen test to exclude adrenocortical insufficiency.

Results

95 patients with type 1 diabetes mellitus were studied. Addison''s disease was identified as the cause of recurrent hypoglycaemia in one patient with type 1 diabetes mellitus.

Conclusion

Addison''s disease is a relatively rare but remedial cause of recurrent hypoglycaemia in patients with type 1 diabetes mellitus. A low threshold for investigating patients with type 1 diabetes mellitus and recurrent hypoglycaemia to detect Addison''s disease is therefore suggested.Addison''s disease may present as recurrent hypoglycaemia in patients with type 1 diabetes mellitus^{1,2,3,4,5,6,7} and it is recommended that diabetic patients with unexplained recurrent hypoglycaemia be screened for Addison''s disease.⁸ There are, however, no data on the prevalence of Addison''s disease presenting with recurrent hypoglycaemia in patients with diabetes. We report on the prevalence of Addison''s disease presenting with recurrent hypoglycaemia in patients with type 1 diabetes mellitus.     

Impact of early biliary complications in liver transplantation in the presence or absence of a T-tube: a Chinese transplant centre experience

Background

Biliary complications continue to be an important determinant of the recipient''s survival rate after orthotopic liver transplantation (OLT). The objective of this study was to evaluate the incidence of early biliary complications in OLT in the presence or absence of a T‐tube.

Methods

This retrospective study, based on inpatient data, focused on the relationship between T‐tube placement and early biliary complications of 84 patients after OLT, from November 2002 to June 2005. Patients were divided into two groups based on whether or not a T‐tube was used following bile duct reconstruction: T‐tube group (group I, n = 33); non‐T‐tube group (group II, n = 51).

Results

45.2% of OLT recipients had a malignant neoplasm. There were no significant differences in the demographic characteristics or operation data between the two groups. Overall, early biliary tract complications developed in 19.0% (16/84) of patients. The rate of early biliary complications was 30.3% (10/33) and 11.8% (6/51) in groups I II, respectively (p = 0.035). Biliary complications which were directly caused by T‐tube placement occurred in 12.1% (4/33) of patients in group I. Overall, the percentage of malignant neoplasms, chronic viral cirrhosis, fulminant liver failure and other primary disease recipients with early biliary complications were 6.2%, 37.5%, 43.8% and 12.5%, respectively.

Conclusion

This study suggests that the use of a T‐tube in Chinese patients undergoing OLT causes a higher incidence of early biliary complications. Most of the early biliary complications occurred in chronic viral cirrhosis and fulminant liver failure recipients.Biliary reconstruction is a major cause of morbidity associated with orthotopic liver transplantation (OLT).^1,2 Currently, there are two or three popular reconstruction methods available for surgeons based on their experience. Most centres'' reports showed that non‐T‐tube reconstruction may be associated with fewer complications and could be more cost effective.^{3,4,5,6,7,8,9} According to their reports, cholangitis, fistula, dislodgement, obstruction and peritonitis are complications directly related to the T‐tube, accounting for 60% of all postoperative biliary problems.⁹ However, to date, there have been no formal reports on this problem published in China. Furthermore, Chinese recipients are unique as the main cause of end stage liver disease is different from that in other countries. The aim of this study was to compare early biliary tract complications in the presence or absence of a T‐tube and assess our centre''s experience.     

The SAFE (SGRQ score, air-flow limitation and exercise tolerance) Index: a new composite score for the stratification of severity in chronic obstructive pulmonary disease

Background

This study was proposed to develop a composite of outcome measures using forced expiratory volume percentage of predicted, exercise capacity and quality of life scores for assessment of chronic obstructive pulmonary disease (COPD) severity.

Materials and methods

Eighty‐six patients with COPD were enrolled into a prospective, observational study at the respiratory outpatient clinic, National University Hospital Malaysia (Hospital Universiti Kebangsaan Malaysia ‐ HUKM), Kuala Lumpur.

Results

Our study found modest correlation between the forced expiratory volume in 1 s (FEV₁), 6 min walk distance and the SGRQ scores with mean (SD) values of 0.97 (0.56) litres/s, 322 (87) m and 43.7 (23.6)%, respectively. K‐Means cluster analysis identified four distinct clusters which reached statistical significance which was refined to develop a new cumulative staging system. The SAFE Index score correlated with the number of exacerbations in 2 years (r = 0.497, p<0.001).

Conclusion

We have developed the SGRQ, Air‐Flow limitation and Exercise tolerance Index (SAFE Index) for the stratification of severity in COPD. This index incorporates the SGRQ score, the FEV₁ % predicted and the 6 min walk distance. The SAFE Index is moderately correlated with the number of disease exacerbations.The diagnosis of chronic obstructive pulmonary disease (COPD) is confirmed by spirometry when the forced expiratory volume in 1 s to forced vital capacity (FEV₁/FVC) ratio is less than 70%. Both the American Thoracic Society and the European Respiratory Society recommend a simple staging system to assess COPD severity based on post‐bronchodilator FEV₁ as percentage of the predicted value (FEV₁%Pred).The FEV₁ cut‐off points used to define different stages of COPD are arbitrary and have not been clinically validated. Although FEV₁ does not accurately measure small airflow obstruction, it is the most objective and reproducible measurement to assess physiologically the degree of airflow limitation. A recent study suggested that prognosis of all‐cause mortality was found to be strongly associated with age, smoking, and the best attainable FEV₁%Pred in COPD.¹On the contrary, other studies have shown good correlation between disease severity and quality of life (QOL) scores independent of the underlying physiologic markers measured by spirometry.^2,3,4 Patients with poor QOL scores based on the St George''s Respiratory Questionnaire (SGRQ) are at greater risk of hospital readmission whereas the FEV₁%Pred or FVC is not related to readmission.³QOL scores and spirometric values also measure different dimensions of disease severity.⁵ Wijnhoven et al found that a reduced score on the Health‐Related Quality of Life Questionnaire (HRQOL) was strongly associated with greater respiratory complaints whereas no association between pulmonary function level and symptoms was found.¹Another aspect of disease severity in COPD is exercise tolerance. Studies in pulmonary rehabilitation have shown that assessment of exercise tolerance correlates well with disease severity.^6,7,8 Walking distance also corresponds well with QOL scores, independent of the severity as assessed by spirometry.⁸ In another study by Wegner et al, exercise capacity, dyspnoea scores and airway obstruction independently characterised the pathophysiologic conditions of patients with severe COPD.⁹Would it be possible then to determine the severity of COPD using other independent parameters in addition to the degree of airway obstruction as measured by FEV₁%Pred? In a landmark study, Celli et al introduced and validated a multifactorial grading system that incorporated the body mass index, degree of airflow obstruction, functional dyspnoea and exercise capacity of patients with COPD. The cumulative scores of the BODE index correlated well with mortality.¹⁰ However, no QOL questionnaires were used in the study. The incorporation of a QOL assessment would have provided a more holistic stratification of severity in patients with COPD.Currently the severity of COPD is determined arbitrarily by a spirometric measure of a lung function, FEV₁. Although the decline of FEV₁ is a good marker of disease progression, it does not accurately assess the global manifestations of COPD. We hypothesised that inclusion of other outcome measures such as exercise capacity and health‐related QOL scores, in addition to the spirometric measurement FEV₁%Pred, would provide better overall assessment of COPD severity. In this study we have developed a composite of outcome measures using post‐bronchodilator FEV₁%Pred, exercise capacity and QOL scores to assess the severity of COPD. In addition, we validated the new composite score against the patients'' exacerbation frequency.     

Thrombus aspiration during primary percutaneous coronary intervention associated with reduced platelet activation

Objectives:

To determine the effect of thrombectomy on platelet function in patients undergoing primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction (STEMI).

Methods:

This retrospective study included 413 consecutive STEMI patients who underwent PPCI between March 2012 and September 2013 at Kartal Kosuyolu High Specialty Education and Research Hospital, Istanbul, Turkey that were assigned to the thrombus aspiration (TA) group or the non-TA group. Platelet count and mean platelet volume (MPV) were obtained at baseline and 24 hours (h), 48 h, and 72 h post PPCI.

Results:

Baseline MPV was similar in both groups, whereas the baseline platelet count was higher in the TA group (p=0.42 and p=0.002). The platelet count was higher in the TA group 24 h post PPCI (p=0.02), but was similar in both groups 48 h and 72 h post PPCI (p=0.18 and p=0.07). The MPV 48 h and 72 h post PPCI was higher in the non-TA group than in the TA group (8.4 ± 1.3 fL versus 8.7 ± 1.6 fL [p=0.04] and 8.5 ± 1.1 fL versus 8.9 ± 1.5 fL [p=0.04]).

Conclusion:

Thrombectomy reduced platelet activity via removal of thrombi from the coronary arteries in patients undergoing PPCI for STEMI.In acute ST-segment elevation myocardial infarction (STEMI), the main initiating factor is atherosclerotic plaque rupture or erosion, then platelets become activated and aggregated leading to acute coronary artery occlusion.1 Primary percutaneous coronary intervention (PPCI) is the standard treatment in patients with STEMI.2 In recent years, implementation of adjunctive mechanical and pharmacological therapies during PPCI, including manual thrombus aspiration (TA), has improved myocardial reperfusion and clinical outcome in STEMI patients.3-5 In daily practice, thrombectomy devices are used to remove thrombi or to prevent embolization of thrombi and plaque during PPCI.6 Platelet volume is a marker of platelet activation and is measured via mean platelet volume (MPV).7 An increase in MPV can occur in cases of acute myocardial ischemia, acute myocardial infarction, coronary atherosclerosis,8,9 and early stent thrombosis (ST).10 The Percutaneous Coronary Intervention in Acute Myocardial Infarction (TAPAS) study5 showed that TA therapy during PPCI decreases mortality and reinfarction rate.5 We speculate that the good results obtained with TA therapy are not only related to improved tissue perfusion but also may be related to reduced platelet activation. Therefore, the present study aimed to determine the effect of thrombectomy on platelet function and ST in patients undergoing PPCI for STEMI.     

Are the GFRUP's recommendations for withholding or withdrawing treatments in critically ill children applicable? Results of a two‐year survey

Objective

To evaluate feasibility of the guidelines of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French‐speaking group of paediatric intensive and emergency care; GFRUP) for limitation of treatments in the paediatric intensive care unit (PICU).

Design

A 2‐year prospective survey.

Setting

A 12‐bed PICU at the Hôpital Jeanne de Flandre, Lille, France.

Patients

Were included when limitation of treatments was expected.

Results

Of 967 children admitted, 55 were included with a 2‐day median delay. They were younger than others (24 v 60 months), had a higher paediatric risk of mortality (PRISM) score (14 v 4), and a higher paediatric overall performance category (POPC) score at admission (2 v 1); all p<0.002. 34 (50% of total deaths) children died. A limitation decision was made without meeting for 7 children who died: 6 received do‐not‐resuscitate orders (DNROs) and 1 received withholding decision. Decision‐making meetings were organised for 31 children, and the following decisions were made: 12 DNROs (6 deaths and 6 survivals), 4 withholding (1 death and 3 survivals), with 14 withdrawing (14 deaths) and 1 continuing treatment (survival). After limitation, 21 (31% of total deaths) children died and 10 survived (POPC score 4). 13 procedures were interrupted because of death and 11 because of clinical improvement (POPC score 4). Parents'' opinions were obtained after 4 family conferences (for a total of 110 min), 3 days after inclusion. The first meeting was planned for 6 days after inclusion and held on the 7th day after inclusion; 80% of parents were immediately informed of the decision, which was implemented after half a day.

Conclusions

GFRUPs procedure was applicable in most cases. The main difficulties were anticipating the correct date for the meeting and involving nurses in the procedure. Children for whom the procedure was interrupted because of clinical improvement and who survived in poor condition without a formal decision pointed out the need for medical criteria for questioning, which should systematically lead to a formal decision‐making process.In developed countries, ⩾70% of children die in hospital, mainly in paediatric intensive care units (PICUs).^1,2 Decisions on forgoing life‐sustaining treatment are made for 30–40% of dying children.^3,4,5Although formal guidelines in the English language for withholding or withdrawing treatment in critically ill children have been available since the 1990s, recommendations in French were lacking until recently.^6,7,8 Because of this lack and because several studies have shown that French‐speaking doctors in the intensive care units did not follow US guidelines,⁹ the French‐speaking group of the intensive care unit organised a workshop, including PICU nurses and doctors, parents of patients, palliative care specialists, philosophers and people who had conducted ethics research. This group worked from 1999 to 2000 and its conclusions were published in July 2002 as a book that was disseminated to all French PICUs.¹⁰ Recently, French paediatric guidelines were derived directly from this text and validated by the ethics commission of the French Paediatric Society; the proposed procedure is summarised in box 1.¹¹ Contrary to English guidelines that regard parents as the most appropriate bearers of decisional authority, French guidelines are more doctor centred, recommending that parents choose their level of participation, without shifting the weight of responsibility for the decision on them.The purpose of this study was to evaluate the feasibility of the procedure, to record related medical and paramedical time, and to point out ethical problems that could be implied by the procedure itself.     

Synergistic effect of triptolide combined with 5-fluorouracil on colon carcinoma

Aim

To investigate the inhibitive effects of triptolide (TPL) combined with 5‐fluorouracil (5‐FU) on colon carcinoma HT‐29 cells in vitro and in vivo and their side effects.

Methods

HT‐29 cells were cultured with RPMI 1640 medium. The single or combined effects of TPL and 5‐FU on HT‐29 cells were examined by MTT assay, flow cytometry. The combined effects were evaluated by the median‐effect principle. The model of tumour xenografts was established in nude mice. TPL 0.25 mg/kg/day and 5‐FU 12 mg/kg/day, either in combination or on their own, were injected into mice and the inhibitive effects and side effects were observed.

Results

TPL and 5‐FU either combined or alone inhibited significantly the proliferation of HT‐29 cells and induced obvious apoptosis. Mean (SD) growth inhibition rate reached 94.92 (2.76)% and the apoptic rate at 48 h reached 41.71 (1.38)%. The combined effects were synergistic (CI<1) at lower concentrations. TPL or 5‐FU alone inhibited significantly the growth of tumour xenografts and the inhibition rates were 78.53% and 84.16%; the drugs combined had more significant effect, the tumour inhibition rate reaching 96.78%. During the course of chemotherapy, no obvious side effect was observed.

Conclusion

The combined effects of TPL and 5‐FU on the growth of colon carcinoma in vitro and in vivo were superior to the effects when the agents were used individually. TPL combined with 5‐FU had synergistic effects at lower concentrations and promoted apoptosis, but did not increase the side effects of chemotherapy.Colon carcinoma is one of the most common malignant diseases worldwide.^1,2 Generally, approximately half of all patients with colon cancer can be cured with surgical resection of the primary tumour, while the remainder will eventually succumb to the predominant distant disease. Metastasis may already occur before the primary tumour can be detected. This characteristic of the disease has prevented any remarkable improvement in the cure rates in spite of the advances in surgical techniques. In order to improve the prognosis, chemotherapy is often used in a variety of clinical situations. The toxicity of these chemotherapeutic agents to normal tissues has been one of the major obstacles to successful cancer chemotherapy. Therefore, combined treatments with several chemotherapy regimens or even chemopreventive medicine are often used not only to enhance the treatment effect, but also to reduce the toxicity of these drugs.Over the past 40 years, 5‐fluorouracil (5‐FU) has been the major chemotherapeutic agent for treating colorectal carcinoma; however, response rates have been around 20–35% with median overall survival no more than 1 year.^3,4,5 So finding new anti‐cancer drugs with high therapeutic effect which can be used in combination with existing agents may provide an important way forward in the treatment of colorectal carcinoma.Triptolide (TPL) is a diterpenoid triepoxide derived from the herb Tripterygium wilfordii that has been used as a natural medicine in China for many years. TPL exerts both anti‐inflammatory and antifertility activities through its ability to inhibit the proliferation of both activated monocytes and spermatocytes.^6,7,8,9 Several reports have indicated that TPL also inhibits the proliferation of cancer cells in vitro and reduces the growth of some tumours and sensitises them to chemotherapy.^{10,11,12,13,14} In addition, clinical trials in China showed that TPL could achieve a total remission rate of 71% in mononucleocytic leukaemia and 87% in granulocytic leukaemia, which was more effective than any other chemotherapeutic agent currently available.^13,15In this study, we examined the effects of TPL combined with 5‐FU in regard to their activity against colon carcinoma in vitro and in vivo.     

Early percutaneous transhepatic gallbladder drainage compared with endoscopic retrograde cholangiopancreatography and papillotomy treatment for severe gallstone associated acute pancreatitis

Objective

Percutaneous transhepatic gallbladder drainage (PTGD) was compared with endoscopic treatment (within 72 hours after the onset of symptoms) in patients with severe biliary pancreatitis to evaluate the curative effect of PTGD in preventing bile track complications in these patients.

Methods

Eligible patients were randomised to receive early treatment with PTGD or endoscopic treatment. If the initial emergency endoscopic or PTGD treatment failed, patients received another drainage treatment within 24 hours. From November 2001 to August 2005, 101 patients were randomly assigned to early PTGD (n = 51) or endoscopic retrograde cholangiopancreatography (ERCP) (n = 50). Overall mortality, mortality due to pancreatitis and complications were compared in these two groups.

Results

48 of 52 patients were successfully treated with ERCP and 53 of 55 with PTGD. Seven patients (6.9%; three in the endoscopic treatment group and four in the PTGD group) died within four months after the onset of pancreatitis (p = 0.798); three patients in the endoscopic group and three in the PTGD group died from acute biliary pancreatitis. The overall rate of complications was similar in the two groups and there were no major differences in the incidence of local or systemic complications.

Conclusions

PTGD treatment is a simple, convenient and effective treatment of severe gallstone associated acute pancreatitis when endoscopic treatment fails.In China, gallstones account for approximately 50–70% of cases of acute pancreatitis.^1,2 The pathogenesis of acute biliary pancreatitis is not fully understood and may be multifactorial.^3,4,5,6,7,8 Most gallstones that initiate an episode of acute pancreatitis pass spontaneously through the ampulla of Vater into the duodenum and can subsequently be recovered in the faeces within a few days. It is uncertain whether or not early surgical or endoscopic removal of gallstones is beneficial in mild gallstone associated acute pancreatitis (GAP).^9,10 However, early endoscopic retrograde cholangiopancreatography (ERCP) with or without endoscopic sphincterotomy has been advocated to reduce complications in patients with a severe attack of GAP.^9,10,11,12Although early endoscopic intervention is the procedure of choice in patients with stone impaction and cholangitis, some patients are unable to tolerate endoscopic intervention, especially those with early severe pancreatitis who have developed organ failure within 72 hours after the onset of pain.¹³ Therefore, it is not sufficient to rely solely on endoscopic treatment to release bile matter in severe GAP. We need to find alternatives for those patients who fail to be cured by endoscopic treatment.Percutaneous transhepatic gallbladder drainage (PTGD) has been widely accepted as an alternative to operative decompression in critically ill patients with cholecystitis or cholangitis, especially in the elderly.^14,15,16 However, little is known about the factors affecting the outcome of PTGD in severe GAP. In clinical practice, we have been successful in using PTGD in some patients who were unable to receive endoscopic intervention and had complicating obstructive jaundice. In this study, we have performed a prospective, randomised trial to compare early PTGD (within 72 hours after the onset of symptoms) with endoscopic treatment in patients with severe GAP.     

Effects of stem cell therapy on dilated cardiomyopathy

Objectives:

To perform a meta-analysis of clinical trials and investigate the effect of stem cell therapy on dilated cardiomyopathy.

Methods:

A systematic literature search was carried out between May 2012 and July 2013 in PubMed, Medline, Cochrane Library, and Excerpta Medica Database (EMBASE). The study took place in the Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China. The weighted mean difference (WMD) was calculated for left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), mortality and heart transplantation, and the 6-minute walk test (6-MWT) distance using the RevMan 5.0 software.

Results:

Seven trials with 599 participants evaluated the association between the stem cell therapy and control groups. Compared with the control group, stem cell therapy group improved the LVEF (WMD: 3.98%, 95% confidence interval [CI]: 0.55 - 7.41%, p=0.02) and the 6-MWT distance (WMD: 132.12 m, 95% CI: 88.15-176.09 m, p<0.00001), and reduced mortality and heart transplantation (odds ratio [OR]: 0.48, 95% CI: 0.29-0.80, p=0.005). However, the LVEDD showed no significant difference between the 2 groups (WMD: -1.53 mm, 95% CI: -1.15-0.10 mm, p=0.10).

Conclusion:

This meta-analysis demonstrated that stem cell therapy improves cardiac function and reduces mortality in dilated cardiomyopathy patients, which suggested that stem cell therapy may represent a new therapy option for dilated cardiomyopathy.Dilated cardiomyopathy (DCM) is a primary myocardial disease of unknown etiology characterized by left ventricular or biventricular dilation and impaired contractility.1 Patients with DCM many have an increased myocardial mass and an altered extracellular collagen network,2 which is referred to as myocardial remodeling and eventually leads to heart failure. Reversing this process to reduce its morbidity and mortality remains one of the major challenges in healthcare practice. Recent studies have focused on stem cell therapy. In animal experiments, stem cell therapy improved both cardiac function and adverse left ventricular remodeling and reduced mortality.3 In clinical trials, short-term studies indicated that intra-coronary infusion of stem cells increased the left ventricular ejection fraction (LVEF)4 and improved other clinical outcomes.5-7 Furthermore, long-term studies produced the same results.8-10 Martino et al11 demonstrated the safety of bone marrow mononuclear cell transplantation, and that it is feasible in DCM patients with severe ventricular dysfunction. Previous studies have investigated the effects of stem cells on DCM. However, the sample size of these trials was small, and the conclusions were inconsistent. In most of these studies, the effect of stem cells was measured by LVEF, left ventricular end-diastolic diameter (LVEDD), the 6-minute walk test (6-MWT) distance, and the combined mortality and heart transplantation rate. The objective of this study is to perform a meta-analysis of all known clinical trials reporting the effects of stem cells on changes in LVEF, LVEDD, 6-MWT distance, and mortality and heart transplantation.     

Effects of occupational therapy on quality of life of patients with metastatic prostate cancer: A randomized controlled study

Objectives:

To evaluate the efficiency of occupational therapy relative to a home program in improving quality of life (QoL) among men who were treated for metastatic prostate cancer (MPC).

Methods:

Fifty-five men were assigned randomly to either the 12-week cognitive behavioral therapy based occupational therapy (OT-CBSM) intervention (treatment group) or a home program (control group) between March 2012 and August 2014 in the Department of Occupational Therapy, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey. The Canadian Occupational Performance Measure (COPM) was used to measure the occupational performance and identify difficulties in daily living activities. The QoL and symptom status were measured by The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C30 and its Prostate Cancer Module. A 12-week OT-CBSM intervention including client-centered training of daily living activities, recreational group activities, and cognitive behavioral stress management intervention were applied.

Results:

The COPM performance and satisfaction scores, which indicate occupational participation and QoL increased statistically in the treatment group in relation to men who were included in the home-program (p≤0.05).

Conclusion:

A 12-week OT-CBSM intervention was effective in improving QoL in men treated for MPC, and these changes were associated significantly with occupational performance.Prostate cancer is one of the most frequent male malignancies in the world.1 The development of serum prostate-specific antigen (PSA) and advanced prostate cancer treatment modalities increased 10-year survival rates from ~60% to >70%.2 Prostate cancer can be occurred as a local disease or advanced metastatic disease. The standard of care for metastatic prostate cancer (MPC) is hormone (androgen blockade) therapy, which delays progression and relieves pain for an average of 18 months to 24 months.3,4 Nearly all patients who have hormone therapy eventually develop significant disease and treatment related morbidity including fatigue, decrease in bone density, bone pain, weight loss, gynecomastia, and hot flushes.3 Increased survival and subsequent functional, physical, and psychological needs produced a growing acceptance of understanding the rehabilitation needs to increase the occupational performance and quality of life (QoL) of the patients with MPC.5 Occupational therapy (OT), one of the core elements of oncologic rehabilitation, is in a unique position to contribute to the development and fulfillment of occupational performance and participation with the motto of ‘live life to its fullest’.6 The role of the occupational therapist in oncology is to facilitate and enable an individual to achieve maximum functional performance, both physically and psychologically, in everyday living skills regardless of his or her life expectancy.6 Occupational performance or participation in everyday occupations is vital for all humans as defined by the International Classification of Functioning, Disability and Health7 (ICF). Occupational performance has a positive influence on health, well-being, and the presence of cancer has been found to lead to participation in meaningful activities /occupations that are effected by the cancer and its treatments.8 Previous studies9-14 have ably identified OT interventions mostly in general oncology and palliative care. The literature on OT, specifically on patients with breast cancer, investigates management of pain, fatigue, nausea, metastatic patients intervention, stress reducing and management program, the value of engagement in meaningful activities, lymphedema, vocational rehabilitation, creative and therapeutic use of activity, cognitive therapy, and, changing life style with cognitive behavioral therapy.9-14 According to the literature, a survey on women with breast cancer provides a picture of the interventions employed by the occupational therapists and can help to create an OT service to regain the patients level of control and independence by maintaining or resuming engagement in purposeful occupations and meaningful activities; however, the effect of OT in patients’ QoL was not completely specified.15,16 Another interdisciplinary study recommended examination of the effectiveness of OT in patients’ functional needs and to promote evidence-based practice of OT in oncology.8,17Prostate cancer oriented rehabilitation interventions may be valuable in functioning, and activity participation in daily living activities and also in helping men to acknowledge, express, accept, and use a problem solving approach on the changes that occur as a result of treatment and to seek out adaptive solutions for enduring fatigue, bone pain, weight loss, gynecomastia, and hot flushes.18 Such interventions may lead to significant improvements in functional, cognitive, and emotional coping skills, use of social support, utilization of health care, and management of symptoms.5,18-21 Rehabilitation interventions were adapted to meet the needs of cancer patients including functional individualized support and group therapy interventions22 and stress management intervention23 approaches. The research shows that effective stress management components include relaxation training to lower arousal, disease information and management, an emotionally supportive environment in which participants can address fears and anxieties, behavioral and cognitive coping strategies, and social support.19,20 Participation in rehabilitation intervention provides a clear and robust benefit to cancer patients by relieving treatment-related symptoms, reducing the physiologic concomitants of stress, and improving mood. Previous study19 found that the benefits in coping with cancer may be quite significant in male participants.19 This is supported by the positive experiences that men report from their participation in rehabilitation programs. Although, collectively, these findings indicated that men treated for prostate cancer derive benefit from a rehabilitation experience, most studies did not include a randomized intervention design and did not study the occupational performance of the participants.15,23 Only a few studies20,21 have investigated the efficacy of structured stress-management interventions in improving QoL and the mechanisms associated with such improvements despite stressful and negative side effects associated with treatment with limited activity participation.The limited reports in the literature indicates that there is a lack of study on the effect of OT combined cognitive behavioral stress management skills in patients with MPC. In the current study, it was hypothesized that participants treated for MPC enrolled in the cognitive behavioral stress management based OT (OT-CBSM) would demonstrate greater improvements in occupational performance and QoL compared with a control group (CG) enrolled in the home-program. The objectives of this study were to identify the effect of OT-CBSM on occupational participation and QoL, and to explore the areas/activities of daily life that were the most commonly affected, and needed support in patients with MPC.     

Hyperlipidemia in rheumatoid arthritis patients in Saudi Arabia: Correlation with C-reactive protein levels and disease activity

Objectives:

To determine the prevalence of hyperlipidemia in patients from Saudi Arabia with rheumatoid arthritis (RA), and to investigate its relationship with C-reactive protein level and disease activity.

Methods:

A cross-sectional 3-year study was conducted on RA patients at King Abdulaziz University Hospital, Saudi Arabia between January 2011 and December 2013. Lipid profiles were determined following 12-hour overnight fasting, and the association of lipid profiles with C-reactive protein (CRP) levels and disease activity was determined.

Results:

This study involved a total of 180 RA patients (mean age: 40.49±12.19 years). These subjects displayed a high prevalence of elevated total cholesterol (55.1%), and low-density lipoprotein cholesterol (51.2%). Notably, we detected a significant association between increased total cholesterol and high CRP levels (p=0.002). Moreover, we observed a positive correlation between total cholesterol and disease activity, as measured using the 28-Joint Disease Activity Score index (r=0.23, p=0.036).

Conclusions:

Hyperlipidemia is common among RA patients and is significantly associated with CRP levels and disease activity. Our findings emphasize the need to raise awareness among healthcare professionals regarding the development of hyperlipidemia when RA is active.Rheumatoid arthritis (RA) is a chronic inflammatory disorder that typically affects middle-aged individuals. The estimated prevalence of RA in Saudi Arabia is 2.2 per thousand people; it is more common in women, and incidence increases with age.1 If left untreated, RA is associated with high morbidity and mortality, which specifically results from cardiovascular disease (CVD).2,3 In order to reduce the CVD-related mortality rate in RA patients, the European League Against Rheumatism (EULAR) has recommended annual risk assessment, management of identified risk factors, and aggressive suppression of inflammation.4-6 In this regard, it has been demonstrated that treating RA with disease-modifying anti-rheumatic drugs (DMARDs) can effectively reduce CVD-related mortality.4,7 Cardiovascular disease is not only linked to traditional risk factors as hyperlipidemia, but also to nontraditional risk factors including chronic systemic inflammation. Notably, changes in lipid profiles have been established as traditional cardiovascular (CV) risk factors, but also as non-traditional that is directly linked to active inflammation (namely, disease activity).8-11 In fact, studies on CVD in RA patients have indicated that chronic systemic inflammation can enhance the development of atherosclerosis and hyperlipidemia.12,13 In this regard, the prevalence of hyperlipidemia in RA patients is known to vary between 20-45%.14,15 Hyperlipidemia in RA patients in Saudi Arabia has not been thoroughly investigated to date. Therefore, the objective of the present study was to estimate the prevalence of hyperlipidemia in RA patients in Saudi Arabia, and to identify possible associated risk factors, including inflammatory markers.