Medical management of painful achalasia: a patient-driven systematic review.

Achalasia is a rare esophageal disorder characterized by abnormal esophageal motility and swallowing difficulties. Pain and/or spasms often persist or recur despite effective relief of the obstruction. A survey by UK charity 'Achalasia Action' highlighted treatments for achalasia pain/spasms as a key research priority. In this patient-requested systematic review, we assessed the existing literature on pharmacological therapies for painful achalasia. A systematic review of the literature using Medline, Embase and Cochrane databases was performed to identify studies evaluating pharmacological therapies for achalasia. Methodological quality of included randomized controlled trials was assessed using the Cochrane Risk of Bias tool. In total, 70% (40/57) of survey respondents reported experiencing pain/spasms. A range of management strategies were reported. Thirteen studies were included in the review. Seven were randomized controlled trials. Most studies were >30 years old, had limited follow-up, and focussed on esophageal manometry as the key endpoint. Generally, studies found improvements in lower esophageal pressures with medications. Only one study evaluated pain/spasm specifically, precluding meta-analysis. Overall risk of bias was high. The achalasia patient survey identified that pain/spasms are common and difficult to treat. This patient-requested review identified a gap in the literature regarding pharmacological treatments for these symptoms. We provide an algorithm for investigating achalasia-related pain/spasms. Calcium channel blockers or nitrates may be helpful when esophageal obstruction and reflux have been excluded. We advocate for registry-based clinical trials to expand the evidence base for these patients.

Over-interpretation of findings in diagnostic accuracy studies of infectious diseases.

OBJECTIVES: To assess the prevalence of overly positive interpretation, also called 'spin',-of results in diagnostic accuracy studies of infectious diseases and to identify suggestions for improvement. METHODS: A PubMed search was performed to identify diagnostic accuracy studies of infectious diseases published between January and March 2019. Each article was assessed by two authors independently to identify study characteristics and forms of actual and potential over-interpretation. 'Actual over-interpretation' was defined as conclusions that were not on the basis of study aims or conclusions that were more favourable than justified by the study findings. There are other practices that may result in the over-interpretation of study findings and these have been described as 'potential over-interpretation'. RESULTS: The final analysis included 120 studies. Favourable or promising recommendations were made in the main text of 101 (84%) of the included studies. Evidence of actual over-interpretation (spin) was found in 30 (25%) articles, with 22 (18%) studies reporting a conclusion that did not match the study aims and 56 (47%) studies with a more positive conclusion in the abstract than the main text. All analysed studies exhibited at least one form of potential over-interpretation, with was most commonly a lack of sample size calculation (n = 109, 91%) and not reporting a null hypothesis (n = 115, 96%). DISCUSSION: Evidence of over-interpretation of results was found in one-third of the included studies. We have proposed possible interventions to prevent overly positive interpretations of results in diagnostic accuracy studies.

Vestibular neuronitis after COVID-19 vaccination.

A woman in her 50s presented with acute vertigo and vomiting within 72 hours of receiving the Pfizer-BioNTech COVID-19 vaccine. The only neurological deficit was an impaired vestibulo-ocular reflex with horizontal nystagmus. The patient was subsequently diagnosed with vestibular neuronitis. She was managed symptomatically with prochlorperazine and betahistine, and underwent vestibular rehabilitation for 6 weeks. She made a full recovery and experienced no further symptoms. She received the second dose of the vaccine without complications.This case demonstrates a temporal association between COVID-19 vaccination and vestibular neuronitis. Neurological adverse events are rare but recognised side effects of COVID-19 vaccines and healthcare professionals should be aware of them. This ensures timely management of patients with such presentations. Treatment should be the same as for non-vaccine-associated vestibular neuronitis. The nature of the relationship between COVID-19 vaccination and vestibular neuronitis remains unclear and patients therefore require investigations to exclude other recognised causes of vestibular neuronitis.

Establishing a novel community-focussed lactation support service: a descriptive case series.

BACKGROUND: Although breastfeeding is widely acknowledged as protecting both infant and maternal health postnatally, a partial or complete shortfall of maternal milk can occur for a range of reasons. In this eventuality, the currently available options for feeding infants are screened donor human milk (DHM), infant formula or unscreened shared human milk. In the UK, DHM has only been widely available in specific clinical contexts for the last 40 years, mainly to reduce the risk of necrotising enterocolitis in extremely preterm infants alongside optimal support for maternal lactation and breastfeeding. The Hearts Milk Bank (HMB) was established in 2017 as an independent, non-profit human milk bank that aimed to ensure equitable, assured access to screened DHM for neonatal units. As a result of the generosity of mothers, a surplus of DHM rapidly became available and together with lactation support, has since been provided to families with a healthcare referral. This programme has now been formalised for families facing lactational challenges, and DHM stocks are permanently maintained to meet their needs. CASE SERIES: This case series describes the clinical paths of four families who accessed lactation support and DHM from the HMB, along with a description of the process for community provision. To date, the HMB has supported over 300 families. Working collaboratively with key stakeholders, the HMB team has developed a prioritisation strategy based on utilitarian ethical models, protocols that ensure safe handling and appropriateness of use, broader donor recruitment parameters that maintain safety with a pragmatic approach for full term healthy infants, and a process to ensure parents or carers have access to the knowledge needed to give informed consent and use DHM appropriately. CONCLUSIONS: Stakeholders, including parents, healthcare professionals, and milk banks, will need to discuss priorities for both DHM use and research gaps that can underpin the equitable expansion of services, in partnership with National Health Service (NHS) teams and third-sector organisations that support breastfeeding and maternal mental health.

Symptomatic, biochemical and radiographic recovery in patients with COVID-19.

BACKGROUND: The symptoms, radiography, biochemistry and healthcare utilisation of patients with COVID-19 following discharge from hospital have not been well described. METHODS: Retrospective analysis of 401 adult patients attending a clinic following an index hospital admission or emergency department attendance with COVID-19. Regression models were used to assess the association between characteristics and persistent abnormal chest radiographs or breathlessness. RESULTS: 75.1% of patients were symptomatic at a median of 53 days post discharge and 72 days after symptom onset and chest radiographs were abnormal in 47.4%. Symptoms and radiographic abnormalities were similar in PCR-positive and PCR-negative patients. Severity of COVID-19 was significantly associated with persistent radiographic abnormalities and breathlessness. 18.5% of patients had unscheduled healthcare visits in the 30 days post discharge. CONCLUSIONS: Patients with COVID-19 experience persistent symptoms and abnormal blood biomarkers with a gradual resolution of radiological abnormalities over time. These findings can inform patients and clinicians about expected recovery times and plan services for follow-up of patients with COVID-19.

Use of donor human milk in nonhospitalized infants: An infant growth study.

When mother's own milk (MOM) is unavailable or insufficient, donor human milk (DHM) is recommended as the next best alternative for low birthweight infants. DHM use for healthy, term infants is increasing, but evidence for growth and tolerability is limited. This retrospective study evaluated growth in term infants in the community who received DHM from a UK milk bank. Mothers of infants receiving DHM between 2017 and 2019 were contacted (n = 49), and 31 (63.2%) agreed to participate. Fourteen infants received DHM as a supplement to other feeds (MOM and/or infant formula) and 17 were exclusively fed DHM where breastfeeding was impossible (range: 3-6 weeks). Growth was assessed by deriving z-scores using the WHO standard for infant growth and compared with 200 exclusively breastfed infants. Multivariate regression analysis revealed no feeding method-specific association between z-score and age, nor between weight and age, suggesting that z-scores and growth velocity were not affected by feeding exclusive MOM, supplemental DHM or exclusive DHM. DHM was well-tolerated with no adverse events that led to early cessation. After receiving supplemental DHM group, 63% of infants whose mothers had no physical barrier to breastfeeding (5/8 infants) were exclusively breastfed. This novel study reports adequate growth outcomes of healthy nonhospitalized infants receiving DHM, either as the sole milk source or supplement. Prospective studies are needed to confirm whether DHM is a suitable feeding alternative for term infants in the community, optimal durations, as well as the impact of DHM availability on breastfeeding rates and maternal mental health.