Bladder capacity in an elimination communication infant: a case report.

BACKGROUND: Bladder capacity is essential in assessing children with voiding dysfunction, yet it is currently unclear how best to determine a benchmark bladder capacity; various formulas have been proposed. CASE PRESENTATION: This report details the unique case of an elimination communication Caucasian infant (< 2 years old) who achieved nighttime and daytime dryness by 6 months of age. His first morning voids were measured from 8 to 20 months of age and compared with three formulas: (1) the Koff formula, a widely used formula based on fill volumes in anesthetized infants; (2) the Kaefer formula, a formula based on fill volume in nonanesthetized infants; and (3) the Holmdahl formula, a formula based on frequency-volume charts in normal infants. CONCLUSION: This infant's first morning void was found to be most consistent with Kaefer's formula. Further research is required to determine if formulas based on fill volume in nonanesthetized infants provide the more accurate benchmark bladder capacity in infants.

Intolerance upon statin rechallenge: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Although statins are often discontinued when myalgia arises, a causal relationship may not always exist. How well-tolerated statins are when rechallenge is blinded and controlled is unclear. METHODS AND FINDINGS: We performed a systematic review and meta-analysis (PROSPERO CRD42023437648) to evaluate the success of statin rechallenge versus matched placebo in those who were previously statin intolerant. Our primary outcome was intolerance; our secondary outcome was the myalgia or global symptom score. Medline, Embase, CINAHL Plus, Scopus, and CENTRAL were searched from inception to May 1, 2023. Eligible trials were randomized controlled trials with parallel or crossover designs examining statin rechallenge in statin-intolerant adults. Two independent reviewers selected studies, extracted data, and assessed risk of bias (Cochrane Collaboration's risk-of-bias tool 1). Relative risk (RR) and mean difference (MD) were estimated using fixed effect Mantel-Haenszel statistics. Of 1,941 studies screened, 8 met our inclusion criteria (8 to 491 participants from Asia, Europe, North America, and Oceana). Compared to placebo, intolerance was more common in statin users [325/906 (36%) vs 233/911 (26%), RR 1.40, 95% CI, 1.23 to 1.60, I2 = 0%, 7 trials, number needed to harm 10] and there was no statistically significant difference in myalgia or global symptom score on a 100-point scale [MD 1.08, 95% CI, -1.51 to 3.67, I2 = 0%, 5 trials]. Limitations include only 1 trial asking participants about intolerable symptoms (vs inferring intolerance from discontinuation or trial withdrawal); the small number of trials; the possibility of attrition bias; and the potential for carryover effects in crossover/n-of-1 trial designs. CONCLUSIONS: Of those previously intolerant of statins who were rechallenged with a statin and compared to placebo recipients, medication intolerance was more common amongst statin recipients. However, there was no significant difference in mean myalgia or global symptom score between statin and placebo, and only one-third of those previously believed to be statin intolerant were unable to tolerate a statin on blinded rechallenge; one-quarter were intolerant of placebo.

Scoping review of cytolytic vaginosis literature.

BACKGROUND: Cytolytic vaginosis (CV) is a little-known, controversial condition that is typically not considered for women presenting with vulvovaginitis symptoms. Objective: The objective of this scoping review was to identify and compile the global evidence on CV. METHODS: A medical librarian searched Prospero, Wiley Cochrane Library, Ovid Embase, Ovid Medline, EBSCO CINAHL, ProQuest Dissertations and Theses Global, and Scopus, from inception to April 4, 2019 and updated to October 17, 2021. Studies were eligible if they discussed CV. Two independent reviewers conducted study selection and data extraction. RESULTS: Sixty-four studies were identified, with 67% of studies (n = 43) published since 2007. Studies were from around the world, including the United States (28%, n = 18), Brazil (11%, n = 7), Portugal (11%, n = 7), and China (11%, n = 7). Fifty percent of studies (n = 32) were reviews; the remainder were observational; and of these, 78% (n = 25) were cross-sectional. The most frequent topics included: diagnosis (19%, n = 12), prevalence (17%, n = 11), and overview of CV (50%, n = 32). Evidence for prevalence in symptomatic women (median prevalence of 5%, interquartile range 3%-8%) was based only on 16% of studies (n = 10) with minimal evidence on prevalence in asymptomatic women and across different geographic regions. Microbiological findings, including abundant lactobacilli and fragmented epithelial cells, were found useful to distinguish between CV and vulvovaginal candidiasis, and Lactobacillus crispatus was noted to dominate the vaginal flora in women with CV. Most studies used subjective criteria to diagnose CV as the condition lacks gold-standard microscopic criteria. The suggested primary treatment (baking soda irrigations) was largely based on expert opinion, and there was minimal evidence on associations between CV and other conditions. CONCLUSION: Knowledge gaps currently exist in all realms of CV research. Additional research is needed to confirm the validity of CV and ensure that women are diagnosed and treated effectively.

A Case for Offering HPV Self-Sampling to Well-Screened Women. Comment on Lesack et al. Willingness to Self-Collect a Sample for HPV-Based Cervical Cancer Screening in a Well-Screened Cohort: HPV FOCAL Survey Results. Curr. Oncol. 2022, 29, 3860-3869.

Lesack et al. recently published a cross-sectional study that focused on human papillomavirus (HPV) self-sampling in the screened population, a population not conventionally thought of for HPV self-sampling. They found 52% of well-screened, highly educated women who participated in the Human Papillomavirus For Cervical Cancer (HPV FOCAL) screening trial in British Columbia, Canada, would be willing to self-collect an HPV sample. We published a similar study in 2021 on well-screened, highly educated women affiliated with a family medicine clinic in Edmonton, Alberta, Canada, and found that 60% of these women preferred to have the option of HPV self-sampling. Our findings reinforce Lesack et al.'s results and together provide evidence for offering HPV self-sampling as an option for the well-screened population.

Antihypertensive medication in frail older adults: A narrative review through a deprescribing lens.

Purpose of review: The management of hypertension in frail older adults remains controversial, as these patients are underrepresented in clinical trials and practice guidelines. Overtreatment may cause harm while undertreatment may lead to greater risk of cardiovascular events. Our research aims to examine this controversy and provide guidance regarding deprescribing decisions in frail older adults. Results: Current evidence suggests that there may be minimal cardiovascular benefit and significant harm of antihypertensive medication in the frail older adult population. A minority of hypertension guidelines provide sufficient recommendations for frail older adults, and there are limited tools available to guide clinical decision-making. Conclusion: Randomized controlled trials and well-designed observational studies are needed to confirm the benefit-to-harm relationship of antihypertensive medication in frail older adults. Decision tools that comprehensively address antihypertensive deprescribing would be advantageous to help clinicians with hypertension management in this population. Clinicians should engage in shared decision-making with the patient and family to ensure that decisions regarding antihypertensive deprescribing best meet the needs of all involved.

Attitudes Toward Human Papillomavirus Self-Sampling in Regularly Screened Women in Edmonton, Canada: A Cross-Sectional Study.

OBJECTIVE/PURPOSE: The aim of the study was to determine the level of interest in human papillomavirus (HPV) self-sampling as a method of cervical cancer screening in a population of women affiliated with a primary care clinic. MATERIALS AND METHODS: A survey was given to women (N = 182) between the ages of 25 and 69 years attending a family medicine clinic in Edmonton, Canada. Primary outcome measures include (1) the percentage of women who feel that HPV self-sampling should be available and (2) the percentage of women who would prefer HPV self-sampling to the Pap test. Secondary outcomes include the percentage of women aware of HPV self-sampling and factors associated with a preference for HPV self-sampling using logistic regression. RESULTS: Most women (84%) were up-to-date on Pap testing, and most (85%) had had postsecondary education (either completed or in progress). The percentage of the women who moderately or strongly felt that HPV self-sampling should be available was 60%; the percentage of the women who would prefer HPV self-sampling was 24%. Only 7% of the women reported being previously aware of HPV self-sampling. The factor associated with a preference for HPV self-sampling was the Pap comfort score, with an odds ratio of 1.51 (95% CI = 1.05-2.16, p = .026). CONCLUSIONS: In this population of well-educated women who were mostly up-to-date on cervical screening, there was a clear interest to have the option of HPV self-sampling. It is important for cancer screening programs to take this into account, given that women are the ultimate beneficiaries of these programs.

A Scoping Review on the Attributes of Cluster Randomized Controlled Trials in Long-Term Care Facilities.

Cluster randomized trial design, where groups of participants are randomized instead of individual participants, is increasingly being used in long-term care research. The purpose of this review was to determine the characteristics of cluster randomized trials in long-term care facilities. A medical librarian conducted the literature search. Two independent reviewers reviewed each paper. Studies were included if the design was cluster randomized and participants were from long-term care facilities. For each included study, two independent data extractors captured data on study attributes, including: journal, location, year published, author discipline, funding, methodology, number of participants, and intervention target. The literature search yielded 7,679 unique studies, with 195 studies meeting the selection criteria and being included for data extraction. The included studies were published between 1976 and 2017, with 53% of studies published after 2009. The term cluster randomized was in the title of only 45% of the studies. The studies were conducted worldwide; the United States had the largest number of studies (23%), followed by the United Kingdom (18%). Ten percent of studies were published in journals with an impact factor >10. The most frequent discipline of the first and last authors was medicine (34%), followed by nursing (17%). Forty-nine percent of the studies had government funding, while only 20% had medical industry funding. In studies with <1000 residents, 85% of the studies obtained consent from the resident and/or their proxy, while in studies with ≥ 1000 residents, it was 31%. The most frequent intervention targets were infection (13%), falls/fracture (13%), and behavior/physical restraint (13%). Cluster randomized controlled trials in long-term care have a unique set of characteristics. Results of this review will provide guidance to researchers conducting studies in long-term care facilities.

Treatment of pruritus in a palliative care patient with low-dose paroxetine: a case report.

BACKGROUND: Pruritus is a distressing symptom seen in palliative care. There is limited high-quality evidence of pharmaceutical treatments for pruritus in palliative care, including the use of paroxetine. CASE PRESENTATION: I present a case of a 70-year-old caucasian woman with metastatic ovarian cancer who presented with severe pruritus. She had been diagnosed with bile duct obstruction 1 month earlier. Antihistamines and over-the-counter skin creams were first trialed, to no effect. Paroxetine was started at 5 mg in the evening, with the intention of titrating up. However, 5 mg of paroxetine was effective, and the patient's pruritus fully resolved after the second day. CONCLUSIONS: This case supports the use of paroxetine as a therapy for pruritus in palliative care patients and suggests that paroxetine may be effective at a very low dose.

The impact of breast reduction surgery on breastfeeding: Systematic review of observational studies.

BACKGROUND: Almost half a million breast reduction surgeries are performed internationally each year, yet it is unclear how this type of surgery impacts breastfeeding. This is particularly important given the benefits of breastfeeding. OBJECTIVES: To determine if breast reduction surgery impacts breastfeeding success and whether different surgical techniques differentially impact breast feeding success. METHODS: Databases were searched up to September 5, 2017. Studies were included if they reported the number of women successful at breastfeeding or lactation after breast reduction surgery, and if they reported either the total number of women who had children following breast reduction surgery, or the total number of women who attempted to breastfeed following surgery. RESULTS: Of 1,212 studies, 51 studies met the inclusion criteria; they were located worldwide and had 31 distinct breast reduction techniques. The percentage of breastfeeding success among studies was highly variable. However, when analyzed by the preservation of the column of parenchyma from the nipple areola complex to the chest wall (subareolar parenchyma), a clear pattern emerged. The median breastfeeding success was 4% (interquartile range (IQR) 0-38%) for techniques with no preservation, compared to 75% (IQR 37-100%) for techniques with partial preservation and 100% (IQR 75-100%) for techniques with full preservation. CONCLUSIONS: Techniques that preserve the column of subareolar parenchyma appear to have a greater likelihood of successful breastfeeding. The preservation of the column of subareolar parenchyma should be disclosed to women prior to surgery. Guidelines on the best breast reduction techniques to be used in women of child bearing years may be advantageous to ensure women have the greatest potential for successful breastfeeding after breast reduction surgery.

Influence of School Year on Seasonality of Norovirus Outbreaks in Developed Countries.

Factors affecting the seasonal distribution of norovirus outbreaks are not well understood. This study examined whether grade school settings at the start of the school year may be a factor. We searched Ovid Medline from January 2002 to June 2014 for studies that provided all reported norovirus outbreaks in a developed country by month for a minimum of three years. Historical school years were obtained from verifiable sources. The start of the norovirus seasonal outbreak peak and peak outbreak month were determined for each study and compared to the start month of school. Northern hemisphere and southern hemisphere countries had a different norovirus seasonality and different school year structures (traditional compared to year round). In the two studies that provided outbreaks by age, outbreaks among children started several months before outbreaks in the adult population. The median number of months between school start and start of the seasonal outbreak peak was two months (interquartile range [IQR] = 2.0-3.0), while the median number of months between school start and peak outbreak month was four months (IQR = 3.0-4.0). These findings suggest the possibility the school setting at the start of the school year may be a factor in the seasonality of norovirus.

Contributors to primary care guidelines: What are their professions and how many of them have conflicts of interest?

OBJECTIVE: To determine the professions of those who contribute to guidelines, guideline variables associated with differing contributor participation, and whether conflict of interest statements are provided in primary care guidelines. DESIGN: Retrospective analysis of the primary care guidelines from the Canadian Medical Association website. Two independent data extractors reviewed the guidelines and extracted relevant data. SETTING: Canada. MAIN OUTCOME MEASURES: Sponsors of guidelines, jurisdiction (national or provincial) of guidelines, the professions of those who contribute to guidelines, and the reported conflict of interest statements within guidelines. RESULTS: Of the 296 guidelines in the family medicine section of the CMA Infobase, 65 were duplicates and 35 had limited relevance to family medicine. Twenty did not provide contributor information, leaving 176 guidelines for analysis. In total, there were 2495 contributors (authors and committee members): 1343 (53.8%) non-family physician specialists, 423 (17.0%) family physicians, 141 (5.7%) nurses, 75 (3.0%) pharmacists, 269 (10.8%) other clinicians, 203 (8.1%) nonclinician scientists, and 41 (1.6%) unknown professions. The proportion of contributors from the various professions differed significantly between provincial and national guidelines, as well as between industry-funded and non-industry-funded guidelines (both P < .001). For provincial guidelines, 30.8% of contributors were family physicians and 37.3% were other specialists compared with 13.9% and 57.4%, respectively, for national guidelines. Of industry-funded guidelines, 7.8% of contributors were family physicians and 68.6% were other specialists compared with 19.4% and 49.9%, respectively, for non-industry-funded guidelines. Conflicts of interest were not reported in 68.9% of guidelines. When reported, conflict of interest statements were present for 48.6% of non-family physician specialists, 30.0% of pharmacists, 27.7% of family physicians, and 10.0% or less of the remaining groups; differences were statistically significant (P < .001). CONCLUSION: Non-family physician specialists outnumber all other health care providers combined and are more than 3 times more likely to contribute to primary care guidelines than family physicians are. Conflict of interest statements were provided in the minority of guidelines, and for guidelines in which conflict of interest statements were included, non-family physician specialists were most likely to report them. Guidelines targeted to primary care should have much more primary care and family medicine representation and include fewer contributors who have conflicts of interest.