Interventions for Managing Late Gastrointestinal Symptoms Following Pelvic Radiotherapy: a Systematic Review and Meta-analysis.

AIMS: Pelvic radiotherapy can induce gastrointestinal injury and symptoms, which can affect quality of life. We assessed interventions for managing these symptoms. MATERIALS AND METHODS: A review of randomised controlled trials published between January 1990 and June 2023 from databases including MEDLINE, EMBASE, CENTRAL, CINAHL, clinicaltrials.gov, ISRCTN and grey literature sources was conducted. Meta-analyses were carried out using the DerSimonian and Laird random effects model to produce overall treatment differences with 95% confidence intervals. RESULTS: Twenty-eight studies (2392 participants) of varying methodological quality were included. 4% formalin was superior to sucralfate for improving gastrointestinal symptom score (standardised mean difference [SMD] -1.07, 95% confidence interval -1.48 to -0.65). Argon plasma coagulation (APC) was inferior to sucralfate (SMD 1.22, 95% confidence interval 0.84 to 1.59). Counselling positively influenced symptom score (SMD -0.53, 95% confidence interval -0.76 to -0.29), whereas hyperbaric oxygen therapy showed conflicting results. Sucralfate combined with APC increased endoscopic markers of moderate-severe bleeding versus APC alone (risk ratio 2.26, 95% confidence interval 1.12 to 4.55). No definite conclusions on pain, incontinence, diarrhoea, tenesmus or quality of life interventions were confirmed. CONCLUSIONS: Small study sizes, methodological quality and heterogeneity limit support of any individual intervention. APC and 4% formalin seem to be promising interventions, with further larger randomised controlled trials now warranted.

Ultrasound Probe Positions for Internal Jugular Vein Cannulation: A Prospective Study of Different Techniques.

OBJECTIVE: We compared sonoanatomy of the internal jugular vein (IJV) the high (HA), conventional (CA) and the medial oblique approach (MA) to identify the best approach and head position for IJV cannulation. MATERIALS & METHODS: Total of 45 volunteers aged 18-65 years were included in this study. The degree of overlap in percentage, depth of IJV from skin, antero-posterior (AP) and transverse diameters (TD) of IJV were measured in real time with ultrasound (US). Measurements were taken in the HA, CA and MA in neutral and 30° head rotation on both the right and left side of the neck. RESULTS: The HA had lower percentage of overlap when compared to CA and MA in neutral and 30° head rotation (p= 0.002 to ≤0.001). The IJV was more shallow in the CA and MA. The AP and TD of the IJV were larger in the MA when compared to HA (p=<0.001) and CA (p =0.026 to < 0.001) and the right IJV has a larger AP and TD in all approaches. DISCUSSION: The HA had the least percentage of overlap compared to CA and MA, therefore the risk of accidental ICA puncture can be reduced. The apparent overlap seen in MA may not reflect the actual scenario because of the way the US beam cuts the vessel. The AP and TD of IJV were significantly increased in the MA, which would ease CVC. CONCLUSION: We conclude and recommend the medial oblique probe position with 30° head rotation provides optimal real time sonographic parameters for US guided IJV cannulation.

What is the role of small bowel capsule endoscopy in established coeliac disease?

INTRODUCTION: Patients with established coeliac disease (CD) can present with signs and symptoms requiring small bowel capsule endoscopy (SBCE) to assess for persistent disease beyond the duodenum and to rule out complications. There is paucity of data on extent of disease on SBCE in relation to histology, clinical and serological parameters. The aim of this study was to assess the relationship between symptoms, CD serology and Marsh classification of disease and extent of disease on SBCE in patients with established CD. METHODS: Hundred patients with established CD and 200 controls underwent a SBCE. SBCEs were reviewed by expert reviewers. Extent of disease on SBCE, CD findings and small bowel transit were recorded. RESULTS: Considering duodenal histology (D2; Marsh 3a or above) as the gold standard for diagnosing CD activity, the sensitivity of SBCE to delineate active disease was 87.2%. The specificity was 89.0%. Age at SBCE (P=0.006), albumin (P=0.004) and haemoglobin (P=0.0001), Marsh score of histology from the duodenal bulb (D1) (P=0.0001) and the second part of the duodenum (P=0.0001), refractory CD (P=0.007) on histology correlated with extent of affected small bowel (SB) mucosa on univariate analysis. On multiple regression analysis, albumin (P=0.036) and Marsh score of histology (D1) (P=0.019), vitamin B12 (P=0.001) and folate levels (P=0.008) were statistically significant. Extent of affected SB mucosa (11.0% vs 1.35%) was greater in patients with complications including those with refractory CD (P=0.008). CONCLUSIONS: This is the first study showing correlation between extent of disease and severity of duodenal histology, markers of malabsorption such as folate levels and vitamin B12 and complications of CD.

Persistent mucosal damage and risk of epilepsy in people with celiac disease.

BACKGROUND AND PURPOSE: Celiac disease (CD) is associated with an increased risk of developing epilepsy, a risk that persists after CD diagnosis. A significant proportion of patients with CD have persistent villous atrophy (VA) on follow-up biopsy. The objective of this study was to determine whether persistent VA on follow-up biopsy affected long-term epilepsy risk and epilepsy-related hospital emergency admissions. METHODS: This was a nationwide cohort study. We identified all people in Sweden with histological evidence of CD who underwent a follow-up small intestinal biopsy (1969-2008). We compared those with persistent VA with those who showed histological improvement, assessing the development of epilepsy and related emergency hospital admissions (defined according to relevant International Classification of Diseases codes in the Swedish Patient Register). Cox regression analysis was used to assess outcome measures. RESULTS: Villous atrophy was present in 43% of 7590 people with CD who had a follow-up biopsy. The presence of persistent VA was significantly associated with a reduced risk of developing newly-diagnosed epilepsy (hazard ratio, 0.61; 95% confidence interval, 0.38-0.98). On stratified analysis, this effect was primarily amongst males (hazard ratio, 0.35; 95% confidence interval, 0.15-0.80). Among the 58 patients with CD with a prior diagnosis of epilepsy, those with persistent VA were less likely to visit an emergency department with epilepsy (hazard ratio, 0.37; 95% confidence interval, 0.09-1.09). CONCLUSIONS: In a population-based study of individuals with CD, persisting VA on follow-up biopsy was associated with reduced future risk of developing epilepsy but did not influence emergency epilepsy-related hospital admissions. The mechanism as to why persistent VA confers this benefit requires further exploration.

Long-term care for patients with coeliac disease in the UK: a review of the literature and future directions.

Coeliac disease is a common digestive disorder that affects 1% of adults. It is characterised by mucosal damage of the small intestine caused by dietary gluten. The main treatment for coeliac disease is a lifelong gluten-free diet, which can reduce morbidity and mortality and also improve quality of life. Despite the benefits, adhering to this diet is often challenging, with patients often struggling to sustain dietary restriction. Structured follow-up for coeliac disease is recommended in international guidelines for improving adherence and for detecting complications;however, uncertainty exists concerning exactly who should be administering this follow-up care. Here, we undertake a review of the current approaches described in the literature to follow-up patients with coeliac disease, and assess the efficacy of these differing models. We also explore future directions for the care of these patients in the context of the UK National Health Service (a publicly funded healthcare system). Although the focus of this review pertains to follow-up within the UK healthcare system, these problems are recognised to be international, and so the findings of our review are likely to be of interest to all healthcare professionals seeing and managing patients with coeliac disease.

Changing trends in the UK management of upper GI bleeding: is there evidence of reduced UK training experience?

OBJECTIVE: The aim of this study was to evaluate UK trainee experience in endoscopy for acute upper gastrointestinal bleeding (AUGIB). METHODS: Data was prospectively collected from all patients presenting to South Yorkshire Hospitals with AUGIB from September 2011 to December 2011 and compared with data from 1996. Concurrently, all gastroenterology trainees registered with the British Society of Gastroenterology were invited to respond to a web-based questionnaire regarding their experience in AUGIB management. RESULTS: 77% (589/766) of the patient cohort underwent endoscopy for AUGIB; 15% (90/589) were performed by trainees. 7.2% (9/125) of the out of hours endoscopy case load was performed by trainees; all were low-risk or medium-risk cases (pre-endoscopy Rockall score ≤4). During the study period, dual therapy was delivered by a trainee on only four occasions. Comparison with the 1996 cohort demonstrated a marked reduction in the number of trainee performed endoscopies (76% vs 15%; p<0.001). Questionnaires were returned by 51% (245/478) of British Society of Gastroenterology trainees. 81% (198/245) thought that <10% of the gastroscopies they had performed involved therapeutic intervention. 23% (57/245) felt they would not be competent in AUGIB endoscopy by completion of specialty training. CONCLUSIONS: This study demonstrates the decline over time in trainee experience in AUGIB endoscopy. It also highlights a lack of trainee exposure to more challenging cases, out of hours endoscopy and therapeutic procedures. Furthermore, trainees are concerned that a level of competency may not be attained during specialty training. We advocate reviewing UK endoscopic training provision for AUGIB to ensure that experienced endoscopists are produced to meet future service needs.

Correlation of visual analogue scale foot and ankle (VAS-FA) to AOFAS score in malleolar fractures using Indian language questionnare.

BACKGROUND: Visual analogue scale foot and ankle (VAS-FA score) is a new score, validated in previous studies, but never compared to AOFAS score. OBJECTIVE: Analysis of the two scores using Indian language questionnaire. METHODS: Fifty patients with Malleolar fractures were assessed for functional outcome, time for calculation of scores, difficulty in correlation and comprehension of the questionnaire, in Malayalam language. The score parameters were compared by SSPSS. RESULTS: There was similarity in pattern of score values in both systems but also a difference between values in each category, with VAS-FA having lower values, reflecting its efficacy. There was significant correlation, similar sensitivity and agreement between the scoring systems. VAS-FA correlated better with patient's outcome and required less time for assessment. CONCLUSION: This study shows that Indian language VAS-FA has a similar pattern of extracting scores as AOFAS and can be an efficient tool in ankle outcome assessment in Indian patients.

Velopharyngeal incompetence in patients with cleft palate, flexible video pharyngoscopy and perceptual speech assessment: a correlational pilot study.

OBJECTIVES: To assess the role of video endoscopy in evaluating velopharyngeal incompetence and investigate a possible relationship between velopharyngeal incompetence type and speech defect in cleft palate patients. METHODS: A prospective study of 28 pre- or post-operative cleft palate patients with speech defects who attended Plastic Surgery-Cleft Palate and ENT out-patient clinics was performed. The velar defect type was determined using a flexible endoscope and findings were video recorded. Speech pathology was assessed using the cleft palate audit protocol for speech. RESULTS: A significant, clinically relevant relationship was noted between the perceived characteristics of hypernasality and velopharyngeal insufficiency type. Hypernasal speech was a definite clinical indicator of velopharyngeal incompetence, and the type 1 velopharyngeal defect was most common. Type 1 velopharyngeal coronal-type dysfunction was strongly associated with hypernasality (p < 0.05). When speech substitution was noted, type 2 velopharyngeal (or sagittal) incompetence could be predicted (p < 0.05). CONCLUSION: In the management of cleft palate patients, it is important that surgical correction of the defect and achieving velopharyngeal competency for speech are performed simultaneously. Pre-operative velopharyngeal endoscopy with speech assessment will define the anatomical and functional bases for velopharyngeal correction and assist in planning and tailoring the pharyngeal flap.

Serological testing for coeliac disease in Type 1 diabetes mellitus: is immunoglobulin A level measurement necessary?

AIMS: Immunoglobulin A (IgA) measurement is advocated when case finding for coeliac disease in patients with Type 1 diabetes mellitus. Currently, there is a paucity of contemporary studies assessing IgA deficiency in Type 1 diabetes. This study evaluates the prevalence of IgA deficiency in individuals with Type 1 diabetes, compared with patients with coeliac disease and control subjects. In addition, we evaluate whether routine IgA measurement is justifiable when case finding for coeliac disease in patients with Type 1 diabetes. METHODS: All patients were assessed using IgA endomysial antibodies, IgA anti-tissue transglutaminase antibodies and total IgA levels. Altogether, 2434 individuals were tested: 1000 patients with Type 1 diabetes, 234 patients with coeliac disease and 1200 population control subjects. Definitive IgA deficiency was defined as total IgA levels < 0.07 g/l. RESULTS: The prevalence of IgA deficiency was significantly more common in patients with Type 1 diabetes (0.9%, n = 9/1000; P = 0.036) and coeliac disease (1.29%, n = 3/234; P = 0.041) when compared with population control subjects (prevalence of 0.17%, 2/1200). No statistical difference between Type 1 diabetes and coeliac disease for IgA deficiency was identified (P = 0.87). Of patients in the group with Type 1 diabetes, 3.3% (33/1000) had coeliac disease, and of those only one patient had IgA deficiency leading to an antibody-negative presentation. Both IgA-deficient individuals within the population control subjects had normal duodenal biopsies and no relevant symptoms. CONCLUSIONS: IgA deficiency is more common in Type 1 diabetes compared with population control subjects. Despite this, very few individuals with Type 1 diabetes and IgA deficiency appear to have villous atrophy on biopsy. These outcomes question the practice of routine IgA measurement when case finding for coeliac disease in patients with Type 1 diabetes.

Managing patients with gastrostomy tubes in the community: can a dedicated enteral feed dietetic service reduce hospital readmissions?

BACKGROUND/OBJECTIVES: Post-gastrostomy complications range from 8 to 30%. These complications often occur following discharge into the community and may result in hospital readmission. Our unit previously reported a readmission rate of 23% in 6 months. There is a paucity of data evaluating community gastrostomy management. We therefore aimed to evaluate the benefits of a dedicated dietetic home enteral feed (HEF) team. SUBJECTS/METHODS: Demographic data, gastrostomy complications, readmission rates and HEF team input was prospectively collected from a cohort of discharged gastrostomy patients over a 1-year period and comparisons made with a similar historical cohort. RESULTS: A total of 371 complications were encountered in 313 gastrostomy patients during this period, with the commonest complication being over-granulated stoma sites (27%). Of these, 227 hospital admissions were avoided because of direct actions taken by the HEF team. Fifty-nine gastrostomy patients were admitted to the hospital, of which only seven (12%) were specifically for gastrostomy-related problems. Introduction of the HEF team significantly reduced gastrostomy-related hospital readmissions from 23 to 2% (P = 0.0001). CONCLUSION: Although patients with gastrostomies may need attention to a variety of complex medical problems, many encounter problems specifically related to their gastrostomy after discharge. This is the largest prospective study demonstrating how dietitians trained in gastrostomy aftercare may optimize the management of gastrostomy complications and reduce unnecessary hospital readmissions.

Bilateral, spontaneous cerebrospinal fluid rhinorrhoea: endoscopic, uninasal, trans-septal approach for simultaneous closure.

BACKGROUND: Bilateral, spontaneous cerebrospinal fluid rhinorrhoea is extremely rare, with only one previous case report (this patient developed contralateral cerebrospinal fluid leakage four years after successful endoscopic repair). We present the first English-language report of simultaneous, bilateral, spontaneous cerebrospinal fluid rhinorrhoea. OBJECTIVE: To recommend a simple alternative endoscopic technique for simultaneous closure of bilateral, spontaneous cerebrospinal fluid rhinorrhoea. CASE REPORT: A 47-year-old woman presented with recent onset of bilateral, spontaneous cerebrospinal fluid rhinorrhoea, a recent history suggestive of meningitis, and a past history of pneumococcal meningitis. Bony defects on both sides of the cribriform plate were closed endoscopically in the same anaesthetic session, via a uninasal, trans-septal approach, enabling both leakage sites to be sealed simultaneously. CONCLUSION: In cases of bilateral, spontaneous cerebrospinal fluid rhinorrhoea, uninasal, trans-septal endoscopic repair is a simple and effective technique for simultaneous closure of cerebrospinal fluid leakage.

Modified endotracheal tube: emergency alternative to paediatric tracheostomy tube.

BACKGROUND: In an emergency, the non-availability of a conventional paediatric tracheostomy tube is a therapeutic challenge for the attending surgeon. OBJECTIVE: To describe a simple alternative to a paediatric tracheostomy tube for use in an emergency situation. METHOD: Case report of a 14-year-old boy who developed tracheomalacia following partial cricotracheal resection for subglottic stenosis. As a suitably sized tracheostomy tube (with a long narrow segment) was not available, an endotracheal tube was modified and used successfully. Details of the modification, and a relevant literature review, are also discussed. CONCLUSION: In the paediatric age group, when an appropriately sized tracheostomy tube is not available, a modified endotracheal tube is a simple temporary alternative; this may be especially useful in an emergency.

Neonatal screening for hearing loss: pilot study from a tertiary care centre.

Many developed countries have well established universal neonatal hearing screening programs. In India, the viability of such a program, in an already overburdened health system is indeed a challenge. This cross sectional study was undertaken to evaluate the possible burden of hearing loss among neonates born at a tertiary care hospital in Southern India. Five hundred neonates were screened with automated distortion product otoacoustic emission (aDPOAE) for hearing loss, 9.2% of whom had one or more high risk factors. Although 6.4% had hearing loss at initial assessment, only 1.6% had hearing loss on retesting with aDPOAE. Retesting with OAE before an automated Auditory brainstem response (aABR) helped to exclude patients without hearing loss. The frequency of moderate to moderately severe hearing loss in this study was 0.6%. This pilot study underscores the importance of the introduction of screening for congenital deafness in specialized centers in India, despite its challenges.