Declining Use of Corticosteroids for Crohn's Disease Has Implications for Study Recruitment: Results of a Pilot Randomized Controlled Trial.

BACKGROUND: Corticosteroids (CS) have been used extensively to induce remission in Crohn's disease (CD); however, they are associated with severe side effects. We hypothesized that the administration of an exclusive enteral nutrition (EEN) formula to CS would lead to increased CD remission rates and to decreased CS-related adverse events. We proposed to undertake a pilot study comparing EEN and CS therapy to CS alone to assess decrease symptoms and inflammatory markers over 6 weeks. AIM: The overall aim was to assess study feasibility based on recruitment rates and acceptability of treatment in arms involving EEN. METHODS: The pilot study intended to recruit 100 adult patients with active CD who had been prescribed CS to induce remission as part of their care. The patients were randomized to one of three arms: (i) standard-dose CS; (ii) standard-dose CS plus EEN (Modulen 1.5 kcal); or (iii) short-course CS plus EEN. RESULTS: A total of 2009 CD patients attending gastroenterology clinics were screened from October 2018 to November 2019. Prednisone was prescribed to only 6.8% (27/399) of patients with active CD attending outpatient clinics. Of the remaining 372 patients with active CD, 34.8% (139/399) started or escalated immunosuppressant or biologics, 49.6% (198/399) underwent further investigation and 8.8% (35/399) were offered an alternative treatment (e.g., antibiotics, surgery or investigational agents in clinical trials). Only three patients were enrolled in the study (recruitment rate 11%; 3/27), and the study was terminated for poor recruitment. CONCLUSION: The apparent decline in use of CS for treatment of CD has implications for CS use as an entry criterion for clinical trials.

Evaluation of routine postoperative chest X-rays in the management of the cardiac surgical patient.

OBJECTIVES: To evaluate the role of routine chest X-rays in the management of patients post cardiac surgery. METHODS: 340 adult patients undergoing cardiac surgery were studied in three consecutive groups (A, B, C) of 100 patients each. Forty patients were excluded due to the intensive care stay greater than 36 h (n = 35), or early mortality within 36 h (n = 5). Routine chest X-rays were performed according to different protocols in Groups A and B. In group C there were no routine chest X-rays during the entire postoperative period [corrected]. In all three groups chest X-rays were performed where clinically indicated. Group A had three routine chest X-rays post-operation. Group B had one routine chest X-ray on day 4 post-operation. Group C had chest X-rays only when indicated. The X-rays were evaluated in terms of their assistance value and the resultant number of interventions. RESULTS: The three groups were similar preoperatively for age, sex, preoperative left ventricular function, presence of chronic obstructive airway disease and type of operation performed. The total number of chest X-rays in groups A, B and C were 304, 133 and 36, respectively. The number of chest X-rays leading to interventions were five, four and four in groups A, B and C, respectively. Chest X-rays that helped in management were 36, 28, and 28, respectively, in the same groups. There was no mortality or morbidity attributable to non-performance of routine chest X-ray. CONCLUSIONS: Routine chest X-rays post-cardiac surgery are of very little value and patients are adequately managed by performing chest X-rays only when clinically indicated. There was no increased mortality or morbidity attributed to lack of routine chest X-rays in any of these groups. We recommend performing chest X-rays only when clinically indicated in satisfactorily recovering adult cardiac surgical patients.

Does a bloody tap prevent postdural puncture headache?

The regional anaesthesia records of 274 obstetric patients who had inadvertent dural puncture were reviewed to see whether a bloody dural tap resulted in a lower incidence of postdural puncture headache. No such influence was found.