The impact of loneliness on mental and physical health outcomes: An umbrella review

Loneliness and related constructs associated with isolation are public health problems with increasing prevalence. The aim of this umbrella was to collate and grade evidence analyzing actual and subjective loneliness as a health risk factor. Following prospective registration, a systematic search was conducted in Pubmed, Embase, Scopus, Web of Sciences, psycoINFO and Cochrane Library until August 2023. Systematic reviews assessing the association between actual and subjective loneliness with adverse health outcomes were selected. Risk of bias was evaluated using AMSTAR-2 tool. Data were tabulated and synthesis was narrative. A total of 13 systematic reviews was selected (four included meta-analysis). The methodological quality was critically low in 10 reviews (76.92%) and low in 3 (23.08%). Results showed that loneliness was related to poor well-being and increase the risk of negative mental and physical health. The available data suggested but did not allow the confirmation of a causal association. Most constructs of loneliness seem to be related to mental and physical health conditions. A preventive strategy ought to be recommended, especially for vulnerable populations.

Quality assessment of online patient information on upper gastrointestinal endoscopy using the modified Ensuring Quality Information for Patients tool

INTRODUCTION

Websites and online resources are increasingly becoming patients' main source of healthcare information. It is paramount that high quality information is available online to enhance patient education and improve clinical outcomes. Upper gastrointestinal (UGI) endoscopy is the gold standard investigation for UGI symptoms and yet little is known regarding the quality of patient orientated websites. The aim of this study was to assess the quality of online patient information on UGI endoscopy using the modified Ensuring Quality Information for Patients (EQIP) tool.

METHODS

Ten search terms were employed to conduct a systematic review. for each term, the top 100 websites identified via a Google search were assessed using the modified EQIP tool. High scoring websites underwent further analysis. Websites intended for professional use by clinicians as well as those containing video or marketing content were excluded.

FINDINGS

A total of 378 websites were eligible for analysis. The median modified EQIP score for UGI endoscopy was 18/36 (interquartile range: 14-21). The median EQIP scores for the content, identification and structure domains were 8/18, 1/6 and 9/12 respectively. Higher modified EQIP scores were obtained for websites produced by government departments and National Health Service hospitals (p=0.007). Complication rates were documented in only a fifth (20.4%) of websites. High scoring websites were significantly more likely to provide balanced information on risks and benefits (94.6% vs 34.4%, p<0.001).

CONCLUSIONS

There is an immediate need to improve the quality of online patient information regarding UGI endoscopy. The currently available resources provide minimal information on the risks associated with the procedure, potentially hindering patients' ability to make informed healthcare decisions.

Quality indicators for the diagnosis and treatment of breast cancer integrated assistance: A critical appraisal

INTRODUCTION

Quality indicators (QIs) are essential for adequate control of the health care management process, recognizing areas of improvement and providing solutions. We aimed to evaluate the Integrated Breast Cancer (BC) Care Process QIs.

METHODS

We studied 487 consecutive BC cases diagnosed from November 1st, 2013, to November 30th, 2019, in a Spanish healthcare area, and we estimated the associated QIs.

RESULTS

Four indicators did not meet the standards and were analysed based on related sociodemographic and clinical variables. The surgical delay after a multidisciplinary team discussion (mean 64%, IQR 59.6-68.5) was lower in elder people (p=0.027), and early histological grades (p=0.019) and stages (p=0.008). The adjuvant treatment delay (mean 55.7%, IQR 51.1-60.3) was lower in advance stages (p=0.002) and when there was no reoperation (p=0.001). The surgical delay after inclusion (mean 83.2%, IQR 79.3-87.2) was lower in early histological grades (p=0.048). The immediate reconstruction (mean 42.3%, IQR 34.0-50.5) reached 72.3% in young women compared to 11.8% in older than 70 years (p=0.001) and it was higher in early stages (45.3% vs 36.2%; p=0.049).

CONCLUSION

The study of QIs evaluated their compliance and analysed the variables influencing them to propose improvement measures. Not all the indicators were equally valuable. Some depended on the available resources, and others on the mix of patients or complementary treatments. It would be essential to identify the specific target populations to estimate the indicators or provide standards stratified by the related variables.

Obesity and female sexual dysfunctions: A systematic review of prevalence with meta-analysis

Obesity represents a major global health challenge. Female sexual dysfunctions have a negative impact on quality of life and overall health balance. A higher rate of female sexual dysfunctions in obese women has been suggested. This systematic review summarized the literature on female sexual dysfunction prevalence in obese women. The review was registered (Open Science Framework OSF.IO/7CG95) and a literature search without language restrictions was conducted in PubMed, Embase and Web of Science, from January 1990 to December 2021. Cross-sectional and intervention studies were included, the latter if they provided female sexual dysfunction rate data in obese women prior to the intervention. For inclusion, studies should have used the female sexual function index or its simplified version. Study quality was assessed to evaluate if female sexual function index was properly applied using six items. Rates of female sexual dysfunctions examining for differences between obese vs class III obese and high vs low quality subgroups were summarized. Random effects meta-analysis was performed, calculating 95% confidence intervals (CI) and examining heterogeneity with I2 statistic. Publication bias was evaluated with funnel plot. There were 15 relevant studies (1720 women participants in total with 153 obese and 1567 class III obese women). Of these, 8 (53.3%) studies complied with >4 quality items. Overall prevalence of female sexual dysfunctions was 62% (95% CI 55-68%; I2 85.5%). Among obese women the prevalence was 69% (95% CI 55-80%; I2 73.8%) vs 59% (95% CI 52-66%; I2 87.5%) among those class III obese (subgroup difference p=0.15). Among high quality studies the prevalence was 54% (95% CI 50-60%; I2 46.8%) vs 72% (95% CI 61-81%; I2 88.0%) among low quality studies (subgroup difference p=0.002). There was no funnel asymmetry. We interpreted that the rate of sexual dysfunctions is high in obese and class III obese women. Obesity should be regarded as a risk factor for female sexual dysfunctions.

[Longitudinality in Primary Care and Polypharmacy. A Systematic Review]

The aim of this work was to collect, evaluate and interpret the available evidence on the relationship between continuity in primary care (i.e., longitudinality), and the prevalence of polypharmacy and its associated problems. Following the PRISMA reporting statement, we carried out a systematic review of the literature searching PubMed and Scopus databases. The screening of titles and summaries and the review of references carried out independently by two authors detected 16 works of potential interest, of which 4 were discarded after the independent review of all the originals because they did not meet inclusion criteria. The 12 papers selected studied the relationship between Longitudinality, measured with various quantitative indices, and the rate of polypharmacy or various associated problems, such as duplicate drugs, inadequate prescriptions or drug interactions. They all showed a significant relationship, often strong (RR>2 or<0.5), between longitudinality indicators and the various dependent variables. Although our knowledge could be improved by prospective studies that more directly evaluate longitudinality and its impact on problems due to excess medication, with the existing evidence, we can affirm that the protection and promotion of continuity in primary care can be a key element for the control of polypharmacy and associated problems.

Evidence-based medicine needs patient and public involvement to remain relevant: A proposal for a new curriculum

INTRODUCTION

Public partnerships, a route to sharing expertise, networks and resources anchored in the United Nations Sustainable Development Goals, has been championed by multiple stakeholders.

OBJECTIVE

To propose a new evidence-based medicine (EBM) curriculum for harnessing patient and public expertise to ensure that EBM teaching and learning can become more relevant and impactful.

METHODS

A curriculum development group comprising of EBM teachers, patient and public involvement representatives, clinicians, clinical epidemiologists, public health experts and educationalists, with experience of delivering and evaluating face-to-face and online EBM courses across many countries and continents, prepared a new EBM course.

RESULTS

A student-centred, problem-based and clinically integrated course for teaching and learning EBM was developed. In the spirit of shared decision-making, practitioners can learn to support patients, articulate their perspectives, recognise the need for their contribution and ensure community involvement when generating and applying evidence. With end users in mind, the application of research findings, delivery of care and EBM effectiveness in the workplace would carry increased priority.

CONCLUSIONS

Embracing patients as EBM collaborators can help deliver cognitive diversity and inspire different ways of thinking and working. Adopting the proposed approach in EBM education lays the foundations for a joint practitioner-patient partnership to ask, acquire, appraise and apply EBM in a more holistic context which will strengthen the EBM proposition.

[Systematic reviews in five steps: V. Interpreting the findings]

The last step in a systematic review is the interpretation of the findings. The important findings need to be explicitly identified. A level of strength of evidence should be assigned to support each key finding, based on factors such as study design, methodological quality and risk of publication bias. Variations in the magnitude of associations observed also need to be explored. The aim of this analysis is to determine in which clinical groups the intervention is more or less effective, the impact of exposure is greater or lesser, or a diagnostic test is more useful. At this stage, for better interpretation of the findings, the magnitude of the association can be estimated either globally or stratified according to the characteristics of the participants. All this is helpful in formulating recommendations for clinical practice and policy.

Lifestyle interventions in women with polycystic ovary syndrome: A scoping systematic review of randomised evidence

OBJECTIVE

Lifestyle interventions (LSI) are recommended as first-line treatment for polycystic ovary syndrome (PCOS), yet the strength of evidence underpinning LSIs effectiveness remains unclear. We systematically reviewed the literature on LSIs in PCOS, evaluated evidence quality and summarised recommendations for clinical practice.

MATERIAL AND METHODS

We searched MEDLINE, EMBASE and CENTRAL for all randomised trials evaluating any LSI in PCOS until April 2021. We extracted data on the LSIs' characteristics, dietary composition, duration, implementation, compliance assessment, and reported outcomes. We evaluated the evidence gap using a network-map of evaluated interventions.

RESULTS

We screened 550 citations and included 79 trials (n=4659 women). Most trials were from high-income countries (57/79, 72%) over a decade ago (48/79, 61%) and enrolled obese/overweight women (57/77, 74%). BMI was the commonest reported outcome (58/79, 73%), followed by weight (49/79, 62%), and testosterone (45/79, 57%). More than half of the trials had high-risk of randomisation (51/79, 65%) and allocation bias (49/79, 62%). Only 27 were registered prospectively (27/79, 34%). Two-thirds evaluated a dietary intervention (70/79, 88%), most commonly a hypocaloric diet (32/70, 46%); nineteen evaluated a combined dietary with pharmacological intervention (19/79, 24%), six combined diet with physical or behavioural intervention (6/79, 8%), and only one trial included all four elements.

CONCLUSIONS

Evidence on LSI in PCOS is of poor quality with high variations in trial design, comparisons, and outcome reporting. Hypocaloric diet is the most commonly recommended LSI intervention for primary care. Future trials are needed to evaluate pragmatic and simple LSIs in robust multicenter studies.

PROSPERO REGISTRATION

CRD42020186571.

Effects of progressive resistance training in individuals with type 2 diabetic polyneuropathy: a randomised assessor-blinded controlled trial

AIMS/HYPOTHESIS

The aim of this study was to evaluate the effects of progressive resistance training (PRT) on muscle strength, intraepidermal nerve fibre density (IENFD) and motor function in individuals with type 2 diabetic polyneuropathy (DPN) and to compare potential adaptations to those of individuals with type 2 diabetes without DPN and healthy controls.

METHODS

This was an assessor-blinded trial conducted at the Neurology department, Aarhus University Hospital. Adults with type 2 diabetes, with and without DPN and healthy control participants were randomised to either supervised PRT or non-PRT for 12 weeks. Allocation was concealed by a central office unrelated to the study. The co-primary outcomes were muscle strength in terms of the peak torque of the knee and ankle extensors and flexors, and IENFD. Secondary outcome measures included the 6 min walk test (6MWT), five-time sit-to-stand test (FTSST) and postural stability index obtained by static posturography.

RESULTS

A total of 109 individuals were enrolled in three groups (type 2 diabetes with DPN [n = 42], type 2 diabetes without DPN [n = 32] and healthy control [n = 35]). PRT resulted in muscle strength gains of the knee extensors and flexors in all three groups using comparative analysis (DPN group, PRT 10.3 ± 9.6 Nm vs non-PRT -0.4 ± 8.2 Nm; non-DPN group, PRT 7.5 ± 5.8 Nm vs non-PRT 0.6 ± 8.8 Nm; healthy control group, PRT 6.3 ± 9.0 Nm vs non-PRT -0.4 ± 8.4 Nm; p<0.05, respectively). Following PRT the DPN group improved the 6MWT (PRT 34.6 ± 40.9 m vs non-PRT 2.7 ± 19.6 m; p=0.001) and the FTSST (PRT -1.5 ± 2.2 s vs non-PRT 1.5 ± 4.6 s; p=0.02). There was no change in IENFD following PRT in any of the groups.

CONCLUSIONS/INTERPRETATION

PRT improved muscle strength of the knee extensors and flexors and motor function in individuals with type 2 diabetic polyneuropathy at levels comparable with those seen in individuals with diabetes without DPN and healthy control individuals, while no effects were observed in IENFD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03252132 FUNDING: Research reported in this paper is part of the International Diabetic Neuropathy Consortium (IDNC) research programme, supported by a Novo Nordisk Foundation Challenge Program grant (grant no. NNF14OC0011633) and Aarhus University.

Inguinal hernia repair: a systematic analysis of online patient information using the Modified Ensuring Quality Information for Patients tool

BACKGROUND

Online resources are a fundamental source of healthcare information due to the increasing popularity of the internet. Ensuring accuracy and reliability of websites is crucial to improving patient education and enhancing patient outcomes. Inguinal hernia repair is the most commonly performed general surgical procedure worldwide. This study analyses the quality of online patient information about inguinal hernia repair using the Modified Ensuring Quality Information for Patients (EQIP) tool.

METHODS

A systematic review of online information on inguinal hernia repair was conducted using four search terms: 'inguinal hernia', 'groin hernia', 'inguinal hernia repair' and 'inguinoscrotal hernia'. The top 100 websites for each term identified using Google were assessed using the modified EQIP tool (score 0-36). Websites for the paediatric population or intended for medical professional use were excluded from analysis.

FINDINGS

A total of 142 websites were eligible for analysis, 52.8% originating from the UK. The median EQIP score for all websites was 17/36 (interquartile range 14-21). The median EQIP scores for content, identification and structure were 8/18, 2/8 and 8/12, respectively. Complications of inguinal hernia repair were included in 46.5% of websites, with only 9.2% providing complication rates and 14.1% providing information on how complications are handled.

CONCLUSION

This study highlights that the current quality of online patient information on inguinal hernia repair is poor, with minimal information available on complications, hindering patients' ability to make informed decisions regarding their healthcare. To improve patient education, there is an immediate need for improved quality online resources to meet international standards.

Early cryoprecipitate transfusion versus standard care in severe postpartum haemorrhage: a pilot cluster-randomised trial

There is a lack of evidence evaluating cryoprecipitate transfusion in severe postpartum haemorrhage. We performed a pilot cluster‐randomised controlled trial to evaluate the feasibility of a trial on early cryoprecipitate delivery in severe postpartum haemorrhage. Pregnant women (>24 weeks gestation), actively bleeding within 24 h of delivery and who required at least one unit of red blood cells were eligible. Women declining transfusion in advance or with inherited clotting deficiencies were not eligible. Four UK hospitals were randomly allocated to deliver either the intervention (administration of two pools of cryoprecipitate within 90 min of first red blood cell unit requested plus standard care), or the control group treatment (standard care, where cryoprecipitate is administered later or not at all). The primary outcome was the proportion of women who received early cryoprecipitate (intervention) vs. standard care (control). Secondary outcomes included consent rates, acceptability of the intervention, safety outcomes and preliminary clinical outcome data to inform a definitive trial. Between March 2019 and January 2020, 199 participants were recruited; 19 refused consent, leaving 180 for analysis (110 in the intervention and 70 in the control group). Adherence to assigned treatment was 32% (95%CI 23–41%) in the intervention group vs. 81% (95%CI 70–90%) in the control group. The proportion of women receiving cryoprecipitate at any time‐point was higher in the intervention (60%) vs. control (31%) groups; the former had fewer red blood cell transfusions at 24 h (mean difference −0.6 units, 95%CI −1.2 to 0); overall surgical procedures (odds ratio 0.6, 95%CI 0.3–1.1); and intensive care admissions (odds ratio 0.4, 95%CI 0.1–1.1). There was no increase in serious adverse or thrombotic events in the intervention group. Staff interviews showed that lack of awareness and uncertainty about study responsibilities contributed to lower adherence in the intervention group. We conclude that a full‐scale trial may be feasible, provided that protocol revisions are put in place to establish clear lines of communication for ordering early cryoprecipitate in order to improve adherence. Preliminary clinical outcomes associated with cryoprecipitate administration are encouraging and merit further investigation.

Normative reference values for the dorsal sural nerve derived from a large multicenter cohort

•

We determined reference values for the dorsal sural nerve from a large cohort, aged 21-80.

•

Amplitude and conduction velocity depended on both age and height.

•

We provide formulas for reference limits.

Objectives

Dorsal sural nerve conduction studies (NCS) may increase the sensitivity for the diagnosis of polyneuropathy, but clinical use is limited by a lack of reliable normative reference values in all age-groups. The aim of our study was to develop reference values for the dorsal sural nerve, based on a large multicenter cohort of healthy subjects.

Methods

Bilateral antidromic NCS were performed using standard surface electrodes in 229 healthy subjects (aged 21–80 years; median: 54 years). We assessed the normality of data distribution for amplitudes and conduction velocity (CV) and for their logarithmic (ln) transformation. The effects of age and height were determined using linear regression analysis.

Results

Sensory potentials were present in all subjects. Logarithmically transformed data were normally distributed. Age² and height were most significantly associated with amplitude, and age and height with CV, respectively. There was no significant side-difference. Mean amplitudes (right and left) were 4.8 and 4.9 μV and mean CV 46.7 and 46.9 m/s. Reference limits were e ^{(3.712515 – 0.0000956 * age2 – 0.0115883 * height ± 1.96 * 0.51137)} for amplitude and e ^{(4.354374 – 0.0021081 * age – 0.0023354 * height ± 1.96 * 0.11161)} for CV.

Conclusions

Dorsal sural nerve NCS are robust and have well defined normative limits.

Significance

The findings provide a basis for more sensitive NCS in clinical practice and future studies of the diagnostic accuracy of NCS in polyneuropathy.

Falls in individuals with type 2 diabetes; a cross-sectional study on the impact of motor dysfunction, postural instability and diabetic polyneuropathy

AIM

To estimate the incidence of falls in individuals with type 2 diabetes compared to healthy controls and to describe the characteristics of fallers with type 2 diabetes in relation to motor dysfunction, postural instability and diabetic polyneuropathy (DPN).

METHODS

This is a cross-sectional study of individuals with type 2 diabetes with DPN (n = 54), without DPN (n = 38) and healthy controls (n = 39). Falls were recorded within the preceding year. DPN was defined by clinical scores and nerve conduction studies. Motor function was assessed by a 6-min walk test (6 MWT), five-time sit-to-stand test (FTSST) and isokinetic dynamometry at the non-dominant ankle and knee. An instability index (ST) was measured using static posturography. Univariate and bivariate descriptive statistics were used for group comparisons.

RESULTS

Compared with healthy controls, individuals with diabetes had a higher incidence of falls 36%, (n = 33) versus 15%, (n = 6), p = 0.02. There were no differences in falls when comparing individuals with and without DPN. Fallers had an impaired 6 MWT versus non-fallers (450 ± 153 m vs. 523 ± 97 m respectively), a slower FTSST (11.9 ± 4.2 s vs. 10.3 ± 2.9 s respectively) and a higher ST (53 ± 29 vs. 41 ± 17 respectively), p < 0.02 for all.

CONCLUSION

Individuals with type 2 diabetes reported a higher number of falls within the preceding year compared to healthy controls, irrespective of the presence of DPN. The main factors associated with falls were increased postural instability, lower walking capacity and slower sit-to-stand movements. The 6 MWT, FTSST and posturography should be considered in future screening programs in identification of individuals at risk for falls.

995 Clinical Outcomes Following Incomplete Colonoscopy

Introduction

Following incomplete colonoscopy (IC) it is reported that there is up to five-fold increased risk of colorectal cancer. Our aim was to determine the final clinical outcome for patients with a prior IC.

Method

A multi-centre retrospective observational study involving three endoscopy units. All consecutive patients having colonoscopy from over 18 months were analysed. Exclusion criteria included IC was due to obstructing cancer, follow up was not performed due to non-attendance at clinic or investigation and incomplete data set. Electronic notes were analysed to determine patient’s final clinical outcome. All patients were followed up for minimum of six months.

Results

Of the 8,490 colonoscopies, 733 (8.6%) were IC. 86 (11.7%) were excluded. Of the 647 included, 469 (72.4%) were females and 473 (73.1%) has further colonic investigations. Secondary investigations were: CT colonography 169 (35.7%), repeat colonoscopy 161 (34.0%), barium enema 95 (20.1%) and others 48 (10.1%). The repeat colonoscopy group achieved a complete colonoscopy in 111 (68.9%) patients. For those who had further investigations 15 (3.2%) had colorectal cancer and 12 (2.5%) has polyps ≥1cm.

Conclusions

There is significant risk of missing colorectal malignancy and large polyps following IC. Further colonic investigations should be carried out in this cohort of patients.

930 Impact of the COVID-19 Pandemic on Higher General Surgical Training – A West of Scotland Experience

Introduction

COVID-19 pandemic has caused significant disruption in all aspects of training. Our aim was to explore the degree of impact caused by the pandemic on higher general surgical trainees.

Method

All higher general surgical trainees in a single UK deanery were invited to participate in an online, voluntary, anonymous survey via SurveyMonkey.

Results

64 (72.7%) of the trainees responded. 39.1% were ST3/4, 29.7% were ST5/6, 20.3% were ST7/8 and 10.9% were out of training (maternity & research). Thirty-five (55.6%) worked in district general hospitals. Forty (68.9%) trainees felt that they had fewer opportunities to be primary surgeon. Forty-two (67.7%) trainees did not have access to laparoscopic simulation trainers. Fifty-two (88.1%) trainees had their courses and 2 (3.4%) had their FRCS part 2 exam postponed. 16 (27.1%) trainees reported they had been off-sick, with a median of 7 days off (range 3-35 days). Thirty-three (55.9%) trainees felt more stressed due to the pandemic and 35 (59.4%) had symptoms of burnout.

Conclusions

The COVID-19 pandemic has had an unprecedented impact on all aspects of higher surgical training. The most noticeable impact has been on the reduction in the confidence in laparoscopic and endoscopic skills.

Sensory and motor axonal excitability testing in early diabetic neuropathy

OBJECTIVE

The aim of the present study was to gain insight into the pathophysiology of diabetic polyneuropathy (DPN) and examine the diagnostic value of sensory and motor axonal excitability testing.

METHODS

One hundred and eleven type 2 diabetics with and without DPN (disease duration: 6.36 ± 0.25 years) and 60 controls were included. All participants received a thorough clinical examination including Michigan Neuropathy Screening Instrument (MNSI) score, nerve conduction studies (NCS), and sensory and motor excitability tests. Patients were compared by the likelihood of neuropathy presence, ranging from no DPN (17), possible/probable DPN (46) to NCS-confirmed DPN (48).

RESULTS

Motor excitability tests showed differences in rheobase and depolarizing threshold electrotonus measures between NCS-confirmed DPN group and controls but no changes in hyperpolarising threshold electrotonus or recovery cycle parameters. Sensory excitability showed even less changes despite pronounced sensory NCS abnormalities. There were only weak correlations between the above motor excitability parameters and clinical scores.

CONCLUSIONS

Changes in excitability in the examined patient group were subtle, perhaps because of the relatively short disease duration.

SIGNIFICANCE

Less pronounced excitability changes than NCS suggest that axonal excitability testing is not of diagnostic value for early DPN and does not provide information on the mechanisms.

Does nosocomial COVID-19 result in increased 30-day mortality? A multi-centre observational study to identify risk factors for worse outcomes in patients with COVID-19

This study aimed to determine whether nosocomial coronavirus disease 2019 (COVID-19) has a worse outcome compared with community-acquired COVID-19. This was a prospective cohort study of all hospitalized patients with confirmed COVID-19 in three acute hospitals on 9th April 2020. Patients were followed-up for at least 30 days. Nosocomial infection was defined as a positive swab after 7 days of admission. In total, one hundred and seventy-three patients were identified, and 19 (11.0%) had nosocomial infection. Thirty-two (18.5%) patients died within 30 days (all cause) of a positive swab test; there were no significant differences in 30-day all-cause mortality rates between the three groups (i.e. patients admitted with suspected COVID-19, patients with incidental COVID-19 and patients with nosocomial COVID-19): 21.1% vs 17.6% vs 21.6% (P=0.755). Nosocomial COVID-19 is not associated with increased mortality compared with community-acquired COVID-19.

Myths and conspiracy theories on vaccines and COVID-19: Potential effect on global vaccine refusals

The current coronavirus disease 2019 (COVID-19) pandemic is one of the international crises and researchers are working collaboratively to develop a safe and effective COVID-19 vaccine. The World Health Organization recognizes vaccine hesitancy as the world's top threat to public health safety, particularly in low middle-income countries. Vaccine hesitancy can be due to a lack of knowledge, false religious beliefs, or anti-vaccine misinformation. The current situation regarding anti-vaccine beliefs is pointing towards dreadful outcomes. It raises the concern that will people believe and accept the new COVID-19 vaccines despite all anti-vaccine movements and COVID-19-related myths and conspiracy theories. This review discusses the possible detrimental impacts of myths and conspiracy theories related to COVID-19 and vaccine on COVID-19 vaccine refusals as well as other vaccine programs.

MRI of Skeletal Muscles in Participants with Type 2 Diabetes with or without Diabetic Polyneuropathy

BackgroundDiabetic polyneuropathy (DPN) is associated with loss of muscle strength. MRI including diffusion-tensor imaging (DTI) may enable detection of muscle abnormalities related to type 2 diabetes mellitus (DM2) and DPN.PurposeTo assess skeletal muscle abnormalities in participants with DM2 with or without DPN by using MRI.Materials and MethodsThis prospective cross-sectional study included participants with DM2 and DPN (DPN positive), participants with DM2 without DPN (DPN negative), and healthy control (HC) participants enrolled between August 2017 and June 2018. Muscle strength at the knee and ankle was determined with isokinetic dynamometry. MRI of the lower extremities included the Dixon sequence, multicomponent T2 mapping, and DTI calculated fat fractions (FFs), T2 relaxation of muscle (T2_water), fractional anisotropy (FA), and diffusivity (mean, axial, and radial). One-way analysis of variance and Tukey honestly significant difference were applied for comparison between groups, and multivariate regression models were used for association between MRI parameters, nerve conduction, strength, and body mass index (BMI).ResultsTwenty participants with DPN (mean age, 65 years ± 9 [standard deviation]; 70% men; mean BMI, 34 kg/m² ± 5), 20 participants without DPN (mean age, 64 years ± 9; 55% men; mean BMI, 30 kg/m² ± 6), and 20 HC participants (mean age, 61 years ± 10; 55% men; mean BMI, 27 kg/m² ± 5) were enrolled in this study. Muscle strength adjusted for age, sex, and BMI was lower in participants with DPN than in DPN-negative and HC participants in the upper and lower leg (plantar flexors [PF], 62% vs 78% vs 89%; P < .001; knee extensors [KE], 73% vs 95% vs 93%; P < .001). FF was higher in leg muscle groups of participants with DPN than in DPN-negative and HC participants (PF, 20% vs 10% vs 8%; P < .001; KE, 13% vs 8% vs 6%; P < .001). T2_water was prolonged in leg muscle groups of participants with DPN when compared with HC participants (PF, 33 msec vs 31 msec; P < .001; KE, 32 msec vs 31 msec; P = .002) and in the lower leg when compared with participants without DPN (PF, 33 msec vs 32 msec; P = .03). In multivariate regression models, strength was associated with FA (b = -0.0004), T2_water (b = -0.03 msec), and FF (b = -0.1%) at thigh level (P < .001). Furthermore, FA (b = -0.007), T2_water (b = -0.53 msec), and FF (b = -4.0%) were associated with nerve conduction at calf level (P < .001).ConclusionMRI of leg muscle groups revealed fat accumulation, differences in water composition, and structural changes in participants with type 2 diabetes mellitus and neuropathy. Abnormalities were most pronounced in the plantar flexors.© RSNA, 2020Online supplemental material is available for this article.See also the editorial by Sneag and Tan in this issue.

MScanFit motor unit number estimation and muscle velocity recovery cycle recordings in diabetic polyneuropathy

OBJECTIVE

Motor Unit Number Estimation (MUNE) methods may be valuable in tracking motor unit loss in diabetic polyneuropathy (DPN). Muscle Velocity Recovery Cycles (MVRCs) provide information about muscle membrane properties. This study aimed to examine the utility of the MScanFit MUNE in detecting motor unit loss and to test whether the MVRCs could improve understanding of DPN pathophysiology.

METHODS

Seventy-nine type-2 diabetic patients were compared to 32 control subjects. All participants were examined with MScanFit MUNE and MVRCs in anterior tibial muscle. Lower limb nerve conduction studies (NCS) in peroneal, tibial and sural nerves were applied to diagnose large fiber neuropathy.

RESULTS

NCS confirmed DPN for 47 patients (DPN + ), with 32 not showing DPN (DPN-). MScanFit showed significantly decreased MUNE values and increased motor unit sizes, when comparing DPN + patients with controls (MUNE = 71.3 ± 4.7 vs 122.7 ± 3.8), and also when comparing DPN- patients (MUNE = 103.2 ± 5.1) with controls. MVRCs did not differ between groups.

CONCLUSIONS

MScanFit is more sensitive in showing motor unit loss than NCS in type-2 diabetic patients, whereas MVRCs do not provide additional information.

SIGNIFICANCE

The MScanFit results suggest that motor changes are seen as early as sensory, and the role of axonal membrane properties in DPN pathophysiology should be revisited.

Accuracy of imaging modalities for adnexal torsion: a systematic review and meta-analysis

BACKGROUND

Adnexal torsion (AT), a serious gynaecological emergency, often presents with non-specific symptoms leading to delayed diagnosis.

OBJECTIVE

To compare the test accuracy of ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) to diagnose AT.

SEARCH STRATEGY

We searched EMBASE, MEDLINE and Cochrane CENTRAL until December 2019.

SELECTION CRITERIA

Studies reporting on the accuracy of any imaging modality (Index Test) in female patients (paediatric and adult) suspected of AT compared with surgical diagnosis and/or standard clinical/radiological follow-up period until resolution of symptoms (Reference Standard).

DATA COLLECTION AND ANALYSIS

We assessed study quality using QUADAS-2. We conducted test accuracy meta-analysis using a univariate model or a hierarchical model.

MAIN RESULTS

We screened 3836 citations, included 18 studies (1654 women, 665 cases), and included 15 in the meta-analyses. Ultrasound pooled sensitivity (n = 12, 1187 women) was 0.79 (95% CI 0.63-0.92) and specificity was 0.76 (95% CI 0.54-0.93), with negative and positive likelihood ratios of 0.29 (95% CI 0.13-0.66) and 4.35 (95% CI 2.03-9.32), respectively. Using Doppler with ultrasound (n = 7, 845 women) yielded similar sensitivity (0.80, 95% CI 0.67-0.93) and specificity (0.88, 95% CI 0.72-1.00). For MRI (n = 3, 99 women), the pooled sensitivity was 0.81 (95% CI 0.63-0.91) and specificity was 0.91 (95% CI 0.80-0.96). A meta-analysis for CT was not possible with two case-control studies and one cohort study (n = 3, 232 women). Its sensitivity range was 0.74-0.95 and specificity was 0.80-0.90.

CONCLUSIONS

Ultrasound has good performance as a first-line diagnostic test for suspected AT. Magnetic resonance imaging could offer improved specificity to investigate complex ovarian morphology, but more evidence is needed.

TWEETABLE ABSTRACT

To investigate adnexal torsion, ultrasound is a good first-line diagnostic test with a pooled sensitivity of 0.79 and specificity of 0.76.

Virtual reality for acute pain in outpatient hysteroscopy: a randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of virtual reality as a distraction technique in the management of acute pain and anxiety during outpatient hysteroscopy.

DESIGN

Parallel group, prospective randomised controlled trial.

SETTING

UK University Hospital.

METHODS

Forty consenting, eligible women were randomised to virtual reality intervention (immersive video content as a distraction method) or standard care during outpatient hysteroscopy from August to October 2018.

MAIN OUTCOME MEASURES

Pain and anxiety outcomes were measured as a numeric rating score (scale 0-10).

RESULTS

Compared with standard care, women with virtual reality intervention experienced less average pain (score 6.0 versus 3.7, mean difference 2.3, 95% CI 0.61-3.99, P = 0.009) and anxiety (score 5.45 versus 3.3, mean difference 2.15, 95% CI 0.38-3.92, P = 0.02).

CONCLUSION

Virtual reality was effective in reducing pain and anxiety during outpatient hysteroscopy in a mixed-methods randomised control trial. Its wide potential role in ambulatory gynaecological procedures needs further evaluation.

TWEETABLE ABSTRACT

Virtual reality can be used as a part of a multimodal strategy to reduce acute pain and anxiety in patients undergoing outpatient hysteroscopy.

Pravastatin for early-onset pre-eclampsia: a randomised, blinded, placebo-controlled trial

Objective

Women with pre‐eclampsia have elevated circulating levels of soluble fms‐like tyrosine kinase‐1 (sFlt‐1). Statins can reduce sFlt‐1 from cultured cells and improve pregnancy outcome in animals with a pre‐eclampsia‐like syndrome. We investigated the effect of pravastatin on plasma sFlt‐1 levels during pre‐eclampsia.

Design

Blinded (clinician and participant), proof of principle, placebo‐controlled trial.

Setting

Fifteen UK maternity units.

Population

We used a minimisation algorithm to assign 62 women with early‐onset pre‐eclampsia (24⁺⁰–31⁺⁶ weeks of gestation) to receive pravastatin 40 mg daily (n = 30) or matched placebo (n = 32), from randomisation to childbirth.

Primary outcome

Difference in mean plasma sFlt‐1 levels over the first 3 days following randomisation.

Results

The difference in the mean maternal plasma sFlt‐1 levels over the first 3 days after randomisation between the pravastatin (n = 27) and placebo (n = 29) groups was 292 pg/ml (95% CI −1175 to 592; P = 0.5), and over days 1–14 was 48 pg/ml (95% CI −1009 to 913; P = 0.9). Women who received pravastatin had a similar length of pregnancy following randomisation compared with those who received placebo (hazard ratio 0.84; 95% CI 0.50–1.40; P = 0.6). The median time from randomisation to childbirth was 9 days (interquartile range [IQR] 5–14 days) for the pravastatin group and 7 days (IQR 4–11 days) for the placebo group. There were three perinatal deaths in the placebo‐treated group and no deaths or serious adverse events attributable to pravastatin.

Conclusions

We found no evidence that pravastatin lowered maternal plasma sFlt‐1 levels once early‐onset pre‐eclampsia had developed. Pravastatin appears to have no adverse perinatal effects.

Tweetable abstract

Pravastatin does not improve maternal plasma sFlt‐1 or placental growth factor levels following a diagnosis of early preterm pre‐eclampsia #clinicaltrial finds.

Pravastatin does not improve maternal plasma sFlt‐1 or placental growth factor levels following a diagnosis of early preterm pre‐eclampsia #clinicaltrial finds.

C-reactive protein level as a predictor of difficult emergency laparoscopic cholecystectomy

Background

Studies focused on C‐reactive protein (CRP) as a marker of difficult laparoscopic cholecystectomy are limited to small case series. The aim of this study was to evaluate the association between preoperative CRP concentration and difficulty of laparoscopic cholecystectomy in patients admitted with a biliary emergency presentation.

Methods

Patients with an emergency admission for biliary disease treated between 2012 and 2017 with a documented preoperative CRP level were analysed. Elective patients and those with other concurrent causes of increased CRP concentration were excluded. The intraoperative difficulty grade was based on the Nassar scale. Statistical analysis was conducted to determine the association of preoperative CRP level with difficulty grading, adjusted for the interval to surgery.

Results

A total of 804 emergency patients were included. The mean preoperative peak CRP level was 64·7 mg/l for operative difficulty grade I, 69·6 mg/l for grade II, 98·2 mg/l for grade III, 217·5 mg/l for grade IV and 193·1 mg/l for grade V, indicating a significant association between CRP concentration and Nassar grade (P < 0·001). Receiver operating characteristic (ROC) curve analysis showed an area under the curve of 0·78 (95 per cent c.i. 0·75 to 0·82), differentiating patients with grade I–III from those with grade IV–V operative difficulty. ROC curve analysis found a cut‐off CRP value of 90 mg/l, with 71·5 per cent sensitivity and 70·5 per cent specificity in predicting operative difficulty of grade IV or V. Logistic regression analysis found preoperative peak CRP level to be predictive of Nassar grade I–III versus grade IV–V operative difficulty, also when adjusted for timing of surgery (odds ratio 5·90, 95 per cent c.i. 2·80 to 12·50).

Conclusion

Raised preoperative CRP levels are associated with greater operative difficulty based on Nassar scale grading.