Evaluating fracture risk in acute ankle sprains: Any news since the Ottawa Ankle Rules? A systematic review

BACKGROUND

Ankle sprain is frequently encountered, both in primary care and in emergency departments. Since 1992, the Ottawa ankle rules (OAR) can assist clinicians in determining whether an X-ray should be performed to exclude a fracture. Several guidelines recommend the use of OAR based on a systematic review from 2003. Ten years later, one can wonder if this recommendation should be changed.

OBJECTIVE

To review systematically the current evidence on the most accurate method to assess the fracture risk after an ankle sprain in adults.

METHODS

A methodical search for systematic reviews, meta-analyses and primary studies was carried out in Medline, Cochrane Database of systematic reviews, Embase, Pedro, CINAHL, Medion and specific guideline search engines. At least two independent researchers performed selection, quality appraisal (with validated checklists) and data extraction.

RESULTS

One systematic review and 21 primary studies were selected. Sensitivity and specificity of the OAR range from 92-100% and from 16-51%, respectively. To improve the OAR specificity, other tools are proposed such as the Bernese ankle rules. Vibrating tuning fork test and ultrasound could be useful in patient with OAR positive to decrease the need for radiographs. No evidence was found in favour of the use of magnetic resonance imaging (MRI) or computed tomography (CT) in the acute phase of ankle sprain.

CONCLUSION

The findings confirm the value of the OAR at ruling out fractures after an ankle sprain and propose other or additional tools to decrease the need for X-rays.

LC determination of impurities in azithromycin tablets

A LC method with UV detection for determining azithromycin impurities in tablets as pharmaceutical form has been developed. It is to be employed in routine and stability tests. A linear gradient elution was employed starting with 47% A and 53% B to reach 28% A and 72% B at 48 min. Mobile phase A was KH2PO4 10 mM (H2O) at pH 7.00. B was a mixture methanol:acetonitrile 1:1 (v/v). UV detection was performed at 210 nm. The chromatographic column was Phenomenex Synergi MAX-RP 4 microm 250 x 460 mm kept at 50 degrees C. Six impurities were separated and identified and it was possible to quantify five out of the six with reasonable accuracy and precision.

Study designs for clinical trials applied to personalised medicine: a scoping review

OBJECTIVE

Personalised medicine (PM) allows treating patients based on their individual demographic, genomic or biological characteristics for tailoring the 'right treatment for the right person at the right time'. Robust methodology is required for PM clinical trials, to correctly identify groups of participants and treatments. As an initial step for the development of new recommendations on trial designs for PM, we aimed to present an overview of the study designs that have been used in this field.

DESIGN

Scoping review.

METHODS

We searched (April 2020) PubMed, Embase and the Cochrane Library for all reports in English, French, German, Italian and Spanish, describing study designs for clinical trials applied to PM. Study selection and data extraction were performed in duplicate resolving disagreements by consensus or by involving a third expert reviewer. We extracted information on the characteristics of trial designs and examples of current applications of these approaches. The extracted information was used to generate a new classification of trial designs for PM.

RESULTS

We identified 21 trial designs, 10 subtypes and 30 variations of trial designs applied to PM, which we classified into four core categories (namely, Master protocol, Randomise-all, Biomarker strategy and Enrichment). We found 131 clinical trials using these designs, of which the great majority were master protocols (86/131, 65.6%). Most of the trials were phase II studies (75/131, 57.2%) in the field of oncology (113/131, 86.3%). We identified 34 main features of trial designs regarding different aspects (eg, framework, control group, randomisation). The four core categories and 34 features were merged into a double-entry table to create a new classification of trial designs for PM.

CONCLUSIONS

A variety of trial designs exists and is applied to PM. A new classification of trial designs is proposed to help readers to navigate the complex field of PM clinical trials.

An evaluation of managed entry agreements in Belgium: A system with threats and (high) potential if properly applied

OBJECTIVE

To evaluate the strengths and weaknesses of managed entry agreements (MEAs) in Belgium.

METHODS

All Belgian MEAs signed between 2010 and 2015 (n = 71) were studied, including the re-evaluations of 16 reimbursement requests for which the initial MEA had ended. The analysis was supported by the findings from a systematic literature review and structured interviews with Belgian stakeholders.

RESULTS

The current application of MEAs provides the short-term advantage of getting a positive reimbursement decision with lower confidential prices. However, it is not clear whether the negotiated prices are in line with the added value of the interventions. Furthermore, the contracts do not provide incentives for manufacturers to gather evidence or to set public prices at an acceptable level.

CONCLUSIONS

Based on our analysis of the Belgian MEAs and discussions with Belgian stakeholders, an overview of various issues and pitfalls related to the current application of the system is given. Recommendations are made related to providing correct incentives to deliver good evidence, establishing a correct link between identified uncertainties/problems and the type and content of the MEA, reducing the risk of making the system non-transparent, the importance of international collaboration, etc. in order to optimize the potential of this system. These recommendations are addressed to both the Belgian policymakers and stakeholders in other countries making use of MEAs.

The statistical distribution of wrist movements during sleep

The purpose of this work was to describe the basic statistical properties of the process of production of movements measured with a wrist actimeter, along a complete sleep period in normal human subjects. Two distinct types of random magnitudes were considered to analyze the data, the times between successive groups of movements and the number of movements at each fixed time (1 min) measurement epoch. Suitable probabilistic models for the two variates were chosen, fitting theoretical distribution functions to the observed data. It is concluded that interval data fit a one-parameter exponential distribution, while the number of movements fit a two-parameter negative binomial distribution. The estimated values of these parameters, besides being necessary to perform further statistical analysis, are a measure of the intensity and frequency of the movements. Finally the relationship between polysomnography measures and the elicited parameters was studied.

The importance of test accuracy in economic evaluations of companion diagnostics

BACKGROUND

Economic evaluations of companion diagnostics often fail to include the impact that tests have on the overall economic value of test-drug combinations. 

METHODS

To illustrate the importance of test accuracy on the cost-effectiveness of companion diagnostics by means of examples. Data were extracted from the literature.

RESULTS

The accuracy of a test and in particularly its specificity, is often more influential on the overall cost-effectiveness results than the price of the test. Specificity becomes more crucial when prevalence of the biomarker is low. Multiple, simultaneous testing faces specific challenges regarding its overall specificity.

CONCLUSION

This article opens a discussion on some fundamental points linked to economic evaluations of test-therapy combinations.

Atypical toxoplasmic retinochoroiditis in patients with malignant hematological diseases

In immunocompromised patients, toxoplasmosis may have atypical presentation with bilateral, extensive or multifocal involvement. We report a case series of atypical toxoplasmic retinocoroiditis in patients with malignant hematological diseases who are usually immunosuppressed. Four patients were diagnosed of atypical toxoplasmic retinochoroiditis, all of them had immunosuppression (100%) and half of them (50%) had received a bone marrow transplant. The polymerase chain reaction for toxoplasma was positive in 75% of cases, and in one case (25%) the diagnosis was made with clinical and serological criteria. One patient presented ocular toxoplasmosis despite being on prophylactic treatment with atovaquone. Patients with atypical ocular toxoplasmosis and hematological diseases are generally immunocompromised, but they do not always have history of a bone marrow transplant. The presentation may be due to a primary infection or a reactivation of the disease. The aqueous humor and/or vitreous polymerase chain reaction allow confirming the diagnosis to perform a proper treatment.

Obstacles to the recognition of medical prescriptions issued in one EU country and presented in another

A study involving the presentation of 192 Belgian or Finnish prescriptions in pharmacies in five other member states was undertaken to assess whether, as envisaged by European Union law, prescriptions issued in one member state are dispensed by pharmacists in another and to identify factors that influence such decisions. Overall, pharmacists were willing to dispense in 108 cases. Detailed results show important differences depending on the country where prescriptions are presented and whether prescriptions were written by International Nonproprietary Name and in English, as opposed to prescriptions written by brand in a national language.

Unraveling the Mystery of Polyvalent Immunoglobulins in Belgium: Do We Have an Indication?

INTRODUCTION

Worldwide, polyvalent immunoglobulin (Ig) use is rising. Together with the limited supply, this puts pressure on Ig availability. A clear overview on a country's usage pattern helps in forecasting future needs. This research aims to provide an overview of Ig use in Belgium on the different indications, including an estimation of off-label use.

METHODS

Multiple data sources were used. Existing claims data were explored for reimbursed Ig use between 2010 and 2018. General 2018 sales data from the firms were compared to the reimbursed use to serve as a proxy for off-label use. Indication-specific information was retrieved via a proxy: diagnostic codes available during day-care and inpatient hospitalization.

RESULTS

In 2018, 7,556 patients had reimbursed Ig. The most prevalent indication, both in terms of patient numbers and volume, was primary immunodeficiency (PID). In Belgian hospitals, the currently reimbursed indications represented 84.4% of patients (PID [≈35%], secondary immunodeficiency [SID] [≈21%], primary immune thrombocytopenia [≈10%], chronic inflammatory demyelinating neuropathy [CIDP] [≈8%], Guillain-Barre syndrome [≈6%], Kawasaki [≈2%], streptococcal toxic shock [≈2%] and multiple motor neuropathy [≈1%]), and 82.4% of Ig use (predominantly PID [≈33%] and CIDP [≈21%]). Although no direct data on off-label use were available, crude estimates derived from indirect sources showed a proportion of around 15.4%.

CONCLUSION

Our research offers the first comprehensive overview on Ig use in Belgium, including a detailed description of reimbursed use, as well as approximations to off-label use. In view of increasing pressure on Ig availability, better understanding Ig needs and trends, would benefit from an effective indication-specific national registry system (ideally covering both reimbursed and nonreimbursed use).

What to do when presented with a prescription from another European country: insight from a qualitative study of pharmacists in England

OBJECTIVES

Prescriptions for medicines issued by healthcare professionals in other parts of the European Union are legally valid in the UK. However, it is not known whether this is fully understood by British community pharmacists. In this study we aimed to understand the implementation of UK pharmacy policy on dispensing prescriptions from other parts of the European Union and to investigate pharmacists' knowledge and interpretation of the relevant provisions in a mystery shopping exercise in English pharmacies.

METHODS

We reviewed the policy literature on regulations and practices pertaining to the prescribing and dispensation of prescription-only medicines in the UK. We interviewed key English informants in pharmacy. We then conducted a 'mystery shopping' exercise in 60 randomly selected pharmacies in urban, peri-urban and rural areas of England to investigate how community pharmacists manage four different types of prescriptions from another EU country.

KEY FINDINGS

From the eight interviews conducted there was broad consensus that existing processes for verifying the authenticity of foreign prescriptions could be improved. Of the 60 pharmacies visited, only 27% (16 out of 60) were willing to dispense the medication. Pharmacists unwilling to dispense were invited to explain their reasons for refusal. The most common were that they believed that English pharmacists are unauthorised to dispense foreign prescriptions, and that prescriptions must be in the English language or issued by a UK-recognised prescriber.

CONCLUSION

Existing processes available to English pharmacists for verifying the authenticity of foreign prescriptions seem to be insufficient. Strategies to overcome these problems were proposed by pharmacists and key informants, and include the creation of a database or registry of all authorised European Economic Area/Swiss prescribers, development of EU standards on prescription content and on dosage of medications, consistent international non-proprietary name (INN) prescribing and the use of an agreed common language for key information on prescriptions.

Overwintering of Piezodorus guildinii (Heteroptera, Pentatomidae) Populations

Piezodorus guildinii (Westwood) is a soybean pest that causes significant economic losses in the Americas. The variability of overwintering (diapause) traits was evaluated in populations of the Southwest (SW) (33°55'-34°17'S, 57°13'-57°46'W) during 2-year period (2011-2013) and of the Northwest (NW) (32°01'-33°02'S, 57°50'-57°24'W) during 1-year period (2014-2015) Regions of Uruguay. Samples were taken from different plant species (cultivated legumes, wild shrubs, and trees) and from overwintering sites (leaf litter and bark). Alfalfa, Medicago sativa L. was the main host, with a collection period of 10-11 months in the SW and 12 months in the NW. Cluster analysis for each sex was carried out to group the months according to the similarity in diapause traits of populations (body size, body lipid content, immature reproductive organs, and clear type of pronotum band and connexivum in females). Female diapause in the SW was longer (beginning of autumn to end of winter) than that in the NW (mid-autumn to mid-winter). Male diapause was longer (mid-autumn to mid-winter) in SW1 (1st year) than in SW2 (2nd year) and NW (late-autumn to mid-winter). In both regions, male diapause was shorter than female. Differences were associated with maximum temperature at daylight hours ≤ 12.1, being necessary maximum temperatures below 23.8 °C for females and 19.2 °C for males to initiate diapause.

Obstetric outcome of ethnic Turkish women in London: a retrospective case-control study

There is concern that the maternal mortality in ethnic minority women is significantly greater than that of Caucasian British women. The objective of this study was to compare the demographic and obstetric outcomes between these two groups. Data were collected retrospectively over a 2-year period from 148 index and 148 control cases. The study group had statistically similar maternal age, labour duration, blood loss and mode of delivery compared with Caucasian British women (p > 0.05). A total of 68% of Turkish women spoke little or no English; were more likely to be non-smokers and also more likely to be married to unemployed spouses (p = 0.0001). This is the first study comparing obstetric outcomes of immigrant Turkish women with their Caucasian British counterparts. There was no significant difference in maternal or fetal outcomes, which could be attributed to the 'healthy migrant' theory, coupled with increased vigilance in ethnic minority pregnancies.

Machine learning can reliably predict malignancy of breast lesions based on clinical and ultrasonographic features

PURPOSE

To establish a reliable machine learning model to predict malignancy in breast lesions identified by ultrasound (US) and optimize the negative predictive value to minimize unnecessary biopsies.

METHODS

We included clinical and ultrasonographic attributes from 1526 breast lesions classified as BI-RADS 3, 4a, 4b, 4c, 5, and 6 that underwent US-guided breast biopsy in four institutions. We selected the most informative attributes to train nine machine learning models, ensemble models and models with tuned threshold to make inferences about the diagnosis of BI-RADS 4a and 4b lesions (validation dataset). We tested the performance of the final model with 403 new suspicious lesions.

RESULTS

The most informative attributes were shape, margin, orientation and size of the lesions, the resistance index of the internal vessel, the age of the patient and the presence of a palpable lump. The highest mean negative predictive value (NPV) was achieved with the K-Nearest Neighbors algorithm (97.9%). Making ensembles did not improve the performance. Tuning the threshold did improve the performance of the models and we chose the algorithm XGBoost with the tuned threshold as the final one. The tested performance of the final model was: NPV 98.1%, false negative 1.9%, positive predictive value 77.1%, false positive 22.9%. Applying this final model, we would have missed 2 of the 231 malignant lesions of the test dataset (0.8%).

CONCLUSION

Machine learning can help physicians predict malignancy in suspicious breast lesions identified by the US. Our final model would be able to avoid 60.4% of the biopsies in benign lesions missing less than 1% of the cancer cases.

The Burden of Pressure Ulcers in Spain

Pressure ulcers are a serious and debilitating condition treated in all care settings and have a significant impact on both patients and healthcare resources. The objective of this study was to estimate overall treatment costs to the Spanish healthcare system by using a bottom-up costing approach. This study demonstrates that the cost to heal a pressure ulcer increases substantially with the severity of the ulcer, ranging from €24 ([$32.16], Grade I) to €6802 ([$9115], Grade IV) for patients treated in hospitals. Ulcer severity increases overall costs because the time to heal is longer and the incidence of complications is higher in more severe cases. The total cost of pressure ulcer treatment in Spain is approximately €461 million ([$618 million], roughly 5% of total annual healthcare expenditure). Of this, 15% represents the cost of dressings and other materials, while 19% represents the cost of nursing time, and 45% represents the cost of ulcer-related hospital stays.

Diagnostic immunohistochemistry use in Belgian laboratories

OBJECTIVES

In Belgium, the use of IHC testing has grown in the last decade. However, there is a lack of information on the specific indications for which it is reimbursed. The aim of the study is to offer an overview on the use of diagnostic inmunohistochemistry (IHC) testing and its recent trends.

METHODS

Our analysis is limited to reimbursed use, which in Belgium is restricted to a maximum of 4 different IHC stains per sampling session for diagnostic IHC. Consulted sources included data from the compulsory health insurance, and data extracted from a sample of pathology reports gathered from Belgian laboratories for the year 2019.

RESULTS

Over the last 10 years, the use of IHC in Belgium grew from 729 030 stains in 2012 to 1,194,331 in 2019, an increase of 63.8 % while the increase in the number of histological or cytological examinations was 13.3 %. The main stains used in 2019 were H. pylori, Ki-67 and broad spectrum CK, which were used in multiple body sites, reflecting the difficulties to identify specific indications. The gastro-intestinal tract is the body site with the highest number of IHC stains (38.2 % of all stains performed), and the most frequently used stain in gastro intestinal biopsies were H. pylori (43.1 %), and CD3 (6.8 %).

CONCLUSION

This study offers an overview of the most frequent indications for which diagnostic IHC staining is used in Belgium, and reflects the evolving nature of this field, highlighting the importance to increase clarity and improve data collection.

Ocular alterations in divers: 2 case reports and literature review

Scuba diving can be practiced recreationally or professionally. In both modalities the diver can be exposed to risks such as decompression syndrome and thus, the use of a hyperbaric chamber, hyper-oxygenation of the gas cylinder, barotrauma, and immersion in closed circuits. These situations have some phenomena in common, such as the great pressure differences, which can cause a wide range of alterations, including ophthalmological ones. The development of index myopia and nuclear cataract are ocular findings frequently associated with increased oxygen pressure. In this context, an imbalance is established between oxidative species and antioxidant defences, such as glutathione, which has a key role in maintaining the transparency of the lens. The cases are presented of 2 young coral fisher patients, who had recently developed a progressive myopisation associated with nuclear cataracts.