Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline

CLINICAL QUESTION

What are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)? This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice.

CURRENT PRACTICE

Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing.

RECOMMENDATION

The guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old).

HOW THIS GUIDELINE WAS CREATED

A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach.

THE EVIDENCE

The systematic review included 21 trials with 2192 participants. For adults with SCH, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid related symptoms, including depressive symptoms, fatigue, and body mass index (moderate to high quality evidence). Thyroid hormones may have little or no effect on cardiovascular events or mortality (low quality evidence), but harms were measured in only one trial with few events at two years' follow-up.

UNDERSTANDING THE RECOMMENDATION

The panel concluded that almost all adults with SCH would not benefit from treatment with thyroid hormones. Other factors in the strong recommendation include the burden of lifelong management and uncertainty on potential harms. Instead, clinicians should monitor the progression or resolution of the thyroid dysfunction in these adults. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of thyroid hormones in multilayered evidence summaries and decision aids available in MAGIC (https://app.magicapp.org/) to support shared decisions and adaptation of this guideline.

Scandinavian clinical practice guideline on fluid and drug therapy in adults with acute respiratory distress syndrome

Background

The objective of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) task force on fluid and drug therapy in adults with acute respiratory distress syndrome (ARDS) was to provide clinically relevant, evidence‐based treatment recommendations according to standards for trustworthy guidelines.

Methods

The guideline was developed according to standards for trustworthy guidelines, including a systematic review of the literature and use of the GRADE methodology for assessment of the quality of evidence and for moving from evidence to recommendations.

Results

A total of seven ARDS interventions were assessed. We suggest fluid restriction in patients with ARDS (weak recommendation, moderate quality evidence). Also, we suggest early use of neuromuscular blocking agents (NMBAs) in patients with severe ARDS (weak recommendation, moderate quality evidence). We recommend against the routine use of other drugs, including corticosteroids, beta2 agonists, statins, and inhaled nitric oxide (iNO) or prostanoids in adults with ARDS (strong recommendations: low‐ to high‐quality evidence). These recommendations do not preclude the use of any drug or combination of drugs targeting underlying or co‐existing disorders.

Conclusion

This guideline emphasizes the paucity of evidence of benefit – and potential for harm – of common interventions in adults with ARDS and highlights the need for prudence when considering use of non‐licensed interventions in this patient population.

Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis

Background

For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non‐perforated appendicitis.

Methods

A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non‐perforated appendicitis. Key outcomes were analysed using random‐effects meta‐analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference −2·6 (95 per cent c.i. –6·3 to 1·1) per cent (low‐quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference −7·2 (−18·1 to 3·8) per cent (very low‐quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high‐quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high‐quality evidence). For every 100 patients with non‐perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year.

Conclusion

The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value‐ and preference‐dependent, suggesting a change in practice towards shared decision‐making is necessary.

Limitations of each evolving

Perceived food intolerance in subjects with irritable bowel syndrome-- etiology, prevalence and consequences

OBJECTIVES

This study estimates the prevalence of perceived food intolerance and its consequences in subjects with irritable bowel syndrome (IBS), evaluates the utility of common tests for food intolerance, studies the relation between perceived food intolerance and other disorders, and discusses the etiology.

DESIGN

Cross-sectional study.

SETTING

National health survey.

SUBJECTS

A selection of the population (n=11,078) in Oppland county, Norway, was invited to a health screening, and a sample of subjects with IBS were included in the study.

INTERVENTIONS

A medical history of food intolerance, musculoskeletal pain, mood disorders and abdominal complaints was taken, and tests were performed for food allergy and malabsorption. A dietician evaluated the dietary habits of the subjects.

RESULTS

Out of 4,622 subjects with adequately filled-in questionnaires, 84 were included in the study, 59 (70%) had symptoms related to intake of food, 62% limited or excluded food items from the diet and 12% had an inadequate diet. The mean numbers of food items related to symptoms and the number of foods limited or excluded from the diet were 4.8 and 2.5, respectively. There were no associations between the tests for food allergy and malabsorption and perceived food intolerance. Perceived food intolerance was unrelated to musculoskeletal pain and mood disorders.

CONCLUSIONS

Perceived food intolerance is a common problem with significant nutritional consequences in a population with IBS. The uselessness of current antibody tests and tests for malabsorption and the lack of correlation to psychiatric co-morbidity make the etiology obscure.

The value of a general therapeutic approach in subjects with irritable bowel syndrome

BACKGROUND

The general therapeutic approach is the cornerstone in the management of irritable bowel syndrome, but the effect is poorly documented.

AIM

To evaluate the effect of the general therapeutic approach for irritable bowel syndrome.

METHODS

Subjects with irritable bowel syndrome identified in a public screening were included. Scores for abdominal symptom (range 0-12), musculoskeletal pain and mood disorders were calculated. After exclusion of other disorders, a doctor presented irritable bowel syndrome as a positive diagnosis, gave information, reassurance and lifestyle advice, but no pharmacotherapy. A dietician gave dietary advice. There was a follow-up after 6 months.

RESULTS

Sixty-five persons (females/males: 44/21) with mean age 49 years (range 31-76) were included, 31 (48%) were recommended dietary changes. Twenty subjects (31%) had satisfactory relief of symptoms after 6 months. The scores for abdominal symptom was reduced from 3.1 to 2.2 (P = 0.007), the reduction was 2.2 in the diarrhoea-predominant group given advice compared with 0.4 in the other subjects (P = 0.035). Previous consultations for the complaints, visits for psychiatric disorders, and presence of mood disorders were predictors of persistent complaints.

CONCLUSIONS

There was a significant relief of symptoms after 6 months, those with psychological co-morbidity responded less well. The effect of dietary advice was only seen in those with diarrhoea-predominant irritable bowel syndrome.

Comorbidity of irritable bowel syndrome in general practice: a striking feature with clinical implications

BACKGROUND

Somatic comorbid symptoms might identify irritable bowel syndrome patients with different aetiologies and needs of treatment.

AIMS

To measure comorbid symptoms in patients with irritable bowel syndrome in general practice, and to explore characteristics of patients with low, intermediate and high somatic comorbidity.

METHODS

Prospective study of 208 of 278 consecutive patients with irritable bowel syndrome (Rome II) in nine general practices. Questionnaires assessed 22 comorbid symptoms (subjective health complaint inventory), psychosocial factors including psychological distress (Symptom Check list-10) and quality of life (Short form-12). Subjective health complaint data from 1240 adults (controls) constituted a reference material. Patients with low, intermediate and high somatic comorbidity were identified by a somatic comorbidity score (17 subjective health complaint items). Health care seeking was assessed after 6-9 months.

RESULTS

Patients with irritable bowel syndrome (67% females, mean age 50, s.d. 16) reported 20 of 22 comorbid symptoms significantly more frequent than controls (odds ratios = 2-7, P < 0.001). The somatic comorbidity score correlated with psychological distress (R = 0.46, P < 0.001). Patients with high somatic comorbidity reported higher levels of mood disorder, health anxiety, neuroticism, adverse life events and reduced quality of life and increased health care seeking when compared to those with low and intermediate somatic comorbidity (P-values < 0.05).

CONCLUSIONS

Our findings support the hypothesis that structured assessment of comorbid somatic symptoms might identify subgroups with different aetiology and needs of treatment.

Lactose malabsorption in a population with irritable bowel syndrome: prevalence and symptoms. A case-control study

BACKGROUND

Symptoms after intake of milk are common in persons with irritable bowel syndrome (IBS). The aims of this study were to compare the prevalence of lactose malabsorption (LM) and symptoms related to intake of milk and lactose in subjects with IBS with that of healthy volunteers, and to search for symptoms that are characteristic of LM.

METHODS

A case-control study in a Norwegian population was initiated. Subjects with IBS were asked for symptoms related to intake of milk and lactose, tested for LM, and compared with a group of healthy volunteers.

RESULTS

The study comprised a total of 187 persons (82 with IBS and 105 volunteers), females/males: 138/49, mean age 47 years. In subjects with IBS and in healthy volunteers, LM was present in 3/74 (4.1%) and 4/105 (3.8%), respectively (ns), milk-related symptoms in 32/79 (40%) and 13/105 (12%), respectively (P < 0.001) and symptoms after intake of lactose in 28/74 (38%) and 21/104 (20%), respectively (P=0.01). Borborygmi starting within 5 h after intake of lactose and lasting for more than 2 h indicated LM (OR 61 (95% CI: 8-475), P < 0.001).

CONCLUSIONS

IBS and LM are unrelated disorders in a Norwegian population. Milk-related symptoms and symptoms after intake of lactose are unreliable predictors for LM. Precise symptom-based criteria might enhance the diagnostic accuracy for LM.

Diagnosing irritable bowel syndrome: poor agreement between general practitioners and the Rome II criteria

BACKGROUND

The new guidelines for diagnosing irritable bowel syndrome (IBS) in clinical practice recommend the use of the Rome II criteria. In this study the agreement between general practitioners (GPs) and the Rome II criteria for diagnosing of IBS and functional bowel disorders (FBD) is examined.

METHODS

Consecutive patients in general practice were asked to report on abdominal complaints, for which they had consulted or wanted to consult a GP. Patients with such complaints completed a questionnaire based on the Rome II criteria for FBD. After consultations, the GPs reported their diagnoses on the abdominal complaints.

RESULTS

Of 3097 screened patients, 553 patients were diagnosed by their GP and had complete data in the questionnaire. Of these patients, 107 had IBS according to the GPs and 209 had IBS according to the Rome II criteria (agreement 58%, kappa 0.01 (CI: -0.06; 0.09)). Agreement on IBS and FBD in patients without organic disease, without reflux or dyspepsia and in patients with a verified diagnosis was 45%-58%, with kappa values from -0.02 to 0.13. IBS and FBD cases were diagnosed by the Rome II criteria more often than by the GPs in all these groups of patients (P < 0.001). In patients with diagnostic discrepancies concerning IBS, 'stress-related symptoms' was predictive of a diagnosis of IBS made by the GPs only (OR 2.17 (CI: 1.1; 4.2)).

CONCLUSIONS

This study shows poor agreement in the diagnosis of IBS between GPs and the Rome II criteria. Therefore, current knowledge about IBS based on strict criteria is not necessarily transferable to patients with IBS in general practice.

[The chain that saves life. Prehospital treatment of myocardial infarction]

A 53-year old woman living in a rural area 220 km from the nearest hospital experienced an acute myocardial infarction. The local doctor contacted the emergency service and requisitioned an air ambulance. 29 minutes later the physician-manned helicopter arrived, and thrombolytic treatment was started after 15 minutes. The patient arrived at the county hospital 35 minutes later, after having been electroconverted three times because of ventricular fibrillation. The patient was discharged from hospital ten days later with no cerebral sequelae, and left ventricular ejection fraction 49%. This example shows that active use of emergency communications systems and air ambulances enables both prompt thrombolytic treatment and the effective treatment of complications associated with myocardial infarction to be accomplished.