Evidence-based guideline: unexplained infertility†

STUDY QUESTION

What is the recommended management for couples presenting with unexplained infertility (UI), based on the best available evidence in the literature?

SUMMARY ANSWER

The evidence-based guideline on UI makes 52 recommendations on the definition, diagnosis, and treatment of UI.

WHAT IS KNOWN ALREADY

UI is diagnosed in the absence of any abnormalities of the female and male reproductive systems after 'standard' investigations. However, a consensual standardization of the diagnostic work-up is still lacking. The management of UI is traditionally empirical. The efficacy, safety, costs, and risks of treatment options have not been subjected to robust evaluation.

STUDY DESIGN, SIZE, DURATION

The guideline was developed according to the structured methodology for ESHRE guidelines. Following formulation of key questions by a group of experts, literature searches, and assessments were undertaken. Papers written in English and published up to 24 October 2022 were evaluated.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Based on the available evidence, recommendations were formulated and discussed until consensus was reached within the guideline development group (GDG). Following stakeholder review of an initial draft, the final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

This guideline aims to help clinicians provide the best care for couples with UI. As UI is a diagnosis of exclusion, the guideline outlined the basic diagnostic procedures that couples should/could undergo during an infertility work-up, and explored the need for additional tests. The first-line treatment for couples with UI was deemed to be IUI in combination with ovarian stimulation. The place of additional and alternative options for treatment of UI was also evaluated. The GDG made 52 recommendations on diagnosis and treatment for couples with UI. The GDG formulated 40 evidence-based recommendations-of which 29 were formulated as strong recommendations and 11 as weak-10 good practice points and two research only recommendations. Of the evidence-based recommendations, none were supported by high-quality evidence, one by moderate-quality evidence, nine by low-quality evidence, and 31 by very low-quality evidence. To support future research in UI, a list of research recommendations was provided.

LIMITATIONS, REASONS FOR CAUTION

Most additional diagnostic tests and interventions in couples with UI have not been subjected to robust evaluation. For a large proportion of these tests and treatments, evidence was very limited and of very low quality. More evidence is required, and the results of future studies may result in the current recommendations being revised.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in the care of couples with UI, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in the field. The full guideline and a patient leaflet are available in www.eshre.eu/guideline/UI.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was developed by ESHRE, who funded the guideline meetings, literature searches, and dissemination of the guideline in collaboration with the Monash University led Australian NHMRC Centre of Research Excellence in Women's Health in Reproductive Life (CREWHIRL). The guideline group members did not receive any financial incentives; all work was provided voluntarily. D.R. reports honoraria from IBSA and Novo Nordisk. B.A. reports speakers' fees from Merck, Gedeon Richter, Organon and Intas Pharma; is part of the advisory board for Organon Turkey and president of the Turkish Society of Reproductive Medicine. S.B. reports speakers' fees from Merck, Organon, Ferring, the Ostetric and Gynaecological Society of Singapore and the Taiwanese Society for Reproductive Medicine; editor and contributing author, Reproductive Medicine for the MRCOG, Cambridge University Press; is part of the METAFOR and CAPE trials data monitoring committee. E.B. reports research grants from Roche diagnostics, Gedeon Richter and IBSA; speaker's fees from Merck, Ferring, MSD, Roche Diagnostics, Gedeon Richter, IBSA; E.B. is also a part of an Advisory Board of Ferring Pharmaceuticals, MSD, Roche Diagnostics, IBSA, Merck, Abbott and Gedeon Richter. M.M. reports consulting fees from Mojo Fertility Ltd. R.J.N. reports research grant from Australian National Health and Medical Research Council (NHMRC); consulting fees from Flinders Fertility Adelaide, VinMec Hospital Hanoi Vietnam; speaker's fees from Merck Australia, Cadilla Pharma India, Ferring Australia; chair clinical advisory committee Westmead Fertility and research institute MyDuc Hospital Vietnam. T.P. is a part of the Research Council of Finland and reports research grants from Roche Diagnostics, Novo Nordics and Sigrid Juselius foundation; consulting fees from Roche Diagnostics and organon; speaker's fees from Gedeon Richter, Roche, Exeltis, Organon, Ferring and Korento patient organization; is a part of NFOG, AE-PCOS society and several Finnish associations. S.S.R. reports research grants from Roche Diagnostics, Organon, Theramex; consulting fees from Ferring Pharmaceuticals, MSD and Organon; speaker's fees from Ferring Pharmaceuticals, MSD/Organon, Besins, Theramex, Gedeon Richter; travel support from Gedeon Richter; S.S.R. is part of the Data Safety Monitoring Board of TTRANSPORT and deputy of the ESHRE Special Interest Group on Safety and Quality in ART; stock or stock options from IVI Lisboa, Clínica de Reprodução assistida Lda; equipment/medical writing/gifts from Roche Diagnostics and Ferring Pharmaceuticals. S.K.S. reports speakers' fees from Merck, Ferring, MSD, Pharmasure. HRV reports consulting and travel fees from Ferring Pharmaceuticals. The other authors have nothing to disclose.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at www.eshre.eu/guidelines.).

O-159 Uniform communication by nurses and midwives in anticipation of an IVF treatment

Study question

How do patients perceive the pre-IVF treatment communication by the nursing and midwifery team and how do they evaluate implemented optimization?

Summary answer

Patient satisfaction with the pre-IVF treatment communication by the nursing and midwifery team improved from 86% to 98% after implementation of standardized written patient information.

What is known already

Nurses are the main point of contact for patients undergoing medically assisted reproduction techniques (Applegarth et al., 2008). Morris (2001) suggested that infertility nurses could more specifically be involved in informative counselling in anticipation of the fertility treatment. Specific training for nurses and midwives would be required in order to achieve that central role in effective fertility counselling (Applegarth et al., 2012). However, little has been published in peer reviewed literature on how to assess and improve these pre-IVF treatment information sessions.

Study design, size, duration

The pre-IVF communication by the nurse/midwife was assessed by female patients with a self-developed questionnaire (cohort 1). The nursing and midwifery team was subsequently informed about the results of the questionnaire and efforts were undertaken to optimise future patient communication. Four years later, a follow-up questionnaire assessed patient satisfaction about the intervention (cohort 2). Each cohort comprised fifty patients and nurses and midwives were blinded for patient participation to the study.

Participants/materials, setting, methods

The study was performed at an academic fertility centre and was approved by the Investigational Review Board. Data were collected with SurveyMonkey (pre intervention) and REDCap (post intervention). A descriptive analysis of the cohorts and patient feedback was performed. The intervention consisted of (1) the optimization of patient information documents if needed (2) providing a training to the nursing and midwifery staff, and (3) a follow-up questionnaire in a second cohort of female fertility patients.

Main results and the role of chance

The first questionnaire revealed that overall, patients were satisfied with the informative counselling session in anticipation of the IVF treatment. However, some patients indicated that they received a lot of information at once and that specific information that was of relevance for the further treatment (e.g. oocyte pick-up) was sometimes missed. Also, the data showed that not all patients received the same information. Therefore, all information that patients needed during an IVF treatment was gathered into a patient binder. It was supplemented with a timeline of the whole IVF trajectory, QR codes to movies explaining the administration of medication, and answers to common patients’ questions. It was possible to individualize the content of the binder per patient. Ideally, patients received this binder before the informative counselling session so they could read the content in advance. The binder was developed by a member of the nursing and midwifery team and was reviewed by the medical, laboratory, and administrative staff. Then, the nursing and midwifery team was trained on the use of the patient binder. The follow-up questionnaire revealed that patient satisfaction with the pre-IVF treatment counselling was 98% after the optimization of patient documentation (compared to 86% before the optimization).

Limitations, reasons for caution

Eligible patients were recruited by the treating physician. As no records were kept of the number of solicited patients for this study, no assessment of the response rate is possible. The cohorts were self-selected and limited in size and could therefore not reflect the general patient population.

Wider implications of the findings

A patient questionnaire and follow-up is a useful tool for a centre specific assessment and improvement of pre-IVF nurse/midwife communication with patients. Clinics could make efforts to invest in complete and written information and ask colleagues of the nursing and midwifery team to be involved in its creation.

Trial registration number

NCT04420169

O-165 Expert panel and evidence-based development of the Logbook for the Nurses and Midwives Certification programme of the European Society of Human Reproduction and Embryolog

Study question

How was the Logbook for the Nurses and Midwives Certification programme of the European Society of Human Reproduction and Embryology (ESHRE) developed?

Summary answer

The Logbook for the ESHRE Nurses and Midwives Certification programme, which questions 56 roles, was developed based on an extensive literature review and expert opinion.

What is known already

The ESHRE Executive Committee established the Nurses and Midwives Certification Committee (NMCC) in 2012. Since inception (2015), the certification programme has been delivered annually, with the exception of 2020 because of SARS-CoV-2. One-hundred-fourteen nurses/midwives have obtained ESHRE certification (passing rate=72%) and the programme is now accessible to nurses/midwives globally. The Certification program aims (i) to recognise the extended role of nurses/midwives delivering fertility care and (ii) to expand their theoretical background. The pre-requisites for certification are (i) being educated to a bachelor level of education and (ii) completing a practice based Logbook to demonstrate supervision of professional experience. 

Study design, size, duration

Between 2012 and 2014, the NMCC completed a systematic literature search for papers relating to clinical, non-clinical and extended roles of nurses and midwives in fertility settings. In addition, the NMCC invited a larger expert panel of European senior nurses and midwives to a meeting to discuss their needs and preferences regarding the certification programme and to survey the diverse roles performed by nurses and midwives in their country.

Participants/materials, setting, methods

The NMCC comprised four nurses/midwives, one clinical embryologist, and one medical doctor (both in advisory capacity). The Medline database was searched by entering a search string in PubMed combining (MeSH) terms related to reproductive medicine and nursing or midwifery. Opinion and empirical papers relating to roles of nurses/midwives in fertility settings were included. The surveyed expert panel included twelve nurses/midwives, representing Belgium, Denmark, Finland, France, Norway, Slovenia, Sweden, Turkey, Ukraine, and the United Kingdom.

Main results and the role of chance

A total of 49 papers, of which 24 empirical papers, were identified with the search string (n = 47) and snowball strategy (n = 2). The papers originated from 13 countries spread across Asia, Oceania, Europe, and North America. All twelve European senior nurses and midwives responded to the survey. Finally, 56 different roles were included in the Logbook. Forty-four roles were performed by nurses/midwives working in fertility settings according to the surveyed expert panel (n = 18), the literature (n = 8), or both the surveyed expert panel and literature (n = 18). An additional twelve observations of laboratory procedures were added by the NMCC. Substantial variation in roles and responsibilities existed across the countries from which the evidence originated. Whereas a considerate proportion of roles were performed in at least five countries (n = 16/56), a minority of roles were only performed by nurses/midwives in some countries (n = 7/56). Eight specialist roles (e.g. embryo transfer) were performed independently by nurses/midwives in some countries, whilst in other countries, nurses/midwives merely had an assisting role. In addition to completing the Logbook, participants were expected to write two ethical cases according to a guideline, testifying to their ability to reflect as a senior nurse/midwife. From 2015, the content of the Logbook was further developed.

Limitations, reasons for caution

This abstract relates to the development and content of the Logbook and not the curriculum/educational material required for the theoretical exam of the Nurses and Midwives Certification programme. The NMCC continuously improves the Logbook and elements have been added and removed since its creation.

Wider implications of the findings

The review and survey illustrated the variation in roles and responsibilities of nurses/midwives across the studied countries, further highlighting the opportunity for professional development within fertility care. Further research is required to elicit the experience of certified nurses/midwives with the programme and its impact on their professional and personal development.

Trial registration number

Not applicable

Technique and outcome of day case laparoscopic hiatus hernia surgery for small and large hernias: a five-year retrospective review from a high-volume UK centre

INTRODUCTION

Laparoscopic anti-reflux surgery is the standard surgical treatment for gastro-oesophageal reflux disease in patients for who long-term pharmacotherapy is intolerable or ineffective. Advances in anaesthesia and minimally invasive surgery have led to day case treatment being adopted by some centres. The objective of this study is to describe our day case pathway and peri- and postoperative outcomes.

MATERIALS AND METHODS

This is a single centre, retrospective case series review of a prospectively collected database from October 2014 to August 2019 performed in a tertiary centre for upper gastrointestinal surgery. Data collected included demographics, comorbidities, indications, complications, length of stay and readmission.

RESULTS

A total of 362 patients underwent laparoscopic anti-reflux surgery with or without hiatus hernia repair of up to 10cm, with day case rates of 59%. Unplanned admission following day surgery was 5.1% (13/225) and 30-day readmission was 2.2% (8/362); 90.6% of patients remained in hospital for less than 24 hours. There was one intraoperative complication and one patient required revisional surgery within 30 days. The rate of all postoperative complications was 1.38% (5/362) with one postoperative mortality.

DISCUSSION

The inclusion of larger hernias is unusual, as most studies limit size to 5cm or less. Our results show the safety and feasibility of the procedure even when applied to hiatus hernias up to 10cm. Success was multifactorial and based on standardisation of procedures and support from dedicated specialist nursing staff.

CONCLUSION

Laparoscopic anti-reflux surgery can be performed safely as a day case procedure even in larger hiatus hernias, with a dedicated care pathway and specialist nurse practitioners to support it.

Correlation between sonographic follow-up of follicular growth, serum and salivary estradiol in women undergoing controlled ovarian stimulation (IVF/ICSI)

AIM OF THE STUDY

Investigation of the correlation between serum estradiol (E2), salivary E2 and sonographic measurements of follicles in women undergoing controlled ovarian stimulation (COS) for IVF/ICSI.

METHODS

This is a prospective study performed at the Department of Reproductive Medicine of Ghent University Hospital (Belgium) between November 2016 and January 2017 over a total of 40 patients. During routine COS, two-dimensional measurements of the follicles were performed using transvaginal ultrasound (TVUS) and E2 was measured in saliva and serum. A linear Mixed-Effects model (MIXED) was built, using SPSS Statistics 24.

RESULTS

Statistical analysis shows a strong linear correlation between serum and salivary E2. For every single unit increase in serum E2 (+ 1 ng/L) the estimated saliva E2 concentration is expected to increase with 0.011 pg/mL (95% CI [0.009 - 0.01]). Strong linear correlations between both saliva and serum E2 and follicular dimensions were also found. For every millimetre increase in follicle diameter the estimated serum E2 concentration is expected to increase with 8.32 ng/L (95% CI [7, 10-9, 54]). For every millimetre increase in follicle diameter the estimated saliva level of E2 is expected to increase with 0.11 pg/mL (95% CI [0.09 - 0.13]).

CONCLUSIONS

A strong correlation between serum and salivary E2 concentrations was found. In addition, both are strongly correlated with the product of the number of follicles and their average diameter, measured by TVUS. More investigation needs to be done to find out if salivary E2 is an effective tool for monitoring IVF cycles.

Etifoxine impairs neither alertness nor cognitive functions of the elderly: A randomized, double-blind, placebo-controlled crossover study

Etifoxine hydrochloride (Stresam^®), a treatment indicated for psychosomatic manifestations of anxiety, could be an alternative to benzodiazepines. While no impact on alertness and cognitive functions has been proven among youth, data on elderly are lacking. The primary objective of this study was to measure the impact of etifoxine, lorazepam or placebo on alertness in the elderly. The secondary objectives were to evaluate cognitive performances and adverse effects. In this randomized, placebo-controlled, double-blind, 3-way crossover design, 30 healthy volunteers aged 65 to 75 years underwent three one-day sessions. After treatment intake, standardized cognitive tests were conducted using the Cambridge Neuropsychological Test Automated Batteries and other psychological tests (Stroop, Rey Auditory Verbal Learning Test, Digit Span). The reaction time (RTI) as primary endpoint was analysed using a 3 × 3 latin square variance analysis. A 100-mg dose of etifoxine has no deleterious impact on alertness and causes no cognitive disorders as compared to placebo (RTI: 744 ± 146 ms versus 770 ± 153 ms; p = 1.00). As expected, a 2-mg dose of lorazepam impairs alertness (RTI: 957 ± 251 ms versus placebo; p < 0.0001) and cognitive functions. A similar frequency of adverse events was observed with etifoxine and placebo while their incidence was 3-fold higher with lorazepam, drowsiness being the most frequent adverse event. No serious adverse events were observed. This study demonstrates in the elderly that a single dose of etifoxine does neither impair alertness nor any of the cognitive parameters evaluated. Etifoxine may be a good option when anxiolytic treatment is required, especially in elderly people.

Correlation between saliva and serum concentrations of estradiol in women undergoing ovarian hyperstimulation with gonadotropins for IVF/ICSI

AIM OF THE STUDY

To examine saliva- and serum concentrations correlation of estradiol (E2) in women undergoing ovarian hyperstimulation for IVF/ICSI. Saliva measurements could simplify stimulation follow up. A 'home' test for E2 could be useful.

METHODS

Prospective interventional academic monocentric study at the Centre for Reproductive Medicine of the University Hospital of Ghent, Belgium. Between November 2014 and August 2015 thirty-one patients were included after random selection (inclusion criteria: < 41 years of age, any rank of IVF/ICSI cycle, serum anti- Müllerian hormone concentration ≥ 1 μg/L, treatment completely at the University Hospital.) Measurements took place using immunoassay serum measurements. Estradiol was determined in saliva and serum by LC-MS/MS. At every control, E2 was measured in saliva and serum. Equilibrium analysis on a part of the serum samples took place. Statistic method used is a linear Mixed- Effects model (MIXED) in SPSS.

RESULTS

Statistical analysis shows a strong linear relation between serum and salivary E2, (R2 of 0.75). E2 in equilibrium dialysis and E2 in serum were also strong correlated (R2 of 0.85).

CONCLUSIONS

Strong correlation between serum and salivary E2 concentrations was found. Equilibrium dialysis showed good correlation with salivary E2. Saliva can be a good surrogate for free E2 in women undergoing ovarian hyperstimulation. This may create an opportunity to develop a point of care test for measuring E2, in purpose to simplify screening for OHSS risk.

Effect of adjustable gastric banding on quality of life and weight loss in the Helping Evaluate Reduction in Obesity (HERO) registry study: 2 year analysis

OBJECTIVE

This report from the Helping Evaluate Reduction in Obesity (HERO) Study investigated weight loss, health-related quality of life (HRQOL), and factors predictive of HRQOL improvement during a 2 year period following Lap-Band AP implantation (post-LBAP).

RESEARCH DESIGN AND METHODS

This prospective, observational study included patients with 1 and 2 year follow-up data post-LBAP (N = 585). Changes in body mass index (BMI), percentage of weight loss (%WL), excess weight loss (%EWL) and HRQOL (Impact of Weight on Quality of Life [IWQOL]-Lite measure), and differences between <30% EWL and ≥30% EWL subgroups were assessed at 1 and 2 years post-LBAP. Multiple linear regression examined association of %EWL groups with IWQOL-Lite scores controlling for age, gender, region (US vs outside US), household income, employment status, and comorbidities.

RESULTS

Most patients were female (80.2%) and from the US (64.8%); overall mean (SD) age was 43.6 (11.28) years and 65.8% of patients had ≥30% EWL at year 2. At 2 years post-LBAP, mean %EWL was 43.5%; %EWL was 12.4% in the <30% EWL group and 59.6% in ≥30% EWL group (P ≤ 0.0001). Changes in IWQOL total and subscores were significantly greater in ≥30% EWL versus <30% EWL patients (all P < 0.0005) at years 1 and 2; Self-Esteem and Physical subscores had the largest changes. Multiple regression analysis showed that patients with ≥30% EWL had clinically meaningful improvements in HRQOL compared with patients having <30% EWL (P ≤ 0.001). Similarly, US patients and females had a clinically significant change in IWQOL score versus their counterparts (P ≤ 0.001). Conversely, income, comorbidities and employment status were not significant predictors of change in IWQOL scores at year 2.

CONCLUSIONS

These results support and extend findings regarding the effectiveness of LBAP for weight loss and illustrate the importance of ≥30% EWL as a significant factor in predicting clinically significant improvement in HRQOL 1 and 2 years post-LBAP.

CLINICAL TRIAL REGISTRATION

NCT00953173.

A retrospective study of the pregnancy, delivery and neonatal outcome in overweight versus normal weight women with polycystic ovary syndrome

STUDY QUESTION

Do overweight women with polycystic ovary syndrome (PCOS) have a higher risk of perinatal complications than normal weight women with PCOS?

SUMMARY ANSWER

Overweight women with PCOS with an ongoing singleton pregnancy have an increased risk of preterm birth as well as an increased risk of giving birth to a baby with a higher birthweight than normal weight women with PCOS.

WHAT IS KNOWN ALREADY

There is evidence that overweight (BMI > 25 kg/m²) has a negative influence on the prevalence of gestational diabetes mellitus and fetal macrosomia in women with PCOS.

STUDY DESIGN, SIZE, DURATION

We set up a retrospective comparative cohort study of 93 overweight (BMI ≥ 25 kg/m²) and 107 normal weight (BMI < 25 kg/m²) women with PCOS who were scheduled for fertility treatment between January 2000 and December 2009 and achieved a pregnancy as a result of a treatment cycle, or spontaneously before or between treatment cycles.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All data (patient characteristics, medical information, pregnancy, delivery and neonatal outcome) were retrieved from patient medical files. All pregnancy, delivery and neonatal outcome parameters were adjusted for age and pre-pregnancy smoking behaviour. The neonatal outcome parameters were additionally adjusted for gestational age.

MAIN RESULTS AND THE ROLE OF CHANCE

The median BMI in the overweight and normal weight women was, respectively, 30.8 kg/m² [interquartile quartile range (IQR) 5.8] and 20.9 kg/m² (IQR 2.3) (P < 0.001). Baseline characteristics did not differ between groups, except for free testosterone and fasting insulin levels, which were higher, and sex hormone-binding globulin, which was lower, in overweight versus normal weight women (all P < 0.001). The time-to-pregnancy was significantly higher in the overweight group (P = 0.01). Multivariate analyses of the ongoing singleton pregnancies showed significantly more preterm births in overweight (10/61) versus normal weight (2/71) women [adjusted odds ratio 0.1, 95% confidence interval (CI) 0-0.6, P = 0.01]. The mean birthweight of newborns was significantly higher in overweight (3386 ± 663 g) than in normal weight (3251 ± 528 g) women (adjusted mean difference 259.4, 95% CI 83.4-435.4, P = 0.004).

LIMITATIONS, REASON FOR CAUTION

Our results only represent the pregnancy, delivery and neonatal outcome of ongoing singleton pregnancies. The rather small sample size and observational nature of the study are further limitations.

WIDER IMPLICATIONS OF THE FINDINGS

Our results suggest the importance of pre-pregnancy weight loss in overweight women with PCOS in order to reduce the risk of adverse perinatal outcomes.

STUDY FUNDING/COMPETING INTERESTS

Veerle De Frène is holder of a Special PhD Fellowship by the Flemish Foundation for Scientific Research (FWO-Vlaanderen). Petra De Sutter is holder of a fundamental clinical research mandate by the Flemish Foundation for Scientific Research (FWO-Vlaanderen). There are no competing interests.

Gastric bands: what the general radiologist should know

Obesity in the UK is increasing, it is estimated that in England 24% of men and 25% of women are obese.(1,2) In recent years bariatric surgery has become increasingly common and is effective in producing long-term weight loss.(4,5) The most popular form of bariatric surgery in Europe is laparoscopic adjustable gastric banding (LAGB).(6) Radiologists play a key role assessing the normal function of bands, adjusting their filling under fluoroscopic guidance, and in recognizing and managing complications. This review will describe the general principles of LAGB; how they are assessed, how to recognize the most common complications, an overview of the appearances of the bands used in the UK, and novel developments in their use and design.

Management of late postoperative complications of bariatric surgery

Background

The prevalence of obesity is increasing worldwide and the past decade has witnessed an exponential rise in the number of bariatric operations performed. As a consequence, an increasing number of patients are presenting to non-specialist units with complications following bariatric procedures. This article outlines the management of the most common late postoperative complications that are likely to present to the general surgeon.

Methods

A search was conducted for late postoperative complications after bariatric surgery using PubMed, Embase, OVID and Google search engines, and combinations of the terms bariatric surgery, gastric bypass, gastric banding or sleeve gastrectomy, and late or delayed complications. Only studies with follow-up longer than 6 months were included.

Results

The most common long-term complications after gastric banding include band slippage and erosion. Deflation or removal of the band is often required. Internal hernia, adhesions and anastomotic stenosis are common causes of intestinal obstruction after gastric bypass surgery. Hepatobiliary complications pose a particular challenge because of the altered anatomy. Functional disorders such as reflux and dumping, and nutritional deficiencies are common and should be differentiated from conditions that require urgent investigations and timely surgical intervention.

Conclusion

The immediate management of bariatric patients presenting with complications outside the immediate postoperative period requires adherence to basic surgical principles. Accurate diagnosis often relies on high-quality contrast and cross-sectional imaging, and effective surgical intervention necessitates a broad understanding of the altered anatomy, advanced surgical skills and liaison with specialists in the field when necessary.

Analysis of the rate of missing data, the rate of discordance between readers, and the rate of site versus central discordance in clinical studies of recently approved breast cancer agents that have used blinded independent central review

Abstract #2081

Background: The United States Food and Drug Administration (USFDA) recommends blinded independent central review (BICR) for oncology registration studies when the primary study endpoint is based on tumor measurements, such as progression-free survival (PFS) or objective response rate (ORR). However, there is no published guidance regarding acceptable metrics during the BICR.&#x2028; Method: The USFDA Summary Basis of Approvals and Oncologic Drugs Advisory Committee (ODAC) transcripts for the following recently approved breast cancer therapies: Gemzar, Abraxane, Tykerb, Ixempra, and Avastin, were reviewed with attention to metrics referable to the BICR. The findings are summarized.&#x2028; Results: Up to 13% of subjects were reported as unevaluable at the BICR based on missing data, with missing data defined as missing radiographic evaluations. The rates of discordance between two readers during the BICR were reportedly between 34-51% depending on the number of adjudication variables. The rates of discordance between the site and BICR were reportedly between 34-49% for the date of progression and 24-29% for the progression status. Up to 9% of subjects enrolled with measurable disease at baseline did not have this confirmed by the BICR. The causes of discordance were reportedly related to differences in the methodologies used to perform the reviews, and clinical or image data that was missing at the time of the BICR. Additional reported causes included imaging requirements not detailed in the protocol, the BICR charter containing more stringent requirements for determining response and progression than was indicated in the protocol, protocol amendments issued midway through the study which changed the imaging eligibility criteria for the sites while the BICR used the same requirements throughout the study, differences in the choice and classification of lesions, radiographic exams only repeated at subsequent time points if deemed positive by the investigator resulting in missing data and unevaluable assessments at the BICR, variability in measurement of small lesions, and discordance in the determination of new lesions. Inter- and intra-reader variability was reported in a small population of subjects; 8% resulted in 1-step response discrepancies for inter-reader variability and 31% for intra-reader variability.&#x2028; Conclusion: Based on FDA approvals, metrics as described above may prove to be valuable benchmarks when using BICR data to determine endpoints in future breast cancer studies.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2081.

CT scan in patients with suspected appendicitis: clinical implications for the acute care surgeon

OBJECTIVE

To determine the influence of computed tomography (CT) scans on diagnosis and management of patients with suspected appendicitis.

METHODS

Retrospective 2-year review of 1,630 patients with suspected appendicitis, categorized into three groups based on the likelihood (Alvarado scores) of having appendicitis. Group 1: low likelihood (Alvarado score < or =4); group 2: intermediate likelihood (Alvarado scores 5-7), and group 3: high likelihood (Alvarado score > or = 8). CT scan utilization, hospital course, and final pathology were retrospectively reviewed.

RESULTS

More patients received a CT scan in 2006 as compared with 2005 (60 vs. 52%; p = 0.001). The overall appendectomy rate was similar between the 2 years (57% in 2005 vs. 57% in 2006; p = 0.995). The overall appendectomy rate in patients with a CT was significantly higher as compared with those without (60 vs. 53%; p = 0.002). The appendectomy rate in patients with Alvarado scores < or =4 and no CT scan was significantly lower than in those with a CT scan (12 vs. 48%; p < 0.0001). The overall negative appendectomy rate in patients with a CT scan was similar to that in those without: 31/546 (6%) vs. 23/383 (6%).

CONCLUSIONS

CT scan utilization increased the appendectomy rate only in patients with a low clinical suspicion for appendicitis. Preoperative CT scans did not decrease the negative appendectomy rate.

Selection of patients for resection of hepatic metastases: improved detection of extrahepatic disease with FDG pet

A rapidly emerging clinical application of positron emission tomography (PET) is the detection of tumor tissue at whole-body studies performed with the glucose analogue 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG). High rates of recurrence after partial hepatic resection in patients with colorectal cancer liver metastases indicate that current presurgical imaging strategies are failing to show extrahepatic tumor deposits. Although FDG PET cannot match the anatomic resolution of conventional imaging techniques in the liver and the lungs, it is particularly useful for identification and characterization of extrahepatic disease. FDG PET can show foci of metastatic disease that may not be apparent at conventional anatomic imaging and can aid in the characterization of indeterminate soft-tissue masses. Several sources of benign and physiologic increased activity at FDG PET emphasize the need for careful correlation with findings of other imaging studies and clinical findings. FDG PET can improve the selection of patients for partial hepatic resection and thereby reduce the morbidity and mortality associated with inappropriate surgery.

Use of heparin in the investigation of obscure gastrointestinal bleeding

OBJECTIVE

To determine if the administration of heparin improves the predictive value of angiography in the investigation of obscure gastrointestinal (GI) bleeding.

METHODS

18 patients with a history of chronic GI bleeding were investigated with angiography. For 6 patients, the cause of GI bleeding was established with angiography; the 12 patients who had negative results were given heparin for 24 h and were reassessed with angiography.

RESULTS

After heparin administration, the source of GI bleeding was determined with angiography for 6 of the remaining 12 patients. Thus, heparinization increased diagnostic yield from 33% (6 of 18) to 67% (12 of 18). No significant complications, such as uncontrolled GI bleeding, occurred.

CONCLUSION

Heparinization improves the diagnostic yield of angiography when obscure GI bleeding is being investigated.

Value of double-contrast barium enema performed immediately after incomplete colonoscopy

OBJECTIVE

The purpose of this study was to evaluate the ease, completeness, and clinical utility of double-contrast barium enema (DCBE) performed immediately after incomplete colonoscopy.

SUBJECTS AND METHODS

During a 30-month period, a prospective study was performed in 103 patients (79 women, 24 men) to determine the ease and completeness of DCBE immediately after failed colonoscopy and any additional useful information provided by the enema. The ease with which DCBE was performed was graded from 1 (easy) to 10 (difficult).

RESULTS

DCBE revealed the entire colon in 97 patients (94%). Incomplete DCBE was a result of obstruction and incontinence in three patients each. The mean score for ease of performing DCBE was 5.0. In 14 patients (14%), significant additional diagnostic information was provided by the immediate DCBE. In eight patients, abnormalities were identified on DCBE that had not been seen at colonoscopy (five malignant neoplasms, one diverticular mass, two extrinsic masses, and multiple strictures). In four patients, a suspected colonoscopic abnormality was excluded with DCBE findings; and in two patients, a colonoscopic abnormality was further characterized with DCBE.

CONCLUSION

Immediate DCBE after incomplete colonoscopy allows complete colonic evaluation in most cases, often adds vital diagnostic information, and eliminates repeated bowel preparation and unnecessary delay in diagnosis.

Sedation and analgesia in adult patients: evaluation of a staged-dose system based on body weight for use in abdominal interventional radiology

PURPOSE

To evaluate the safety and effectiveness of a systematic protocol for sedation and analgesia in interventional radiology.

MATERIALS AND METHODS

Ninety-one adult patients underwent 113 abdominal interventional procedures. Fentanyl citrate and midazolam hydrochloride were administered in one to five steps (A, B, C, D, E) until the patient was drowsy and tranquil at the effective loading dose (ELD). Doses per step were as follows: A, fentanyl 1 microg per kilogram of body weight; B, midazolam 0.010-0.035 mg/kg; C, repeat dose in A; D, repeat half the dose in B; and E, midazolam 1-2-mg boluses (maximum, 0.15 mg/kg).

RESULTS

The ELD was reached in no procedure after step A, in 70 after B, in 23 after C, and in 18 after D. Step E was needed in two procedures. The mean maximum pain score (scale of 0 to 10) was 3.4; pain scores in 85 (75%) procedures were 4 or less (discomforting). Severe pain occurred in seven (6%) procedures. Hypoxia (oxygen saturation < 90%) occurred in 11 (22%) procedures performed in patients breathing room air and four (6%) performed in those breathing supplemental oxygen (P: =.04). All patients responded to supplemental oxygen.

CONCLUSION

This stepwise "ABCDE protocol" allows safe and effective sedation of patients. It is easy to use and may be useful in training radiology residents, staff, and nurses in the techniques of sedation and analgesia. Supplemental oxygen should be used routinely.

Detection of unsuspected colonic abnormalities using the pneumocolon technique during small bowel meal examination

AIMS

The pneumocolon technique in small bowel meal examination is used to obtain double-contrast views of the distal ileum. The purpose of this study was to determine the proportion of cases in which an overhead pneumocolon radiograph demonstrated clinically relevant findings in the colon.

METHODS

The overhead pneumocolon radiographs in 151 patients who underwent small bowel meals were evaluated retrospectively. A chart review was performed on those patients with positive colonic findings to determine if the suspected abnormalities affected patient management.

RESULTS

Colonic abnormalities were identified in 34 of the 151 patients. One patient had a previously undiagnosed ascending colonic cancer; 17 had evidence of acute or chronic colitis; 13 had diverticulosis; one had a caecal polyp; one had an ileosigmoid fistula; one had a filling defect in the ascending colon. In 25 cases the colonic abnormality was visible only on the pneumocolon radiograph and not on the preceding single-contrast images. Management was altered by the colonic findings in seven cases. False-positive findings occurred in two cases.

CONCLUSIONS

A routine overhead radiograph following use of the pneumocolon technique is a useful adjunct to small bowel meal examination as it can yield unsuspected and clinically significant colonic findings.Chou, S. (2000). Clinical Radiology55, 459-464.

Magnetic resonance imaging. Application to family practice

OBJECTIVE

To review indications, contraindications, and risks of using magnetic resonance imaging (MRI) in order to help primary care physicians refer patients appropriately for MRI, screen for contraindications to using MRI, and educate patients about MRI.

QUALITY OF EVIDENCE

Recommendations are based on classic textbooks, the policies of our MRI group, and a literature search using MEDLINE with the MeSH headings magnetic resonance imaging, brain, musculoskeletal, and spine. The search was limited to human, English-language, and review articles. Evidence in favour of using MRI for imaging the head, spine, and joints is well established. For cardiac, abdominal, and pelvic conditions, MRI has been shown useful for certain indications, usually to complement other modalities.

MAIN MESSAGE

For demonstrating soft tissue conditions, MRI is better than computed tomography (CT), but CT shows bone and acute bleeding better. Therefore, patients with trauma or suspected intracranial bleeding should have CT. Tumours, congenital abnormalities, vascular structures, and the cervical or thoracic spine show better on MRI. Either modality can be used for lower back pain. Cardiac, abdominal, and pelvic abnormalities should be imaged with ultrasound or CT before MRI. Contraindications for MRI are mainly metallic implants or shrapnel, severe claustrophobia, or obesity.

CONCLUSIONS

With the increasing availability of MRI scanners in Canada, better understanding of the indications, contraindications, and risks will be helpful for family physicians and their patients.

Terminal ileal imaging with ileoscopy versus small-bowel meal with pneumocolon

Disease of the terminal ileum can be diagnosed by ileocolonoscopy or barium radiography. We compared the diagnostic accuracy in the terminal ileum of ileocolonoscopy and small-bowel meal with pneumocolon. Consecutive patients during an 18-month period who had both ileocolonoscopy and small bowel meal with pneumocolon were identified and their colonoscopy reports, radiographs, and ileal biopsies reviewed blindly by paired gastroenterologists, radiologists, and pathologists, respectively. A gold-standard diagnosis was determined for each patient by consensus. Of 48 study subjects, 14 (29.2%) had Crohn's disease, 5 (10.4%) had lymphoid nodular hyperplasia, and 29 (60.4%) were normal. The sensitivity for a diagnosis of Crohn's ileitis was 92.9% for ileocolonoscopy and 100% for small-bowel meal, while their specificities were 100% and 97.1% respectively. The gold standard diagnosis confirmed ileocolonoscopic findings in 45 patients (93.8%) and radiographic findings in 42 patients (87.5%). Agreement between ileocolonoscopy and small bowel meal occurred in 39 cases (81.2%). By combining histology with ileocolonoscopy, the sensitivity and specificity could be increased to 100% for all diagnoses. Ileocolonoscopy and small-bowel meal with pneumocolon are complementary techniques for imaging the terminal ileum. A prospective comparative trial is now needed to more objectively assess their accuracy, cost effectiveness, and adverse effects.

A prospective blinded randomized trial comparing oral sodium phosphate and polyethylene glycol solutions for bowel preparation prior to barium enema

PURPOSE

A prospective blinded randomized trial to compare oral sodium phosphate (NaP) solution with polyethylene glycol (PEG) preparations as bowel preparation prior to barium enema examination.

PATIENTS AND METHODS

One hundred and ten patients consented to take part and each patient was randomly assigned to receive either NaP (Oral Fleet Prep) or PEG (Lyteprep). The barium enemas were reviewed by two radiologists blinded to the type of bowel preparation the patient had received. The colon was divided into six segments and each segment was assessed for the amount of stool and water present, the adequacy of coating, the ability to exclude inflammatory bowel disease and the presence of polyps. A score of 0-3 (failure to good) was assigned per segment on each of these criteria.

RESULTS

The average individual score for the NaP group was 89.2. The average individual score for the PEG group was 88.81. No significant difference was found in the quality of bowel cleansing between the two agents. In particular there was no significant difference in the scores for water retention (two-tailed P = 0.748) and the difference for the quality of coating was considered not quite significant (two-tailed P = 0.0818).

CONCLUSION

Oral sodium phosphate cleans the colon as well as polyethylene glycol solutions. The use of NaP will result in significant cost savings and improved patient compliance.

MR imaging of the female pelvis: current perspectives and review of genital tract congenital anomalies, and benign and malignant diseases

MR imaging continues to be an integral problem-solving modality in the evaluation of congenital anomalies and acquired diseases of the female genital tract organs and provides effective clinical information to the practicing gynecologist in those patients in whom sonography is technically suboptimal or the results are equivocal. This article describes the state-of-the art MR imaging of the female pelvis and addresses its current perspectives in the following sections: (1) technical aspects of MR in imaging the female pelvis, (2) normal pelvic anatomy and variations that are seen on MRI, (3) role of MRI in the diagnosis of congenital uterine and vaginal anomalies, (4) MR imaging approach to diagnose congenital uterine and vaginal anomalies, (5) advantages and limitations of MR in the evaluation of various benign diseases and malignant neoplasms of the female genital tract, (6) a MR staging system and criteria for each gynecologic malignancy, (7) fundamental MR criteria to differentiate benign from malignant tumors and recurrent tumors from fibrosis, and (8) the present cost-effective value of MR in pregnancy and obstetrics. Magnetic resonance (MR) technology continues to be an important problem-solving modality in the evaluation of benign, malignant, and recurrent diseases of the female pelvic organs with the development of new software and improved hardware over the last few years. The main issues addressed in this article are (1) to review the basic and expanded applications of the current state-of-the art MR imaging in the diagnosis and management of various congenital and acquired disorders of the female pelvic organs, (2) to illustrate a simplified clinico-radiologic (MRI) approach to the diagnosis of congenital and acquired pathologies of the pelvic organs, (3) to provide relevant information to the clinicians to make rational choices among the competing imaging modalities, and (4) to outline the future potential of this modality in the pelvis.

MR imaging of anorectal Crohn disease: a pictorial essay

Magnetic resonance (MR) imaging has proved useful in the evaluation of perianal and perirectal lesions resulting from Crohn disease. On T1-weighted MR images, sinus tracts and fistulas are hypointense due to their fluid content; on T2-weighted images, their signal intensity depends on their fluid content and the degree of surrounding fibrosis. Other pathologic entities, such as abscesses in the ischioanal fossa, may become evident at MR imaging even though they remain hidden at digital examination. Rectal wall thickening and perirectal inflammatory changes are often seen at MR imaging of the pelvis. The multiplanar capability of MR imaging greatly facilitates the detection of fistulous tracts that extend into the supralevator space. MR imaging can be helpful to both the surgeon and the gastroenterologist in the assessment of perianal and perirectal complications arising from Crohn disease and, when necessary, in the planning of surgical intervention. MR imaging also recommends itself to the patient because it is noninvasive and does not cause discomfort.

Outcome of patients discharged from a coronary care unit with a diagnosis of "chest pain not yet diagnosed"

OBJECTIVE

To determine the outcome and 3-year mortality rate among patients discharged from a coronary care unit (CCU) with a diagnosis of "chest pain not yet diagnosed."

DESIGN

Prospective observational cohort study.

SETTING

CCU in a university teaching hospital.

PATIENTS

All 158 eligible patients discharged from the CCU between August 1986 and December 1988. Of them, 27 refused to participate and 31 did not meet the inclusion criteria because of significant co-morbidity or transportation difficulties.

INTERVENTIONS

Evaluation with maximal and thallium exercise stress testing and four major gastrointestinal (GI) investigations: 24-hour intraesophageal pH monitoring, upper GI endoscopy with biopsy, esophageal motility studies and an upper GI barium series.

OUTCOME MEASURES

Results of investigations and incidence of recurrent chest pain, CCU readmission, coronary angiography, coronary artery bypass surgery, myocardial infarction and death at 6, 12, 24 and 36 months after the index visit.

RESULTS

Of the patients enrolled in the study 79% (79/100) had a normal exercise thallium stress test result, 74% (68/92) had an abnormal result from the 24-hour pH monitoring, 87% (82/94) had abnormal endoscopic results, 90% (84/93) had abnormal manometric results, and 89% (83/93) had signs of reflux with the barium series. At 3 years 50 patients had recurrent chest pain and 3 underwent coronary artery bypass surgery. Three patients died over the 3 years, all of noncardiac causes.

CONCLUSION

Many patients discharged from the CCU with a diagnosis of chest pain not yet diagnosed have a high incidence of esophageal disorders and a very low 3-year mortality rate. More research into the early and effective identification and management of patients with such a diagnosis is needed.

Diagnosis of Hirschsprung's disease

OBJECTIVE

Our aims were to determine the validity of using low-osmolality water-soluble contrast enemas (WSCE) in neonates and infants with suspected Hirschsprung's disease (HD) and to devise a scoring system that uses a checklist of radiologic signs to determine the probability of HD.

MATERIALS AND METHODS

The records of all patients referred by pediatric surgeons from 1988 through 1992 for the radiologic investigation of possible HD were retrospectively reviewed. Thirty-eight patients who were from 2 days to 9 months old were studied; 20 of them were neonates (less than 1 month old). Of all the patients, 24 underwent WSCE and the other 14 underwent barium enema. For all patients, HD had been diagnosed by rectal biopsy or excluded by biopsy, clinical follow-up, or both. Radiographs were read by a gastrointestinal radiologist who used a checklist of diagnostic criteria reported in the literature. The sensitivity had specificity of the findings were compared with those in the literature.

RESULTS

Of the 18 patients with HD, 12 were neonates. All reported radiologic diagnostic criteria were seen; the frequency, sensitivity, and specificity of the findings were reported. Twenty percent (n = 2) of HD patients in the WSCE group (n = 10) had negative findings. Two of the 12 neonates developed colonic perforation, one during the enema and the other within 24 hr of the procedure.

CONCLUSION

WSCE has a sensitivity and specificity equivalent to those of the barium enema for the detection of HD. For the two patients with perforation, the use of WSCE was of considerable benefit, avoiding the problems associated with barium spillage into the peritoneal cavity. A scoring system for diagnostic enemas is feasible.

Comparison of nutrient intake among depressed and nondepressed individuals

OBJECTIVE

The study investigated the nutrient intake of depressed and nondepressed subjects.

METHOD

Twenty-nine depressed subjects and a matched group of nondepressed subjects completed a 3-day food record.

RESULTS

Results revealed that depressed and nondepressed groups consume similar amounts of all nutrients except protein and carbohydrates. Nondepressed subjects consume more protein and depressed subjects consume more carbohydrates. The increase in carbohydrate consumption comes primarily from an increase in sucrose consumption.

DISCUSSION

The increased carbohydrate consumption is consistent with the carbohydrate cravings characteristic of the depressed and may relate to the development or maintenance of depression.

Improving visualization of distal and terminal ileum during the small bowel meal: an evaluation of fluoroscopic manoeuvres

This study evaluated a variety of fluoroscopic manoeuvres used during small bowel meals for assessment of the terminal ileum and pelvic loops of small bowel. The purpose was to identify those manoeuvres which provide maximum diagnostic yield. Fifty-six consecutive patients undergoing small bowel meal and pneumocolon entered the study. The individual manoeuvres were graded and their contribution to diagnostic quality determined. An analysis of variance was used to determine the diagnostic value of the manoeuvres. There was a significant difference in the diagnostic quality provided by the different manoeuvres. Compression of the terminal ileum with the 'F spoon' and of the pelvic bowel loops with the compression paddle in the supine position provided the best diagnostic information in single contrast. The double contrast images obtained with the pneumocolon contributed most to the diagnostic quality of the examination. The results enable us to recommend a sequence of manoeuvres which are most likely to provide diagnostic views of the terminal ileum and pelvic ileal loops yielding maximum information and optimizing use of fluoroscopic time.

Digital subtraction in defecography

BACKGROUND

Defecography is commonly used in investigation of pelvic floor and anorectal dysfunction, and incorporates measurement of pelvic floor movement during various maneuvers. These measurements are usually referenced to bony landmarks, particularly the ischial tuberosities. These bony landmarks may be difficult to visualize; theoretically, the use of digital subtraction in filming defecography studies should eliminate the need to pinpoint bony position.

METHODS

We filmed 25 defecogram studies in both non-subtracted and subtracted formats, and interpreted each study blindly, subsequently comparing diagnoses and measurements.

RESULTS

Subtraction was of limited benefit in only one case, was impossible in one case, added no useful information in 18 cases, and hindered visualization of abnormalities in five cases.

CONCLUSIONS

Because of the multiple overlapping densities and the inability to restrict patient movement, digital subtraction is unhelpful in defecography.

Premature contraction of the cricopharyngeus: a new sign of gastroesophageal reflux disease

BACKGROUND

A cricopharyngeal bar seen on barium fluoroscopy has been shown to be related to the presence of gastroesophageal reflux (GER). We investigated premature contraction of the cricopharyngeus (PCC) muscle, which may be a precursor of a fixed cricopharyngeal bar, to assess its significance in GER.

METHODS

The prevalence of PCC on barium swallow was recorded in three groups: (1) 83 patients with non-cardiac chest pain who were investigated for possible GER; (2) 21 patients with severe GER undergoing fundoplication; and (3) 25 normal controls.

RESULTS

Group 1: PCC was observed in 42 of 77 with documented GER (54.5%), and in two of six patients without GER. Group 2: PCC was present in 11 of 21 fundoplication subjects. Group 3: PCC was seen in five of 25 normal controls. The incidence of PCC in patients with GER was statistically significantly higher than in normal subjects (p = 0.002). The sensitivity of the presence of PCC as a predictor of GER is only 0.54, but the specificity is 0.774, with a positive predictive value of 0.883.

CONCLUSION

We conclude that observing premature cricopharyngeal contraction during the first swallows of an upper gastrointestinal (GI) study should direct attention to the possibility of GER.

Contemporary radiological examination of the upper gastrointestinal tract

Barium and endoscopy both have advantages. Endoscopy not only gives you direct visualization but also the ability to biopsy tissue. It does not give you the ability to determine the exact anatomy or the gross appearance of a lesion. Barium on the other hand gives you a dynamic examination which is particularly useful for the assessment of swallowing disorders and oesophageal motility. When the pharynx and oesophagus are not of prime concern and cost is not a problem then endoscopy is the examination of choice. It has been shown that dyspeptic patients who have had both examinations have a definite preference for endoscopy (Stevenson et al, 1991). As endoscopy requires minimal physical effort, it is also a preferable examination for the unwell patient.

Adequacy of the dietary intake of depressed individuals

OBJECTIVE

This study was conducted to assess the dietary intake of individuals experiencing a current episode of major depression.

METHODS

Twenty-two females and 7 males experiencing moderate to severe depression completed 3-day food records. These food records were analyzed to obtain an estimate of the nutrient intake of male and female individuals experiencing a depressive episode and this nutrient intake was compared to the Recommended Dietary Allowances (RDA).

RESULTS

Females, as a group, consumed a diet that provided 100% of the RDA whereas the diet of males was deficient in energy and 4 of 16 nutrients examined. Considerable variation existed in the dietary intake of both males and females with some individuals in both groups consuming a diet containing less than the RDA in one or more nutrients due to a decrease in food intake.

CONCLUSION

A substantial percentage of the depressed sample consumed less than the RDA of one or more nutrients. This seems to be due to an inadequate food intake rather than a deficient diet.