Double-blinded randomised placebo controlled trial of enterosgel (polymethylsiloxane polyhydrate) for the treatment of IBS with diarrhoea (IBS-D).

OBJECTIVE: Irritable bowel syndrome with diarrhoea (IBS-D) is a common and challenging condition that significantly reduces quality of life. Enterosgel (polymethylsiloxane polyhydrate) is an intestinal adsorbent which sequesters harmful molecules and is safe and effective in acute infective diarrhoea. This randomised controlled multicentre trial aimed to investigate its safety and efficacy in patients with IBS-D. DESIGN: After a 2-week screening phase, participants were randomised into an 8-week double-blind phase, followed by an 8-week open-label and follow-up phase. Participants recorded stool consistency, pain and global symptoms in e-diaries and questionnaires. The primary outcome was the percentage of responders on a composite abdominal pain (≥30% decrease in the weekly score) and stool consistency (50% reduction in days per week with at least one stool of BSFS type 6 or 7) score during at least 4 weeks of the treatment period. RESULTS: 440 patients with IBS-D were randomised to the double-blind phase with 393 continuing to the open-label phase. The Primary outcome responder rate by intention-to-treat for enterosgel versus placebo was 37.4% vs 24.3% (OR 1.95, NNT 8, p=0.002). Enterosgel also improved stool consistency (48.5% vs 32.5%, p<0.0001) abdominal pain (53.3% vs 40.2%, p=0.003), stool frequency (treatment effect -0.32 (-0.62 to -0.02)) and urgency (treatment effect -0.59 (-0.85 to -0.33)). 60% of patients reported adequate relief of symptoms after open-label treatment. Adverse event frequency was similar in both groups, with no serious events attributable to enterosgel. CONCLUSION: Enterosgel is safe and effective in IBS-D, providing an alternative to the limited current treatment options. TRIAL REGISTRATION NUMBER: ISRCTN17149988.

Self-Reported Practices in Opioid Management of Chronic Noncancer Pain: An Updated Survey of Canadian Family Physicians.

Chronic pain affects one in five Canadians, and opioids continue to be prescribed to 12.3% of the Canadian population. A survey of family physicians was conducted in 2010 as a baseline prior to the release of the Canadian Opioid Guideline. We repeated the same survey with minor modifications to reflect the updated 2017 opioid prescribing guideline. The online survey was distributed in all provinces and territories in both English and French. There were 265 responses from May 2018 to October 2019, 55% of respondents were male, 16% had advanced training in pain management, 51% had more than 20 years in practice, 54% wrote five or fewer prescriptions of opioids per month, and 58% were confident in their skills in prescribing opioids. Of the 11 knowledge questions, only two were correctly selected by more than 80% of the respondents. Twenty-nine physicians (11%) do not prescribe opioids, and the main factor affecting their decisions were concerns about long-term adverse effects and lack of evidence for effectiveness of opioids in chronic noncancer pain. Of the 12 guideline-concordant practices, only two were performed regularly by 90% or more of the respondents: explain potential harms of long-term opioid therapy and beginning dose of less than 50 mg of morphine equivalent daily. This survey represents a small proportion of family physicians in Canada and its generalizability is limited. However, we identified a number of opioid-related and guideline-specific gaps, as well as barriers and enablers to prescribing opioids and adhering to the guideline.

Enterosgel for the treatment of adults with acute diarrhoea in a primary care setting: a randomised controlled trial.

BACKGROUND: Acute intestinal infections are common conditions causing high morbidity and mortality especially in the young and elderly, resulting in a significant burden on health service resources and the economy. Current National Institute for Health and Care Excellence guidance are fluid and nutritional management; however, this does not reduce the duration of diarrhoea and the challenge of treating diarrhoea itself remains. We investigated the efficacy, tolerability and safety of intestinal adsorbent Enterosgel (polymethylsiloxane polyhydrate) compared with standard care in adults with acute diarrhoea. METHODS: This was a randomised controlled trial enrolling 105 subjects to receive the medical device Enterosgel up to six times daily for up to 8 days with standard care (oral rehydration solution), or standard care alone. The primary endpoint was the duration of diarrhoea (hours) from randomisation to first non-loose stool in the Enterosgel versus control group. RESULTS: A total of 51 subjects were randomised into the Enterosgel group and 54 into the control group, after excluding missing data, the data from 43 subjects in each group were analysed. Duration of diarrhoea was significantly shorter in the Enterosgel group at 27 hours versus 39 hours in the control group (HR was 1.74 [95% CI 1.06 to 2.87]) (p=0.03). This yielded a number needed to treat value of 5. Enterosgel was well tolerated and safe with no serious adverse events. One serious diarrhoea-related event resulting in hospitalisation was reported in the control group. CONCLUSIONS: Enterosgel treatment was associated with a significant reduction in the duration of diarrhoea in adults with patient-reported acute diarrhoea, compared with standard care. These findings support the role of Enterosgel in acute diarrhoea especially in vulnerable groups where rapid resolution of symptoms is required. Reduction in symptom duration could translate to less healthcare costs and socioeconomic burden. TRIAL REGISTRATION NUMBER: ISRCTN20758708.

Síndrome de Mendelson: reporte de un caso / Mendelson syndrome: a case report

El Síndrome de Mendelson es una presentación infrecuente pero catastrófica, consiste en la aspiración de contenido gástrico acido hacia los pulmones causando una neumonitis química por el paso de sustancias toxicas a las vías respiratoria inferiores. El cuadro clínico está caracterizado por hipoxemia, disnea, broncoespasmo, taquipnea, edema pulmonar, hipotensión, cianosis y atelectasias. La dificultad respiratoria se debe al edema agudo de pulmón y la necrosis. El diagnostico del Síndrome de Mendelson es de presunción en base a la sintomatología, la evolución de la enfermedad y los hallazgos en los exámenes de gabinete. Su tratamiento correcto es fundamental debido a la alta morbimortalidad que conlleva. Se presenta el caso de síndrome de Mendelson en un paciente de 89 años de edad debido a la enfermedad de Alzheimer, un trastorno neurodegenerativo. Se presentó a emergencias con un cuadro de vómitos postprandiales en abundante cantidad con contenido bilioso con secreciones flemosas, nauseas y dolor abdominal. La broncoscopia de urgencia fue clave para el diagnostico y el posterior tratamiento.

Mendelson's Syndrome is a rare but catastrophic presentation, is the aspiration of acidic gastric contents into the lungs causing chemical pneumonitis by the passage of toxic substances the lower respiratory tract. The clinical picture is characterized by hypoxemia, dyspnea, bronchospasm, tachypnea, pulmonary edema, hypotension, cyanosis, and atelectasis. Shortness of breath is due to acute pulmonary edema and necrosis. The diagnosis of Mendelson's Syndrome presumption is based on the symptoms, the disease evolution and the findings on tests of staff. Proper treatment is essential because of the high morbidity and mortality involved. For Mendelson's syndrome occurs in a patient of 89 years of age due to Alzheimer's disease, a neurodegenerative disorder. It was presented to emergency with symptoms of postprandial vomiting plenty flemosas content with bilious secretions, nausea and abdominal pain. Emergency bronchoscopy was key to the diagnosis and subsequent treatment.

Characteristics of patients receiving long-term opioid therapy for chronic noncancer pain: a cross-sectional survey of patients attending the Pain Management Centre at Hamilton General Hospital, Hamilton, Ontario.

BACKGROUND: Characteristics of patients receiving long-term opioid therapy (≥ 6 months) for chronic noncancer pain are poorly understood. We conducted a cross-sectional survey of this patient population to explore demographic variables, pain relief, functional improvement, adverse effects and impressions of an educational pamphlet on long-term opioid therapy. METHODS: We invited 260 adult patients presenting to the Pain Management Centre at the Hamilton General Hospital, Hamilton, Ontario, with chronic noncancer pain to complete a 20-item survey. Patients who presented for procedures were not eligible for our study. We used adjusted logistic regression models to explore the association between higher morphine equivalent dose and pain relief, functional improvement, adverse events and employment. RESULTS: The survey was completed by 170 patients (a response rate of 65.4%). Most respondents (87.6%; 149 out of 170) were receiving long-term opioid therapy, and the median morphine equivalent dose was 180 mg daily (interquartile range 60-501). Most respondents reported at least modest (> 40%) opioid-specific pain relief (74.1%; 106 out of 143) and functional improvement (67.6%; 96 out of 142), and 46.5% (66 out of 142) reported troublesome adverse effects that they attributed to their opioid use. Most patients were receiving disability benefits (68.3%; 99 out of 145) and, among those respondents who were less than 65 years of age (90.3%; 131 out of 145), 10 (7.6%) were working full-time and 14 (10.7%) part-time. In our adjusted analyses, higher morphine equivalent dose was associated with greater self-reported functional improvement (odds ratio [OR] 1.45, 95% confidence interval [CI] 1.07-1.96) but not with pain relief (OR 1.38, 95% CI 1.00-1.89), troublesome adverse effects (OR 0.92, 95% CI 0.70-1.20) or employment (OR 0.80, 95% CI 0.56-1.15). INTERPRETATION: Most outpatients receiving long-term opioid therapy for chronic noncancer pain at a tertiary care chronic pain clinic reported at least moderate pain relief and functional improvement; however, adverse effects were common and few patients were engaged in competitive employment.

What implementation interventions increase cancer screening rates? a systematic review.

BACKGROUND: Appropriate screening may reduce the mortality and morbidity of colorectal, breast, and cervical cancers. However, effective implementation strategies are warranted if the full benefits of screening are to be realized. As part of a larger agenda to create an implementation guideline, we conducted a systematic review to evaluate interventions designed to increase the rate of breast, cervical, and colorectal cancer (CRC) screening. The interventions considered were: client reminders, client incentives, mass media, small media, group education, one-on-one education, reduction in structural barriers, reduction in out-of-pocket costs, provider assessment and feedback interventions, and provider incentives. Our primary outcome, screening completion, was calculated as the overall median post-intervention absolute percentage point (PP) change in completed screening tests. METHODS: Our first step was to conduct an iterative scoping review in the research area. This yielded three relevant high-quality systematic reviews. Serving as our evidentiary foundation, we conducted a formal update. Randomized controlled trials and cluster randomized controlled trials, published between 2004 and 2010, were searched in MEDLINE, EMBASE and PSYCHinfo. RESULTS: The update yielded 66 studies new eligible studies with 74 comparisons. The new studies ranged considerably in quality. Client reminders, small media, and provider audit and feedback appear to be effective interventions to increase the uptake of screening for three cancers. One-on-one education and reduction of structural barriers also appears effective, but their roles with CRC and cervical screening, respectively, are less established. More study is required to assess client incentives, mass media, group education, reduction of out-of-pocket costs, and provider incentive interventions. CONCLUSION: The new evidence generally aligns with the evidence and conclusions from the original systematic reviews. This review served as the evidentiary foundation for an implementation guideline. Poor reporting, lack of precision and consistency in defining operational elements, and insufficient consideration of context and differences among populations are areas for additional research.

Effective interventions to facilitate the uptake of breast, cervical and colorectal cancer screening: an implementation guideline.

BACKGROUND: Appropriate screening may reduce the mortality and morbidity of colorectal, breast, and cervical cancers. Several high-quality systematic reviews and practice guidelines exist to inform the most effective screening options. However, effective implementation strategies are warranted if the full benefits of screening are to be realized. We developed an implementation guideline to answer the question: What interventions have been shown to increase the uptake of cancer screening by individuals, specifically for breast, cervical, and colorectal cancers? METHODS: A guideline panel was established as part of Cancer Care Ontario's Program in Evidence-based Care, and a systematic review of the published literature was conducted. It yielded three foundational systematic reviews and an existing guidance document. We conducted updates of these reviews and searched the literature published between 2004 and 2010. A draft guideline was written that went through two rounds of review. Revisions were made resulting in a final set of guideline recommendations. RESULTS: Sixty-six new studies reflecting 74 comparisons met eligibility criteria. They were generally of poor to moderate quality. Using these and the foundational documents, the panel developed a draft guideline. The draft report was well received in the two rounds of review with mean quality scores above four (on a five-point scale) for each of the items. For most of the interventions considered, there was insufficient evidence to support or refute their effectiveness. However, client reminders, reduction of structural barriers, and provision of provider assessment and feedback were recommended interventions to increase screening for at least two of three cancer sites studied. The final guidelines also provide advice on how the recommendations can be used and future areas for research. CONCLUSION: Using established guideline development methodologies and the AGREE II as our methodological frameworks, we developed an implementation guideline to advise on interventions to increase the rate of breast, cervical and colorectal cancer screening. While advancements have been made in these areas of implementation science, more investigations are warranted.

El odontólogo frente al maltrato infantil / The dentist and the child abuse

El maltrato y el abandono de los niños y adolescentes es un problema social en aumento que no se limita a las profesiones legales o de servicio social, sino también a la Estomatología. La presente revisión define el Maltrato Infantil y orienta al odontólogo a detectar, documentar, informar y ayudar a tratar a niños, adolescentes y sus familias que presenten este problema y prevenir episodios de maltrato.

The abuse and abandonment of children and adolescents is a social problem that is increasding, its not limited to legal and social services professions, but also to Dentistry. This review article gives an overview of child abuse and orient dentists to detect, document, inform and help with treatment of children, adolescents and their families who have this problem and prevent future occurrence.