Pharmacist's knowledge regarding the management of overactive bladder in elderly women.

OBJECTIVE: Anticholinergic drugs are the mainstay treatment of OAB. Anticholinergic load is the cumulative effect of taking anticholinergic medication. Recent evidence suggests that in the elderly this can have a detrimental affect, with the potential to develop dementia. A previous study found that knowledge of anticholinergic load was lacking in our healthcare professionals. The aim of this study was to assess knowledge of pharmacists, who in the UK have the potential where qualified to prescribe as well as dispense. STUDY DESIGN: A questionnaire was formulated based on the previous study. It was sent out to 418 pharmacists from; a south London hospital trust, a south London clinical commissioning group and United Kingdom Clinical Pharmacists Association. RESULTS: Seventy-five pharmacists completed the questionnaire. Solifenacin and tolterodine was the most popular drug prescribed in the elderly without dementia, whilst mirabegron was the most popular in the elderly with dementia. One pharmacist suggested using oxybutynin. Sixty-two percent discuss anticholinergic load with the patients, 40 % advice prescribers and 42 % consider anticholinergic load when dispensing the drug. Fifteen percent have had patients report confusion/memory loss. Thirty percent know how to assess anticholinergic load. Only 15 % felt dementia was a concern with anticholinergic drugs. Worryingly, 54 % though mirabegron exerted anticholinergic effects. CONCLUSION: This is the first study looking at pharmacist knowledge on the use of anticholinergic medication for OAB in elderly women. Knowledge amongst all healthcare professionals including pharmacists is lacking and needs to be improved.

What affects the placebo effect?

OBJECTIVE: To determine whether electronic bladder diaries are associated with a larger placebo effect than paper diaries in studies of overactive bladder (OAB). To identify any other factors in study design that may influence the placebo effect. STUDY DESIGN: This is a secondary analysis of a previous systematic review and network meta-analysis on the efficacy and tolerability of mirabegron. Each study was analysed and placebo response rate (PRR) was calculated. Statistical analysis was used to look for associations with different factors and PRR. RESULTS: The PRR was considerable in the studies analysed (10.5 % when calculated for change in number of micturitions over 24 h and 41.2 % for change in urgency urinary incontinence episodes over 24 h). Paper bladder diaries were associated with a significantly larger placebo response rate than electronic (10.76 % vs 10.22 %), although this may be clinically small. The size of study had a moderate positive correlation with PRR. Length of bladder diary was not associated with increased PRR. CONCLUSIONS: The PRR in studies of OAB is varied and significant. It is clear that it can be affected by factors in study design including type of bladder diary. When designing clinical studies this should be borne in mind. Equally, when attempting to optimise patient care, the benefit of the therapeutic encounter should be remembered.

Is there enough evidence to justify the use of laser and other thermal therapies in female lower urinary tract dysfunction? Report from the ICI-RS 2019.

AIMS: There is increasing evidence to suggest that thermomodulation may have a role in the management of women with lower urinary tract dysfunction (LUTD) and there has been widespread adoption of laser and radiofrequency (RF) therapies within clinical practice. However, in many areas of LUTD, the data are still limited and there remains a need for further evaluation of the safety and efficacy of thermal therapy. The aim of this study proposal is to report the findings of the International Consultation on Incontinence Research Society to clarify our current knowledge regarding the evidence for thermal therapy in LUTD and to set research priorities for the future. METHODS: Literature review based on the search terms: "laser," "radiofrequency," "genitourinary syndrome of the menopause" or "urogenital atrophy," "stress urinary incontinence (SUI)," "pelvic organ prolapse," "OAB" or "overactive bladder," and "urinary tract infection." RESULTS: The current available evidence, though of low or very low quality, appears promising for the use of laser therapy in the management of genitourinary syndrome of the menopause, there are some data to suggest a possible role in SUI although very little evidence for urogenital prolapse. At present, the evidence supporting the use of laser in OAB and recurrent urinary tract infection is limited or lacking, while the available evidence for RF in the management of all forms of LUTD is much less robust. CONCLUSIONS: Laser and RF are being introduced clinically as a minimally invasive, low-risk interventions for women with LUTD although at present, the evidence supporting usage is limited. Consequently, there is an urgent need to demonstrate the safety and efficacy with prospective long-term studies including sham studies and comparative studies with current standard therapy.

Psychometric Characteristics of the Revised Illness Perception Questionnaire (IPQ-R) in People Undergoing Weight Loss Surgery.

The Illness Perception Questionnaire-Revised (IPQ-R) has been used extensively across many health conditions to measure patient illness and treatment perceptions. The constructs have an association with treatment adaptation and adherence which, in turn, are considered core factors involved in bariatric surgery outcome. This study examines the factorial validity and internal reliability of a modified (IPQ-R) in bariatric surgery candidates. After wording modifications, participants (N = 310) completed the IPQ-R as part of standard pre-surgery assessments. After removal of two items, confirmatory factor analysis (CFA) supported the original 7-factor solution of the Beliefs scale, with good to marginal subscale internal consistency. Exploratory factor analysis (EFA), with two items removed only partially supported the original 5-factor Causal Attributions scale. Internal consistency was unacceptably low for two subscales. Further research is needed to generate new items which better fit the IPQ-R to this population before research can explore the relevance of illness perceptions.

Stricture rate after chemoradiotherapy and radiotherapy for oesophageal squamous cell carcinoma: a 20-year experience.

BACKGROUND: Definitive chemoradiation for oesophageal squamous cell carcinoma (SCC) is the first-line treatment in many centres. However, it is not without morbidity. We assess outcomes for patients treated with definitive chemoradiotherapy and radiotherapy. METHODS: A retrospective review of a prospectively maintained database (Radiotherapy Department, Canterbury District Health Board) was undertaken. All patients who underwent definitive radiotherapy for oesophageal SCC between October 1996 and April 2015 were included. RESULTS: Sixty patients underwent chemoradiotherapy with curative intent and 17 underwent definitive radiotherapy with curative intent. Median age was 69 years (44-84 years) for those undergoing chemoradiotherapy and 73 years (36-85 years) for those who underwent definitive radiotherapy. Tumour location in all patients was upper third in 14 (18%), middle third in 39 (51%), lower third in 22 (29%) cases and junctional tumour in two (3%). Staging information was complete for 73 of 77 patients (stage I 16/77 (21%), stage II 40/77 (52%), stage III 17/77 (22%)). Median dose of external beam radiotherapy for those who underwent definitive chemotherapy was 50.4 Gy (30-63 Gy) and 60 Gy (50-64 Gy) for definitive radiotherapy. Median length of follow-up was 39 months (range 4-120 months). Strictures developed in 58% of all patients (52% chemoradiotherapy and 76% definitive radiotherapy). Twenty-four (32%) patients were dilated and 14 (18%) stented. The chemoradiotherapy group had higher 5-year survival than definitive radiotherapy group (34% versus 6%, P = 0.0034). CONCLUSION: Oesophageal SCC treated with chemoradiation has a 5-year survival rate of 34%. Post-treatment strictures occur in 52% of patients with chemoradiotherapy and 76% with definitive radiotherapy.

Understanding resilience as it affects the transition from the UK Armed Forces to civilian life.

There has been growing interest among policy officials, charity representatives and academic experts in understanding the transition process of UK Service leavers. While recent evidence suggests that resilience is important for a successful transition, no systematic review has been undertaken on this topic before this study. FiMT commissioned RAND Europe to research whether - and how - resilience can affect individual transition pathways and outcomes for UK Service leavers.

AbobotulinumtoxinA for the treatment of overactive bladder.

INTRODUCTION: Overactive bladder is a common condition that can have a negative impact on quality of life. Botulinum Toxin A is a third line treatment for overactive bladder following conservative measures and anticholinergic medication. At present, OnabotulinumtoxinA is the only preparation licensed for this indication. More recently, trials have been undertaken to compare the efficacy of this to AbobotulinumtoxinA. Areas covered: This article aims to provide an overview of AbobotulinumtoxinA, which is currently not yet licensed for overactive bladder or neurogenic detrusor overactivity. It will detail the pharmacokinetics and dynamics, assess the available clinical trial data and make comparisons with current clinical practice. A systematic literature search was completed, using ovid Medline and Embase, with the aim to review all data concerning the administration of AbobotulinumtoxinA for the treatment of overactive bladder. Expert opinion: Currently, there are a lack of data on the use of AbobotulinumtoxinA for overactive bladder or neurogenic detrusor overactivity. Current evidence concentrates on its use in neurogenic detrusor overactivity, and there are data to show it may be as efficacious as OnabotulinumtoxinA. However, there is a lack of homogenous data to compare the two products and therefore we are unable to recommend this currently.

Intramural oesophageal haematoma-a rare complication of dabigatran.

An 85-year-old female presented to hospital with haemoptysis. She underwent investigations which confirmed oesophageal submucosal haematoma. Oesophageal haematoma along with Mallory-Weiss and Boerhaave's syndromes make up acute mucosal injury of the oesophagus. It can be managed conservatively in the majority of cases.

Digital assessment and quantification of pelvic organ prolapse (DPOP-Q): a randomised cross-over diagnostic agreement trial.

INTRODUCTION: Pelvic Organ Prolapse Quantification (POP-Q) system, measured in centimetres using a ruler (e.g. POPstix®), is recommended to quantify prolapse severity. POPstix® are costly (US $1/ruler). Home-made devices are used instead, but these have not been shown to be reproducible. HYPOTHESIS: Digitally assessed POP-Q (DPOP-Q) is as reliable, reproducible and acceptable as POP-Q assessed using POPstix®. METHODS: In this randomised crossover diagnostic agreement trial, each assessor measured the index finger of their dominant hand using a ruler. At visit one, patients were randomised to either POPstix® POP-Q assessment in a modified lithotomy position or DPOP-Q in both modified a lithotomy and a standing position. After the first clinician conducted this assessment, a second blinded clinician then carried out the remaining assessment on the same patient. For each examination, duration was recorded, along with a patient-completed discomfort score. Twenty-five women were invited for visit two, at which DPOP-Q was recorded by the same clinician who undertook DPOP-Q at the first visit. This allowed evaluation of inter- and intraobserver agreement together with examination acceptability. RESULTS: One hundred and nine women were recruited [median age 55 years, parity 2, body mass index (BMI) 27.1]. Of the 25 patients invited, 23 returned for visit two. DPOP-Q had high interobserver reliability [κ = 0.94, 95 % confidence interval (CI) 0.878-0.996] and intraobserver reliability (α = 0.96) with POPstix®. DPOP-Q was significantly quicker (p = 0.02) and less uncomfortable (p < 0.01) than POPstix® POP-Q. CONCLUSION: DPOP-Q is reliable, acceptable and cost effective.

The Pattern of Adjustments after Laparoscopic Adjustable Gastric Band.

BACKGROUND: The success of laparoscopic adjustable gastric band (LAGB) is dependent on gradual adjustments over time. The aim of this study is to describe that pattern of LAGB adjustments that are required after surgery. METHODS: A non-randomized observational study of consecutive LAGB from a single practise. Patients were sourced from a prospective database. Details of each LAGB adjustment were recorded along with weight loss and complications. RESULTS: There were 125 consecutive LAGB between March 2009 and September 2011 (mean age 46.6 ± 11.9 years; 113 female, BMI 42.1 ± 5.9 kg/m(2)). The mean %EBWL was 41.4 ± 19.1 % at 2 years. There was a total of 746 band adjustments with mean 7.1 ± 4.4 per patient. Approximately, a third of patients (34 %) reached optimal volume within 6 months but 49 patients (39 %) still required adjustments beyond a year. Weight loss was maximal prior to the first adjustment (41 % of mean total weight loss). The rate of weight loss decreased down to 1-3 %EBWL between later fills despite repeated increases in band volume. Urgent deflations were required in 63 patients with 24 of these patients having multiple overfills. There were two patients who had gastric prolapse but no other LAGB-related complications occurred in the first 2 years after surgery. CONCLUSIONS: LAGB requires a considerable postoperative commitment that may take several months. Overfills are common and may be the result of a false perception that tightening the band will hasten weight loss.

A comparison of laparoscopic adjustable gastric band and laparoscopic sleeve gastrectomy: a single surgeon's experience.

AIM: Laparoscopic adjustable gastric band (LAGB) has been a popular form of surgical weight loss in New Zealand but is now being neglected in preference of the laparoscopic sleeve gastrectomy (LSG). Arguments for each operation have focused on differences in weight loss and complication rates. The aim of this study is to compare the results of these two techniques from a single surgeon's practise. METHOD: A non-randomised, observational study comparing patients undergoing either LAGB or LSG by a single surgeon. RESULTS: There were 228 patients who had either a LAGB (94 patients, mean age 45.1 plus or minus 11.9 years, mean BMI 42.2 plus or minus 7.1 kg/m2) or a LSG (134 patients, mean age 44.8 plus or minus 9.11 years, mean BMI 50.2 plus or minus 9.0 kg/m2) between October 2009 and April 2014. The 2-year mean percent excess body weight loss for the LAGB group was 46.1 plus or minus 27.8% compared to 72.1% plus or minus 20.9% for the LSG group (P<0.0001). There were 19 patients (20%) that required 29 reoperations following LAGB, most commonly for gastric prolapse (mean 22.8 plus or minus 13.8 months postop). In contrast, there were 4 patients (3%) that required reoperation following LSG (2 haemorrhage, 1 staple-line leak and 1 check laparoscopy) and 2 patients (1%) that required gastroscopy for sleeve spasm. Reoperation rate was significantly greater for LAGB than LSG (p<0.0001). CONCLUSION: In this current series there was a significantly reduced level of weight loss but higher complication rate following LAGB when compared to LSG. Despite the limitations of this study, the results may explain why LSG has gained preference over LAGB in recent years.

Differences in acute general surgical admissions between obese or overweight patients compared to normal-sized patients.

AIM: Obesity is changing the pattern of modern health and illness. Despite its adverse effect on medical ailments such as diabetes and ischaemic heart disease, its effect on acute general surgical conditions is unknown. This study aims to determine the effect that excess weight and obesity have on acute general surgical conditions. METHODS: A prospective observational cohort study comparing the pattern of acute general surgical admissions in patients with a BMI >25 kg/m(2) to those with a normal BMI from a single tertiary-level hospital. RESULTS: There were 2,676 (21.5%) patients who were overweight or obese (mean BMI 32.4 ± 6.3 kg/m(2)). These patients were significantly younger than those with normal BMI (48.3 ± 18.1 years versus 50.5 ± 22.4 years; p<0.0001). They had a shorter average hospital stay (2.9 ± 4.2 compared to 3.2 ± 5.0 days; p=0.14). However, more overweight patients required a visit to theatre (34% compared to 29%; p<0.0001, OR 1.25 (1.14 to 1.37; 95% CI)). Overweight patients were more likely to suffer from biliary conditions (13% compared to 8%; p<0.0001; OR 1.84 (1.60-2.10)) and pancreatitis (6% compared to 4 %; p<0.0001; OR 1.71 (1.42 to 2.06)). In contrast, they were less likely to present with bowel obstruction (4% compared to 6%; p<0.0001, OR 0.63 (0.5 to 0.78)) or GI bleeding (4% compared to 6%; p<0.0001; OR 0.64 (0.51 to 0.79)). CONCLUSIONS: Overweight or obese patients present at a younger age and with a higher predominance of gallstone related diseases.

Metastatic renal cell carcinoma--an unexpected finding after laparoscopic cholecystectomy.

Tumours metastasising to the gallbladder from other sites are rare; we aim to present a case of this unusual site of metastasis and give an overview of the current literature surrounding it. A case of renal cell carcinoma (RCC) with gallbladder metastasis is presented, along with a brief summary of the literature. A 55-year-old female presented with symptoms due to a large right RCC. Staging investigations were negative for metastasis and she underwent curative resection. She presented 8 years later with cholecystitis, and histological examination of the gallbladder specimen identified metastatic renal cell carcinoma which was not identified on preoperative imaging. RCC metastases to the gallbladder are unusual, but probably more common than recognised. They're frequently not identified preoperatively, and prognosis is similar to isolated metastases to other organs.

Portal vein thrombosis as a complication of laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is a popular form of weight loss surgery in New Zealand. The current case report describes an incident of portal vein thrombosis (PVT) following this surgery and serves to increase the understanding of the unique risks of this operation.

Laparoscopic adjustable gastric bands and the effect of living in distant towns.

AIM: To investigate whether the results of laparoscopic adjustable gastric bands (LAGB) are adversely affected when patients live in towns distant from their surgeons. METHODS: A retrospective observational cohort study was conducted of patients having LAGB at Christchurch, New Zealand between March 2009 and March 2011. Patient demographics, postoperative band adjustments, and weight loss were recorded. The results were compared between those patients living in Christchurch and those that reside outside this region. RESULTS: There were 142 patients (123 female) with 97 (68%) living in Christchurch. These local patients were younger on average (mean age 45.6 plus or minus 11.3 years compared to 49.9 plus or minus 8.9 years; p=0.026) and of lesser size (mean BMI 43.1 plus or minus 7.1 kg/m2 compared 55.0 plus or minus 12.3 kg/m2; p<0.001) than those living beyond this region. There was no significant difference in the number of postoperative band adjustments between the two groups (Christchurch mean of 7.8 plus or minus 4.5 adjustments compared to 6.5 plus or minus 4.2 adjustments; (p=0.156) nor in the final volume that the band was adjusted to (Christchurch mean 4.6 plus or minus 1.3 mL compared to 4.1 plus or minus 1.7 mL; p=0.069). There was no significant difference in the weight loss between the groups at 2 years (Christchurch mean 41.4 plus or minus 17.3% excess body weight lost (EBWL) compared to 42.5 plus or minus 15.2% EBWL; p=0.829). DISCUSSION: This current study demonstrates that patients undergoing LAGB in Christchurch are not disadvantaged if they live in towns beyond this region.