Systematic review of the prevalence of faecal incontinence.

BACKGROUND: Faecal incontinence (FI) is widely recognized as a significant problem in the community. Conjecture exists around the proportion of the population affected. This systematic review evaluated studies reporting the community prevalence of FI in terms of methodology, design and definitions. METHODS: MEDLINE, Embase, CINAHL, the Cochrane Collaboration and National Guideline databases were searched for studies investigating the prevalence of FI in community-based adults published from January 1966 to February 2015. Study data, including methodology, sample size, response rate, definition of FI and prevalence rates, were extracted on to a pro forma and appraised critically. Where possible, FI prevalence estimates were pooled. RESULTS: Thirty studies were analysed from 4840 screened articles. FI prevalence estimates varied from 1·4 to 19·5 per cent. This variation was explained by differences in data collection method and two factors within definitions of FI: type of stool and frequency of FI episodes. When these factors were accounted for, the FI prevalence at a threshold of at least once per month for liquid or solid stool was 8·3-8·4 per cent for face-to-face or telephone interviews, and 11·2-12·4 per cent for postal surveys. The pooled prevalence rate from studies for functional FI (defined by ROME II criteria) was 5·9 (95 per cent c.i. 5·6 to 6·3) per cent. CONCLUSION: When comparable methodologies and definitions are used, studies produce remarkably similar prevalence rates in different community populations. FI remains an unspoken symptom, with lower rates reported in personal interviews compared with anonymous postal questionnaires.

Mortality risk stratification in severely anaemic Jehovah's Witness patients.

The aim of this retrospective cohort study was to identify early risk factors of mortality and develop a mortality risk stratification instrument for severely anaemic Jehovah's Witness patients. It has been shown that Jehovah's Witness patients with the Auckland Anaemia Mortality Risk Score (Auckland AMRS) of 0 to 3 had 4% mortality, Auckland AMRS 4 to 5 32%, Auckland AMRS 6 to 7 50% and Auckland AMRS 8 and above 83%. It is concluded that the Auckland AMRS predicts mortality of severely anaemic Jehovah's Witness patients.

Clinical benefits and cost-effectiveness of allogeneic red-blood-cell transfusion in severe symptomatic anaemia.

BACKGROUND: It is well known that blood transfusion is life-saving, but also that it carries a serious risk of transmitting viral infections. Introduction of new methods of testing for transmissible diseases, blood banking and dispatch regulations has considerably increased the cost of blood products. However, the clinical benefits and cost-effectiveness of allogeneic red-blood-cell (ARBC) transfusion remain assumed yet undetermined. We assessed the clinical benefits and cost-effectiveness of ARBC transfusion in severe anaemia. METHODS: This was a multicenter observational study comparing Jehovah's Witness (JW) patients with matched ARBC-transfused patients. Inclusion criteria were age ≥15 years and severe anaemia (haemoglobin ≤ 80 g/l). Two JW patients with palliative care cancer and five JW patients with haemoglobin (Hb) concentration between 70·1 and 80 g/l, mild symptoms of anaemia and Auckland Anaemia Mortality Risk Score of 0-3 were excluded. RESULTS: The entry criteria were met by 103 JW patients and the same number of patients treated with ARBC transfusion. ARBC transfusion reduced mortality by 94%, shock by 88%, gastrointestinal bleeding by 81%, infective complications by 81%, cardiac arrhythmia by 96%, angina by 86%, ischaemic myocardial injury by 81%, acute/acute on chronic renal failure by 66%, neurologic complications by 92%, delirium by 76%, depression by 91% and syncopal episodes by 95%. The incremental cost-effectiveness ratio of ARBC transfusion was 2011 US$22 515 for death prevented. CONCLUSION: ARBC transfusion in anaemic patients is clinically beneficial and cost-effective.

Determining levels of fecal incontinence in the community: a New Zealand cross-sectional study.

BACKGROUND: Fecal incontinence is a socially stigmatized condition, and its prevalence in the community has been problematic to quantify because of difficulty with its definition. OBJECTIVE: This study estimates the community prevalence of fecal incontinence in New Zealand by 3 scales of measurement: patient perceptions of a "problem with bowel control," their symptoms, and their quality of life. DESIGN/MAIN OUTCOME MEASURES: A postal survey of 2000 people, aged >18, randomly selected from the national electoral roll, was performed. This used a validated, reliability-tested, anonymous questionnaire, the Comprehensive Fecal Incontinence Questionnaire, incorporating the identification of a "problem with bowel control," the Fecal Incontinence Severity Index, and the Fecal Incontinence Quality of Life Scale. RESULTS: The response rate was 68.7%. A total of 14.7% (95% CI: 12.6-16.7) of participants "felt they had a problem with bowel control" and 12.4% (95% CI: 10.5-14.5) had fecal incontinence when defined using the Fecal Incontinence Severity Index table as "leakage of liquid or solid stool ≥ 1/month." In terms of quality of life, 26.8% of the population (95% CI: 24.2-29.4) noted some impairment on the Fecal Incontinence Quality of Life Scale. In total, 155 (13.2%) participants reported at least 2 of the 3 possible diagnostic measures, and this may provide a way to incorporate the 3 measures into a new definition of fecal incontinence. LIMITATIONS: This study incorporated a new "generic" question enquiring about an individual's perception of a bowel control problem and also introduced a "cutoff" value for Fecal Incontinence Quality of Life Scale to attempt to identify those with any impairment "due to accidental bowel leakage." CONCLUSIONS: This study helps to highlight some of the challenges involved with suitably identifying those who have fecal incontinence within the community. The prevalence rate of 13.2% represents a realistic measure of the burden of fecal incontinence in the general population, and further research in this area is recommended.

Putting it bluntly: communication skills in the Iliad.

In current undergraduate medical curricula, much emphasis is placed on learning the skills of communication. This paper looks at Homer's Iliad and argues that from it we may learn that our skills can be mechanistic, shallow and simplistic. Homer was regarded in the Greek and Roman world as the father of rhetoric. This reputation rested greatly on book 9 of the Iliad, the embassy from the Greek leaders to the bitter, wrathful Achilles. The mission of the three emissaries is to persuade him to return to the ranks of the Greeks, who are being routed since his refusal to fight. We learn how the outcome of a conversation may be predetermined by the previous relationship of the speakers, and how a man beyond reason responds to reason; we should reflect that Homer's audience heard the piece knowing the outcome, giving it a tragic inevitability. We, the audience, cannot analyse the discourse rationally, because in this, as in all communication, reason is disturbed by emotion.

Vehicle interior interactions and kinematics of rear facing child restraints in frontal crashes.

The performance of rear facing child restraints in frontal crashes can be determined by controlling a) the child's kinematics and b) interactions with vehicle structures. Twelve sled tests were performed to analyze the effect of the location and structural properties of vehicle interior components. The role of restraint kinematics was studied by developing computational models which underwent idealized motions. Stiff structures originally offset from the restraint, but which contact the restraint late in the test, cause increased injury values. Attachment methods which reduce child restraint rotation and more rigidly couple the restraint to the vehicle result in the best safety performance.

Interstitial nephritis associated with perianeurysmal retroperitoneal fibrosis.

Renal failure in retroperitoneal fibrosis is usually secondary to ureteric obstruction. We report a patient whose renal failure did not improve following relief of obstruction. Renal biopsy showed an interstitial nephritis, and function improved with steroid therapy. We suggest that renal biopsy should be considered in cases of renal failure associated with retroperitoneal fibrosis that do not respond to the relief of ureteric obstruction.

Use of odds ratios on anaesthesia related studies.

In line with other medical journals, odds ratios are increasingly being reported in anaesthesia literature. The frequency of the use of odds ratio and how well it relates to the relative risk when it is interpreted as relative risk remains unknown. We investigated the use of odds ratio, and its relationship to relative risk and the incidence of outcome in this study. We identified 60 meta-analyses and 87 original articles that reported odds ratios. While relative risk could have been reported in 79% of the studies, only a small proportion (3%) of these studies have estimated and reported the relative risk in addition to the odds ratio. There is a significant bias if odds ratio is interpreted as relative risk, especially so when the incidence of outcome is high. While odds ratio is a valid measure of treatment effect in its own right, anaesthetists and investigators should be careful not to interpret odds ratio as equivalent to relative risk.

Post-operative paraplegia following spinal cord infarction.

Thoracic epidural analgesia is a frequently utilised technique. Neurological complications are uncommon, but of grave consequence with significant morbidity. Spinal cord infarction following epidural anaesthesia is rare. We present a case where a hypertensive patient underwent an elective sigmoid colectomy under combined general/epidural anaesthesia for a suspected malignant abdominal mass. An epidural infusion was used for intra-operative and post-operative analgesia. During surgery, the blood pressure was labile and she was hypotensive. Postoperatively, the patient became confused, pyrexial and tachycardic and developed systemic inflammatory response syndrome requiring intensive care management. She developed a flaccid paralysis at L3 level with areflexia, analgesia and impaired sensation. A spinal cord infarct in the region of the conus extending into the thoracic cord was diagnosed. Complications of epidural anaesthesia are easily recognised when they develop immediately; their relationship to the anaesthesia and the post-operative period may be misjudged or underestimated when they appear after a delay, if neurological signs are masked by lack of patient cooperation and drowsiness or if the epidural anaesthesia is prolonged by long-acting drugs. New neurological deficits should be evaluated promptly to document the evolving neurological status and further testing or intervention should be arranged if appropriate. The association with epidural anaesthesia as a cause of paraplegia is reviewed. The aetiological factors that may have contributed to this tragic neurological complication are discussed.

The use of classification and regression trees in clinical epidemiology.

A critique is presented of the use of tree-based partitioning algorithms to formulate classification rules and identify subgroups from clinical and epidemiological data. It is argued that the methods have a number of limitations, despite their popularity and apparent closeness to clinical reasoning processes. The issue of redundancy in tree-derived decision rules is discussed. Simple rules may be unlikely to be "discovered" by tree growing. Subgroups identified by trees are often hard to interpret or believe and net effects are not assessed. These problems arise fundamentally because trees are hierarchical. Newer refinements of tree technology seem unlikely to be useful, wedded as they are to hierarchical structures.

Displaying clinical data relationships using scaled rectangle diagrams.

A method is presented to draw rectangles to represent categorical data relationships. The idea is an adaptation of a scaled Venn diagram. Rectangles are drawn with area proportional to the frequency of categories and the rectangles are positioned to overlap each other so that the areas of overlap are in proportion to the joint frequencies of the characteristics. The diagrams are especially useful to illustrate symptom co-occurrence.

Determining and visualising at-risk groups in case-control data.

BACKGROUND: Case-control research is often exploratory; to determine factors that increase risk. Often, regression methods are used to determine combinations of risk factors that predispose to excess risk. Recently, tree-based methods have also been proposed. Both have limitations. An alternative approach is suggested, based on a search algorithm to identify at-risk subgroups. METHODS: Statistical methods to determine and visualise at-risk sub-groups in case-control studies are presented. The method of determining sub-groups--search partition analysis (SPAN)--searches among different Boolean combinations of risk factors. Sub-groups that have been identified are visualised by scaled rectangle diagrams. These show the size of sub-groups and the extent to which they overlap. RESULTS: Theory is presented for applying the method to case-control data. The methods are illustrated by analysis of three case-control studies: one on sudden infant death syndrome, a second on heart disease and a third on child pedestrian injuries. CONCLUSIONS: The methods provide a useful alternative to regression and tree-based analysis. They demarcate subgroups that, in the three examples, are easy to interpret and would not have been found by other methods. Scaled rectangle diagrams are a useful way to visualise the results.

Cardiomyopathy in children.

The cardiomyopathies are a group of disorders of the myocardium associated with a decrease in cardiac function. This article describes the three functional types: (1) dilated or congestive; (2) obstructive, as in hypertrophic cardiomyopathy, and (3) restrictive as in infiltrative disorders such as the storage diseases.

A case-crossover analysis of a case-control study of alcohol consumption and coronary events: the effects of exposure definition and the use of control data.

BACKGROUND: Case-crossover studies can be used to assess the effects of transient exposures in acute events by comparing cases' exposures at the time of the event against their usual exposure. Cases from a case-control study can also be analysed by this method if appropriate information is obtained. METHODS: We apply the case-crossover method to data collected in a case-control study of acute coronary events, to estimate the risk of alcohol consumption in the 24 h before a coronary event. Two questions, concerning the usual frequency of consuming alcohol and how much was consumed, were used in the analysis. The sensitivity of effect estimates to the two questions and to different ways of eliciting probabilities from them, are examined. The cases and controls were both analysed in the same way, assigning controls a 'pseudo-event' time at random. It is suggested that controls may provide a benchmark to establish whether bias exists in the case-series analysis. RESULTS: We find that the case-crossover analysis is sensitive to how exposure probabilities are assigned. Adopting a Poisson model for exposures leads to inflated risk estimates. The bias is removed if the control series is used to adjust estimates. There appears to be a small protective effect from alcohol consumption. CONCLUSION: Case-crossover designs have considerable potential, but reliable information on usual exposure limits their applicability. More research is required on how best to elicit exposure probabilities.