Gastric Electrical Stimulation for the Treatment of Gastroparesis or Gastroparesis-like Symptoms: A Systemic Review and Meta-analysis.

BACKGROUND: The effects of gastric electrical stimulation are not fully understood. We aimed to assess the efficacy of gastric electrical stimulation (GES) for patients with gastroparesis and gastroparesis-like symptoms. MATERIALS AND METHODS: We searched PubMed, Scopus, Cochrane, Web of Science, Embase, and Science Direct to identify controlled trials and cohort studies. We used random effects models to estimate pooled effects. A total of nine studies met the criteria and were included for the final qualitative synthesis and the quantitative analysis. We examined the mean absolute differences (MD) and 95% CIs. RESULTS: Nine studies (n = 730) met the criteria and were included for the final qualitative synthesis and the quantitative analysis. There was significant improvement in gastrointestinal (GI) total symptom score (TSS) with the GES group compared with controls during the randomized blind trials. This effect was sustained at 12 months after treatment compared with before treatment (MD = -6.07; 95% CI, -4.5 to -7.65; p < 0.00001). The pooled effect estimate showed a significant improvement in frequency of weekly vomiting episodes at 12 months compared with before treatment (MD = -15.59; 95% CI, -10.29 to -20.9; p < 0.00001). CONCLUSION: GES appears beneficial, with significant improvement in GI TSS, weekly vomiting frequency, gastric emptying study, and quality of life.

Rectal Distension Increased the Rectoanal Gradient in Patients with Normal Rectal Sensory Function.

BACKGROUND: Frequent observation of abnormal manometric patterns consistent with dyssynergia in healthy volunteers has warranted the need for reassessment of the current methods to enhance the diagnostic value of anorectal manometry in functional defecatory disorders. Whether rectal distention at simulated evacuation will affect anorectal pressure profile and increase rectoanal gradient is not known. METHODS: One hundred and eight consecutive patients with chronic constipation, 93 females, median age 53 years (interquartile range: 40-65), were studied. Simulated evacuation was performed firstly with empty balloon and subsequently after balloon distention to 50 and 100 ml. Anorectal pressures were compared. We also performed subgroup analysis in relation to outcome of balloon expulsion test (BET). In addition, we studied the effect of rectal distension on the rectoanal pressure gradient with respect to rectal sensory function. RESULTS: Rectal balloon distension at simulated evacuation improved rectoanal gradient and decreased the rate of dyssynergia during high-resolution anorectal manometry. In subgroup analysis, the increase in rectoanal gradient and correction of dyssynergia with rectal distension was limited to the patients who had normal BET and normal rectal sensory function. Rate of anal relaxation, residual anal pressures, and rectoanal gradient were significantly different between patients with and without normal BET at 50 ml of rectal distension. Rectoanal gradient recorded only after rectal distension, along with BMI and maximum tolerable volumes, could predict BET results independently in patients with chronic constipation. CONCLUSIONS: Rectal distension during simulated evacuation will affect the anorectal pressure profile. Increase in rectoanal gradient and correction of dyssynergia was only significant in patients with normal rectal sensory function and normal BET.

CE: Original Research: The Clinical Research Nurse: Exploring Self-Perceptions About the Value of the Role.

: Background: Clinical research nursing is an emerging specialty practice. Clinical research nurses (CRNs) work to make protocol-related care safe for the research subjects while simultaneously maintaining protocol fidelity. They must continuously balance the needs of the research subjects and the study requirements. PURPOSE: The purpose of this qualitative study was to describe CRNs' perceptions of the value of their role. METHODS: Two focus groups were conducted with a purposive sample of 18 CRNs. An interview guide consisting of eight open-ended items was used. Data analysis used critical elements from Krueger's systematic steps for analyzing focus group data. RESULTS: Five major themes emerged from 168 coded statements contained within the focus group transcripts: comprehensive nursing care of research subjects, training and education of research subjects and staff, contributions to clinical science, unique combination of clinical and critical thinking skills, and CRN practice attributes. Subcategories were also identified. In general, participants felt strongly about the value they added.Clinical research nursing requires the use of a variety of abilities and skills, including critical thinking and problem solving, as well as clinical and research knowledge. The CRNs in this study described incorporating these and other elements into their practice, which they associated with their specialized role. The five themes that emerged help elucidate the importance and utility of including CRNs on research teams. CONCLUSIONS: The unique combination of applied research knowledge and expert clinical skills sets the specialty of clinical research nursing apart. The study findings, in particular the five themes, provide an evidence-based framework that will be useful in the development of competencies for CRN specialty practice. In helping to bring research findings to bear on clinical care, the impact of CRNs' practice extends beyond the individual patient to larger patient populations.

Primary Hepatic Follicular Lymphoma Presenting as Sub-acute Liver Failure: A Case Report and Review of the Literature.

Sub-acute liver failure is a term that describes the relatively sudden loss of liver function, usually >21 days and <26 weeks, with impaired synthetic function and associated encephalopathy in a person with no pre-existing liver disease or cirrhosis. It is commonly caused by viruses and drugs, less so by malignancy. Our patient is a 71-year-old Japanese man who presented with signs of sub-acute liver failure. A subsequent liver biopsy demonstrated involvement by B-cell non-Hodgkin lymphoma. Evaluation of the bone marrow demonstrated significant marrow involvement by B-cell lymphoma. The fluorescence in situ hybridization (FISH) returned positive for t(14; 18). Noted was the patient's clinical presentation of cholestasis secondary to hepatic lymphoma with no evidence of lymphadenopathy or peripheralized lymphoma. Given the disease distribution, the overall findings are consistent with primary hepatic follicular lymphoma as described in few case reports and small case series in the literature.

Survey of heat use during peripheral IV insertion by health care workers.

Health care workers at an academic medical center in the Midwest were surveyed to identify common practices regarding heat use during peripheral intravenous (PIV) catheter insertion. Of the 907 who responded, the majority used heat to facilitate PIV insertion at least sometimes, when veins were not easily seen or not palpable, applying a commercial dry hot pack for 2 to 5 minutes before selecting an insertion site. Heat use correlated with practice role and population, frequency of PIV insertion, and perceived PIV skill. Findings will guide development of a research protocol to compare the effects of dry heat, moist heat, and no heat on PIV insertion success.

Informed consent and research subject understanding of clinical trials.

CONTEXT: Current evidence suggests many clinical trial participants have incomplete understanding of research objectives and methods. OBJECTIVE: Determine consent standards compliance, satisfaction with facility and study staff, and research subject understanding of clinical trials. DESIGN: Retrospective review of responses gathered when subjects were interviewed at the inception of clinical trial participation. SETTING: Clinical research unit at the University of Wisconsin, Madison. PATIENTS: Clinical trials participants on the research unit. MAIN OUTCOME MEASURES: Understanding of the particular trial in which each subject was participating; research team compliance with informed consent standards; and satisfaction with the research facility, staff, and clinical trials teams. RESULTS: 423 of 570 research participants were oncology patients; 298 were males. Age range was 10 to 90 years old (mean of 56.6 (+/- 16.6) years old). Most subjects (99%) had signed the consent form; 97% reported satisfaction with the research facility and 96% with the study staff. Four-fifths of participants had accurate knowledge of study aims, methods, and risks, but 20% of subjects understood considerably less. Oncology subjects were older (mean age 60.1 [+/- 12.5] years vs 46.4 [+/- 21.9] years, P < 0.001). Non-oncology subjects and patients under age 61 demonstrated superior study knowledge (P < 0.001). CONCLUSION: Compliance with informed consent standards and satisfaction with services and staff was excellent. Future efforts should focus on better informing older subjects and those on oncology trials.

A systems analysis of obstetric triage.

OBJECTIVE: The purpose of this study is to examine some of the variables involved in obstetric triage in an effort to develop a more efficient patient care delivery system in a high-volume obstetric unit. An efficient triage system is essential to a busy labor and delivery unit for the evaluation of unscheduled patient visits. In hospitals that lack an efficient obstetric triage system, it is very difficult to regulate patient flow and wait times. METHOD: The study was designed to determine whether a triage room and/or standing orders decreased length of stay as compared to the existing system of evaluating women in labor rooms. In 2 separate phases, women who met triage criteria were randomly assigned to either the triage room or the standard care labor room. During phase 1, the effect of room assignment was evaluated. During phase 2, the effect of room assignment and the intervention of standing orders in common obstetric problems were utilized. The total sample size was 398 patients. The study took place on a midsize labor and delivery unit, in an academic medical center averaging 3600 births per year. RESULTS: Results showed that using a triage room and/or standing orders did not significantly decrease length of stay. CONCLUSION: The results of this study suggest that the triage process in this setting is strongly dependent on the provider's availability to assess, triage, and discharge patients.