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Preview: British Medical Bulletin - current issue

British Medical Bulletin Current Issue





Published: Thu, 14 Dec 2017 00:00:00 GMT

Last Build Date: Thu, 14 Dec 2017 12:43:47 GMT

 



Management of Zika virus in pregnancy: a review

Thu, 14 Dec 2017 00:00:00 GMT

Abstract
Introduction/background
Since 2015, an epidemic of Zika virus spread across the Americas. This coincided with an increased incidence of microcephaly reported at birth in Brazil, with subsequent evidence of a causal association.
Sources of data
Systemic reviews, observational studies, public health organizations.
Areas of agreement
Zika virus causes microcephaly and brain abnormalities in infants born to mothers infected during or shortly before pregnancy. Zika virus is a trigger for Guillain Barre Syndrome. Whilst mosquito bite is the main route of transmission, sexual transmission is another confirmed route.
Areas of controversy
Uncertainty remains regarding the proportion of Zika-infected pregnancies that will give rise to a significantly affected infant.
Growing points
The development of a vaccine remains a priority whilst public health efforts continue to educate at risk populations on reducing transmission.
Areas timely for developing research
Follow-up studies of affected infants are vital to inform on prognosis and guide screening programmes of the future.



Outcome of ankle arthrodesis and ankle prosthesis: a review of the current status

Thu, 23 Nov 2017 00:00:00 GMT

Abstract
Introduction
In advanced stages of ankle osteoarthritis (OA), ankle arthrodesis (AA) or total ankle arthroplasty (TAR) may be necessary. Our purpose is to compare AA and total ankle replacement for the surgical management of end stage ankle OA.
Sources of data
We conducted a literature search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using the terms ‘ankle’ in combination with ‘OA’, ‘arthrodesis’, ‘arthroplasty’, ‘joint fusion’, ‘joint replacement’. Studies where treatment was exclusively total ankle replacement or AA were excluded. Treatment characteristics and outcome parameters (overall postoperative outcome and complication rate) were reviewed.
Areas of agreement
When counseling patients who are considering their options with regard to ankle arthritis treatment, surgeons should determine on an individual basis which procedure is more suitable.
Areas of controversy
TAR has become an accepted treatment for end-stage OA, but revision rates for TAR are significant higher than for AA (odds ratio 2.28 95% confidence interval [CI], 1.63–3.19; P < 0.0001).
Growing points
The results of TAA are gradually improving, but the procedure cannot yet be recommended for the routine management of ankle OA.
Areas timely for developing research
Although there is some evidence to support TAR to conserve ankle motion and offer improved function and decreased pain with high satisfaction rates, revision rates for TAR are significantly higher than revision rates for AA. Proper patient selection should be better addressed in future studies for successful treatment of end-stage ankle OA.
Level of evidence
Systematic review, level III.






Perioperative management of the obese surgical patient

Mon, 13 Nov 2017 00:00:00 GMT

Abstract
Introduction
The escalation in the prevalence of obesity throughout the world has led to an upsurge in the number of obese surgical patients to whom perioperative care needs to be delivered.
Sources of data
After determining the scope of the review, the authors used PubMed with select phrases encompassing the words in the scope. Both preclinical and clinical reports were considered.
Areas of agreement
There were no controversies regarding preoperative management and the intraoperative care of the obese surgical patient.
Areas of controversy
Is there a healthy obese state that gives rise to the obesity paradox regarding postoperative complications?
Growing points
This review considers how to prepare for and manage the obese surgical patient through the entire spectrum, from preoperative assessment to possible postoperative intensive care.
Areas timely for developing research
What results in an obese patient developing ‘unhealthy’ obesity?



Faecal transplantation for IBD management—pitfalls and promises

Mon, 13 Nov 2017 00:00:00 GMT

Abstract
Background
Faecal microbiota transplantation (FMT) as a potential treatment for inflammatory bowel disease (IBD) is an area of active current research, having been stimulated by the remarkable efficacy of FMT in treatment of Clostridium difficile-associated colitis.
Sources of data
This review is based on data from numerous case series on FMT in IBD since 1989 and results of four RCTs in ulcerative colitis (UC); three fully published.
Areas of agreement
Early signals of short to medium-term efficacy of FMT for UC are promising
Areas of controversy
Methodology, underlying mechanisms and questions regarding safety of FMT remain controversial.
Growing points
Many trials of FMT in adults and children are currently recruiting.
Areas timely for developing research
Future trials of FMT will likely revisit Crohn’s disease and patients undergoing pouch surgery. Advances in microbial culture complementing genetic sequencing and investigations into the virome and mycobiome in IBD will be of great future interest.



Retraction

Tue, 31 Oct 2017 00:00:00 GMT




The rise and potential fall of pancreas transplantation

Fri, 27 Oct 2017 00:00:00 GMT

Abstract
Background
The aim of this review is to bring pancreatic transplantation out of the specialist realm, informing practitioners about this important procedure, so that they feel better equipped to refer suitable patients for transplantation and manage, counsel and support when encountering them within their own speciality.
Sources of data
Narrative review conducted in May 2017. OVID interface searching EMBASE and MEDLINE databases, using Timeframe: Inception to June 1, 2017. Articles were assessed for clinical relevance and most up to date content with articles written in english as the only inclusion criteria. Other sources, used included conference proceedings/presentations, unpublished data from our institution (Oxford Transplant Centre).
Areas of agreement
Pancreas transplantation has evolved from an experimental procedure to the gold standard of care for patients with type 1 diabetes and uraemia. Currently, it remains the most effective method of establishing and maintaining euglycemia over the longer term, halting and potentially reversing many of the secondary complications associated with diabetes. Significant improvements to quality of life and better life expectancy make it in the longer term, a lifesaving procedure compared to waiting candidates.
Areas of controversy
The future of solid organ pancreas transplantation remains uncertain, with extensive comorbidity and advances in alternative therapies makes the long-term growth of the procedure questionable.
Growing points and areas timely for developing research
Therapies to alleviate problems associated with ischaemia reperfusion injury, graft pancreatitis and more effective monitoring methods for detecting and treating organ rejection are the key areas of growth.



Friedreich’s ataxia: clinical features, pathogenesis and management

Wed, 25 Oct 2017 00:00:00 GMT

Abstract
Introduction
Friedreich’s ataxia is the most common inherited ataxia.
Sources of data
Literature search using PubMed with keywords Friedreich’s ataxia together with published papers known to the authors.
Areas of agreement
The last decade has seen important advances in our understanding of the pathogenesis of disease. In particular, the genetic and epigenetic mechanisms underlying the disease now offer promising novel therapeutic targets.
Areas of controversy
The search for effective disease-modifying agents continues. It remains to be determined whether the most effective approach to treatment lies with increasing frataxin protein levels or addressing the metabolic consequences of the disease, for example with antioxidants.
Areas timely for developing research
Management of Freidreich’s ataxia is currently focussed on symptomatic management, delivered by the multidisciplinary team. Phase II clinical trials in agents that address the abberrant silencing of the frataxin gene need to be translated into large placebo-controlled Phase III trials to help establish their therapeutic potential.



Sustainable Development Goals (SDGs), and their implementationA national global framework for health, development and equity needs a systems approach at every level

Tue, 24 Oct 2017 00:00:00 GMT

Abstract
Introduction
The Sustainable Development Goals (SDGs) are a set of global goals for fair and sustainable health at every level: from planetary biosphere to local community. The aim is to end poverty, protect the planet and ensure that all people enjoy peace and prosperity, now and in the future.
Sources of data
The UN has established web-sites to inform the implementation of the SDGs and an Inter-Agency and Expert Group on an Indicator Framework. We have searched for independent commentaries and analysis.
Areas of agreement
The goals represent a framework that is scientifically robust, and widely intuitive intended to build upon the progress established by the Millennium Development Goals (MDGs). There is a need for system wide strategic planning to integrate the economic, social and environmental dimensions into policy and actions.
Areas of controversy
Many countries have yet to understand the difference between the MDGs and the SDGs, particularly their universality, the huge potential of new data methods to help with their implementation, and the systems thinking that is needed to deliver the vision. The danger is that individual goals may be prioritized without an understanding of the potential positive interactions between goals.
Growing points
There is an increasing understanding that sustainable development needs a paradigm shift in our understanding of the interaction between the real economy and quality of life. There would be many social, environmental and economic benefits in changing our current model.
Areas timely for developing research
We need to develop systems wide understanding of what supports a healthy environment and the art and science of making change.



The role of complement inhibition in kidney transplantation

Sat, 21 Oct 2017 00:00:00 GMT

Abstract
Introduction and background
The complement system which belongs to the innate immune system acts both as a first line of defence against various pathogens and as a guardian of host homeostasis. The role of complement has been recently highlighted in several aspects of kidney transplantation: ischaemia-reperfusion, antibody-mediated rejection and native kidney disease recurrence.
Sources of data
Experimental data, availability of complement-blocking molecules (mainly the anti-C5 monoclonal antibody, eculizumab) and several trials in human kidney transplant recipients has led to some areas of agreement and some disappointment.
Areas of agreement and controversies
So far, eculizumab has shown great efficacy in treatment and prevention of atypical haemolytic and uraemic syndrome, some efficacy in the prevention of antibody-mediated and so far no efficacy in the prevention of delayed graft function.
Growing points
Among the numerous potentially available drugs potentially interfering with complement, recent focus has been made on C1 blockers in the setting of antibody-mediated rejection with promising results.
Areas timely for developing research
Complement is now recognized as a major player in transplant immunology, several targets are going to be tested to define precisely which ones may be potentially useful in clinical practice.



Who bears the cost of NICE public health recommendations?

Thu, 19 Oct 2017 00:00:00 GMT

Abstract
Background
In the UK, NICE issues guidance on public health initiatives. Failure to report which sectors of the economy are affected by their implementation precludes the appropriate accounting for the full opportunity costs, and has the potential to result in erroneous decision making and inefficient budgetary planning.
Sources of data
We reviewed all NICE public health guidances available at the time of research, categorizing the sector on which the cost burden of the public health initiatives fall and the extent to which this burden was estimated.
Areas of agreement
The majority of guidances were determined to be associated with a cost burden on the NHS (n = 48) and local authorities’ public health spend (n = 47).
Areas of controversy
Explicit identification and quantification of cost burden by sector of the economy was reported for only eight guidances.
Growing points
Increasing numbers of research studies are developing methods to robustly consider the implications of cross sector budget impacts.
Areas timely for developing research
Future NICE guidance should report disaggregated costs across the sectors where they fall. Further research is needed to conceptualize the opportunity cost of financial burdens falling on non-health budgets before optimal decision making in public health is possible.



Pharmacogenetics: a general review on progress to date

Wed, 11 Oct 2017 00:00:00 GMT

Abstract
Background
Pharmacogenetics is not a new subject area but its relevance to drug prescribing has become clearer in recent years due to developments in gene cloning and DNA genotyping and sequencing.
Sources of data
There is a very extensive published literature concerned with a variety of different genes and drugs.
Areas of agreement
There is general agreement that pharmacogenetic testing is essential for the safe use of drugs such as the thiopurines and abacavir.
Areas of controversy
Whether pharmacogenetic testing should be applied more widely including to the prescription of certain drugs such as warfarin and clopidogrel where the overall benefit is less clear remains controversial.
Growing points
Personal genotype information is increasingly being made available directly to the consumer. This is likely to increase demand for personalized prescription and mean that prescribers need to take pharmacogenetic information into account. Projects such as 100 000 genomes are providing complete genome sequences that can form part of a patient medical record. This information will be of great value in personalized prescribing.
Areas timely for developing research
Development of new drugs targeting particular genetic risk factors for disease. These could be prescribed to those with an at risk genotype.



Immunology of cystic echinococcosis (hydatid disease)

Sat, 07 Oct 2017 00:00:00 GMT

Abstract
Background
The neglected disease cystic echinococcosis is caused by larval Echinococcus granulosus flatworms, which form bladder-like hydatid cysts in liver, lungs, and other organs.
Sources of data
Published literature.
Areas of agreement
Establishing larvae are susceptible to antibody-dependent killing, as attested by successful animal vaccination, whereas once established they are partially protected by the so-called laminated layer. Host responses are Th2 dominated, with a Th1 component. Diagnostic antigens from cyst fluid are known, but responses appear absent in one-fifth of patients.
Areas of controversy
Is evasion mainly based on induction of Th2 or regulatory responses by the parasite?
Growing points
The parasite induces regulatory responses. The laminated layer has immune-regulatory properties.
Areas timely for developing research
Develop tools for functional genomics; characterize immunologically interesting proteins suggested by genomic information; analyse infection in broader context of granulomatous responses; identify molecules secreted/excreted by intact larvae/cysts towards their outside, including diffusible immune-regulators.



Management of chronic pain through pain management programmes

Wed, 13 Sep 2017 00:00:00 GMT

Abstract
Introduction
Chronic pain carries significant impact and is difficult to treat with limited success. Pain management programmes (PMPs) use cognitive behavioural therapy (CBT)-based multidisciplinary rehabilitative approaches to drive functional improvement.
Sources of data
A search was conducted using Medline and the Cochrane Library to identify published literature about PMPs or CBT to treat chronic pain.
Areas of agreement
PMPs have significant benefit on functioning for some patients but relatively little impact on the pain. Not all patients, nor pain types, benefit. Around a third of patients show improvement, with considerable variability.
Areas of controversy
There is much heterogeneity between approaches and outcomes measured, and the extent and duration of benefit is inconsistently reported. The investment required of patients, staff and commissioners is significant. Existing data provides limited information to judge whether PMPs represent good value for each of those stakeholders.
Growing points
The British Pain Society provide guidelines for PMPs, due for revision in 2018 which may provide opportunities for greater clarity and demonstrating value. Other approaches are emerging and being evaluated.
Areas timely for developing research
Participation may have more subjective impact than objective outcomes and merits qualitative research. With a (significant) minority of patients showing improvement, research into patient and treatment selection is essential alongside longterm outcomes and sustaining benefits.



Adipose-derived stem cells in orthopaedic pathologies

Mon, 21 Aug 2017 00:00:00 GMT

Abstract
Introduction
To examine the current literature regarding the clinical application of adipose-derived stem cells (ADSCs) for the management of orthopaedic pathologies
Sources of data
MEDLINE,SCOPUS, CINAHL and EMBASE (1950 to April 14, 2017) were searched by two independent investigators for articles published in English. Reviews, meta-analyses, expert opinions, case reports, mini case series and editorials were excluded. Furthermore, we excluded animal studies, cadaveric studies and in vitro studies.
Areas of agreement
ADSCs seem to produce excellent clinical results. However, the length and modalities of follow-up in the different conditions are extremely variable. Nevertheless, it appears that the use of adipose-derived stem cells is associated with subjective and objective clinical improvements and minimal complication rates.
Areas of controversy
None of the studies identified is a randomized double-blinded trial, and most of the selected studies present major limitations, and different methods, confounding the results of our review.
Growing points
It is necessary to conduct more and better studies to ascertain whether ADSCs really play a role in orthopaedic surgery with particular attention to ADSCs harvesting method, type of administration and the conditions treated.
Areas timely for developing research
The current literature regarding the use of ADSCs for orthopaedic pathologies is limited. At present, long-term safety is the biggest challenge of ADSCs based regenerative medicine.
Level of evidence
Level IV—Study of Level I, II, III, IV