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Preview: British Medical Bulletin - current issue

British Medical Bulletin Current Issue





Published: Thu, 07 Sep 2017 00:00:00 GMT

Last Build Date: Tue, 03 Oct 2017 12:44:24 GMT

 






Abnormal uterine bleeding

2017-08-28

Abstract
Introduction
It is not uncommon for a woman to suffer from abnormal uterine bleeding (AUB) or heavy menstrual bleeding (HMB) at some point during her lifetime. Once pathology is excluded, in practice, management needs to be individualised, taking into account the improvement of the woman's symptoms and quality of life.
Sources of data
Peer-reviewed journals, governmental and professional society publications.
Areas of agreement
There is now agreement on a structured, universal approach to the diagnosis of AUB, with the aide memoirs PALM (polyps, adenomyosis, leiomyoma, malignancy) and COEIN (coagulopathies, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). Once malignancy and significant pelvic pathology have been ruled out, medical treatment is an effective first-line therapeutic option, with surgery, including endometrial ablation and hysterectomy, offered when medical management has failed to resolve symptoms and fertility is no longer desired.
Areas of controversy
There remains controversy around the management of the types and subtypes of adenomyosis and leiomyoma, and understanding their impact on clinical reproductive outcomes.
Areas currently under development
Standardised assessment tools for measuring outcomes of AUB are being developed.
Areas timely for developing research
Novel diagnostic and monitoring tools should be developed to help stratify treatment for women with AUB, particularly relating to ‘unclassified’ and ‘endometrial’ causes.



Paediatric nuclear medicine imaging

2017-08-21

Abstract
Background
Nuclear medicine imaging explores tissue viability and function by using radiotracers that are taken up at cellular level with different mechanism. This imaging technique can also be used to assess blood flow and transit through tubular organs. Nuclear medicine imaging has been used in paediatrics for decades and this field is continuously evolving.
Sources of data
The data presented comes from clinical experience and some milestone papers on the subject.
Areas of agreement
Nuclear medicine imaging is well-established in paediatric nephro-urology in the context of urinary tract infection, ante-natally diagnosed hydronephrosis and other congenital renal anomalies. Also, in paediatric oncology, I-123-meta-iodobenzyl-guanidine has a key role in the management of children with neuroblastic tumours. Bone scintigraphy is still highly valuable to localize the source of symptoms in children and adolescents with bone pain when other imaging techniques have failed. Thyroid scintigraphy in neonates with congenital hypothyroidism is the most accurate imaging technique to confirm the presence of ectopic functioning thyroid tissue.
Areas of controversy
Radionuclide transit studies of the gastro-intestinal tract are potentially useful in suspected gastroparesis or small bowel or colonic dysmotility. However, until now a standardized protocol and a validated normal range have not been agreed, and more work is necessary. Research is ongoing on whether magnetic resonance imaging (MRI), with its great advantage of great anatomical detail and no ionizing radiations, can replace nuclear medicine imaging in some clinical context. On the other hand, access to MRI is often difficult in many district general hospitals and general anaesthesia is frequently required, thus adding to the complexity of the examination.
Growing points
Patients with bone pain and no cause for it demonstrated on MRI can benefit from bone scintigraphy with single photon emission tomography and low-dose computed tomography. This technique can identify areas of mechanical stress at cortical bone level, difficult to demonstrate on MRI, which can act as pain generators. Positron emission tomography (PET) is being tested in the staging, response assessment and at the end of treatment of several paediatric malignancies. PET is becoming more widely utilized in neurology in the pre-surgical assessment of some children with drug resistant epilepsy.
Areas timely for developing research
The use of PET/MRI scanners is very attractive as it combines benefits of MR imaging with the assessment of cellular viability and metabolism with PET in one examination. This imaging technique will allow important research on tumour in-vivo metabolism (possible applications include lymphomas, neuroblastomas, malignant germ cell tumours andbrain tumours), with the aim of offering a personalized biological profile of the tumour in a particular patient. Ground-breaking research is also envisaged in neurosciences, especially in epilepsy, using PET tracers that would enable a better identification of the epileptogenic focus, and in psychiatry, with the use of radiolabeled neurotransmitters. In paediatric nephro-urology, the identification of the asymptomatic child with ante-natally diagnosed hydronephrosis at risk of losing renal parenchymal function if left untreated is another area of active research involving radionuclide renography.



Genomic medicine and data sharing

2017-08-10

Abstract
Introduction
Effective data sharing does not occur in the UK despite being essential for the delivery of high-quality genomic services to patients across clinical specialities and to optimize advances in genomic medicine.
Sources of data
Original papers, reviews, guidelines, policy papers and web-resources.
Areas of agreement
Data sharing for genomic medicine requires appropriate infrastructure and policies, together with acceptance by health professionals and the public of the necessity of data sharing for clinical care.
Areas of controversy
There is ongoing debate around the different technical approaches and safeguards that could be used to facilitate data sharing while minimizing the risks to individuals of identification. Lack of consensus undermines trust and confidence.
Growing points
Ongoing policy developments around genomics and health data create opportunities to ensure systems and policies are in place to support proportionate, effective and safeguarded data sharing.
Areas timely for developing research
Mechanisms to improve public trust.



Think adult—think child! Why should staff caring for dying adults ask what the death means for children in the family?

2017-08-10

Abstract
Introduction
Bereaved children and young people in the UK are ‘hidden mourners’.
Sources of data
Review of primary and secondary evidence on childhood bereavement.
Area of agreement
Children experience grief that varies according to the circumstance of death and their cognitive ability. Voluntary organizations can be supportive, but provision is patchy and vulnerable to austerity.
Areas of concern
Adult-centric denial of the importance and long-term consequences of childhood grief; uncertainty in how best to relate to bereaved children in faiths and in schools.
Growing points
Increased awareness of the immediate and long-term consequences of childhood bereavement; even young children can experience loss through death.
Areas timely for research
Better knowledge of the numbers of affected children; longitudinal data to track experiences and outcomes; measuring effectiveness of different approaches; identifying risk factors for early intervention in complicated or prolonged grief; the importance of faith and rituals around death; mapping the provision of services to monitor the impact of austerity.
Recommendations
‘Think adult—think child’ means that all staff caring for dying adults should take responsibility for asking what the death means for the children in the family, with schools, primary care and faith organizations having protocols and expertise available to support grieving children; recent catastrophes expose need for agencies to have management plans that focus on vulnerable children and young people.



Paediatric and maternal schistosomiasis: shifting the paradigms

2017-08-09

Abstract
Background
In endemic areas, schistosomiasis causes both overt and subclinical disease in young children and their mothers, as well as in returned travellers.
Sources of data
Key recently published literature.
Areas of agreement
An action plan for paediatric schistosomiasis and female genital schistosomiasis (FGS) is needed with expanded access to praziquantel (PZQ) treatment required.
Areas of controversy
Schistosomiasis-related morbidity is underappreciated. Present and future demand for PZQ treatment is bottlenecked, imbalanced and inequitable. Current dosing, treatment algorithms and access plans are suboptimal with treatment stalled during pregnancy.
Growing points
Raised dosing of PZQ (>40 mg/kg) is being explored in young children. Surveillance of female genital schistosomiasis FGS is increasing. Use of PZQ in pregnancy is safe and preventive chemotherapy guidelines are being revised in morbidity- and transmission-control settings.
Areas timely for developing research
Shifting focus of population-level control to individual-case management. Detection and prevention of FGS within general health services and integration of PZQ treatment for women and children in antenatal clinics. Feasibility studies assessing alternative and expanded access to PZQ treatment to at-risk children and mothers and pregnant women.



Pricing as a means of controlling alcohol consumption

2017-07-13

Abstract
Background
Reducing the affordability of alcohol, by increasing its price, is the most effective strategy for controlling alcohol consumption and reducing harm.
Sources of data
We review meta-analyses and systematic reviews of alcohol tax/price effects from the past decade, and recent evaluations of tax/price policies in the UK, Canada and Australia.
Areas of agreement
While the magnitudes of price effects vary by sub-group and alcoholic beverage type, it has been consistently shown that price increases lead to reductions in alcohol consumption.
Areas of controversy
There remains, however, a lack of consensus on the most appropriate taxation and pricing policy in many countries because of concerns about effects by different consumption level and income level and disagreement on policy design between parts of the alcoholic beverage industries.
Growing points
Recent developments in the research highlight the importance of obtaining accurate alcohol price data, reducing bias in estimating price responsiveness, and examining the impact on the heaviest drinkers.
Areas timely for developing research
There is a need for further research focusing on the substitution effects of taxation and pricing policies, estimation of the true tax pass-through rates, and empirical analysis of the supply-side response (from alcohol producers and retailers) to various alcohol pricing strategies.



Transtendon repair in partial articular supraspinatus tendon tear

2017-07-13

Abstract
Introduction
Partial thickness rotator cuff tears (PTRCTs) are common, with an incidence between 17% and 37%, and a high prevalence in throwing athletes. Different surgical procedures are suggested when partial tears involve the articular portion of the rotator cuff, including arthroscopic debridement of the tear, debridement with acromioplasty, tear completion and repair, and lately transtendon repair. This systematic review describes the transtendon repair and examines indications, contraindications, complications and clinical outcome.
Source of data
We identified clinical studies listed in the Pubmed Google Scholar, CINAHL, Cochrane Central and Embase Biomedical databases in English and Italian concerning the clinical outcomes following treatment of partial articular supraspinatus tendon tear using transtendon surgical repair.
Areas of agreement
Eighteen studies fulfilled our inclusion criteria. All were published between 2005 and 2016, three were retrospective, and 15 prospective. The total number of patients was 507 with a mean age of 50.8 years.
Areas of controversy
Tear completion and repair and transtendon repair alone produce similar results.
Growing points
Transtendon surgical repair allows to obtain good-excellent results in the treatment of partial articular supraspinatus tendon tears.
Areas timely for developing research
Further studies are needed to produce clear guidelines in the treatment of partial articular supraspinatus tendon tears.
Level of evidence
IV.



Physician-assisted suicide—a clean bill of health?

2017-07-13

Abstract
Background
Physician-assisted suicide (PAS) laws have been enacted in five US States and, along with physician-administered euthanasia, in Canada and the Netherlands.
Sources of data
Annual reports of the Oregon Health Authority and published research papers.
Areas of agreement
Not all recipients of lethal drugs use them to end their lives. Improvements in palliative care provision.
Areas of controversy
Rising numbers of deaths from PAS. Emergence of ‘doctor shopping’ and multiple-prescribing. Absence of qualitative scrutiny of assessment process. No re-assessment or oversight when prescribed drugs are ingested. Recent pressures to extend Oregon's PAS law.
Growing points
Reasons given for seeking PAS indicate this is a societal rather than a clinical issue and raise the question whether adjudicating on requests for legalized PAS is an appropriate role for doctors.
Areas for timely research
Research into quality of decision-making in requests for PAS and into potential role of doctors as expert witnesses rather than judges in requests for PAS.



The contribution of genetics and environment to obesity

2017-07-07

Abstract
Background
Obesity is a global health problem mainly attributed to lifestyle changes such as diet, low physical activity or socioeconomics factors. However, several evidences consistently showed that genetics contributes significantly to the weight-gain susceptibility.
Sources of data
A systematic literature search of most relevant original, review and meta-analysis, restricted to English was conducted in PubMed, Web of Science and Google scholar up to May 2017 concerning the contribution of genetics and environmental factors to obesity.
Areas of agreement
Several evidences suggest that obesogenic environments contribute to the development of an obese phenotype. However, not every individual from the same population, despite sharing the same obesogenic environment, develop obesity.
Areas of controversy
After more than 10 years of investigation on the genetics of obesity, the variants found associated with obesity represent only 3% of the estimated BMI-heritability, which is around 47–80%. Moreover, genetic factors per se were unable to explain the rapid spread of obesity prevalence.
Growing points
The integration of multi-omics data enables scientists having a better picture and to elucidate unknown pathways contributing to obesity.
Areas timely for developing research
New studies based on case–control or gene candidate approach will be important to identify new variants associated with obesity susceptibility and consequently unveiling its genetic architecture. This will lead to an improvement of our understanding about underlying mechanisms involved in development and origin of the actual obesity epidemic. The integration of several omics will also provide insights about the interplay between genes and environments contributing to the obese phenotype.



Dystonia

2017-07-04

Abstract
Introduction
Dystonia is a clinically heterogeneous group of hyperkinetic movement disorders. Recent advances have provided a better understanding of these conditions with significant clinical impact.
Sources of data
Peer reviewed journals and reviews. PubMed.gov.
Areas of agreement
A recent consensus classification, including the assessment of phenomenology and identification of the dystonia syndromes, has provided a helpful tool for the clinical assessment. New forms of monogenic dystonia have been recently identified.
Areas of controversy
Despite recent advances in the understanding of dystonia, treatment remains symptomatic in most patients.
Growing points
Recent advances in genetics have provided a better understanding of the potential pathogenic mechanisms involved in dystonia. Deep brain stimulation has shown to improve focal and combined forms of dystonia and its indications are constantly expanding.
Areas timely for developing research
Growing understanding of the disease mechanisms involved will allow the development of targeted and disease-modifying therapies in the future.



Anticoagulation after coronary stenting: a systemic review

2017-07-01

Abstract
Introduction or background
Anticoagulant therapy is mainly used to prevent patients from suffering coronary and systemic thromboembolism after stenting. Many studies have been done to formulate an optimized regimen of a post-PCI or long-time anticoagulant therapy. Recent advances in the selection and duration of anticoagulant agents will be conducive to the management of patients who are considered to need anticoagulant therapy after stenting.
Sources of data
Key recent published literature, including international guidelines and relevant reviews.
Areas of agreement
Anticoagulant therapy has been acknowledged to improve the prognosis of patients after stenting by reducing the risk of coronary and systemic thromboembolism.
Areas of controversy
Firstly, the benefit–risk ratio of post-PCI parenteral anticoagulation to prevent stent thrombosis locally in the coronary artery is still unclear. Secondly, the efficacy and safety of bivalirudin deserve to be discussed. Furthermore, the recommendation to use long-time oral anticoagulant therapy to prevent systemic thromboembolism after stenting should also be emphasized.
Growing points
Studies of anticoagulant therapy in patients after stenting add to the understanding of an optimized anticoagulant regimen and contribute to improving clinical outcomes.
Areas for developing research
  • The safety and efficacy of bivalirudin, a direct thrombin inhibitor, need to be further investigated by more large-scale randomized clinical trials.
  • Based on the widespread use of ticagrelor and prasugrel for patients who need long-time oral anticoagulant therapy, further study is needed to find an optimal strategy that balances the risk of bleeding and ischemic events after coronary stenting.



Is elimination of hepatitis C from the UK by 2030 a realistic goal?

2017-06-09

Abstract
Introduction
Highly effective, combination therapy for chronic hepatitis C virus (HCV) infection is now available. Current cure rates are close to 100% and applicable to all patients irrespective of race, age, severity of liver disease or viral genotype. Remarkably for persistent infection, current treatment is recommended for as little as 12 weeks; recent studies suggest even shorter courses. In contrast to interferon-based therapy, present regimens have few side effects and serious adverse events are rare. The success and safety of these regimens has stimulated interest in the possible eventual elimination of HCV. Barriers to elimination include cost of drugs and finding patients in the community less likely to interact with medical services who are a potential reservoir of infection.
Sources of data
Pubmed.
Areas of agreement
Antiviral agents already available are highly effective.
Areas of controversy
The cost of the newer antiviral agents is very high, restricting treatment numbers in the UK in 2015/16 and focusing therapy on those patients with significant fibrosis. Recently, patients with less severe disease have been offered therapy, but delivery may be slowed by high costs. Many believe that insufficient pressure has been brought to bear to reduce costs. Eventual elimination will depend first on reducing treatment costs for those known to have chronic HCV infection and then finding patients in the community with infection unaware of their illness or reluctant/unable to engage with medical services.
Areas for developing research
Determining the most effective strategies to identify ‘invisible’ patients in the community with chronic HCV infection.



Management of combined injuries of the posterior cruciate ligament and posterolateral corner of the knee: a systematic review

2017-05-10

Abstract
Background
Approximately 60% of posterior cruciate ligament (PCL) injury are associated with a posterolateral corner (PLC) tear.
Sources of data
We performed a systematic review of the literature according to the PRISMA guidelines. The following key words were searched on Medline, Cochrane, EMBASE, Google Scholar, and Ovid: ‘posterior cruciate ligament’ or ‘PCL’ with ‘posterolateral corner’ or ‘PLC’ and ‘chronic’; ‘injury’; ‘management’; ‘reconstruction’; ‘outcomes’; ‘complications’.
Areas of agreement
There was a statistically significant improvement of all clinical scores after surgery regardless of the procedure performed to reconstruct both PCL and PLC.
Areas of controversy
No randomized control trials were identified on the topic. Standardized methods of functional outcomes assessment are necessary to improve communication on the functional results of the management of PC–PLC.
Growing points
Single stage surgical reconstruction of PCL and PLC is recommended in patients with posterolateral rotatory instability of the knee.
Areas timely for developing research
Adequately powered randomized trials with appropriate subjective and objective outcome measures are necessary to reach definitive conclusions.