To return or to discard? Randomised trial on gastric residual volume management

Background: The control of gastric residual volume (GRV) is a common nursing intervention in intensive care; however the literature shows a wide variation in clinical practice regarding the management of GRV, potentially affecting patients" clinical outcomes. The aim of this study is to determine the effect of returning or discarding GRV, on gastric emptying delays and feeding, electrolyte and comfort outcomes in critically ill patients. Method: A randomised, prospective, clinical trial design was used to study 125 critically ill patients, assigned to the return or the discard group. Main outcome measure was delayed gastric emptying. Feeding outcomes were determined measuring intolerance indicators, feeding delays and feeding potential complications. Fluid and electrolyte measures included serum potassium, glycaemia control and fluid balance. Discomfort was identified by significant changes in vital signs. Results: Patients in both groups presented similar mean GRV with no significant differences found (p=0.111), but participants in the intervention arm showed a lower incidence and severity of delayed gastric emptying episodes (p=0.001). No significant differences were found for the rest of outcome measurements, except for hyperglycaemia. Conclusions: The results of this study support the recommendation to reintroduce gastric content aspirated to improve GRV management without increasing the risk for potential complications.

"Ojo clínico" y evidencia científica

En nuestra profesión, el ojo clínico puede definirse como el don que poseen algunos médicos para realizar diagnósticos rápidos y certeros. Este término, antaño popular, ha caído en desuso y en la actualidad se utiliza con mayor frecuencia en ambientes no médicos, para resaltar la habilidad de anticipar acontecimientos o de calibrar a simple vista aspectos ocultos de la naturaleza humana. Por el contrario, el concepto evidencia científica es claramente actual. Aplicado a la práctica de la medicina, no solo es...

The Pelosi-type versus the modified Misgav-Ladach: a randomized trial of two surgical techniques for cesarean section

Cesarean section (CS) is now the most common major surgical procedure performed on women worldwide. A quarter of deliveries in Spain are performed by cesarean section. With the increasing rates of the operation, there is the need to use evidence-based techniques to optimize outcomes and minimize complications. The goal of this study is to employ a well-designed randomized controlled trial to evaluate the intraoperative blood loss of two surgical techniques for cesarean section, the Pelosi-type and the modified Misgav-Ladach. The trial will take place in Hospital Universitari de Girona Dr. Josep Trueta From 2014 to 2015, 512 pregnant women undergoing delivery by their first lower segment cesarean section in this center will be selected through a consecutive nonprobability sampling. We will collect the main obstetrical characteristics, intraoperative outcomes, short-term outcomes for the baby and postoperative outcomes. We will evaluate the intraoperative blood loss by comparing the changes in hemoglobin levels, pre and postoperatively. Patients will be followed during the postoperative period and in a two-week postoperative appointment. We will analyze the continuous variables, such as the differences in hemoglobin levels, using an unpaired two-sided Student’s t-test, while for the categorical variables Fischer’s exact test will be used

ESTRO-HERO survey: Guidelines for equipment and staffing of radiotherapy facilities in the European countries: Final results of the ESTRO-HERO survey

Background and purpose: In planning to meet evidence based needs for radiotherapy, guidelines for the provision of capital and human resources are central if access, quality and safety are not to be compromised. A component of the ESTRO-HERO (Health Economics in Radiation Oncology) project is to document the current availability and content of guidelines for radiotherapy in Europe. Materials and methods: An 84 part questionnaire was distributed to the European countries through their national scientific and professional radiotherapy societies with 30 items relating to the availability of guidelines for equipment and staffing and selected operational issues. Twenty-nine countries provided full or partial evaluable responses. Results: The availability of guidelines across Europe is far from uniform. The metrics used for capital and human resources are variable. There seem to have been no major changes in the availability or specifics of guidelines over the ten-year period since the QUARTS study with the exception of the recent expansion of RTT staffing models. Where comparison is possible it appears that staffing for radiation oncologists, medical physicists and particularly RTTs tend to exceed guidelines suggesting developments in clinical radiotherapy are moving faster than guideline updating. Conclusion: The efficient provision of safe, high quality radiotherapy services would benefit from the availability of well-structured guidelines for capital and human resources, based on agreed upon metrics, which could be linked to detailed estimates of need

Peutz-Jeghers syndrome: a systematic review and recommendations for management

Peutz¿Jeghers syndrome (PJS, MIM175200) is an autosomal dominant condition defined by the development of characteristic polyps throughout the gastrointestinal tract and mucocutaneous pigmentation. The majority of patients that meet the clinical diagnostic criteria have a causative mutation in the STK11 gene, which is located at 19p13.3. The cancer risks in this condition are substantial, particularly for breast and gastrointestinal cancer, although ascertainment and publication bias may have led to overestimates in some publications. Current surveillance protocols are controversial and not evidence-based, due to the relative rarity of the condition. Initially, endoscopies are more likely to be done to detect polyps that may be a risk for future intussusception or obstruction rather than cancers, but surveillance for the various cancers for which these patients are susceptible is an important part of their later management. This review assesses the current literature on the clinical features and management of the condition, genotype¿phenotype studies, and suggested guidelines for surveillance and management of individuals with PJS. The proposed guidelines contained in this article have been produced as a consensus statement on behalf of a group of European experts who met in Mallorca in 2007 and who have produced guidelines on the clinical management of Lynch syndrome and familial adenomatous polyposis.

Inappropriate prescribing to the oldest old patients admitted to hospital: prevalence, most frequently used medicines, and associated factors

Background: Scientific evidence on treatments of chronic diseases in patients 85 years old or older is very limited, as is available information on inappropriate prescription (IP) and its associated factors. The study aimed to describe medicine prescription, potentially inappropriate medicines (PIM) and potentially prescribing omissions (PPO) and their associated factors on this population. Methods: In the context of an observational, prospective and multicentric study carried out in elderly patients admitted to seven Spanish hospitals for a year, a sub-analysis of those aged 85 years and over was performed. To assess PIMs, the Beers and STOPP criteria were used, and to assess PPOs, the START and the ACOVE-3 criteria were used. To assess factors associated with IP, a multivariate logistic regression analysis was performed. Patients were selected randomly every week on consecutive days from the hospitalization lists. Results: A total of 336 patients were included in the sub-analysis with a median (Q1-Q3) age of 88 (8690) years. The median medicines taken during the month prior to admission was 10 (713). Forty-seven point two per cent of patients had at least one Beers-listed PIM, 63.3% at least one STOPP-listed PIM, 53.6% at least one START-listed PPO, and 59.4% at least one ACOVE-3-listed PPO. Use of benzodiazepines in patients who are prone to falls (18.3%) and omission of calcium and vitamin D supplements in patients with osteoporosis (13.3%) were the most common PIM and PPO, respectively. The main factor associated with the Beers-listed and the STOPP-listed PIM was consumption of 10 or more medicines (OR = 5.7, 95% CI 1.8-17.9 and OR = 13.4, 95% CI 4.0-44.0, respectively). The main factors associated with the START-listed PPO was a non-community dwelling origin (OR 2.3, 95% CI 1.0-5.0), and multimorbidity (OR1.8, 95% CI 1.0-3.1). Conclusions: Prescribed medicines and PIM and PPO prevalence were high among patients 85 years and over. Benzodiazepine use in those who are prone to falls and omission of calcium and vitamin D in those with osteoporosis were the most frequent PIM and PPO, respectively. Factors associated with PIM and PPO differed with polypharmacy being the most important factor associated with PIM.