Management of post-acute COVID-19 in primary care
Post-acute covid-19 (“long covid”) seems to be a multisystem disease, sometimes occurring after a relatively mild acute illness. Clinical management requires a whole-patient perspective. This article, intended for primary care clinicians, relates to the patient who has a delayed recovery from an episode of covid-19 that was managed in the community or in a standard hospital ward. Broadly, such patients can be divided into those who may have serious sequelae (such as thromboembolic complications) and those with a non-specific clinical picture, often dominated by fatigue and breathlessness.
LISTEN to podcast:
‘What do we know about long covid?’
Living systematic review: comparing effects of drug treatments for COVID-19
A network meta-analysis was performed on data extracted from the US Centers for Disease Control and Prevention COVID-19 Research Articles Downloadable Database. 23 trials were included, in which people with suspected, probable, or confirmed covid-19 were randomised to drug treatment or to standard care or placebo. The certainty of the evidence for most comparisons was very low because of risk of bias and serious imprecision.
Glucocorticoids were the only intervention with evidence for a reduction in death compared with standard care and mechanical ventilation (moderate certainty). Three drugs might reduce symptom duration compared with standard care: hydroxychloroquine (low certainty), remdesivir (moderate certainty), and lopinavir-ritonavir (low certainty). Hydroxychloroquine might increase the risk of adverse events compared with the other interventions, and remdesivir probably does not substantially increase the risk of adverse effects leading to drug discontinuation. No other interventions included enough patients to meaningfully interpret adverse effects leading to drug discontinuation.
The value of this resource is in its ‘living’ status. The review will be updated (for up to two years) to reflect emerging evidence.
READ full article in the BMJ...
- Infographic (Use Microsoft Edge)...
JHH COVID-19 SPECIAL UPDATE
As of 08:30 this morning Health Districts in NSW have been directed by Elizabeth Koff, NSW Health Secretary to escalate to Amber Risk Status.
Today the JHH Executive, along with Dr John Ferguson gave an update via Broadcast, the link to this broadcast can be found here.
One key requirement is that all health staff are required to wear standard, level 2 surgical masks if they are within 1.5m of patients. Visitors will also be asked to mask.
During our usual weekly JHH ALL Staff Information Broadcast on Wednesday, Dr Ferguson referred to a handwashing technique video which can be accessed via this link.
Please keep an eye on the CE news, Webinars and COVID site on the Intranet as to how you can help us keep us all safe.
Injections are two-and-a-half times safer when nurses use revamped guidelines
The UK's National Health Service (NHS) is changing the way it writes its guidelines for giving injections in hospitals, following new research from the University of Bath. The study found that hospital nurses make far fewer mistakes when administering medicines intravenously if they follow instructions written with nurses in mind. Current NHS guidelines on intravenous injections are written by pharmacists with little input from their primary audience - nurses. These instructions can be confusing or overly complicated, which contributes to 30-50% of intravenous doses being incorrect in some way. Researchers used a process called 'user testing', which identifies where mistakes are being made and introduces changes so the instructions are easier to use.
READ full article...
- Lead author Matthew Jones discuss the study...
Mask use provides significant protective effect on the spread of respiratory viruses in healthcare workers
This recent meta-analyses based on 21 studies found that use of masks by healthcare workers (HCWs) and non-healthcare workers (Non-HCWs) can reduce the risk of respiratory virus infection by 80% and 47%. Masks had a protective effect against influenza viruses, SARS, and SARS-CoV-2. The protective effect of wearing masks in Asia appeared to be higher than that of Western countries.
READ full article...
COVID -19: Implementing sustainable low cost physical distancing and enhanced hygiene
SARS-CoV-2 continues to disseminate globally and there are likely to be recurrent waves of infection into the foreseeable future. We would argue that low cost interventions including physical distancing and enhanced hygiene have increasing relevance. They will protect against the emerging concern for pre-symptomatic transmission and their optimisation will better enable the more restrictive and economically damaging constraints to be relaxed.
READ this article in the MJA
by local public health physician Craig Dalton
Or this one by the same author
in the Conversation
New PubMed has now replaced legacy PubMed
Legacy PubMed has been retired, and New PubMed
has become the default PubMed site. If it’s been a while since you ran a search on PubMed – or feel a little anxious about the changes – don’t worry, here’s an article
that will walk you through the new features.
They include: mobile-friendly design; a cite button - that lets you toggle between different formats, or download citations as an Endnote-compatible file; social media sharing buttons; and a button to copy a permalink. All collections and saved searches stored in your ‘My NCBI’ account are available in the new site.
Find out how to build a search strategy, manage results, save records and see comparisons to legacy PubMed on the Library webpage – ‘Tutorials and Guides’ - PubMed
For more search tips – see the National Library of Medicine
COVID-19 research has overall low methodological quality thus far: case in point for chloroquine/hydroxychloroquine
This article examines recent hydroxychloroquine-azithromycin research, and finds that it is underpinned by very low-quality methodology. The authors, who include researchers from Health Research Methods, Evidence and Impact
and the GUIDE Research Methods Group
at McMaster University, consider the overall body of recent COVID-19 research to be unreliable. Flawed methodology and sub-optimal reporting of research findings could lead to biased estimates of effect. This could lead to substandard treatment decisions, and may be detrimental to patients. The article provides specific suggestions for improving on COVID-19 research methods and reporting, with a focus on issues that researchers must consider in their methodology and reporting if we are to have confidence in the estimates of effect.
READ full-text article
Discussion on the Centre for Evidence-Based Medicine
Surviving Sepsis Campaign: Guidelines on the management of critically ill adults with COVID-19
A panel of 36 experts from 12 countries, proposed 53 questions relevant to the management of COVID-19 in critically ill patients in the ICU. All panel members completed the World Health Organization conflict of interest disclosure form. They identified relevant and recent systematic reviews on most questions relating to supportive care. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. The panel then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations. No recommendation was provided for the following topics: infection control, laboratory diagnosis and specimens, hemodynamic support, ventilatory support, and COVID-19 therapy. When available, the panel will provide new recommendations in further releases of the guidelines.
READ SSC guidelines
to author discussion
VIEW full-size infographic
How safe are library books?
Current research says that in ideal lab conditions, the COVID-19 virus can survive for up to 24 hours on cardboard and up to 2-3 days on plastic and stainless steel. We want to help you stay safe in the library – so we’ve implemented book quarantines, social distancing, and regular cleaning of surfaces such as tables, door handles and computer keyboards and mice.
CDC guidance on mitigating COVID-19 when managing paper-based, circulating, and other types of collections
SOURCE: National Institutes of Health news release
NEJM: Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1
COVID-19: get the latest research
Coronaviruses are important human and animal pathogens. At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China. It rapidly spread, resulting in an epidemic throughout China, with sporadic cases reported globally. In February 2020, the World Health Organization (WHO) designated the disease COVID-19, which stands for coronavirus disease 2019. Previously, this virus was referred to as 2019-nCoV.
The COVID-19 update presented to interns on 11 March 2020 is now available via the Library website
. Presenters included: Dr Tony Merritt (Public Health Physician, Population Health), Dr Catherine Berry (Staff Specialist, Immunology and Infectious Diseases Unit, JHH), and Assoc Prof Chris Grainge (Staff Specialist, Respiratory and General Medicine, JHH)
This UpToDate topic
discusses the epidemiology, clinical features, diagnosis, management, and prevention of COVID-19
Understanding of this novel coronavirus is evolving try this PubMed filter to locate recent literature
Access BMJ Best Practice resources on coronavirus
including BMJ topic page
, learning modules
and patient leaflets
A counter showing in real time the global number of COVID-19 cases, deaths and recoveries from Johns Hopkins University
MJA RESEARCH SKILLS – Stepped wedge cluster randomised trials
The basic premise of a stepped wedge cluster randomised trial (SW-CRT) is that all clusters start in the control condition, and they switch to the intervention condition in an order determined by randomisation. SW-CRTs differ from cluster crossover trials in that the switch is only in one direction, from control to intervention condition.
Find out more in this instalment of MJA Research Skills
The health effects of fine particulate air pollution (bush fire smoke)
Short term exposure to fine particulate matter with diameter less than 2.5 µm (PM2.5) - bush fire smoke - has previously been associated with increased risk of mortality
and hospital admissions
due to cardiovascular and respiratory diseases
, diabetes mellitus, neurological diseases, and deep vein thrombosis
. A recent US study published in the BMJ
, including data from 95,277,169 participants (aged 65 or older admitted to hospital), found short term exposure to PM2.5 was also positively associated with risks of several prevalent but rarely studied causes of hospital admissions, such as septicemia, fluid and electrolyte disorders, and acute and unspecified renal failure. These associations remained even at a daily PM2.5 concentration below the WHO 24 hour guideline. Substantial economic costs were linked to a small increase in short term PM2.5.
Find out more in the December issue of the Library newsletter
READ editorial (Requires Library membership)
RESULTS of the FluTracking Bushfire Smoke Symptoms survey
READ author's opinion piece
Listen to an interview with the author on Norman Swan's Health Report on the ABC
Telephone-delivered CBT can provide lasting benefits for people with IBS
This NIHR-funded study published in the Lancet
is the 24-month follow-up to an earlier publication of 12-month outcomes for 558 people with irritable bowel syndrome (IBS) receiving usual care alone or additional telephone or web-based cognitive behavioural therapy (CBT). The former paper
showed that both therapies helped people deal with their IBS. This longer-term follow-up shows that CBT continues to benefit patients months after therapy sessions have stopped. IBS can be a very debilitating and difficult condition to treat. The present study helps strengthen the case for the provision of remote talking therapies, particularly telephone-based therapy (71% of study participants experienced a clinically significant improvement in their IBS symptoms), as a way to improve access and outcomes for patients.
READ NIHR review
Diagnosis and management of Guillain-Barre Syndrome in 10 steps
Guillain–Barré syndrome (GBS) is a rare, but potentially fatal, immune-mediated disease of the peripheral nerves and nerve roots that is usually triggered by infections. The incidence of GBS can therefore increase during outbreaks of infectious diseases, as was seen during the Zika virus epidemics in 2013 in French Polynesia and 2015 in Latin America. Diagnosis and management of GBS can be complicated as its clinical presentation and disease course are heterogeneous, and no international clinical guidelines are currently available. To support clinicians, the authors have developed a globally applicable guideline for the diagnosis and management of GBS. The guideline, published in Nature reviews. Neurology
, is based on current literature and expert consensus, and has a ten- step structure to facilitate its use in clinical practice.
READ the consensus statement
VISIT 'John Hunter Medicine Grand Rounds' on the Library website to access related resources. Scroll down to 26 September 2019 – ‘Longer term outcomes in GBS’. (Access restricted to HNEH/Mater staff)
How long does a hip replacement last?
Total hip replacement is a common and highly effective operation. All hip replacements eventually fail if in-situ long enough and it is important that patients understand when this might happen. This meta-analysis published in the Lancet
, included 44 case series that reported long-term outcomes of 13,212 hip replacement procedures. The authors also carried out a meta-analysis of data taken from national joint replacement registries in Australia and Finland. These provided 215,676 procedures, with outcomes at 15, 20 and 25 years. After 15 years, 89.4% of hip replacements had survived (data from Australian and Finnish registries). After 25 years, 57.9% were still intact (but data only available from the Finnish registry).
Read NIHR review
Reducing the use of broad spectrum antibiotics may help to cut rates of hospital-acquired VRE
In a research letter published recently in the Medical Journal of Australia
, researchers from John Hunter Hospital reported that a global shortage of piperacillin/tazobactam in 2017 had prompted the hospital to shift to the use of intravenous amoxicillin/clavulanate (IVAC). Researchers noted that the number of hospital-acquired cases of vancomycin-resistant enterococcus (VRE) almost halved, dropping from 191 in the 12 months before the shortage to 101 in the 12 months afterwards (down 47%). The rate of methicillin-resistant staphylococcus aureus (MRSA) also fell from 53 to 31 (down 42%), but this was not statistically significant.
Listen to podcast with Dr John Ferguson
Review of patient relevant outcomes of partial vs. total knee replacement
Partial (or unicompartmental) and total knee replacement are both viable surgical options for treating partial knee osteoarthritis, but most patients with this condition currently undergo total knee replacement. This recent study from the BMJ
attempts to provide evidence to improve shared decision making. Partial knee replacement has several advantages over total knee replacement, including shorter time in hospital, fewer serious medical complications, lower mortality, lower deep infection rate, and better functional outcome. Revision surgery is less likely after total knee replacement, but reoperation for other causes occurs at the same rate for both procedures.
UpToDate Practice Changing Update: Use TAVI in patients with aortic stenosis and low surgical risk
In this recent Practice Changing Update from UpToDate,
the authors recommend transfemoral transcatheter aortic valve implantation (TAVI) rather than surgical aortic valve replacement (SAVR) (Grade 1B evidence), for most patients with symptomatic severe aortic stenosis who are at low surgical risk. However, SAVR is preferred to TAVI for patients with one or more of the following features: bicuspid or unicuspid aortic valve, poor transfemoral access, severe left ventricular outflow tract calcification, or an adverse aortic root.
Click to read more - then scroll down page
ICARUSS is superior to usual care in achieving best-practice recommendations for traditional risk factors, as well as behavioural and functional outcomes, in stroke survivors
Local authors undertook a double-blind randomized controlled trial (n=249) in three Australian cities, testing a new model that implements best-practice recommendations for risk factor management in stroke survivors who have been admitted to stroke units to prevent stroke recurrence, and discharged from hospital to return to their primary care physicians. The Integrated Care for the Reduction of Secondary Stroke (ICARUSS) model is a shared care, multifaceted integrated program that includes bidirectional feedback between general practitioner and specialist unit, education, and engagement of patient and carer in self-management with ongoing input from a multidisciplinary team.
Read more in International journal of stroke
Local recommendations for perioperative management of antihyperglycemic medication
The implications for perioperative management of new oral antihyperglycemic
medications and new insulin treatment technologies are reviewed by local authors in this recent issue of Current opinion in anaesthesiology
Improved hospital care delivery standards, quality assurance, process improvements, consistency in clinical practice, and coordinated multidisciplinary teamwork
should be a major focus for improving outcomes of perioperative patients with diabetes.
Exercise prevents falls in older people living in the community
A recent Cochrane Review
including 23,407 participants -
mostly women, average age 76, from across 25 countries – found high-certainty evidence that exercise programmes reduce the rate of falls and the number of people
experiencing falls in older people living in the community. Exercise programmes that reduce falls primarily involve balance and functional exercises,
while programmes that reduce falls include multiple exercise categories - typically balance and functional exercises, plus resistance exercises.
MJA RESEARCH SKILLS – Cluster randomised trials
Cluster randomised trials randomise groups of individuals, rather than individuals themselves, to interventions. The groups might be communities, schools, workplaces, hospitals, or patients treated by a particular doctor. There are a number of reasons for the use of cluster trials as opposed to individually randomised trials. They may be the only available choice, as when a city is randomised to a mass intervention. Another reason is that the investigators may wish to reduce the risk of contamination, or it may be more effective, more convenient or cheaper to deliver an intervention to a group rather than to an individual.
Find out more in this instalment of MJA Research Skills
Clinical Practice Guideline for the management of Infantile Hemangiomas (aka strawberry birthmarks)
Infantile hemangiomas (IHs) occur in as many as 5% of infants, making
them the most common benign tumour of infancy. Most IHs are small, innocuous, self-resolving, and require no treatment. However, because of their
size or location, a significant minority of IHs are potentially problematic. This clinical practice guideline, published recently in Pediatrics
, defines those IHs that are potentially higher risk and discusses their specific growth characteristics. Early intervention (ideally by
1 month of age) is recommended. When systemic treatment is indicated, propranolol is the drug of choice. Topical timolol may be used to treat select
small, thin, superficial IHs. Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution.
Read 'Abridged Cochrane systematic review and GRADE assessments for IHs'
MJA CLINICAL SKILLS – The Timed Up and Go test
The Timed Up and Go test provides a quick and valid way to estimate
an older person's risk of falls, as well as other adverse outcomes. Find out more about the test, from a local expert, in this latest
instalment of MJA Clinical Skills
Glucocorticoids for croup in children
The findings of this high quality Cochrane review
(n=4,565 children) reinforce current recommendations and practice with a moderate degree of certainty. They suggest that corticosteroids rapidly
reduce symptoms of croup in children, within about 2 hours and that the effect lasts for at least 24 hours. Corticosteroids included beclomethasone,
betamethasone, budesonide, dexamethasone, fluticasone, and prednisolone. Most studies compared corticosteroids to placebo, although some compared
them to adrenaline, to another corticosteroid, or combination of corticosteroids; or compared corticosteroids given in different ways, or amounts.
The findings may support earlier escalation of therapy. Shorter hospital stays and the reduction in readmission rates from about 20% to 10% are
important outcomes. Few studies had a low overall risk of bias, and many biases were unclear from the reporting. However, using the GRADE system
the certainty of evidence was thought to be moderate meaning that readers can be moderately confident in the effect estimate.
Read Cochrane review
Read NIHR review
MJA RESEARCH SKILLS – Network meta-analysis in health care decision making
Network meta-analysis (NMA) represents an extension of pairwise meta-analysis that allows for the simultaneous comparison of three or more interventions
by considering both direct and indirect evidence. NMA provides an estimate of the relative effectiveness of all pairs of comparisons for both benefits and harms and represents the best way of deciding which available treatments
remain viable options and which should no longer be considered. The authors of this recent instalment of MJA Research Skills
point out that all ranking interventions have limitations, and evaluation
of the certainty of evidence, using tools such as GRADE, is imperative.
Additional physical therapy services reduce length of stay and improve health outcomes in people with acute and subacute conditions
This systematic review by Australian authors found moderate-quality
evidence that additional physical therapy services reduced length of stay by 3 days in subacute settings, and low-quality evidence that it
reduced length of stay by 0.6 days in acute settings. Published in Archives of physical medicine and rehabilitation
the review also found that additional physical therapy led to small improvements in self-care, activities of daily living, and health-related
quality of life, with no increases in adverse events. There was no significant change in walking ability. Methodological quality was assessed
using the PEDro scale, and the GRADE approach was applied to each meta-analysis.
Laparoscopic cholecystectomy reduces the rate of major complications in high risk patients with acute cholecystitis – compared to percutaneous catheter drainage
The CHOCOLATE multicentre clinical superiority trial randomised high-risk patients
with acute calculous cholecystitis (APACHE II score of 7 or more) to either laparoscopic cholecystectomy or percutaneous catheter drainage. The trial was
concluded early after a planned interim analysis. This study, published in the BMJ
, provides strong evidence that laparoscopic
cholecystectomy is superior to percutaneous catheter drainage in the treatment of high risk patients with acute calculous cholecystitis. Cholecystectomy not
only reduced the rate of major complications (ie, infectious and cardiopulmonary complications, or need for reintervention, or recurrent biliary disease), but also
reduced utilisation of healthcare resources and costs by more than 30 percent.
CLINICAL PRACTICE GUIDELINE: Atraumatic vs. conventional needles for lumbar puncture
Is the needle tip configuration important when performing a lumbar puncture
for any indication? A systematic review published in the Lancet
earlier this year suggests that it is. The review – which
was highlighted in Health News (22.05.2018)
– found that using atraumatic (pencil-point) lumbar puncture needles instead
of conventional lumbar puncture needles reduced the risk of post-dural-puncture headache and of return to hospital for additional pain control.
This BMJ clinical practice guideline
, following GRADE methodology standards, makes a strong recommendation for the use of
atraumatic needles for lumbar puncture in all patients regardless of age (adults and children) or indication instead of conventional needles.
Read more in the BMJ
Read the Lancet article
Assessing evidence quality: the GRADE approach
In 2004, a group of international experts in methodology and practice
guidelines first published the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of
evidence supporting medical interventions and develop recommendations. Since then, the group has published a six-part series for clinicians
using GRADE guidelines, and a series of articles supporting systematic review authors and guideline groups using GRADE in their work. Over
100 organisations worldwide — including the World Health Organization, the Cochrane Collaboration, the Joanna Briggs Institute, the American
College of Physicians, DynaMed Plus and UpToDate — have endorsed or adopted GRADE.
Read more in the MJA
GRADE working group website
Effect of aspirin on cardiovascular events and bleeding in the healthy elderly: ASPREE clinical trials
Aspirin is a well-established therapy for the secondary prevention of
cardiovascular events. However, its role in the primary prevention of cardiovascular disease is unclear, especially in older persons, who have
an increased risk. This trial published in the New England Journal of Medicine (NEJM)
enrolled 19,114 community-dwelling
men and women in Australia and the United States who were 70 years of age or older and did not have cardiovascular disease, dementia, or disability.
9525 participants received 100 mg of enteric-coated aspirin, and 9589 received placebo. After a median of 4.7 years of follow-up, the rate of
cardiovascular disease was 10.7 events per 1000 person-years in the aspirin group and 11.3 events per 1000 person-years in the placebo group.
The rate of major haemorrhage was 8.6 events per 1000 person-years and 6.2 events per 1000 person-years, respectively.
Effect of aspirin on disability-free survival in the healthy elderly
Effect of aspirin on all-cause mortality in the healthy elderly
MJA RESEARCH SKILLS – Survival studies: competing risks, immortality & censoring
If time is an integral part of a study, then a key issue is what else
happened to the participants during the time between their recruitment and the time at which we tried to record their outcomes. If we did not
find them, is that because they emigrated or died? If they died, was their death related to their original illness? Did they take some other
therapy in the interim? Time complicates all studies, but most complications can be managed by collecting detailed data on participants over
time and using survival analysis. Find out about survival analysis in this recent latest instalment of the MJA Research Skills
Increasing omega-6 fats reduces total serum cholesterol, but not other blood fat fractions or adiposity
This recent Cochrane review
assessed the effects
of increasing omega-6 fats (linoleic acid, gamma-linolenic acid, dihomo-gamma-linolenic acid and arachidonic acid) on cardiovascular health, mortality,
lipids and adiposity, using previously unpublished data. 19 RCTs, including 6461 participants who were followed for one to eight years, were included.
The authors found no evidence that increasing omega-6 fats reduces cardiovascular outcomes other than myocardial infarction (MI) – where 53 people may
need to increase omega-6 fat intake to prevent 1 person from experiencing MI. High-quality evidence suggests increasing omega-6 fats reduces total serum
cholesterol, but not other blood fat fractions or adiposity.
Early, intense rehabilitation aids recovery after serious traumatic head injury
A review of 11 studies, published in Archives
of physical medicine and rehabilitation
, found that starting rehabilitation early, while people were still in intensive
care – even while still unconscious, and continuing intensive neurorehabilitation, promotes functional recovery and improve outcomes
for people with moderate to severe traumatic brain injury compared with usual care. These effects were replicated based solely on
studies with a low overall risk of bias.
Read NIHR review
MJA RESEARCH SKILLS - Understanding statistical principles in linear and logistic regression
In a recent instalment of the MJA Research Skills
series, the authors introduce the concept of multivariable regression. A regression model establishes the relationship between one or
more exposure, or explanatory, variables and an outcome. The resulting model describes the nature of the relationship between explanatory
variables and outcome, and can be used to predict an unknown outcome value based on given values of the explanatory variables.
Fewer side-effects and similar benefits from shorter chemotherapy after bowel cancer surgery
Guidelines worldwide recommend a six-month combination of a
fluoropyrimidine chemotherapy drug with oxaliplatin, for people with high-risk stage II or III colorectal cancer that has spread through the
bowel wall or to nearby lymph nodes. Side effects of oxaliplatin, including disabling neuropathy, increase with dose. The international SCOT
trial, published in Lancet oncology
, enrolled 6,088 patients and demonstrated similar effectiveness with a three-month
chemotherapy course with the same drugs. Less than half as many patients reported severe neuropathy. Quality of life scores were better with
Read NIHR review
In-hospital 24 hour delay before surgery not a risk factor for complications in patients with acute appendicitis
This meta-analysis of 45 studies (152,314 patients) published in the British
journal of surgery
demonstrates that delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 hours after admission does not
appear to be a risk factor for complicated appendicitis, postoperative surgical-site infection or morbidity.
MJA CLINICAL SKILLS – Bedside cognitive assessment
Cognitive impairment and its related syndromes can be challenging to
diagnose in a short patient encounter. Brief evidence-based assessments of cognition are sensitive, and practical screens can determine if
further testing and intervention are required. For these reasons, cognitive screening is important, as early cognitive impairment can be easily
missed. A recent instalment of MJA Clinical Skills
offers some tips on conducting a brief bedside cognitive examination.
Physiotherapy before abdominal surgery helps prevent pneumonia
A recent Australian and New Zealand study involving adult patients listed for elective upper
abdominal surgery (n=432), published in the BMJ
, found that a 30 minute preoperative physiotherapy session provided within existing
hospital multidisciplinary preadmission clinics halves the incidence of postoperative pulmonary complications and specifically hospital acquired pneumonia. Further
research is required to investigate benefits to mortality and length of stay.
Read NIHR review
Atraumatic needles reduce headaches following lumbar puncture
Use of atraumatic, rather than conventional, needles for lumbar puncture more
than halves the rate of post-procedure headache, according to a recent systematic review of high-quality evidence published in the Lancet
Moreover, this improvement does not come at the expense of procedure success rates. These findings offer clinicians and stakeholders a comprehensive assessment
and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture.
Read NIHR review
RANZCP clinical practice guidelines for mood disorders: Bipolar disorder summary
This guideline summary from the Royal Australian and New Zealand College of
Psychiatrists (RANZCP) published in the MJA
focuses on bipolar disorder. It is intended as an aid to the management of
this complex disorder for primary care physicians working in collaboration with psychiatrists to implement successful long term management.
MJA RESEARCH SKILLS – Guided by the research design: choosing the right statistical test
Choosing the right statistical test or model can be baffling for researchers, and if it
is not conducted correctly, the results from statistical analyses can be misleading. The latest instalment in the MJA Research Skills
series discusses some common medical research designs, ranging from simple to more complicated, and provides an outline of which statistical test to apply in
each instance. In these contexts, data are collected from a sample that is assumed to be representative of a wider population, and the conclusions drawn from the
analyses apply to the wider population.
Stopping biological drugs for rheumatoid arthritis can lead to twice the relapse rate
Drug treatments for rheumatoid arthritis suppress the immune system,
putting people at higher risk of infection. The disease has episodes of improvement and deterioration so judging the effects of treatment can be difficult.
This review published in Annals of rheumatic diseases
aims to inform shared decisions on optimal drug doses to balance
the risk of side effects with the risk of relapse for those wishing to reduce their dose.
Read NIHR review
MJA RESEARCH SKILLS – Distributions and what to do when they are non-normal
Medical researchers often want to find out how medically relevant outcomes
are related to other factors. To do so, they carry out analyses and fit models that are based on assumptions about the nature of the research data.
The latest instalment in the MJA Research Skills
series describes three methods which may be used when one commonly
made assumption is not met. The methods are demonstrated on a real dataset in which the outcome is an index of harmful use of alcohol, with higher
scores indicating a higher incidence of harmful behaviours.
Biological therapies for psoriasis do not increase serious infection risk
People with psoriasis who take an immune-modulating treatment
are no more likely to get serious infections than people taking standard therapies, according to a recent study published in the Journal
of investigative dermatology
. This study used a large database of people with psoriasis from the UK and Ireland. It compared serious
infection risk of the biological therapies – etanercept, adalimumab or ustekinumab (n=5,617) – with non-biological oral therapies (n=3,421). After
accounting for factors such as other illnesses, it found none of the biological therapies studied had a higher risk of infection compared to non-biological
therapies or compared to each other.
Read NIHR review
MJA CLINICAL SKILLS - Spirometry: key to the diagnosis of respiratory disorders
The latest instalment in the MJA Clinical Skills
discusses spirometry. It remains the cornerstone of respiratory function testing and is the key to diagnosing and monitoring the most common respiratory disorders.
Local nerve blocks can improve outcomes for people with hip fracture
Local nerve blocks around the time of hip fracture surgery reduced pain on movement
within 30 minutes of injection. People had less need for opioid pain-relief and were quicker to mobilise after surgery. This updated Cochrane review
identified 31 trials providing moderate to high-quality evidence. The benefits were small but could make a meaningful difference to the patient’s experience and
outcomes. Earlier mobilisation combined with less need for opioids and their associated risk of respiratory depression may have contributed to reduced risk of pneumonia.
Read NIHR review
Using mesh does not improve results in vaginal prolapse surgery
This large pragmatic study published in The Lancet
at over 3000 women with vaginal prolapse. Half of these were randomised; the rest contributed data but were not part of the main evaluation. The study separately
compared synthetic mesh and biological tissue grafts to a repair without these additions. It also took account of whether it was women’s first or subsequent repair
operation. There was no difference in prolapse symptoms or quality of life at two years in women who had surgery that used mesh or biological graft and those who
had standard surgery. About 12% of women overall had minor or major complications from the mesh.
SEE ALSO: Report in 'Health technology assessment' by same authors