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
Effects of cannabis among adults with chronic pain
Cannabis is increasingly available for the treatment of chronic
pain, yet its efficacy remains uncertain. This systematic review published in Annals of internal medicine
assessed the benefits of plant-based cannabis preparations for treating chronic pain in adults and the harms of cannabis use in chronic pain
and general adult populations. From 27 chronic pain trials, there is low-strength evidence that cannabis alleviates neuropathic pain in
some patients, but insufficient evidence exists for other types of chronic pain. According to 11 systematic reviews and 32 primary studies,
harms in general population studies include increased risk for motor vehicle accidents, psychotic symptoms, and short-term cognitive
impairment. Present research is limited by: few methodologically rigorous trials; cannabis formulations studied may not reflect commercially
available products; and few trials of older, chronically ill populations and patients who use cannabis heavily.
MJA RESEARCH SKILLS - Statistical and clinical significance
In published research, a statistically significant result is often wrongly interpreted as
representing a clinically important finding. In this article – the latest instalment in the MJA
series outlining accessible statistics
for clinicians – the author explores the meanings of statistical and clinical significance.
Allied health professionals have an important role in the treatment of juvenile idiopathic arthritis
Juvenile idiopathic arthritis (JIA) is a chronic, autoimmune, inflammatory joint disease.
It is the most common arthritis in children and adolescents. Pharmaceutical therapy including non-steroidal anti-inflammatory drugs, corticosteroid injections
and biological drugs are the forefront of gold standard care in JIA. Emerging evidence on the non-invasive, physical and mechanical therapies in JIA, suggest
that allied health professionals (AHP) also play an important role as part of this gold standard approach. This paper by local authors, published in the Journal
of paediatrics and child health
, aims to assist AHP in attaining gold standard practice, by providing evidence-based summaries on the presentation
of lower limb pathologies in JIA and the allied health therapies available.
Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration
This recent Cochrane review
included a total of
five RCTs with data available for 76,756 people. The trials were conducted in Australia, Finland, and the USA, and investigated vitamin C,
vitamin E, beta-carotene, and multivitamin supplements. All trials were judged to be at low risk of bias. They found that taking vitamin E or
beta-carotene supplements will not prevent or delay the onset of age-related macular degeneration (AMD). The same probably applies to vitamin C
and the multivitamin (Centrum Silver) investigated in the one trial reported to date. There is no evidence with respect to other antioxidant
supplements, such as lutein and zeaxanthin. Although generally regarded as safe, vitamin supplements may have harmful effects, and clear evidence
of benefit is needed before they can be recommended.
SEE ALSO: Cochrane Review on antioxidant vitamin and mineral supplements for slowing the progression of AMD, written by the same review team
Improved Assessment of Chest pain Trial (IMPACT)
A recent study from the Royal Brisbane and Women’s Hospital, published in the MJA
reported that three-quarters of patients presenting to EDs with chest pain could be rapidly assessed using risk stratification tools, early troponin testing and selective objective testing. The
Improved Assessment of Chest pain Trial (IMPACT) included 1366 patients who presented over 3 years with symptoms of suspected acute coronary syndrome (ACS). The researchers found an
overall 30-day ACS rate of 6.6%, none of which occurred in the low risk group. There were 14 ACS cases (1.8%) in intermediate risk patients.
Clinical Practice Guideline: Laparoscopic hysterectomy for benign indications
Since the introduction of minimally invasive gynecologic surgery, the percentage of advanced
laparoscopic procedures has greatly increased worldwide. The Dutch Society of Gynecological Endoscopic Surgery developed a national guideline for laparoscopic
hysterectomy according to the principles of evidence-based medicine in collaboration with clinical librarians. This article published in Archives of gynecology
provides a summary of the main recommendations.
Acupuncture effective for chronic pain in primary care
This synthesis of high-quality data from 18000 patients, published in the UK NIHR journal
Programme grants for applied research
found that acupuncture was more effective than both usual care and sham acupuncture for
chronic pain, consisting of musculoskeletal pain related to the neck and low back, knee osteoarthritis, and chronic headache. Acupuncture also improved quality of
life compared with standard care and was assessed to be a good use of NHS resources.
Read NIHR review
MJA RESEARCH SKILLS – Understanding statistical hypothesis tests and power
The latest instalment in the MJA
outlining accessible statistics for clinicians, co-written by HNELHD staff member John Attia, examines the importance of clinical and biological
science in the construction and clinical interpretation of statistical hypothesis tests.