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The 76th Bubble Wrap

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With millions of journal articles published yearly, it is impossible to keep up.  Our team have scoured the literature, so you don’t have to… or it might spark an interest to go and have a look at the full article.

A very Merry Christmas from the BW team, and all the Best Wishes for 2024!

  

Article 1: What is adherence like in young people with ulcerative colitis?

Jayasooriya N, Pollok RC, Blackwell J, Bottle A, Petersen I, Creese H, Saxena S; POP-IBD study group. Adherence to 5-aminosalicylic acid maintenance treatment in young people with ulcerative colitis: a retrospective cohort study in primary care. Br J Gen Pract. 2023 Oct 26;73(736):e850-e857. doi: 10.3399/BJGP.2023.0006. PMID: 37666511; PMCID: PMC10498382.

What’s it about? 

Roughly 30% of patients with ulcerative colitis are diagnosed as children or young adults, and this early diagnosis is associated with poorer long-term outcomes. Therefore, rapid and sustained remission is critical. Oral 5-aminosalicylic acid (5-ASA) is one of the main treatments used.

This paper retrospectively assembled a cohort of patients diagnosed with UC between 1998 and 2016 and aged between 10 and 24. They were identified on the Clinical Practice Research Datalink, a validated Primary Care database of 18 million patients in the UK. In total, 607 patients met the criteria for inclusion.

The primary outcome measure was the time patients collected their repeat prescriptions, i.e. their adherence. The secondary outcome measure was the Proportion of Days Covered (PDC), a percentage of the number of days of treatment requested in their first year of treatment.

25% of patients stopped 5-ASA treatment within one month, and 69% had stopped by one year.

The median time to discontinuation was 169 days. Risk factors for stopping treatment included age 18-24 and living in more deprived areas. Those who had an acute flare requiring steroids were more likely to remain adherent to 5-ASA therapy.

Why does it matter? 

Patients with poor adherence to 5-ASA therapy (PDC <80%) have a 5x increased risk of disease relapse.

The mean PDC in the study was 72%. This is equivalent to missing 3 out of 12 months of treatment a year and indicates widespread, sub-optimal treatment of UC – in a cohort most at risk of poor outcomes.

Treatment failure leads to the increased use of alternatives such as steroids. Further work is needed to reduce socio-economic barriers to treatment.

30% of patients with IBD avoid picking up a prescription because of cost. A further 15% take medication less frequently to reduce costs.

Clinically Relevant Bottom Line:

As patients transition from paediatric to adult services, they are more likely to have poor adherence to 5-ASA therapy. This puts them at a significantly increased risk of disease relapse.

Disease relapse should not automatically be assumed to mean failure of therapy. 

Reviewed by: Dr Andy Moriarty and Dr Luke Mitchell

Article 2: How can we promote good sexual health?

Crocker, B.C.S., Pit, S.W., Hansen, V. et al. A positive approach to adolescent sexual health promotion: a qualitative evaluation of key stakeholder perceptions of the Australian Positive Adolescent Sexual Health (PASH) Conference. BMC Public Health 19, 681 (2019). https://doi.org/10.1186/s12889-019-6993-9

What’s it about? 

Positive youth development (PYD) programs promoting adolescent sexual health behaviours differ from sex education programs in that they focus more on strengthening wellbeing, skills and relationships, with sexual health incorporated within these. The key elements of Positive Youth Development programs include a positive, supportive environment, strengthening the school and family context, empowering youth, building skills and engaging youth in real activities and roles.

This qualitative study undertaken with thirteen participants attending the Australian Positive Adolescent Sexual Health (PASH) conference in 2019 explored how the conference was able to engage young people to strengthen their sexual health & wellbeing.

Why does it matter? 

“Sex ed” sucks. A 2013 study found that half of young Australians are dissatisfied with school-based sex education. They believe that Sex Ed programs are irrelevant to real-life experience and contain inadequate discussion of important issues, including consent or positive sexual relationships.

By contrast, PYD programs are more holistic, with an emphasis on strengthening wellbeing, skills and relationships, with sexual health incorporated as part of the program. As clinicians, we have an opportunity to provide strengths-oriented sexual health care to adolescents & young adults.

A great post on what’s ‘normal’ sexual behaviour in young children can be found here Sexual Behaviour in Children – what is “normal”? – Don’t Forget the Bubbles (dontforgetthebubbles.com)

Clinically Relevant Bottom Line:

Young people identified that having professionals who were comfortable discussing sex and sexual health was a positive way of normalising discussions around sex-related topics. As health professionals, we have a responsibility to normalise developmentally appropriate, non-judgemental conversations around sexual health.

Reviewed by: Henry Goldstein

Article 3: Can we use MicroMend to close wounds?

Nizami T, Beaudoin F, Suner S, et al. Evaluation of microMend wound closure device in repairing skin lacerations. Emergency Medicine Journal 2023;40:564-568. doi.org/10.1136/emermed-2022-212667

What’s it all about?

MicroMend is a wound closure device with a mix of small staples and adhesive tape. It is applied similarly to steri-strips and could be used to close wounds where the edges are less than 1cm apart.

This is a small, open label, single-arm prospective study looking at the acceptability of microMend. Data was collected at 2 emergency departments in America and included assessment by both clinicians and patients for a total of 31 patients. The device was assessed by the clinicians (emergency medicine doctors) using it on ease of use, speed of use and the appearance of the closed wound. It was also assessed by patients on pain of application, pain of removal and the wound repair. Finally, the wounds were also assessed by 2 plastic surgeons utilising a wound assessment score and a visual analogue score at 7, 30 and 60 days.

Overall, the study found that the wound results were comparable to the use of wound adhesive and that it was acceptable to use for both clinicians and patients.

Why does it matter?

Wounds are a common presentation to both adult and paediatric emergency departments. Effective, easy-to-use wound closure methods are important in treating these patients especially if simple methods can be used over sutures which require local anaesthetic (or even sedation in some cases) and further time to remove later. 

An excellent article on wounds can be found here: Managing wounds – Don’t Forget the Bubbles (dontforgetthebubbles.com)

The Bottom Line:

This device could present an opportunity to close wounds that are not amenable to steri-strips or wound adhesive, without sutures. It may be especially useful in the paediatric population where the use of local anaesthetic can be more difficult. However, as this is a single arm study of a small number of patients, further studies will be needed to compare this to other wound closure methods. The wounds assessed were also relatively small (mean 2.35cm) and did not include any on flexor or extensor surfaces so extrapolating to other wounds is not currently possible.

Reviewed by: Dr Emma Faragher

Article 4: Does PPI use increase the risk of serious bacterial infections in young children?

Lassalle M, Zureik M, Dray-Spira R. Proton Pump Inhibitor Use and Risk of Serious Infections in Young Children. JAMA Pediatr. 2023 Oct 1;177(10):1028-1038. doi: 10.1001/jamapediatrics.2023.2900. PMID: 37578761; PMCID: PMC10425862.

What’s it about?

This French nationwide cohort study looked at data from Mother-Child EPI-MERES Register built from the French Health Data System (SNDS). The study included all children born between January 1, 2010, and December 31, 2018, who received a treatment for gastroesophageal reflux disease or other gastric acid–related disorders, namely PPIs, histamine 2 receptor antagonists, or antacids/alginate. Follow up was until loss of follow up, serious bacterial infection, death or a time point of December 31st 2019.

The exposure of interest to the study was PPI use. This was categorized into: Exposed or unexposed, (history of exposure: none, past, ongoing and duration of therapy: (unexposed, ≤6 months, 7-12 months, >12 months).

The outcome was diagnosis of a serious infection classified as: requiring hospitalization. The infections were classified by site (ENT, lower respiratory tract, urinary tract, skin, MSK and nervous system).

The study population comprised 1 262 424 children, 606 645 who received PPI and 655 779 who did not receive PPI. Associations between PPI use and serious infection were reported as adjusted hazard ratios (AHR).

PPI exposure was associated with an increased risk of serious infections overall (aHR, 1.34; 95% CI, 1.32-1.36). In terms of sites of infection PPI use was most significantly was increased in infections in the digestive tract (aHR, 1.52; 95% CI, 1.48-1.55), in addition to ENT, LRTI, urinary tract and nervous system. In addition PPI use was associated with increased risk for both bacterial (aHR, 1.56; 95% CI, 1.50-1.63) and viral infections (aHR, 1.30; 95% CI, 1.28-1.33).

This was a comprehensive study looking at the French population. However the data does not given information on indications for the treatment of reflux, meaning some of the medications could have been prescribed inappropriately. There was no information collected on breast feeding (in terms of protective factor for infection) or social interaction. Other variables were accounted for.

Why does it matter?

PPI’s alter the gastric microbiome. This microbiome undergoes huge changes during infancy. PPI use during this period could have a significant impact. PPI’s may also affect multiple other functions of the immune system. PPI’s are used in GORD which can be difficult to diagnose. The use of PPI’s is increasing in higher income countries.

An excellent article on management of GORD can be found here Managing Gastro-Oesophageal Reflux Disease – Don’t Forget the Bubbles (dontforgetthebubbles.com)

The bottom line

In this study PPI use in young children was associated with increased risk of serious infection (defined as requiring hospitalisation). The use of PPI’s in this population should be considered and justified in this population- with a discussion with the family regarding potential implications.

Reviewed by: Vicki Currie

Article 5: Does occluding the femoral artery during neonatal CPR increase the likelihood of ROSC? (In lambs?)

Rawat M, Mani S, Gugino SF, Koenigsknecht C, Helman J, Nielson L, Nair J, Munshi U, Chandrasekharan P, Lakshminrusimha S. Femoral Occlusion during Neonatal Cardiopulmonary Resuscitation Improves Outcomes in an Ovine Model of Perinatal Cardiac Arrest. Children. 2023 Nov 10(11), 1804; https://doi.org/10.3390/children10111804

What’s it about?

The goal of chest compressions during neonatal resuscitation is to increase cerebral and coronary blood flow with the intention to achieve a return of spontaneous circulation (ROSC). The time this takes is an important prognostic indicator to neurodevelopment disability. This paper aimed to evaluate whether simple manual femoral artery occlusion could reduce the time taken to ROSC via increasing the afterload to promote carotid and coronary flow. A similar haemodynamic effect of adrenaline without the time taken for siting an umbilical vein catheter and intubation.

This was a single centre prospective randomised animal (lamb) study randomised into two arms; the femoral occlusion group and the control group. Both were partly delivered via caesarian section, flow probes inserted into carotid, pulmonary and left circumflex coronary arteries. Umbilical vein catheter (UVC) inserted and arterial line for invasive BP. The lamb then underwent induced asphyxiation by umbilical cord occlusion.

The femoral occlusion (FO) group had both femoral arteries occluded using thumbs and hip flexion until ROSC or 20 minutes had passed. The control group had no form of femoral artery occlusion or hip flexion. Both groups underwent standard neonatal resuscitation programme (NRP) recommendations. Epinephrine was initially given to both groups after 5 minutes of chest compressions, this delay was based on a previous simulation study looking at length of time to site an UVC.

19 lambs were studied with 10 in the FO group and 9 in the control. 7 of the FO achieved ROSC and 4 in the control (p = 0.37) but more impressively the average time to ROSC was 5 ± 2 mins compared to 13 ± 6 in the control (p = 0.02). This is believed to be as a result of the statistically significantly increased diastolic blood pressure, carotid artery blood flow and coronary artery blood flow in the FO group prior to any epinephrine. As a secondary measure, oxygen requirement for the observed two hours post ROSC was significantly reduced in the FO group vs control (35 ± 25% vs 56 ± 35%, p < 0.0001). In all lambs that achieved ROSC the femoral pulses were normal and no evidence of limb ischaemia. 

Clearly this is NOT going to change practice in the human population based on the results of this trial alone….. (reminder this was done in lambs) but this isn’t the first time that we have looked at data from sheep to help us in neonatal resuscitation. Studies done 20 years ago are still helping to inform us about what PEEP to use The 73rd Bubble Wrap – Don’t Forget the Bubbles (dontforgetthebubbles.com)

Why does it matter?

This is the first study evaluating the effect of femoral occlusion in a transitional model of cardiac arrest due to severe asphyxia. Femoral occlusion is a simple manoeuvre that can be easily adapted during CPR in resource-poor settings as well as potentially in the early stages of resuscitation prior to intravenous access and in this small study has been shown to reduce the time taken to ROSC and in turn potentially reduce the chances of neurodevelopment disability.

Clinically Relevant Bottom Line:

This research won’t change current clinical practice but could be a driving force to look at future clinical trials.

Reviewed by: Graham Clarke

If we have missed out on something useful or you think other articles are worth sharing, please add them in the comments!

That’s it for this month. Many thanks to our reviewers who have taken the time to scour the literature, so you don’t have to.

All articles reviewed and edited by Vicki Currie

Author

  • Vicki is a Paediatric Registrar in the West Midlands in the UK , starting PEM in September 2021. Vicki is passionate about good communication in teams and with patients along with teaching at undergraduate and postgraduate level. When not editing Bubble wrap Vicki can be found running with her cocker spaniel Scramble or endlessly chatting with friends.

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