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47 ["Prescribing medical cannabis: ethical considerations for primary care providers"] 10.1136/medethics-2019-105759 http://dx.doi.org/10.1136/medethics-2019-105759 2019-12-18T22:15:30Z ["Health Policy", "Arts and Humanities (miscellaneous)", "Issues, ethics and legal aspects", "Health(social science)"] 27 1 ["0306-6800", "1473-4257"] Journal of Medical Ethics <jats:p>Medical cannabis is widely available in the USA and legalisation is likely to expand. Despite the increased accessibility and use of medical cannabis, physicians have significant knowledge gaps regarding evidence of clinical benefits and potential harms. We argue that primary care providers have an ethical obligation to develop competency to provide cannabis to appropriate patients. Furthermore, specific ethical considerations should guide the recommendation of medical cannabis. In many cases, these ethical considerations are extensions of well-established principles of beneficence and nonmaleficence, which indicate that providers should recommend cannabis only for conditions that have the strongest evidence base. Additionally, the contested status of cannabis in American culture raises specific issues related to shared decision-making and patient education, as well as continuing clinical education.</jats:p> 2 ["http://orcid.org/0000-0002-2282-9253"] ["Aaron Glickman", "Dominic Sisti"] [""] [""] [""]
42 ["Hyper-reflexia in Guillain-Barr\u00e9 syndrome: systematic review"] 10.1136/jnnp-2019-321890 http://dx.doi.org/10.1136/jnnp-2019-321890 2020-01-14T22:33:50Z ["Surgery", "Psychiatry and Mental health", "Clinical Neurology"] 43 1 ["0022-3050", "1468-330X"] Journal of Neurology, Neurosurgery & Psychiatry <jats:p>Areflexia or hyporeflexia is a mandatory clinical criterion for the diagnosis of Guillain-Barré syndrome (GBS). A systematic review of the literature from 1 January 1993 to 30 August 2019 revealed 44 sufficiently detailed patients with GBS and hyper-reflexia, along with one we describe. 73.3% of patients were from Japan, 6.7% from the USA, 6.7% from India, 4.4% from Italy, 4.4% from Turkey, 2.2% from Switzerland and 2.2% from Slovenia, suggesting a considerable geographical variation. Hyper-reflexia was more frequently associated with antecedent diarrhoea (56%) than upper respiratory tract infection (22.2%) and the electrodiagnosis of acute motor axonal neuropathy (56%) than acute inflammatory demyelinating polyneuropathy (4.4%). Antiganglioside antibodies were positive in 89.7% of patients. Hyper-reflexia was generalised in 90.7% of patients and associated with reflex spread in half; it was present from the early progressive phase in 86.7% and disappeared in a few weeks or persisted until 18 months. Ankle clonus or Babinski signs were rarely reported (6.7%); spasticity never developed. 53.3% of patients could walk unaided at nadir, none needed mechanical ventilation or died. 92.9% of patients with limb weakness were able to walk unaided within 6 months. Electrophysiological studies showed high soleus maximal H-reflex amplitude to maximal compound muscle action potential amplitude ratio, suggestive of spinal motoneuron hyperexcitability, and increased central conduction time, suggestive of corticospinal tract involvement, although a structural damage was never demonstrated by MRI. Hyper-reflexia is not inconsistent with the GBS diagnosis and should not delay treatment. All GBS variants and subtypes can present with hyper-reflexia, and this eventuality should be mentioned in future diagnostic criteria for GBS.</jats:p> 3 ["http://orcid.org/0000-0002-8131-8912", "http://orcid.org/0000-0002-4716-8578"] ["Antonino Uncini", "Francesca Notturno", "Satoshi Kuwabara"] [""] [""] [""]
45 ["Success of 4CMenB in preventing meningococcal disease: evidence from real-world experience"] 10.1136/archdischild-2019-318047 http://dx.doi.org/10.1136/archdischild-2019-318047 2020-02-06T22:15:25Z ["Pediatrics, Perinatology, and Child Health"] 0 1 ["0003-9888", "1468-2044"] Archives of Disease in Childhood <jats:p>Meningococcal disease remains one of the most feared infectious diseases worldwide because of its sudden onset, rapid progression and high case fatality rates, while survivors are often left with severe long-term sequelae. Young children have the highest incidence of invasive meningococcal disease (IMD), and nearly all cases in the UK, as in most of Europe and many other industrialised countries, are due to group B meningococci (MenB). The licensure of a broad-coverage, recombinant protein-based MenB vaccine (4CMenB) in 2013 was, therefore, heralded a major breakthrough in the fight against IMD. This vaccine was, however, licensed on immunogenicity and reactogenicity studies only, raising uncertainties about field effectiveness, long-term safety and antibody persistence. In 2015, the UK became the first country to implement 4CMenB into the national infant immunisation schedule and, since then, several countries have followed suit. Seven years after licensure, a wealth of real-world data has emerged to confirm 4CMenB effectiveness, along with large-scale safety data, duration of protection in different age groups, successful strategies to reduce vaccine reactogenicity, impact on carriage in adolescents and the potential for 4CMenB to protect against other meningococcal serogroups and against gonorrhoea. A number of questions, however, remain unanswered, including the investigation and management of vaccine-associated fever in infants, as well as disease severity and assessment of breakthrough cases in immunised children. Increasing use of 4CMenB will provide answers in due course. We now have vaccines against all the major serogroups causing IMD worldwide. Next-generation and combination vaccines against multiple serogroups look very promising.</jats:p> 4 [] ["Catherine Isitt", "Catherine A Cosgrove", "Mary Elizabeth Ramsay", "Shamez N Ladhani"] [""] [""] [""]
43 ["Thyroid scintigraphy differentiates subtypes of congenital hypothyroidism"] 10.1136/archdischild-2019-317665 http://dx.doi.org/10.1136/archdischild-2019-317665 2019-11-14T22:15:30Z ["Pediatrics, Perinatology, and Child Health"] 0 1 ["0003-9888", "1468-2044"] Archives of Disease in Childhood <jats:sec><jats:title>Introduction</jats:title><jats:p>UK screening for congenital hypothyroidism (CH) is based on dried blood spot Thyroid Stimulating Hormone (TSH). Scintigraphy may identify CH subtypes classified as dysplasia, gland in situ (GIS) and ectopia, but is not performed in all centres. We retrospectively investigated the role of scintigraphy to identify CH subtypes in a single tertiary centre cohort.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>Babies who screened positive for CH between 2007 and 2017 were studied (n=418 of 534 783). Scintigraphy outcomes were correlated with TSH and levothyroxine dose. GIS patients were analysed for 3-year outcomes.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>303 patients started levothyroxine. Scintigraphy demonstrated three subtypes: GIS (n=139, 46%) ectopia (n=84, 28%) and dysplasia (n=80, 26%). Three-year follow up demonstrated permanence in 54% of 37 GIS cases.</jats:p></jats:sec><jats:sec><jats:title>Discussion</jats:title><jats:p>Thyroid scintigraphy differentiates subtypes of CH and suggests a higher than expected proportion of patients with GIS and ectopia. CH is permanent in half of those with GIS.</jats:p></jats:sec> 6 [] ["Chris Worth", "Beverly Hird", "Lesley Tetlow", "Neville Wright", "Leena Patel", "Indraneel Banerjee"] [""] [""] [""]
40 ["Infant sleep and child mental health: a longitudinal investigation"] 10.1136/archdischild-2019-318014 http://dx.doi.org/10.1136/archdischild-2019-318014 2020-03-10T03:55:23Z ["Pediatrics, Perinatology, and Child Health"] 25 1 ["0003-9888", "1468-2044"] Archives of Disease in Childhood <jats:sec><jats:title>Objective</jats:title><jats:p>To determine whether infants with severe persistent sleep problems are at increased risk of (1) meeting diagnostic criteria for a psychiatric disorder (age 10 years), and (2) having elevated symptoms of mental health difficulties (ages 4 and 10 years), in comparison with infants with settled sleep.</jats:p></jats:sec><jats:sec><jats:title>Design and setting</jats:title><jats:p>Prospective longitudinal community cohort study—the Maternal Health Study. Mothers completed questionnaires/interviews at 15 weeks' gestation; 3, 6, 9 and 12 months post partum; and when their child turned 4 and 10 years old. Measures included parental report of infant night waking and sleep problems and child mental health (Strengths and Difficulties Questionnaire; Spence Children’s Anxiety Scale; Development and Well-being Assessment).</jats:p></jats:sec><jats:sec><jats:title>Participants</jats:title><jats:p>1460 mother-infant dyads.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>283 (19.4%) infants had persistent severe sleep problems, 817 (56.0%) had moderate/fluctuating sleep problems and 360 (24.7%) infants were settled. Infants with persistent severe sleep problems were more likely to report emotional symptoms at age 4 (adjusted odds ratio (AOR)=2.70, 95% CI 1.21 to 6.05, p=0.02), and meet diagnostic criteria for an emotional disorder at age 10 (AOR=2.37, 95% CI 1.05 to 5.36, p=0.04). Infants with persistent severe sleep problems also had elevated symptoms of separation anxiety (AOR=2.44, 95% CI 1.35 to 4.41, p&lt;0.01), fear of physical injury (AOR=2.14, 95% CI 1.09 to 4.18, p=0.03) and overall elevated anxiety (AOR=2.20, 95% CI 1.13 to 4.29, p=0.02) at age 10.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Infants with persistent severe sleep problems during the first postnatal year have an increased risk of anxiety problems and emotional disorders at age 10.</jats:p></jats:sec> 6 ["http://orcid.org/0000-0001-6477-3940"] ["Fallon Cook", "Laura J Conway", "Rebecca Giallo", "Deirdre Gartland", "Emma Sciberras", "Stephanie Brown"] ["199222", "433006", "491205"] ["National Health and Medical Research Council", "Victorian Government Operational Infrastructure Support Program"] ["10.13039/501100000925", [""]]
44 ["Adult intussusception secondary to diverticular disease"] 10.1136/bcr-2018-226678 http://dx.doi.org/10.1136/bcr-2018-226678 2018-11-09T07:25:40Z [] 9 1 ["1757-790X"] BMJ Case Reports <jats:p>Intussusception is the invagination of a proximal segment of bowel into the lumen of an adjacent distal segment. It is a common condition in the paediatric age group although it rarely occurs in adults. Organic lesions in the bowel wall are the primary cause of adult intussusceptions with malignant neoplasms being the most common. However, we present a rare case of a 92-year-old man diagnosed with an intussusception of the sigmoid-rectal colon secondary to a diverticular stricture.</jats:p> 4 ["http://orcid.org/0000-0003-0461-0861"] ["Habib Syed", "Labib Syed", "Umesh Parampalli", "Mokhtar Uheba"] [""] [""] [""]
41 ["Therapeutic hypothermia in acute traumatic spinal cord injury"] 10.1136/jramc-2017-000792 http://dx.doi.org/10.1136/jramc-2017-000792 2017-10-13T00:25:27Z ["General Medicine"] 117 1 ["0035-8665", "2052-0468"] Journal of the Royal Army Medical Corps <jats:p>Therapeutic hypothermia is already widely acknowledged as an effective neuroprotective intervention, especially within the acute care setting in relation to conditions such as cardiac arrest and neonatal encephalopathy. Its multifactorial mechanisms of action, including lowering metabolic rate and reducing acute inflammatory cellular processes, ultimately provide protection for central nervous tissue from continuing injury following ischaemic or traumatic insult. Its clinical application within acute traumatic spinal cord injury would therefore seem very plausible, it having the potential to combat the pathophysiological secondary injury processes that can develop in the proceeding hours to days following the initial injury. As such it could offer invaluable assistance to lessen subsequent sensory, motor and autonomic dysfunction for an individual affected by this devastating condition. Yet research surrounding this intervention’s applicability in this field is somewhat lacking, the majority being experimental. Despite a recent resurgence of interest, which in turn has produced encouraging results, there is a real possibility that this potentially transformational intervention for treating traumatic spinal cord injury could remain an experimental therapy and never reach clinical implementation.</jats:p> 1 [] ["James Collis"] [""] [""] [""]
39 ["Immunohistochemistry for the detection of BRCA1 and BRCA2 proteins in patients with ovarian cancer: a systematic review"] 10.1136/jclinpath-2019-206276 http://dx.doi.org/10.1136/jclinpath-2019-206276 2019-11-12T22:15:46Z ["Pathology and Forensic Medicine", "General Medicine"] 65 1 ["0021-9746", "1472-4146"] Journal of Clinical Pathology <jats:sec><jats:title>Background</jats:title><jats:p>Loss of function in either breast cancer type 1 susceptibility protein (BRCA1) or breast cancer type 2 susceptibility protein (BRCA2) is a major risk factor for epithelial ovarian cancer (EOC) development. BRCA1 or BRCA2 deficiencies are associated with short-term prognosis and might have importance for the treatment of women with the disease. However, the screening of all possible mechanisms of dysfunction is expensive, time-consuming and difficult to apply in clinical practice. On the other hand, immunohistochemistry (IHC) is a simple and reliable method to access the expression of several proteins in tumour tissues.</jats:p></jats:sec><jats:sec><jats:title>Materials and methods</jats:title><jats:p>This systematic review aims to evaluate the current usage of IHC to detect BRCA1 and BRCA2 deficiencies in EOC. We searched and evaluated all primary literature on the use of IHC for evaluating BRCA1 and BRCA2 proteins expression in EOC. The main concepts for the search were: ovarian neoplasms, IHC, BRCA1 and BRCA2.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Forty-four studies from 925 unique titles were included. A total of 4206 tumour samples were evaluated for BRCA1 and 1041 for BRCA2 expression. Twelve BRCA1 primary antibodies were used in 41 studies, and the most common was the MS110 clone (75.6%). Seven BRCA2 primary antibodies were used in ten studies. Using the cut-off of 10%, 47.0% of EOCs are associated with loss of BRCA1 and 34.5% with the loss of BRCA2 expression.</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>IHC was effective to detect loss of BRCA1 protein expression in EOC; however, data on BRCA2 expression were heterogeneous and difficult to interpret.</jats:p></jats:sec> 2 ["http://orcid.org/0000-0003-1053-2046", "http://orcid.org/0000-0001-5758-5917"] ["Lorena Alves Teixeira", "Francisco Jose Candido dos Reis"] ["303210/2018-4", "130162/2017-5"] ["Conselho Nacional de Desenvolvimento Cient\u00edfico e Tecnol\u00f3gico"] ["10.13039/501100003593"]
46 ["Impact of self-administration of misoprostol for early medical abortion: a prospective observational cohort study"] 10.1136/bmjsrh-2018-200278 http://dx.doi.org/10.1136/bmjsrh-2018-200278 2019-08-17T21:25:18Z [] 25 1 ["2515-1991", "2515-2009"] BMJ Sexual & Reproductive Health <jats:sec><jats:title>Introduction</jats:title><jats:p>In October 2017, Scotland legalised the home use of misoprostol for the purpose of early medical abortion (EMA). Women up to 9+6 weeks’ gestation can now self-administer the drug at home, 24–48 hours after receiving mifepristone in the clinic.</jats:p></jats:sec><jats:sec><jats:title>Objective</jats:title><jats:p>To evaluate the impact of this change on the uptake and success rate of EMA, and on the provision of effective contraception on discharge.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>A prospective observational study was conducted to compare the outcomes of two cohorts of women in the 6 months before and 6 months after the introduction of home administration of misoprostol. The main outcome measures were uptake of EMA, success of EMA and provision of long-acting reversible contraception (LARC) to women undergoing EMA.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>There was a statistically significant increase in the uptake of EMA from 698/1075 (64.9%) women in the first study period to 823/1146 (71.8%) in the second study period. There was no statistically significant difference in the success rate of EMA: 99.3% and 98.9% in clinic and home misoprostol cohorts, respectively. There was also no statistically significant difference in the proportion of women provided with LARC: 37.7% and 33.7% in clinic and home misoprostol cohorts, respectively.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Self-administration of misoprostol at home increased uptake of EMA, with no effect on the high success rate that was previously seen with clinic administration of misoprostol. In addition, the reduced number of visits associated with home use of misoprostol has not affected the provision of effective contraception to women.</jats:p></jats:sec> 4 ["http://orcid.org/0000-0003-0044-5635"] ["Rebecca Elizabeth Finch", "Kevin McGeechan", "Anne Johnstone", "Sharon Cameron"] [""] [""] [""]
38 ["A case of protrusion of an intraperitoneal chemotherapy catheter through rectum"] 10.1136/ijgc-00009577-200501000-00026 http://dx.doi.org/10.1136/ijgc-00009577-200501000-00026 2019-03-06T16:30:38Z ["Obstetrics and Gynaecology", "Oncology"] 0 1 ["1048-891X", "1525-1438"] International Journal of Gynecologic Cancer <jats:p>Bowel penetration of an intraperitoneal catheter occurred in a patient who had received a course of uncomplicated intraperitoneal chemotherapy for a persistent ovarian carcinoma. One month after the termination of chemotherapy, she presented with protrusion of a catheter through anus. At operation, the catheter was removed, the rectum was repaired primarily, and a cytoreductive surgery was performed.</jats:p> 5 [] ["Y. Bilsel", "E. Balik", "D. Bugra", "S. Yamaner", "A. Akyuz"] [""] [""] [""]

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