Michael Moffatt

Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years

BACKGROUNDnGastro-esophageal reflux (GER) is the refluxing of gastric contents into the esophagus. Fifty per cent of all infants 0 to 3 months regurgitate at least once a day. This drops to 5% once infants are 10 to 12 months old. Three per cent of parents of 10 to 12 month old infants view this as a problem.nnnOBJECTIVESnTo investigate the effectiveness of thickened feeds, positioning, and metoclopramide as compared to placebo in improving the outcome of GER in developmentally normal infants aged one month to two years.nnnSEARCH STRATEGYnTrials were identified by searching Cochrane Central Register of Controlled Trials (The Cochrane Library 2003), MEDLINE (January 1966 to 23 January 2003), EMBASE (January 1985 to 27 January 2003), and reference lists of articles. Searches in all databases were updated in April 2009.nnnSELECTION CRITERIAnRandomised studies (parallel or cross over) which evaluated thickened feeds, positional alternations or metoclopramide for the treatment of GER in children between the age of one month and two years who were developmentally normal.nnnDATA COLLECTION AND ANALYSISnAll three reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.nnnMAIN RESULTSnTwenty trials involving 771 children met the inclusion criteria: eight dealt with thickened feeds, five with positioning, and seven with metoclopramide. Few comparisons could be made, and so summary measures were often made with two or three studies. Thickened feeds reduce the regurgitation severity score (standardized mean difference (SMD) -0.94;95% confidence interval -1.35 to -0.52), as well as the frequency of emesis (SMD -0.91; confidence interval -1.22 to -0.61). The reflux index was not reduced (weighted mean difference (WMD) 0.48%; 95% confidence interval -3.27 to 4.23). All five positioning studies utilized esophageal pH monitoring as their outcome measure. Elevating the head of the crib for treating reflux in the supine position is not justifiable. The seven metoclopramide studies used a variety of outcomes. Compared to placebo, metoclopramide appears to reduce daily symptoms ( SMD -0.73; 95% confidence interval -1.16 to -0.30), and reduce the reflux index (WMD -2.80%; 95% confidence interval -5.58 to -0.01). It does increase side effects.nnnAUTHORS CONCLUSIONSnThickened feeds are helpful in reducing the symptoms of GER. Elevating the head of the crib in the supine position does not have any effect. Metoclopramide may have some benefit in comparison to placebo in the symptomatic treatment for GER, but that must be weighed against possible side effects. .

Colonoscopy and its complications across a Canadian regional health authority

BACKGROUNDnDefining the complication rate of endoscopy performed across an entire city will capture usual as opposed to referral center data.nnnOBJECTIVEnOur purpose was to evaluate the current practice of colonoscopy and complications associated with lower GI endoscopy in usual clinical practice.nnnDESIGNnAll admissions within 30 days of an outpatient lower GI endoscopy at any of the 6 adult-care Winnipeg hospitals were identified. This includes endoscopy for both complex and routine patients. A chart audit of all cases with potential complications was performed.nnnRESULTSnA total of 24,509 outpatient lower GI endoscopies for adults were performed at the 6 hospitals over the 2 study years (April 1, 2004, to March 31, 2006). There were 303 admissions with potential complications. The colonoscopy completion rate was 65% (72% for gastroenterologists vs 59% for general surgeons, P < .005). Quality of bowel preparation and nature of polyps were often not documented. The overall rate of complications was 2.9/1000 procedures; the perforation rate after polypectomy was 1.8/1000; and the postpolypectomy bleeding rate was 6.4/1000. Most (67%) complications were recognized after discharge for the index procedure. The complication rate was highest for the endoscopists performing fewer than 200 procedures per year (5.4/1000 vs 2.7/1000 for the rest, P = .02, relative risk 2 [95% CI, 1.1-3.7]).nnnLIMITATIONSnChart audit was limited to cases requiring admission within 30 days of the index procedure.nnnCONCLUSIONSnThe overall complication rate after lower GI endoscopy in usual clinical practice in Winnipeg is comparable to that previously reported. A higher complication rate after endoscopy by low-volume endoscopists needs to be further evaluated. The reporting of endoscopy must be standardized to enhance outcomes interpretation.

CAREGIVER KNOWLEDGE AND ATTITUDES OF PRESCHOOL ORAL HEALTH AND EARLy CHILDHOOD CARIES (ECC)

Objectives. Prevention strategies are integral to improving the oral health for young Aboriginal children. For such to be effective, it is important to understand the social value that parents and caregivers ascribe to primary teeth. The purpose of this paper is to report caregiver knowledge and attitudes toward preschool oral health and early childhood caries (ECC) from 4 communities in Manitoba. Study Design. Cross-sectional study, including a retrospective interview with caregivers. Methods. Children and their main caregivers served as the sample. Preschoolers underwent a comprehensive dental screening while caregivers completed a questionnaire that explored knowledge and attitudes toward preschool dental health. Caregiver responses were matched with findings from each child’s examination. Results. A majority agreed that primary teeth were important, that dental disease could lead to health problems and that a first dental visit should be made by age 1. Caregivers of children with ECC were more likely to believe that caries could not affect a child’s health while those who believed primary teeth are important had children with significantly less decay. Conclusions. Most caregivers believed that primary teeth are important and correctly responded to inquiries about knowledge and attitudes toward oral health. Attitudes on the importance of baby teeth and bottle feeding after one year of age, the effect of rotten teeth on childhood health and night-time nursing emerged as variables most associated with the absence/presence of ECC and deft rates. Incorporating such questioning into caries risk assessments may be a useful means to determine a child’s risk for ECC.

Force Platform Feedback for Standing Balance Training After Stroke

BACKGROUNDnStanding balance deficits are common in individuals after stroke. One way to address these deficits is to provide the individual with feedback from a force platform while balance activities are performed. The feedback can take visual and/or auditory form.nnnOBJECTIVESnTo determine if visual or auditory force platform feedback improves the clinical and force platform standing balance outcomes in clients with stroke.nnnSEARCH STRATEGYnWe searched the Cochrane Stroke Group trials register (last searched December 2003), and the following electronic bibliographic databases: the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2003), MEDLINE (1966 to May 2003), EMBASE (1974 to May 2003), CINAHL (1982 to May 2003), PEDro (May 2003), CIRRIE (May 2003) and REHABDATA (May 2003). Reference lists of articles were reviewed and manufacturers of equipment were contacted.nnnSELECTION CRITERIAnRandomized controlled trials comparing force platform with visual feedback and/or auditory feedback to other balance treatments.nnnDATA COLLECTION AND ANALYSISnTwo reviewers independently assessed trials for inclusion, methodological quality, and data extraction. Trials were combined for meta-analysis according to outcome and type of feedback.nnnMAIN RESULTSnWe included seven trials (246 participants). Force platform feedback did not improve clinical measures of balance when moving or walking (Berg Balance Scale and Timed Up and Go). Significant improvements in laboratory force platform indicators of stance symmetry were found for regimens using visual feedback (standardised mean difference (SMD) -0.68, 95% confidence interval (CI) -1.31 to -0.04, p = 0.04) and the concurrent visual and auditory feedback (weighted mean difference (WMD) -4.02, 95% CI -5.99 to -2.04, p = 0.00007). There were no significant effects on laboratory postural sway indicators, clinical outcomes or measures of function at follow-up assessment.nnnREVIEWERS CONCLUSIONSnForce platform feedback (visual or auditory) improved stance symmetry but not sway in standing, clinical balance outcomes or measures of independence.

Predictors of serious complications associated with lower gastrointestinal endoscopy in a major city-wide health region.

BACKGROUNDnThere are limited data regarding complications associated with colonoscopy and flexible sigmoidoscopy in usual clinical practice in Canada.nnnOBJECTIVEnTo determine the risk factors for lower gastrointestinal (GI) endoscopy-associated complications in usual clinical practice.nnnMETHODSnAll outpatient lower GI endoscopies performed in Winnipeg (Manitoba) between April 1, 2004 and March 31, 2006, were identified from the provincial physicians claims database. All subsequent hospital admissions within 30 days that documented potential complications associated with lower GI endoscopies were identified from the electronic hospital discharges database and reviewed. Multivariate generalized estimating equation regression analysis was performed to determine independent factors (patient, endoscopist and procedure) associated with the risk of developing complications.nnnRESULTSnThere were 29,990 outpatient lower GI endoscopies performed in Winnipeg during the years studied. Seventy-seven (0.26%) procedures were associated with complications requiring hospitalization within 30 days of the index procedure. Stricture dilation (rate ratio [RR] 23.14; 95% CI 6.70 to 76.51), polypectomy (RR 5.93; 95% CI 3.66 to 9.62), increasing patient age (for each year increase in age, RR 1.03; 95% CI 1.01 to 1.05) and performance of endoscopy by low-volume endoscopists (fewer than 200 procedures per year, RR 2.28; 95% CI 1.18 to 4.42) and family physicians (RR 2.23; 95% CI 1.39 to 3.58) were independently associated with complications.nnnCONCLUSIONSnThe results of the present study suggest that increasing patient age, complex procedures and performance of the index procedure by low-volume endoscopists are independent risk factors for lower GI endoscopy-associated complications in usual clinical practice. This suggests that it may be time to consider implementing minimum volume requirements for endoscopists performing non-screening lower GI endoscopies.

What is the value and impact of quality and safety teams? A scoping review

BackgroundThe purpose of this study was to conduct a scoping review of the literature about the establishment and impact of quality and safety team initiatives in acute care.MethodsStudies were identified through electronic searches of Medline, Embase, CINAHL, PsycINFO, ABI Inform, Cochrane databases. Grey literature and bibliographies were also searched. Qualitative or quantitative studies that occurred in acute care, describing how quality and safety teams were established or implemented, the impact of teams, or the barriers and/or facilitators of teams were included. Two reviewers independently extracted data on study design, sample, interventions, and outcomes. Quality assessment of full text articles was done independently by two reviewers. Studies were categorized according to dimensions of quality.ResultsOf 6,674 articles identified, 99 were included in the study. The heterogeneity of studies and results reported precluded quantitative data analyses. Findings revealed limited information about attributes of successful and unsuccessful team initiatives, barriers and facilitators to team initiatives, unique or combined contribution of selected interventions, or how to effectively establish these teams.ConclusionsNot unlike systematic reviews of quality improvement collaboratives, this broad review revealed that while teams reported a number of positive results, there are many methodological issues. This study is unique in utilizing traditional quality assessment and more novel methods of quality assessment and reporting of results (SQUIRE) to appraise studies. Rigorous design, evaluation, and reporting of quality and safety team initiatives are required.