Simon Fleming

Diagnostic accuracy of single baseline measurement of Elecsys Troponin T high-sensitive assay for diagnosis of acute myocardial infarction in emergency department: systematic review and meta-analysis

Objective To obtain summary estimates of the accuracy of a single baseline measurement of the Elecsys Troponin T high-sensitive assay (Roche Diagnostics) for the diagnosis of acute myocardial infarction in patients presenting to the emergency department. Design Systematic review and meta-analysis of diagnostic test accuracy studies. Data sources Medline, Embase, and other relevant electronic databases were searched for papers published between January 2006 and December 2013. Study selection Studies were included if they evaluated the diagnostic accuracy of a single baseline measurement of Elecsys Troponin T high-sensitive assay for the diagnosis of acute myocardial infarction in patients presenting to the emergency department with suspected acute coronary syndrome. Study appraisal and data synthesis The first author screened all titles and abstracts identified through the searches and selected all potentially relevant papers. The screening of the full texts, the data extraction, and the methodological quality assessment, using the adapted QUADAS-2 tool, were conducted independently by two reviewers with disagreements being resolved through discussion or arbitration. If appropriate, meta-analysis was conducted using the hierarchical bivariate model. Results Twenty three studies reported the performance of the evaluated assay at presentation. The results for 14 ng/L and 3-5 ng/L cut-off values were pooled separately. At 14 ng/L (20 papers), the summary sensitivity was 89.5% (95% confidence interval 86.3% to 92.1%) and the summary specificity was 77.1% (68.7% to 83.7%). At 3-5 ng/L (six papers), the summary sensitivity was 97.4% (94.9% to 98.7%) and the summary specificity was 42.4% (31.2% to 54.5%). This means that if 21 of 100 consecutive patients have the target condition (21%, the median prevalence across the studies), 2 (95% confidence interval 2 to 3) of 21 patients with acute myocardial infarction will be missed (false negatives) if 14 ng/L is used as a cut-off value and 18 (13 to 25) of 79 patients without acute myocardial infarction will test positive (false positives). If the 3-5 ng/L cut-off value is used, <1 (0 to 1) patient with acute myocardial infarction will be missed and 46 (36 to 54) patients without acute myocardial infarction will test positive. Conclusions The results indicate that a single baseline measurement of the Elecsys Troponin T high-sensitive assay could be used to rule out acute myocardial infarction if lower cut-off values such as 3 ng/L or 5 ng/L are used. However, this method should be part of a comprehensive triage strategy and may not be appropriate for patients who present less than three hours after symptom onset. Care must also be exercised because of the higher imprecision of the evaluated assay and the greater effect of lot-to-lot reagent variation at low troponin concentrations. Systematic review registration PROSPERO registration number CRD42013003926.

A randomized placebo controlled trial of preoperative carbohydrate drinks and early postoperative nutritional supplement drinks in colorectal surgery.

There is evidence that preoperative carbohydrate drinks and postoperative nutritional supplements improve the outcome of colorectal surgery. There is little information on their individual contribution.

Acute high-intensity interval running increases markers of gastrointestinal damage and permeability but not gastrointestinal symptoms

The purpose of this study was to investigate the effects of high-intensity interval running on markers of gastrointestinal (GI) damage and permeability alongside subjective symptoms of GI discomfort. Eleven male runners completed an acute bout of high-intensity interval training (HIIT) (eighteen 400-m runs at 120% maximal oxygen uptake) where markers of GI permeability, intestinal damage, and GI discomfort symptoms were assessed and compared with resting conditions. Compared with rest, HIIT significantly increased serum lactulose/rhamnose ratio (0.051 ± 0.016 vs. 0.031 ± 0.021, p = 0.0047; 95% confidence interval (CI) = 0.006 to 0.036) and sucrose concentrations (0.388 ± 0.217 vs. 0.137 ± 0.148 mg·L-1; p < 0.001; 95% CI = 0.152 to 0.350). In contrast, urinary lactulose/rhamnose (0.032 ± 0.005 vs. 0.030 ± 0.005; p = 0.3; 95% CI = -0.012 to 0.009) or sucrose concentrations (0.169% ± 0.168% vs. 0.123% ± 0.120%; p = 0.54; 95% CI = -0.199 to 0.108) did not differ between HIIT and resting conditions. Plasma intestinal-fatty acid binding protein (I-FABP) was significantly increased (p < 0.001) during and in the recovery period from HIIT whereas no changes were observed during rest. Mild symptoms of GI discomfort were reported immediately and at 24 h post-HIIT, although these symptoms did not correlate to GI permeability or I-FABP. In conclusion, acute HIIT increased GI permeability and intestinal I-FABP release, although these do not correlate with symptoms of GI discomfort. Furthermore, by using serum sampling, we provide data showing that it is possible to detect changes in intestinal permeability that is not observed using urinary sampling over a shorter time-period.

Effectiveness of interventions to reduce ordering of thyroid function tests: a systematic review

Objectives To evaluate the effectiveness of behaviour changing interventions targeting ordering of thyroid function tests. Design Systematic review. Data sources MEDLINE, EMBASE and the Cochrane Database up to May 2015. Eligibility criteria for selecting studies We included studies evaluating the effectiveness of behaviour change interventions aiming to reduce ordering of thyroid function tests. Randomised controlled trials (RCTs), non-randomised controlled studies and before and after studies were included. There were no language restrictions. Study appraisal and synthesis methods 2 reviewers independently screened all records identified by the electronic searches and reviewed the full text of any deemed potentially relevant. Study details were extracted from the included papers and their methodological quality assessed independently using a validated tool. Disagreements were resolved through discussion and arbitration by a third reviewer. Meta-analysis was not used. Results 27 studies (28 papers) were included. They evaluated a range of interventions including guidelines/protocols, changes to funding policy, education, decision aids, reminders and audit/feedback; often intervention types were combined. The most common outcome measured was the rate of test ordering, but the effect on appropriateness, test ordering patterns and cost were also measured. 4 studies were RCTs. The majority of the studies were of poor or moderate methodological quality. The interventions were variable and poorly reported. Only 4 studies reported unsuccessful interventions but there was no clear pattern to link effect and intervention type or other characteristics. Conclusions The results suggest that behaviour change interventions are effective particularly in reducing the volume of thyroid function tests. However, due to the poor methodological quality and reporting of the studies, the likely presence of publication bias and the questionable relevance of some interventions to current day practice, we are unable to draw strong conclusions or recommend the implementation of specific intervention types. Further research is thus justified. Trial registration number CRD42014006192.

OC-085 Nutritional intervention in patients undergoing colorectal surgery: support for the routine prescription of oral nutritional supplements pre- and post-operatively

Introduction There is good evidence that nutritional support is beneficial. The advent of minimal access surgery allied with enhanced recovery pathways allows us to successfully feed patients earlier than ever before. With data suggesting early feeding is preferential to “nil by mouth” in terms of morbidity and hospital length of stay, we set out to determine the most important periods in which to provide nutritional support by assessing the temporal relationship between nutrition provision and surgery. Furthermore, based on the extensive works of Lungqvist, we assessed impact of feeding against physiological endpoints such as glucose homeostasis as well as more conventional clinical endpoints. Methods Prospective four-armed double-blind randomised control trial. Patients allocated to one of four nutritional interventions: control pre-op/control post-op, active pre-op/control post-op, active pre-op/active post-op and control pre-op/active post-op. Patients were either given pre-op® or placebo pre-operatively, or fortifresh® or placebo postoperatively according to allocation. Caloric intake was assessed pre-operatively and during the early postoperative period. Endpoints included, glucose homeostasis, insulin resistance, biochemical markers of inflammation and morbidity/mortality data. Results 120 patients were recruited. Demographically, groups were well matched. 94% of patients reported weight loss in the 3 months prior to surgery, of which 55% reported weight loss >5% of their normal body weight. Glucose homeostasis was better in supplemented groups (p=0.004), and there were reductions in insulin resistance (p=0.001) compared with standard care (placebo/placebo). Muscle strength (p<0.001) and lung function (p=0.035) were similarly improved following surgery. There were no significant differences in immediate post-operative complications but at 30 days the group receiving pre- and post-operative supplements developed fewer complications than those receiving standard care (placebo/placebo) (p=0.003, χ2=8.695). Conclusion Disease-related malnutrition is prevalent within patients suffering from colorectal cancer. Nutritional intake in the peri-operative period remains inadequate and poor nutritional intake should be corrected with oral nutritional supplements as even modest intake results in improved biochemical response to stress and reductions in morbidity.

Understanding diabetes – A biochemical perspective

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