Does occurrence of ventricular arrhythmia reduce the survival rate in dogs with gastric dilatation volvulus (GDV)?

PICO question Does occurrence of ventricular arrhythmia reduce the survival rate in dogs with gastric dilatation and volvulus (GDV)? Clinical bottom line Category of research question Prognosis The number and type of study designs reviewed The number and type of study designs that were critically appraised were three retrospective observational case-control studies (Brourman et al., 1996; Green et al., 2012; and Mackenzie et al., 2010) and one prospective, observational study (Aona et al., 2017) Strength of evidence Critical evaluation and appraisal of the papers that met the inclusion criteria provided only weak evidence to support the clinical question. This is due to the lack of recent (within the last 5 years) and specific (do the presence of cardiac arrythmias affect mortality of dogs with GDV) studies conducted on the subject. Additionally, more in-depth statistical analysis (e.g. P values and confidence intervals (CI)) may also help to determine the strength of association between the presence of ventricular arrythmia and survival rates. However, there is room for further research to continue investigating the proposed hypothesis. Several of the evaluated studies were carried out more than 10 years before this Knowledge Summary was written, meaning that the knowledge and technology at the time may not be relevant to clinical practice today Outcomes reported Green et al. (2012) concluded that ‘cardiac arrhythmia was not a prognostic indicator’ for GDV. Of the two papers (Mackenzie et al., 2010; and Brourman et al., 1996) that found a significant association between the development of cardiac arrhythmias (specifically, those of ventricular origin) and an increase in the mortality rates of dogs with GDV, one (Brourman et al., 1996) noted that a greater number of dogs that died prior to discharge were diagnosed with preoperative ventricular tachycardia, while the other (Mackenzie et al., 2010) found that the greatest mortality rate was among those dogs that developed postoperative ventricular tachycardia. The final study, Aona et al. (2017), was the only paper to categorise and grade the ventricular arrhythmias using previously published scales. It was discovered that increased levels of cTn1 (cardiac troponin 1) made a dog more likely to develop a higher grade of arrhythmia, however, no association was found between the type or grade of arrhythmia and patient mortality Conclusion Taking into account the strength of evidence and the outcomes presented by the appraised studies the following conclusion has been drawn; although there is some evidence to suggest that ventricular tachycardia may be associated with an increase in mortality rates in patients with GDV, further research is required in order to make any further conclusions that may definitively answer the clinical question How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

Letting Tourette's be?

Tourette Syndrome is almost exclusively seen through the lens of disruptive tics. The most relevant clinical question seems to be: how to combat tics? In line with emerging calls from those diagnosed, we argue for a more positive approach focused on the Tourettic person, rather than on disruptions flowing from tics. This change of focus is ethically motivated but has important theoretical implications. As an exercise in ‘letting be’ (i.e. of finding out what something is on its own terms, through sensitively interacting with it), it brings out the basic relationalities of Tourette’s with both the non-human and the social environment. Echoing Tourettic lived experience, disruptive tics then emerge as the tips of icebergs consisting of spontaneous, even playful, interactions with the environment. A more nuanced view emerges in which problems experienced by those diagnosed are no longer located in individual brains but require comprehensive study of how tics situationally develop. Listening attentively to lived experience reports leads to a dramatic shift away from the classical ‘lack of inhibition’ model, to reveal a constant pressure to inhibit actions that one feels strongly and spontaneously compelled to do. This inhibition is dependent on what is signaled as disruptive by others and is therefore suppressed for their sake. The Tourettic person’s distress or felt impairment seems more tied to an onlooker’s focus on their tics, than on the severity and frequency of their tics. We conclude that ‘letting be’ is an attitude towards Tourette’s that is worth considering, both clinically and theoretically. In fact, we believe that the overall good prognosis as to felt impairment correlates with finding trusted environments where one is ‘let be’ (without being ‘let go of’) instead of living under constant scrutiny.

Abstract 1122‐000144: Experiences and Strategies Developing an Evidence‐Based Clinical Guideline for Ischemic Stroke in a Middle‐income Setting

Introduction : Developing an evidence‐based clinical practice guideline in a middle‐income country is challenging. After a discussion with the stakeholders, we identified and prioritized the need for a clinical guideline about ischemic stroke in our country. We defined stakeholders to anyone who has an interest in the recommendations of the guideline, including patients' representatives, practitioners, policy/decision makers, commissioners of guidelines and other end users. Methods : We developed an evidence‐based guideline using the Grades of Recommendation, Assessment, Development, and Evaluation System (GRADE) approach with a multidisciplinary team including independent methodologists, local and international clinical experts. Systematic step‐by‐step search strategy was used. Four clinical guidelines were identified, quality of development of these guidelines was evaluated using the Appraisal of Guidelines for Research & Evaluation (AGREE II) tool. In the absence of a systematic review in the guideline to answer the clinical question, we proceeded to search for primary studies. The certainty of evidence was classified according to the GRADE system, as high, moderate, low, and very low. Recommendations were classified according to strength, as strong or conditional, and to direction, as in favor or against. Applicability and acceptability were evaluated by the stakeholders and patient’s representatives. External validation by national and international experts in the field was performed. Results : Eight clinical questions related to diagnosis, management, and early rehabilitation for ischemic stroke were formulated. Evidence from systematic reviews and meta‐analysis for every clinical question was discussed, an update was made when needed, and finally, twenty‐eight trustworthy recommendations (8 strong and 20 conditional) were developed. Also, thirty‐eight good practice points and two flowcharts were developed. Conclusions : In a setting with limited resources a high‐quality clinical guideline could be developed using good quality data from the systematic reviews found in previous guidelines. The GRADE approach could be very useful to contextualize the available evidence, making the process feasible and efficient.

Effectiveness of Chest CT in Children: CT Findings in Relation to the Clinical Question

Purpose To estimate the effectiveness and efficiency of chest CT in children based on the suspected diagnosis in relation to the number of positive, negative, and inconclusive CT results. Materials and Methods In this monocentric retrospective study at a university hospital with a division of pediatric radiology, 2019 chest CT examinations (973 patients; median age: 10.5 years; range: 2 days to 17.9 years) were analyzed with regards to clinical data, including the referring department, primary questions or suspected diagnosis, and CT findings. It was identified if the clinical question was answered, whether the suspected diagnosis was confirmed or ruled out, and if additional findings (clinically significant or minor) were detected. Results The largest clinical subgroup was the hematooncological subgroup (n = 987), with frequent questions for inflammation/pneumonia (66 % in this subgroup). Overall, CT provided conclusive results in 97.6 % of all scans. In 1380 scans (70 %), the suspected diagnosis was confirmed. In 406/2019 cases (20 %), the CT scan was negative also in terms of an additional finding. In 8 of 9 clinical categories, the proportion of positive results was over 50 %. There were predominantly negative results (110/179; 61 %) in pre-stem cell transplant evaluation. In the subgroup of trauma management, 81/144 exams (57 %) showed positive results, including combined injuries (n = 23). 222/396 (56 %) of all additional findings were estimated to be clinically significant. Conclusion In a specialized center, the effectiveness of pediatric chest CT was excellent when counting the conclusive results. However, to improve efficiency, the clinical evaluation before imaging appears crucial to prevent unnecessary CT examinations. Key Points: Citation Format

Compulsory treatment of physical illness under MHA 1983

Taken together, Sections 145 and 63 of the Mental Health Act 1983 (MHA) provide for treatment without consent of physical illness ancillary to the mental disorder with which a patient presents. On a daily basis, clinicians make both the decision that the Act’s authority can be applied to their patient’s case, and that it should be applied. But in the unusual circumstances where there is uncertainty as to the applicability of the MHA to the ancillary treatment of physical illness, the assistance of a court may be sought. In so doing, the law (and thence the courts) may justify compulsion but never prescribes it; the clinician is presented with authority that he or she could use but is left to decide whether it should be employed. This paper explores how the clinical question is set before the court, and whether the distinction between symptom, manifestation and consequence is sufficiently understood. This has important consequences in the context of self-neglect and its close cousin self-harm: the question whether the relevant ailment was attributable to or exacerbated by neglect or self- inflicted harm will determine whether compulsion under the MHA is applicable; and furthermore, whether or not compulsion is clinically acceptable.

Improving Primary Care Access to Respirologists Using eConsult

Background: Patients and primary care providers (PCP) can experience frustration about poor access to specialist care. The Champlain Building Access to Specialists through eConsultation (BASETM) is a secure online platform that allows PCPs to ask a clinical question to 142 different specialty groups. The specialist is expected to respond within 7 days. Methods: This is a retrospective review of the Champlain BASETM respirology eConsults from January 2017 to December 2018. The eConsults were categorized by types of question asked by the referring provider, and by the clinical content of the referral. Specialists’ response time and time spent answering the clinical question was analyzed. Referring providers close out surveys were reviewed to assess the impact of the respirology eConsult service on traditional referral rates and clinical course of action. Results: Of the 26,679 cases submitted to the Champlain BASE TM eConsult service 268 were respirology cases (1%). 91% were sent by family physicians, 9% by nurse practitioners. The median time to respond by specialists was 0.8 days, and the median time billed by specialists was 20 minutes. The most common topics were pulmonary nodules and masses (16.4%), cough (10.4%), infective problems (8.6%), COPD (8.6%) and dyspnea NYD (7.8%). The most common types of question asked by PCP were related to investigations warranted (43.1% of cases), general management (17.5%), monitoring (12.6%), need for a respirology referral (12.3%), and drug of choice (6.3%). In 23% of cases the PCP indicated they were planning to refer the patient and no longer need to (avoided referrals) and in 13% of cases the PCP was not going to refer but did after receiving the eConsult advice (prompted referrals). The eConsult led to a new or additional clinical course of action by the PCP in 49% of cases. In 51% of cases the PCP suggested the clinical topic would be well suited to a CME event. Conclusions: Participation in eConsult services can improve timely access to respirologists while potentially avoiding clinic visit and significantly impacting referring PCPs clinical course of action. Using the most common clinical topics and types of question for CME planning should be considered. Future research may include a cost analysis, and provider perspectives on the role of eConsult in respirology care.

Steps 1 and 2: Asking a Compelling Clinical Question and Searching for the Best Evidence

A compelling clinical question using the PICOT format sets the stage for a successful search for relevant evidence. This column describes the PICOT format with examples for each component and uses a specific example to demonstrate, through a first-person librarian narrative, how to conduct a literature search for relevant evidence.

Topic duplication and research waste at the ‘Overviews of systematic reviews’ level: Survey of overlapping overviews

Background Multiple overviews of systematic reviews conducted on the same topic (“overlapping overviews”) represent a waste of research resources and can confuse or mislead clinicians and policymakers. We aimed to assess the frequency and characteristics of published overviews addressing the same clinical question or topic. Methods We used MEDLINE, Epistemonikos and Cochrane databases to locate overviews that: focused on synthesising reviews; conducted systematic searches; had a methods section; and examined a health intervention or clinical treatment. We then determined which overviews addressed the same or overlapping populations/settings, interventions, and outcomes [PIO]). Overlap in topic was defined as: duplication of PIO elements, not representing an update of a previous overview, and not a replication for quality purposes. Results Of 541 overviews located (2000–2018), 178 (33%) overlapped with another overview addressing a similar PIO. The topics of overlapping overviews fell within 13 WHO ICD-10 medical classifications, and there were 65 overlapping topics in total. The most prevalent topic with overlap across 7 overviews was smoking cessation (pharmacologic and non-pharmacologic interventions). Five overlapping overviews related to acupuncture for pain, 5 addressed cannabinoids for pain and symptoms, and 5 addressed exercise for bone and muscle health. For 15/65 (22%) of these topics, one author was involved in at least two of the overlapping overviews. Conclusions We found significant duplication and unnecessary overlap across overviews. To avoid waste and redundancy, protocols of overviews should be registered in a targeted database, and overviews should cite other studies on similar topic with a rationale.

An assessment of referrals to a liaison psychiatry team within a large district general hospital – Completing the Cycle

AimsIn 2019 members of the Liaison Psychiatry Department at Frimley Park Hospital completed an audit of the referrals to the service1. The quality of referrals was found to be highly variable, for example only 28% included a risk assessment and frequently omitted both past psychiatric and past medical histories. As such an intervention was designed involving three parts;Multidisciplinary education of staffNew and more readily available referral guidelinesNew referral formThis re-audit seeks to complete the audit cycle and assess the impact of the intervention.MethodThe first 50 referrals to the Liaison Psychiatry Department of Frimley Park Hospital during February 2021 were assessed using the following criteria:Staff type, referral source, physically fit for assessment, physical cause ruled out, drugs / alcohol involved, appropriate reason for referral, clinical question asked, did final diagnosis match referral diagnosis, risk assessment included, information about admission included, past psychiatric history included and past medical history included.The percentage of referrals received for each criterion (e.g. the percentage with a risk assessment completed) was then derived from the data.ResultThere has been a marked improvement in a variety of areas. The percentage of referrals containing a risk assessment increased from 28% to 96%. This is likely due to the risk box now requiring an entry prior to being able to submit the referral form. Similarly the percentage containing past psychiatric history has risen from 38.8% to 90%. Previously 46.2% of referrals contained a working diagnosis which was not consistent with the clinical picture, but again this has improved, with 60% of initial diagnoses now matching the final outcome. There are however areas for improvement. Only 14% of referrals contained a specific clinical question, which is lower than the 20% achieved previously. This may be because the new referral form does not provide a specific free text box for this.ConclusionThe intervention yielded a marked improvement in the quality of referrals received by the Liaison Psychiatry Department at Frimley Park Hospital, and it is the intention to continue to use the current process. Based on the new results we will look to make small adjustments, for example adding a free text box for a specific clinical question and emphasising the importance of this information.