Home

Bluesky · LinkedIn

Category: Hot Topic

  • NEGATIVE FAECAL CALPROTECTIN RESULT USEFUL FOR RULING OUT IBD IN CHILDREN

    Henderson P, Anderson NH, Wilson DC. The diagnostic accuracy of fecal calprotectin during the investigation of suspected pediatric inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterol 2014;109(5):637-645.

    Abstract here

    Not just children but adults as well. I’m sure there is unwritten law that when something interesting happens in medicine, when an article appears in the media or a patient brings in an Internet printout, like buses several articles appear at once. It happened to me recently with a patient who was diagnosed with Postural Tachycardia Syndrome (POTS) when an article appeared in the Telegraph stating that up to a third of fibromyalgia sufferers may have POTS (I was seeing my patient that day). It also happened with a PBSGL we did on infant feeding problems when other guidance came out and again it was in the media. So when this POEM arrived after I had recently attended the excellent Essential Knowledge Update course run by the Wessex Faculty of the RCGP, it was unsurprising to find the subject of faecal calprotectin being raised. This was on the background on recent local guidance for our practice and one of my GP partners attending an educational event.

    This POEM is a summary of a meta-analysis looking at the use of the test in children when considering the diagnosis of Inflammatory Bowel Disease (IBD). The bottom line for me as a GP is to screen out the worried well & refer the suspected cases. I therefore need a test that correctly identifies those without disease – if I have a clinical concern, I will refer. The test measures the level of calprotectin and a cut off value is determined. Obviously the higher the cut off, the more accurate the test is at the cost of false negatives. The commonest cut off is 50ug per g of stool.

    Whilst writing this I reviewed the NICE guidance which was produced in Oct 13. The results are remarkably convergent and I suspect the studies in both meta-analyses are similar (although I could not confirm this). The test has a high sensitivity – a patient with IBD is highly likely to have a positive test – with a sensitivity approaching 100% with a cut off of 50ug. The specificity varied, the greatest variation noted by NICE occurring in the paediatric group (44 to 93%) which was exactly the same as this study.

    The likelihood ratios were quoted. The positive ratio was 3.1. This isn’t that high so it is saying that the test is moderately helpful as a test to identify IBD. This is because of it being raised in other conditions so whilst someone with IBD will have a positive test, if it is applied to a population, you will get IBD sufferers plus others. However the negative likelihood ratios was 0.03. This means the test is highly discriminatory in patients without IBD. If it is negative, it is very unlikely the patient has IBD.

    In summary, in children the test is very useful for reassuring a patient does not have IBD but if it is positive, it doesn’t necessarily mean the child has IBD. Ultimately I would be guided by clinical presentation and parental ideas, concerns & expectations. One thing I have noticed about paediatricians is they are very helpful reviewing children of worried well parents. As a parent myself, that reassures me.

  • Teachers & Social Networking part 2

    British Journal of Educational Technology Vol 43 No 5 2012 754-769

    This research in the article aimed to answer 3 research questions.

    Domain: how does the domain (and particularly the way it is approached) impact on group membership?

    Network: does it make sense to distinguish between different types of participatory attitudes and behaviours, involving different levels of engagement in the group?

    Practice: does engagement with a group of professionals sharing practices have an impact on ‘real life’ and professional development?

    It did this by testing several hypotheses. I will not go into details but suffice to say the statistical analyses seem sound although there are some confounders which I will address later. The analysis was based on several sub-groups of the 1107 respondents dividing the groups into generic & themed. An analogous example of the themed group would be a group of doctors interested in ADHD, the generic group our own PBSGL. Divisions were also made on whether the group was open or by application and how long individuals had been members for.

    Domain: There was a distinction here between themed and generic. For themed groups, FB provided emotional support and bonding social capital. Members were likely to have known one another before joining. For the generic group, FB provided a means for sharing information and ideas. It provided bridging social capital converting latent ties into weak ties.

     Network: Senior members demonstrated more active and confident behaviours compared to junior members, as would be expected. However the impact on professional life was similar regardless of length of time of membership. This impact was greater in the generic group reinforcing previous evidence that the motivation behind SNS was sharing ideas & projects.

     Practice: Thematic groups tended to use FB as a social support mechanism as there was already significant off-line co-operation and interaction. The members knew & worked with each other in real life with the SNS providing emotional support away from this. Interestingly the generic group was more likely to start projects in real life after on-line discussion and sharing. This is real evidence that SNS can have an impact in off-line activities.

     Applying the READER critical reading model:

     Relevance: Not primary care, not English. But it did look at a cohort of professionals looking to share information and develop educational ideas.

     Education: The authors make a good argument, it is well referenced and uses terms familiar to most readers. The theoretical background is explored in some detail. There is a logic to it, funnelling the arguments down to the three research questions (relevant to NOPs) being asked. Therefore there was an educational impact.

     Applicability: Highly applicable to the Salisbury Plain PBSGL, albeit with a lot smaller numbers. It is also very relevant to my assignment. The demographics could slightly bias it applicability though with more female members (87.2%).

     Discrimination: The research was amongst Italian teachers. However it could quite easily apply to Primary care. The themes that emerged from the questionnaires are relevant: ‘Feeling less isolated’, ‘sharing ideas and projects’, ‘keep me updated on group topics’.

     Evaluation: Interestingly, the Generic FB groups (sharing school experiences in general) generally had more positive outcomes than the Thematic FB groups (special interest eg ASD). The latter felt the group decreased isolation. The former felt it enabled sharing of ideas.

     Reaction: Once I had worked through the article and digested what they were saying, my reaction was very positive. Here is some evidence that SNS could improve the outcomes in our PBSGL group. Further research is required however, or in my case, more reading. It is a start though…

     

     

  • The Familial Risk of Autism

    On the way to a leaving lunch the other day, I was tuned into Radio 4 listening to an article on Autistic Spectrum Disorder and the lengths to which some parents will go to help their children. One mother interviewed was spending up to £700 every three months on dietary supplements. Her child had been diagnosed with a variety of imbalances and too much mercury (a part of Thimerosal – useful link here: http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/UCM096228). She had also been told children with ASD are unable to excrete certain toxins as well as children without it. To a medical professional who is used to Evidence Based Medicine and with a suspicion of some of the ‘quackery’ practised by certain organisations (plus their fees), I found myself getting angry at people being taken for a ride. I also thought that these parents are so desperate for help and so dedicated to their children, they spend thousands of pounds on treatments which are essentially placebo treatments. An expert in the field made valid comment on the paucity of good quality research out there with only £4M being spent annually compared to £650M on cancer and £150M on cardiovascular diseases.

    Coincidentally I received my daily InfoPOEM today which summarised an article about ASD. I talked about how ICT can be used to help improve knowledge and skills ‘whenever and wherever’. I used to subscribe to this when a) it was very expensive (my subscription of $249 pa expired in 2007) and b) when I was writing my assignment & thinking about how I had used learning technologies in the past to assist in my education. From the Essential Evidence Plus website:

    ‘Daily POEMs (“Patient-Oriented Evidence that Matters”) are synopses of new evidence carefully filtered for relevance to patient care and evaluated for validity. Daily POEMs emerge from continuous review, grading, and critical appraisal of all 3000+ studies published monthly in more than 100 journals. Using Essential Evidence Plus, you will have complete visibility into the archived collection of 3,500+ regularly updated Daily POEMs. Tap into summaries of relevant and essential evidence-based research that are presented in an easy-to-understand format. Quickly identify and understand the information you need and apply the research to your clinical practice’

    It is now $85 pa and I have re-subscribed with one of the intentions of blogging about freely available full text articles raised by InfoPOEMs with my own take on them. One of the concerns I have realised immediately is how easy it is to infringe on copyright and inadvertently plagiarise. I have linked to the InfoPOEMs site in the vain hope lenience will be applied by the judge when I am sentenced as a charlatan poaching other people’s hard work.

    I have linked to the full text of the article. This is essentially a large cohort study of over 2 million patients which looked how relatedness affected risk of ASD. The most closely related were monozygotic twins with decreasing relative risk with reduced relatedness. There is a lot more to it than that though and with such a large cohort, it carries some weight. The article is worth a read as it is relevant to primary care, is a similar population (Swedish) and is applicable in the context of counselling parents who may visit for advice.

    Click to access sandin-et-al_2014.pdf

    https://www.essentialevidenceplus.com/index.cfm

  • Top 100 tools for learning

    This list is a pretty comprehensive list of, as the title suggests’ the top 100 tools for learning.  Funnily enough Twitter is number 1 which does not surprise me.  There is an interesting discussion of the pros and cons of social media here with some comments afterwards. Unfortunately the full text cannot be accessed from this site as far as I could see.

    Evernote is something I have been introduced to on learning technology course which is free and cross platform. I would also advocate Google Drive and Dropbox if you haven’t got them.

  • Social Networking and Learning

    This editorial is worth reading if only to whet the appetite for what is happening in SNS (Social Networking Services).  It is from the British Journal of Educational Technology (Vol 43, Issue 5; Sept 2012).  Unfortunately it is not free access. However one of the papers in the journal is available here. In it, Pachler and Cook discuss the relative merits of SNS in both the informal and work based learning environments.