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Haran C, Ghafouri K, Xu W, Hayes I, Stiles M, Khashram M. Prevalence of Genetically Triggered Aortopathy in Acute Aortic Syndrome in Aotearoa New Zealand. Eur J Vasc Endovasc Surg 2023; 66:879-880. [PMID: 37714295 DOI: 10.1016/j.ejvs.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/01/2023] [Accepted: 09/08/2023] [Indexed: 09/17/2023]
Affiliation(s)
- Cheyaanthan Haran
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand. https://twitter.com/CheyHaran
| | - Khashayar Ghafouri
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - William Xu
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ian Hayes
- Genetic Health Service New Zealand - Northern Hub, Auckland, New Zealand
| | - Martin Stiles
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Cardiology, Waikato Hospital, Hamilton, New Zealand
| | - Manar Khashram
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand.
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Mekhail A, Young P, Mekhail AM, Tinawi G, Haran C, Clayton N, Galvin S. Stress Ulcer Prophylaxis in Cardiac Surgery: A Retrospective Cohort Study to Analyze the Effects of SUP Cessation. J Intensive Care Med 2023; 38:917-921. [PMID: 37093762 DOI: 10.1177/08850666231171327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Upper gastrointestinal bleeding (UGIB) is an important complication among critically ill adults, especially those having cardiac surgery as management is complicated by the requirement for antiplatelet/anticoagulant therapy. As a result, stress ulcer prophylaxis (SUP) has become routine practice in many centers, utilizing either proton pump inhibitors (PPIs) or histamine-2 receptor blockers (H2RBs). Recent evidence from the PEPTIC trial indicated an increase in mortality risk among cardiac surgery patients receiving PPIs compared to H2RBs. Considering these findings, alongside practical difficulties surrounding the transition to H2RBs as a prophylactic agent in New Zealand, Wellington Hospital intensive care unit elected to discontinue routine PPI use for SUP in cardiac surgery patients. A retrospective study was conducted to assess patient outcomes following the discontinuation of routine SUP. METHOD A retrospective cohort study was conducted of all adult patients who underwent cardiac surgery at Wellington Hospital between February/2018 and January/2022, and divided patients into cohorts before and after the discontinuation of routine use of SUP on the 31st of January 2020. The primary outcomes were the rate of UGIB, oesophagogastroduodenoscopy (OGD) and 180-day postoperative mortality. Secondary outcomes included rates of postoperative Clostridium difficile enteritis, pneumonia, deep sternal wound infection, and length of stay of the index admission. RESULTS The rate of UGIB statistically significantly increased since the cessation of routine SUP in January 2020 (2.4% vs 5.4%, P-value = .004). This finding was mirrored with the increased rates of OGD (1.9% vs 4.0%, P-value = .005). There were no significant changes in 180-day mortality, hospital length of stay, or any of the postoperative infective complications analyzed, pneumonia, deep sternal wound infection, or C difficile enteritis. CONCLUSION This study suggests an association between routine use of SUP and reduced rates of clinically significant UGIB and OGD requirements in cardiac surgery patients without increasing risk of infective complications or postoperative mortality.
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Affiliation(s)
- Andrew Mekhail
- Department of Cardiothoracic Surgery, Wellington Hospital, Wellington, New Zealand
| | - Paul Young
- Department of Intensive Care Medicine, Wellington Hospital, Wellington, New Zealand
| | - Ann-Marie Mekhail
- Department of Intensive Care Medicine, Wellington Hospital, Wellington, New Zealand
| | - Georges Tinawi
- Department of Cardiothoracic Surgery, Wellington Hospital, Wellington, New Zealand
| | - Cheyaanthan Haran
- Department of Cardiothoracic Surgery, Wellington Hospital, Wellington, New Zealand
| | - Nicholas Clayton
- Department of Cardiothoracic Surgery, Wellington Hospital, Wellington, New Zealand
| | - Sean Galvin
- Department of Cardiothoracic Surgery, Wellington Hospital, Wellington, New Zealand
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Xu W, Haran C, Dean A, Lim E, Bernau O, Mani K, Khanafer A, Pitama S, Khashram M. Acute aortic syndrome: nationwide study of epidemiology, management, and outcomes. Br J Surg 2023; 110:1197-1205. [PMID: 37303206 PMCID: PMC10416687 DOI: 10.1093/bjs/znad162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/03/2023] [Accepted: 05/07/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Epidemiological studies on acute aortic syndrome (AAS) have relied largely on unverified administrative coding, leading to wide-ranging estimates of incidence. This study aimed to evaluate the incidence, management, and outcomes of AAS in Aotearoa New Zealand. METHODS This was a national population-based retrospective study of patients presenting with an index admission of AAS from 2010 to 2020. Cases from the Ministry of Health National Minimum Dataset, National Mortality Collection, and the Australasian Vascular Audit were cross-verified with hospital notes. Poisson regression adjusted for sex and age was used to investigate trends over time. RESULTS During the study interval, 1295 patients presented to hospital with confirmed AAS, including 790 with type A (61.0 per cent) and 505 with type B (39.0 per cent) AAS. A total of 290 patients died out of hospital between 2010 and 2018. The overall incidence of aortic dissection including out-of-hospital cases was 3.13 (95 per cent c.i. 2.96 to 3.30) per 100 000 person-years, and this increased by an average of 3 (95 per cent c.i. 1 to 6) per cent per year after adjustment for age and sex adjustment on Poisson regression, driven by increasing type A cases. Age-standardized rates of disease were higher in men, and in Māori and Pacific populations. The management strategies used, and 30-day mortality rates among patients with type A (31.9 per cent) and B (9.7 per cent) disease have remained constant over time. CONCLUSION Mortality after AAS remains high despite advances over the past decade. The disease incidence and burden are likely to continue to increase with an ageing population. There is impetus now for further work on disease prevention and the reduction of ethnic disparities.
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Affiliation(s)
- William Xu
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Cheyaanthan Haran
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Anastasia Dean
- Department of Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Eric Lim
- Department of Vascular Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Oliver Bernau
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Adib Khanafer
- Department of Vascular Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Suzanne Pitama
- Māori/Indigenous Health Institute, University of Otago, Christchurch, New Zealand
| | - Manar Khashram
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
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Study Management Group, Varghese C, McGuinness M, Wells CI, Elliott BM, Gunawardene A, Edwards M, Expert Advisory Group, Vohra R, Griffiths EA, Connor S, Poole GH, Windsor JA, Wright D, Harmston C, Collaborating Authors, Wang JHS, Windsor J, Chen E, Ghate K, Lal S, Lekamalage B, Ratnayake M, Bansal A, Windsor J, von Keisenberg S, Hemachandran A, Singhal M, Joseph N, Bhat S, Rossaak J, Carson D, Dubey N, Pan M, Ferguson L, Watt I, Choi J, Mclauchlan J, Connor S, Nicholas E, Al-Busaidi I, Wood D, Haran C, Lin A, Fagan P, Bathgate A, Patel S, Mak J, Espiner E, Poole G, Hassan S, Javed Z, Randall M, Clough S, Cook W, Clark S, Finlayson C, Poole G, Bahl P, Singh S, Lin C, Wang C, Kittaka R, Morreau M, Ing A, Logan S, Guest S, Sutherland K, Lewis A, Roberts J, Watson B, Tietjens J, Teague R, Su'a B, Modi A, Modi V, Williams Y, Morreau J, Khoo C, Desmond B, Young M, Christmas R, Holm T, Harmston C, Long K, Garton B, Niki kau, Barber L, Amer M, Haddow J, Amer M, Fearnley-Fitzgerald C, Suresh K, Zeng E, Young-Gough A, Skeet J, El-Haddawi F, Alvarez M, Nguyen S, King J, Crichton J, Welsh F, Edwards M, Tan J, Luo J, Banker K, Field X, Allan P, Rennie S, Ratnayake CB, Srinivasa S, Gloria Kim JH, Bradley S, Singh N, Kang G, Xu W, Srinivasa S, Cook H, Mistry V, Dabla K, de Oca AM, Yoganandarajah V, Lill M, Lu J, Bonnet LA, Uiyapat T. Variation in the practice of cholecystectomy for benign biliary disease in Aotearoa New Zealand: a population-based cohort study. HPB (Oxford) 2023:S1365-182X(23)00128-4. [PMID: 37198069 DOI: 10.1016/j.hpb.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 03/26/2023] [Accepted: 04/18/2023] [Indexed: 05/19/2023]
Abstract
INTRODUCTION Cholecystectomy for benign biliary disease is common and its delivery should be standardised. However, the current practice of cholecystectomy in Aotearoa New Zealand is unknown. METHODS A prospective, national cohort study of consecutive patients having cholecystectomy for benign biliary disease was performed between August and October 2021 with 30-day follow-up, through STRATA, a student- and trainee-led collaborative. RESULTS Data were collected for 1171 patients from 16 centres. 651 (55.6%) had an acute operation at index admission, 304 (26.0%) had delayed cholecystectomy following a previous admission, and 216 (18.4%) had an elective operation with no preceding acute admissions. The median adjusted rate of index cholecystectomy (as a proportion of index and delayed cholecystectomy) was 71.9% (range 27.2%-87.3%). The median adjusted rate of elective cholecystectomy (as proportion of all cholecystectomies) was 20.8% (range 6.7%-35.4%). Variations across centres were significant (p < 0.001) and inadequately explained by patient, operative, or hospital-factors (index cholecystectomy model R2 = 25.8, elective cholecystectomy model R2 = 50.6). CONCLUSIONS Notable variation in the rates of index and elective cholecystectomy exists in Aotearoa New Zealand not attributable to patient, operative or hospital factors alone. National quality improvement efforts to standardise availability of cholecystectomy are needed.
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Haran C, Sivakumaran Y. Contemporary uses of inferior vena cava balloon occlusion. Ann Vasc Surg 2023:S0890-5096(23)00238-8. [PMID: 37121341 DOI: 10.1016/j.avsg.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 05/02/2023]
Abstract
The evolution of the hybrid operative environment has expanded the utility of inferior vena cava balloon occlusion (IVCBO) in contemporary surgical practice. First described in the management of acute decompensated heart failure and venous thromboembolism, IVCBO has been utilised in deployment of thoracic endoprosthesis, repair of aorto-caval fistula, management of inferior vena cava (IVC) tumour thrombus and abdominal IVC trauma. More recently, IVCBO has also been utilised as a therapeutic strategy to assist patients with reduced ejection fraction and exercise tolerance in the form of an implantable device. Here we present a narrative review of the physiological impact of IVCBO as well as its historical, contemporary and future uses. The contemporary utilisation of IVCBO is a novel example of employing endovascular technology in the hybrid operative environment; paramount for the modern vascular surgeon who is now increasingly involved in multi-disciplinary management of complex clinical presentations.
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Affiliation(s)
- Cheyaanthan Haran
- Department of Vascular Surgery, Auckland City Hospital, Auckland, New Zealand; Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Yogeesan Sivakumaran
- Department of Vascular Surgery, Princess Alexandra Hospital, Brisbane, Australia; Greater Brisbane Clinical School, University of Queensland, Brisbane, Australia
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Mekhail A, Haran C, Doig F, Galvin SD. Repair of un-ruptured sinus of valsalva aneurysm. ANZ J Surg 2023. [PMID: 36716282 DOI: 10.1111/ans.18298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 01/18/2023] [Indexed: 02/01/2023]
Affiliation(s)
- Andrew Mekhail
- Department of Cardiothoracic Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Cheyaanthan Haran
- Department of Cardiothoracic Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Fiona Doig
- Department of Cardiothoracic Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Sean D Galvin
- Department of Cardiothoracic Surgery, Wellington Regional Hospital, Wellington, New Zealand
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Haran C, Kong V, Cheung C, Rajaretnam N, Bruce J, Laing G, Manchev V, Clarke D. Managing the acutely threatened airway following head and neck trauma – Requiem for cricothyroidotomy? Surgery in Practice and Science 2022. [DOI: 10.1016/j.sipas.2022.100124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Haran C, Lim YK, Aljanabi I, Bann S, Wickremesekera S. Bariatric surgery and the neurohormonal switch: Early insulin resistance recordings after laparoscopic sleeve gastrectomy. Medicine (Baltimore) 2022; 101:e29687. [PMID: 35905279 PMCID: PMC9333479 DOI: 10.1097/md.0000000000029687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Laparoscopic sleeve gastrectomy (LSG) is a bariatric operation with a safe risk profile. It has been proven to successfully reduce weight, decrease insulin resistance (IR), and ameliorate diabetes mellitus. The aim of this study was to determine if there is an early improvement in IR after LSG and its association with weight loss. This was a prospective observational study of 32 patients who underwent LSG at a single center over a 3-year period. Serum insulin and fasting glucose levels were recorded preoperatively, on day 1 postoperatively, and 3 weeks after LSG. IR levels were calculated using the Homeostasis Model Assessment 2 Version 2.23. IR levels were compared along with the overall weight loss, via body mass index. β-cell function was the secondary outcome. IR significantly improved the day after surgery with a statistically significant mean difference of 0.89 units (P = .043) and significantly more so 3 weeks postoperatively, with a mean difference of 4.32 units (P < .0005). β-cell function reduced 3 weeks postoperatively, with a mean difference of 23.95 %β (P = .025), while body mass index significantly reduced, with a mean difference of 4.32 kg/m2 (P < .0005). Early improvement of IR was observed on postoperative day 1 after LSG before any weight loss. This raises the possibility of an undetermined, underlying neurohormonal switch that improves IR. Further investigation is needed to determine this mechanism, as it may lead to an improvement in the medical management of diabetes mellitus.
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Affiliation(s)
- Cheyaanthan Haran
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
- Wellington School of Medicine, Otago University, Wellington, New Zealand
- *Correspondence: Cheyaanthan Haran, Department of General Surgery, Wellington Regional Hospital, Riddiford Street, Newtown, Wellington 6021, New Zealand (e-mail: )
| | - Yu kai Lim
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Imad Aljanabi
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Simon Bann
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
- Wellington School of Medicine, Otago University, Wellington, New Zealand
- Victoria University of Wellington, Wellington, New Zealand
| | - Susrutha Wickremesekera
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
- Wellington School of Medicine, Otago University, Wellington, New Zealand
- Victoria University of Wellington, Wellington, New Zealand
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Haran C, Kyngdon RJ. Herpes zoster: a rare cause of Ogilvie syndrome. ANZ J Surg 2021; 91:E637-E639. [PMID: 33590666 DOI: 10.1111/ans.16667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Cheyaanthan Haran
- General Surgery Department, Wairarapa Hospital, Masterton, New Zealand
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Haran C, Fischer N, Oliver T, Grant M. Mirror-image confusion: successful giant hiatus hernia repair in situs inversus totalis. N Z Med J 2019; 132:66-68. [PMID: 31170135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Cheyaanthan Haran
- PGY2 House Officer, Department of General Surgery, Wellington Regional Hospital, Wellington
| | - Nicholas Fischer
- Senior General Surgery Registrar, Department of General Surgery, Wellington Regional Hospital, Wellington
| | - Thomas Oliver
- Junior General Surgery Registrar, Department of General Surgery, Wellington Regional Hospital, Wellington
| | - Mark Grant
- Consultant General Surgeon, Department of General Surgery, Wellington Regional Hospital, Wellington
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Brunger N, Gimpel D, Haran C, Srivastava T, Mccormack D, Gamel AE. Red Cell Distribution Width as a Predictive Measure of Outcome in Patients Undergoing Cardiac Surgery. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.02.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kularatna M, Lauti M, Haran C, MacFater W, Sheikh L, Huang Y, McCall J, MacCormick AD. Clinical Prediction Rules for Appendicitis in Adults: Which Is Best? World J Surg 2018; 41:1769-1781. [PMID: 28258458 DOI: 10.1007/s00268-017-3926-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Clinical prediction rules (CPRs) provide an objective method of assessment in the diagnosis of acute appendicitis. There are a number of available CPRs for the diagnosis of appendicitis, but it is unknown which performs best. AIM The aim of this study was to identify what CPRs are available and how they perform when diagnosing appendicitis in adults. METHOD A systematic review was performed in accordance with the PRISMA guidelines. Studies that derived or validated a CPR were included. Their performance was assessed on sensitivity, specificity and area under curve (AUC) values. RESULTS Thirty-four articles were included in this review. Of these 12 derived a CPR and 22 validated these CPRs. A narrative analysis was performed as meta-analysis was precluded due to study heterogeneity and quality of included studies. The results from validation studies showed that the overall best performer in terms of sensitivity (92%), specificity (63%) and AUC values (0.84-0.97) was the AIR score but only a limited number of studies investigated at this score. Although the Alvarado and Modified Alvarado scores were the most commonly validated, results from these studies were variable. The Alvarado score outperformed the modified Alvarado score in terms of sensitivity, specificity and AUC values. CONCLUSION There are 12 CPRs available for diagnosis of appendicitis in adults. The AIR score appeared to be the best performer and most pragmatic CPR.
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Affiliation(s)
- Malsha Kularatna
- Department of Surgery, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand.
| | - Melanie Lauti
- Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Cheyaanthan Haran
- Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Wiremu MacFater
- Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Laila Sheikh
- Department of Surgery, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand
| | - Ying Huang
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand
| | - John McCall
- Department of Surgery, University of Otago, Dunedin, New Zealand
| | - Andrew D MacCormick
- Department of Surgery, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand. .,Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand.
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McCormack D, El-Gamel A, Haran C, Conaglen P, Kejriwal N, Lin Z, Odom N, Parkinson G, Levine A, O’Rourke T. Mortality From Cardiac Arrest After Cardiac Surgery: What Can be Done? Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rees S, Haran C, Mccormack D, El-Gamel A. Ethnicity and Premorbidity State of Patients for Isolated Coronary Artery Bypass Grafting Surgery: The Waikato Cardiothoracic Unit Experience. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.04.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
BACKGROUND International guidelines advocate using daily inhaled corticosteroids (ICS) in the management of children and adults with persistent asthma. However, in real world clinical settings, these medicines are often used at irregular intervals by patients. Recent evidence suggests that the use of intermittent ICS, with treatment initiated at the time of early symptoms, may still have benefits for reducing the severity of an asthma exacerbation. OBJECTIVES To compare the efficacy and safety of intermittent ICS versus placebo in the management of children and adults diagnosed with, or suspected to have, symptoms of mild persistent asthma. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of trials (CAGR), the ClinicalTrials.gov website and the World Health Organization (WHO) trials portal in March 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared intermittent ICS versus placebo in children and adults with symptoms of persistent asthma. No co-interventions were permitted other than rescue relievers and oral corticosteroids used during exacerbations. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, methodological quality and extracted data. The primary efficacy outcome was the risk of asthma exacerbations requiring oral corticosteroids and the primary safety outcome was serious adverse health events. Secondary outcomes included exacerbations, lung function tests, asthma control, adverse effects, and withdrawal rates. Quality of the evidence was assessed using the GRADE criteria. MAIN RESULTS Six trials (representing 490 preschool children, 145 school-aged children and 240 adults) met the inclusion criteria. Study durations were 12 to 52 weeks. Results for preschool children were presented in a separate analysis as this represents a distinct clinical condition, not necessarily related to the development of long term asthma.There was a reduction in the risk of patients experiencing one or more exacerbations requiring oral corticosteroids in older children (145 participants, odds ratio (OR) 0.57; 95% confidence interval (CI) 0.29 to 1.12, low quality evidence) and adults with asthma (240 participants, OR 0.10; 95% CI 0.01 to 1.95, low quality evidence). These analyses were each based on the findings of a single study. No group difference was observed in the risk of serious adverse health events (385 participants; OR 1.00; 95% CI 0.14 to 7.25, moderate quality evidence). Compared to the placebo group, there was an insufficient number of participants to make firm conclusions whether the intermittent ICS group displayed any reduction in the rate of hospitalisations, day time and night time symptoms scores, or adverse events. Lung function tests reported by a single study favoured the use of ICS. There was no significant group difference in growth rate of children, or overall withdrawals.In preschool children with frequent wheezing episodes, the use of intermittent ICS at the onset of early symptoms reduced the likelihood of requiring rescue oral corticosteroids by half (490 participants; OR: 0.48; 95% CI 0.31 to 0.73, moderate quality evidence with minimal heterogeneity). Intermittent therapy was associated with fewer serious adverse events (439 participants; OR 0.42; 95% CI 0.17 to 1.02, low quality evidence). There was no significant difference in hospitalisations or in a single study measuring parent perceived quality of life. However, intermittent therapy was associated with improvements in both day time and night time symptoms. There was no increase in the rates of withdrawals, and overall and treatment-specific adverse events. AUTHORS' CONCLUSIONS In children and adults with mild persistent asthma, two studies have shown that the use of intermittent ICS at the time of exacerbation reduced the chances of needing oral corticosteroids by half. This result is statistically significant if we assume that the effect size is the same for each study population (fixed effects model), but is not statistically significant when using a random effects model. However, the paucity of published evidence limits our conclusions towards the 'as-needed' use of this medication. The small number of studies and participants were the major reasons for downgrading the overall quality of the findings. A corresponding result was found in preschool children with wheeze. In this age group, an improvement in day time and night time asthma symptoms score and parental perceived quality of life of children similarly favoured the ICS group. However, there was no statistical difference in hospitalisation rates in any group. This treatment was not associated with any significant increase in adverse events. There was no growth suppression noted with the use of intermittent ICS in either preschool or school-aged children. Considering the limited number of available studies, we emphasise the need for more randomised controlled studies in order to confirm these findings.
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Affiliation(s)
| | | | - Bhupendrasinh F Chauhan
- University of ManitobaFaculty of PharmacyWinnipegMBCanada
- University of ManitobaKnowledge Synthesis, George and Fay Yee Centre for Healthcare InnovationWinnipeg Regional Health AuthorityWinnipegMBCanada
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Faust M, Fraser J, Schurig L, Ching B, Gillette PC, Goldschlager N, Haran C, Magro S, Ozahowski T, Sweesy M. Educational guidelines for the clinically associated professional in cardiac pacing and electrophysiology. Pacing Clin Electrophysiol 1990; 13:1448-55. [PMID: 1701899 DOI: 10.1111/j.1540-8159.1990.tb04020.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Haran C. A close up look at another nurse entrepreneur--Chea Haran, ARNP. Fla Nurse 1985; 33:3. [PMID: 3850051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Haran C, Rengel AM. Color coding can prevent mishaps. J Ophthalmic Nurs Technol 1985; 4:28-9. [PMID: 3846639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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