Archive for month: April, 2024

A new Society of Radiologists in Ultrasound (SRU) expert consensus statement to improve endometriosis evaluation was published today in the journal Radiology.

Endometriosis is a common condition with substantial diagnostic delay, leading patients to experience pain, infertility, lost wages and interrupted relationships.

The consensus provides recommendations for augmenting routine pelvic ultrasounds through additional maneuvers and imaging to improve diagnosis of deep endometriosis.

Endometriosis, the presence of endometrium-like tissue outside the uterus, is a prevalent and potentially debilitating condition. The condition is estimated to affect 10% of women of reproductive age and occurs in 21% of women undergoing hysterectomy with chronic pelvic pain. In the United States, there is an over seven-year delay between the onset of symptoms and a diagnosis of endometriosis.

Endometriosis is also associated with infertility and subfertility, affecting 20-50% of patients with these conditions. Deep endometriosis, extending to any depth beneath the peritoneal surface, is the most severe form of endometriosis.

Ultrasound is usually the first-line imaging modality used when patients report chronic pelvic pain or have issues of infertility, both common symptoms of endometriosis, but few centers in the U.S. utilize ultrasound to screen for deep endometriosis. Existing scan protocol limitations and lack of awareness lead to suboptimal detection of deep endometriosis on pelvic ultrasounds.

SRU convened a multidisciplinary panel of experts to make recommendations aimed at improving the screening process for endometriosis.

“The purpose of this consensus panel is to recommend methods that increase the diagnostic sensitivity for endometriosis on pelvic ultrasound by increasing awareness, improving interpretation, adding simple techniques that are high yield for deep endometriosis, and improving protocols to triage patients,” said the statement’s first author Scott W. Young, M.D., diagnostic radiology consultant, Division of Ultrasound, at the Mayo Clinic in Phoenix, Arizona.

The panel was composed of experts in the imaging and management of endometriosis, including radiologists, sonographers, gynecologists, reproductive endocrinologists, and minimally invasive gynecologic surgeons. A comprehensive literature review combined with a modified Delphi technique achieved a consensus.

“The statement defines the targeted screening population, describes techniques for augmenting pelvic ultrasound, establishes direct and indirect observations for endometriosis on ultrasound, creates an observational grading and reporting system and makes recommendations for additional imaging and patient management,” Dr. Young said.

Panel recommendations include transvaginal ultrasound of the posterior compartment, observation of the relative positioning of the uterus and ovaries, and the uterine sliding sign maneuver to improve the detection of endometriosis.

“These additional techniques typically can be performed in less than five minutes and could ultimately decrease the delay of an endometriosis diagnosis in at-risk patients,” Dr. Young said.

The panel also recommends that direct and indirect observations of deep endometriosis should be assessed during the exam, and results should be reported using four categories: Incomplete (APU-0), Normal (APU-1), Equivocal (APU-2) and Positive (APU-3) with associated management recommendations.

“The SRU consensus on routine pelvic ultrasound for endometriosis aims to enhance deep endometriosis detection even at an initial ultrasound and with minimal additional time during imaging and no special patient preparation,” Dr. Young said. “Focusing imaging on anatomic regions where deep endometriosis is common can increase detection and decrease diagnostic delay.”

Dr. Young noted that these guidelines are meant for symptomatic patients at typical risk for endometriosis. Patients at high risk because of prior diagnostic or therapeutic laparoscopy for endometriosis or strong clinical indications may benefit from proceeding directly to advanced endometriosis imaging, particularly if they are likely to undergo surgery or if monitoring is needed in the setting of infertility and medical treatment.

Reference:

Scott W. Young,  Priyanka Jha, Luciana Chamié, Shuchi Rodgers, Rosanne M. Kho, Mindy M. Horrow, Phyllis Glanc, Myra Feldman, Yvette Groszmann, Zaraq Khan, Steven L. Young, Liina Poder, Tatnai L. Burnett, Eric M. Hu, Susan Egan, Society of Radiologists in Ultrasound Consensus on Routine Pelvic US for Endometriosis, Radiology, https://doi.org/10.1148/radiol.232191.

A comprehensive review underscores the protective role of antibiotic prophylaxis in preventing infective endocarditis among the high-risk patients following invasive dental procedures. The key highlights of this study were published in the Journal of American Medical Association.

This study meticulously analyzed data up to May 2023 and cast new light on the long-debated effectiveness of the antibiotic prophylaxis guidelines established since 2007. The investigation looked into an extensive array of databases, including PubMed, Cochrane-CENTRAL, Scopus and several others. After sifting through a total of 11,217 records, this study included 30 studies that encompassed over 1.1 million infective endocarditis cases.

The results from this analysis revealed significant reduction in the risk of developing infective endocarditis following dental procedures for patients who received antibiotic prophylaxis in five out of eight studies. Also, the high-risk individuals benefited substantially where the pooled relative risk (RR) of 0.41 indicated a 59% reduced risk when compared to the individuals who did not receive antibiotics. This data aligns well with the recommendations of leading health organizations such as the American Heart Association and the European Society of Cardiology.

These findings from the time-trend analyses gave out a more complex picture. While 9 studies observed no significant change in the incidence of infective endocarditis post-guideline implementation, 7 reported including those at moderate and high risk across various populations was positive. 3 studies, however, did note a significant decline, especially among cases of oral streptococcus-related endocarditis.

This difference in time-trend results underlines the precise impact of antibiotic prophylaxis guidelines over time and across different patient demographics. However, the consensus from more controlled study designs suggests a clear protective benefit of antibiotic prophylaxis for high-risk individuals that reaffirms the current health recommendations.

For moderate-risk patients, the evidence remains inconclusive by highlighting a critical gap in current research and elucidating the need for targeted studies to address this uncertainty. In conclusion, this systematic review supports the continued use of antibiotic prophylaxis in preventing infective endocarditis among the high-risk patients who undergo invasive dental procedures. This calls for a clear interpretation of time-trend data and urges further research to reveal the role of prophylaxis in moderate-risk groups that ensures patient safety and optimal health outcomes.

Source:

Sperotto, F., France, K., Gobbo, M., Bindakhil, M., Pimolbutr, K., Holmes, H., Monteiro, L., Graham, L., Hong, C. H. L., Sollecito, T. P., Lodi, G., Lockhart, P. B., Thornhill, M., Diz Dios, P., Turati, F., & Edefonti, V. (2024). Antibiotic Prophylaxis and Infective Endocarditis Incidence Following Invasive Dental Procedures. In JAMA Cardiology. American Medical Association (AMA). https://doi.org/10.1001/jamacardio.2024.0873

Sweden: Findings from the REDUCE-AMI published in The New England Journal of Medicine have shown no benefit of beta-blockers in revascularized patients with normal ejection fraction (EF) after myocardial infarction (MI).

Experiencing the sort of job insecurity in early adulthood that is often linked to the gig economy, is linked to a heightened risk of a serious alcohol-related illness in later life, suggest the findings of a long term study published online in Occupational & Environmental Medicine.

And men who find themselves in this position as young adults seem to be more at risk than young women, the findings indicate.

The prevalence of ‘precarious employment’, which describes non-standard or temporary work that is often poorly paid, insecure, and unprotected, has increased in recent years, explain the researchers. But few studies have looked at its potential consequences on mental health and vulnerability to alcohol misuse, they add.

To explore these issues further, the researchers drew on 339, 403 participants from the Swedish Work, Illness, and Labour Market Participation (SWIP) group, all of whom were born between 1973 and 1976, and whose data were linked to several nationwide registers for 16–65 year old Swedish residents in 2005.

Information on employment status was collected between 1992 and 2006 when the participants were aged between 19 and 30, and 3 years after they had graduated from the highest level of education attended—school or university.

Their employment status was categorised into 5 mutually exclusive groups: precarious employment; long term unemployment (at least 180 days); substandard employment; standard employment; and other, to include self-employment, not registered as employed, or student.

Information on subsequent ill health, requiring inpatient care, was obtained from the National Hospital Discharge Register, specifically mental and behavioural disorders due to alcohol; alcoholic liver disease; and toxic effects of alcohol.

Most participants were in substandard (107,395; 32%) or standard (133,141; just over 39%) employment. Only 42,232 (12.5%) were experiencing precarious employment: they tended to be male and to have lower levels of educational attainment than those in standard employment.

In all, 6713 (2%) participants required inpatient care at least once for alcohol-related illness during a maximum monitoring period of 28 years. Two thirds of them (4448) were men.

Compared with young adults in standard employment, those in precarious employment were almost twice as likely to have an alcohol-related illness, while the long term unemployed were almost three times as likely to do so.

After taking into consideration several potentially influential factors, including previous mental health and alcohol-related health problems, those in precarious employment were 43% more likely to have an alcohol related illness than those in standard employment.

Similarly, the long term unemployed were almost twice as likely to have an alcohol related illness, while those in substandard employment were 15% more likely to do so.

When stratified by sex, the association between precarious employment and alcohol-related Illness was stronger among men: 50% heightened risk vs 32% heightened risk for women.

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. And the researchers acknowledge that as Swedish registers have limited coverage of educational attainment outside of Sweden, many people would have been excluded from the study, which might limit the wider applicability of the findings.

And important dimensions of precarious employment, including rights and working hours, aren’t captured in employment registry data in Sweden.

Despite these caveats, the findings echo and amplify those of previous studies, point out the researchers. “A potential explanation for our findings could be that young adulthood is a particularly sensitive period in life concerning the initiation and formation of health-related behaviours, such as alcohol use,” they suggest.

“Subsequently, young adults in precarious employment might use alcohol as a coping strategy for stress and form a habit of consuming larger quantities of alcohol compared with individuals in [standard employment] of the same age.”

Referring to the even higher risk of alcohol related illness among those who were long term unemployed as young adults, the researchers write: “To escape unemployment, several young people take the first job offered, which is generally more precarious with less security, lower wages and longer hours.

“The results of the current study suggest that this decision appears to be marginally more beneficial compared with remaining unemployed, which adds to the discussion of whether any job is really better than no job at all,” they conclude.

Reference:

Precarious employment in young adulthood and later alcohol-related morbidity: a register-based cohort study, Occupational and Environmental Medicine (2024). DOI: 10.1136/oemed-2023-109315.