12 minute read
GASTROENTEROLOGY
CLINICAL | GASTROENTEROLOGY
Antireflux surgery may be beneficial for refractory gastro-oesophageal reflux disease (GORD), but only for a highly selected group of patients, according to a New England Journal of Medicine study. Medical vs surgical
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Treatment for refractory heartburn
EARTBURN THAT PERSISTS
despite proton-pump inhibitor (PPI) treatment is a frequent clinical problem with multiple potential causes. Treatments for PPI-refractory heartburn are of unproven efficacy and focus on controlling gastroesophageal reflux with refluxreducing medication or antireflux surgery or on dampening visceral hypersensitivity with neuromodulators.
Roughly 370 Veterans Affairs patients with heartburn refractory to proton-pump inhibitors were enrolled, but 288 were excluded for various reasons (eg, testing revealed non-GORD causes of heartburn). Ultimately, 78 patients were randomised to receive either laparoscopic fundoplication, medical treatment (omeprazole, baclofen, desipramine), or control medication (omeprazole plus placebo).
At 12 months, the proportion of patients who had treatment success (at least a 50% improvement in the GORD Health-Related Quality of Life score) was significantly higher in the surgery group (67% vs. 28% for active medication and 12% for control medication).
An editorialist cautions: "The findings should not translate into more patients with refractory heartburn being offered surgery without each case being judiciously evaluated on its merits, and only after extended trials of medical therapy."
H
METHODS
Patients who were referred to Veterans Affairs (VA) gastroenterology clinics for PPI-refractory heartburn received 20mg of omeprazole twice daily for two weeks, and those with persistent heartburn underwent endoscopy, oesophageal biopsy, oesophageal manometry, and multichannel intraluminal impedance–pH monitoring. If patients were found to have reflux-related heartburn, we randomly assigned them to receive surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo). The primary outcome was treatment success, defined as a decrease of 50% or more in the GORD–Health Related Quality of Life score (range, 0 to 50, with higher scores indicating worse symptoms) at one year.
RESULTS
A total of 366 patients (mean age, 48.5 years; 280 men) were enrolled. Prerandomisation procedures excluded 288 patients: 42 had relief of their heartburn during the two-week omeprazole trial, 70 did not complete trial procedures, 54 were excluded for other reasons, 23 had nonGORD oesophageal disorders, and 99 had functional heartburn (not due to GORD or other histopathologic, motility, or structural abnormality). The remaining 78 patients underwent randomisation. The incidence of treatment success with surgery (18 of 27 patients, 67%) was significantly superior to that with active medical treatment (seven of 25 patients, 28%; P=0.007) or control medical treatment (three of 26 patients, 12%; P<0.001). The difference in the incidence of treatment success between the active medical group and the control medical group was 16% points (95% confidence interval, −5 to 38; P=0.17).
References available on request.
T W E N T Y Y E A R S SADAG
MENTAL HEALTH FACT SHEET
LIFE-TIME PREVALENCE OF MENTAL DISORDERS IN SA
Compared with 14 other countries in the WMH Survey, South Africa is the:
2nd highest for substance abuse disorders (13.3%) 6th highest for anxiety disorders (15.8%) 7th highest for mood disorders (9.8%) MENTAL HEALTH IN SOUTH AFRICA • 3rd biggest contributor to the burden of disease • 7.7% reduction in mental hospital beds across all provinces • 11% of all non-natural death in SA is due to suicide • 16.5% of South Africans suffer from common mental health problems • 43.7% of people with HIV/AIDS have a mental health condition • 75% of clinic staff does not have a caring attitude • South Africa is in the bottom 4 countries providing mental health treatment PATIENT ADHERENCE AT A GOVERNMENT HOSPITAL Only 15.4% of patients take their meds as suggested by their dr 1 in 3 patients do not attend their dr’s appointments • Most common reasons are • Forgetfulness 28.6% • Lack of Support 24.2% • Adverse reactions 13% • Unavailability 11% +/- 6 mil South African suffers from PTSD +/- 8000 South Africans commit suicide each year 82.1% cannot afford private health care > 1% of health budget devoted to mental health
SOCIAL BURDEN FOR MENTAL HEALTH PATIENTS
Can’t take care of dependants Separated/ Divorced Lost friends Negative Family Relationships
17% 26% 47% 49%
SEEKING TREATMENT FOR MENTAL HEALTH
RESOURCES FOR MENTAL HEALTH Per 100,000 of the population there are:
9.72 Nurses 0.4 Social workers 0.27 Psychiatrists 0.32 Psychologists 2.8 beds for in-patients 1% beds for children
Remote wound care during
COVID-19 COVID-19 is an ongoing worldwide pandemic that has created a global health crisis.
Dr Ethel Andrews, President of the South
African Burn Society
ON 23 MARCH 2020, President
Cyril Ramaphosa announced a new measure to combat the spread of the Covid-19 coronavirus in South Africa, which was a nationwide lockdown with severe restrictions on travel and movement. As of 29 April 2020, the total number of confirmed cases (at the time of going to print) is now 5 350 and 103 Coronavirus COVID-19 related deaths. The lockdown coincides with our winter season which normally sees in increase in burns due to heating appliances used, shack fires due to fallen candles, paraffin-related burns and overloading of plugs. According to the World Health Organization (WHO) burns occur mainly in the home and workplace. Children and women are usually burned in domestic kitchens from hot liquids or flames, or from cookstove explosions while men are most likely to be burned in the workplace due to fire, scalds, chemical and electrical burns.1
With the onset of lockdown there has been in increase in paediatric burns in South Africa. Hospitals across the country have tried to reduce the risk to patients
THICKNESS
Superficial
Superficial Partial Deep Partial Full thickness
DEGREE
First
Second
Third
Fourth
DEPTH
Epidermis
Papillary dermis
Reticular dermis
All layers of skin destroyed. May involve fascia, muscle and/ or bone
CHARACTERISTIC
Dry, red, blanches, painful Blisters, weeping, red, blanches, painful Blisters, wet or waxy dry, reduced blanching, painful Charred, waxy white, leathery does not blanch absent pain sensation (Pain present surrounding area)
by discharging patients earlier and opting to make use of outpatient facilities where available, deflecting smaller burns to other hospitals and making use of telehealth and telemedicine. With restrictions on movement, not all burns need to be admitted to hospital with minor burns are being treated at home or on an outpatient basis. The American Burn Association defines minor burns in a disaster as those involving noncritical sites and less than 10% TBSA for partial-thickness burns. Critical sites are all major joints, hands, feet, face and perineum. Excluded from this category are patients with minor burns who also have smoke inhalation or associated traumatic injuries.2 Burn units in South Africa have not changed the admission criteria and if a health care practitioner is in doubt its best to contact the referral hospital directly.
PATIENT QUESTIONS
Is it dry, intact and painful?
Is it red, blistered, swollen, and very painful? Can you see hair follicles or blisters? Is it whitish, charred, or due to translucent? Is the skin peeling off, with minimal sensation in the area?
MANAGING MINOR BURNS REMOTELY. 1. First Aid
Burn first aid includes: Cooling the burn by running under cool water for 20 minutes, or cold compress if running water is not available, take off jewellery and clothes from the burned area and protect the wound by covering it. 3 Manage pain with paracetamol.
2. Wound assessment remotely
Size and depth matters. If possible, a visual image of the wound allows for better assessment and decision making. Telemedicine in South Africa is required to be in line with applicable legislation, in particular the National Health Act No. 61 of 2003 (as amended).
The National Department of Health’s e-Health Strategy South Africa (2012- 2016) specifically refers to telemedicine as ‘a tool that could bridge the gap between rural health and specialist services. 4 On 27 March 2020, the Board of Health Care Funders have informed healthcare providers that telehealth and telemedicine may be practised as a result of South Africa's State of Disaster. 5
A. Location of the wound: Is the burn on face, hands, feet, perineum, circumferential or over a joint? B. Size: The Rule of Nines uses a rough estimate that represent multiples of 9%. In adults the head and neck are roughly 9%, the anterior and posterior chest are 9% each, the anterior and posterior abdomen are 9% each, each upper extremity is 9%, each thigh is 9%, each leg and foot is 9% and the remaining 1% represents the genitalia. 6, 7,8 ,9
The palmar surface of the patient’s hand is approximately 1% of their body surface over all age groups; visualising the patient’s hand covering the burn wound approximates the percentage of body surface area involved6, 7, 10,11. This is an easier method and is more often used in paediatrics and will similarly be an accurate method for measuring wound size remotely especially if no visual is available remotely C. Depth: Burn depth is assessed according to the layers of skin that are damaged by heat source. These are epidermal or superficial (first-degree), partialthickness (second-degree), which may also be classified as superficial or deep partial-thickness) and full-thickness (third-degree) burns (may also be classified as a deep full-thickness).12 D. Presence of infection: Burn wound surfaces are sterile immediately following thermal injury for a short time.13 But humans carry significant numbers of bacteria that will quickly contaminate the open wound.14 The clinical signs of infection in wounds are cellulitis, malodour, increase in pain, delayed healing or deterioration in the wound or wound breakdown and increase in exudate volume (15). Early recognition of infection is important because infection is by far the most frequent complication encountered by patients with burn injuries and it is therefore imperative that practitioners and patients recognise when care needs to be escalated.
E. Signs of none healing: The wound edges can serve as an important parameter to determine whether or not the present wound treatment is effective over time.16 Wound healing occurs when the wound edges of a deep wound show signs of new granulation tissue and a superficial wound’s edges epithelialise and epithelium islands are visible.16 Superficial burns heal within a few days, partial thickness burns heal within three weeks and full thickness burns require surgical management for closure.17 If the wound does not progress according to the expected time-line it might be due to burn conversion, infection or current treatment not being effective in which case the decision for home-based care must be reviewed, adjusted or abandoned and patient referred to hospital.
3. Treatment
Requirements • Dressing pack or gauze, gloves, clean bowl and waste bag • Scissors cleaned prior to use • Wound dressings • Previously boiled cooled down water
METHOD
• Take or administer analgesics • Wash hands thoroughly especially between fingers and palms of hands • Dry hands with a clean towel/kitchen roll • Open dressing pack or create a clean surface with towel • Pour water into dressing tray/ bowl • Position waste bag for dirty dressings close to wound • Open new wound dressings and drop into clean opened dressing pack/ clean towel surface • Remove dressing without touching the inside of the dirty dressing or the wound bed, you might have to wet dressing with tap water if dressing is stuck to wound, do not pull if stuck as this will damage the healing wound • Place dirty dressing into the waste bag • Wash hands again • Apply clean gloves • Clean the wound bed by gently wiping to remove any wound residue and then surrounding skin with tap water and gauze • Ensure that you clean the wound before the surrounding skin and use a new piece of gauze for the surrounding skin • Dependent upon the location of the wound it may be more appropriate to shower, which will ensure that the wound bed and surrounding skin are clean prior to dressing • Pay attention to the condition of wound; colour and size of the wound; new wounds; signs of infection; condition of wound margin; colour, amount and viscosity of wound fluid • Apply dressing • Dispose waste bag safely • Document dressing change and call health professional if you have any concerns.
Remote consultations are not as a replacement for normal ‘face-to-face’ healthcare but an add-on meant to enhance access to healthcare during these difficult times and minimises the risk of being exposed to COVID-19. Successful remote management of burns is dependent on patient selection, selection of an appropriate dressing which minimises pain and frequency of dressing changes, and open communication between the health care practitioner and the patient.
REFERENCES
1. https://www.who.int/news-room/fact-sheets/ detail/burns).
2. Cancio, L.C., Barillo, D.J., Kearns, R.D., et al.
(2016). Guidelines for Burn Care Under Austere Conditions: Surgical and Nonsurgical Wound Management Journal of Burn Care & Research. 2016. DOI: 10.1097/BCR.0000000000000368 3. Ahuja,R.B., Puri, V., Gibran, N., et al. (2016) ISBI Practice Guidelines for Burn Care. Burns. 42(5):953–1021. 4. https://www.hpcsa.co.za/Uploads/Press%20 Realeses/2020/Guidelines_to_telemedicine_in_ South_Africa.pdf 5. https://www.bhfglobal.com/2020/03/27/covid-19- telehealth-telemedicine-result-south-african-stateof-disaster/ 6. Sheridan, R. L.2012. Burns. A Practical approach to immediate treatment and long term care. Manson publishing.
7. Malik, K. I., Malik, M. A. N. & Aslam. A. 2010.
Honey compared with silver sulphadiazine in partialthickness burns. International Wound Journal. vol. 7, pp. 413–417.
8. Wachtel, T. L., Berry, C. C., Wachtel, E. E., et al.
2000. The inter-rater reliability of estimating the size of burns from various burn area chart drawings. Burns. vol. 26, no. 2, pp. 156–170 9. Wallace, 1951. The exposure and treatment of burns. Lancet. no. 6653, pp. 501-504 10. Butcher, M. & Swales, B. 2012. Assessment and management of patients with burns. Nursing Standard. vol. 27, no. 2, pp. 50-56.
11. Sheridan, R. L., Petras, L., Basha, G., et al.
1995. Planimetry study of the percent of body surface represented by the hand and palm: sizing irregular burns is more accurately done with the palm. Journal of Burns Care and Rehabilitation. vol. 6, no. 6, pp. 605-606. 12. Culleiton AL, Simko LM. Caring for patients with burn injuries. Nursing Critical Care:January 2013 - Volume 8 - Issue 1 - p 14–22 doi: 10.1097/01. CCN.0000423824.70370.fa. 13. Church, D, Elsayed, S, Reid, O., et al., 2006. Burn Wound Infections. Clinical Microbiology Reviews. vol. 19, no. 2, pp. 403-434. 14.Santy, J. 2008. Recognising infection in wounds. Nursing Standard. vol. 23, no. 7, pp. 53-60.
15. Cutting, K., White, R. & Mahoney, P. (2005).
Clinical Identification of Wound Infection: a Delphi Approach. 32. S26. https://www.researchgate.net/ publication/275381440 16. Mulder, M. (2009). The selection of wound care products for wound bed preparation Wound Healing Southern Africa.2(2):76-78
17. Karim, A.S., Shaum, K and Gibson, A.L.F.
(2020). Indeterminate-Depth Burn Injury-Exploring the Uncertainty. J Surg Res. Jan;245:183-197. doi: 10.1016/j.jss.2019.07.063. Epub 2019 Aug 14
