ERCP using double-balloon endoscopes in patients with Roux-en-Y anastomosis

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures are difficult to perform in patients with a Roux-en-Y reconstruction. Therefore, at present, at many institutions, ERCP is not generally performed for those with a Roux-en-Y anastomosis.

Methods

However, double-balloon endoscopes (DBEs) have dramatically changed this situation.

Results

The use of a DBE enables an endoscopic approach into the deeply situated small intestine, which has been difficult with a conventional endoscope. Therefore, ERCP for patients with a Roux-en-Y anastomosis has been attempted using a DBE, and good results have been reported.

Conclusion

The development of DBEs has created the possibility of performing ERCP for patients with Roux-en-Y reconstruction in whom an endoscopic approach has conventionally been believed to be difficult.     

Direct cholangioscopy combined with double-balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography

Double-balloon enteroscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is an effective endoscopic approach for pancreatobiliary disorders in patients with altered gastrointestinal anatomy. Endoscopic interventions via DBE in these postoperative settings remain difficult because of the lack of an elevator and the use of extra-long ERCP accessories. Here, we report the usefulness of direct cholangioscopy with an ultra-slim gastroscope during DBE-assisted ERCP. Three patients with choledocholithiasis in postoperative settings (two patients after Billroth II gastrojejunostomy and one patient after Roux-en-Y gastrojejunostomy) were treated. DBE was used to gain access to the papilla under carbon dioxide insufflation, and endoscopic sphincterotomy was performed with a conventional sphincterotome. For direct cholangioscopy, the enteroscope was exchanged for an ultra-slim gastroscope through an incision in the overtube, which was inserted directly into the bile duct. Direct cholangioscopy was used to extract retained bile duct stones in two cases and to confirm the complete clearance of stones in one case. Bile duct stones were eliminated with a 5-Fr basket catheter under direct visual control. No adverse events were noted in any of the three cases. Direct cholangioscopy with an ultra-slim gastroscope facilitates subsequent treatment within the bile duct. This procedure represents another potential option during DBE-assisted ERCP.     

Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography

AIM: To investigate the clinical outcome of double balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) in patients with altered gastrointestinal anatomy.METHODS: Between September 2006 and April 2011, 47 procedures of DB-ERCP were performed in 28 patients with a Roux-en-Y total gastrectomy (n = 11), Billroth II gastrectomy (n = 15), or Roux-en-Y anastomosis with hepaticojejunostomy (n = 2). DB-ERCP was performed using a short-type DBE combined with several technical innovations such as using an endoscope attachment, marking by submucosal tattooing, selectively applying contrast medium, and CO₂ insufflations.RESULTS: The papilla of Vater or hepaticojejunostomy site was reached in its entirety with a 96% success rate (45/47 procedures). There were no significant differences in the success rate of reaching the blind end with a DBE among Roux-en-Y total gastrectomy (96%), Billroth II reconstruction (94%), or pancreatoduodenectomy (100%), respectively (P = 0.91). The total successful rate of cannulation and contrast enhancement of the target bile duct in patients whom the blind end was reached with a DBE was 40/45 procedures (89%). Again, there were no significant differences in the success rate of cannulation and contrast enhancement of the target bile duct with a DBE among Roux-en-Y total gastrectomy (88 %), Billroth II reconstruction (89%), or pancreatoduodenectomy (100%), respectively (P = 0.67). Treatment was achieved in all 40 procedures (100%) in patients whom the contrast enhancement of the bile duct was successful. Common endoscopic treatments were endoscopic biliary drainage (24 procedures) and extraction of stones (14 procedures). Biliary drainage was done by placement of plastic stents. Stones extraction was done by lithotomy with the mechanical lithotripter followed by extraction with a basket or by the balloon pull-through method. Endoscopic sphincterotomy was performed in 14 procedures with a needle precutting knife using a guidewire. The mean total duration of the procedure was 93.6 ± 6.8 min and the mean time required to reach the papilla was 30.5 ± 3.7 min. The mean time required to reach the papilla tended to be shorter in Billroth II reconstruction (20.9 ± 5.8 min) than that in Roux-en-Y total gastrectomy (37.1 ± 4.9 min) but there was no significant difference (P = 0.09). A major complication occurred in one patient (3.5%); perforation of the long limb in a patient with Billroth II anastomosis.CONCLUSION: Short-type DBE combined with several technical innovations enabled us to perform ERCP in most patients with altered gastrointestinal anatomy.     

A retrospective analysis of the incidence of hemolysis in type and screen specimens from trauma patients

BACKGROUND:

Hemolysis of blood samples has been a concern in hospitals. Currently, residents and nurses have replaced traditional teams of skilled phlebotomists for both routine and ‘stat’ blood draws. Although this leads to a decreased operating cost for institutions, the lack of skill and experience leads to a higher percentage of hemolyzed specimens.

OBJECTIVE:

To determine the incidence of hemolyzed ‘type and screen’ blood samples at Staten Island University Hospital (SIUH) (New York, USA).

METHODS:

The study group comprised 615 consecutive trauma patients at SIUH between July 2006 and June 2007. Patients were treated according to the Advanced Trauma Life Support protocol. The primary survey for a trauma patient consists of ‘airway’, ‘breathing’ and ‘circulation’. The primary objective of ‘circulation’ is to establish vascular access and collect blood samples for analysis. The SIUH in-house laboratory provided all of the reports.

RESULTS:

Of the 615 samples collected, 155 samples (25.2%) were hemolyzed.

CONCLUSIONS:

The hemolysis rate of 25.2% for type and screen samples is higher than previously reported in the literature. The data suggest that the high rate of hemolysis in these trauma patients is due to the residents’ lack of experience and skills required to obtain an adequate blood draw.     

Patient satisfaction with medication for gastroesophageal reflux disease: a systematic review

BACKGROUND:

Patient satisfaction is increasingly regarded as an important aspect of measuring treatment success in individuals with gastroesophageal reflux disease (GERD).

OBJECTIVE:

To review how satisfied patients with GERD are with their medication, and to analyze the usefulness of patient satisfaction as a clinical end point by comparing it with symptom improvement.

METHODS:

Systematic searches of the PubMed and EMBASE databases identified clinical trials and patient surveys published between 1966 and 2009.

RESULTS:

Twelve trials reported that 56% to 100% of patients were ‘satisfied’ or ‘very satisfied’ with proton pump inhibitor (PPI) treatment for GERD. Patient satisfaction levels were higher for PPIs than other GERD medications in two trials. The sample-size-weighted average proportion of patients ‘satisfied’ with their PPI after four weeks of treatment in trials was 93% (95% CI 87% to 99%), with 73% (95% CI 62% to 83%) being ‘very satisfied’. In four surveys, the average proportion of patients ‘satisfied’ with their PPI treatment was 82% (95% CI 73% to 90%) and 62% (95% CI 48% to 75%) were ‘very satisfied’. Seven trials found a positive association between patient satisfaction and symptom improvement, and two surveys between satisfaction and improved health-related quality of life. Three trials found that continuous treatment yielded higher rates of satisfaction than on-demand therapy.

CONCLUSIONS:

More than one-half of patients were satisfied with their PPI medication in trials, and more patients were satisfied with PPIs than other medication types. An association between patient satisfaction and symptom resolution was found, suggesting that patient satisfaction is a useful end point for evaluating GERD treatment success.     

Feasibility of Cap-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Altered Gastrointestinal Anatomy

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal (GI) anatomy. We evaluated the feasibility of cap-assisted ERCP in patients with altered GI anatomy.

Methods

The outcome of ERCP procedures (n=136) was analyzed in 78 patients with Billroth II (B-II) gastrectomy (n=72), Roux-en-Y total gastrectomy (n=4), and hepaticoduodenostomy (n=2). The intubation rate for reaching the papilla of Vater (POV), deep biliary cannulation rate, therapeutic interventions and procedure-related complications were analyzed. All of the procedures were conducted using a cap-fitted forward-viewing endoscope.

Results

The rate of access to the POV was 97.1% (132/136). In cases with successful access, selective biliary cannulation was achieved in 98.5% (130/132) of the patients. The successful biliary cannulation rates were 100% (125/125) for B-II gastrectomy, 50% (2/4) for Roux-en-Y gastrectomy and 100% (3/3) for hepaticoduodenostomy. After selective biliary cannulation, therapeutic interventions, including stone extraction (n=57), sphincterotomy (n=54), stent placement (n=37), nasobiliary drainage (n=20), endoscopic papillary balloon dilatation (n=7) and mechanical lithotripsy (n=15), were performed successfully. The procedure-related complication rate was 8.8% (12/136), including immediate bleeding (5.9%, 8/136), pancreatitis (2.2%, 3/136), and perforation (0.7%, 1/136). There were no procedure-related deaths.

Conclusions

Cap-assisted ERCP is efficient and safe in patients with altered GI anatomy.     

A multicentre, observational study of sodium picosulfate and magnesium citrate as a precolonoscopy bowel preparation

BACKGROUND:

Sodium picosulfate with magnesium citrate (PSMC) has been available as a precolonoscopy bowel preparation in Canada since 2005. A high patient acceptability and preference appears to have contributed to its wide adoption across the country. Despite its frequent use, there are relatively few published studies of this product, especially reports regarding its use in routine clinical practice. Moreover, to date, there have been no Canadian studies of any kind.

OBJECTIVE:

To conduct a preliminary evaluation of PSMC by prospectively collecting data describing its effectiveness.

METHODS:

In the present multicentre, observational study, sequential patients used PSMC according to each institution’s standard colonoscopy protocol. Differences in bowel cleansing protocols included dose timing, fluid intake, dietary restrictions and administration of bisacodyl. During colonoscopy, preparation quality was rated separately for the right and left sides of the colon.

RESULTS:

Of the 613 patients entered, 606 were evaluable for efficacy. For the right and left colon, respectively, 93.0% and 96.2% of preparations were rated either ‘excellent’ or ‘adequate’. In the 334 patients who received adjunctive bisacodyl and the 272 patients who did not, the results were similar: for the right and left colon, 92.3% and 97.1% of those who did not, and 93.4% and 95.7% of those who did receive bisacodyl, respectively, were rated either ‘excellent’ or ‘adequate’.

CONCLUSIONS:

Despite the differences in bowel cleansing protocols used at each hospital (including an additional laxative), PSMC consistently yielded a high percentage of positive ratings for efficacy.     

Amiodarone-induced thyrotoxicosis: A review

BACKGROUND:

Amiodarone-induced thyrotoxicosis (AIT) develops in 3% of amiodarone-treated patients in North America. AIT is classified as type 1 or type 2. Type 1 AIT occurs in patients with underlying thyroid pathology such as autonomous nodular goiter or Graves’ disease. Type 2 AIT is a result of amiodarone causing a subacute thyroiditis with release of preformed thyroid hormones into the circulation.

OBJECTIVES:

To review the literature and present an overview of the differentiation between and management of type 1 and type 2 AIT.

METHODS:

PubMed, the Cumulative Index to Nursing and Allied Health Literature and Medscape searches of all available English language articles from 1983 to 2006 were performed. Search terms included ‘amiodarone-induced thyrotoxicosis’, ‘complications’, ‘management’, ‘treatment’ and ‘colour flow Dopper sonography’.

RESULTS:

There is evidence to suggest that to differentiate between type 1 and type 2 AIT, a careful history and physical examination should be performed to identify pre-existing thyroid disease. An iodine-131 uptake test and colour flow Doppler sonography should be performed. Patients with type 2 AIT should receive a trial of glucocorticoids, whereas those with type 1 should receive antithyroid therapy. For patients in whom the mechanism of the thyrotoxicosis is unclear, a combination of prednisone and antithyroid therapy may be considered.     

Antimicrobial resistance surveillance systems: Are potential biases taken into account?

BACKGROUND:

The validity of surveillance systems has rarely been a topic of investigation.

OBJECTIVE:

To assess potential biases that may influence the validity of contemporary antimicrobial-resistant (AMR) pathogen surveillance systems.

METHODS:

In 2008, reports of laboratory-based AMR surveillance systems were identified by searching Medline. Surveillance systems were appraised for six different types of bias. Scores were assigned as ‘2’ (good), ‘1’ (fair) and ‘0’ (poor) for each bias.

RESULTS:

A total of 22 surveillance systems were included. All studies used appropriate denominator data and case definitions (score of 2). Most (n=18) studies adequately protected against case ascertainment bias (score = 2), with three studies and one study scoring 1 and 0, respectively. Only four studies were deemed to be free of significant sampling bias (score = 2), with 17 studies classified as fair, and one as poor. Eight studies had explicitly removed duplicates (score = 2). Seven studies removed duplicates, but lacked adequate definitions (score = 1). Seven studies did not report duplicate removal (score = 0). Eighteen of the studies were considered to have good laboratory methodology, three had some concerns (score = 1), and one was considered to be poor (score = 0).

CONCLUSION:

Contemporary AMR surveillance systems commonly have methodological limitations with respect to sampling and multiple counting and, to a lesser degree, case ascertainment and laboratory practices. The potential for bias should be considered in the interpretation of surveillance data.     

Pleural mesothelioma surveillance: Validity of cases from a tumour registry

BACKGROUND:

Pleural mesothelioma is a rare tumour associated with exposure to asbestos fibres. Fewer than than one-quarter of cases registered in the Quebec Tumour Registry (QTR) have been compensated as work-related. While establishing a surveillance system, this led to questioning as to whether there has been over-registration of cases that are not authentic pleural mesotheliomas in the QTR.

OBJECTIVE:

To assess whether registered cases of pleural mesothelioma could be confirmed.

METHODS:

A medical chart review was designed to assess the proportion of mesothelioma cases newly registered in the QTR in 2001/2002 that could be confirmed. For each registered case, clinical, medical imaging and pathology information were sought and, occasionally, additional immunohistochemistry staining was obtained. Three specialists – a chest physician, a radiologist and a pathologist – reviewed the available information and material, coding each mesothelioma case as to degree of certainty of the mesothelioma diagnosis.

RESULTS:

The QTR reported 190 incident cases of mesothelioma (81% males) for the period. The specialists classified 81% of charts as ‘certain/probable’or ‘possible’ mesotheliomas, 8% as ‘unlikely to be a mesothelioma’ and 11% as ‘not a mesothelioma’. After excluding chart summaries of unsatisfactory quality, 87% to 88% of the charts were classified as ‘certain/probable’ or ‘possible’ mesotheliomas, and 9% to 11% were still considered ‘not a mesothelioma’.

CONCLUSION:

Tumour registry data are a valid source of information for mesothelioma surveillance. While there is some over-registration of mesothelioma cases in the QTR, a significant majority of registered cases appeared to be authentic. Over-registration cannot explain the greater proportion of cases that were not compensated.     

Characteristic Findings of Endoscopic Retrograde Cholangiopancreatography in Autoimmune Pancreatitis

Background/Aims

Diffuse or segmental irregular narrowing of the main pancreatic duct (MPD), as observed by endoscopic retrograde cholangiopancreatography (ERCP), is a characteristic feature of autoimmune pancreatitis (AIP).

Methods

ERCP findings were retrospectively examined in 40 patients with AIP in whom irregular narrowing of the MPD was detected near the orifice. The MPD opening sign was defined as the MPD within 1.5 cm from the orifice being maintained. The distal common bile duct (CBD) sign was defined as the distal CBD within 1.5 cm from the orifice being maintained. Endoscopic findings of a swollen major papilla and histological findings of specimens obtained from the major papilla were examined in 26 and 21 patients, respectively.

Results

The MPD opening sign was detected in 26 of the 40 patients (65%). The distal CBD sign was detected in 25 of the 32 patients (78%), which showed stenosis of the lower bile duct. The patients who showed the MPD opening sign frequently showed the distal CBD sign (p=0.018). Lymphoplasmacytic infiltration, but not dense fibrosis, was histologically detected in biopsy specimens obtained from the major papilla.

Conclusions

On ERCP, the MPD and CBD adjacent to the major papilla are frequently maintained in patients with AIP involving the pancreatic head. These signs are useful for diagnosing AIP on ERCP.     

Angiotensin converting enzyme-regulated,noncholinergic sympathoadrenal catecholamine release mediates the cardiovascular actions of human ‘new pressor protein’ related to coagulation beta-factor XIIa

BACKGROUND:

Human ‘new pressor protein’ (NPP), related to coagulation beta-factor XIIa (β-FXIIa), potently releases sympathoadrenal catecholamines in bioassay rats, with concurrent elevation of systolic and diastolic blood pressure (SBP/DBP) and heart rate (HR). Elevated plasma NPP/β-FXIIa levels in hypertensive anephric pediatric patients on hemodialysis associated with fluid status and blood pressure changes were previously reported, suggesting that NPP/β-FXIIa contributed to their hypertension.

OBJECTIVE:

To investigate the mechanism of action of NPP/β-FXIIa.

METHODS:

Hemodynamic and sympathoadrenal responses to NPP (20 µL plasma equivalent/rat) or coagulation β-FXIIa (300 ng/kg intravenously) were measured in rats treated with pentolinium (ganglion blockade [+GB]) and/or captopril (+CAP; angiotensin converting enzyme [ACE] inhibition).

RESULTS:

In controls not receiving GB or CAP (–GB–CAP), NPP/β-FXIIa raised plasma epinephrine (E) sixfold, SBP/DBP by 14/8 mmHg and HR by 15 beats/min. With blockade of the cholinergic pathway to the sympathoadrenal system (+GB), basal E, norepinephrine (NE), SBP, DBP and HR all dropped. However NPP/β-FXIIa remained capable of raising E 20-fold, NE fourfold, SBP/DBP by 27/11 mmHg and HR by 20 beats/min, suggesting that it acted through a ‘noncholinergic’ mechanism. With +CAP alone, NPP/β-FXIIa raised plasma E 18-fold, NE threefold, SBP/DBP by 29/8 mmHg and HR by 73 beats/min, implicating an ACE-regulated ‘peptidergic’ mechanism. Combining +GB with +CAP potentiated NPP/β-FXIIa actions further by raising E 50-fold, NE sevenfold, SBP/DBP by 55/20 mmHg and HR by 87 beats/min, strengthening the efficacy of this alternate pathway.

CONCLUSIONS:

The cardiovascular effects of NPP/β-FXIIa are considerably mediated by a noncholinergic (peptidergic) ACE-regulated mechanism for sympathoadrenal catecholamine release that is enhanced by +GB and/or +CAP. Under inflammatory procoagulant conditions, endogenously produced NPP/β-FXIIa may interfere with the antihypertensive effects of ACE inhibition therapy.     

Transitioning from 16-slice to 64-slice multidetector computed tomography for the assessment of coronary artery disease: Are we really making progress?

BACKGROUND:

Multidetector computed tomography (MDCT) has demonstrated promise in the noninvasive evaluation of coronary artery disease.

OBJECTIVE:

To systematically review the literature regarding the improved diagnostic accuracy of 64-slice MDCT.

METHODS:

An EMBASE, OVID, PubMed and Cochrane Library database search was performed using the key words ‘computed tomography’ matched with the terms ‘coronary artery’ or ‘coronary angiography’ to identify English-language articles examining MDCT cardiac imaging. Studies that compared 16-slice or 64-slice MDCT with catheter-based coronary angiography for the detection of coronary artery disease in non-revascularized, poststent and post-coronary artery bypass graft patients were included. Data were pooled to obtain a weighted sensitivity, specificity and diagnostic accuracy for MDCT. Negative and positive predictive values, and likelihood ratios were calculated based on sensitivity and specificity.

RESULTS:

Currently, 15 studies involving 1008 patients have examined the efficacy of 64-slice MDCT in the assessment of coronary artery stenosis (more than 50% luminal narrowing). In these studies, 64-slice MDCT has demonstrated a sensitivity (89%), specificity (96%) and diagnostic accuracy (95%) similar to that of 16-slice MDCT. However, 64-slice MDCT was able to assess 5% more coronary artery segments than 16-slice MDCT. In revascularized patients, MDCT can accurately assess both bypass graft occlusion and stenosis. The 64-slice MDCT is also capable of adequately detecting in-stent restenosis. Improvements in spatial and temporal resolution with 64-slice technology have decreased the occurrence of high attenuation and motion artefacts that plagued the previous generation of MDCT scanners.

CONCLUSION:

MDCT offers an accurate assessment of the coronary arteries, stented arteries and bypass grafts. The improved accuracy and safety of MDCT may reduce the need for catheter-based coronary angiography.     

The inconsistent nature of symptomatic pancreatico-jejunostomy anastomotic strictures

Background

Pancreatico-jejunostomy strictures (PJS) after pancreatiocoduodenectomy (PD) are poorly understood.

Methods

Patients treated for PJS were identified from all PDs (n =357) performed for all indications in our practice (2002 to 2009). Technical aspects of the original operation, as well as the presentation, management and outcomes of the resultant stricture were assessed.

Results

Seven patients developed a symptomatic PJS for an incidence of 2%. ‘Soft’ glands and small ducts (≤3 mm) were each present in 3/7 of the original anastomoses. Pancreatic fistula occurred in 6/7. The latency period to stricture presentation averaged 41 months. Diagnosis of PJS was confirmed by secretin magnetic resonance cholangio-pancreatography (MRCP). Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) was attempted – each unsuccessfully – in four patients. All patients required operative correction of their PJS by takedown/revision of the original pancreatico-jejunal anastomoses (PJA) (n =4) ± a modified Puestow (n =2). One patient''s PJS was completely inaccessible due to dense adhesions. Another patient''s stricture recurred and was successfully revised with a stricturoplasty. At a mean follow-up of 25 months, all are alive, but only 4/7 are pain free.

Conclusion

A symptomatic PJS appears to be independent of original pathological, glandular or technical features but pancreatic fistulae may contribute. Secretin MRCP is diagnostically useful, whereas ERCP has been proven to be therapeutically ineffective. Durable resolution of symptoms after surgical revision is unpredictable.     

Retrospective analysis of radiation exposure during endoscopic retrograde cholagiopancreatography: critical determinants

BACKGROUND:

Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) has a logarithmic relationship with radiation exposure, and carries a known risk of radiation exposure to patients and staff. Factors associated with prolonged fluoroscopy duration have not been well delineated.

OBJECTIVES:

To determine the specific patient, physician and procedural factors that affect fluoroscopy duration.

METHODS:

A retrospective analysis of 1071 ERCPs performed at two tertiary care referral hospitals over an 18-month period was conducted. Patient, physician and procedural variables were recorded at the time of the procedure.

RESULTS:

The mean duration of 969 fluoroscopy procedures was 4.66 min (95% CI 4.38 to 4.93). Multivariable analysis showed that the specific patient factors associated with prolonged fluoroscopy duration included age and diagnosis (both P<0.0001). The endoscopist was found to play an important role in the duration of fluoroscopy (ie, all endoscopists studied had a mean fluoroscopy duration significantly different from the reference endoscopist). In addition, the following procedural variables were found to be significant: number of procedures, basket use, biopsies, papillotomy (all P<0.0001) and use of a tritome (P=0.004). Mean fluoroscopy duration (in minutes) with 95% CIs for different diagnoses were as follows: common bile duct stones (n=443) 5.12 (3.05 to 4.07); benign biliary strictures (n=135) 3.94 (3.26 to 4.63); malignant biliary strictures (n=124) 5.82 (4.80 to 6.85); chronic pancreatitis (n=49) 4.53 (3.44 to 5.63); bile leak (n=26) 3.67 (2.23 to 5.09); and ampullary mass (n=11) 3.88 (1.28 to 6.48). When no pathology was found (n=195), the mean fluoroscopy time was 3.56 min (95% CI 3.05 to 4.07). Comparison using t tests determined that the only two diagnoses for which fluoroscopy duration was significantly different from the reference diagnosis of ‘no pathology found’ were common bile duct stones (P<0.0001) and malignant strictures (P<0.0001).

CONCLUSIONS:

Factors that significantly affected fluoroscopy duration included age, diagnosis, endoscopist, and the number and nature of procedures performed. Elderly patients with biliary stones or a malignant stricture were likely to require the longest duration of fluoroscopy. These identified variables may help endoscopists predict which procedures are associated with prolonged fluoroscopy duration so that appropriate precautions can be undertaken.     

Judicious use of transthoracic echocardiography in infective endocarditis screening

BACKGROUND:

Patients with a very low probability of infective endocarditis (IE) do not benefit from transthoracic echocardiography (TTE). Because the term ‘very low probability’ has not yet been defined, the present prospective study sought to identify the population with a ‘very low probability’.

METHODS:

TTE was performed between July 2005 and October 2006 in consecutive patients clinically suspected of having IE. Clinical parameters suggestive of IE and presence of infectious focus were recorded.

RESULTS:

Twenty-four (15.5%) of 155 patients studied had positive findings on TTE. Significant positive predictors were embolic events, intravenous drug use, the presence of a prosthetic valve, positive blood cultures and immunological phenomena. The significant negative predictor was confirmed infection sites other than endocardium. Sixty-three (40.6%) of 155 patients without positive predictors were found to have no vegetation. Thus, the collective absence of these predictors indicated a zero probability of TTE showing evidence of IE. A significant negative predictor was a definite etiology of infection other than IE. Only one in 76 patients was diagnosed with both IE and infection at another site.

CONCLUSIONS:

The absence of positive predictors or the presence of a negative predictor indicate a near-zero probability of IE being detected by TTE. Use of clinical parameters may avoid up to 41% of unnecessary TTE examinations, increasing the likelihood that such a diagnosis will be correct.     

Using a ‘no drain’ policy in 342 laparoscopic hepatectomies: which factors predict failure?

Objectives

The aim of this study was to identify factors that predict the failure of a ‘no drain’ policy in laparoscopic hepatectomy.

Methods

Surgical outcomes in 342 consecutive patients undergoing laparoscopic hepatectomy were reviewed. Drains were placed only for the following predefined criteria: (i) intraoperative bile leak; (ii) bilioenteric anastomosis, and (iii) increased risk for postoperative bleeding (‘no drain’ policy). Factors leading to need for postoperative drainage or reoperation were evaluated.

Results

Drains were placed in 44 patients (drainage group). Postoperatively, additional procedures were required in five (11.4%) patients in the drainage group and in 18 (6.0%) patients in the no-drainage group. Multivariate analysis suggested that blood loss of >400 ml [odds ratio (OR) 4.50, 95% confidence interval (CI) 1.41–14.2; P = 0.010] and preoperative chemotherapy (OR = 2.24, 95% CI 0.82–6.48; P = 0.120) may increase the risk for need for postoperative procedures when intraoperative prophylactic drainage is not used.

Conclusions

Prophylactic drainage during liver resection should be considered not only in the presence of uncontrollable bile leak or concern for postoperative bleeding risk, but also in patients who have undergone neoadjuvant chemotherapy and those in whom intraoperative blood loss is >400 ml. Otherwise, a ‘no drain’ policy is safe and would enhance the advantages of minimally invasive liver surgery.     

Childhood asthma surveillance using administrative data: Consistency between medical billing and hospital discharge diagnoses

BACKGROUND:

The absence of ongoing surveillance for childhood asthma in Montreal, Quebec, prompted the present investigation to assess the validity and practicality of administrative databases as a foundation for surveillance.

OBJECTIVE:

To explore the consistency between cases of asthma identified through physician billings compared with hospital discharge summaries.

METHODS:

Rates of service use for asthma in 1998 among Montreal children aged one, four and eight years were estimated. Correspondence between the two databases (physician billing claims versus medical billing claims) were explored during three different time periods: the first day of hospitalization, during the entire hospital stay, and during the hospital stay plus a one-day margin before admission and after discharge (‘hospital stay ± 1 day’).

RESULTS:

During 1998, 7.6% of Montreal children consulted a physician for asthma at least once and 0.6% were hospitalized with a principal diagnosis of asthma. There were no contemporaneous physician billings for asthma ‘in hospital’ during hospital stay ± 1 day for 22% of hospitalizations in which asthma was the primary diagnosis recorded at discharge. Conversely, among children with a physician billing for asthma ‘in hospital’, 66% were found to have a contemporaneous in-hospital record of a stay for ‘asthma’.

CONCLUSIONS:

Both databases of hospital and medical billing claims are useful for estimating rates of hospitalization for asthma in children. The potential for diagnostic imprecision is of concern, especially if capturing the exact number of uses is more important than establishing patterns of use.     

Physical therapy practice patterns in acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE:

The importance of the multidisciplinary approach to the management of chronic obstructive pulmonary disease is increasingly emphasized. The present study aimed to examine the current practice patterns of physical therapists involved in the management of patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease.

METHOD:

A self-administered postal survey was distributed to the rehabilitation departments of all Canadian acute care hospitals with more than 250 beds. The survey addressed patient assessment, treatment, education and discharge planning for intensive care unit and/or ward admissions.

RESULTS:

In total, 66% of hospitals (n=109) participated in the study, with provincial representation mainly from Ontario (n=36 [33%]) and Quebec (n=36 [33%]). Assessment and treatment techniques did not differ greatly between the ward and the intensive care unit. Assessment focused on patient observation, pulse oximetry and auscultation, and was reported to be used ‘always or frequently’ by 76%, 76% and 69% of respondents, respectively. Less than 18% of respondents used a measure of functional capacity, and health-related quality of life measures were rarely used. Treatment focused on ambulatory techniques, with 78% and 75% of respondents using mobility and transfer training ‘always or frequently’, respectively. The most common educational topics were breathing exercises and positioning, which were addressed by 68% and 67% of respondents, respectively.

CONCLUSION:

Patient assessment focused on physical impairments, with little use of measures of function or health-related quality of life, whereas treatment focused on mobility, with a lesser focus on airway clearance. Further study is needed to identify the factors that impact these practice patterns.