Urban legends series: oral candidosis

Candida species (spp) are commensal yeast that can only instigate oral infection (oral candidosis – OC) when there is an underlying predisposing condition in the host. We investigated four controversial topics on OC: (i) How can a microbiological determination of OC be made as Candida spp. are commensal yeasts and not all of them form hyphae or pseudohyphae during infection? (ii) Is median rhomboid glossitis (MRG) a manifestation of candidal infection? (iii) Can candidal infection cause palate papillary hyperplasia (PPH)? (iv) What is the best therapeutic treatment for denture‐associated erythematous stomatitis (DAES)? Results from extensive literature searches, including a systematic review, suggested the following: (i) the diagnosis of OC merely on the basis of the presence of yeasts is an oversimplification of a complex process. No convincing evidence of a single test or method better able to discriminate the transition from candidal saprophytism to pathogenicity has been reported in the literature; (ii–iii) conclusive evidence of a direct aetiopathogenic relationship between MRG and PPH and candidal infection has not been found; and (iv) only limited evidence is available for any DAES treatment, thus making it impossible to make strong therapeutic recommendations.     

Challenging boundaries: an enhanced recovery programme for radical cystectomy

Introduction

The implementation of enhanced recovery programmes (ERPs) in colorectal surgery has seen improvements in the length of inpatient stay with no increase in complications. We investigated the role of ERP in radical cystectomy at our institution.

Methods

Prospective data were collected from 26 consecutive patients prior to the introduction of the ERP and 51 patients who underwent open radical cystectomy within an ERP. Individuals in the ERP cohort did not receive bowel preparation or nasogastric drainage but received preoperative carbohydrate drinks, perioperative epidural analgesia and immediate mobilisation on day 1. Primary outcome measures included duration of intensive care unit (ICU) stay and length of hospital stay. Secondary outcome measures included the time to the passage of flatus and faeces, and time to mobilisation. Other measures that were analysed included operation time and complications.

Results

Baseline characteristics for both groups were similar. The median length of hospital stay fell from 11.5 days to 10.4 days and the mean ICU stay dropped from 2.4 days to 1.0 days (p=0.01). Time to removal of nasogastric tube, and time to passage of flatus and faeces were significantly shorter in the ERP group, as was the time to full oral diet. Clavien complication rates and 30-day mortality rates were similar in both groups. There were no readmissions.

Conclusions

ERP in radical cystectomy is safe and not associated with any increase in complications or readmissions. It is associated with reductions in ICU stay, and could also reduce length of hospital stay and duration of postoperative ileus.     

Audiovisual distraction reduces pain perception during aural microsuction

Introduction

Aural microsuction is a common ear, nose and throat procedure used in the outpatient setting. Some patients, however, find it difficult to tolerate owing to discomfort, pain or noise. This study evaluated the effect of audiovisual distraction on patients’ pain perception and overall satisfaction.

Methods

A prospective study was conducted for patients attending our aural care clinic requiring aural toileting of bilateral mastoid cavities over a three-month period. All microsuction was performed by a single clinical nurse specialist. Any patients with active infection were excluded. For each patient, during microsuction of one ear, they watched the procedure on a television screen while for the other ear they did not view the procedure. All patients received the same real time explanations during microsuction of both ears. After the procedure, each patient completed a visual analogue scale (VAS) to rate the pain they experienced for each ear, with and without access to the television screen. They also documented their preference and reasons why.

Results

A total of 37 patients were included in the study. The mean pain score for patients viewing the procedure was 2.43 compared with a mean of 3.48 for patients with no television view. This difference in patients’ pain perception was statistically lower in the group who observed the procedure on the television (p=0.003), consistent with the majority of patients reporting a preference to viewing their procedure (65%).

Conclusions

Audiovisual distraction significantly lowered patients’ VAS pain scores during aural microsuction. This simple intervention can therefore reduce patients’ perceived pain and help improve acceptance of this procedure.     

Simplified treatment of acute staphylococcal osteomyelitis of childhood. The Finnish Study Group

OBJECTIVE: Recommendations on treatment of acute staphylococcal osteomyelitis of children, based mostly on retrospective analyses, comprise surgical drainage, up to 6 weeks fo antimicrobials guided by the erythrocyte sedimentation rate, and the possibility of switching to the oral route only if monitoring of serum bactericidal titer is guaranteed. A prospective study was conducted to test whether the treatment could be simplified. DESIGN: Fifty pediatric cases of acute Staphylococcus aureus osteomyelitis were randomized to receive 150 mg/kg/day of cephradine divided in four doses, or 40 mg/kg/day in four doses of clindamycin. The treatment was initiated intravenously, but switched to oral administration mostly within 4 days, using the same doses. The peak antimicrobial serum inhibitory titer or bactericidal titer was not measured. The course of illness was monitored by blood leukocytes, erythrocyte sedimentation rate, and serum C-reactive protein. The follow-up was extended to 1 year posthospitalization. SETTING: Eight tertiary pediatric-orthopedic hospitals in Finland. MAIN OUTCOME MEASURE: Full recovery and remaining healthy at least 12 months from hospital discharge. RESULTS: The lower and upper extremities were affected in 72% and 8% of patients, respectively. No surgery at all or needle aspiration only was performed in 62% and drilling in 38%. C-reactive protein and the sedimentation rate normalized within 9 days and 29 days, respectively. X-ray changes developed in 68% but had no prognostic significance. The mean hospitalization time was 11 days, and the total duration of antimicrobials was 23 days. No failure has occurred nor have long-term sequelae been observed in any patient. CONCLUSIONS: Treatment of pediatric acute staphylococcal osteomyelitis can be simplified and costs reduced by keeping surgery at a minimum, shortening hospitalization and the course of antimicrobials, switching quickly to the oral route, and not monitoring serum bactericidal activity.