Tubo-ovarian abscess in woman with an intrauterine device forgotten for 22 years

We report on a case of pelvic inflammatory disease in a 53 year old woman using an intrauterine contraceptive device (IUD) for a time period of 22 years. Clinical symptoms were fever up to 38°C and severe abdominal pain. Endoscopic findings were a tubo-ovarian abscess of the complete pelvis and a forgotten IUD with a smear positive for Escherichia coli and Candida albicans. The patient was treated with a surgical therapy and by antibiotic combination. Diagnosis was performed by histopathological examination.     

Nulliparous patients with small stature delivering at term have an increased risk of secondary cesarean section

Purpose  

To evaluate the obstetric outcome of pregnant patients with small stature (<5th percentile) with regard to the mode of delivery, maternal injuries, and neonatal parameters.     

Hysteroscopic findings in women with two and with more than two first-trimester miscarriages are not significantly different

The purpose of this study was to analyse hysteroscopic results in patients with recurrent miscarriages and to compare the frequency of uterine anomalies in women with a history of exactly two and with more than two consecutive miscarriages. A retrospective analysis of 206 patients undergoing hysteroscopy for repeated early pregnancy losses was performed at two university centres. Late miscarriages were excluded, terminations of pregnancy were not counted. Eighty-seven patients had suffered from exactly two early miscarriages and 119 from more than two. Both groups were comparable with respect to age at admission (32.95 ± 4.46 versus 34.06 ± 5.02 years) and at first miscarriage (30.43 ± 4.24 versus 29.08 ± 5.38 years). The prevalence of acquired (adhesions, polyps, fibroids) and congenital uterine anomalies (septate or bicornuate uterus, etc.) did not differ significantly (acquired: 28.7 versus 27.7%; congenital: 9.2 versus 16.8%). The rates of uterine anomalies did not differ significantly overall (36.8 versus 42.9%). In conclusion, uterine anomalies are frequently found in patients with two and with more than two early miscarriages. Due to the high rate of anomalies, their risk for adverse pregnancy outcome and a possible therapeutic approach, hysteroscopy might be a diagnostic option even after two early miscarriages.     

Errors and electronic prescribing: a controlled laboratory study to examine task complexity and interruption effects

Objective

To examine the effect of interruptions and task complexity on error rates when prescribing with computerized provider order entry (CPOE) systems, and to categorize the types of prescribing errors.

Design

Two within-subject factors: task complexity (complex vs simple) and interruption (interruption vs no interruption). Thirty-two hospital doctors used a CPOE system in a computer laboratory to complete four prescribing tasks, half of which were interrupted using a counterbalanced design.

Measurements

Types of prescribing errors, error rate, resumption lag, and task completion time.

Results

Errors in creating and updating electronic medication charts that were measured included failure to enter allergy information; selection of incorrect medication, dose, route, formulation, or frequency of administration from lists and drop-down menus presented by the CPOE system; incorrect entry or omission in entering administration times, start date, and free-text qualifiers; and omissions in prescribing and ceasing medications. When errors occurred, the error rates across the four prescribing tasks ranged from 0.5% (1 incorrect medication selected out of 192 chances for selecting a medication or error opportunities) to 16% (5 failures to enter allergy information out of 32 error opportunities). Any impact of interruptions on prescribing error rates and task completion times was not detected in our experiment. However, complex tasks took significantly longer to complete (F(1, 27)=137.9; p<0.001) and when execution was interrupted they required almost three times longer to resume compared to simple tasks (resumption lag complex=9.6 seconds, SD=5.6; resumption lag simple=3.4 seconds, SD=1.7; t(28)=6.186; p<0.001).

Conclusion

Most electronic prescribing errors found in this study could be described as slips in using the CPOE system to create and update electronic medication charts. Cues available within the user interface may have aided resumption of interrupted tasks making CPOE systems robust to some interruption effects. Further experiments are required to rule out any effect interruption might have on CPOE error rates.     

General practitioners' use of online evidence during consultations

BACKGROUND: Clinicians have many unanswered questions during clinical encounters which may impact on the quality and outcomes of decisions made. Provision of online evidence at the point of care is one strategy that provides clinicians with easy access to up-to-date evidence in clinical settings to support evidence-based decision-making. AIM: To determine if and when general practitioners use an online evidence system in routine clinical practice, the type of questions for which clinicians seek evidence and the extent to which the system provides clinically useful answers. DESIGN OF STUDY: A prospective cohort study which involved a 4-week clinical trial of Quick Clinical, an online evidence system specifically designed around the needs of general practitioners. SETTING: Two hundred and twenty-seven clinicians who had a computer with Internet access in their consulting rooms. METHODS: Computer logs and survey analysis. RESULTS: One hundred and ninety-three general practitioners used the online evidence system to conduct on average 8.7 searches/month. The majority of these (81%) were conducted from consulting rooms and carried out between 9a.m. and 7p.m. (83%). The most frequent searches conducted related to diagnosis (40%) and treatment (35%). 83% of clinicians believed that Quick Clinical (QC) had the potential to improve patient care, and one in four users reported direct experience of improvements in care. In 73% of queries with clinician feedback participants reported that they were able to find clinically useful information during their routine work. CONCLUSION: General practitioners will use an online evidence retrieval system in routine practice, and report that its use improves the quality of patient care.     

Ethical Guidance for Hard Decisions: A Critical Review of Early International COVID-19 ICU Triage Guidelines

Health Care Analysis - This article provides a critical comparative analysis of the substantive and procedural values and ethical concepts articulated in guidelines for allocating scarce resources...     

A portrait of germline mutation in Brazilian at-risk for hereditary breast cancer

Purpose

HER2?+?breast cancer (BC) is an aggressive subtype with high rates of brain metastases (BCBM). Two-thirds of HER2?+?BCBM demonstrate activation of the PI3K/mTOR pathway driving resistance to anti-HER2 therapy. This phase II study evaluated everolimus (E), a brain-permeable mTOR inhibitor, trastuzumab (T), and vinorelbine (V) in patients with HER2?+?BCBM.

Patients and methods

Eligible patients had progressive HER2?+?BCBM. The primary endpoint was intracranial response rate (RR); secondary objectives were CNS clinical benefit rate (CBR), extracranial RR, time to progression (TTP), overall survival (OS), and targeted sequencing of tumors from enrolled patients. A two-stage design distinguished intracranial RR of 5% versus 20%.

Results

32 patients were evaluable for toxicity, 26 for efficacy. Intracranial RR was 4% (1 PR). CNS CBR at 6 mos was 27%; at 3 mos 65%. Median intracranial TTP was 3.9 mos (95% CI 2.2–5). OS was 12.2 mos (95% CI 0.6–20.2). Grade 3–4 toxicities included neutropenia (41%), anemia (16%), and stomatitis (16%). Mutations in TP53 and PIK3CA were common in BCBM. Mutations in the PI3K/mTOR pathway were not associated with response. ERBB2 amplification was higher in BCBM compared to primary BC; ERBB2 amplification in the primary BC trended toward worse OS.

Conclusion

While intracranial RR to ETV was low in HER2?+?BCBM patients, one-third achieved CNS CBR; TTP/OS was similar to historical control. No new toxicity signals were observed. Further analysis of the genomic underpinnings of BCBM to identify tractable prognostic and/or predictive biomarkers is warranted. Clinical Trial: (NCT01305941).