Procedural Variations in Performing Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction

Multiple variations exist in performing a primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction (STEMI) among various cardiologists. These variations range from the choice of peripheral access artery (radial vs femoral), performance or time of complete angiography including left ventriculography, and nonculprit vessel angiography before or after intervening on the culprit vessel. The reasons for such variations include emphasis on door-to-balloon time, knowledge of cardiac anatomy before proceeding with pPCI, physician expertise, and the level of comfort with radial approach. Over the last 2 decades, the field of interventional cardiology has changed dynamically leading to marked improvements in the clinical outcomes of patients with STEMI. This includes upstreaming of pPCI along with technical advancements ranging from radial artery catheterization to culprit lesion–guided approach. Increased comfort with use of radial access approach by cardiologists and availability of multiuse guide catheters would both reduce door-to-balloon time and enable complete coronary angiography before performance of percutaneous coronary intervention. There are no clear guidelines or consensus dictating on cardiologists a correct sequence of action during STEMI, or even suggesting what the preferred approach is. Lack of guidelines results in a substantive variation in methodology. This review aims to highlight and to better understand the variations in the current practice, and to emphasize the advantages as well as the disadvantages of each approach. It is also perhaps a call out for guidelines that direct cardiologists to the best practice.     

Evaluation of the introduction of a standardised protocol for the staging and follow-up of colorectal cancer on resection rates for liver metastases

INTRODUCTION

In 2004, an audit in our unit demonstrated wide variation in liver resection rates for colorectal cancer (CRC) metastases within the cancer network. Subsequently, a network-wide CT-based follow-up and referral policy was introduced for all patients. A second audit was performed to assess the impact of the guidelines on liver resection rates.

SUBJECTS AND METHODS

Analysis of prospective liver resection database between 1997 and 2004 and after the introduction of standardised guidelines between January 2005 and April 2008.

RESULTS

A total of 362 patients underwent liver resection for CRC metastases between 1997 and 2008, 237 prior to the introduction of the referral guidelines and 125 after. Liver resection rates according to referring hospital varied from 0.92 to 2.32 per 100,000 population before guidelines were introduced. After 2005, resection rates from the four district hospitals standardised (1.68–1.84 per 100,000 population), but the central unit rate (Sheffield) remained significantly higher (2.67 per 100,000 population). No significant difference in 1-year disease-free survival between patients from Sheffield and the outlying hospitals was found (P = 0.553).

CONCLUSIONS

Introduction of a referral protocol standardised resection rates from the four district hospitals, but these remain lower compared to the specialist centre. The wide-spread adoption of a policy to discuss all patients with liver metastases at an advanced disease multidisciplinary team meeting, in the presence of hepatobiliary specialists, may further increase resection rates across the UK.     

Neonatal septicemia in high risk babies in South-Eastern Nigeria

BACKGROUND: Septicemia is one of the major causes of morbidity and mortality in the neonatal period and it often has a rapid and fulminant course. AIMS: To determine the incidence, predisposing factors, clinical features, bacteriologic pattern and antibiotic sensitivity of neonatal septicemia. DESIGN: A prospective study was undertaken over a 1(1/2)-year period in the neonatal unit of Ebonyi State University Teaching Hospital, Abakaliki, Southeastern Nigeria. METHODS: All newborns (age 0-28 days) admitted with clinical features and/or risk factors suggestive of neonatal septicemia were selected and screened for septicemia. RESULTS: The study identified 33 septicemic neonates of the 138 neonates (23.9%) screened, 19/92 (20.7%) for inborns and 14/46 (30.4%) for outborns, representing an incidence of 7.98/1000 live births. Prolonged/obstructed labor, severe birth asphyxia, maternal pre-partum/peripartum pyrexia and home/traditional birth attendant deliveries were the main predisposing perinatal factors. Respiratory distress, fever and jaundice were the predominant presenting clinical findings. Gram-positive organisms were cultured from 18 neonates with Staphylococcus aureus accounting for 45.5% of the cases, while Escherichia coli was the predominant Gram-negative organism accounting for 18.2% of the cases. Group B streptococcus accounted for only one case and there was no case of Listeria monocytogenes. Early onset septicemia was commoner in in born while late onset septicemia was commoner with out born (chi2 = 10.45, P < 0.05). The bacterial isolates showed a high degree of in vitro antimicrobial resistance to conventional antibiotics and the antibiotic sensitivity pattern of the organisms indicated the use of ceftriaxone and gentamicin as initial therapy while awaiting culture results. The overall mortality rate was 26.7%. Early onset septicemia and concomitant meningitis were associated with high mortality. CONCLUSION: Neonatal septicemia is a major cause of morbidity and mortality in the study site. Most of the predisposing factors were due to poor obstetric care and unsterile delivery practices which could be avoided and prevented, and the causative organisms were different from those in the developed countries. There was appreciable resistance to commonly used antibiotics. Simple and sustainable interventions such as promotion of clean and timely deliveries, modern newborn care and specialized diagnostic facilities, hand washing and barrier nursing, and restriction of antibiotics may help reduce the burden of neonatal infection in the study community.     

Solitary extramedullary plasmacytoma of the bladder: a case report and literature

Plasmacytoma is a rare B-lymphocyte neoplastic disorder that usually presents as the generalized disease multiple myeloma. Less than 5% of the cases present as a solitary mass of monoclonal plasma cells in the bone or soft tissue. Although solitary extramedullary plasmacytoma (SEP) may arise in any organ, it rarely involves the urinary bladder. A 67-year-old male without a history of multiple myeloma presented with urinary frequency and nocturia; he was later diagnosed with SEP of the bladder. The patient was initially treated with a course of radiation therapy without symptomatic improvement; therefore a chemotherapy regimen consisting of lenalidomide and dexamethasone was subsequently given for six cycles. SEP usually carries a better prognosis and higher cure rate than solitary plasmacytoma of bone, as SEP is radiation sensitive. The role of adjuvant chemotherapy in the treatment of SEP that is resistant to radiation therapy is not clear, since most of the recommendations have been derived from the experience of head and neck SEP. The literature also lacks recommendations for choice of a chemotherapy regimen and surveillance of isolated bladder plasmacytoma. Here we present the first case of a radiation-resistant solitary plasmacytoma of the bladder that was successfully treated with lenalidomide and dexamethasone with successful clinical remission.     

A matched case–control study of bean intake and breast cancer risk in urbanized Nigerian women

Cancer Causes & Control - Bean intake has been associated with reduced risk of breast cancer, however; only a few studies considered molecular subtypes status and none in African women living...     

Colonoscopic yield of colorectal neoplasia in daily clinical practice

AIM： To assess the prevalence and location of advanced neoplasia in patients undergoing colonoscopy, and to compare the yield per indication. METHODS： In a multicenter colonoscopy survey （n = 18 hospitals） in the Amsterdam area （Northern Holland）, data of all colonoscopies performed during a three month period in 2005 were analyzed. The location and the histological features of all colonic neoplasia were recorded. The prevalence and the distribution of advanced colorectal neoplasia and differences in yield between indication clusters were evaluated. Advanced neoplasm was defined as adenoma 〉 10 mm in size, with 〉 25% villous features or with high-grade dysplasia or cancer. RESULTS： A total of 4623 eligible patients underwent a total colonoscopy. The prevalence of advanced neoplasia was 13%, with 281 （6%） adenocarcinomas and 342 （7%） advanced adenomas. Sixty-seven percent and 33% of advanced neoplasia were located in the distal and proximal colon, respectively. Of all patients with right-sided advanced neoplasia （n = 228）, 51% had a normal distal colon, whereas 27% had a synchronous distal adenoma. Ten percent of all colonoscopies were performed in asymptomatic patients, 7% of whom had advanced neoplasia. In the respective procedure indication clusters, the prevalence of rightsided advanced neoplasia ranged from 11%-57%. CONCLUSION： One out of every 7-8 colonoscopies yielded an advanced colorectal neoplasm. Colonoscopy is warranted for the evaluation of both symptomatic and asymptomatic patients.