News and Notices

Successfully delivering medical care and acquiring and disseminating the new knowledge that underpins clinical advance requires dealing with a number of both theoretical and organizational issues that may impede progress. Firstly, we have to move beyond the idea that biology and medicine are synonymous, and realize that tropes such as ‘bench to bedside’ or ‘translational’ frequently do not capture the way medical advance occurs. Medicine is more engineering than science, and the constraints imposed by society and economics, as well as historical models of working, may all delay improvements in healthcare delivery. Secondly, the generation of new ideas is influenced by the social organization and financial underpinning of science. Comparisons with other areas of science and technology suggest that medical science is dysfunctional and lacking in genuine innovation, particularly when cost is factored in as a key denominator. There are reasons to believe that matters are getting worse, and that the climate for revolutionary discovery is less supportive in both academia and industry than it was in the mid‐to‐late twentieth century. Thirdly, healthcare delivery is subject to a number of factors that limit cheap and effective care. These include payment systems that encourage unnecessary care, self‐interest by medical guilds and insurers, and regulators that seek to limit new ways of working. Finally, there is also a striking failure to study and understand medical competence, how we educate doctors and other clinicians, and how technology might help to reduce costs.     

The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres

OBJECTIVE: The burden on colonoscopy capacity is considerable and expected to increase further as colorectal cancer screening programmes gain a foothold in Europe. In this situation, it is particularly important to evaluate the quality of the service given. In this article we present our first year of experience with a quality network of endoscopy centres in Norway (Gastronet). MATERIAL AND METHODS: A questionnaire focusing on caecal intubation rate and pain was completed by the endoscopist (on site) and patient (on the day after the examination). Fourteen centres participated with registration of 7370 colonoscopies by 73 endoscopists. RESULTS: There was 100% endoscopist participation, 87% coverage of colonoscopies and an estimated 76% questionnaire coverage of the patient population. Overall caecal intubation rate was 91%, range 83% to 97% between centres (p < 0.001). Patients reporting severe pain during colonoscopy differed from 2 to 24% between centres (p < 0.001). Variations could only partly be explained by differences in procedure practice (sedation, CO2 insufflation). For individual endoscopists, improvement after feedback on performance was restricted to the group of endoscopists having contributed with only 50-99 registered colonoscopies. CONCLUSIONS: In quality assurance programmes we recommend a limited number of variables for registration in order to secure high compliance by endoscopists and patients. One year of experience with Gastronet disclosed a satisfactory overall caecal intubation rate, but considerable variation between centres in practice and ability to offer painless colonoscopy. This suggests a need for formal, centralized training of colonoscopists or the development of quality standards for colonoscopy training and practice.     

Extended-spectrum beta-lactamase-producing Enterobacteriaceae in different environments (humans, food, animal farms and sewage)

OBJECTIVES: This study aimed to determine the presence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae in different environments. METHODS: Clinical samples and stool samples from animal farms, sewage, human faecal carriers attending the emergency room and faecal carriers in the context of food-borne disease outbreaks were subcultured onto MacConkey agar supplemented with cefotaxime for the detection of ESBL-producing Enterobacteriaceae. Identification, susceptibility pattern and ERIC-PCR were used for clone delineation in each sample. Community consumption of antibiotics was also recorded. RESULTS: An ESBL-producing Enterobacteriaceae prevalence of 1.9% was observed in human infections. A cross-sectional survey of human faecal carriers in the community showed a general prevalence of 6.6% with a temporal distribution. High use of antibiotics in winter coincided with a lower prevalence in carriers. ESBL-producing Enterobacteriaceae were detected in the five samples of human sewage, in samples from 8 of 10 pig farms, 2 of 10 rabbit farms, from all 10 poultry farms and in 3 of 738 food samples studied. Faecal carriage of ESBL-producing Enterobacteriaceae was detected in samples from 19 of 61 food-borne outbreaks evaluated. All food-borne outbreaks were due to enteropathogens. The prevalence of carriers in these outbreaks ranged from 4.4% to 66.6%. CONCLUSIONS: This widespread occurrence of ESBL-producing Enterobacteriaceae suggests that the community could act as a reservoir and that food could contribute to the spread of these strains.     

Nifedipine versus ritodrine for suppression of preterm labor. Comparison of their efficacy and secondary effects

OBJECTIVES: To compare the efficacy of nifedipine and ritodrine in prolonging pregnancy beyond 48 h, 1 week and 36.0 weeks and to evaluate maternal side effects and adverse perinatal outcome. STUDY DESIGN: Non-blinded, randomized controlled trial. Eighty patients with singleton pregnancies admitted for preterm labor with intact membranes between 22 and 35 weeks of gestation were included in the study. Preterm labor was defined as the persistence of at least two symptomatic uterine contractions within a 10 min period during 60 min after admission and despite bed rest. RESULTS: Forty women received oral nifedipine and forty intravenous ritodrine. Two patients, one from each group, were excluded because of loss to follow-up after discharge. Therefore, 39 women in the nifedipine and the ritodrine groups, respectively, were evaluable for the final analysis. Baseline characteristics were comparable in both groups. The percentage of initial response, the speed of onset of action and the rate of successful treatment within 48 h were significantly better in the ritodrine group. However, prolongation of pregnancy beyond 7 days and 36 weeks of pregnancy was similar with a significantly lower rate of side effects in the nifedipine group. CONCLUSIONS: In this small trial, ritodrine provided more effective tocolysis within the first 48 h than nifedipine at the doses used in this study, although with a significantly higher rate of side effects.     

La práctica de “descansos” en el uso de anticoncepción hormonal oral en España. Resultados de cuatro encuestas de ámbito nacional

Objective

To investigate whether Spanish women taking oral contraceptives have pill-free intervals.

Subjects and method

Four national surveys were performed at 2-yearly intervals between 1997 and2003. The number of women aged between 15 and 49 years who were surveyed ranged from 2,076 in 1997 to 2,218 in 2001. Information was obtained from personal interviews.

Results

In 1997, 42% of pill users reported pillfree intervals compared with 37% in 2003. More than 60% of these women reported that these intervals were recommended by a doctor.

Conclusions

A training strategy should be devised, aimed at both health professionals and users of hormonal contraceptives, that would eradicate this incorrect practice.     

Oral infectious diseases: a potential risk factor for HIV virus recrudescence?

As the highly active antiretroviral therapy (HAART) has transitioned human immunodeficiency virus (HIV) infection into a 'chronic disease' management strategy, there is growing evidence that infection with non-HIV pathogens in HIV+ patients may have important public health implications in undermining HAART success and acquired immunodeficiency syndrome progression. Several bacterial and host cell products during infections with non-HIV pathogens have shown the capacity to regulate HIV replication in latently infected cells. A high prevalence of oral infections caused by bacteria, viruses and fungi has been described in HIV+ patients, including periodontal disease. The oral cavity appears to be a site of HIV pathogenesis and potential reservoir for the disease as HIV RNA and DNA forms are present in saliva as well as in gingival crevicular fluid, and oral epithelial cells are susceptible to either cell free or cell-associated HIV infection. The clinical and biological bases of potential associations between chronic oral inflammatory disorders, such as periodontal disease, and exacerbation of HIV viraemia have received little attention. This review attempts to evaluate the current understanding of HIV reactivation as a result of co-infection and/or inflammation induced by non-HIV pathogens in HIV-infected patients, and presents a hypothetic model about the potential role of periodontitis as a global oral infection that potentially contributes to HIV recrudescence.     

La cirugía transanal como herramienta en la dehiscencia de la anastomosis colorrectal

The treatment of anastomotic leakage after oncological surgery for rectal cancer is a surgical challenge. The goal of this study is to show how transanal surgery combined with the abdominal approach is a very useful tool to decide on individualized treatment depending on the degree of dehiscence and to assist us in its local management. We present three cases of patients with colorectal anastomotic dehiscence. In two, we demonstrate the treatment of acute colorectal leakage and how transanal surgery allows us to confirm its viability and rule out any underlying ischemia. Furthermore, it facilitates good drainage of the adjacent collection as well as the placement of a vacuum system, if necessary, and its subsequent replacements. The last case is a delayed dehiscence with chronic presacral sinus, and its treatment by transanal access for fenestration.     

Surgically Managed Ovarian Masses at the Royal Children’s Hospital,Melbourne –19 Year Experience

Background/PurposeTo describe the clinicopathological characteristics and management of surgically removed ovarian masses at the Royal Children’s Hospital, Melbourne from 1993 to 2012.MethodsMedical records were reviewed retrospectively. Data regarding clinical findings, imaging and surgical management were evaluated.ResultsThere were 266 ovarian masses found in 258 surgeries (eight had bilateral masses). Most were benign (246/266, 92.5%), 2.3% (6/266) were borderline, and 5.3% (14/266) were malignant. The most common presenting symptom was abdominal pain for benign masses (169/246, 68.7%), and a palpable mass for borderline and malignant masses (12/20, 60.0%).Sensitivity and specificity of ultrasound for detection of malignancy was 64.7% and 52.9% respectively. Ovarian torsion occurred in 22.1% (n = 57), none with malignancy, with seven cases diagnosed under one year of age. Sensitivity and specificity of ultrasound for ovarian torsion was 22.0% and 91.9%, respectively.The proportion undergoing ovarian cystectomy rather than oophorectomy has increased from 56.3% during 1993-1997 to 93.8% during 2008-2012 (p < 0.005). Ovarian torsion was managed with ovarian conservation in 82.6% of cases between 2008-2012.ConclusionThe majority of pediatric and adolescent ovarian masses were benign. Sensitivity of ultrasound was fair for detection of malignancy, and poor for ovarian torsion. Conservative surgeries are increasingly common.Level of EvidenceLevel IV – case series with no comparison groupType of StudyRetrospective Study