Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review

AIM

To assess the published evidence on the endovascular treatment of non-variceal upper gastrointestinal haemorrhage.

MATERIALS AND METHODS

An Ovid Medline search of published literature was performed (1966-2009). Non-English literature, experimental studies, variceal haemorrhage and case series with fewer than five patients were excluded. The search yielded 1888 abstracts. Thirty-five articles were selected for final analysis.

RESULTS

The total number of pooled patients was 927. The technical and clinical success of embolization ranged from 52-100% and 44-100%, respectively. The pooled mean technical/clinical success rate in primary upper gastrointestinal tract haemorrhage (PUGITH) only, trans-papillary haemorrhage (TPH) only, and mixed studies were 84%/67%, 93%/89%, and 93%/64%, respectively. Clinical outcome was adversely affected by multi-organ failure, shock, corticosteroids, transfusion, and coagulopathy. The anatomical source of haemorrhage and procedural variables did not affect the outcome. A successful embolization improved survival by 13.3 times. Retrospective comparison with surgery demonstrated equivalent mortality and clinical success, despite embolization being applied to a more elderly population with a higher prevalence of co-morbidities.

CONCLUSIONS

Embolization is effective in this very difficult cohort of patients with outcomes similar to surgery.

Futile and inappropriate prescribing: an assessment of the issue in a series of patients admitted to a specialist palliative care unit

Focal points

Primary bronchial epithelial cell culture from explanted cystic fibrosis lungs

Lung disease is responsible for more than 95% of morbidity and mortality in cystic fibrosis. The exact pathogenesis of cystic fibrosis lung disease remains poorly understood. Experimental models are therefore vital for use in research. Animal models and immortalized cell lines both have inherent limitations. Explanted lungs removed from people with cystic fibrosis at the time of transplantation represent a potentially valuable but technically and logistically challenging source of primary cystic fibrosis bronchial epithelial cells. In this study, pieces of segmental bronchus from explanted lungs were treated with patient-specific antimicrobials prior to isolation of bronchial epithelial cells. Cultured cells were characterized by their morphology under light microscopy, cytokeratin and hematoxylin-eosin staining, and electrophysiological profile. Primary bronchial epithelial cells were successfully cultured from 15 of 22 patients attempted. The cells exhibited typical epithelial morphology, staining for cytokeratin, lack of responsiveness to forskolin treatment, and remained viable after storage in liquid nitrogen. Seven unsuccessful cultures failed due to early infection with bacteria known to colonize the airways pretransplant. The results show that primary bronchial epithelial cell culture is possible from explanted cystic fibrosis lungs. This provides an important cellular model to elucidate the pathogenic mechanisms in cystic fibrosis lung disease and to investigate potential therapeutic targets.

European Academy of Paediatrics Research in Ambulatory Setting network (EAPRASnet): a multi-national general paediatric research network for better child health

BACKGROUND

In 2008, the European Academy of Paediatrics launched a paediatric-based research network - EAPRASnet (European Academy of Paediatrics Research in Ambulatory Setting network). The network has recruited primary care and general paediatricians from European and Mediterranean countries.

METHODS

Every paediatrician joining the network has been asked to complete a recruitment survey. The aims of the survey were to characterize paediatrician's demographics, practice arrangements and patient's demographics, to define main incentives for research, and to learn what paediatricians view as unsolved issues that need to be studied.

RESULTS

A total of 156 paediatricians from 19 countries were recruited with 144 completing the questionnaire (92%). Majority of respondents (89%) were general paediatricians for more than half of their time. Practice arrangement of 47% of paediatricians was solo practice, with 40% in group practice. Electronic medical records were being used by 72% of respondents. Over 70% of the paediatricians had more than 1000 patients under their clinical care, and patients younger than 6 years old contributed nearly half of the patient population. Areas of most interest for research were: quality of care indicators, communication with parents, obesity, attention deficit hyperactivity disorder and effective well child care. Main incentives for participation in a research project were interest in the topic (81%) and effort to improve quality of care (71%). Lack of time was the leading reported obstacle for research activity (72%). EAPRASnet is growing, and the network's structure, operation and funding are described. Methods for joining the network and the process of study development are presented.

CONCLUSION

A core group of EAP general paediatricians are committed to research in their practices. The information gathered will serve for future planning of research projects in the EAPRASnet to harmonize and optimize the care given to children in the primary care setting in Europe.

Are GPs under-investigating older patients presenting with symptoms of ovarian cancer? Observational study using General Practice Research Database

BACKGROUND

Recent studies suggest that older patients in the United Kingdom are not benefiting as much from improvements in cancer treatments as their younger counterparts. We investigate whether this might be partly due to differential referral rates using ovarian cancer as an example.

METHODS

From the General Practice Research Database (GPRD), we identified all women aged 40-80 years on 1 June 2002 with a Read code for ovarian cancer between 1 June 2002 and 31 May 2007. Using these records, we compared the GPRD incidence of ovarian cancer with rates compiled from the UK cancer registries and investigated the relationship between age and coded investigations for suspected ovarian cancer.

RESULTS

The GPRD rates peaked earlier, at 70-74, and were lower than registry rates for nearly all ages particularly for patients over 59. The proportion investigated or referred by the GP decreased significantly with age and delays between first coded symptom and investigation showed a U-shaped distribution by age.

CONCLUSIONS

GPs appear to be less likely to recognise and to refer patients presenting with ovarian cancer as they get older. If our findings extend to other cancers, lack of or delays in referral to secondary care may partly explain poor UK cancer mortality rates of older people.

Febrile neutropaenia in cancer patients

BACKGROUNDS

Febrile neutropaenia is a common complication of chemotherapy in cancer patients. Empirical antibiotic regimes are based on the epidemiological characteristics of bacterial isolates globally and locally.

METHOD

This study retrospectively reviewed all cases of febrile neutropaenia in patients with confirmed cancer admitted at the University Hospital of the West Indies in the four-year period between, January 1, 2003 and December 31, 2006 and who received chemotherapy. Cases were identified from blood culture records and hospital charts which were reviewed to determine the aetiological agents causing bacteraemia, their antimicrobial susceptibilities and clinicalfeatures. These cases were compared with non-neutropaenic cancer patients admitted with fever.

RESULTS

A total of 197 febrile episodes in cancer patients were reviewed. Thirty-seven per cent had febrile neutropaenia while 62% were non-neutropaenic. Acute myeloid leukaemia was the most common haematological malignancy and the most common solid tumour was breast cancer. Twenty-six per cent of patients had a positive blood culture. In febrile neutropaenic patients, Escherichia coli was the most common organism isolated followed by coagulase-negative staphylococci while in non-neutropaenic patients, coagulase-negative staphylococci was most common. Acinetobacter infections was prominent in non-neutropaenic patients but absent in neutropaenic patients. More than one organism was cultured in 9 neutropaenic and 18 non-neutropaenic patients. Mortality was 10.8% in neutropaenic and 24.4% in non-neutropaenic patients.

CONCLUSION

Gram-negative organisms are the predominant isolates in febrile neutropaenic episodes in this cohort of patients. Non-neutropaenic patients had an increased mortality with an increase in Acinetobacter infections and multiple isolates.

A survey of physicians' knowledge and attitudes regarding antimicrobial resistance and antibiotic prescribing practices at the University Hospital of the West Indies

OBJECTIVE

To identify physicians' knowledge and attitudes regarding antimicrobial resistance and antibiotic prescribing practices at the University Hospital of the West Indies (UHWI).

METHODS

A cross-sectional survey of physicians at the UHWI was conducted between September 2008 and April 2009 using a 28-item, self-administered questionnaire. Eligible physicians from several specialities were identified from departmental rotas.

RESULTS

A total of 174 physicians completed the questionnaire, a response rate of 73%. Most physicians considered antibiotic resistance to be an extremely important global problem (55%) but less significant nationally (35%). Factors identified as important in producing resistance included widespread use of antibiotics (91%), inappropriate empiric choices (79%) and use of broad-spectrum agents (70%). Hand-washing was not considered to be important in reducing resistance. Useful interventions included access to current information on local resistance patterns (90%), institutional specific antibiotic guidelines (89%) and educational programmes (89%). Antibiotic cycling (40%) and restriction (35%) were regarded as less helpful. Knowledge of resistance-prone antibiotics and specific resistant organisms at the UHWI was poor, except for methicillin-resistant Staphylococcus aureus (MRSA). Empiric therapy for common infections was appropriate in most cases, and antibiotic choices were guided by availability of drugs (89%) and patient factors such as renal disease or allergy (80%). Only 45% of physicians would de-escalate to a narrow-spectrum antibiotic guided by a microbiology report, and consultants were more likely to de-escalate therapy than junior staff (p = 0.002).

CONCLUSIONS

Although physicians were aware of the problem of resistance to antibiotics and the contributory factors, their practice did not reflect measures to reduce it. Continuing educational programmes and institution-specific antibiotic prescribing guidelines are needed.

The epidemiology of fungaemia at the University Hospital of the West Indies, Kingston, Jamaica

OBJECTIVES

To determine the epidemiology of fungaemia at the University Hospital of the West Indies (UHWI) as well as the incidence of fungaemia at the UHWI over a four-year period.

METHODS

A cross-sectional survey was conducted over a one-year period (2002). The RapID Yeast Plus Panel Identification kit was used to identify the yeasts found in blood while morphology and dimorphism were used to identify the single mold isolated, Histoplasma capsulatum. In addition, a retrospective review of the number of cases of fungaemia at the UHWI over a four-year period from 1998 was done using the laboratory and clinical records in order to determine the incidence over this period.

RESULTS

The study showed that Yeast not C albicans (YNCA) accounted for 47% of the isolates while Candida albicans accounted for 29%. Of the YNCA species, Candida tropicalis was the most common (75%), followed by C pseudotropicalis (12.5%) and C glabrata (12.5%). Cryptococcus sp accounted for 18% of all fungal isolates and there was one isolate (6%) of Histoplasma capsulatum. The medical wards had the most isolates (47%), followed by surgery (29%) and the Intensive Care Unit (ICU) [24%]. While the rate at which fungi were isolated from the blood remained constant over 1998, 1999 and 2001, this doubled in 2002 from 0.26% to 0.5%.

CONCLUSION

Although the incidence of fungaemia at the UHWI has remained relatively low, there was a marked increase in the last year of the study (2002) with a doubling of the number of positive fungal cultures. Candida species account for most cases of fungaemia at the UHWI. However non-albicans Candida spp were more commonly isolated than C albicans, a trend that needs to be monitored because of its implications for therapy.

Effect of in vitro maturation of mouse oocytes on the health and lifespan of adult offspring

BACKGROUND

In vitro maturation of oocytes can, in some circumstances, provide an alternative approach to gonadotrophin-induced maturation in clinical settings. However, the consequences of these protocols on the long-term health of offspring are unknown. Here, the long-term health status and lifespans of offspring produced by in vitro maturation of mouse oocytes was compared with that of oocytes induced to mature in vivo using gonadotrophin treatment.

METHODS

Mouse oocytes were matured in vitro using both an established optimized system and in the absence of amino acids to produce a suboptimal condition for maturation. Oocytes induced to mature in vivo with gonadotrophins constituted the control group. All metaphase II oocytes were fertilized in vitro and transferred at the 2-cell stage to the oviducts of pseudo-pregnant foster mothers for development to term. Offspring were subjected to a wide variety of physiological and behavioral tests for the first year of life and natural lifespan determined.

RESULTS

There was no difference among the groups in lifespan or in most of the physiological and behavioral analyses. However, the pulse rate and cardiac output were slightly, but significantly, reduced in the optimized in vitro matured group compared with the in vivo matured group (P = 0.0119 and P = 0.0197, respectively). Surprisingly, these decreases were largely abrogated in the in vitro group matured without amino acids.

CONCLUSIONS

Evidence presented here using a mouse model suggests that the in vitro maturation of oocytes has minimal effects on the long-term health of offspring. However, a finding of slight reductions in pulse rate and cardiac output may focus future clinical attention.

Toward a PCR-independent molecular diagnosis of veterinary and medically relevant pathogenic organisms

Bloodstream infections caused by bacteria and fungi are a major problem worldwide. These bloodstream infections can affect both people and livestock, placing a significant burden upon developed and developing economies. In this paper we describe a multiplexed testing format, which can identify a range of bacteria and fungi within a single blood sample. Key to this technique is the specificity and sensitivity of the nucleotide probes that capture the sample. The sensitivity and specificity of the probes may allow detection of disease-causing microorganisms without the need for polymerase chain reaction amplification if the dynamics of probe binding can be observed in real time.