Aspiration in the context of upper gastrointestinal endoscopy

BACKGROUND

Pulmonary aspiration is a life-threatening complication of upper gastrointestinal endoscopy, the incidence of which has not been determined. Endoscopy-related aspiration has not been studied in procedures in which patients swallow a radiolabelled potential aspirate immediately before endoscopy and undergo nuclear scanning postprocedure.

METHODS

A pilot study was conducted in which 200 MBq of nonabsorbable technetium-99m phytate in 10 mL of water was administered orally to 50 patients who were about to undergo endoscopy. Gamma camera images were obtained to ensure that there had been no aspiration before endoscopy. After endoscopy, a repeat scan was performed. Fluid aspirated through the endoscope was also collected and analyzed for radioactivity using a hand-held radiation monitor.

RESULTS

No evidence of pulmonary aspiration was found in any of the patients studied. The mean estimated percentage of the initially administered radioactivity aspirated through the endoscope was 2.66% (range 0% to 10.3%).

CONCLUSION

The present pilot study confirms earlier observations that clinically significant aspiration in the context of upper gastrointestinal endoscopy is uncommon. The incidence of aspiration may, however, be different in acutely bleeding patients undergoing endoscopy. For logistic reasons, this group could not be studied.

Behavioral flexibility impairment with negative feedback in refractory temporal lobe epileptic patients with unilateral amygdala and hippocampal resection

INTRODUCTION

Patients with amygdala dysfunction generally have behavioral impairment. Temporal lobe surgery might be a model of study of unilateral amygdala resection. The objective of this study was to evaluate behavioral flexibility in epileptic patients who undergo amygdala resection for epilepsy surgery and evaluate its relationship with their neuropsychiatric symptoms.

MATERIAL AND METHODS

Ten epileptic patients who underwent amygdala and hippocampal resection (6 left and 4 right) matched by age and educational level with 10 healthy controls were tested with an extensive neuropsychological and neuropsychiatric battery. Psychiatric symptomatology was measured with the positive and negative syndrome scale (PANSS) and the Beck depression inventory. To assess behavioral flexibility the emotion-related visual reversal-learning task (O'Doherty et al., 2001) and the gambling task (Bechara et al., 1994) were used.

RESULTS

Patient's mean scores were: Beck: 8 +/- 1.5; PANSS positive: 10 +/- 1.3, and negative: 14.4 +/- 2.2; intellectual quotient (IQ): 101.4 +/- 6.3; category number in Wisconsin card sorting test: 4.6 +/- 2.4. The emotion-related visual reversal-learning task showed significance differences in the number of reversion: healthy controls: 9.3; epileptic patients: 4.23 (p < 0.001); in the number of trials to the first reversion: healthy controls: 5; epileptic patients: 23.42 (p < 0.05). There was no correlation between reversion and depression, PANSS and IQ.

CONCLUSIONS

Patients with epilepsy who undergo unilateral hippocampal and amygdala resection appear to have alterations in the reversion capacity with an emotional component that would explain the lack of behavior flexibility that they sometimes have and that are not related with either the isolated presence of executive alterations or low intellectual quotient.

Obesity and the pulmonologist

Obese children have more respiratory symptoms than their normal weight peers and respiratory related pathology increases with increasing weight. Some will need specialist assessment (box 1). Obesity produces mechanical effects on respiratory system performance. Breathlessness, wheeze, and cough are not related to increased airway responsiveness and may respond more to weight loss than bronchodilator therapy. A significant number of obese children have signs and symptoms of obstructive sleep apnoea largely related to the effect of obesity on upper airway dimensions. It seems likely that unless action is taken soon, increasing numbers of children will experience preventable respiratory morbidity as a result of nutritional obesity.

Antibiotic use is associated with resistance of environmental organisms in a teaching hospital

An intensive care unit (ICU), acute stroke unit (ASU) and medical day bed unit (MDBU) underwent a standardized four-month environmental screening programme. The aim was to examine environmental organisms from these wards and compare bacterial resistances in association with antimicrobial usage. Hand-touch and other sites were screened using commercial dip-slides, and staff were asked to provide fingertip cultures. Patient blood isolates were retained throughout the study. Organisms were quantitatively and qualitatively assessed including antimicrobial susceptibility testing. Antibiotic consumption data in defined daily doses/1000 patient-days were obtained for each unit for the previous year. Two hundred and seventy-six staphylococci and 67 Gram-negative bacilli were recovered. Antibiotic resistance was significantly associated with individual wards for staphylococci (P<0.0001) and coliforms (P=0.04), and trends were also demonstrated for other Gram-negative organisms (P=0.06) despite fewer numbers. Antibiotic consumption on the ICU was six-fold higher than on the ASU and MDBU. Associations were found between consumption of selected antibiotic groups and corresponding resistances among staphylococci and Gram-negative bacilli. Antibacterial resistance was the only significant difference between environmental bacteria from different wards, and appeared to reflect prescribing pressure. Visual inspection of a ward may not provide a reliable guide regarding the presence of multi-resistant organisms in the hospital environment or the potential risk of infection. These findings have implications for local antibiotic policies, infection control and cleaning schedules.

How to make the RCPCH CPD guidelines work for you

Continuing professional development (CPD) is defined as a systematic process of lifelong learning and professional development. Its aim is to enable career grade doctors (consultants, associate specialists, staff grades, and their equivalents) to maintain and enhance their knowledge, skills, and competence for effective clinical practice to meet the needs of children. This article is designed to assist and improve acquisition of CPD.

Congenital Myotonic Dystrophy

We describe a case of severe congenital myotonic dystrophy (CDM). A 38-year-old primigravida, who was known to suffer from mild myotonic dystrophy (DM), conceived spontaneously and booked for confinement at 11 weeks in our unit. The couple had been fully counseled about the risks of transmission of this condition to their offspring before embarking on this pregnancy. Despite being fully aware of the risks, they declined prenatal diagnosis. The pregnancy was monitored by serial ultrasound scans. The diagnosis of CDM was suspected by ultrasound markers of borderline ventriculomegaly, polyhydramnios, and reduced fetal movements. The pregnancy ended prematurely at 33 weeks in an emergency caesarean section because of severe fetal compromise. The neonate died almost immediately after birth. The genetic analysis of cord blood confirmed severe DM. This case highlights the importance of ultrasound markers for the diagnosis of CDM in the absence of definitive prenatal diagnosis.

Inequalities in coronary revascularisation during the 1990s: evidence from the British regional heart study

OBJECTIVE

To investigate the influence of age and social circumstances on probability of revascularisation among British men.

DESIGN

Prospective population based study

SETTING

24 medium sized British towns, none of which contained a hospital undertaking coronary artery bypass surgery.

SUBJECTS

5814 surviving participants of the BRHS (British regional heart study), aged 52-73 years, with no history of revascularisation when responding to a questionnaire in November 1992.

MAIN OUTCOMES

Incident coronary revascularisations, as documented in general practitioner records, over the following 7.1 years and coronary angiography investigations reported by men in a further questionnaire in November 1996.

RESULTS

160 men underwent at least one revascularisation during this period (4.2/1000 person-years). In multifactorial analysis, which included adjustment for incidence of major coronary heart disease or angina, a lower incidence of revascularisation was found among men aged over 65 years in November 1992 (hazard ratio 0.62, 95% confidence interval (CI) 0.44 to 0.87), among men with manual occupations (0.73, 95% CI 0.53 to 1.02), among men living in households possessing no car (0.44, 95% CI 0.24 to 0.80) or one car (0.60, 95% CI 0.42 to 0.87) compared with two or more cars, among council tenants (0.49, 95% CI 0.25 to 0.97), and among men living outside southern England (0.71, 95% CI 0.51 to 0.99). Only car ownership was related to the incidence of diagnostic angiography: the odds ratio for angiography for those owning fewer than two cars was 0.62 (95% CI 0.42 to 0.89).

CONCLUSION

During the 1990s, there were major inequalities in the probability of undergoing coronary revascularisation between British men according to socioeconomic status, age, and geographic location.

Large loop excision and cold coagulation for management of cervical intraepithelial neoplasia

OBJECTIVES

To evaluate the efficacy of large loop excision of the transformation zone (LLETZ) combined with a single application of the cone probe of a Semm Cold Coagulator as a new treatment for women with cervical intraepithelial neoplasia (CIN).

METHODS

Retrospective case-record review of 666 women treated with large loop excision and cold coagulation (LLECC) from 1992 to 2000.

RESULTS

Of the women who had high-grade CIN at their initial consultation, 4.2% had abnormal cytologic results 6 months after treatment and 0.6% had abnormal cytologic results at 12 months. Of the women who had low-grade CIN at initial presentation, 3.8% had abnormal cytologic results 6 months after treatment and none (0%) at 12 months. Furthermore, there were no reported cases of cervical cancer in this cohort of women during the follow-up period. Short-term bleeding complications (within 24 h of the procedure) occurred in 1% of the women assessed.

CONCLUSIONS

Large loop excision combined with cold coagulation is a new and effective treatment for CIN. Randomized controlled trials are required to confirm these findings and determine the long-term safety of the technique.

Genetic predisposition to wheeze following respiratory syncytial virus bronchiolitis

BACKGROUND

The nature of the association between severe respiratory syncytial virus (RSV) bronchiolitis and subsequent wheezing remains unknown. In a previous study, we showed that genetic variation in the IL-8-promoter region is associated with susceptibility to severe bronchiolitis.

OBJECTIVE

The purpose of this study was to assess the association between wheezing post-bronchiolitis and the genetic variant of IL-8 gene.

METHODS

We collected data from 134 children who had suffered from bronchiolitis, enrolled in our previous study. The occurrence of wheezing post-bronchiolitis was recorded from a questionnaire sent by post. The association between the genotype and wheezing phenotype was assessed by family-based and case-control approaches.

RESULTS

Family-based association showed that the IL-8 variant was transmitted significantly more often than expected in the children who wheezed after the episode of bronchiolitis (transmission=56%, P=0.02). This effect was not observed in the group of children who had bronchiolitis but did not go on to wheeze. Moreover, the variant was significantly more frequent in post-bronchiolitis wheezers compared with the general population (odds ratio=1.6, 95% confidence interval 1.0-2.6).

CONCLUSION

These preliminary results suggest that there is a genetic predisposition to wheeze following severe RSV bronchiolitis.

Tissue plasminogen activator antigen and coronary heart disease Prospective study and meta-analysis

AIMS

To determine whether circulating tissue plasminogen activator (t-PA) antigen concentrations are prospectively related to risk of coronary heart disease (CHD) in the general population.

METHODS AND RESULTS

We measured baseline concentrations of t-PA antigen in the stored serum samples of 606 CHD cases and 1227 controls 'nested' in a prospective cohort of 5661 men monitored for 16 years, and conducted a meta-analysis of previous relevant studies to place our findings in context. Tissue plasminogen activator antigen values were strongly correlated with several vascular risk factors, including serum lipids, body mass index, alcohol consumption, and markers of systemic inflammation. In a comparison of men in the top third compared with those in the bottom third of baseline t-PA antigen values, the odds ratio for CHD was 2.20 (95% confidence interval (CI) 1.70-2.85) after adjustment for age and town only, but this fell to 1.48 (1.09-2.01) after further adjustment. Analysis of t-PA as a continuous variable gave similar results. Similarly, when published information on all seven available prospective cohort studies in general populations (2119 cases and 8832 controls in total) was synthesized, the combined odds ratio was 2.18 (1.77-2.69) after adjustment for age and sex only, and this fell to 1.47 (1.19-1.81) after further adjustment.

CONCLUSION

Although there is a statistically significant association between circulating concentrations of t-PA antigen and subsequent CHD, additional studies are needed to determine to what extent this is independent from more established risk factors.

Mechanical devices for pelvic organ prolapse in women

BACKGROUND

Pelvic organ prolapse is common, with some degree of prolapse seen in up to 50% of parous women in a clinic setting although many are asymptomatic. A number of symptoms may be associated with prolapse and treatments include surgery, mechanical devices and conservative therapies. A variety of mechanical devices or pessaries are described which aim to alleviate the symptoms of prolapse and avert or delay the need for surgery.

OBJECTIVES

To determine the effects of mechanical devices for pelvic organ prolapse.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (24 February 2004), MEDLINE (January 1966 to January 2003), PREMEDLINE (15 January 2003), EMBASE (January 1996 to January 2003), CINAHL (January 1982 to February 2003), PEDro (October 2003), the UK National Research Register (Issue 3, 2003), Controlled Clinical Trials (April 2003) and ZETOC (April 2003). We searched the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials which included a mechanical device for pelvic organ prolapse in one arm of the study.

DATA COLLECTION AND ANALYSIS

No eligible, completed, published or unpublished randomised controlled studies were found, therefore no data collection or analysis was possible.

MAIN RESULTS

There was a dearth of studies on the use of mechanical devices and no published reports of randomised trials were identified. One study on pessary usage was excluded as it was not a randomised trial.

REVIEWERS' CONCLUSIONS

Currently there is no evidence from randomised controlled trials upon which to base treatment of women with pelvic organ prolapse through the use of mechanical devices/pessaries. There is no consensus on the use of different types of device, the indications, nor the pattern of replacement and follow-up care. There is an urgent need for randomised studies to address the use of mechanical devices in comparison with no treatment, surgery and conservative measures.