Review article: acute severe ulcerative colitis - evidence-based consensus statements.

BACKGROUND: Acute severe ulcerative colitis (ASUC) is a potentially life-threatening complication of ulcerative colitis. AIM: To develop consensus statements based on a systematic review of the literature of the management of ASUC to improve patient outcome. METHODS: Following a literature review, the Delphi method was used to develop the consensus statements. A steering committee, based in Australia, generated the statements of interest. Three rounds of anonymous voting were carried out to achieve the final results. Acceptance of statements was pre-determined by ≥80% votes in 'complete agreement' or 'agreement with minor reservation'. RESULTS: Key recommendations include that patients with ASUC should be: hospitalised, undergo unprepared flexible sigmoidoscopy to assess severity and to exclude cytomegalovirus colitis, and be provided with venous thromboembolism prophylaxis and intravenous hydrocortisone 100 mg three or four times daily with close monitoring by a multidisciplinary team. Rescue therapy such as infliximab or ciclosporin should be started if insufficient response by day 3, and colectomy considered if no response to 7 days of rescue therapy or earlier if deterioration. With such an approach, it is expected that colectomy rate during admission will be below 30% and mortality less than 1% in specialist centres. CONCLUSION: These evidenced-based consensus statements on acute severe ulcerative colitis, developed by a multidisciplinary group, provide up-to-date best practice recommendations that improve and harmonise management as well as provide auditable quality assessments.

A fire inside: current concepts in chronic pancreatitis.

Chronic pancreatitis is a necroinflammatory process characterized pathologically by acinar atrophy and fibrosis and clinically by abdominal pain, diabetes and maldigestion. In this review we summarize some of the recent advances in the understanding of the pathogenesis of pancreatitis and how they have shaped our current understanding of chronic pancreatitis. We pay particular attention to advances in the genetic basis of idiopathic, hereditary and tropical pancreatitis as well as research into the relationship between alcohol and the pancreas. We have also reviewed current practices with respect to diagnosis and management of chronic pancreatitis.

Hospitalised patients' views on doctors and white coats.

OBJECTIVES: To determine hospitalised patients' feelings, perceptions and attitudes towards doctors and how these are affected by whether or not doctors wear a white coat. DESIGN: Cross-sectional questionnaire survey. SETTING: The medical and surgical wards of two Sydney teaching hospitals, on one day in January 1999. PATIENTS: 154 of 200 consecutive patients (77%). MAIN OUTCOME MEASURES: The effects of white-coat-wearing on patients' feelings and ability to communicate and on their perceptions of the doctor; why patients think doctors wear white coats and their preferences for the wearing of white coats and doctors' attire in general; and patients' rating of the importance of these effects and preferences. RESULTS: Patients reported that white-coat-wearing improved all aspects of the patient-doctor interaction, and that when doctors wore white coats they seemed more hygienic, professional, authoritative and scientific. The more important that patients considered an aspect, the greater the positive effect associated with wearing a white coat. From a list of doctors' reasons for wearing white coats, patients thought that doctors wore white coats because it made them seem more professional, hygienic, authoritative, scientific, competent, knowledgeable and approachable. 36% of the patients preferred doctors to wear white coats, 19% preferred them not to wear white coats and 45% did not mind. CONCLUSIONS: Patients reported feeling more confident and better able to communicate with doctors who wore white coats. The recognition, symbolism and formality afforded by a white coat may enhance communication and facilitate the doctor-patient relationship.

Recall of radiation pneumonitis after intrapleural administration of doxorubicin.

A 67-year-old woman developed a malignant pleural effusion 18 months after radical mastectomy and radiotherapy for carcinoma of the breast. After drainage, 30 mg of doxorubicin was instilled into the pleural cavity. Thirty-six hours later, she developed fever, dyspnoea, and erythema in the area of the previous radiotherapy field; patchy intrapulmonary opacities were evident on chest X-ray film. These features resolved over two weeks after treatment with prednisone and frusemide. We believe that this represents a radiation-recall phenomenon.

Lung distensibility and airway function in intermediate alpha 1-antitrypsin deficiency (Pi MZ).

We examined the role of intermediate alpha 1-antitrypsin deficiency in predisposing to abnormalities of lung distensibility and airway function in 20 heterozygotes (Pi MZ) who were individually matched with a control Pi M subject of similar age, height, and smoking habits drawn from the same male, working population. There were no significant differences between the heterozygotes and their controls in the results of spirometry, maximum expiratory flow-volume curves (breathing air), single breath nitrogen test, arterialised capillary blood oxygen pressure, or single breath carbon monoxide transfer. Additional studies were made in 12 of the pairs of Pi MZ and Pi M subjects. Comparison of maximum expiratory flow-volume curves breathing air and 80% helium-20% oxygen showed no differences between the Pi MZ and Pi M subjects. Although airway function was similar in the two groups, four of 12 Pi MZ subjects showed abnormalities of the pressure-volume curve of the lung (reduction in lung recoil pressure, abnormal shape factor, increase in functional residual capacity). Abnormalities of washout of a helium-sulphur hexafluoride gas mixture, of a type previously described as characteristic of emphysema, were found in two of the men with abnormal pressure-volume curves. The results suggest that Pi MZ subjects have an increased susceptibility to alveolar abnormalities without increased abnormalities of airway function; this may explain the increased frequency of emphysema at necropsy despite many studies showing no predisposition to abnormal airway function in life. The functional changes we observed would be unlikely to cause symptoms. The risk of disablement from chronic lung disease appears to be only slightly enhanced by intermediate alpha 1-antitrypsin deficiency.