Clinical audit: recent practice in caring for patients with acute severe colitis compared with published guidelines--is there a problem?

BACKGROUND: Acute severe colitis (ASC) is a serious condition with possible outcomes of emergency colectomy and mortality. Validated guidelines exist to help avoid these. AIMS: To examine local adherence to guidelines and identify (a) opportunities to improve care and (b) possible barriers to adherence. METHODS: Retrospective, hospital-wide audit of all patients with ASC during a 2-year period (2009-2010) at a major metropolitan hospital. Cases were identified by an electronic search of all discharges with International Classification of Diseases-10 codes for colitis, colectomy, ulcerative colitis or Crohn disease. RESULTS: Twenty-six patients had 30 ASC admissions (14 female). Most admissions were under gastroenterology (25), 4 (13%) were under general medicine and 1 was under general surgery. Only 8 patients' (26%) management (all under gastroenterology) included all major details: blood investigations, Clostridium difficile test, abdominal X-ray, colonic examination and venous thromboembolism prophylaxis. Only one patient had formal severity scoring on admission, and seven patients (24%) had descriptive severity recorded. On day 3, nine patients (30%) had some recorded severity assessment; however, no formal criteria were used. Four had colectomy, three during first admission and one on re-admission. Of these patients, three received cyclosporine prior to colectomy. The mean duration of admission was 10 days (standard deviation 10.54, range 1-61). CONCLUSION: Opportunities to optimise care exist including formal severity assessments on days 1 and 3, better deep vein thrombosis/pulmonary embolism prophylaxis and prompt colonic examination. Admission under teams other than gastroenterology appeared to be a barrier to better care. Despite the low rate of ideal management, the colectomy rate was acceptably low at 20%.

Potentially avoidable surgery in inflammatory bowel disease: what proportion of patients come to resection without optimal preoperative therapy? A guidelines-based audit.

BACKGROUND: Recently, promulgated inflammatory bowel disease (IBD) guidelines seek to decrease the need for surgery by improving disease control. However, resection rates remain static. AIMS: We therefore sought to determine the proportion of patients coming to surgery where preoperative management was not optimal according to guidelines. METHODS: Case notes of all patients with resection surgery for IBD from January 2007 to March 2008 at a metropolitan teaching hospital were retrospectively reviewed. Judgement was made as to whether preoperative management was optimal or suboptimal depending on whether it met guidelines. RESULTS: A total of 22 subjects with IBD-related resections were identified (15 males and seven females). In total, 17 had Crohn's disease (CD) (11 males) and five ulcerative colitis (UC) (four males). There were 10 smokers (nine CD and one UC). The two most common indications for surgery were inflammatory mass/abscess (n= 8) and refractory to medical therapy (n= 7). While all patients with known IBD (20/22) had seen a gastroenterologist in the past, five known IBD patients had resections undertaken without preoperative gastroenterologist input. Overall preoperative management was judged as optimal in only (9/22) 41%. Of those whose therapy did not meet guidelines (n= 13), five had azathioprine at doses <2 mg/kg, one declined therapy and nine with CD were current smokers. CONCLUSIONS: Over 50% of IBD resection patients had suboptimal preoperative management, with sub-therapeutic thiopurine dosing and smoking in CD the main problems. Thus, there are significant gains to be made with better use of standard therapies, as it appears that ∼50% of resection surgery was 'potentially avoidable'.

QTL for meat tenderness in the M. longissimus lumborum of cattle.

Meat tenderness has been difficult to improve using standard genetic selection. Marker assisted selection holds great promise if markers for meat tenderness can be identified. Here, we report quantitative trait loci (QTL) for beef tenderness identified in 598 animals of three Charolais-Brahman x Belmont Red pedigrees after screening the whole genome using 183 DNA markers. In addition to the usual Warner-Bratzler peak force measurements, tenderness was also measured using compression, adhesion and pressure-heat-treated peak force. Three QTL for meat tenderness in the M. longissimus lumborum muscle were found, two of which have not been reported before. One is located in the HEL9-CSSM47 interval on bovine chromosome 8 with a LOD of 3.1 and an effect of 1.02 phenotypic standard deviations for tensile strength of cooked muscle as measured by adhesion. A second QTL is located near CSRM60 on bovine chromosome 10 with a LOD of 2.4 and an effect of 0.48 phenotypic standard deviations for compression. The third QTL is in a region of bovine chromosome 7 that has previously been reported to have a QTL affecting peak force. This region also shows effects on compression and a combined tenderness index. These QTL are all for the myofibrillar component of meat tenderness. No QTL were found for pressure-treated peak force, which is an estimate of the connective tissue component muscle of meat tenderness.

Uterine incarceration during the third trimester: a rare complication of pregnancy.

Uterine incarceration that manifests during the third trimester or at term is a serious and rare complication of pregnancy. The pregnant patient may complain of low-abdominal pain, low-back pain, urinary retention, and constipation, or the patient may be asymptomatic until labor begins. The diagnosis is difficult, and physical findings can be misleading. Ultrasonography and magnetic resonance imaging can be helpful if the anteriorly displaced cervix is clearly depicted. If incarceration of the retroverted uterus persists until term, a cesarean section is necessary. Recurrent uterine incarceration has been reported; therefore, the patient should be monitored closely during subsequent pregnancies. Herein we describe three cases of uterine incarceration during the third trimester and review the literature with respect to incidence, differential diagnosis, management, and complications of this condition.

Gynecologic cancer in patients with subacute cerebellar degeneration predicted by anti-Purkinje cell antibodies and limited in metastatic volume.

Between 1982 and 1989, 19 patients with gynecologic carcinoma, paraneoplastic cerebellar degeneration, and seropositivity for anti-Purkinje cell cytoplasmic antibodies were identified at our institution. Seven of the patients had no clinical, computed tomographic, or magnetic resonance imaging evidence of cancer but had undergone laparotomy solely because anti-Purkinje cell antibodies were found in their serum; all had high-grade adenocarcinoma. Cerebellar symptoms preceded or coincided with the initial cancer diagnosis in 15 patients and preceded the diagnosis of recurrent cancer in 4 patients. The cancers were 14 ovarian, 2 fallopian tube, 2 surface papillary, and 1 poorly differentiated metastatic adenocarcinoma in a periaortic lymph node. Two remarkable surgical observations in patients with high-grade ovarian and tubal cancers were the conspicuous lack of peritoneal implants and the small metastatic volume. A comparison of the 8 patients who had primary stage III cancer with 24 matched control patients without paraneoplastic cerebellar degeneration revealed no difference in primary tumor volume but a significantly smaller volume of metastatic tumor in the seropositive group (P = 0.05). Anti-Purkinje cell antibodies were not detected in 111 neurologically normal patients with advanced ovarian cancer. The small metastatic volume in the face of high-grade and advanced stage malignancy in seropositive patients with paraneoplastic cerebellar degeneration suggests that an immune response to the tumor (presumably cross-reactive with cerebellar cells) may impair the metastatic process. Earlier diagnosis and treatment of cancer, based on prompt serologic testing, may offer an improved neurologic and oncologic prognosis.

Evidence for a major gene determining the resistance of Indonesian Thin Tail sheep against Fasciola gigantica.

The genetic basis of the high resistance of Indonesian Thin Tail (ITT) sheep against Fasciola gigantica has been studied by measuring the resistance levels of ITT sheep, St. Croix sheep and their F2 and F3 crossbreds. All of the sheep were bred and reared in the same environment. Approximately half of the F2 and F3 crossbreds were as resistant as the ITT parental breed, one-quarter had the low resistance of the St. Croix parental breed and the rest had an intermediate level of resistance. It is concluded that the high resistance is determined by a major gene with incomplete dominance. The prevalence of the gene in the ITT sheep population is estimated to be about 90%. The resistance may be innate or acquired; but, regardless of the mechanism, it could be used to control fasciolosis caused by F. gigantica by breed substitution or by crossbreeding with other breeds of sheep.

The relationships among ecto- and endoparasite levels, class I antigens of the bovine major histocompatibility system, immunoglobulin E levels and weight gain.

Natural infestations of the cattle tick Boophilus microplus, levels of the buffalo fly Haematobia irritants exigua and faecal nematode egg concentrations (Bunostomum phlebotomum, Cooperia spp., Haemonchus placei, Oesophagostomum radiatum and Trichostrongylus axei) were assessed in 221 Belmont Red calves during the post-weaning period, when the animals were between 9 and 18 months of age. In addition, the 98 males of this group were challenged with B. microplus larvae on two separate occasions. There were strong positive correlations among replicate assessments of the same parasite. Field tick counts and tick counts following deliberate challenge were strongly correlated, and both showed negative correlations with post-weaning weight gain. There was a weak positive correlation between buffalo fly counts and post-weaning weight gain. There was a negative correlation between total worm egg count and weight gain. Among worm species, only the effect of O. radiatum on weight gain was significant. Cattle with bovine major histocompatibility (BoLA) antigens W6.1 and W7 had significantly fewer ticks than cattle lacking these antigens. Cattle with BoLA antigens W7 and CA36 had lower concentrations of nematode eggs in their faeces than cattle lacking these BoLA antigens.

Genetic variation and covariation in beef cow and bull fertility.

Single-sire natural mating data from a beef cattle herd in tropical Australia were used to estimate heritabilities of cow fertility (hc2), heritabilities of bull fertility (hb2) and genetic correlations between cow and bull fertility (rg) within each of six genotypes. Estimates of hc2 and hb2 were low, averaging .11 and .08, respectively. The pooled estimate of rg was 0.16, indicating that cow and bull fertility are favorably genetically correlated and therefore that cow fertility could be genetically improved by indirect selection on bull fertility, or some more heritable component of bull fertility.

Evaluation of omeprazole in reflux oesophagitis.

In patients with reflux disease, pH monitoring has shown that omeprazole virtually eliminates oesophageal exposure to a pH of less than 4. Motility studies concurrent with pH monitoring have indicated that reflux continues on omeprazole, its effect on acid exposure being entirely dependent on elevation of gastric pH. Omeprazole and placebo have been compared in 64 patients with erosive or ulcerative oesophagitis; the 4-week healing rates were 81% with omeprazole, 20 mg or 40 mg daily, and 6% with placebo. The efficacies of omeprazole at doses of 20 mg and 40 mg daily, were then compared in 164 patients. At 4 weeks, oesophagitis was healed in 70% and 82% of patients for the 20 mg and 40 mg doses respectively (p = 0.05). Eight-week healing rates (79% for 20 mg and 85% for 40 mg) did not differ significantly. Symptom response was excellent for both doses. Relapse of oesophagitis was determined over 6 months for patients healed with omeprazole. Relapse was shown to occur in 88 of 107 patients by 6 months. Omeprazole is a highly effective treatment for erosive/ulcerative peptic oesophagitis, 40 mg daily being marginally superior to 20 mg. Relapse is almost inevitable within 6 months of cessation of therapy.

Olsalazine in the treatment of active ulcerative colitis: a placebo controlled clinical trial and assessment of drug disposition.

The efficacy, safety and disposition of olsalazine was assessed in patients with left-sided ulcerative colitis or proctitis in a double-blind placebo controlled trial. Thirty patients with a mild-to-moderate attack of ulcerative colitis were randomly allocated to olsalazine capsules, 1 g b.d., or placebo for 6 weeks. Good clinical response was found in six patients receiving olsalazine and in two receiving placebo. Improvement in sigmoidoscopic findings and histological appearance of rectal biopsies was also seen more often in olsalazine-treated patients. Plasma concentrations of olsalazine were significantly higher in patients who improved. Olsalazine showed an advantage over placebo which needs to be confirmed by further studies; it was safe in sulphasalazine-sensitive patients but appeared to cause watery diarrhoea in two patients.

Controlled clinical trials of omeprazole in the long-term management of reflux disease.

Reflux oesophagitis is a chronic relapsing disorder. When treatment is stopped after successful short-term healing of oesophagitis, high relapse rates (80% within 6 months) indicate that prolonged treatment is necessary in order to maintain remission. The results of three long-term, multicentre, controlled, double-blind clinical trials comparing different regimens of omeprazole with ranitidine are reviewed. Omeprazole, 20 mg daily, was found to be a highly effective maintenance therapy in patients with ulcerative oesophagitis, keeping 67-89% of patients in remission for 1 year, compared with 10-25% of patients treated with ranitidine, 150 mg twice daily. Weekend omeprazole therapy, 20 mg daily every Friday, Saturday and Sunday, was, as with daily ranitidine, relatively ineffective. All treatment regimens were well tolerated and gastric mucosal biopsies showed no qualitative changes in gastric enterochromaffin-like cells.

Comparative performance of intensively managed Khaki Campbell and native Indonesian ducks.

Egg Production traits of Khaki Campbell, Alabio, Bali and Tegal ducks were measured to 68 weeks of age under intensive management. Khaki Campbell ducks laid significantly more eggs and required less feed per egg or per gram of egg produced than the Indonesian breeds. Appreciable numbers of local ducks were observed to moult on two occasions during the trial. It was thought that this may have been a response to seasonal factors such as rainfall patterns. Tegal ducks laid significantly fewer eggs and were less efficient than Alabio and Bali ducks. Egg specific gravity was consistently highest in the Alabio and Tegal breeds. The poor production of Tegal ducks compared with that in other studies may have been related to their early onset of lay under the 16 h daylength used in the trial or to a sampling effect.

Fulminant hepatic failure.

Fulminant hepatic failure is an uncommon but dramatic illness with a high mortality. Viral hepatitis or drug toxicity is the usual cause. In the severe forms of the illness the patients, often young and previously healthy, rapidly become profoundly unwell due to extensive hepatic necrosis. Coma is accompanied by a disastrous disturbance of all the synthetic, metabolic and excretory functions of the liver. Management is largely supportive and multisystem complications may demand all the resources of the intensive care unit to allow survival. Systems for temporary hepatic support have aroused interest, based on the assumption that the hepatic lesion is potentially reversible. A number of heroic techniques have been tried and abandoned. Encouraging reports of charcoal column haemoperfusion have yet to be confirmed by controlled clinical trial.

Long term management of hemorrhagic esophagitis with cimetidine and omeprazole.

We report a patient whose severe recurrent anemia was due to overt and occult hemorrhage from peptic esophagitis. Cimetidine treatment was successful for seven years but dose reduction was followed by intractable hemorrhage which did not respond to H2-receptor antagonists. Omeprazole therapy produced dramatic remission of symptoms and anemia.

Time relationships between oviposition, ovulation and egg formation in Khaki Campbell ducks.

1. Ten-month-old Khaki Campbell ducks were killed between 5 min and 15 h after oviposition. Time of oviposition and interval between eggs were recorded prior to killing. 2. Oviposition generally occurred between 04.00 and 06.00 h, 7 to 9 h after the onset of the dark period the previous day. Ninety-seven percent of eggs were laid by 07.00 h. 3. The mean +/- SD time interval between consecutive ovipositions was 24.0 +/- 0.3 h, with a range from 23.5 to 24.5 h. 4. It was estimated that ovulation occurred on average 10 min after oviposition, and the ovum spent 15 to 30 min in the infundibulum, 2.5 to 3 h in the magnum, 2 to 2.5 h in the isthmus and 18.6 h in the shell gland.