Detection of meticillin-resistant Staphylococcus aureus and carbapenemase-producing Enterobacteriaceae in Danish emergency departments - evaluation of national screening guidelines.

BACKGROUND: Multi-resistant bacteria (MRB) are an emerging problem. Early identification of patients colonized with MRB is mandatory to avoid in-hospital transmission and to target antibiotic treatment. Since most patients pass through specialized emergency departments (EDs), these departments are crucial in early identification. The Danish National Board of Health (DNBH) has developed exposure-based targeted screening tools to identify and isolate carriers of meticillin-resistant Staphylococcus aureus (MRSA) and carbapenemase-producing Enterobacteriaceae (CPE). AIM: To assess the national screening tools for detection of MRSA and CPE carriage in a cohort of acute patients. The objectives were to investigate: (i) if the colonized patients were detected; and (ii) if the colonized patients were isolated. METHODS: This was a multi-centre cross-sectional survey of adults visiting EDs. The patients answered the DNBH questions, and swabs were taken from the nose, throat and rectum. The collected samples were examined for MRSA and CPE. Screening performances were calculated. FINDINGS: Of the 5117 included patients, 16 were colonized with MRSA and four were colonized with CPE. The MRSA screening tool had sensitivity of 50% [95% confidence interval (CI) 25-75%] for carrier detection and 25% (95% CI 7-52%) for carrier isolation. The CPE screening tool had sensitivity of 25% (95% CI 1-81%) and none of the CPE carriers were isolated. CONCLUSION: The national screening tools were of limited use as the majority of MRSA and CPE carriers passed unidentified through the EDs, and many patients were isolated unnecessarily.

Patterns of anaphylaxis after diagnostic workup: A follow-up study of 226 patients with suspected anaphylaxis.

BACKGROUND: Most published studies on anaphylaxis are retrospective or register based. Data on subsequent diagnostic workup are sparse. We aimed to characterize patients seen with suspected anaphylaxis at the emergency care setting (ECS), after subsequent diagnostic workup at our Allergy Center (AC). METHODS: Prospective study including patients from the ECS, Odense University Hospital, during May 2013-April 2014. Possible anaphylaxis cases were daily identified based on a broad search profile including history and symptoms in patient records, diagnostic codes and pharmacological treatments. At the AC, all patients were evaluated according to international guidelines. RESULTS: Among 226 patients with suspected anaphylaxis, the diagnosis was confirmed in 124 (54.9%) after diagnostic workup; 118 of the 124 fulfilled WAO/EAACI criteria of anaphylaxis at the ECS, while six were found among 46 patients with clinical suspicion but not fulfilling the WAO/EAACI criteria at the ECS. The estimated incidence rate of anaphylaxis was 26 cases per 100 000 person-years and the one-year period prevalence was 0.04%. The most common elicitor was drugs (41.1%) followed by venom (27.4%) and food (20.6%). In 13 patients (10.5%), no elicitor could be identified. Mastocytosis was diagnosed in 7.7% of adult patients and was significantly associated with severe anaphylaxis. Atopic diseases were significantly associated only with food-induced anaphylaxis. Cofactors were present in 58.1% and were significantly associated with severe anaphylaxis. CONCLUSION: A broad search profile in the ECS and subsequent diagnostic workup is important for identification and classification of patients with anaphylaxis. Evaluation of comorbidities and cofactors is important.

Comparison of buffet and à la carte serving at worksite canteens on nutrient intake and fruit and vegetable consumption.

OBJECTIVE: To evaluate the nutritional composition of worksite canteen lunches and to examine the impact of two meal serving systems on employee intake, i.e. buffet style with a fixed price for a varied number of dishes and à la carte style with a separate price for each item on the menu. DESIGN: Laboratory technicians observed employees' food selection and collected identical dishes. Food items were weighed separately to calculate the content of fruit and vegetables. The content of protein, fat and ash of each dish was chemically analysed and the carbohydrate and energy content calculated. SETTING: Fifteen randomly chosen worksite canteens in Denmark: eight canteens serving buffet style and seven canteens with an à la carte line. SUBJECTS: one hundred and eighty randomly chosen employees having lunch at the worksite canteens. RESULTS: The average percentage energy from fat was 37 +/- 12 among men and 33 +/- 12 among women. No association was found between the meal serving system and energy intake or macronutrient composition. Eating at canteens serving buffet style, on the other hand, was associated with an increased intake of fruit and vegetables, on average 76 g, and a lower energy density of the food for both genders. CONCLUSION: The results highlight the possibilities of promoting healthy food choices in the catering sector and the need to identify models of healthy catering practice. Serving buffet style appears to be a promising strategy in order to increase fruit and vegetable consumption in food served away from home.

Helicobacter pylori test and eradicate versus prompt endoscopy for management of dyspeptic patients: 6.7 year follow up of a randomised trial.

BACKGROUND: Dyspepsia is a chronic disease with significant impact on the use of health care resources. A management strategy based on Helicobacter pylori testing has been recommended but the long term effect is unknown. AIM: To investigate the long term effect of a test and treat strategy compared with prompt endoscopy for management of dyspeptic patients in primary care. PATIENTS: A total of 500 patients presenting in primary care with dyspepsia were randomised to management by H pylori testing plus eradication therapy (n = 250) or by endoscopy (n = 250). Results of 12 month follow up have previously been presented. METHODS: Symptoms, quality of life, and patient satisfaction were recorded during a three month period, a median 6.7 years after randomisation (range 6.1-7.3 years). Number of endoscopies, antisecretory medication, H pylori treatments, and hospital visits were recorded from health care databases for the entire follow up period. RESULTS: Median age was 45 years; 28% were H pylori infected. Use of resources was registered in all 500 patients (3084 person years) of whom 312 completed diaries. We found no difference in symptoms between the two groups. Median proportion of days without symptoms was 0.52 (interquartile range 0.10-0.88) in the test and eradicate group versus 0.64 (0.14-0.90) in the prompt endoscopy group (p = 0.27) (mean difference 0.05 (95% confidence interval (CI) -0.03 to 0.14)). Compared with the prompt endoscopy group, the test and eradicate group underwent fewer endoscopies (mean difference 0.62 endoscopies/person (95% CI 0.38-0.86)) and used less antisecretory medication (mean difference 102 defined daily doses/person (95% CI -1 to 205)). CONCLUSION: On a long term basis, a H pylori test and eradicate strategy is as efficient as prompt endoscopy for management of dyspeptic patients in primary care and reduces the use of endoscopy and antisecretory medication.

[Histological examination of the gallbladder after cholecystectomy]. / Histologisk undersøgelse af galdeblaeren ved kolecystektomi.

BACKGROUND AND OBJECTIVES: Normally, the gallbladder is sent routinely for histological examination after cholecystectomy. From a cost-benefit point of view this may not be optimal. METHODS: Computerised records were used to identify patients with gallbladder carcinoma over a 20-year period, from 1979 to 1999, and these patient records were evaluated manually. RESULTS: The estimated cost for one histological examination was $37. During the period, 4,614 cholecystectomies were performed and 33 patients had gallbladder carcinoma. In 29 of the 33 patients, there was evident preoperative and/or peroperative suspicion of cancer, but no such suspicion in four patients. These four patients had other peroperative macroscopic abnormal findings, besides gallbladder stones. CONCLUSION: This retrospective series indicates that in the case of normal preoperative and/or peroperative macroscopic conditions (except for gallbladder stones) there is no need for histological examination of the gallbladder.

Randomized trial of stent placed above and across the sphincter of Oddi in malignant bile duct obstruction.

BACKGROUND: Placement of stents above an intact sphincter of Oddi might prevent migration of bacteria and deposition of organic material into the stent. In patients with malignant obstructive jaundice prolongation of function time of the stent would be expected if it is placed above the sphincter of Oddi. METHODS: Thirty-four patients were randomized to stent placement either above (n = 17) or across (n = 17) the sphincter of Oddi. Straight 10F gauge Teflon stents were used. The patients were evaluated clinically and biochemically at monthly intervals during follow-up. RESULTS: The median stent function time (i.e., the time from insertion of the stent until stent replacement, patient death, or study termination) were 110 days (25th to 75th percentiles, 61 to 320 days) for stents placed above the sphincter of Oddi and 126 days (25th to 75th percentiles, 89 to 175 days) for stents placed across the sphincter of Oddi (nonsignificant [NS]). Stent replacement rates were 58.8% (10 of 17) in patients with stents placed above the sphincter and 29.4% (5 of 17) in patients with stents placed across the sphincter (NS). Significantly more patients in the former group experienced stent migration (9 vs. 2, p = 0.026). The median time from stent insertion until replacement of the stents placed above and across the sphincter of Oddi were 82 days (25th to 75th percentiles, 31 to 185 days) and 89 days (25th to 75th percentiles, 13 to 150 days), respectively (NS). CONCLUSIONS: No significant difference in overall stent performance between the two groups was found, although more stents placed above the sphincter of Oddi migrated. The time until dysfunction of the stent might be increased if migration of stents placed inside the common bile duct could be avoided.

[Helicobacter pylori in 1997]. / Helicobacter pylori anno 1997.

In this review Helicobacter pylori (H. pylori) infection and its relation to different diseases is presented. H. pylori doesn't cause inconvenience to most infected people, though all infected persons have chronic active gastritis. The 10 year risk of peptic ulcer for people infected with H. pylori is about 10%. Randomized double-blinded trials have shown that eradication of H. pylori can cure most patients with peptic ulcer disease. Some people infected with H. pylori develop atrophic gastritis which is a risk factor for development of gastric cancer. It is not known if H. pylori screening and eradication would have a prophylactic effect against gastric cancer. It is also unknown if persons with non-organic dyspepsia and persons in long-term treatment with proton-pump-inhibitors would benefit from H. pylori eradication.