Guideline adherence for diagnostic faeces testing in primary care patients with gastroenteritis.

Background: Gastroenteritis (GE) is a common reason for primary care consultation. Dutch clinical practice guidelines (CPG) recommend diagnostic faeces testing (DFT) only in primary care patients with severe illness, comprised immunity or increased transmission risk. For its superior accuracy, shorter turnaround time and ease of use, polymerase chain reaction (PCR)-based DFT has largely replaced conventional techniques. It is unknown whether this changed CPG adherence. Objective: To quantify the effect of PCR introduction on adherence to CPG indications for DFT in primary care patients with GE. Methods: We performed a cohort study using routine care data of 225 GPs. Episodes of GE where DFT was performed were extracted from electronic patient records. Presenting symptoms were identified and adherence to CPG indications for DFT assessed in two randomly drawn samples of each 500 patients, one from the period before PCR introduction (2010-11) and one after (2013). The association between PCR introduction and adherence was estimated using multivariable regression analysis. Results: In 88% of all episodes relevant presenting symptoms were reported, most often 'frequent watery stool' (58%) and 'illness duration >10 days' (40%). DFT was performed in 15% of episodes before PCR introduction and in 18% after. Overall, in 17% the DFT request was considered adherent to the CPG, 16% before PCR introduction and 18% after (adjusted OR 1.2, 95% CI 0.9-1.7). Conclusion: Overall adherence to CPG indications when requesting DFT in primary care patient with GE was 17%. Implementation of PCR-based DFT was not associated with a change in CPG adherence.

Design of the PROUD study: PCR faeces testing in outpatients with diarrhoea.

BACKGROUND: Infectious intestinal disease (IID) is an important cause of morbidity in developed countries and a frequent reason for general practitioner (GP) consultation. In recent years polymerase chain reaction (PCR) based techniques have gradually replaced conventional enteropathogen detection techniques like microscopy and culture in primary care patients suspected of IID. PCR features testing of multiple enteropathogens in a single faecal sample with shorter turnaround times and greater sensitivity compared to conventional techniques. However, the associated costs and benefits have not been quantified. Furthermore, primary care incidence and prevalence estimates of enteropathogens associated with IID are sparsely available and predominantly based on conventional techniques. The PROUD-study (PCR diagnostics in Outpatients with Diarrhoea) determines: 1) health (care) effects and 2) cost-effectiveness of PCR introduction in primary care patients suspected of IID; 3) occurrence of major enteropathogens in primary care patients suspected of IID. METHODS: A before-after cohort study will be performed of patients with suspected IID consulting a GP in the Utrecht General Practitioner Network (UGPN), covering the before period (2010-2011) with conventional testing and the after period (2013-2014) with PCR testing. Prospective study data on patient characteristics and primary outcome measures (i.e. healthcare use and disease outcome) will be collected from electronic patient and laboratory records in 2015 and 2016. The effect of PCR introduction is investigated by comparing the primary outcome measures and their associated healthcare costs between the conventional period and the PCR period, and is followed by a cost-effectiveness analysis. To determine the occurrence of enteropathogens associated with IID in primary care, routine care faeces samples from the year 2014 will be screened using PCR. DISCUSSION: The PROUD-study will quantify the costs and effects of the introduction of PCR techniques for enteropathogens in primary care patients suspected of IID and generate up-to-date and sensitive estimates of enteropathogen occurrence among primary care patients.

Hospital-acquired sinusitis is a common cause of fever of unknown origin in orotracheally intubated critically ill patients.

INTRODUCTION: Sinusitis is a well recognised but insufficiently understood complication of critical illness. It has been linked to nasotracheal intubation, but its occurrence after orotracheal intubation is less clear. We studied the incidence of sinusitis in patients with fever of unknown origin (FUO) in our intensive care unit with the aim of establishing a protocol that would be applicable in everyday clinical practice. METHODS: Sinus X-rays (SXRs) were performed in all patients with fever for which an initial screening (physical examination, microbiological cultures and chest X-ray) revealed no obvious cause. All patients were followed with a predefined protocol, including antral drainage in all patients with abnormal or equivocal results on their SXR. RESULTS: Initial screening revealed probable causes of fever in 153 of 351 patients (43.6%). SXRs were taken in the other 198 patients (56.4%); 129 had obvious or equivocal abnormalities. Sinus drainage revealed purulent material and positive cultures (predominantly Pseudomonas and Klebsiella species) in 84 patients. Final diagnosis for the cause of fever in all 351 patients based on X-ray results, microbiological cultures, and clinical response to sinus drainage indicated sinusitis as the sole cause of fever in 57 (16.2%) and as contributing factor in 48 (13.8%) patients with FUO. This will underestimate the actual incidence because SXR and drainage were not performed in all patients. CONCLUSION: Physicians treating critically ill patients should be aware of the high risk of sinusitis and take appropriate preventive measures, including the removal of nasogastric tubes in patients requiring long-term mechanical ventilation. Routine investigation of FUO should include computed tomography scan, SXR or sinus ultrasonography, and drainage should be performed if any abnormalities are found.

Pediatric intensive care: result of a European survey.

OBJECTIVE: To assess and compare the structure, organisation, management, and staffing in different paediatric intensive care units (PICUs) in Europe. DESIGN: Descriptive study. SETTING: A questionnaire was sent to physicians in PICUs. Physician's names were obtained from the membership list of the European Society of Paediatric and Neonatal Intensive Care. INTERVENTIONS: None. PARTICIPANTS: Physicians from 92 European PICUs. MEASUREMENTS AND MAIN RESULTS: Responses were obtained from 92 PICUs (60% of those surveyed, 64% of hospitals with PICUs). A blank response was obtained in <2% of the questions. Considerable diversity in structure, organisation, staffing, and management in European PICUs was found. Significant differences were observed in unit size, which ranged from 2-56 (average: 8-10) beds/unit. In several--predominantly German-speaking--countries paediatric and neonatal intensive care beds are frequently combined in single units. Most European PICUs (98%) had at least part-time coverage by a paediatric intensivist; 78% had 24-h intensivist coverage. Specialized PICU nurses were present in 98% of European PICUs, and most (75%) had 24-h physician coverage by a physician with no responsibilities outside the PICU. CONCLUSIONS: Data obtained in our survey demonstrate the substantial structural, organisational management, and staff diversity of paediatric ICUs. Most European PICUs employ specialized PICU nurses and have at least part time coverage by paediatric intensivists.

Use of 2-octyl-cyanoacrylate skin adhesive (Dermabond) for wound closure following reduction mammaplasty: a prospective, randomized intervention study.

BACKGROUND: 2-Octyl-cyanoacrylate skin adhesive may be used for surgical wound closure. However, its use in plastic surgery has not been properly assessed. METHODS: The authors conducted a prospective, randomized, controlled clinical intervention study in which the scar characteristics after use of skin adhesive were compared with those after suture closure. Bilateral reduction mammaplasty was performed in 50 patients. The method of closure (sutures versus skin adhesive) applied to each breast was determined randomly, using each patient as her own control. Scars were assessed by the patient and by a blinded panel, at 1 week, 6 weeks, and 6 months after surgery, using a visual analogue scale, the modified Hollander Wound Evaluation Scale, and the Patient and Observer Scar Assessment Scale. RESULTS: Both patients and panelists expressed an overall preference for the adhesive side as of 1 week after surgery. Patients' visual analogue scale scores for scar comfort and scar appearance and panelists' visual analogue scale scores for aesthetic outcome were significantly better for the adhesive side after 6 weeks and 6 months (p < 0.05), as was the total Hollander Wound Evaluation Scale score of the panelists after 6 weeks (p < 0.02). The total Patient and Observer Scar Assessment Scale score after 6 months was significantly better for the adhesive side according to the patients (p < 0.01), but not according to the panelists (p = 0.11). CONCLUSION: The authors conclude that 2-octyl-cyanoacrylate is a sound alternative for wound closure.

Anatomically shaped breast prosthesis in vivo: a change of dimension?

BACKGROUND: In addition to the already existing round cohesive gel-filled breast prostheses, anatomically shaped breast prostheses were introduced in 1990 to provide a more natural shape to the augmented or reconstructed breast. To date, however, it is unclear whether the anatomic configuration of the prostheses is maintained after subpectoral implantation. Recently, a three-dimensional (3D) magnetic resonance imaging (MRI) technique became available, offering a precise visualization of the prosthesis in vivo. Using this 3D MRI technique, this study aimed to compare the shape of commercially available round and anatomically shaped silicone gel-filled breast prostheses before and after implantation. METHODS: Using 3D MRI, 6 conventionally round and 12 symmetrically shaped silicone gel-filled prostheses were scanned in vitro. Scans were made in vivo 6 weeks after subpectoral implantation of these prostheses in nine patients. The in vivo 3D images were compared with the in vitro 3D images. RESULTS: Overall, a 3.5% decrease in projection was found on the in vivo images, as compared with the in vitro images. On the craniocaudally oriented images, a slight lateral shift of the cohesive gel was observed in the majority of the prostheses. Inamed Style 510 prostheses showed the best in vivo preservation of their configuration. CONCLUSIONS: The results show that both the round and the anatomically shaped silicone prostheses in vivo largely maintain their original in vitro configuration after subpectoral implantation.

Combined use of ultrasonic-assisted liposuction and semicircular periareolar incision for the treatment of gynecomastia.

BACKGROUND: Of the wide range of excisional and liposuction techniques used to correct gynecomastia, so far, no single one was suitable for all grades of gynecomastia. We introduce ultrasonic-assisted liposuction (UAL) combined with conventional liposuction and partial gland resection without skin excision as the standard surgical technique for all such grades. PATIENTS AND METHODS: Twenty-eight men (aged 17 to 80 years) were consecutively treated from March 2004 through April 2006 for grade Ia (n = 3), Ib (n = 2), IIa (n = 6), IIb (n = 6), III (n = 8), or IV (n = 3) gynecomastia. Their characteristics and the outcome of surgery were retrospectively assessed. RESULTS: A mean of 848 mL (range, 300 to 1400 mL) of liquefied breast tissue was aspirated, and 31 g (range, 3 to 180 g) of fibroglandular tissue were excised per breast. No immediate or delayed adjuvant skin reduction was needed in any of the patients. Moderate postoperative ecchymosis was observed in 2 patients, but no complications were encountered in this series. The cosmetic outcome was good to excellent in all. CONCLUSIONS: UAL in combination with gland resection through a minimal caudal semicircular periareolar incision and conventional liposuction effectively corrects all grades of gynecomastia. This combination has little morbidity, requires no skin excision, and leads to uniformly good esthetic results.