Laboratory and clinical impacts of an overnight laboratory service.

Delayed initiation of effective antimicrobial therapy for sepsis is associated with increased mortality. Whilst automated blood culture machines operate continuously, this does not align with conventional staff working hours and so turn-around-times (TAT) for reporting gram stains to clinicians are 3-7 times longer for blood cultures that flag positive overnight. We retrospectively compared laboratory TATs and clinical outcomes for blood cultures from 183 patients that flagged positive overnight during a 4-month period before and after the implementation of an overnight laboratory service. Enterobacterales and urinary tract infections were the most frequent pathogens and clinical syndrome respectively, and the prevalence of multi-resistant organisms was 15%. Compared with the pre-implementation period, the post-implementation period was associated with shorter median time from blood culture positivity to gram stain (7.4 vs 1.2 h), first genus level identification (7.2 vs 5.8 h) and first antimicrobial susceptibility result (24.1 vs 7.9 h). Similarly, the median time from blood culture positivity to clinicians first being informed was significantly shorter (9.2 vs 1.3 h). After removal of likely contaminants, 78% of patients were on effective empiric antimicrobials and for patients on ineffective empiric antimicrobials, effective therapy was initiated a median of 3.2 h sooner during the post-implementation period, without impact on mortality. Implementation of an overnight laboratory service was associated with significantly faster TAT for reporting blood culture results and more prompt initiation of effective antimicrobials for patients receiving ineffective empiric therapy, improving attainment of sepsis management goals.

Outcomes After Percutaneous Coronary Intervention in Women: Are There Differences When Compared with Men?

Despite advances in the diagnosis and treatment of coronary artery disease, there remains evidence of a disparity in the outcomes for women when compared with men. This article provides a review of the evidence for this discrepancy and discusses some of the potential contributing factors.

Quality of life following fistulotomy - short term follow-up.

AIM: Anal fistula causes pain and discharge of pus and blood. Treatment by fistulotomy has the highest success, but can risk continence; treatment needs to balance cure with continence. This study assessed the impact of fistulotomy on quality of life (QOL) and continence. METHOD: Patients selected for fistulotomy prospectively completed the St Mark's Continence Score (full incontinence = 24) and Short Form-36 questionnaires preoperatively at two institutions with an interest in anal fistula. Patients were reassessed 3 months' postoperatively. RESULTS: There were 52 patients with a median age of 44 (range 19-82) years; 10 were women. Preoperative continence scores were median 0 (range 0-23) and there was no significant difference compared with postoperative scores (median 1, range 0-24). Following fistulotomy QOL was significantly improved in four of eight domains - Bodily Pain (P < 0.001), Vitality (P < 0.01), Social Functioning (P < 0.05) and Mental Health (P < 0.001) - and returned to that of the general population. QOL for patients with intersphincteric fistula improved postfistulotomy, and for those with trans-sphincteric fistula it remained the same. Data were further examined in two groups, with and without deterioration in continence score. Where continence improved postoperatively, QOL improved in three domains; where continence deteriorated QOL improved in two domains (P < 0.05). Patients with postoperative continence scores of < 5 had worse QOL than those scoring 4 or less. CONCLUSION: QOL significantly improved at 3 months' follow-up after fistulotomy where continence was maintained or a small reduction occurred.

CO2 exposure as translational cross-species experimental model for panic.

The current diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders are being challenged by the heterogeneity and the symptom overlap of psychiatric disorders. Therefore, a framework toward a more etiology-based classification has been initiated by the US National Institute of Mental Health, the research domain criteria project. The basic neurobiology of human psychiatric disorders is often studied in rodent models. However, the differences in outcome measurements hamper the translation of knowledge. Here, we aimed to present a translational panic model by using the same stimulus and by quantitatively comparing the same outcome measurements in rodents, healthy human subjects and panic disorder patients within one large project. We measured the behavioral-emotional and bodily response to CO2 exposure in all three samples, allowing for a reliable cross-species comparison. We show that CO2 exposure causes a robust fear response in terms of behavior in mice and panic symptom ratings in healthy volunteers and panic disorder patients. To improve comparability, we next assessed the respiratory and cardiovascular response to CO2, demonstrating corresponding respiratory and cardiovascular effects across both species. This project bridges the gap between basic and human research to improve the translation of knowledge between these disciplines. This will allow significant progress in unraveling the etiological basis of panic disorder and will be highly beneficial for refining the diagnostic categories as well as treatment strategies.

Quality of life with anal fistula.

INTRODUCTION: Anal fistula affects people of working age. Symptoms include abscess, pain, discharge of pus and blood. Treatment of this benign disease can affect faecal continence, which may, in turn, impair quality of life (QOL). We assessed the QOL of patients with cryptoglandular anal fistula. METHODS: Newly referred patients with anal fistula completed the St Mark's Incontinence Score, which ranges from 0 (perfect continence) to 24 (totally incontinent), and Short form 36 (SF-36) questionnaire at two institutions with an interest in anal fistula. The data were examined to identify factors affecting QOL. RESULTS: Data were available for 146 patients (47 women), with a median age of 44 years (range 18-82 years) and a median continence score of 0 (range 0-23). Versus population norms, patients had an overall reduction in QOL. While those with recurrent disease had no difference on continence scores, QOL was worse on two of eight SF-36 domains (p<0.05). Patients with secondary extensions had reduced QOL in two domains (p<0.05), while urgency was associated with reduced QOL on five domains (p<0.05). Patients with loose seton had the same QOL as those without seton. No difference in urgency was found between patients with and without loose seton. In primary fistula patients, 19.4% of patients experienced urgency versus 36.3% of those with recurrent fistulas. CONCLUSIONS: Patients with anal fistula had a reduced QOL, which was worse in those with recurrent disease, secondary extensions and urgency. Loose seton had no impact on QOL.

The brain acid-base homeostasis and serotonin: A perspective on the use of carbon dioxide as human and rodent experimental model of panic.

Panic attacks (PAs), the core feature of panic disorder, represent a common phenomenon in the general adult population and are associated with a considerable decrease in quality of life and high health care costs. To date, the underlying pathophysiology of PAs is not well understood. A unique feature of PAs is that they represent a rare example of a psychopathological phenomenon that can be reliably modeled in the laboratory in panic disorder patients and healthy volunteers. The most effective techniques to experimentally trigger PAs are those that acutely disturb the acid-base homeostasis in the brain: inhalation of carbon dioxide (CO2), hyperventilation, and lactate infusion. This review particularly focuses on the use of CO2 inhalation in humans and rodents as an experimental model of panic. Besides highlighting the different methodological approaches, the cardio-respiratory and the endocrine responses to CO2 inhalation are summarized. In addition, the relationships between CO2 level, changes in brain pH, the serotonergic system, and adaptive physiological and behavioral responses to CO2 exposure are presented. We aim to present an integrated psychological and neurobiological perspective. Remaining gaps in the literature and future perspectives are discussed.

Severe bleeding events in adults and children with primary immune thrombocytopenia: a systematic review.

BACKGROUND: The burden of severe bleeding in adults and children with immune thrombocytopenia (ITP) has not been established. OBJECTIVES: To describe the frequency and severity of bleeding events in patients with ITP, and the methods used to measure bleeding in ITP studies. PATIENTS/METHODS: We performed a systematic review of all prospective ITP studies that enrolled 20 or more patients. Two reviewers searched Medline, Embase, CINAHL and the Cochrane registry up to May 2014. Overall weighted proportions were estimated using a random effects model. Measurement properties of bleeding assessment tools were evaluated. RESULTS: We identified 118 studies that reported bleeding (n = 10 908 patients). Weighted proportions for intracerebral hemorrhage (ICH) were 1.4% for adults (95% confidence interval [CI], 0.9-2.1%) and 0.4% for children (95% CI, 0.2-0.7%; P < 0.01), most of whom had chronic ITP. The weighted proportion for severe (non-ICH) bleeding was 9.6% for adults (95% CI, 4.1-17.1%) and 20.2% for children (95% CI, 10.0-32.9%; P < 0.01) with newly-diagnosed or chronic ITP. Methods of reporting and definitions of severe bleeding were highly variable in primary studies. Two bleeding assessment tools (Buchanan 2002 for children; Page 2007 for adults) demonstrated adequate inter-rater reliability and validity in independent assessments. CONCLUSIONS: ICH was more common in adults and tended to occur during chronic ITP; other severe bleeds were more common in children and occurred at all stages of disease. Reporting of non-ICH bleeding was variable across studies. Further attention to ITP-specific bleeding measurement in clinical trials is needed to improve standardization of this important outcome for patients.

Localization and behaviors in null mice suggest that ASIC1 and ASIC2 modulate responses to aversive stimuli.

Acid-sensing ion channels (ASICs) generate H(+) -gated Na(+) currents that contribute to neuronal function and animal behavior. Like ASIC1, ASIC2 subunits are expressed in the brain and multimerize with ASIC1 to influence acid-evoked currents and facilitate ASIC1 localization to dendritic spines. To better understand how ASIC2 contributes to brain function, we localized the protein and tested the behavioral consequences of ASIC2 gene disruption. For comparison, we also localized ASIC1 and studied ASIC1(-/-) mice. ASIC2 was prominently expressed in areas of high synaptic density, and with a few exceptions, ASIC1 and ASIC2 localization exhibited substantial overlap. Loss of ASIC1 or ASIC2 decreased freezing behavior in contextual and auditory cue fear conditioning assays, in response to predator odor and in response to CO2 inhalation. In addition, loss of ASIC1 or ASIC2 increased activity in a forced swim assay. These data suggest that ASIC2, like ASIC1, plays a key role in determining the defensive response to aversive stimuli. They also raise the question of whether gene variations in both ASIC1 and ASIC2 might affect fear and panic in humans.

Systematic review of small bowel diaphragm disease requiring surgery.

AIM: To perform a systematic review of all cases of small bowel diaphragm disease requiring surgery. Small bowel diaphragm disease is a rare complication of small bowel enteropathy secondary to the use of non-steroidal anti-inflammatory drugs (NSAIDs). The objective was to determine the presenting symptoms, duration of NSAID use, mode of diagnosis and type of surgery associated with cases of small bowel diaphragm disease requiring surgery. METHOD: A comprehensive search of the world literature between January 1980 and December 2010 was undertaken. The search terms 'diaphragm disease' and 'mucosal diaphragm disease' in combination with the terms 'surgery', 'intestine' or 'small bowel' were used. All cases of small bowel diaphragm disease requiring surgery in adult patients within the the last 30 years were included. Data including age, gender, mode of presentation, NSAID use, mode of diagnosis, form of surgery, affected area of small bowel and mortality were recorded and analysed. RESULTS: There were 55 cases of small bowel diaphragm disease requiring surgery (31F:18M) with a median age of 69 years. NSAID use occurred in 44 cases and the mean duration of NSAID use was 7 years. The most common presentation was with anaemia in combination with obstructive symptoms. The diagnosis was established by a laparotomy in 51% of cases followed by capsule endoscopy in 25% of cases. Operations performed included small bowel resection (56), combined resection and strictureplasty (three), strictureplasty (one) and hemicolectomy (two). There was only one death. CONCLUSION: Small bowel diaphragm disease presenting as a surgical emergency is likely to become more common due to the increased use of NSAIDs. A history of NSAID use in patients with iron deficiency anaemia or obstructive symptoms should lead to a high index of suspicion for this condition and should be preoperatively investigated.

The Hammersmith colorectal foot pedal.

AIM: This technical note describes use of a footpedal to switch on a rigid sigmoidoscope/proctoscope, demonstrating increased speed and efficiency of proctoscopy examination. METHOD: Use of a footpedal to control the light source of a rigid sigmoidoscope/proctoscope, enabling the user to switch the light source on and off with their foot, rather then at the wall, switch, leaving hands free. RESULTS: Benefits include increased efficiency and speed of examination with reduced time on the couch for the patient and reduced risk of the halogen lighting bulb being left switched on, thus prolonging the life of the equipment. CONCLUSION: Although we do not claim originality for its use we have found it particularly helpful and believe that its use should be more widely publicised.

Impact of laparoscopic right hemicolectomy for colon cancer.

INTRODUCTION: This study specifically examined right colonic cancer resection, a common operation for colorectal surgeons starting laparoscopic resection, to assess the impact of commencing laparoscopy. PATIENTS AND METHODS: A total of 56 patients undergoing open (n = 34) and attempted laparoscopic (n = 22) elective right hemicolectomy for colorectal cancer between November 2003 and March 2007 were compared. Postoperative stay was the primary outcome. Secondary outcomes included analgesic requirements, bowel recovery, morbidity and mortality. Frequency of laparoscopic versus open surgery over time was also examined. RESULTS: Resections attempted laparoscopically increased from 9.1% to 75% in the first and last quarters of the study period, respectively (P = 0.0002). Uptake of 'enhanced recovery' was mainly in the laparoscopic group. Conversion was required in two of 22 patients. Attempted laparoscopic cases had a shorter median postoperative stay (6 vs 10 days; P < 0.0001), duration of parenteral or epidural analgesia (48 vs 72 h; P < 0.0001) and time to first bowel action (3 vs 4 days; P = 0.001) compared with open cases. Demography, tumour characteristics, morbidity and mortality were comparable between groups. Multivariate analysis identified decreased age, attempted laparoscopic surgery, use of enhanced recovery and absence of complications as independently shortening postoperative stay. CONCLUSIONS: Advantages of laparoscopic surgery and enhanced recovery, even early in a surgeon's experience, suggest this is the preferred mode for elective right colon cancer resection.

Laparoscopic resection for colorectal cancer.

BACKGROUND: This study examined one surgeon's practice to determine the place of laparoscopic colorectal cancer surgery. METHODS: Some 365 patients undergoing elective colorectal cancer resection (219 colonic, 146 rectal) were studied prospectively. Early (1994-1997; 104 patients), middle (1998-2001; 112) and late (2002-2005; 149) cohorts were analysed with respect to suitability for laparoscopic surgery, conversion and outcome. RESULTS: Forty-six of 135 patients undergoing open resection were suitable for laparoscopic surgery but randomized to open surgery. The proportion of attempted laparoscopic resections (35.6, 65.2 and 80.6 per cent in early, middle and late cohorts) and patients thought suitable for laparoscopic resection (37.5, 87.5 and 94.0 per cent respectively; P = 0.001) increased over time. Independent predictors of conversion were rectal cancer surgery (odds ratio (OR) 3.12 versus colonic surgery) and body mass index 28 kg/m(2) or more (OR 3.87). Conversion was necessary in all five patients with a threatened margin predicted by preoperative magnetic resonance imaging. After exclusion of these patients the conversion rate in the late cohort was 8.7 per cent. During the same period, inclusion of 20 patients who were suitable for laparoscopic surgery but underwent open resection meant that 135 (90.6 per cent) of 149 patients were actually suitable for laparoscopic resection. CONCLUSION: With experience, laparoscopic surgery is feasible in around 90 per cent of elective colorectal cancer resections.

Managing behavioural symptoms of dementia: effectiveness of staff education and peer support.

This study was designed to investigate the impact of staff education on the behaviour and quality of life of residents with dementia and on staff members' attitudes about working with people with dementia and level of burnout. Staff from three aged care facilities participated in the study (n=52). These facilities were randomly assigned to one of two intervention groups or a control group. Staff assigned to the intervention groups received an eight-week behaviourally-based programme. Staff from one aged care facility also participated in a peer support group designed to reinforce educational material and facilitate positive changes among staff members. Behavioural symptoms displayed by residents (n=76) in each of the facilities were also assessed. Assessments were conducted at pre-intervention, post-intervention, three- and six-month follow-up. The results of this study indicated that education or peer support was not associated with an improvement in resident behaviour or quality of life. Education or peer support also did not impact on staff members' level of burnout. There was, however, a change in staff members' attitudes about working with people with dementia. Possible explanations for these findings and implication for further research are considered.

Endoscopic haemostasis of staple-line haemorrhage following colorectal resection.

OBJECTIVE: Bleeding from stapled colonic stapled anastomoses is rare, but occasionally may be severe enough to require re-operation, with associated morbidity. Endoscopic therapy is a potential alternative. METHOD: We examined a large 15-year prospective series of patients who had undergone colorectal resection with stapled anastomosis. We reviewed the management of cases where severe postoperative rectal bleeding had occurred. RESULTS: In six of 777 (0.8%) patients, bleeding occurred that was severe enough to require intervention. In the first three cases, conventional re-operation was performed. In the latter three cases, endoscopic therapy (adrenaline injection, diathermy or endoscopic clipping) was used to control the bleeding. No complications occurred as a result of endoscopic therapy, either patient or anastomosis related. CONCLUSION: Endoscopic management using standard endoscopic techniques appears safe and effective for haemostasis in colorectal stapled anastomotic bleeding. Endoscopic therapy should probably be attempted before re-operation is considered.