The development of a protocol for post-mortem management of Ebola virus disease in the setting of developed countries.

The management of the recent Ebola virus disease (EVD) epidemic continues to pose currently insuperable challenges to health care providers in the resource-deprived countries of West Africa. In an age where air travel facilitates rapid movement of people between countries and continents, there is an urgent requirement for health systems around the globe to develop management strategies and protocols in the event that EVD cases are suspected or confirmed. Departments of forensic pathology play an important, and underestimated, role in public health service delivery, particularly at times of novel infectious disease emergence. This role can include disease identification, characterization, and notification, as well as close engagement with agencies responsible for disease surveillance and treatment provision. A mass outbreak of EVD in the Western world is considered highly unlikely; however, there is clear responsibility on departments of forensic pathology to develop protocols for rapid assessment of sporadic or suspected cases while ensuring the health and safety of mortuary and pathology personnel. The Ontario Forensic Pathology Service and the Victorian Institute of Forensic Medicine have collaborated on the development of a protocol for management of EVD cases presenting at a scene or in the mortuary. It is hoped that this trans-national, inter-departmental exercise will serve as a model for future co-operative endeavors. The protocol has been distributed to forensic pathology departments around Australia and may be modified to accommodate local resource capabilities.

Improved detection of adenomas and sessile serrated polyps is maintained with continuous audit of colonoscopy.

BACKGROUND: The audit process may help improve performance indicators for colonoscopy quality but it is unclear whether this is sustained over several years. METHODS: 44138 procedures for 28 endoscopists from 2004 to 2019 were analysed for polyp detection rate and withdrawal time. From 2012, 14 endoscopists were analysed with additional data on polyp histology and number of polyps removed. RESULTS: Polyp detection increased from 40.7% in 2004 to 62.2% in 2019; removal of polyps>1 cm remained constant (11%). Adenoma detection rate was 25.8% in 2012 and 28.3% in 2019. Sessile serrated polyp (SSP) detection rate increased from 4.5% to 14.7%; most of the increase was in the first 2 years of the histology part of the audit. There was a significant correlation of adenoma detection rate with mean number of adenomas (r=0.72, p=0.004) and a significant correlation of SSP detection with mean number of SSPs (r=0.85, p=0.0001). CONCLUSION: The audit process appears to encourage a higher rate of polyp detection. This was due to increased detection of smaller polyps and increased detection of SSPs.

Chromoendoscopy versus standard colonoscopy for detection of nonpolypoid dysplasia in patients with inflammatory bowel disease.

AIM: Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer. Studies show that chromoendoscopy (CE) can increase the detection of dysplasia at surveillance colonoscopy, compared to standard white light endoscopy (WLE). We performed a retrospective cohort study to compare standard WLE to CE with targeted biopsies in detecting nonpolypoid dysplasia in IBD patients undergoing surveillance colonoscopy at a single tertiary centre. METHOD: Data was collected on 110 consecutive patients with IBD who underwent surveillance colonoscopy from 1 August 2015 to 31 July 2017 at Counties Manukau District Health Board, Auckland. Patients had either WLE or CE. Patient characteristics, endoscopic and histologic descriptions were reviewed. Rates of dysplasia detection by the different endoscopic techniques were compared using an exact Poisson test. RESULTS: 76/110 (69%) had WLE (mean age 56y; median disease duration 18y) and 34/110 (31%) had CE (median age 59y; median disease duration 19y). Nonpolypoid dysplasia was detected in 0/76 (0%) patients who had WLE. Seven nonpolypoid dysplastic lesions were detected in 4/34 (11.8%) patients who had CE. Dysplasia pick up rate was significantly higher in the CE group with a risk difference of 11.8%, 95% confidence interval (0.93, 22.59), p=0.008. Dysplasia detection rate per patient was also significantly higher in the CE group with a rate difference of 20.6 lesions per 100 patients, 95% confidence interval (5.3, 35.8), p=0.0003. As expected, there was no difference between the number of polypoid dysplastic lesions found between the two groups (p=0.12). CONCLUSION: In our cohort of IBD patients undergoing surveillance colonoscopy, CE with targeted biopsy is associated with a significantly increased nonpolypoid dysplasia detection rate when compared to WLE. These results are comparable to studies performed in the rest of the world.

A fatal case of atrioesophageal fistula following radiofrequency ablation of left atrium and pulmonary veins for atrial fibrillation.

Atrial fibrillation (AF) is associated with significant morbidity and mortality. Hemodynamic compromise and formation of thrombi within the fibrillating atrium or atrial appendage can occur. Surgical treatment aims to eliminate dysrhythmia-triggering foci in the pulmonary veins and posterior left atrium by radiofrequency ablation techniques using ohmic heat. As medical treatment may be ineffective, radiofrequency catheter ablation is increasingly being used by interventional cardiac electrophysiologists for AF. Serious complications have been observed among patients who have undergone radiofrequency ablation, atrioesophageal fistula being a very rare example. This case describes a 43-year-old man who died after the development of an atrioesophageal fistula following radiofrequency ablation of the left atrium and pulmonary veins for treatment of AF.

Colonoscopy audit over 10 years--what can be learnt?

INTRODUCTION: The goals of colonoscopy are changing over time and it is important to regularly determine if endoscopists are achieving key performance indicators. METHODS: Data on key performance indicators were recorded independently by nursing staff for all colonoscopies performed during a 10-year period. The results were discussed at regular meetings and feedback given to endoscopists. RESULTS: Audit data was recorded for 67,570 procedures. The key performance indicators (time to caecum, withdrawal time, adjusted caecal intubation rate and polyp detection rate) all improved over the audit period (p<0.0001 for trend). For each endoscopist the mean withdrawal time was highly variable ranging from 3.1 mins (95%CI 3.0; 3.1) to 11.2 mins (11.0; 11.3). For each endoscopist mean polyp detection rate varied from 29% (CI 26, 31%) to 69% (CI 68, 70%). There was a significant correlation between mean withdrawal time and mean polyp detection rate for each endoscopist (r=0.42; p=0.03). The polyp detection rate improved from 29% in 1999 to 49% in 2010. The proportion of procedures with more than 2 polyps increased from 22% in 2001 to 33% in 2010. There was a significant association of patient discomfort with time to caecum and also to level of consciousness, p<0.0001. There was a significant decrease in the proportion with significant discomfort over the audit period, p<0.0001. CONCLUSIONS: Colonoscopy audit as a routine process with data collection by endoscopy nurses over several years may be able to improve key performance indicators by the process of regular feedback to endoscopists. Audit should be encouraged as a routine process rather than simply as a research tool for a limited period.

Case report: acute postoperative neurological impairment from fat embolism syndrome.

PURPOSE: To describe a case of fat embolism syndrome (FES) following elective tendon contracture release in a patient with myotonic dystrophy, to highlight the importance of considering this entity in the differential diagnosis of acute postoperative neurocognitive dysfunction. CLINICAL FEATURES: A 34-yr-old man with myotonic dystrophy underwent uneventful tendon contracture release under regional anesthesia. In the immediate postoperative period, neurological and respiratory complications developed, requiring intensive care support. The patient showed the classical clinical triad of hypoxemia, neurological impairment and a petechial rash associated with the FES. A diagnosis of FES was made and, despite therapy including fluid and inotropic support, the patient succumbed to the condition. There was no demonstrated intracardiac shunt, suggesting a physiological intrapulmonary shunt was responsible for the development of systemic manifestations of FES. CONCLUSIONS: Postoperative neurological dysfunction is a difficult condition with numerous possible causes. All possible etiologies, including FES, need to be considered in the differential diagnosis and postoperative management of patients developing acute postoperative neurological impairment and hypoxemia.