Postoperative mortality in children after 101,885 anesthetics at a tertiary pediatric hospital.

BACKGROUND: Mortality is a basic measure for quality and safety in anesthesia. There are few anesthesia-related mortality data available for pediatric practice. Our objective for this study was to determine the incidence of 24-hour and 30-day mortality after anesthesia and to determine the incidence and nature of anesthesia-related mortality in pediatric practice at a large tertiary institution. METHODS: Children ≤ 18 years old who had an anesthetic between January 1, 2003, and August 30, 2008, at the Royal Children's Hospital, Melbourne, Australia, were included for this study. Data were analyzed by merging a database for every anesthetic performed with an accurate electronic record of mortality of children who had ever been a Royal Children's Hospital patient. Cases of children dying within 30 days and 24 hours of an anesthetic were identified and the patient history and anesthetic record examined. Anesthesia-related death was defined as those cases whereby a panel of 3 senior anesthesiologists all agreed that anesthesia or factors under the control of the anesthesiologist more likely than not influenced the timing of death. RESULTS: During this 68-month period, 101,885 anesthetics were administered to 56,263 children. The overall 24-hour mortality from any cause after anesthesia was 13.4 per 10,000 anesthetics delivered and 30-day mortality was 34.5 per 10,000 anesthetics delivered. The incidence of death was highest in children ≤ 30 days old. Patients undergoing cardiac surgery had a higher incidence of 24-hour and 30-day mortality than did those undergoing noncardiac surgery. From 101,885 anesthetics there were 10 anesthesia-related deaths. The incidence of anesthesia-related death was 1 in 10,188 or 0.98 cases per 10,000 anesthetics performed (95%confidence interval, 0.5 to 1.8). In all 10 cases, preexisting medical conditions were identified as being a significant factor in the patient's death. Five of these cases (50%) involved children with pulmonary hypertension. CONCLUSIONS: Anesthesia-related mortality is higher in children with heart disease and in particular those with pulmonary hypertension. The lack of anesthetic-related deaths in children who did not have major comorbidities reinforces the safety of pediatric anesthesia in healthy children.

Clinical significance of questionnaire-elicited or clinically reported anorectal symptoms for rectal Neisseria gonorrhoeae and Chlamydia trachomatis amongst men who have sex with men.

BACKGROUND: Although Neisseria gonorrhoeae (Ng) and Chlamydia trachomatis (Ct) are common infections in men who have sex with men, it is unclear from previous studies whether anorectal symptoms are reliable clinical indicators of infection. AIM: The objective of the study was to investigate the clinical significance of questionnaire-elicited or clinically reported anal symptoms for rectal Ng and Ct. METHODS: During 2002 to 2003, men who have sex with men (MSM) screened or tested for Ng or Ct according to the national guidelines were invited to participate in a questionnaire. RESULTS: During the study period, 366 MSM were enrolled into the study (88% recruitment rate), of whom 20 (5%) and 25 (7%) were diagnosed with rectal Ng or Ct, respectively. Overall, 'any' anorectal symptoms on a questionnaire were reported equally by those with and without rectal Ng (75 v. 74%, P=0.69), but heavy anal discharge (P<0.01) and anal pain (P=0.04) were more common in those with rectal Ng. Symptoms on the questionnaire were not different among those with and without Ct. Any anal symptoms were reported substantially more often via questionnaire than in a clinical consultation (75 v. 16%, P<0.01) and symptoms reported in a clinical consultation were not associated with Ng or Ct detection. CONCLUSION: The weak or absent association between symptoms and the presence of Ct or Ng highlights the importance of annual sexually transmitted infection screening in MSM regardless of symptoms.

Comprehensive clinical care on-site in men-only saunas: confidential STI/HIV screening outreach clinic.

During 2001 and 2002 an anonymous outreach-screening programme in Melbourne, Australia, offered testing for gonorrhoea and chlamydia on-site at men-only saunas. Modifications were made to this screening programme to offer a comprehensive testing clinic for sexually transmissible infections (STIs), including HIV. The comprehensive clinic was evaluated after one year of operation, and comparisons were made with the earlier anonymous screening programme. The comprehensive outreach clinic made contact with fewer men (n = 557), however, men tested had a higher prevalence of gonorrhoea and chlamydia (17%), and all men tested positive for STIs/HIV were followed up. The findings and comparisons outlined in this paper may be used for different communities to decide what screening programme model best suits their individual situation: anonymous programme with fewer tests offered, confidential and comprehensive STI/HIV testing programme, or both. On the basis of our evaluation, we have opted to continue the comprehensive STI/HIV testing programme in local men-only saunas.

Introduction of screening guidelines for men who have sex with men at an STD clinic, the Melbourne Sexual Health Centre, Australia.

BACKGROUND: A recent audit indicated that a substantial proportion of men who have sex with men (MSM) were not screened for rectal gonorrhoea and chlamydia at the Melbourne Sexual Health Clinic, Melbourne, Australia. In response, screening guidelines for MSM were introduced at the clinic using a computer reminder. The aim of this study was to evaluate the impact of the guidelines and alert on screening MSM for gonorrhoea and chlamydia. METHODS: The medical records of MSM were reviewed for gonorrhoea and chlamydia screening by site (pharyngeal, urethral and rectal), four months before the implementation of the guidelines and alert (July to October 2002), and one year thereafter (beginning November 2002). RESULTS: After the introduction of the guidelines there was a significant increase in rectal chlamydia testing (55% to 67%, P < 0.001), and significant reduction in pharyngeal chlamydia and gonorrhoea testing (65% to 28%, P < 0.001, and 83% to 76%, P = 0.015 respectively). The proportion of tests that were positive by any site did not change (7% to 7%). CONCLUSIONS: The introduction of a computer reminder for new guidelines was temporally associated with screening that conformed more closely to clinical guidelines.

Variability of the Chlamydia trachomatis omp1 gene detected in samples from men tested in male-only saunas in Melbourne, Australia.

A recent screening program in Melbourne, Victoria, Australia, has shown that Chlamydia trachomatis is an important infection among men who frequent male-only saunas. To evaluate the C. trachomatis isolates circulating in local saunas, the C. trachomatis-positive samples collected during the program underwent amplification and sequencing of the omp1 gene, and the corresponding serovars were deduced. Forty-seven C. trachomatis-positive samples collected (from October 2001 to September 2002) from 39 men were evaluated. The deduced serovars found, in descending order of prevalence, were D, G, and J; and serovars B, E, F, and H were each found in single samples. The seven different serovars identified in the study sample indicate that local saunas are a reservoir of multiple C. trachomatis strains, possibly maintained by the introduction of new patrons or regular patrons who have been exposed to C. trachomatis elsewhere. No significant genetic variants were found, as most variable positions were silent and were detected only in single samples.