Epistaxis management at Guy's Hospital, 2009-2011: full audit cycles.

OBJECTIVE: To assess management of epistaxis at a tertiary ENT referral hospital against a recently published standard of best practice. METHODS: Fifty consecutive cases of acute epistaxis that required admission to Guy's Hospital in 2009 were evaluated. Epistaxis education sessions were held to introduce our algorithm of best practice in tandem with an emphasis on emergency department care. Similar retrospective reviews were carried out in both 2010 and 2011 (on groups of 50 patients). RESULTS AND CONCLUSION: The first audit cycle demonstrated that only 8 per cent of patients underwent a suitable nasal examination in the emergency department prior to transfer, with no documented attempts at nasal cautery. Surgical intervention procedures were performed on only 40 per cent of eligible patients. The audit cycles that followed the introduction of the epistaxis algorithm demonstrated continued improvement in initial evaluation and management of epistaxis. In select patients, sphenopalatine artery ligation can provide timely, definitive management of refractory epistaxis.

Surveillance colonoscopies for colorectal polyps--too often, too many! An Audit at a Large District General Hospital.

INTRODUCTION: The British society of Gastroenterologists (BSG) have laid down guidelines for surveillance colonoscopies in patients with large bowel adenomatous polyps. However, numerous studies have shown the gross over-utilization of colonoscopic services in their management. We audited our practice of polyp management and looked at guideline compliance amongst patients on our colonoscopic surveillance list. METHOD: All patients undergoing adenoma surveillance and those with newly detected adenomas over a 2-month period were included in the first loop of the audit. Data on the colonoscopic findings, histology and management were retrieved from paper and on-line records. The BSG guidelines were printed, laminated and displayed in the colorectal clinics. Following this, we re-audited (second loop) our practice. In the second part of the study, we randomly retrieved 533/1800 case notes from our colonoscopic waiting list. Amongst those on surveillance for polyps, compliance was ascertained as regards need for procedure and appropriateness of surveillance interval. FINDINGS: Fifty-four patients were included in the first loop and 59 during the second loop of the audit. Guidelines were followed in 16% (4/25, 95% CI: 0.054-0.33) of patients in the first loop and 46.5% (13/28, 95% CI: 0.293-0.642) in the second loop (P = 0.017). Of the patients on our colonoscopic waiting list for adenomatous polyps, 17.7% satisfied guidelines, 23.4% did not require any further surveillance and 58.9% were booked for a procedure earlier than recommended. CONCLUSION: The mere framing of guidelines is insufficient to improve clinical practice. Strategies to improve implementation need to be explored. Audit of individual practice is recommended.

[Experiences with the cancer marker CA 125 in gynecologic diseases]. / Erfahrungen mit dem Krebsmarker CA 125 bei gynäkologischen Erkrankungen.

CA 125 was determined in the sera of 94 female patients afflicted with various gynecological diseases. Benign ovarian tumors and gynecologic malignancies outside the ovaries had normal CA 125 values in most cases. Patients with ovarian carcinomas in advanced stage had high levels. 6 women, who had hepatic metastases from ovarian cancer, showed a so-called prozone effect in serum titration, that means, the CA 125 concentration at first rises to reach a peak at a dilution of 1:2 to maximally 1:20, and then reveal a normal reciprocal dilution behavior. Whether hepatic metastases as a possible source of marker production are responsible for this phenomenon should be examined in future studies.

A new monoclonal antibody (A46-B/B10) highly specific for the blood group H type 2 epitope: generation, epitope analysis, serological and histological evaluation.

A monoclonal antibody recognizing the blood group H type 2 antigen has been obtained from a BALB/c mouse immunized with MCF-7 (human mammary carcinoma) cells. The specificity of this antibody (A46-B/B10, IgM, kappa) has been identified by haemagglutination tests, immunohistochemistry, binding inhibition studies, and absorption experiments performed with synthetic oligosaccharides. The antibody is virtually nonreactive with H type 1 antigen or with closely related type 2 structures (e.g., Y antigen). A46-B/B10 strongly agglutinates human erythrocytes according to the amount of H substance expressed and can, therefore, easily discriminate between blood groups A1 and A2 as well as A1B and A2B (A1 and A1B are not or only weakly agglutinated). In immunohistochemistry, this antibody seems to provide a highly specific reagent for a restricted number of carcinomas and epithelial lineages in tissue sections and in vitro.

Monoclonal anti-H antibody A46-B/B10 suited for differentiating blood groups A1 and A2 reveals also heterogeneity within blood group B.

A monoclonal antibody (mAb) recognizing H antigen was obtained from a BALB/c mouse immunized with MCF-7 (human mammary carcinoma) cells. This antibody (A46-B/B10, IgM) has been tested on a total of 753 blood samples. It strongly agglutinates human erythrocytes of blood groups 0, A2 and A2B, but not or only very weakly A1 and A1B. This mAb promises to be useful in the determination of A and AB subgroups in blood group serology. Evidence is presented that this antibody might also be able to define B subgroups. Among 263 B blood samples, 45 (17.1%) were negative or only weakly positive with A46-B/B10.

[Atrophic corpus gastritis and autoimmune gastritis]. / Atrophische Korpusgastritis und Autoimmungastritis.

The authors tried to clarify relations between autoimmune gastritis and isolated atrophic corpus gastritis by bioptic corporal and antral examinations from 150 probands as well as examinations of gastrin in serum and parietal cell antibody tests. Only 30% of all patients examined with isolated atrophic gastritis of the corpus part revealed criteria of an autoimmune gastritis. Therefore investigations of antibodies against parietal cells are necessary to mark off both clinical pictures. This differentiation seems to be necessary regarding the high risk of gastric cancer following an autoimmune gastritis.

[Tumor marker diagnosis in non-seminomatous testicular tumors using human chorionic gonadotropin (HCG) and alpha fetoprotein (AFP)]. / Tumormarkerdiagnostik bei nicht-seminomatösen Hodentumoren mittels Humanchoriongonadotropin (HCG) und Alpha-Fetoprotein (AFP).

In 28 patients with non-seminomatous testicle tumour the tumour markers human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) were determined radioimmunologically and enzymeimmunologically, respectively. While tumours with chorionic carcinoma (n = 8) always were marker-positive, in the embryonic carcinoma in 2 out of 10 cases falsely negative findings appeared. On 5 patients the biochemical monitoring of the course of the testicle tumour disease is demonstrated in detail by means of HCG and AFP and estimated as very helpful method. Advantages and problems of the marker diagnostics are shown and discussed. The positive marker findings were absolutely evident for a metastasation. On the other hand, marker negativation was not always to be equated with absence of a tumour and demanded a further control of the patient by means of all other available methods of diagnostics up to the second-look-operation.

[The CEA-concentration in plasma of patients with colorectal carcinoma and polyps has been determined by radioimmunoassay (RIA, Z-gel-method)]. / Zur CEA-Bestimmung im Plasma von Patienten mit Karzinomen und Polypen des Kolons und Rektums.

82% of the cancer patients and 52% of the patients with polyps showed CEA levels above the upper normal limit of 2,5 microgram/1. CEA-values of more than 10 microgram/1 could only be detected in patients with carcinoma. Complete removal of the tumour by surgery has been followed by a marked decrease of prior increased plasma-CEA to values in the normal range, which could not be observed in the cases with tumour residues or metastases. In the patient's follow-up recurrence or metastases could be recognized several months before clinical detection by a renewed increased of the CEA-level in plasma.