Investigating the frail elderly patient with lower bowel symptoms: what do we do now and can we improve?

AIMS: To assess the utility of flexible sigmoidoscopy (FS) and minimal preparation CT (MPCT) in investigating lower gastrointestinal (LGI) symptoms in elderly patients who are too frail to undergo colonoscopy or spiral CT. METHODS: All FS examinations performed in patients aged over 70 between 1 January and 31 December 2008 were analysed. Predictors of usefulness were determined using multivariable analysis. In patients who also underwent MPCT, we analyzed the correlation between FS and MPCT. RESULTS: 426 FS were performed. Bowel preparation was inadequate in 24% of procedures. Indications in which FS was useful were: radiological abnormality (odds ratio [OR] 9.32), history of polyps (OR 4.54) and rectal bleeding (OR 1.73). Indications for which FS was least useful were: change in bowel habit (OR 0.22), diarrhoea (OR 0.46) and constipation (OR 0.38). CONCLUSIONS: LGI investigation in frail elderly patients can be rationalised according to indication. Performing FS and MPCT together is not always necessary.

Barriers to implementing a policy not to attempt resuscitation in acute medical admissions: prospective, cross sectional study of a successive cohort.

OBJECTIVE: To establish whether acutely unwell patients admitted to hospital wish to participate in discussions about resuscitation. DESIGN: Prospective, cross sectional study of a successive cohort of patients. SETTING: Admission through the emergency department. PARTICIPANTS: 374 adult patients. MAIN OUTCOME MEASURE: Whether acutely unwell patients wished to participate in discussions about resuscitation. RESULTS: Of the total sample, 74 patients consented to take part in the study and provide full data. Of the remaining patients, 189 could not be approached for practical reasons and 111 did not wish to participate. Of the 74 patients who read the leaflet, 65 (88%) reported having little or no prior knowledge, 70 (96%) understood it, 56 (77.8%) preferred for resuscitation decisions to be discussed with them, and 55 (77.5%) did not mind discussing resuscitation within 24 hours of admission and overall showed a decline in their anxiety score. CONCLUSION: Many patients admitted through the emergency department for medical reasons cannot participate in their decision not to attempt resuscitation within 24 hours of admission. Patients who were willing to participate rated the information leaflet that was provided positively.

Prevention of percutaneous endoscopic gastrostomy site infections caused by methicillin-resistant Staphylococcus aureus.

Percutaneous endoscopic gastrostomy (PEG) is widely used to maintain enteral nutrition in patients who are unable to swallow. Peristomal wound infection is the most common complication of this procedure. In a hospital endemic for methicillin-resistant Staphylococcus aureus (MRSA), MRSA can be the most common organism associated with these infections. We have evaluated a strategy consisting of screening, skin decontamination and glycopeptide prophylaxis for preventing PEG-site infections. None of the 34 patients who received the decontamination protocol and glycopeptide prophylaxis (Group A) developed PEG-site infections within one month of surveillance. Two patients were infected with MRSA after that period. One of seven patients who received the decontamination protocol alone (Group B) was infected within the period of surveillance, while another patient was infected after that period. Both were infected with MRSA. None of nine patients who received glycopeptide prophylaxis alone (Group C) were infected. The results suggest that the strategy of screening, decontamination and glycopeptide prophylaxis is effective in the prevention of PEG-site infections with MRSA. Further trials are necessary to confirm these findings.

Commitment to change statements: a way of understanding how participants use information and skills taught in an educational session.

BACKGROUND: Commitment to change has gained increasing use in assessing short course effectiveness. This study examined the changes that learners intended to make in practice following an intensive day-long course offered at multiple sites, counted changes relative to the curriculum's focus, and analyzed which changes were implemented in practice. METHODS: Participants at a course on the management of male sexual dysfunction were asked to identify the changes to which they would commit. Six months after the course, they were asked to indicate which changes they implemented fully, partially, or not at all. RESULTS: A total of 352 physicians attended the courses held in 21 centers. A majority of attendees (344 or 97.7%) completed forms at the end of the course, providing 1,635 commitment statements. Six months later, 197 (57.3%) physicians provided follow-up data about 935 (55.4%) of the commitment statements originally submitted. Of these, 602 (66.52%) were completely implemented. Many of the changes related to two specific aspects of the course, namely, sexual history taking and medical intervention, accounting for 45.93% of the intended commitments and 47.67% of the changes completely implemented. Slightly over half (58%) of the course time was devoted to these two areas. There was a significant correlation between the number of changes and the amount of time allocated to that content within the course. FINDINGS: Commitment to change statements offered by course participants can be used to examine the impact of a course relative to its learning focus. Continuing medical education providers must take a critical look at commitment to change statements as an "intervention" in their own right and determine how the tool can best be used as a continuing medical education intervention.

Sex and familiarity of colonoscopists: patient preferences.

BACKGROUND AND STUDY AIMS: The gender preference of patients for doctors has been noted in many areas of medicine, but has never been studied in those undergoing the potentially embarrassing procedures of colonoscopy and sigmoidoscopy. We were interested in whether patients did express a preference for either the sex of a doctor, or a doctor whom they had previously met, so that we might in future consider offering a choice of endoscopist. PATIENTS AND METHODS: A total of 101 patients attending for colonoscopy or flexible sigmoidoscopy were prospectively asked to complete an anonymous questionnaire enquiring about gender preference and preference for an endoscopist with whom they were familiar. The questionnaire also asked about the patient's age and whether patients felt sufficiently strongly about their choice that they would be prepared to wait longer for the procedure if necessary. RESULTS: The response rate for completion of the questionnaire was 100% (65 female patients and 34 male patients, with two patients not disclosing their sex). Among the female patients, 48% preferred a female colonoscopist, whereas no male patients preferred a male colonoscopist (chi2 = 26.8, df = 2; P < 0.0001). Women also felt more strongly about seeing a familiar colonoscopist, with 56% of women and 35% of men preferring the same doctor they had seen in the outpatient department to perform the test (chi2 = 21.2, df = 2, P < 0.0001). CONCLUSION: By offering the choice of a female endoscopist to female patients, and a doctor that the patient has already met in the outpatient department to perform the procedure, the stress of lower gastrointestinal endoscopy might be minimized. This might reduce the proportion of patients failing to attend for booked procedures and thereby increase both the detection of serious pathology and the efficiency of the endoscopy unit.

Changing physicians' practices: the effect of individual feedback.

OBJECTIVE: To determine whether physicians who received feedback from six peers, six referring/referral physicians, six co-workers, and 25 patients about 55 aspects of their medical practices (e.g., able to reach doctor by phone after office hours) would make changes to their practices based on that feedback. METHOD: In an earlier study, 308 physicians were given feedback about 106 aspects of their practices in the form of mean Likert-scale ratings that (1) the peers made on 26 aspects; (2) the referring/referral physicians made on 23 aspects; (3) the co-workers made on 17 aspects; and (4) the patients made on 40 aspects. Three months later 255 of these physicians responded when asked to indicate whether they had contemplated or initiated changes, or whether no change had been necessary, regarding 31 practice aspects, each of which was a summary of one or more of 55 of the original 106 aspects on which they had received ratings. These 55 were considered the aspects most amenable to change over a short period. The physicians were also asked about the educational interventions that they felt would help them make changes. Multivariate analysis of variance was used to see whether the types of changes reported for the specific aspects of practice were associated with the feedback ratings received for those aspects. RESULTS: An examination of the responses showed that 83% of the 255 physicians reported having contemplated a change, and 66% reported having initiated a change for at least one aspect of practice. Changes were contemplated most frequently for aspects of practice associated with clinical skills and resource use. Changes were initiated most frequently for aspects of practice associated with communication with patients and support of patients. Physicians who contemplated or initiated changes had lower (i.e., more negative) mean ratings than did physicians who reported that no change was necessary, which suggests that the physicians did use their feedback ratings to decide about changes, although their qualitative comments indicated other sources as well. Printed material was chosen most often as a method of receiving continuing medical education related to making changes in the practice areas examined.

Assessment of physician performance in Alberta: the physician achievement review.

The College of Physicians and Surgeons of Alberta, in collaboration with the Universities of Calgary and Alberta, has developed a program to routinely assess the performance of physicians, intended primarily for quality improvement in medical practice. The Physician Achievement Review (PAR) provides a multidimensional view of performance through structured feedback to physicians. The program will also provide a new mechanism for identifying physicians for whom more detailed assessment of practice performance or medical competence may be needed. Questionnaires were created to assess an array of performance attributes, and then appropriate assessors were designated--the physician himself or herself (self-evaluation), patients, medical peers, consultants and referring physicians, and non-physician coworkers. A pilot study with 308 physician volunteers was used to evaluate the psychometric and statistical properties of the questionnaires and to develop operating policies. The pilot surveys showed good statistical validity and technical reliability of the PAR questionnaires. For only 28 (9.1%) of the physicians were the PAR results more than one standard deviation from the peer group means for 3 or more of the 5 major domains of assessment (self, patients, peers, consultants and coworkers). In post-survey feedback, two-thirds of the physicians indicated that they were considering or had implemented changes to their medical practice on the basis of their PAR data. The estimated operating cost of the PAR program is approximately $200 per physician. In February 1999, on the basis of the operating experience and the results of the pilot survey, the College of Physicians and Surgeons of Alberta implemented this innovative program, in which all Alberta physicians will be required to participate every 5 years.

Concordance in communication between surgeon and patient.

OBJECTIVES: To examine (1) the capability of using interactive voice response (IVR) system technology for clinical research studies involving assessment of clinician-patient interactions and (2) the concordance of surgeons and their breast cancer patients about the content of a postbiopsy pre-treatment decision meeting. DESIGN: A descriptive comparison of the perceptions of 2 volunteer groups--surgeons and their patients--using interactive voice technology. SETTING: Surgeons' offices. PARTICIPANTS: Twenty-six dyads of surgeons and their patients with newly diagnosed breast cancer. OUTCOME MEASURES: Concordance as determined through a 15-item patient questionnaire and a parallel 11-item surgeon questionnaire addressing surgical and psychosocial aspects of breast cancer treatment. RESULTS: Fifty-four percent to 100% of the 26 dyads indicated concordance about treatment preference, treatment choice, how treatment was chosen, preference for how treatment was chosen, time for discussion about treatment, and discussion about lymph-node removal. Only 27% to 50% of dyads agreed about patient understanding of lymph-node removal, the thoroughness of discussions about adjuvant treatment, the thoroughness of discussion about emotional coping, and the sufficiency of time for the discussion of patient's concerns. In these areas of disagreement surgeons often underestimated the patient's ability to understand and underestimated the patient's perception of the thoroughness of discussions about the psychosocial aspects of the illness (concerns and coping). CONCLUSION: Surgeons and patients demonstrated concordance on their perceptions of the type of treatment desired and needed but were discordant on their perceptions of the degree of patients' understanding about post-treatment and psychosocial issues.

Mycobacterial DNA not detected in liver sections from patients with primary biliary cirrhosis.

BACKGROUND/AIMS: Recent studies in primary biliary cirrhosis have reported the detection of serum antibodies against Mycobacterium gordonae and of mycobacterial DNA in liver sections. The aim of this study was to investigate whether mycobacterial DNA is present in liver biopsy material in primary biliary cirrhosis. METHODS: Archival liver biopsy specimens from 11 patients with primary biliary cirrhosis (10 female, mean age 52 years) and 11 patients with autoimmune hepatitis (10 female, mean age 53 years) were identified. Positive control tissue comprised five archival lymph node specimens from patients with tuberculous lymphadenopathy, three of which had stained positive on ZN staining, and also a liver biopsy specimen from a patient with tuberculous hepatitis (ZN positive). Fixed sections were deparaffinised and DNA was extracted by mechanical disruption with glass beads. DNA was purified by use of diatoms and lysis in guanidinium thiocyanate in a technique previously validated for archival DNA. Primers were directed to amplify a partial 16S ribosomal RNA gene yielding the species-specific character for mycobacteria, and also to amplify the constitutively-expressed human gene GAPDH. RESULTS: The polymerase chain reaction was shown to be capable of detecting 1 fg of M. gordonae DNA in 'spiked' samples, equivalent to 1-5 bacterial cells. No mycobacterial DNA was detected in liver biopsy samples from either the primary biliary cirrhosis or autoimmune hepatitis groups. Of the tuberculous control sections, mycobacterial DNA was detected in four of five lymph nodes and the liver biopsy specimen. GAPDH amplification was detected in all tested samples from liver disease and tuberculous control samples. CONCLUSION: These data do not support a role for mycobacteria in the aetiology of primary biliary cirrhosis.

Chronic ecstasy (3,4-methylenedioxymetamphetamine) abuse: a recurrent and unpredictable cause of severe acute hepatitis.

Fifteen reports of hepatitis induced by ecstasy (MDMA, 3,4-methylenedioxymetamphetamine) have been published over the last 3 years. With the increasing enthusiasm for "Rave" parties, the incidence appears to be increasing, and is an important and often concealed cause of acute hepatitis in young people. We report two cases of recurrent ecstasy-associated hepatitis where the interval between drug consumption and jaundice was variable and the link therefore initially obscured. Liver biopsies of both patients showed acute hepatitis. One was of relatively mild degree, and the other was severe, with features suggesting auto-immune hepatitis. Both cases resolved spontaneously. A high index of suspicion and careful specific enquiry are necessary to make the diagnosis and warn the patient to abstain in future, since subsequent attacks may be fatal and insidious chronic damage may occur.

Mycobacterial granulomatous inflammation in the ulcerated caecum of indomethacin-treated rats.

We report mycobacterial granulomatous inflammation in the ulcerated caecum of rats that received indomethacin. Two groups of male rats were treated with dietary indomethacin 3 mg/kg/day or untreated diet for 3 weeks. Six out of 8 indomethacin treated rats showed both ulceration and inflammation of the caecal mucosa. Two of the rats showing caecal ulceration also showed distinct granulomatous inflammation of the caecal mucosa and acid-fast bacilli were identified within granulomata. None of the other indomethacin treated or control rats contained acid-fast bacilli within caecal tissue sections but they were present, in the same sections, within the lumen of most rats in both groups. Polymerase chain reaction analysis identified the mycobacterial 65 kDa GroEL gene within control and granulomatous caecal tissue. In a repeat of indomethacin administration to a third group of rats, culture of both non-granulomatous caecal tissue (containing histologically identified luminal acid-fast bacilli) and faecal samples for mycobacteria was negative.

Specific detection of Mycobacterium paratuberculosis DNA associated with granulomatous tissue in Crohn's disease.

The role of mycobacteria, specifically Mycobacterium paratuberculosis, in Crohn's disease has aroused considerable controversy for many years. Using the ultra sensitive polymerase chain reaction some studies have reported detection of M paratuberculosis DNA in as many as 65% of Crohn's disease patients but also in patients without disease. Other studies have been negative for both groups. We therefore designed a double blind control trial to investigate the presence of mycobacterial DNA in age, sex, and tissue matched paraffin wax embedded tissues from 31 Crohn's disease tissues, 20 diseased gut control tissues, and 10 ulcerative colitis tissues. The specimens were coded and analysed blind with three separate polymerase chain reactions (PCR) based on DNA sequences specific for M paratuberculosis (IS900), M avium (RFLP type A/1) (IS901), and the Mycobacterium genus (65 kDa gene, TB600). The number of granulomata and presence of acid fast bacilli in each Crohn's disease tissue was also investigated. The sensitivity of the system was determined using similarly prepared gut tissue from an animal infected with M paratuberculosis. Four of 31 Crohn's disease tissues and none of the 30 control and ulcerative colitis derived tissues amplified M paratuberculosis DNA. Crohn's disease tissues containing granulomata were significantly more likely to amplify M paratuberculosis specific DNA on PCR than the non-Crohn's disease tissues (p = 0.02). All the positive Crohn's disease tissues contained granulomata, and none contained acid fast bacilli. Equivalent numbers of Crohn's and non-Crohn's disease tissues amplified the region of the 65 kD gene on PCR for non-specific mycobacterial DNA (11/31 and 9/30 respectively). No sections produced an amplified product with the IS901 PCR. These results suggest that few Crohn's disease gut biopsy sections contain M paratuberculosis DNA in association with granulomata. The absence of such DNA in any control and ulcerative colitic tissue strengthens the case for it having a specific association, which may be pathogenic, with Crohn's disease in this minority of patients.