Clinical audit: recent practice in caring for patients with acute severe colitis compared with published guidelines--is there a problem?

BACKGROUND: Acute severe colitis (ASC) is a serious condition with possible outcomes of emergency colectomy and mortality. Validated guidelines exist to help avoid these. AIMS: To examine local adherence to guidelines and identify (a) opportunities to improve care and (b) possible barriers to adherence. METHODS: Retrospective, hospital-wide audit of all patients with ASC during a 2-year period (2009-2010) at a major metropolitan hospital. Cases were identified by an electronic search of all discharges with International Classification of Diseases-10 codes for colitis, colectomy, ulcerative colitis or Crohn disease. RESULTS: Twenty-six patients had 30 ASC admissions (14 female). Most admissions were under gastroenterology (25), 4 (13%) were under general medicine and 1 was under general surgery. Only 8 patients' (26%) management (all under gastroenterology) included all major details: blood investigations, Clostridium difficile test, abdominal X-ray, colonic examination and venous thromboembolism prophylaxis. Only one patient had formal severity scoring on admission, and seven patients (24%) had descriptive severity recorded. On day 3, nine patients (30%) had some recorded severity assessment; however, no formal criteria were used. Four had colectomy, three during first admission and one on re-admission. Of these patients, three received cyclosporine prior to colectomy. The mean duration of admission was 10 days (standard deviation 10.54, range 1-61). CONCLUSION: Opportunities to optimise care exist including formal severity assessments on days 1 and 3, better deep vein thrombosis/pulmonary embolism prophylaxis and prompt colonic examination. Admission under teams other than gastroenterology appeared to be a barrier to better care. Despite the low rate of ideal management, the colectomy rate was acceptably low at 20%.

Potentially avoidable surgery in inflammatory bowel disease: what proportion of patients come to resection without optimal preoperative therapy? A guidelines-based audit.

BACKGROUND: Recently, promulgated inflammatory bowel disease (IBD) guidelines seek to decrease the need for surgery by improving disease control. However, resection rates remain static. AIMS: We therefore sought to determine the proportion of patients coming to surgery where preoperative management was not optimal according to guidelines. METHODS: Case notes of all patients with resection surgery for IBD from January 2007 to March 2008 at a metropolitan teaching hospital were retrospectively reviewed. Judgement was made as to whether preoperative management was optimal or suboptimal depending on whether it met guidelines. RESULTS: A total of 22 subjects with IBD-related resections were identified (15 males and seven females). In total, 17 had Crohn's disease (CD) (11 males) and five ulcerative colitis (UC) (four males). There were 10 smokers (nine CD and one UC). The two most common indications for surgery were inflammatory mass/abscess (n= 8) and refractory to medical therapy (n= 7). While all patients with known IBD (20/22) had seen a gastroenterologist in the past, five known IBD patients had resections undertaken without preoperative gastroenterologist input. Overall preoperative management was judged as optimal in only (9/22) 41%. Of those whose therapy did not meet guidelines (n= 13), five had azathioprine at doses <2 mg/kg, one declined therapy and nine with CD were current smokers. CONCLUSIONS: Over 50% of IBD resection patients had suboptimal preoperative management, with sub-therapeutic thiopurine dosing and smoking in CD the main problems. Thus, there are significant gains to be made with better use of standard therapies, as it appears that ∼50% of resection surgery was 'potentially avoidable'.

QTL for meat tenderness in the M. longissimus lumborum of cattle.

Meat tenderness has been difficult to improve using standard genetic selection. Marker assisted selection holds great promise if markers for meat tenderness can be identified. Here, we report quantitative trait loci (QTL) for beef tenderness identified in 598 animals of three Charolais-Brahman x Belmont Red pedigrees after screening the whole genome using 183 DNA markers. In addition to the usual Warner-Bratzler peak force measurements, tenderness was also measured using compression, adhesion and pressure-heat-treated peak force. Three QTL for meat tenderness in the M. longissimus lumborum muscle were found, two of which have not been reported before. One is located in the HEL9-CSSM47 interval on bovine chromosome 8 with a LOD of 3.1 and an effect of 1.02 phenotypic standard deviations for tensile strength of cooked muscle as measured by adhesion. A second QTL is located near CSRM60 on bovine chromosome 10 with a LOD of 2.4 and an effect of 0.48 phenotypic standard deviations for compression. The third QTL is in a region of bovine chromosome 7 that has previously been reported to have a QTL affecting peak force. This region also shows effects on compression and a combined tenderness index. These QTL are all for the myofibrillar component of meat tenderness. No QTL were found for pressure-treated peak force, which is an estimate of the connective tissue component muscle of meat tenderness.

A meta-analytic assessment of a thyroglobulin marker for marbling in beef cattle.

A meta-analysis was undertaken reporting on the association between a polymorphism in the Thyroglobulin gene (TG5) and marbling in beef cattle. A Bayesian hierarchical model was adopted, with alternative representations assessed through sensitivity analysis. Based on the overall posterior means and posterior probabilities, there is substantial support for an additive association between the TG5 marker and marbling. The marker effect was also assessed across various breed groups, with each group displaying a high probability of positive association between the T allele and marbling. The WinBUGS program code used to simulate the model is included as an Appendix available online at www.edpsciences.org/gse.

Death, disease and diversity in Australia, 1951 to 2000.

There has been a substantial decline in mortality in Australia during the 20th century, with a major improvement in life expectancy. There has been a broad "health transition", from a pattern of high mortality from infectious diseases to one of lower overall mortality from non-communicable diseases and injury. From 1951, trends in death rates from major causes were evident, with the rise and partial fall of two epidemics (coronary heart disease and stroke, and lung cancer). This overall picture masks significant inequalities in health for Indigenous people and the socioeconomically disadvantaged.

Genetic diversity of Asian water buffalo (Bubalus bubalis): mitochondrial DNA D-loop and cytochrome b sequence variation.

Swamp and river buffalo mitochondrial DNA (mtDNA) was sequenced for 303 bp of the cytochrome b gene for 54 animals from 14 populations, and for 158 bp of the D-loop region for 80 animals from 11 populations. Only one cytochrome b haplotype was found in river buffalo. Of the four haplotypes identified in swamp buffalo, one found in all populations is apparently ancestral both to the other swamp haplotypes and to the river haplotype. The phylogenetic relationships among the 33 D-loop haplotypes, with a cluster of 11 found in swamp buffalo only, also support the evolution of domesticated swamp and river buffalo from an ancestral swamp-like animal, most likely represented today by the wild Asian buffalo (Bubalus arnee). The time of divergence of the swamp and river types, estimated from the D-loop data, is 28,000 to 87,000 years ago. We hypothesise that the species originated in mainland south-east Asia, and that it spread north to China and west to the Indian subcontinent, where the rive type evolved and was domesticated. Following domestication in China, the domesticated swamp buffalo spread through two separate routes, through Taiwan and the Philippines to the eastern islands of Borneo and Sulawesi, and south through mainland south-east Asia and then to the western islands of Indonesia.

Acid pump inhibitors. The treatment of gastroesophageal reflux.

BACKGROUND: The place of acid pump inhibitors at the top of the efficacy table in the league of reflux therapies, and their eager patient acceptance, has aroused debate on their role. OBJECTIVE: To understand the role of gastric acid and its inhibition in the pathogenesis and treatment of gastroesophageal reflux disease. DISCUSSION: Gastroesophageal reflux disease results from excessive exposure of the oesophagus to acidic contents. Acid pump inhibitors provide the most effective medical control of gastric acid throughout day and night, returning oesophageal pH to normal levels. They provide fast symptom relief and rapidly restore quality of life in all reflux patients more effectively than H2 receptor antagonists or prokinetic drugs. APIs heal oesophagitis of all grades of severity and provide safe, effective maintenance of healing with prevention of complications in longer term use.

Genetic diversity of Asian water buffalo (Bubalus bubalis): microsatellite variation and a comparison with protein-coding loci.

Twenty-one microsatellite loci in 11 populations of Asian water buffalo (eight swamp, three river type) were analysed and, within and among populations, genetic variability was compared with results from 25 polymorphic protein-coding loci. Within-population mean heterozygosity ranged from 0.380-0.615, approximately twice that estimated from the protein-coding loci (0.184-0.346). Only eight significant departures from Hardy-Weinberg equilibrium (involving four loci) were detected; global tests showed significant heterozygote deficiencies for these four loci. Non-amplifying alleles are likely to be segregating in some or all populations for one of these loci, and probably for the other three. There was significant differentiation between the swamp and river types of water buffalo, and among populations within each buffalo type. Estimates of theta (measure of population differentiation) for each locus for the eight swamp populations were all highly significant (mean theta = 0.168 +/- 0.018). Mean theta for protein-coding loci was not significantly different (0.182 +/- 0.041). The variance among protein-coding loci was significantly higher than among microsatellite loci, suggesting balancing selection affecting allele frequencies at some protein-coding loci. Genetic distances show clear separation of the swamp and river types, which were estimated to have diverged at least 10,000-15,000 years ago. The topology of the swamp populations' microsatellite tree is consistent with their geographical distribution and their presumed spread through south-east Asia. By contrast, the tree based on the protein-coding loci distances is quite different, being clearly distorted by a bottleneck effect in one population, and possibly in at least two others. As many domestic livestock breeds are possibly descended from small numbers of founders, microsatellite-based trees are to be preferred in assessing breed genetic relationships.

New markers on bovine chromosome 1 are closely linked to the polled gene in Simmental and Pinzgauer cattle.

In this study, four new markers located on bovine Chromosome 1 were tested for linkage with the polled condition in the Simmental and Pinzgauer breeds. The microsatellites INRA212 (D1S42) and the gene for keratin-associated protein 8 (KAP8) show significant linkage with polled at theta = 0.00 (Lod = 6.92), and theta = 0.033 (Lod = 6. 52) respectively. The microsatellite INRA117 (D1S20) and the gene for interferon-alpha receptor (IFNAR) show maximum Lod scores of 2.1 and 1.8 at a recombination rate of zero.

Evidence for a major gene determining the resistance of Indonesian Thin Tail sheep against Fasciola gigantica.

The genetic basis of the high resistance of Indonesian Thin Tail (ITT) sheep against Fasciola gigantica has been studied by measuring the resistance levels of ITT sheep, St. Croix sheep and their F2 and F3 crossbreds. All of the sheep were bred and reared in the same environment. Approximately half of the F2 and F3 crossbreds were as resistant as the ITT parental breed, one-quarter had the low resistance of the St. Croix parental breed and the rest had an intermediate level of resistance. It is concluded that the high resistance is determined by a major gene with incomplete dominance. The prevalence of the gene in the ITT sheep population is estimated to be about 90%. The resistance may be innate or acquired; but, regardless of the mechanism, it could be used to control fasciolosis caused by F. gigantica by breed substitution or by crossbreeding with other breeds of sheep.

Modulatory effect of esophageal intraluminal mechanical and chemical stressors on salivary prostaglandin E2 in humans.

As has been demonstrated, infusion of hydrochloric acid (HCl) and pepsin into the human esophageal lumen, which mimics the natural gastroesophageal reflux, results in a significant increase in salivary volume, salivary bicarbonate and epidermal growth factor. However, the impact of intraluminal acid/pepsin solution on salivary prostaglandin E2 (sPGE2), the major protective factor of the upper alimentary tract, has never been explored. Therefore, using the newly developed esophageal perfusion model, the impact of both mechanical and chemical stimuli of the esophagus on sPGE2 secretion in humans was studied. Salivary PGE2 was assessed in saliva collected during basal conditions, chewing of parafilm, placement of intraesophageal tubing, inflation of intraesophageal balloons, and perfusion with sodium chloride, HCl, or HCl/pepsin solutions. The concentration of sPGE2 was measured using the RIA kit from Amersham (Arlington Heights, IL) after the solid-phase extraction and derivatization. The concentration of sPGE2 in the basal saliva was (mean +/- standard error of mean) 186 +/- 31 pg/mL and was similar during the chewing of parafilm (171 +/- 32 pg/mL). The placement of intraesophageal tubing, however, resulted in a significant decline of sPGE2 concentration to the value of 91 +/- 22 pg/mL (P < 0.01). This decline was maintained when intraesophageal balloons, which compartmentalized a 7.5 cm perfused segment of the esophagus, were inflated (86 +/- 17 pg/mL; P < 0.01). This decline was potentiated further when subsequent perfusion with saline was implemented to reach the lowest value of 46 +/- 17 pg/mL (P < 0.001 versus basal and P < 0.05 versus tubing and balloon evoked values) at the end of the perfusing procedure. Esophageal perfusion with acid and acid/pepsin solution, however, partly restored the significant decline in sPGE2 concentration observed during prolonged perfusion with saline. The sPGE2 output during basal conditions was 89 +/- 13 pg/min and increased dramatically during stimulation by placement of intraesophageal tubing (241 +/- 48 pg/min; P < 0.01) and inflation of intraesophageal balloons (244 +/- 48 pg/min; P < 0.01). Subsequent esophageal perfusion with saline resulted in a gradual decline of sPGE2 output evoked by mechanical stimuli that reached the final value of 178 +/- 39, which was not significantly different from that observed in the basal condition (P < 0.1 versus basal value). Introduction of HCl and pepsin into the perfusing solution significantly prevented the decline of sPGE2 output observed during perfusion with saline (252 +/- 36 pg/min; P < 0.01 versus basal). The modulatory impact of mechanical and chemical stimulation on sPGE2, demonstrated for the first time in humans, may suggest the potential contribution of salivary prostanoids to the maintenance of the integrity of the esophageal mucosa.

Gestational trophoblastic disease presenting as a large metastasis to the finger.

Cutaneous metastases of gestational trophoblastic disease are extremely uncommon. A patient with metastatic, poor prognosis disease and a large metastatic lesion on her left fifth digit is presented. The clinical course and complete response to EMACO chemotherapy are outlined. The presence of metastatic disease in a reproductive-age woman requires consideration of gestational trophoblastic disease in the differential diagnosis.

Staging and recurrence of disease in squamous cell carcinoma of the vulva.

In order to determine the prognostic significance of applying the revised FIGO staging system and identify factors contributing to survival after documentation of recurrent disease, a retrospective chart review of our vulvar cancer population was performed. Over a 17-year interval 135 patients were uniformly treated with primary surgical treatment consisting of radical vulvectomy and bilateral groin dissection. Factors contributing to disease-free survival were analyzed using a Cox proportional hazards model. Covariates of survival after recurrence of disease were analyzed using the log-rank method. Neither the clinical assessment of the groin nodes, nor the presence or absence of perineal involvement were related to outcome. Only lesion size and surgical status of the inguinal nodes were significant predictors of disease-free survival (P = 0.02 and P = 0.03, respectively). In addition, there was a statistically significant relationship between the extent of groin involvement (negative, unilateral positive, and bilateral positive nodes) and associated decrement in disease-free survival (P = 0.01). Thirty patients developed recurrence of disease from 2.0 to 47.3 months following surgery. The location of the recurrence, interval from primary therapy to recurrence, and status of the groin nodes at initial surgery were significant prognostic factors in subsequent survival. The revised staging system demonstrated an improvement in patient stratification compared to the criteria of the prior classification. The data are also consistent with the distinction made between Stage III and IV disease in the new classification. The status of the groin nodes at original surgery remained an important prognostic factor even in those patients who later demonstrated recurrence of disease.

A set of polymorphic DNA microsatellites useful in swamp and river buffalo (Bubalus bubalis).

DNA microsatellites have found widespread application in gene mapping, pedigree determination and population genetics. In closely related species such as bovids, heterologous polymerase chain reaction (PCR) primers may in some cases be used, bypassing the need to isolate and characterize microsatellite-containing sequences and design PCR primers. We report on the ability of a set of eighty bovine derived DNA microsatellite primers to amplify sequences in the two types (swamp and river) of water buffalo (Bubalus bubalis). Number of alleles and per cent heterozygosities in a large number of animals were determined on a subset of microsatellite loci selected on the robustness of the primers. These loci will form the basis of a set of polymorphic DNA markers for use in water buffalo.

The cosmid CSSM25 assigns syntenic group U2 to bovine chromosome 9 and is localized to ovine chromosome 8.

The cosmid-derived microsatellite CSSM 25 has previously been shown to map to bovine syntenic group U2 by linkage and hybrid somatic cell analysis. We have mapped the cosmid by fluorescent in situ hybridization to bovine Chromosome (Chr) 9q17-21 and ovine Chr 8q17-21 and hence assign U2 to Chr 9 in cattle. Bovine Chr 9 and ovine Chr 8 show strong banding pattern homology, and the localization of CSSM 25 to the same region confirms the strong conservation of gene locations on these chromosomes.

Risk factors for ulcerative reflux oesophagitis: a case-control study.

A case-control study was undertaken to investigate the effects of smoking, alcohol consumption, use of non-steroidal anti-inflammatory and other analgesic medications and family and medical history on the risk of ulcerative reflux oesophagitis (URO). We recruited 191 cases with URO diagnosed at endoscopy, 162 hospital controls who had also undergone endoscopy and 140 community controls from the Adelaide metropolitan area. From these three groups of subjects, 134 case-community control pairs, Matched on age, sex and postcode of residence and 142 case-hospital control pairs, matched on age, sex, hospital and endoscopist, were formed. Elevated non-significant risks were found in those smoking at least 20 cigarettes per day relative to those who never smoked (relative risk = 1.9, 95% confidence interval: 0.9-3.9 in case-hospital control pairs; relative risk = 1.9, 95% confidence interval: 0.9-3.7 in case-community control pairs). There was no elevation in risk associated with the use of non-steroidal anti-inflammatory drugs, with alcohol consumption, factors related to medical and reproductive history, nor with family history except for paternal history of heartburn (relative risk = 2.5, 95% confidence interval: 1.2-5.4 in case-hospital control pairs; relative risk = 1.9, 95% confidence interval: 1.0-4.0 in case-community control pairs). With the possible exception of smoking, no other risk factors for ulcerative reflux oesophagitis related to lifestyle are apparent.

Evaluation of the intestinal absorption of erythromycin in man: absolute bioavailability and comparison with enteric coated erythromycin.

To determine the role of acid hydrolysis on the gastrointestinal absorption of erythromycin, six healthy subjects received erythromycin as a 240 mg intravenous dose, a 250 mg oral solution administered via endoscope directly into the duodenum and bypassing the stomach, and an enteric-coated 250 mg capsule. Blood samples were collected for 6 hours and serum erythromycin quantified by a microbiological method. The time to achieve maximum serum concentrations for the solution was 0.25 +/- 0.08 (mean +/- SD) hours and for the capsule was 2.92 +/- 0.55 hours. The absolute bioavailability of erythromycin from the capsule was 32 +/- 7% and for the duodenal solution 43 +/- 14%. The ratio of the areas under the serum erythromycin concentration-time curve of capsule to solution was 80 +/- 28% (range 38 to 110%). There is substantial loss of erythromycin apart from gastric acid hydrolysis, which cannot be accounted for by hepatic first-pass metabolism. Attempts to further improve the oral bioavailability of erythromycin beyond 50% by manipulation of formulation are likely to be futile.

The effect of esophageal mechanical and chemical stimuli on salivary mucin secretion in healthy individuals.

Because of a newly developed model of esophageal perfusion in humans, the authors could study the role of esophago-salivary reflex in salivary neutral and acidic mucin output. The basal rate of neutral mucin output was 0.24 +/- 0.06 mg per minute. Placement of intraesophageal tubing and inflation of balloons resulted in a highly significant increase in salivary mucin output (2.10 +/- 0.22 mg per minute; p < 0.00001). However, implementation of esophageal perfusion with saline resulted in a significant decline of salivary mucin output (1.28 +/- 0.10 mg/mL NaCl4 versus 2.08 +/- 0.24 mg/mL NaCl1; p < 0.001). Esophageal perfusion with hydrochloric acid prevented the decline of salivary mucin output observed during perfusion with saline, whereas infusion of hydrochloric acid/pepsin resulted in a significant enhancement of salivary mucin output (2.89 +/- 0.31 mg per minute; p < 0.01). Therefore, mechanical and chemical stimulations resulted in an overall 9-fold and 12-fold increase in the rate of salivary mucin output over the basal value, respectively. The basal rate of acidic mucin secretion was 0.26 +/- 0.06 mg per minute. After placement of intraesophageal tubing, inflation of balloons, perfusion hydrochloric acid, or hydrochloric acid-pepsin solution, a significant enhancement in the rate of salivary acidic mucin output, similar to that observed during measurement of neutral mucin, was observed. Therefore, during mechanical and chemical stimulation, the rate of salivary acidic mucin output increased 7.3-fold and 11.1-fold over the basal value, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Omeprazole v ranitidine for prevention of relapse in reflux oesophagitis. A controlled double blind trial of their efficacy and safety.

The aim of this study was to compare recurrence rates of reflux oesophagitis (after endoscopic healing with omeprazole) over a 12 month period of randomised, double blind, maintenance treatment with either daily omeprazole (20 mg every morning; n = 53), weekend omeprazole (20 mg on three consecutive days a week, n = 55) or daily ranitidine (150 mg twice daily, n = 51). Patients were assessed for relapse by endoscopy (with gastric biopsy) at six and 12 months, or in the event of symptomatic recurrence, and serum gastrin was monitored. At 12 months, the estimated proportions of patients in remission (actuarial life table method) were 89% when receiving daily omeprazole compared with 32% when receiving weekend omeprazole (difference 57%, p < 0.001, 95% confidence intervals: 42% to 71%) and 25% when receiving daily ranitidine (difference 64%, p < 0.001, 95% confidence intervals: 50% to 78%). Median gastrin concentrations increased slightly during the healing phase, but remained within the normal range and did not change during maintenance treatment. No significant pathological findings were noted, and no adverse events were attributable to the study treatments. In conclusion, for patients who respond favourably to acute treatment with omeprazole 20 mg every morning, the drug is a safe and highly effective maintenance treatment for preventing relapse of reflux oesophagitis and its associated symptoms over 12 months. By contrast, weekend omeprazole and daily ranitidine were ineffective.