Esophageal cancer. American College of Gastroenterology

Antimicrobial resistance among common respiratory pathogens has become a significant problem. However, there remain multiple treatment options, including the newer macrolides, third-generation cephalosporins, beta-lactam/beta-lactamase inhibitor antibiotics, and the newer fluoroquinolones.     

Findings from the American College of Epidemiology's survey on Ethics guidelines. The American College of Epidemiology Ethics and Standards of Practice Committee

PURPOSE: A survey to establish both the need and subject areas for a possible new set of ethics guidelines for epidemiologists was conducted among a random sample of 300 North American (Canada, Mexico, and United States) members of three major United States-based professional epidemiology organizations. METHODS: An 88% response rate revealed wide agreement on topics to be included in any new set of guidelines, but uncertainty prevailed about the need for new guidelines; 41% agreed that there was a need to develop a new set, 43% had no opinion, and 16% disagreed. RESULTS: There was almost no difference in preferences between men and women for topics to be included in a new set of guidelines, or between those aware or unaware of extant ethics guidelines in epidemiology. Fifty-four percent were aware of such guidelines and only 29% of these said they could describe the content of the guidelines. CONCLUSION: More needs to be done to evaluate the utility of ethics codes in epidemiology.     

Practice guideline for forensic pathology. Members of the Forensic Pathology Committee, College of American Pathologists

The guideline for forensic pathology was prepared by the Forensic Pathology Committee of the College of American Pathologists. The definitional criteria for forensic pathology included in this guideline have been approved both by the House of Delegates and the Board of Governors of the College of American Pathologists. The guideline presents an overview of forensic pathology and an approach to the forensic autopsy and medicolegal death investigation. Emphasis is placed on the role of forensic pathology in maintaining public health, welfare, and safety. The guideline is intended to serve as an educational tool, and its use should be determined by the individual circumstances and settings of specific cases.     

Alcoholic liver disease: proposed recommendations for the American College of Gastroenterology

OBJECTIVE: The objective of this work was to develop practice guidelines for the management of alcoholic liver disease. METHOD: A computerized search using the Medline Data Base from 1966-July 1997 was performed with the search headings; alcohol, alcoholic hepatitis, alcoholic liver disease, liver transplant, diagnosis, epidemiology, human, and English only. All randomized controlled trials, case-control studies, and meta-analyses were read in depth. A manual search was also done using references from each retrieved report, review articles, editorials, postgraduate course syllabi, and textbooks. In the subsequent review, evidence was evaluated using a hierarchical scale with randomized, controlled trials given the most importance. Abstracts presented at national meetings were included only when unique data were obtained from those studies.     

The National Cancer Data Base report on completeness of American Joint Committee on Cancer staging in United States cancer facilities. The American College of Surgeons Commission on Cancer and the American Cancer Society

BACKGROUND: American Joint Committee on Cancer (AJCC) staging is increasingly accepted as a prognostic standard for cancer management. The Commission on Cancer requires approved cancer programs to use AJCC staging for all cancers. Previous studies document increasing use of AJCC staging by hospitals with cancer programs. This review examines programmatic and clinical factors affecting AJCC staging completeness. METHODS: The data are registry records submitted to the National Cancer Data Base (NCDB) for cases diagnosed during 1993 or, for comparison, 1988. RESULTS: The mean facility staging rate was 87% in 1993, up from 65% in 1988. Approximately 64% of facilities staged greater than 90% of their stageable cases; 3% staged less than 5%. Even facilities with "complete" staging implementation were unable to stage substantial portions of some sites. Accessibility of tumor and overall prognosis affected the choice between pathologic and clinical staging. Staging completeness and the mix of pathologic and clinical staging also differed by state of the reporting facility. CONCLUSIONS: AJCC staging use is high among common tumors for which treatment is dependent upon stage of disease. However, if accurate staging is not expected to affect the treatment or outcome of the case or the overall outcome is poor, staging is less frequently recorded.     

Quantitative and ultrastructural analysis of rectal mucosal mast cells in acute infectious diarrhea

The role of mast cells, potential mediators of mucosal immunity and inflammation, was studied morphologically in the rectal mucosa in two acute diarrheal diseases, cholera and shigellosis. Quantitation of mucosal mast cells showed that they were significantly higher in the deeper lamina propria where blood vessels and nerves were more abundant. There was no difference in mast cell counts or degranulation in the mucosa in both groups of patients and controls. Intraepithelial mast cells were decreased in the patients. The prevalence of lipid bodies was significantly higher in mast cells from patients with cholera and shigellosis (P < 0.01). These findings suggest that mast cell populations are more dense around blood vessels and nerves and that inflammatory mediators derived from arachidonic acid metabolites, as indicated by the lipid bodies, are the response of mast cells to the alterations in diarrhea, despite differences in the etiology of diarrhea.     

Infection prevention and control in the long-term-care facility. SHEA Long-Term-Care Committee and APIC Guidelines Committee

More than 1.5 million residents reside in US nursing homes. In recent years, the acuity of illness of nursing home residents has increased. Long-term-care facility residents have a risk of developing nosocomial infection that is similar to acute-care hospital patients. A great deal of information has been published concerning infections in the long-term-care facility, and infection control programs are nearly universal. This position paper reviews the literature on infections and infection control program in the long-term-care facility, covering such topics as tuberculosis, bloodborne pathogens, epidemics, isolation systems, immunization, and antibiotic-resistant bacteria. Recommendations are developed for long-term-care infection control programs based on interpretation of currently available evidence. The recommendations cover the structure and function of the infection control program, including surveillance, isolation, outbreak control, resident care, and employee health. Infection control resources also are presented.     

Guidelines or potentially dangerous recommendations? The AANS/CNS Committee on Assessment of Quality. American Association of Neurological Surgeons. Congress of Neurological Surgeons

This report uses a mathematical modeling system to define optimal orthopedic coverage for trauma centers. Data from 2,325 patients treated with emergency orthopedic operations within 24 hours of admission at 78 randomly sampled and at four totally sampled verified centers were used to create a profile of (1) admission by month, day, and hour; (2) operation times; and (3) operation duration. The reason for operation included (1) open fracture or crush (809 patients); (2) irreducible dislocations (164 patients); (3) fracture with vascular injury (seven patients); (4) dislocation with vascular injury (17 patients); (5) compartment syndrome (11 patients); (6) femoral neck fracture in young patients (36 patients); (7) combination of categories 1 to 6 (70 patients); (8) fracture with multiple injuries (171 patients); and (9) urgent not emergent (1,040 patients). The program defined the frequency that an injured patient needing an orthopedic consult would wait beyond 30 minutes because the orthopedic surgeon was doing a trauma related operation at a center with one or two orthopedic surgeons on call. The probability that a patient cannot be seen promptly by one orthopedic surgeon in a center doing 25, 50, 75, 100, 200, and 300 emergency procedures per year is 0.17, 0.74, 1.6, 3.1, 12.5, and 28 patients per year. When two are on call, 1.3 patients, yearly, will wait more than 30 minutes in a center doing 300 emergency procedures. Thus, mandatory orthopedic backup call for a trauma center performing fewer than 100 emergent trauma procedures within 24 hours is unwarranted.     

Aldehyde disinfectants and health in endoscopy units. British Society of Gastroenterology Endoscopy Committee

Summary of main recommendations(1) Glutaraldehyde, used in most endoscopy units in the United Kingdom for the disinfection of flexible gastrointestinal endoscopes, is a toxic substance being an irritant and a sensitiser; symptoms associated with glutaraldehyde exposure are common among staff working in endoscopy units.(2) The Control of Substances Hazardous to Health Regulations 1988 (COSHH) obliges the employer to make a systematic assessment of risk to staff of exposure to glutaraldehyde and institute measures to deal effectively with exposure.(3) At present glutaraldehyde remains the first line agent for the disinfection of flexible gastrointestinal endoscopes. Other agents are being developed; a standard means of assessment for flexible endoscope disinfectants should be devised.(4) Equipment and accessories that are heat stable should be sterilised by autoclaving; disposable accessories should be used wherever possible.(5) Flexible gastrointestinal endoscopes should be disinfected within automated washer/disinfectors; trays, bowls or buckets for this purpose are unacceptable.(6) Local exhaust ventilation must be used to control glutaraldehyde vapour. Extracted air may be discharged direct to the atmosphere or passed over special absorbent filters and recirculated. Such control measures must be regularly tested and records retained.(7) Endoscope cleaning and disinfection should be carried out in a room dedicated to the purpose, equipped with control measures to maintain the concentration of glutaraldehyde vapour at a level certainly below the current occupational exposure standard of 0.2 ppm and preferably below the commonly used working limit of 0.1 ppm. Sites other than the endoscopy unit where endoscopy is regularly performed, such as the radiology department, should have their own fully equipped cleaning and disinfection room.(8) COSHH limits the use of personal protective equipment to those situations where other measures cannot adequately control exposure. Such equipment includes nitrile rubber gloves, apron, chemical grade eye protection, and respiratory protective equipment for organic vapours.(9) Monitoring of atmospheric levels of glutaraldehyde should be performed by a competent person such as an occupational hygienist; the currently preferred method of sampling uses a filtration technique, the commercially available meters being less reliable.(10) Health surveillance of staff is mandatory; occupational health records must be retained for 30 years.(11) Endoscopy staff must be informed of the risks of exposure to glutaraldehyde and trained in safe methods of its control. Only staff who have completed such an education and training programme should be allowed to disinfect endoscopes.(12) The unsafe use of glutaraldehyde has significant health and legal consequences; the safe use of glutaraldehyde may have revenue consequences that contribute significantly to the cost of gastrointestinal endoscopy.