Mycoplasma pneumoniae as a cause of vulvar ulcers in a non-sexually active girl: a case report

Non-sexually active young females very rarely develop genital ulcers. Such ulcers pose a diagnostic challenge as well as physical and emotional distress for patients and family; therefore, the search for their...

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Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery

Abstract

Background. The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems.Methods. We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest).Results. A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a three-fold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a two-fold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failure-to-rescue, indicating differences between hospitals in the risk of death among patients after they develop complications.Conclusions. Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries.

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Intraoperative dexamethasone alters immune cell populations in patients undergoing elective laparoscopic gynaecological surgery

Abstract

Background. Anaesthetists use dexamethasone principally for its anti-emetic effect. The purpose of this study was to characterize the effects of a single intraoperative dose of dexamethasone on cellular and metabolic components of the immune system in patients undergoing laparoscopic surgical procedures.Methods. In this prospective double-blind trial, female patients undergoing elective major laparoscopic surgery were randomized to receive saline (Control group, n=16) or dexamethasone 4 mg (Dexamethasone group, n=16) i.v. after the induction of anaesthesia. Inflammatory markers and immune cell counts were examined at 24 and 48 h and 6 weeks after surgery. The changes from baseline preoperative values were compared between groups using a Mann–Whitney U-test, and linear mixed models were used to validate the findings.Results. No differences in concentrations of serum glucose and interleukin-6 were observed between groups after surgery. The increase in C-reactive protein concentration at 24 h after surgery was greater in the control group [median (interquartile range), 33 (25–65) vs 17 (7–26) mg dl⁻¹; P=0.018]. Extensive changes in the counts of white cells, including most lymphocyte subsets, were observed 24 h after surgery, and dexamethasone appeared to attenuate most of these changes. Changes at 48 h and 6 weeks did not differ between groups.Conclusions. In female patients undergoing elective laparoscopic gynaecological surgery, dexamethasone administration appears to attenuate inflammation and to alter immune cell counts at 24 h, with no effects identified after this time. The importance of these changes for postoperative immune function is unknown.Trial registration. Australia and New Zealand Clinical Trials Registry (ACTRN12608000340336).

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Duty of candour: a statutory obligation or just the right thing to do?

In 1990 the case of Robbie Powell catalogued a story of medical errors and neglect that ultimately lead to his untimely death from Addison's disease at 10 years of age. In this high-profile case, the child's father felt that events were made even more unbearable by failures of health care providers to offer credible explanations for what had occurred and subsequently by the detrimental actions of investigatory bodies.¹ Despite tireless and tenacious legal challenges, Robbie Powell's father was denied the truth for nearly 2 decades. It is now established that forgery and falsification of patient medical records occurred and investigations were plagued by conflict of interest and dishonesty, including cabinet ministers providing false parliamentary answers.² Indeed, two Police Complaints Authority investigations into the handling of the case named the Dyfed-Powys police force as 'institutionally incompetent' and identified 35 separate potential criminal offences including falsification of documents and perverting the course of justice.³ No criminal prosecutions were brought and in May 2000 the European Court of Human Rights stated in a judgement on the case that:As the law stands now … doctors have no duty to give parents of a child who died as a result of their negligence a truthful account of the circumstances of the death, nor even refrain from deliberately falsifying records.⁴Although this case must be considered rare and indeed extreme, it is important to take a moment to reflect on a purely human level how one would feel if a loved one suffered serious harm or death as the result of a medical incident. Add to that emotional turmoil the distress of not being told what had happened or the insult of being deceived by those with whom care and support had been entrusted. In the 27 years since this tragic case, the National Health Service (NHS) has slowly moved towards a culture of transparency and openness. This article discusses the UK statutory Duty of Candour (DoC) and the implications for enacting the legislation with respect to perioperative and intensive care medicine.

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Prolonged and high dosage of tigecycline – successful treatment of spondylodiscitis caused by multidrug-resistant Acinetobacter baumannii: a case report

The incidence of infectious spondylodiscitis has been increasing over the last few years. This reflects the expanding elderly and immunocompromised populations and the rising implementation of invasive spinal ...

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