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Archive for March, 2011

‘Quality and Safety in Medicine’ Series

30 Mar, 11 | by Emma

Markers to measure quality and safety in health care are much debated. A decline in adverse event reporting may represent a genuine decline in adverse events or merely a decline in their reporting; just as a rise in the reporting of poor outcomes may represent significant cultural changes in a healthcare system more vigilant or more responsible. While audits of quality control or patient satisfaction have their place, case reports are an opportunity to present well managed patients who have received good care; and, at the same time near misses promptly dealt with and complex cases well worked through.

Our aim is to become a repository of well managed cases. The cases need not be rare, indeed we learn much more from each other’s experience of pitfalls in common cases and rare presentations of common diseases. In the upcoming weeks we will present a series of cases that illustrate aspects of quality and safety in medicine and invite you to submit your experience of quality and safety in healthcare.

Seema Biswas

This is an example of a rare presentation of a common condition, recognised because of the vigilance of the medical team.

Optic nerve involvement as a first manifestation of acute lymphoblastic leukaemia after remission

Life-threatening event during skin-to-skin contact in the delivery room

17 Mar, 11 | by Emma

Case reports come into their own when they report aspects of routine clinical practice that all doctors can easily relate to. This case report describes an episode of apnoea in a newborn baby handed to his mother after delivery.

The baby suffers cardiorespiratory arrest, is resuscitated and taken to the neonatal ICU. Thankfully, after recovery, the baby is discharged from hospital and we read that he is progressing well.

Most doctors can think of an unexpected complication or misadventure that occured in a clinical setting where, up until that point, everything seemed to be going well. The report of this case highlights that rare but potentially fatal events can occur in the most innocuous of environments and that where risk is not mitigated (it seems natural that a newborn baby should be handed to his mother and be embraced) how promptly complications are recognised and how well they are dealt with is crucial to outcome.

The situation is described well enough for anyone of us to imagine that we might have been there – and indeed it could, and does, happen to us all – but we learn our own and each others experience.

Seema Biswas

Life-threatening event during skin-to-skin contact in the delivery room

Media labels – Three-parent IVF

14 Mar, 11 | by Dr Dean Jenkins

The alarmingly labelled ‘three-parent IVF’ treatment has been discussed in the media over the last week following the publication of research in Nature by researchers from Newcastle. (1)

The technique they studied used abnormally fertilised embryos (1 or 3 pronuclear zygotes that are not usually used in IVF) to see if the pronuclei could be transferred without taking any of the cytoplasmic mitochondrial DNA with it. They concluded:

Our studies show that in human zygotes, pronuclear transfer has the potential to “treat” human mtDNA disease at a genetic level. The recent development of metaphase II spindle transfer has confirmed in non-human primates that this closely related method also holds great promise.

Somewhere in the transfer of this information from science journal to mainstream media the ‘three parent’ label became attached with its unnatural connotations. Is this the best way to describe the technique? I think the issue is with the word ‘pronuclear’. The pronucleus is the male or female half of the genome that combine to form the nucleus of the fertilised embryo.

To avoid the tedious detail of having to explain zygotes and pronuclei (along with explaining mitochondrial DNA) the journalists prefer the literary trick of summarising it all in a new shocking name. “Three-parent IVF” certainly sounds more attention grabbing than “pronuclear transfer” which sounds like something that physicists would do at CERN.

1) Craven L, Tuppen HA, Greggains GD, et al. Pronuclear transfer in human embryos to prevent transmission of mitochondrial DNA disease. Nature. 2010;465(7294):82-85.

Man with vCJD dies after a long and public illness

7 Mar, 11 | by Dr Dean Jenkins

Jonathan Simms from Belfast has died of variant CJD. He had survived 10 years with the disease and his case has been widely discussed in the media.

Initially, doctors thought he had multiple sclerosis. But Jonathan’s illness was later confirmed as vCJD. He was given just months to live.

After a court battle, the family won the right to use the experimental drug pentosan polysulphate in January 2003.

It had not previously been tested on human beings.

At that time, his father, Don Simms said the decision to give their son the drug was a “calculated risk based on 20 years of science”. …

Speaking after Jonathan’s death, Mr Simms said: “How it came about was so sudden, unexpected. We are a family who are left devastated.

“The times when we did expect it to happen, he fought through it.

“However, we feel that he himself had grown tired and was unable to fight any more.”

“There have been 173 cases of variant Creutzfeldt-Jakob disease (vCJD) in the UK, as of 5 July 2010, as a result of the bovine spongiform encephalopathy epidemic.” de Marco MF, Linehan J, Gill ON, Clewley JP, Brandner S. Large-scale immunohistochemical examination for lymphoreticular prion protein in tonsil specimens collected in Britain. J Pathol. 2010 Dec;222(4):380-7.

Lung protective strategy and prone ventilation resulting in successful outcome in a patient with ARDS due to H1N1

2 Mar, 11 | by Emma

Imagine having to watch a common cold turning into a violent pneumonia in your 3 year old child and having to see him/her go under the ventilator for nearly a month.

Imagine the relief having him/her back intact after the ordeal!

This case report depicts one such incident that is best described as one of the heartening triumphs of modern medicine that is perhaps happening daily around the globe but often goes unsung.

The authors Sarkar et al have painstakingly documented the entire illness trajectory of a child with H1N1 flu who went through the above mentioned life threatening challenge and we are sure this will be useful to health professionals and even patient relatives battling similar illnesses globally.

Rakesh Biswas
Deputy Editor

Lung protective strategy and prone ventilation resulting in successful outcome in a patient with ARDS due to H1N1

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