Is methicillin-resistant Staphylococcus aureus (MRSA) contamination of ward-based computer terminals a surrogate marker for nosocomial MRSA transmission and handwashing compliance?

A survey of two acute district general hospitals (A and B) was undertaken to investigate the extent of methicillin-resistant Staphylococcus aureus (MRSA) contamination of ward-based computer terminals. Of 25 terminals examined, MRSA was identified in six (24%). Environmental contamination was of a low level. Five of the MRSA positive terminals were from hospital A which had a significantly higher rate of MRSA transmission compared to hospital B (1.02 vs. 0.49 new inpatient MRSA cases per 100 hospital admissions for 1999). MRSA containment and handwashing policies were similar at both hospitals, though only hospital B actively audited handwashing compliance and had a 44% higher rate of paper towel usage per hospital bed. Ward-based computer terminals pose a low risk of MRSA cross-infection. This risk can be further reduced if all staff wash their hands before and after patient contact.     

What is the randomised evidence for surgery and stereotactic radiosurgery for patients with solitary (or few) brain metastases?

Patients with solitary (or few) brain metastases are often treated with surgery (S) or stereotactic radiosurgery (SRS) with or without adjuvant whole brain radiotherapy (WBRT). This review examines the randomised evidence supporting this aggressive approach. A search of MEDLINE, EMBASE and Cochrane databases for published papers and Abstracts on relevant randomised trials was undertaken. Fourteen randomised trials were identified, 11 final reports and 3 Abstracts, investigating various combinations of S, SRS and WBRT. Most of these trials had significant limitations and the results therefore need to be viewed with caution. Surgery and SRS improve local control, maintenance of performance status and survival for favourable prognosis patients with solitary brain metastases relative to WBRT alone, although the absolute survival benefit for the majority is modest. Limited data suggest similar outcomes from S and SRS, but few patients are truly suitable for both options. For multiple (2-4) brain metastases, SRS improves local control and functional outcome but not survival; there is no randomised evidence for S. Adjuvant WBRT also improves intracranial control but not survival; however, the neurocognitive risk : benefit ratio of WBRT remains controversial. Quality of life data are currently limited.     

Erythrocyte thiamine (Th) esters: a major factor of the alcohol withdrawal syndrome or a candidate marker for alcoholism itself?

AIMS: Thiamine (Th) deficiency is a major problem in alcoholics. In this study, the relationship of alcohol withdrawal syndrome (AWS) to Th and its esters, as well as the diagnostic power of Th and its esters were investigated. PATIENTS AND METHODS: Th and its esters were assessed in a series of chronic alcoholics (and in controls) using an improved method. RESULTS: No association was found between AWS severity and Th and its esters, while the diagnostic power of thiamine diphosphate (TDP) and Th was very high. TDP was the most significant among the parameters under study, confirming that erythrocyte TDP is a suitable marker of alcoholism: TDP sensitivity across subjects was 84.1%, specificity 85.4%, positive predictive value 82.4%, and negative predictive value 88.0%.     

A Centre for the Diagnosis and Treatment of Tuberculosis (CDT) in a resource-limited setting: a dragnet for patients with heart disease?

Background

Cardiovascular disease is a growing public health problem in sub-Saharan Africa. Cough and dyspnea are symptoms of both lung diseases and heart failure. This study aimed at determining the contribution of cardiac diseases versus pulmonary diseases in the etiological profile of patients presenting with cough and dyspnea in a Center for the Diagnosis and Treatment of Tuberculosis (CDT), in a semi-rural area in Cameroon.

Methods

This is a cross-sectional analysis of data from patients aged 18 years or more who consulted for cough and or dyspnea between December 2009 and December 2010 at the CDT of Lafe-Baleng, Bafoussam, Cameroon.

Results

A total of 1196 patients were received for various complaints during the study period; 348 (29.1%) of them presented with cough and or dyspnea, and were included in the study. 186 patients (53.4%; 95% CI: 48.2-58.6) had a pure cardiac disease, while 122 patients (35.1%; 95% CI: 30.2-40.2) had a pulmonary disease. The prevalence of hypertension was 50.9%, and hypertensive heart disease was the most frequent cardiac disease with a prevalence rate of 37.6%. Heart failure was diagnosed in 222 patients, representing 63.8% (95% CI: 58.9-68.9) of patients with cough and or dyspnea, and 18.6% (95% CI: 16.5-21.0) of all the patients received at the CDT of Lafe-Baleng during the study period. Compared to patients with a pulmonary disease, patients with cardiac disease were older (p < 0.001) and more likely to present with dyspnea (p < 0.001) and to have hypertension (p < 0.001).

Conclusion

We found a high prevalence of heart failure in this Centre for the Diagnosis and Treatment of Tuberculosis thus, a veritable dragnet for patients with heart disease. Our findings emphasize the urgent need to increase the access to cardiovascular care and to continuously raise the awareness of the communities on cardiovascular diseases in Cameroon.     

Does X(a) mark the spot? An indirect mixed treatment comparison of Xa inhibitors compared to warfarin for patients with atrial fibrillation

The study sets out to compare the safety and efficacy of oral Non-vitamin K antagonists and warfarin in patients with atrial fibrillation.BackgroundPatients with atrial fibrillation carry a higher than normal risk for stroke, thus making them dependent on long-term anticoagulation treatment. While warfarin is considered to be the gold standard, several of its attributes, hinder adherence of patients to the therapeutic regimen. A new therapeutic category, the oral Non-vitamin K antagonist oral anticoagulants, aims to provide better and safer care to patients presenting with atrial fibrillation.MethodAn indirect mixed treatment comparison using data from published randomised controlled trials.ResultsLooking at the primary efficacy endpoint of stroke or systematic embolism, apixaban, rivaroxaban and dabigatran, demonstrated significant superiority compared to warfarin, while a trend exists for edoxaban [OR: 0.84 (95% CI 0.74–1.02)]. At the primary safety endpoint of major bleeding, evidence suggest that apixaban and edoxaban are superior to warfarin. Warfarin proved to be safer regarding gastrointestinal bleeding, compared to rivaroxaban, dabigatran and edoxaban. At the secondary efficacy endpoints of hemorrhagic and intracranial stroke, all Non-vitamin K antagonists oral anticoagulants were related to reduced risk versus warfarin.ConclusionsThe Non-vitamin K antagonist oral anticoagulants constitute a new and promising category in the field of atrial fibrillation, even in the context of uncertainty, which an indirect comparison yields.     

Is travel-time to a specialist centre a risk factor for non-referral,non-attendance and loss to follow-up among patients with hepatitis C (HCV) infection?

Little is known about why many people diagnosed with hepatitis C virus (HCV) infection fail to reach and stay within specialist care services. We used a Geographic Information System and logit regression to investigate whether travel-time to a specialist centre was associated with an increased likelihood of non-referral, non-attendance and loss to follow-up among persons diagnosed with HCV between 1991 and 2003 in Tayside, Scotland (UK). Information was available on referral to, and utilisation of, the single HCV specialist centre in Tayside between 1991 and 2006. Longer travel-time to a specialist centre was associated with an increased likelihood of non-referral to a specialist centre following diagnosis (Odds Ratio: 1.25, 95% Confidence Interval: 1.09, 1.44). Patients living further from an HCV specialist centre were less likely to be referred to it for treatment that could cure their HCV infection. Neither a history of intravenous drug use (IDU), nor area deprivation predicted non-referral. Subsequent to referral, travel-time to a specialist centre was not associated with either non-attendance (0.83 (0.56, 1.21)) or loss to follow-up (0.98 (0.78, 1.22)), although a history of IDU was a strong predictor of both non-attendance and loss to follow-up. Non-attendance was less likely among older patients, while loss to follow-up was more common among those living in deprived areas. Once referred, patients appear able to cope with stress and financial cost of long and frequent journeys to hospital. However, as rates of referral improve from more geographically remote areas, long travel-times to an HCV specialist centre may become an important factor determining future utilisation.     

Diagnosing attention‐deficit hyperactivity disorder (ADHD) in children involved with child protection services: are current diagnostic guidelines acceptable for vulnerable populations?

Children involved with child protection services (CPS) are diagnosed and treated for attention‐deficit hyperactivity disorder (ADHD) at higher rates than the general population. Children with maltreatment histories are much more likely to have other factors contributing to behavioural and attentional regulation difficulties that may overlap with or mimic ADHD‐like symptoms, including language and learning problems, post‐traumatic stress disorder, attachment difficulties, mood disorders and anxiety disorders. A higher number of children in the child welfare system are diagnosed with ADHD and provided with psychotropic medications under a group care setting compared with family‐based, foster care and kinship care settings. However, children's behavioural trajectories change over time while in care. A reassessment in the approach to ADHD‐like symptoms in children exposed to confirmed (or suspected) maltreatment (e.g. neglect, abuse) is required. Diagnosis should be conducted within a multidisciplinary team and practice guidelines regarding ADHD diagnostic and management practices for children in CPS care are warranted both in the USA and in Canada. Increased education for caregivers, teachers and child welfare staff on the effects of maltreatment and often perplexing relationship with ADHD‐like symptoms and co‐morbid disorders is also necessary. Increased partnerships are needed to ensure the mental well‐being of children with child protection involvement.     

Is the methodological quality of guidelines declining in the US? Comparison of the quality of US Agency for Health Care Policy and Research (AHCPR) guidelines with those published subsequently

Objective: To determine whether North American guidelines published subsequent to and in the same topic areas as those developed by the US Agency for Health Care Policy and Research (AHCPR) meet the same methodological criteria.

Study design: A guideline appraisal instrument containing 30 criteria was used to evaluate the methodological quality of the AHCPR guidelines, "updates" of the AHCPR guidelines authored by others, and guidelines that referenced or were adapted from the AHCPR guidelines. The frequency with which the criteria appeared in each guideline was compared and an analysis was performed to determine guidelines with two key features of the ACHPR guidelines—multidisciplinary guideline development panels and systematic reviews of the literature. Data were extracted from the guidelines by one investigator and then checked for accuracy by the other.

Results: Fifty two guidelines identified by broad based searches were evaluated. 50% of the criteria were present in every AHCPR guideline. The AHCPR guidelines scored 80% or more on 24 of the 30 criteria compared with 14 for the "updates" and 11 for those that referenced/adapted the AHCPR guidelines. All of the 17 AHCPR guidelines had both multidisciplinary development panels and systematic reviews of the literature compared with five from the other two categories (p<0.05).

Conclusions: North American guidelines developed subsequent to and in the same topic areas as the AHCPR guidelines are of substantially worse methodological quality and ignore key features important to guideline development. This finding contrasts with previously published conclusions that guideline methodological quality is improving over time.

     

Trends in cardiovascular risk factor levels in the Minnesota Heart Survey (1980-2002) as compared with the National Health and Nutrition Examination Survey (1976-2002): A partial explanation for Minnesota's low cardiovascular disease mortality?

The authors compared trends in and levels of coronary heart disease (CHD) risk factors between the Minneapolis-St. Paul, Minnesota, metropolitan area (Twin Cities) and the entire US population to help explain the ongoing decline in US CHD mortality rates. The study populations for risk factors were adults aged 25-74 years enrolled in 2 population-based surveillance studies: the Minnesota Heart Survey (MHS) in 1980-1982, 1985-1987, 1990-1992, 1995-1997, and 2000-2002 and the National Health and Nutrition Examination Survey (NHANES) in 1976-1980, 1988-1994, 1999-2000, and 2001-2002. The authors found a continuous decline in CHD mortality rates in the Twin Cities and nationally between 1980 and 2000. Similar decreasing rates of change in risk factors across survey years, parallel to the CHD mortality rate decline, were observed in MHS and in NHANES. Adults in MHS had generally lower levels of CHD risk factors than NHANES adults, consistent with the CHD mortality rate difference. Approximately 47% of women and 44% of men in MHS had no elevated CHD risk factors, including smoking, hypertension, high cholesterol, and obesity, versus 36% of women and 34% of men in NHANES. The better CHD risk factor profile in the Twin Cities may partly explain the lower CHD death rate there.