Impact of an educational program and policy changes on decreasing catheter-associated bloodstream infections in a medical intensive care unit in Brazil

BACKGROUND: Central venous catheter-associated bloodstream infections (CVC-BSI) are a frequent cause of morbidity and mortality in intensive care settings. Many strategies have been used to decrease the risk of CVC-BSI; however, few studies have explored the educational intervention as an approach to reduce the CVC-BSI rates. OBJECTIVE: The purpose of this study was to determine the impact of an educational program targeted to specific points observed during CVC care practices on decreasing CVC-BSI in a medical intensive care unit. METHODS: An educational program was developed by a multidisciplinary task force to highlight correct practices for CVC care. Relative risk ratios, 95% confidence intervals, and P values were determined for all primary and secondary outcomes. The chi 2 linear test for trends of CVC-BSI rates was performed during the study period and the following year. RESULTS: Forty-eight primary bloodstream infections occurred in 2450 catheter-days (20 per 1000 catheter-days) in the 16 months before the intervention. After the educational intervention and policy changes such as standardized povidone-iodine use during dressing care, the number of CVC-BSI dropped to 16 in 1381 catheter-days (11 per 1000 catheter-days), a decrease of 40%. The rate of CVC-BSI remained almost the same, 22 in 1701 catheter-days (12 per 1000 catheter-days), during the following year after the educational intervention (P = .07). The distribution of pathogens was different comparing the pre- and postintervention period. Staphylococcus aureus was the most common pathogen in preintervention, decreasing significantly during the study period (P = .02). The adhesion to the overall catheter care policy improved significantly in the postintervention period (P < .01). CONCLUSION: A multiple approach included an educational strategy, targeted to specific problems observed during a careful evaluation of CVC care practices, and policy changes can decrease rates of CVC-BSI. However, despite the good results, our rates are still high, and reinforcement of CVC care practices will be continued.     

Potential of dose reduction after marker placement with full-field digital mammography

OBJECTIVES: The purpose of our study was to assess the potential for radiation dose reduction in digital postinterventional digital mammograms after marker placement. MATERIALS AND METHODS: One hundred consecutive cases of marker placement (hook-wire localization or postbiopsy clip marker placement), with 200 full-field digital baseline mammograms (craniocaudal and mediolateral), were included in this prospective trial. For the postinterventional digital mammograms, the milliampere seconds were reduced either by 50% or by 75%. Dose-reduced images were evaluated for sufficient image quality to verify the position of the marker. RESULTS: In 193 of 200 cases (96.5%), image quality was sufficient to verify the correct position of the marker. One (1%) case with insufficient image quality occurred in the 50% dose-reduction group and 6 (6%) in the 75% dose-reduction group (P = 0.06). CONCLUSION: Our results indicate that under evaluation of each individual case, a dose reduction of 50% to 75% can be recommended in postinterventional digital mammograms.     

Method of patient dose evaluation in the angiographic and interventional radiology procedures

PURPOSE: The aim of this study was to evaluate the effective dose in interventional radiology and angiography procedures on the basis of the dose-area product (DAP), either measured or calculated using two different methods. MATERIALS AND METHODS: We studied 2072 examinations carried out on several X-ray systems both in angiography and in interventional radiology. Some of the systems were equipped with an on-board transmission chamber for DAP measurements; for these systems we took direct DAP measurements for each type of examination. For the systems without the dose measurement device, we used a portable transmission chamber, acquiring the data from a set of sampling frames. We then derived the dose values from the systems' dosimetry data and the information about each examination. To this end, the dosimetry of each x-ray system was done by measuring tube output in the different acquisition modes, backscatter factor and field-homogeneity factor. Survey data sheets were filled in after every examination indicating the exposure data (mean Kv, mAs, focus-skin distance and field size). These values combined with the dosimetric data were used to evaluate the DAP for each exam. Where possible, we compared the measured and calculated DAP values by assessing the percentage deviation between each pair of values. A similar comparison was made for the single examinations using a simplified calculation algorithm reported in the literature. For all the examinations for which we had adequate survey data sheets, we estimated the DAP and the entrance dose values and, with the aid of WinODS software, the effective dose. RESULTS: The direct measurements of DAP showed that, in interventional radiology and angiographic procedures, the variability in examination conditions leads to a wide range of possible patient doses even within the same examination type.The comparison between the measured and calculated DAP using our algorithm showed substantial agreement (mean difference 30%, maximum 80%). By contrast, using the algorithm proposed in the literature, we obtained deviations higher than 100%.An estimate of the effective dose for all the recorded examinations (2072) permitted evaluation of both magnitude and variability of patient doses in special radiology procedures such as angiography and interventional radiology. However, it should be noted that evaluations based on calculated DAP values may be as uncertain as those estimated for DAP, and that clearly the evaluations made for the examinations for which direct measurements are available are more accurate.In particularly 'invasive' examinations in terms of entrance dose, where the threshold limits for deterministic effects might possibly be exceeded, the equivalent doses to critical organs were also assessed. This analysis showed that in a small percentage of patients (5%) 2 Gy to the skin was exceeded in the areas exposed with possible transient erythema, while in fewer than 2% of patients, the 3 Gy limit for temporary epilation was exceeded. CONCLUSIONS: Many interventional radiology, especially haemodynamic, examinations have shown to give significant exposure to patients. The direct dose measurement method has shown to be the only method able to provide reliable information on such exposure.However, the authors believe that since the patient dose cannot be established in advance, even in terms of magnitude and since direct dose measurement cannot be performed on all patients, it is nonetheless interesting to be able to assess, at least semiqualitatively, the amount of the above doses.     

Feeding patterns of Triatoma longipennis Usinger (Hemiptera, Reduviidae) in peridomestic habitats of a rural community in Jalisco State, Mexico

We analyzed triatomine blood feeding patterns to evaluate the role of peridomiciles in Trypanosoma cruzi transmission at the rural village of Tepehuaje de Morelos at Jalisco State, Mexico (1999). A total of 206 bugs were collected in 11 out of 26 households (42.3%). Nymphs predominated in the collections (64.9% of the total). Except for one Triatoma barberi female, a species that belongs to the protracta species complex, all adults were Triatoma longipennis, a species of the phyllosoma complex. Triatomines were exclusively present in peridomestic sites mainly piles of tiles and bricks, and none were found indoors. Overall infection rate was 56.6% and no significant differences (P > 0.05) were observed between nymphs and adults or males and females. Identified blood meals were chicken (29.4%), opossum (20.9%), pig (24.5%), murid (20.9%), dog (3.5%), and armadillo (0.7%). No gut content reacted against anti-human, anti-bovine, anti-rabbit, and anti-cat sera. In contrast to fifth nymphs and adults, 87% of the small nymphs fed on one host, indicating that they are less mobile than other stages. Most fifth nymphs and adults fed on domestic hosts, while small nymphs mainly fed on opossum and murid. Infection blood-meal indexes were around 50% for single meals on opossum and murid, stressing their importance as trypanosome donors. Peridomiciles in Tepehuaje could be regarded as interaction sites among domestic and wild and synanthropic mammals and triatomines, which would facilitate circulation of the same T. cruzi strains between domestic and sylvatic cycles. Stone-made walls and building materials, which hold synanthropic rodents and opossums, should be considered as targets for vector control measures.     

Vertical forces in labial and lingual orthodontics applied on maxillary incisors--a theoretical approach

Theoretical and experimental biomechanical analyses explain most labial orthodontics (LaO); however, lingual orthodontic (LiO) biomechanical principles are rarely introduced. The objective of this study was to apply basic biomechanical considerations in understanding the influence of maxillary incisor inclination and to compare the effect of labial vs lingual intrusive/extrusive forces on tooth movement. Basic anatomic and geometric hypotheses were assumed, ie, tooth length (crown and root), location of the center of resistance, and crown thickness. Incisor inclination as related to a perpendicular line to the occlusal plane (OP) varied between -35 degrees (retroclination) and 45 degrees (proclination). A 0 degrees inclination was defined as a tooth position with its long axis perpendicular to the OP. The buccolingual moment for characterizing root movement was calculated for an applied force perpendicular to the OP. The results showed that when using LaO, an extrusion force resulted in labial root movement from a retroclination of 20 degrees up to a proclination of 45 degrees. In LiO, labial root movement occurred only when the tooth was proclined more than 20 degrees. In all other tooth inclinations, lingual root movement occurred. The opposite tooth movement occurred when an intrusive force was applied. Application of a vertical force has different clinical effects on tooth movement with labial and lingual appliances. Application of a lingual force is more complicated, and its effect on tooth movement depends on bracket position and initial tooth inclination.     

Efficacy of pulsed radio frequency energy therapy in temporomandibular joint pain and dysfunction

This randomized double-blind study evaluated the effectiveness of pulsed radio frequency energy therapy (PRFE) in patients with temporomandibular joint arthralgia. Forty subjects (age range 22 to 55 yrs.) were assigned randomly into two equal groups: (1) Experimental group received PRFE using the Energex unit (Energex, Inc. Emerson, New Jersey) and (2) Control group received PRFE placebo treatment using a sham device. Both groups received six applications to the TMJ area over two weeks. Data were analyzed for the following times: baseline, first and second follow-up visits. Numerical Rating Scale scores for TMJ pain showed a significant reduction over time for the experimental group (mean = 6.13 to 3.05, p < 0.001). There was also a significant effect for the controls (mean = 5.35 to 4.20, p = 0.01). The effect for experimental subjects was a mean reduction of 3.07 versus 1.15 for controls. The significant reduction in controls was attributed to the placebo effect. The experimental group showed a significant increase in mouth opening (mean = 34.95 to 41.70 mm, p = 0.002), right lateral movement (mean = 7.85 to 10.80 mm, p = 0.001) and left lateral movement (mean = 7.65 to 10.85 mm, p < 0.0001). No significant (p > 0.1) change in the control group occurred for mouth opening (mean = 38.50 to 39.65 mm), right lateral movement (mean = 8.60 to 8.75 mm) and left lateral movement (mean = 8.50 to 8.80 mm). No side effects were reported during the treatment and the two week follow-up. These results suggest strongly that PRFE is a safe and effective treatment for TMJ arthralgia as well as for increasing mandibular range of motion.     

Clinical and microbial evaluation of dental scaling associated with subgingival minocycline in chronic periodontitis subjects

The aims of this double-blind randomized clinical trial were to evaluate the presence of periodontal pathogens and the clinical response of periodontal pockets treatment to scaling and root planing (SRP) associated with subgingival minocycline (SM). A total of 36 subjects, 26 to 60 years old (40.7 +/- 9.1), who had been previously diagnosed with chronic periodontitis, were included in the present study. Eighteen subjects were selected for the test group (TG), who were treated with SRP plus SM (new treatment), and 18 subjects for the control group (CG) who received SRP plus vehicle (current treatment). Two homologous sites in each subject with a probing depth (PD) > or = 6 mm were chosen. To evaluate the clinical response after treatment, PD was measured at baseline and at 90 days. Microbiological evaluation was performed to detect 7 periodontal pathogens using polymerase chain reaction at baseline, 30, and 120 days. A mean reduction in PD of 2.8 and 2.1 mm was observed in the TG and CG, respectively. At baseline, P. gingivalis was the most prevalent organism in both test (65.8%) and control (48.6%) groups. After 120 days it fell to 30.8% in TG and to 23.1% in CG. There were no statistically significant differences between the test and control groups concerning PD (p > 0.05 by Wilcoxon test) or presence of periodontal pathogens (p > 0.05 by Wilcoxon and chi-square; p > 0.01 by Signal test). The results observed showed that the new treatment was as effective as the current treatment in reducing periodontal pathogens and PD among chronic periodontitis subjects.     

A novel activation-induced cytidine deaminase gene mutation in a Tunisian family with hyper IgM syndrome

Mutations in activation-induced cytidine deaminase can cause an autosomal recessive form of hyper-IgM syndrome. We have examined a Tunisian family composed of six members: two healthy parents, their two healthy daughters and two affected sons. We found a homozygous transversion G to T in the two sons while heterozygosity for the mutation was found in all other family members. This alteration is localised in intron 2 at the +1 position resulting in defective splicing. Use of various intronic cryptic splice-sites led to expression of various aberrant mRNA species. Conclusion:This is a novel mutation found in the gene encoding for activation-induced cytidine deaminase in a Tunisian family with hyper-IgM type 2 syndrome. This alteration leads to the use of two cryptic splicing sites causing the formation of two different mRNA species.C. Fiorini and S. Jilani contributed equally to this work.     

Catecholaminergic polymorphic ventricular tachycardia: successful emergency treatment with intravenous propranolol

Catecholaminergic polymorphic ventricular tachycardia (VT) is a rare arrhythmogenic disorder, which may cause sudden death and whose relationships with mutations in cardiac ryanodine receptor gene have been recently established. The present article reports a catecholaminergic polymorphic VT case of a 9-year-old girl, without any previous history of syncope, who has been found unconscious while playing and referred comatose to pediatric intensive care unit. The electrocardiogram pattern showed runs of bidirectional and polymorphic VT degenerating into ventricular fibrillation, without QT interval abnormalities. Various attempts of cardioversion, lidocaine, and magnesium sulfate intravenous infusions were only partially effective. Owing to catecholaminergic polymorphic VT highly suggesting electrocardiogram pattern, intravenous propranolol was administered, achieving immediate VT interruption. Long-term nadolol therapy effectively prevented further arrhythmias, with no relapses up to 10 months later; a good neurologic recovery was also obtained. Genetic evaluation revealed in this patient-but not in relatives-a mutation in ryanodine receptor gene on chromosome 1.