Vital Signs: Estimated Effects of a Coordinated Approach for Action to Reduce Antibiotic-Resistant Infections in Health Care Facilities — United States

BackgroundTreatments for health care–associated infections (HAIs) caused by antibiotic-resistant bacteria and Clostridium difficile are limited, and some patients have developed untreatable infections. Evidence-supported interventions are available, but coordinated approaches to interrupt the spread of HAIs could have a greater impact on reversing the increasing incidence of these infections than independent facility-based program efforts.MethodsData from CDC’s National Healthcare Safety Network and Emerging Infections Program were analyzed to project the number of health care–associated infections from antibiotic-resistant bacteria or C. difficile both with and without a large scale national intervention that would include interrupting transmission and improved antibiotic stewardship. As an example, the impact of reducing transmission of one antibiotic-resistant infection (carbapenem-resistant Enterobacteriaceae [CRE]) on cumulative prevalence and number of HAI transmission events within interconnected groups of health care facilities was modeled using two distinct approaches, a large scale and a smaller scale health care network.ResultsImmediate nationwide infection control and antibiotic stewardship interventions, over 5 years, could avert an estimated 619,000 HAIs resulting from CRE, multidrug-resistant Pseudomonas aeruginosa, invasive methicillin-resistant Staphylococcus aureus (MRSA), or C. difficile. Compared with independent efforts, a coordinated response to prevent CRE spread across a group of inter-connected health care facilities resulted in a cumulative 74% reduction in acquisitions over 5 years in a 10-facility network model, and 55% reduction over 15 years in a 102-facility network model.ConclusionsWith effective action now, more than half a million antibiotic-resistant health care–associated infections could be prevented over 5 years. Models representing both large and small groups of interconnected health care facilities illustrate that a coordinated approach to interrupting transmission is more effective than historical independent facility-based efforts.Implications for Public HealthPublic health–led coordinated prevention approaches have the potential to more completely address the emergence and dissemination of these antibiotic-resistant organisms and C. difficile than independent facility–based efforts.     

What Do Healthcare Providers Know About Nutrition Support? A Survey of the Knowledge,Attitudes, and Practice of Pharmacists and Doctors Toward Nutrition Support in Malaysia

Background and Aims: Malnutrition is one of the health problems that can be prevented by appropriate nutrition care provided by healthcare providers. However, this practice is still lacking possibly because of the providers' inadequate knowledge. The aim of this study was to evaluate the self‐reported knowledge, attitudes, and practices of pharmacists and doctors toward nutrition support in a tertiary care hospital setting. Methods: A validated questionnaire was distributed to all the doctors and pharmacists working in a tertiary hospital in Penang, Malaysia. Seven individuals including academics, general surgeons, and pharmacists performed the face and content validity. The questionnaire was piloted using 24 healthcare providers at a different hospital. Result: Of 400 surveyed, 158 doctors and 72 pharmacists from various grades completed the questionnaire. More doctors (31.6%) than pharmacists (15.3%) reported adequate knowledge to perform patients' nutrition screening. However, in the knowledge assessment, pharmacists had a higher mean score (6.07 ± 1.77) than the doctors did (4.59 ± 1.87; P < .001), and most (70.4%) of them were grouped in the “average” score range. In addition, both pharmacists and doctors have ambivalent attitudes toward nutrition support. Only 31.3% stated that they perform nutrition screening on admission, and half of them performed nutrition assessment during hospitalization. Conclusion: Inappropriate nutrition care might be due to the lack of guidelines and insufficient knowledge among doctors and pharmacists. Special nutrition training and education for both pharmacists and doctors should be established.     

Root damage induced by intraosseous anesthesia–An in vitro investigation

Objectives: The principle of the intraosseous anesthesia (IOA) relies on the perforation of the cortical plate of the bone for direct application of the local anesthetic solution into the underlying cancellous structures. During this procedure, IOA needles might accidentally come in contact with the tooth roots. The aim of the current in vitro study was to examine the consequences of this ‘worst case scenario’ comparing five commercially available IOA systems. Material and Methods: Extracted human roots were randomly perforated using five different IOA systems with a drilling time ≤5s. To simulate normal in vivo conditions, the roots were kept humid during the drilling procedure. Data was statistically evaluated using F-test (SPSS16, SPSS Inc., Chicago, USA) and the significance level was set at p≤0.05. Results: All examined systems resulted in root perforation. Drill fractures occurred in either none 0% (Quicksleeper®, Anesto®, Intraflow®, Stabident®) or 100% (X-Tip®) of the applications. Excessive heat generation, as evident by combustion odor as well as metal and tooth discoloration, appeared in 30% (Quicksleeper®), 40% (Anesto®), 60% (Intraflow®), 90% (Stabident®) and 100% (X-Tip®) of all perforations. Conclusion: Within the limits of in-vitro studies, the results show a potential for irreversible root damage that might be inflicted by an improper use of IOA systems. Key words:Intraosseous anesthesia, complication, root damage.     

CD146 mediates VEGF‐induced melanoma cell extravasation through FAK activation

CD146 is an adhesion molecule expressed by both melanoma and endothelial cells and thus is well positioned to control melanoma extravasation. Nevertheless, during melanoma metastasis, the involvement of CD146 expressed within tumor microenvironment has never been analyzed. To investigate whether host CD146 mediates the extravasation of melanoma cells across the endothelium, we generated CD146 KO mice. We demonstrated that host CD146 did not affect melanoma growth or tumor angiogenesis but promoted hematogenous melanoma metastasis to the lung. Accordingly, the survival of CD146‐deficient mice was markedly prolonged during melanoma metastasis. Interestingly, vascular endothelial growth factor‐induced vascular permeability was significantly decreased in CD146 KO mice. We also provided evidence that VEGF‐induced transendothelial migration of melanoma cells was significantly reduced across CD146 KO lung microvascular endothelial cells (LMEC). CD146 deficiency decreased the expression of VEGFR‐2/Ve‐cadherin and altered focal adhesion kinase (FAK) activation in response to VEGF. In addition, inhibition of FAK phosphorylation reduced transmigration of B16 melanoma cells across WT LMEC at the same level that across CD146 KO LMEC. Altogether, we propose a novel mechanism involving the VEGF/CD146/FAK/Ve‐cadherin network in melanoma extravasation across the vessel barrier that identifies CD146‐targeted therapy as a potential strategy for the treatment of melanoma metastasis.     

Relation of plasma total homocysteine, folate and vitamin B12 levels to bone mineral density in Moroccan healthy postmenopausal women

To test whether in Moroccan healthy postmenopausal women, levels of plasma total homocysteine (tHcy), folate, and vitamin B12 are related to BMD. A total of 188 volunteer postmenopausal women were recruited from our blood taking center between April 2008 and December 2008. Each subject completed a standardized questionnaire designed to document putative risk factors of osteoporosis. Bone mineral density was determined by a Lunar Prodigy Vision DXA system, and blood samples for plasma tHcy, folate, vitamin B12, and serum parathyroid hormone (PTH) were taken. Comparison between women with osteoporosis, osteopenia and normal BMD showed that the osteoporotic women were significantly older, had lower weight and height than the women of the other groups. Plasma tHcy was significantly higher in the osteoporotic group. Levels of tHcy were inversely related to BMD at the lumbar spine, at the total hip and plasma vitamin B12 and positively related to age and creatinine. Multiple regression analysis showed that age and BMI were the main predictors of BMD at the lumbar spine, whereas the main predictors of BMD at the total hip were age, BMI, plasma tHcy, and plasma vitamin B₁₂. tHcy and vitamin B12 are independent risk factors for osteoporosis in Moroccan healthy postmenopausal women.     

Choosing Wisely—Barriers and Solutions to Implementation in Low and Middle-Income Countries

Globally, there is increasing emphasis on value-based cancer care. Rising healthcare costs and reduced health care spending and budgets, especially in low- and middle-income countries (LMICs), call for patients, providers, and healthcare systems to apply the Choose Wisely (CW) approach. This approach seeks to advance a dialogue on avoiding unnecessary medical tests, treatments, and procedures. Several factors have been described as barriers and facilitators to the implementation of the Choosing Wisely recommendations in high-income countries but none for LMICs. In this review, we attempt to classify potential barriers to the Choose Wisely implementation relative to the sources of behavior and potential intervention functions that can be implemented in order to reduce these barriers.