Reduction in hospitalwide incidence of infection or colonization with methicillin-resistant Staphylococcus aureus with use of antimicrobial hand-hygiene gel and statistical process control charts.

OBJECTIVE: To evaluate the impact of serial interventions on the incidence of methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: Longitudinal observational study before and after interventions. SETTING: The Alfred Hospital is a 350-bed tertiary referral hospital with a 35-bed intensive care unit (ICU). INTERVENTIONS: A series of interventions including the introduction of an antimicrobial hand-hygiene gel to the intensive care unit and a hospitalwide MRSA surveillance feedback program that used statistical process control charts but not active surveillance cultures. METHODS: Serial interventions were introduced between January 2003 and May 2006. The incidence and rates of new patients colonized or infected with MRSA and episodes of MRSA bacteremia in the intensive care unit and hospitalwide were compared between the preintervention and intervention periods. Segmented regression analysis was used to calculate the percentage reduction in new patients with MRSA and in episodes of MRSA bacteremia hospitalwide in the intervention period. RESULTS: The rate of new patients with MRSA in the ICU was 6.7 cases per 100 patient admissions in the intervention period, compared with 9.3 cases per 100 patient admissions in the preintervention period (P=.047). The hospitalwide rate of new patients with MRSA was 1.7 cases per 100 patient admissions in the intervention period, compared with 3.0 cases per 100 patient admissions in the preintervention period (P<.001). By use of segmented regression analysis, the maximum and conservative estimates for percentage reduction in the rate of new patients with MRSA were 79.5% and 42.0%, respectively, and the maximum and conservative estimates for percentage reduction in the rate of episodes of MRSA bacteremia were 87.4% and 39.0%, respectively. CONCLUSION: A sustained reduction in the number of new patients with MRSA colonization or infection has been demonstrated using minimal resources and a limited number of interventions.     

Seguridad clínica en atención primaria. los errores médicos (II)

The first article of this series on Clinical Safety was dedicated to the epidemiology and systemic preventive policies. In the present review we focus on medical errors with special emphasis on diagnostic type errors. These errors sometimes arise from the elusive characteristics of the disease itself, the way in which the patients present their symptoms, and the characteristics of the professionals themselves. If we consider a general practitioner as a diagnostic machine, -paradigm of “physician as a robot”- it would be easier for us to accept some cognitive limitations and introduce institutional strategies that would humanise the treatment occasionally received. More specifically we will examine three strategies for improving clinical reasoning: recognising dangerous situations, metacognition, and an internal supervisor.     

Two cases of dysfibrinogenemia characterized by abnormal FPB release: fibrinogen Madrid I & II

Congenital dysfibrinogenemia was found in two non related and asymptomatic families. Low levels of plasma fibrinogen were found using a chronometric assay but normal levels were found using both an immunologic method and a method to measure the fibrin formed after two hours incubation with thrombin. Kinetic analysis of fibrinopeptide release revealed a delay in the thrombin catalyzed release of fibrinopeptide B from both abnormal fibrinogens. Timed release of fibrinopeptide A was normal. Analysis of fibrinopeptides by high-performance liquid chromatography showed the same retention times in both normal and abnormal fibrinogens. Polymerisation of fibrin monomers and the sialic acid content per mol of fibrinogen were normal. Although these cases seem similar, until their structural defects are determined, it is proposed to provisionally designate them fibrinogens Madrid I & II.     

Efficacy of teicoplanin-gentamicin given once a day on the basis of pharmacokinetics in humans for treatment of enterococcal experimental endocarditis

With the aim of investigating home therapy for enterococcal endocarditis, we compared the efficacy of teicoplanin combined with gentamicin given once a day or in three daily doses (t.i.d.) with the standard treatment, ampicillin plus gentamicin administered t.i.d., for treating experimental enterococcal endocarditis. The antibiotics were administered by using "human-like pharmacokinetics" (H-L), i.e, pharmacokinetics like those in humans, that simulated the profiles of these drugs in human serum. Animals with catheter-induced endocarditis were infected intravenously with 10(8) CFU of Enterococcus faecalis EF91 (MICs and MBCs of ampicillin, gentamicin, and teicoplanin, 0.5 and 32, 16 and 32, and 0.5 and 1 microg/ml, respectively) and were treated for 3 days with ampicillin H-L at 2 g every 4 h plus gentamicin H-L at 1 mg/kg every 8 h, or teicoplanin H-L at 10 mg/kg every 24 h, alone or combined with gentamicin, administered at dose of H-L at 1 mg/kg every 8 h or H-L at 4.5 mg/kg every 24 h. The results of therapy for experimental endocarditis due to EF91 showed that teicoplanin alone was as effective as ampicillin alone in reducing the bacterial load (P > 0.05). The combination of ampicillin or teicoplanin with gentamicin was more effective than the administration of both drugs alone in reducing the log(10)CFU/gram of aortic vegetation (P < 0.01 and P < 0.05, respectively). Teicoplanin plus gentamicin H-L at 4.5 mg/kg, both administered every 24 h, showed an efficacy equal to the "gold standard," ampicillin plus gentamicin H-L at 1 mg/kg t.i.d. (P > 0.05). Increasing the interval of administration of gentamicin to a single daily dose combined with teicoplanin resulted in a reduction of bacteria in the vegetations equivalent to that achieved with the recommended regimen of ampicillin plus thrice-daily gentamicin in the treatment of experimental endocarditis due to E. faecalis. Teicoplanin plus gentamicin, both administered once a day, may be useful home therapy for selected cases of enterococcal endocarditis.     

The advantages and challenges of unannounced standardized patient methodology to assess healthcare communication

Objective

This paper provides an overview of the implementation of using unannounced standardized patients (USPs) to conduct health communication research in clinical settings.

Methods

Certain types of health communication situations are difficult to capture because of their rarity or unpredictable nature. In primary care the real reasons for a visit are frequently unknown until the consultation is well under way. Therefore, it is logistically difficult for communication studies to capture many real-time communications between patients and their physicians. Although the USP methodology is ideal for capturing these communication behaviors, challenges to using this method include developing collaborative relationships with clinical practices, logistical issues such as safeguarding the identity of the USP, training USPs and creating their identities, maintaining fidelity to the role, and analyzing the resultant data.

Results

This paper discusses the challenges and solutions to USP implementation. We provide an example of how to implement a USP study using an on-going study being conducted in primary care practices.

Conclusion

This paper explores the advantages and challenges as well as strategies to overcome obstacles to implementing a USP study.

Practice implications

Despite the challenges, USP methodology can contribute much to our understanding of health communication and practice.     

A historical reflection of the contributions of Cajal and Golgi to the foundations of neuroscience

In 1906, the Spaniard Santiago Ramón y Cajal and the Italian Camillo Golgi shared the Nobel Prize in Physiology or Medicine, in recognition of their work on the structure of the nervous system. Although both were well-known scientists who had made a large number of important discoveries regarding the anatomy of the nervous system, each defended a different and conflicting position in relation to the intimate organization of the grey matter that makes up the brain. In this communication we will review the importance of Cajal's studies using the method of impregnation discovered by Golgi, as well as the relevant studies carried out by Golgi, the concession of the Nobel Prize and the events that occurred during the Nobel conferences. In summary, we will précis the important contribution of both scientists to the founding of modern Neuroscience.     

The ‘Public Accountability Approach’: Suggestions for a Framework to Characterise,Compare, Inform and Evaluate Gambling Regulation

It is argued that the analytical comparison of gambling regulatory frameworks across jurisdictions requires the identification of salient dimensions to provide the basis for such. It is further suggested that governmental ‘conflict of interest’ might provide a useful dimension for such comparison, as operationalised by concomitant EGM harm and government dependence criteria. The same ‘conflict of interest’ criteria are then suggested as a guide for gambling regulation within single jurisdictions, this being named the ‘Public Accountability Approach.’ These points are discussed within broader reference to lines and webs of harm production within a public health analysis. Broader reference is also made to the proper role of government within contemporary democracy.

Bladder infection by schistosoma: an uncommon cause of haematuria

Immigration is a real phenomenon in our country with direct consequences into the public health system. In the attendance to these patients we do not have to forget the existence unusual diseases in our setting. We presented the clinical case of a patient with hematuria caused by bladder schistosomiasis.