Don't just do something,stand there! The value and art of deliberate clinical inertia

It can be difficult to avoid unnecessary investigations and treatments, which are a form of low‐value care. Yet every intervention in medicine has potential harms, which may outweigh the potential benefits. Deliberate clinical inertia is the art of doing nothing as a positive response. This paper provides suggestions on how to incorporate deliberate clinical inertia into our daily clinical practice, and gives an overview of current initiatives such as ‘Choosing Wisely’ and the ‘Right Care Alliance’. The decision to ‘do nothing’ can be complex due to competing factors, and barriers to implementation are highlighted. Several strategies to promote deliberate clinical inertia are outlined, with an emphasis on shared decision‐making. Preventing medical harm must become one of the pillars of modern health care and the art of not intervening, that is, deliberate clinical inertia, can be a novel patient‐centred quality indicator to promote harm reduction.     

Respiratory virology and microbiology in intensive care units: a prospective cohort study

Our aim was to determine the frequency of 12 common respiratory viruses in patients admitted to intensive care units with respiratory symptoms, evaluate the clinical characteristics and to compare the results to routine microbiological diagnostics. Throat swabs from 122 intensive care‐patients >18 years with acute respiratory symptoms were collected upon admission and analysed with multiplex real‐time polymerase chain reaction, for 12 community respiratory viruses. Blood and respiratory tract specimens were analysed for bacteria and fungi upon clinicians' request. Clinical and paraclinical data were collected. Viruses were detected in 19 (16%) of the 122 study patients. Five virus‐positive patients (26%) had possible clinically relevant bacteria or fungi co‐detected. Patients with exacerbation in COPD were associated with a viral infection (p = 0.02). Other comorbidities, clinical and paraclinical parameters, and death were independent of a viral infection or co‐detection of bacteria/fungi. In conclusion, respiratory viruses were frequently detected in the patients. The investigated clinical and paraclinical parameters were not different in viral infections compared to other agents, thus respiratory viruses likely have similar impact on the clinical course as other agents. In 25% of the virus‐positive patients, polymicrobial aetiology was identified. Comprehensive and sensitive diagnostic methods should be emphasized to enhance respiratory diagnostics.     

PEG shielded polymeric double-layered micelles for gene delivery.

A combination of A-B and B-C block copolymers was used to encapsulate DNA inside pEG coated particles, where A is a cationic block (poly(dimethylaminoethyl methacrylate), pDMAEMA) for DNA binding and condensation, B is a hydrophobic block (poly(butylmethacrylate), pBMA) and C is a polyethylene glycol (pEG) block. The AB and BC block copolymers were synthesized by transition metal mediated radical polymerization. The AB block copolymer had a fixed pBMA molecular weight of 3800 g/mol and a varying pDMAEMA molecular weight (from 22 to 65 kg/mol), the BC block copolymer had a fixed composition (pBMA 9000 g/mol; pEG 2000 g/mol). Plasmid DNA containing particles were made via a detergent dialysis method. By this method, particles of approximately 120 nm, as determined by dynamic light scattering (DLS), with a near neutral charge were formed, independent of the DMAEMA block size. DLS measurements and gel electrophoresis indicated that the particles were very stable in cell culture medium at 37 degrees C and resistant to anionic exchange by poly-l-aspartic acid. The particles were able to transfect COS-7 and OVCAR-3 cells with minor toxicity if incubated for 1 or 4 h; incubation for 24 h resulted in an increased toxicity. This paper shows that small polyplexes with near neutral charge can be obtained via a convenient detergent dialysis method using pDMAEMA-b-pBMA and pBMA-b-pEG. These particles may be interesting for in vivo experiments where particles with high positive charges have adverse interactions with blood components.     

A Prospective Evaluation of Missed Injuries in Trauma Patients, Before and After Formalising the Trauma Tertiary Survey

Objective

This study prospectively evaluated in-hospital and postdischarge missed injury rates in admitted trauma patients, before and after the formalisation of a trauma tertiary survey (TTS) procedure.

Methods

Prospective before-and-after cohort study. TTS were formalised in a single regional level II trauma hospital in November 2009. All multitrauma patients admitted between March–October 2009 (preformalisation of TTS) and December 2009–September 2010 (post-) were assessed for missed injury, classified into three types: Type I, in-hospital, (injury missed at initial assessment, detected within 24 h); Type II, in-hospital (detected in hospital after 24 h, missed at initial assessment and by TTS); Type III, postdischarge (detected after hospital discharge). Secondary outcome measures included TTS performance rates and functional outcomes at 1 and 6 months.

Results

A total of 487 trauma patients were included (pre-: n = 235; post-: n = 252). In-hospital missed injury rate (Types I and II combined) was similar for both groups (3.8 vs. 4.8 %, P = 0.61), as were postdischarge missed injury rates (Type III) at 1 month (13.7 vs. 11.5 %, P = 0.43), and 6 months (3.8 vs. 3.3 %, P = 0.84) after discharge. TTS performance was substantially higher in the post-group (27 vs. 42 %, P < 0.001). Functional outcomes for both cohorts were similar at 1 and 6 months follow-up.

Conclusions

This is the first study to evaluate missed injury rates after hospital discharge and demonstrated cumulative missed injury rates >15 %. Some of these injuries were clinically relevant. Although TTS performance was significantly improved by formalising the process (from 27 to 42 %), this did not decrease missed injury rates.     

Magnetic-resonance-imaging-based three-dimensional muscle reconstruction of hip abductor muscle volume in a person with a transfemoral bone-anchored prosthesis: A feasibility study

Background: Persons with transfemoral amputation typically have severe muscle atrophy of the residual limb. The effect of bone-anchored prosthesis use on existing muscle atrophy is unknown. A potentially feasible method to evaluate this is magnetic resonance imaging (MRI)-based three-dimensional (3D) muscle reconstruction. We aimed to (1) examine the feasibility of MRI-based 3D muscle reconstruction technique in a person with a cobalt–chrome–molybdenum transfemoral bone-anchored prosthesis; and (2) describe the change of hip abductor muscle volume over time. Methods: In this single case, 1-year follow-up study we reconstructed the 3D hip abductor muscle volumes semiautomatically from MRI scans at baseline, 6- and 12-month follow-up. The number of adverse events, difficulties in data analysis, time investment and participants’ burden determined the level of feasibility. Results: We included a man (70 years) with a transfemoral amputation who received a bone-anchored prosthesis after 52 years of socket prosthesis use. No adverse events occurred. The accuracy of the 3D reconstruction was potentially reduced by severe adipose tissue interposition. Data analysis was time-intensive (115 h). Participants’ burden was limited to 3-h time investment. Compared to baseline, the total hip abductor volume of both the residual limb (6 month: 5.5%; 12 month: 7.4%) and sound limb (6 month: 7.8%; 12 month: 5.5%) increased. Conclusion: The presented technique appears feasible to follow muscle volume changes over time in a person with a cobalt–chrome–molybdenum transfemoral bone-anchored prosthesis in an experimental setting. Future research should focus on analysis of muscle tissue composition and the feasibility in bone-anchored prostheses of other alloys.     

How would Australian hospital staff react to an avian influenza admission,or an influenza pandemic?

Objective: To estimate the expected staff absentee rates and work attitudes in an Australian tertiary hospital workforce in two hypothetical scenarios: (i) a single admission of avian influenza; and (ii) multiple admissions of human pandemic influenza. Methods: A survey conducted at hospital staff meetings between May and August 2006. Results: Out of 570 questionnaires distributed, 560 were completed. For scenario one, 72 (13%) indicated that they would not attend work, and an additional 136 (25%) would only work provided that immunizations and/or antiviral medications were immediately available, so that up to 208 (38%) would not attend work. For scenario two, 196 (36%) would not attend work, and an additional 95 (17%) would work only if immunizations and/or antiviral medications were immediately available, so that up to 291 (53%) staff would not attend work. Staff whose work required them to be in the ED (odds ratios 2.2 and 1.6 for each scenario respectively) or on acute medical wards (odds ratios 2.2 and 2.0 respectively) were more likely to work. Conclusion: High absenteeism among hospital staff should be anticipated if patients are admitted with either avian or pandemic influenza, particularly if specific antiviral preventative measures are not immediately available. Measures to maximize the safety of staff and their families would be important incentives to attend work. Education on realistic level of risk from avian and pandemic influenza, as well as the effectiveness of basic infection control procedures and personal protective equipment, would be useful in improving willingness to work.