Nursing resources: a major determinant of nosocomial infection?

PURPOSE OF REVIEW: There is growing concern that changes in nurse workforce and hospital-restructuring interventions negatively impact on patient outcomes. This review focuses on the association between understaffing and health-care-associated infections. RECENT FINDINGS: There is a large number of studies showing that overcrowding, understaffing or a misbalance between workload and resources are important determinants of nosocomial infections and cross-transmission of microorganisms. Importantly, not only the number of staff but also the level of their training affects outcomes. The nurse workforce is ageing, mainly due to fewer individuals' engaging in a nursing career. This phenomenon, combined with cost-driven downsizing, contributes to a nursing shortage, and this tendency is not expected to revert unless important system changes are implemented. The causal pathway between understaffing and infection is complex, and factors might include lack of time to comply with infection control recommendations, job dissatisfaction, job-related burnout, absenteeism and a high staff turnover. SUMMARY: The evidence that cost-driven downsizing and changes in staffing patterns causes harm to patients cannot be ignored, and should not be considered as an inevitable outcome. More research is needed to better define the optimal patient-to-nurse ratio in various hospital settings and to estimate the economical impact of the nursing shortage. All quality-improvement interventions should carefully take into account systems and processes to be successful, as the issue of staffing is essentially a structural problem.     

Bimanual coordination involving homologous and heterologous joint combinations: when lower stability is associated with higher flexibility

Variability in behavior is often put in an unfavorable light as a marker of lack of skill. Here, we provide evidence that increased variability during preferred patterns of coordination is associated with higher flexibility in adopting new patterns. Twelve right-handed subjects performed cyclical bimanual flexion and extension patterns with four homologous and six heterologous joint combinations involving shoulder, elbow, wrist, and finger movements. Preferred (isofrequency) as well as less preferred (multifrequency) coordination patterns were studied. The findings revealed less accurate and less stable 1:1 coordination patterns during heterologous as compared to homologous limb segment combinations. Conversely, coordination patterns with a 2:1 frequency ratio were performed more accurately and more consistently during heterologous as compared to homologous conditions. Accordingly, a lower degree of coupling between effectors during performance of preferred coordination patterns was associated with more successful performance of less familiar patterns. This suggests that variability may promote the creative exploration of new performance modes.     

Use of soluble fibrin antigen instead of D-dimer as fibrin-related marker may enhance the prognostic power of the ISTH overt DIC score

The overt DIC score of the DIC subcommittee of the ISTH includes a fibrin-related marker (FRM) as indicator of intravascular fibrin formation. The type of marker to be used has not been specified, but D-dimer antigen, or fibrin degradation products are used by most investigators. Soluble fibrin complexes have been suggested as more specific indicators of acute intravascular fibrin formation. The aim of the present study was to compare the predictive value of the overt DIC score concerning clinical outcome in a surgical intensive care cohort, using either D-dimer antigen, or soluble fibrin antigen as FRM. The cutoff values for 2 and 3 score points for the FRM were assigned on the basis of the 25% and 75% quartiles of 1870 plasma samples obtained from 359 ICU patients during a period of 6 months. For 331 patients with complete diagnostic workup and day 1 blood samples, the Iatro SF as FRM component of the overt DIC score displayed the highest prognostic power concerning clinical outcome. The 28-day mortality of patients with overt DIC at day 1, using Iatro SF as FRM assay was 50.0%, whereas 28-day mortality of patients without overt DIC was 14.0% (p <0.0001). Using MDA D-dimer, and TINAquant D-dimer, 28-day mortality was between 35.5% and 39.3% in patients with overt DIC, and 15.5% to 15.6% in patients without overt DIC. Selection of the FRM as component of the DIC score has a small, but relevant impact on the prognostic performance of the overt DIC score. The present data on the distribution of values may provide a basis for the selection of appropriate cutoff points for assigning 2, and 3 points in the score.     

Chromosomal translocation t(18;21)(q23;q22.1) indicates novel susceptibility loci for frontotemporal dementia with ALS

A chromosomal translocation t(18;21)(q23;q22) is reported in a patient with frontotemporal dementia (FTD) and amyotrophic lateral sclerosis (ALS). We exclude the physical involvement and silencing of the ALS-linked gene for copper/zinc superoxide dismutase (SOD1) on chromosome 21q22.1. The breakpoints are assigned to sequences flanked by the markers ATA1H06, D18S462, D21S1915, and D21S1898. These critical regions may contain susceptibility loci for FTD associated with ALS.     

Validity of symptom assessment in psychotic disorders: information variance across different sources of history

BACKGROUND: Factors such as poor insight, amotivation, suspiciousness, disorganized speech and attentional problems may interfere with the ability of acutely ill individuals with psychotic disorders to provide a valid account of their symptoms. This study was designed to determine the degree to which history provided by such subjects is consistent with that obtained from other sources. METHOD: Fifty-five subjects presenting with psychotic disorders were multiply evaluated with a semi structured interview, the Comprehensive Assessment of Symptoms and History (CASH), which includes the Scales for the Assessment of Negative and Positive symptoms (SANS and SAPS). One interviewer assessed the severity of the patient's symptoms in the previous month based solely on information provided by the patient. A second rater made symptom ratings based on information obtained from a "best informant". Following this, a consensus rating was established based on an extensive evaluation and review of all sources of information. An item-by-item comparison of the three sets of symptom ratings was then quantified by paired t-tests, simple and multiple correlations. RESULTS: Positive and negative symptoms ratings based on the subjects' report were significantly lower than the corresponding consensus ratings. However, those based on the informants' report did not differ from consensus ratings for negative symptoms. Information obtained from subjects and from informants together accounted for a majority of the variance of the consensus ratings. CONCLUSIONS: These findings demonstrate that assessment limited to patients' own reports are likely to underestimate psychopathology in acutely ill patients with psychotic disorders. Obtaining corroborative history from a family member may substantially improve the validity of the assessment of negative symptoms.     

Affective and schizoaffective mixed states

Abstract. Although both DSM-IV and ICD-10 define schizoaffective mixed states, they have not received much attention—neither in the clinical nor in research context. We present preliminary results of a prospective study of bipolar affective (n = 100) and bipolar schizoaffective (n = 177) patients. 25% of the bipolar affective and 32% of the bipolar schizoaffective patients had at least one (schizo)mixed episode during the illness course. Nevertheless, (schizo)mixed episodes were rare—only 5.6% of all episodes. There was a trend that patients with (schizo)mixed episodes were more often women and exhibited more disability (reflected by higher rates of disability payments). Nevertheless, these differences failed to reach significance. Overall, schizo-mixed episodes are as frequent as pure affective mixed episodes. They might be linked to a less favourable course. Nevertheless, while their diagnostic criteria are problematic, they are systematically underdiagnosed.     

Funded research in psychosomatic medicine, medical psychology, and psychotherapy

This paper, summarizing the activities of the research task force of the German College of Psychosomatic Medicine (DKPM), reviews how research in psychosomatic medicine, medical psychology and psychotherapy has been funded by different institutions. The review reveals that psychosocial research has received considerable grants especially by the German Research Council and the Federal Ministry of Education and Research but also from other funding institutions. Besides an overview of potential sources for funding in the psychosocial disciplines, recommendations are formulated that might be helpful for raising research funds in the future.