Paediatric critical incident analysis: lessons learnt on analysis,recommendations and implementation

The objectives of this study were to identify causal and contributing factors of serious patient safety incidents in a paediatric university hospital, to report on ensuing recommendations and to assess the extent of implementation of the recommendations. The possible causal and contributing factors identified in 17 incidents were classified by a system devised by Vincent et al. Proposed recommendations were classified by the same system, and degrees of implementation were established. A median of 5 causal and contributing factors per incident were identified. Twenty-two percent of all factors were related to teamwork and 22 % to task factors. A median of 5 recommendations per analysis were formulated. Most recommendations were related to task factors (36 %). The time load of each analysis was a mean of 27 h. One third of the recommendations have been acted upon, mostly those related to task and team factors. Conclusion: Incident analysis is time-consuming but yields indispensable information on causal and contributing factors, presenting numerous opportunities for quality improvement. The value of these analyses could be improved by appointing responsibilities and setting up time frames for implementation. A bottom-up approach with managerial support appears to be a key to turning incident analysis and quality improvement into an ongoing process.     

Über die Wirkstoffe des Crotonöls

Zusammenfassung Es wird ein Trennungsgang zur systematischen Fraktionierung von Crotonöl beschrieben, der unter Anwendung multiplikativer Verteilungs- und chromatographischer Verfahren sowie geeigneter biologischer Teste die Isolierung von zwei hochwirksamen Substanzen A und B in reproduzierbarer Weise ermöglicht. Diese Substanzen enthalten praktisch die gesamte toxische, entzündliche und cocarcinogene Aktivität des Crotonöls. Die beiden harzartigen Wirkstoffe unterscheiden sich signifikant im R _f-Wert, wandern aber jeweils als einheitliche Flecken und zeigen sehr ähnliche physikalische, chemische und biologische Eigenschaften. Sie stellen die wirksamsten bisher beschriebenen Cocarcinogene dar.

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Summary For systematic fractionation of Croton Oil a separation scheme is described employing multiple distribution and chromatography in combination with suitable biological assays. In a reproducible manner two highly active compounds have been isolated which represent together practically all the toxic, irritant and cocarcinogenic activity of Croton Oil. In thin layer chromatography the resinous compounds show significantly different R _f-values but migrate as one single spot respectively. They show very similar physical, chemical and biological properties and represent the most potent cocarcinogens described as yet.

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Herrn Prof. Dr. H. Hamperl zum 65. Geburtstag in dankbarer Verehrung gewidmet.     

Hypothetical vaccination of the Dutch population with a herpes simplex virus vaccine: estimation of the profitability using a demographic projection model

The apparently increasing evidence of herpes simplex virus infections of the genital tract has focused attention on preventing the infection by vaccination. Herpes genitalis is not, however, the most quantitatively important clinical manifestation of herpes simplex virus infections. Because 41% of the hospitalized patients are younger than 20 years, vaccination of birth cohorts would be more favourable. In this paper the financial benefits of a hypothetical herpes simplex virus vaccination were calculated with the use of a population projection model. For the Netherlands, if the price of the hypothetical herpes simplex virus vaccine equals the cost price of the mumps component of the combined mumps-measles-rubella vaccine, the herpes vaccine would be profitable within 8 years.     

Segmented filamentous bacteria are potent stimuli of a physiologically normal state of the murine gut mucosal immune system

Segmented filamentous bacteria (SFB) are autochthonous bacteria inhabiting the intestinal tracts of many species, including humans. We studied the effect of SFB on the mucosal immune system by monoassociating formerly germfree C3H/HeN mice with SFB. At various time points during 190 days of colonization, fragment cultures of small intestine and Peyer's patches (PP) were analyzed for total immunoglobulin A (IgA) and SFB-specific IgA production. Also, phenotypic changes indicating germinal center reactions (GCRs) and the activation of CD4(+) T cells in PP were determined by using fluorescence-activated cell sorter analyses. A second group of SFB-monoassociated mice was colonized with a gram-negative commensal, Morganella morganii, to determine if the mucosal immune system was again stimulated and to evaluate the effect of prior colonization with SFB on the ability of M. morganii to translocate to the spleen and mesenteric lymph nodes. We found that SFB stimulated GCRs in PP from day 6 after monoassociation, that GCRs only gradually waned over the entire length of colonization, that natural IgA production was increased to levels 24 to 63% of that of conventionally reared mice, and that SFB-specific IgA was produced but accounted for less than 1.4% of total IgA. Also, the proportion of CD4(+), CD45RBlow T cells, indicative of activated cells, gradually increased in the PP to the level found in conventionally reared mice. Secondary colonization with M. morganii was able to stimulate GCRs anew, leading to a specific IgA antibody response. Previous stimulation of mucosal immunity by SFB did not prevent the translocation of M. morganii in the double-colonized mice. Our findings generally indicate that SFB are one of the single most potent microbial stimuli of the gut mucosal immune system.     

A mitochondrial myopathy in an infant with lactic acidosis

We describe a girl with mitochondrial myopathy, who presented with general muscle weakness, muscle hypotonia and motor retardation. The level of blood lactate and pyruvate was consistently increased. Enzymatic studies showed impairment of NADH-dehydrogenase activity (complex I of the respiratory chain) in skeletal muscle. Electron-microscopy of a muscle biopsy showed abnormalities of a mitochondrial myopathy. The girl, now aged 30 months, has been treated with riboflavine (vitamin B2) since the age of 14 months, and lactate and pyruvate levels have decreased to normal. The patient still shows mild muscle hypotonia and weakness, but good motor progress and normal cognitive development.     

Unconscious thought reduces intrusion development: A replication and extension

Background and ObjectivesIntrusive images after a traumatic event, a hallmark feature of post-traumatic stress disorder, are suggested to develop because the trauma memory is disorganized and not integrated into autobiographical memory. Unconscious Thought Theory predicts that information can be conceptually organized after a period of unconscious thought (UT), more so than after conscious thought (CT). We aimed to test the hypothesis that UT decreases intrusions and increases conceptual organization in memory.MethodsParticipants were shown a stressful film and were required to perform an UT task, a CT task, or a distraction task. Intrusions of the film, intrusion qualities, and sequence memory were measured afterwards.ResultsWe confirmed our hypothesis that UT (versus CT or mere distraction) leads to fewer intrusions, thereby replicating earlier research. Contrary to prediction, we found no difference between the conditions on sequence memory. In addition, conscious thought appeared to increase intrusion nowness and arousal.LimitationsThe analogue design and healthy participant sample prevent from generalizing results to other populations. Intrusion frequency and qualities were assessed immediately after the film thereby prohibiting us from drawing conclusions about any long-term effects.ConclusionsEngaging in unconscious thought after a stressful film can reduce intrusion frequency. This has potential implications for clinical interventions to prevent initial stress symptoms. The underlying mechanism remains unclear for now and provides an avenue for future research.     

Haemodynamic effects of patent foramen ovale and atrial septal defect closure: a comparison during percutaneous shunt closure

Objectives: We investigated the haemodynamic effect of percutaneous closure of an intra‐atrial shunt, using non‐invasive finger pressure measurements. Background: Percutaneous closure of both patent foramen ovale (PFO) and atrial septal defect (ASD) is widely practised. Currently no data are available on short‐term haemodynamic changes induced by closure. Methods: Twenty‐five consecutive patients (mean age 49 ± 17 years, 10 men) who underwent a percutaneous closure of a PFO (n = 15) or ASD (n = 10) were included in this study. During the procedure blood pressure and heart rate (HR) were monitored continuously with a Finometer^®. Changes in systolic, mean, and diastolic pressure, stroke volume (SV), cardiac output (CO) and total peripheral resistance (TPR) were computed from the pressure registrations using Modelflow^® methodology. Results: Baseline characteristics were similar for the PFO and ASD patients. After PFO closure none of the haemodynamic parameters changed significantly. After ASD closure the systolic, mean, and diastolic pressures increased 7·1 ± 5·4 (P = 0·003), 3·8 ± 3·5 (P = 0·007) and 2·0 ± 3·0 mmHg (P = ns) respectively. HR decreased 5·1 ± 5·3 beats per minute (P = 0·01). SV, CO and TPR increased 8·5 ± 6·4 ml (13·5%; P = 0·002), 0·21 ± 0·45 l min^?1 (5·6%; P = ns) and 0·02 ± 0·14 dynes (4·1%; P = ns) respectively. The changes in SV differ between the PFO and ASD patients (P = 0·009). Conclusions: Using non‐invasive finger pressure measurements, we found that SV, mean and systolic blood pressure increased immediately after percutaneous closure of an ASD in adults, whereas the percutaneous PFO closure had no effect on haemodynamic characteristics.