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PubMed2003

[High mortality due to infectious diseases and unnatural causes of death among asylum seekers in the Netherlands, 1998-1999].

OBJECTIVE: Description of causes of death among asylum seekers in the Netherlands compared to the Dutch standard population and identification of preventive measures to avoid preventable death. METHODS: An analysis of the causes of death of asylum seekers accommodated in housing facilities of the Central Organ Asylum seekers (COA) for the period 1998-1999 was performed. The primary cause of death was attributed using the International Classification of Diseases (ICD-10) and grouped according to the most important causes of death list issued by Statistics Netherlands. After stratification for gender and age standardised mortality ratios (SMR) were computed. RESULTS: In 82% of the observed deaths amongst asylum seekers a description of the cause and circumstances of death could be obtained. During the 2-year study period 156 asylum seekers died (of which 49 due to an unnatural cause of death and 15 due to infectious diseases). Fourteen stillbirths were registered in an index population of 37,688 in 1998 and 54,110 in 1999. The crude mortality rate was 1.95 per 1000 for male asylum seekers and 1.25 per 1000 for female asylum seekers. Compared to the Dutch standard population, the SMR was 1.23 (95%-CI: 1.01-1.42) for male asylum seekers and 0.85 (0.59-1.11) for female asylum seekers. The elevated mortality in male asylum seekers was due to the high mortality for infectious diseases with an SMR of 4.1 (1.3-6.9) and unnatural death with an SMR of 2.5 (1.7-3.2). More specifically, drowning had an SMR of 11.1 (2.3-20.7), murder and manslaughter 7.3 (2.5-12.0) and suicide 2.8 (1.5-4.1). AIDS accounted for half of the mortality due to infectious diseases. CONCLUSION: In 1998-1999, drowning, murder, manslaughter and suicide contributed significantly to an elevated mortality rate amongst male asylum seekers in the Netherlands. Some of these unnatural deaths could be avoided by implementing preventive measures.

Adolescent↗
PubMed2000

The probability distribution of the number of loci indicating exclusion in a core set of STR markers.

The distribution of the number of loci out of the 13 in the CODIS STR set that would show an exclusion (i.e., a genotype set incompatible either with the prosecution hypothesis or with Mendelian transmission) was estimated in different scenarios. The knowledge of this distribution would provide a framework against which casework evidence can be compared. I used allele frequencies in Iberian and in Italian populations to generate individual genotypes at random and to test in 1 million simulation replicates, how many of the 13 loci would give an exclusion in an individual identification case, a paternity case, and a double parenthood case. All three scenarios were tested under an expected overall exclusion, both for unrelated individuals and for cases in which the suspect or the alleged father was the brother of the real culprit or real father. Paternity and double parenthood cases were also tested in the true scenario, with exclusionary loci due to mutation. In individual identification cases, the average number of exclusionary loci was 11.95 with a minimum of 7. This STR set also showed sufficient power to resolve identification cases in which the evidence sample came from a suspect's sib. False paternity cases yielded an average of 7.65 exclusionary loci and exclusions with only one (0.0108%) or two (0.14%) exclusionary loci were obtained only rarely. The cases of exclusion with one locus could lead to likelihood ratios in favour of paternity, while both true and false paternity cases with two exclusionary loci would often lead to non-conclusive likelihood ratios. The average number of exclusionary loci in a paternity case where the alleged father was the real father's brother was 3.82, with a significant number of cases where no exclusions were obtained.

Child↗
PubMed1994

Associations between social and environmental factors and perinatal mortality in Jamaica.

Social and environmental factors in Jamaica were compared between 9919 mothers delivering in a 2-month period a singleton who survived the early neonatal period and 1847 mothers who were delivered of a singleton perinatal death in a contiguous 12-month period. Logistic regression showed independent positive statistically significant increased odds of having a perinatal death among mothers who lived in rural parishes, older mothers (aged 30 +), single parents, no other children in the household, large number of adults in the household, mother unemployed, the major wage earner of the household not being in a managerial, professional or skilled non-manual occupation, the household not having sole use of toilet facilities, smaller mothers and those classified as obese or undernourished. Variations were found for different categories of death. Intrapartum asphyxia deaths were not related to union (marital) status, occupation of major wage earner, number of adults nor to the use of the toilet. Antepartum fetal deaths did not vary significantly with occupation of major wage earner or maternal height, but did show a relationship with maternal education, mothers with lowest levels having reduced risk. Deaths from immaturity were significantly related only to occupation of major wage earner, number of children in the household, number of social amenities available (negative relationships) and maternal age (< 17 at highest risk). In conclusion there was little to indicate that social deprivation per se was related to perinatal death, although specific features of the environment showed strong relationships.

Adolescent↗
PubMed1994

Percutaneous transluminal coronary angioplasty in women compared with men.

OBJECTIVES: This study compares in-hospital and long-term outcome after angioplasty in women and men. BACKGROUND: The recognition that coronary artery disease is the most common cause of death in women has increased interest in outcome studies of coronary artery disease in women. METHODS: Patients who had previous coronary revascularization and those who underwent angioplasty in the setting of acute myocardial infarction were excluded. Angioplasty was performed with standard methods. Clinical data were retrieved from a clinical data base and analyzed with standard statistical methods. RESULTS: There were 2,845 women and 7,940 men. The women were older (62 +/- 11 vs. 57 +/- 10 years) and had more hypertension (54.5% vs. 40.1%), diabetes (19.3% vs. 11.7%), grade III to IV angina (71.5% vs. 58.4%) and congestive failure (4.3% vs. 2.1%) than men (all p < 0.0001). More men had a previous myocardial infarction (35.4% vs. 31.0%) and were taller and weighed more (all p < 0.0001). The men had lower ejection fractions and more multivessel disease (31.0% vs. 25.2%) (both p < 0.0001). In women there was a trend toward more Q wave myocardial infarctions (1.1% vs. 0.75%, p = 0.10), and hospital mortality was higher (0.7% vs. 0.1%, p < 0.0001). Angina at follow-up was more common in women 40.2% vs. 26.7%, p < 0.0001). The multivariate correlates of in-hospital death were short stature, reduced ejection fraction and multivessel disease, with trends for older age and female gender. Five-year survival was 95% in men and 92% in women (p = 0.0002). However, female gender was not a multivariate correlate of long-term survival and was accounted for by other characteristics, primarily age. The multivariate correlates of long-term survival were older age, congestive failure, reduced ejection fraction, multivessel disease, diabetes, hypertension and a trend for severe angina. No difference between women and men was noted in long-term freedom from myocardial infarction. There were more additional procedures in men than in women. CONCLUSIONS: Despite higher in-hospital mortality, long-term mortality and clinical outcome were similar in both genders when age and body habitus were accounted for.

Age Distribution↗
PubMed2006

Associations between Neospora caninum specific antibodies in serum and milk in two dairy herds in Scotland.

The study evaluated the use of the Mastazyme ELISA for quantification of Neospora caninum (N. caninum) specific IgG in bovine milk and examined the relationship between serum and milk antibodies in two dairy herds. The serum and milk antibodies both had bimodal distributions in each herd. This was mainly due to between cow variation: in both herds, approximately two thirds of cows were either clearly and consistently seropositive or seronegative for N. caninum with one third consistently near the threshold. Milk and serum N. caninum IgG were strongly related. This relationship was modelled using a linear mixed model including a polynomial term for serum, the effect of herd, and between and within cow variance components. The latter gave a significantly better fit to the data than a model that allowed for a different relationship for the positive and negative (according to the serum test) groups of observations. The sensitivity and specificity (based on serum percentage positivity (pp)) of the milk antibody was determined for different milk pp thresholds. In spite of the differences between the relationship of milk to serum seen for the two herds, for those estimates with sufficient precision, sensitivity and specificity greater than 0.73 for both herds were obtained using single thresholds of 14 and 15.5 for milk pp in both herds based on, as our gold standard, serum antibody pp thresholds of 22.5 and 25, respectively. If milk antibody is to be used for detecting persistently infected cows, the higher threshold of 15.5 may be suitable while for epidemiological screening 14 would be preferable. Further validation in a greater number of herds is required, but our results suggest that this test may prove to be a useful adjunct to serum N. caninum IgG assays in the monitoring of N. caninum infection as part of herd health programmes and epidemiological studies.

Abortion, Veterinary↗
PubMed2005

[Comparison of time-oriented cost accounting catalogs to control a department of radiology].

PURPOSE: Within a hospital, the radiology department has taken over the role of a cost center. Cost accounting can be applied to analyze the costs for the performance of services. By assigning the expenditures of resources to the service, the cash value can directly be distributed to the costs of equipment, material and rooms. Time-oriented catalogs of services are predefined to calculate the number of the employees for a radiology department. Using our own survey of time data, we examined whether such catalogs correctly represent the time consumed in a radiology department. Only services relevant for the turnover were compared. MATERIALS AND METHODS: For 96 primary radiological services defined by the score-oriented German fee catalog for physicians (Gebuhrenordnung fur Arzte), a ranking list was made for the annual procedures in descending frequency order. According to the Pareto principle, the 11 services with the highest frequency were chosen and the time consumed for the technical and medical services was collected over a period of 2 months. This survey was compared with the time-oriented catalogs TARMED and EBM 2000plus. RESULTS: The included 11 relevant radiological services represented 80.3 % of the annual procedures of our radiology department. When comparing the technical services between the time-oriented catalogs and our own survey, TARMED gives a better description of the time consumed in 7 of the 11 services and EMB 2000plus in 3 services. When comparing the medical services, TARMED gives a better description of the time consumed in 6 of the 11 services and EBM 2000plus in 4 services. When averaging all the radiological services, TARMED overestimates the current number of physicians necessary for primary reading by a factor of 10.0 % and EBM 2000plus by a factor of 2.6 %. CONCLUSION: As to the time spent on performing the relevant radiological services, TARMED is slightly superior to describe the radiology department of a hospital than EBM 2000plus. For calculating the number of physicians necessary for primary reading, EBM 2000plus is superior to TARMED.

Accounting↗
PubMed2004

Peptic esophageal stricture: a report from Argentina.

Peptic esophageal stricture (PES) is a major complication of gastroesophageal reflux disease. The aims of this paper were to determine the characteristics of these patients with regard to demography, morphology, functional status and results of therapy. The charts of the patients treated at our service who underwent esophageal dilatation for PES between 1971 and 1998 were reviewed. Statistical analyses were performed by means of chi2, Mann-Whitney and Student's t-tests. One hundred and thirty-five patients with PES were dilated by various means. The mean age was 61.1 +/- 16.3 years, the ratio of men to women was 2.75/1 and mean duration of symptoms was 44.4 +/- 74.6 months. Their symptoms were dysphagia in 100%, pyrosis in 70%, and regurgitation in 40% of the cases. There was an average weight loss of 3.3 +/- 6 kg. The upper gastro-intestinal series showed pre- and post-dilatation diameters at the stricture of 8 +/- 2.5 mm and 15.9 +/- 1.2 mm, respectively. The stricture was located at the lower third of the esophagus in 97% and at the middle third in 3% of the cases. We found PES endoscopically in all instances, with different degrees of erosions in 64%, ulcers in 20% and Barrett's esophagus in 16% of the cases. The biopsy samples showed intestinal metaplasia in 16% and esophagitis in 75.5%, being normal in the remaining 8.5%. Brush cytology was negative for malignancy in 100% of the cases. Esophageal manometry showed peristaltic wave amplitude of 40 +/- 3 mmHg and presence of peristaltic waves of 62 +/- 38.6%. LES pressure was 8.6 +/- 6.3 mmHg (NV 24.2 +/- 6.3 mmHg). Measurement of pH showed 15% of patients had pH < 4. Patients needed a mean of 4.7 +/- 1.6 dilations per case, with successful results in 87.2% of cases. The perforation rate was 0.1% of the total number of procedures and 0.7%, of patients. The mortality rate was 0.7% (one case). We observed PES relapse in 32% of the cases. There was no correlation between relapse, age, duration of the stenosis or pharmacological treatment with H2 blockers or proton pump inhibitors. We conclude that in Argentina, demography, morphology, functional status and results of dilatation of PES patients are similar to those reported in the Western world, with the exception of the different behavior seen after treatment with H2 blockers or proton pump inhibitors.

Adult↗
PubMed2001

Comorbidity and glycemic control in patients with type 2 diabetes.

BACKGROUND: It is commonly believed that good glycemic control is hard to achieve in patients with diabetes mellitus and concurrent chronic illnesses. OBJECTIVE: To determine the impact of comorbidity on glycemic control at presentation and subsequent follow-up in patients with type 2 diabetes. METHODS: We studied 654 consecutive patients who presented to a diabetes clinic in 1997. Comorbidity was rated using the Chronic Disease Score (CDS) index, which is a validated, weighted score that takes into account the patient's age, sex, and classes of medications. Univariate and multivariate linear regressions were used to determine the contribution of age, body mass index (calculated as weight in kilograms divided by the square of height in meters), diabetes duration, type of therapy, and CDS to initial hemoglobin A(1c) (HbA(1c)) level. A similar analysis was performed for the 169 patients with follow-up HbA(1c) levels 6 months after presentation. RESULTS: Patients were 90% African American, and 66% female, with average age of 53 years. Average diabetes duration was 5 years; body mass index, 33; HbA(1c) level, 8.8%; and CDS, 1121 (range, 232-7953). At presentation, patients with higher CDSs tended to be older and to have a lower HbA(1c) level, but multivariate linear regression showed that receiving pharmacological therapy, younger age, and having a lower C-peptide level were the only significant contributors to HbA(1c) level. In the 169 follow-up patients, presenting characteristics were not significantly different from those of the full cohort: average initial HbA(1c) level was 8.8%; CDS, 1073. Their HbA(1c) level at 6 months averaged 7.5% and the CDS had no significant impact on their follow-up HbA(1c) level. CONCLUSION: Comorbidity does not appear to limit achievement of good glycemic control in patients with type 2 diabetes.

Age Distribution↗
PubMed2002

Dilutional hyponatremia in patients with cirrhosis and ascites.

OBJECTIVES: To analyze the predisposing factors, modifications of vasoactive systems, and prognosis of patients with cirrhosis and hyponatremia. PATIENTS AND METHODS: Fifty-four patients with hyponatremia (serum sodium level of <130 mEq/L after 5 days of hyponatremic diet and no diuretic therapy). Twenty cirrhotic patients served as controls. We measured plasma renin activity and levels of plasma aldosterone, norepinephrine, and antidiuretic hormone. Follow-up identified the development of hepatorenal syndrome and death. RESULTS: A higher percentage of patients with hyponatremia had decreased liver size, higher levels of plasma renin activity, and higher serum concentrations of aldosterone and norepinephrine. Renal insufficiency was detected in 31 of them (57%). Precipitating factors (hemorrhage or infections) were detected in 27 patients (50%). Incidence of hepatorenal syndrome and death were higher in patients with spontaneous development of hyponatremia (n = 23 [85%] and n = 25 [93%], respectively) than in patients with precipitating factors (n = 15 [56%] and n = 12 [44%], respectively) and cirrhotic controls (n = 1 [5%] and n = 5 [25%], respectively) (P<.001). Results of multivariate analysis showed that Child-Pugh index, presence of hepatocarcinoma, and serum concentration of urea were associated with mortality. After excluding those patients with kidney failure at the time of admission, only Child-Pugh index and norepinephrine concentrations were independent predictors of mortality. CONCLUSIONS: Hyponatremia is an alteration in patients with advanced liver disease. Although survival is significantly reduced in patients with spontaneous development of hyponatremia, a reduced sodium concentration cannot be considered as a independent predictor of the risk for death.

Age Distribution↗
PubMed2002

Levothyroxine treatment and occurrence of fracture of the hip.

BACKGROUND: Levothyroxine sodium is widely prescribed and has been implicated as a cause of reduction in bone mineral density and, therefore, suggested to be a major contributor to the risk of osteoporotic fractures. OBJECTIVE: To investigate whether levothyroxine use increases the risk of developing osteoporotic fractures. METHODS: We conducted a population-based, case-control analysis of the risk of a femur fracture in a large cohort of patients who had been prescribed levothyroxine. We used the United Kingdom General Practice (primary care) Research Database to identify 23,183 patients who had been prescribed long-term thyroid hormone therapy and to identify for each patient taking levothyroxine 4 controls matched for age, sex, primary care practice, and duration of registration on the database. The number of patients who had sustained a fracture of the proximal femur was ascertained for each group, together with drug therapies and medical diagnoses likely to affect fracture risk. RESULTS: Of the 23,183 patients prescribed thyroid hormone, a mean +/- SE of 1.61% +/- 0.08% had sustained a fracture of the femur, compared with 1.44% +/- 0.04% of 92,732 controls (P =.06). When analyzed according to sex, a significant difference in rate of fracture between patients taking levothyroxine and controls was found in males (P =.008). Compared with controls, patients taking levothyroxine had higher reported rates of medical diagnoses and therapies, potentially confounding the fracture risk. Independent predictors of the occurrence of fracture after adjustment for other factors were age (adjusted odds ratio [AOR], 1.11; 95% confidence interval [CI], 1.10-1.11; P<.001), medical diagnoses including rheumatoid arthritis (AOR in females, 1.69; 95% CI, 1.27-2.26; P<.001), excessive use of alcohol (AOR in females, 3.05; 95% CI, 1.94-4.76; P<.001), and prescription of drugs (eg, anticonvulsants; AOR in females, 2.49; 95% CI, 2.00-3.09; P<.001). Prescription of levothyroxine was an independent predictor of fracture occurrence in males (AOR, 1.69; 95% CI, 1.12-2.56; P =.01) but not females (AOR, 1.03; 95% CI, 0.92-1.16; P =.60). CONCLUSIONS: The lack of association between fracture and levothyroxine prescription in the whole cohort is reassuring, although an independent association between levothyroxine prescription and fracture occurrence in male patients suggests that levothyroxine may contribute to fracture risk in this specific group.

Adult↗
PubMed1995

Orbital fractures in children.

OBJECTIVE: To determine if the pattern of orbital fractures may be influenced by the changing craniofacial ratio of the growing child, as the orbit is the boundary between the face and the cranium. DESIGN: Retrospective case series of 40 patients between the ages of 1 year and 16 years with orbital fractures. SETTING: The Albany (NY) Medical Center Hospital, a tertiary level 1 trauma center. OUTCOME MEASURES: The sex, age, site, and mechanism of injury, associated injury, and treatment methods for children admitted to the Albany Medical Center Hospital with orbital fractures between July 1986 and June 1992. RESULTS: Fourteen children had fractures of the orbital roof, 10 children had fractures of the orbital floor, 14 children had mixed fractures, and two children had fractures of the medial wall. The mean age (4.8 +/- 3.3 years) of the 14 patients with roof fractures was significantly less than the mean age (12.0 +/- 4.2 years) of the 26 children with other orbital fractures. Logistic regression demonstrated that the age at which the probability of lower orbital fractures exceeds the probability of orbital roof fractures is 7.1 +/- 1.0 years. Orbital roof fractures had a significantly greater likelihood of associated neurocranial injuries. The need for surgical repair was significantly lower among children with roof fractures as well as among children 7 years of age and younger. CONCLUSIONS: Orbital roof fractures are a type of skull fracture that occur primarily in younger children as a consequence of the proportionally larger cranium and the lack of frontal sinus pneumatization. Lower orbital fractures are a type of facial fracture that occur primarily in older children as a consequence of the increased vulnerability of the face due to growth and the pneumatization of the paranasal sinuses.

Adolescent↗
PubMed2001

Hospitalizations for pediatric intoxication in Washington State, 1987-1997.

BACKGROUND: Intoxication (or poisoning) that necessitates hospitalization remains an important source of morbidity in children. OBJECTIVE: To determine changes, during an 11-year period (1987-1997), in the incidence of hospitalization due to intoxication among children in Washington State and circumstances of ingestion, agents used, hospital length of stay, charges, and mortality. METHODS: A computerized database of all hospital discharges (Comprehensive Hospital Abstract Reporting System [CHARS] database) in Washington was used. Cases included all children younger than 19 years with a primary or secondary diagnosis for an intoxication or with an external cause of injury code (E code) for an intoxication from 1987 to 1997. RESULTS: There were 7322 hospitalizations (45 per 100 000 children per year); the annual rate significantly decreased during the study period. Most patients (75%) were teenagers. Sixty-five percent were female. Pharmaceutical agents were used in 80% of cases. Analgesics were the most commonly used (34%), followed by antidepressants (12%) and psychotropic drugs (8%). Nonpharmaceutical agents were more prevalent in children younger than 12 years than in teenagers. Self-inflicted intoxication was the most frequent cause identified by E codes (47%). Median length of stay was 1 day, and median hospital charges were $2096. Mortality was low (0.2%) and did not change significantly over time. CONCLUSIONS: Acute intoxication continues to be an important cause of hospitalization in children. The type of agent involved did not change significantly over time. Teenage girls continue as the highest risk group for suicide attempt from ingestions. Self-inflicted intoxications were associated with higher costs, length of stay, and readmissions. Although preventive measures and development of poison centers have contributed to decrease mortality from acute intoxication in children in the last 50 years, efforts need to be targeted toward suicide prevention, especially among teenage girls.

Adolescent↗
PubMed2004

Hepatitis C prevalence in children with perinatal human immunodeficiency virus infection enrolled in a long-term follow-up protocol.

OBJECTIVE: To evaluate the prevalence of hepatitis C virus (HCV) infection in children with perinatal human immunodeficiency virus (HIV) infection. DESIGN: Cross-sectional substudy. SETTING: Multicenter study from 41 sites in the United States. PATIENTS: Children with perinatal HIV infection were randomly selected from a large, long-term, follow-up protocol. MAIN OUTCOME MEASURE: Hepatitis C infection was defined as having positive test results on both HCV antibody and HCV RNA assays. RESULTS: Five hundred thirty children enrolled in the substudy; definitive HCV test results were available for 525 children. Eighty-three percent were of a minority race or ethnicity. They were equally distributed by sex, had a median age of 10.7 years, and were relatively healthy, with 75% having CD4+ lymphocyte counts greater than 500 cells/mm3. Eight of 525 children (1.5%; 95% confidence interval [CI], 0.7%-3.0%) infected with HIV were coinfected with HCV. In contrast, the rate of HCV infection in a serosurvey of more than 2700 children aged 6 to 11 years from the National Health and Nutrition Examination Survey was 0.2% (95% CI, 0.04%-0.6%). In our study, there were no differences between children coinfected with HIV and HCV and those without HCV infection in terms of demographic characteristics, CD4+ or CD8+ T-lymphocyte counts, HIV 1 RNA levels, preterm or mode of delivery, or liver disease; however, the number of children coinfected with HIV and HCV was small. CONCLUSION: While HCV prevalence infection rates are low in children with perinatal HIV infection, they are 8 to 10 times higher than reported in HCV serosurveys of children in the United States.

Adolescent↗
PubMed2006

Lifetime prevalence and pseudocomorbidity in psychiatric research.

CONTEXT: Comorbidity is the rule rather than the exception with psychiatric disorders and is consequently of great interest to both researchers and clinicians. However, many studies of psychiatric comorbidity have been based on lifetime prevalence with mixed-age samples, a practice that (1) biases the assessment of epidemiologic comorbidity and (2) creates the appearance of comorbidity even when disorders are randomly associated. This bias is what we refer to as pseudocomorbidity. OBJECTIVES: To clarify the source of the problem and to discuss strategies that might be adopted to deal hereafter with lifetime prevalence data. METHODS: A simulated example is presented to show that even when there is only random association between disorders, there will appear to be nonrandom comorbidity when lifetime prevalence is used with mixed-age samples. An actual example relating psychosis to phobia is presented to show the bias that can result and to illustrate one way of dealing with lifetime prevalence data. CONCLUSIONS: Use of lifetime prevalence with mixed-age samples, used almost exclusively in psychiatric research, generates problematic results, especially when used for assessment of comorbidity, and should be viewed with some skepticism. Hereafter, we recommend that any future use of lifetime prevalence should require determination of the age of onset, even if only by retrospective report. Comorbidity then should be reported by age.

Adolescent↗
PubMed2004

The impact of bedside behavior on catheter-related bacteremia in the intensive care unit.

HYPOTHESIS: The success of an educational program in July 1999 that lowered the catheter-related bloodstream infection (CRBSI) rate in our intensive care unit (ICU) 3-fold is correlated with compliance with "best-practice" behaviors. DESIGN: Before-after trial. SETTING: Surgical ICU in a referral hospital. PATIENTS: A random sample underwent bedside audits of central venous catheter care (n = 187). All ICU admissions during a 39-month period (N = 4489) were prospectively followed for bacteremia. INTERVENTIONS: On the basis of audit results in December 2000, a behavioral intervention was designed to improve compliance with evidenced-based guidelines of central venous catheter management. MAIN OUTCOME MEASURES: Compliance with practices known to decrease CRBSI. Secondary outcome was CRBSI rate on all ICU patients. RESULTS: Multiple deficiencies were identified on bedside audits 18 months after the previous educational program. After the implementation of a separate behavioral intervention in July 2001, a second set of bedside audits in December 2001 demonstrated improvements in documenting the dressing date (11% to 21%; P<.001) and stopcock use (70% to 24%; P<.001), whereas nonsignificant trends were observed in hand hygiene (17% to 30%; P>.99) and maximal sterile barrier precautions (50% to 80%; P =.29). Appropriate practice was observed before and after the behavioral intervention in catheter site placement, dressing type, absence of antibiotic ointment, and proper securing of central venous catheters. Thirty-two CRBSIs occurred in 9353 catheter-days 24 months before the behavioral intervention compared with 17 CRBSIs in 6152 catheter-days during the 15 months after the intervention (3.4/1000 to 2.8/1000 catheter-days; P =.40). CONCLUSIONS: Although a previous educational program decreased the CRBSI rate, this was associated with only modest compliance with best practice principles when bedside audits were performed 18 months later. A behavioral intervention improved all identified deficiencies, leading to a nonsignificant decrease in CRBSIs.

Adult↗
PubMed2005

Gastric banding interferes with esophageal motility and gastroesophageal reflux.

BACKGROUND: Gastroesophageal reflux and progressive esophageal dilatation can develop after gastric banding (GB). HYPOTHESIS: Gastric banding may interfere with esophageal motility, enhance reflux, or promote esophageal dilatation. DESIGN: Before-after trial in patients undergoing GB. SETTING: University teaching hospital. PATIENTS AND METHODS: Between January 1999 and August 2002, 43 patients undergoing laparoscopic GB for morbid obesity underwent upper gastrointestinal endoscopy, 24-hour pH monitoring, and stationary esophageal manometry before GB and between 6 and 18 months postoperatively. MAIN OUTCOME MEASURES: Reflux symptoms, endoscopic esophagitis, pressures measured at manometry, esophageal acid exposure. RESULTS: There was no difference in the prevalence of reflux symptoms or esophagitis before and after GB. The lower esophageal sphincter was unaffected by surgery, but contractions in the lower esophagus weakened after GB, in correlation with preoperative values. There was a trend toward more postoperative nonspecific motility disorders. Esophageal acid exposure tended to decrease after GB, with fewer reflux episodes. A few patients developed massive postoperative reflux. There was no clear correlation between preoperative testing and postoperative esophageal acid exposure, although patients with abnormal preoperative acid exposure tended to maintain high values after GB. CONCLUSIONS: Postoperative esophageal dysmotility and gastroesophageal reflux are not uncommon after GB. Preoperative testing should be done routinely. Low amplitude of contraction in the lower esophagus and increased esophageal acid exposure should be regarded as contraindications to GB. Patients with such findings should be offered an alternative procedure, such as Roux-en-Y gastric bypass.

Adult↗