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PubMed2006

Evidence-based practice to reduce central line infections.

BACKGROUND: In 2003, through the Greater Cincinnati Health Council nine health care systems agreed to participate and fund 50% of a two-year project to reduce hospital-acquired infections among patients in intensive care units (ICU) and following surgery (SIP). METHODS: Hospitals were randomized to either the CR-BSI or SIP project in the first year, adding the alternative project in year 2. Project leaders, often the infection control professionals, implemented evidence-based practices to reduce catheter-related blood stream infections (CR-BSIs; maximal sterile barriers, chlorhexidine) at their hospitals using a collaborative approach. Team leaders entered process information in a secure deidentifled Web-based database. RESULTS: Of the four initial sites randomized to CR-BSI reduction, all reduced central line infections by 50% (CR-BSI, 1.7 to 0.4/1000 line days, p < .05). At the project midpoint (3 quarters of 2004), adherence to evidence-based practices increased from 30% to nearly 95%. DISCUSSION: The direct role of hospital leadership and development of a local community of practice, facilitated cooperation of physicians, problem solving, and success. Use of forcing functions (removal of betadine in kits, creation of an accessory pack and a checklist for line insertion) improved reliability. The appropriate floor for central line infections in ICUs is < 1 infection /1,000 line days.

Awards and Prizes↗
PubMed1997

Lifestyle, education, and prevalence of hypertension in populations of African origin. Results from the International Collaborative Study on Hypertension in Blacks.

Lifestyle Incongruity has been shown to be associated with elevated blood pressure in various developing societies. We sought to test this model in an international collaborative study of hypertension in populations of African origin. Data were available for 4770 men and women, aged 25-74, from Africa, the Caribbean, and the United States. The main effects of lifestyle score (LSS) and education on hypertension prevalence were explored, as well as interactions predicted by the Lifestyle Incongruity model. Significant interactions were observed, but only the U.S. men conformed to the pattern predicted. For this group, adjusted ORs for LSS were 4.45 among low-education and 0.71 among high-education subgroups (risk OR = 0.16, 0.03-0.84 95% CI). The Lifestyle Incongruity model therefore received limited support. The model was designed to describe processes in societies experiencing modernization and opportunities for lifestyle differentiation, conditions that may not have been met in some sites.

Adult↗
PubMed1990

Validation of a new automatic system for biplane quantitative coronary arteriography.

In a collaboration between the University of Texas (software) and the University of Zürich (hardware) a compact, automatic system for biplane quantitative coronary arteriography was developed. The system is based on a 35 mm film projector, a slow-scan CCD-camera (image digitizing) and a computer workstation (Apollo DN 3000, image storage and processing). A new calibration procedure based on two fixed reference points in the center of the image intensifier was used (isocenter technique). Contour detection of coronary arteries was carried out in biplane projection using a geometric-densitometric edge-detection algorithm. The proximal and distal luminal areas, as well as the minimal luminal area of the stenotic vessel segment were determined. Accuracy and precision were determined from precision drilled holes in a plexiglas cube which were filled with 50%, 75% and 100% contrast medium. The diameter of the holes ranged from 0.5 to 5.0 mm. The mean difference and the standard deviation of the differences between the true and the measured diameters were 0.12 +/- 0.14 mm for plane A and 0.26 +/- 0.17 mm for plane B, respectively. After a second order correction the mean difference amounted to 0.02 +/- 0.09 mm for plane A and 0.02 +/- 0.12 mm for plane B, respectively. Intra- and interobserver variability were evaluated in 5 patients (age 60 +/- 10 years) with coronary artery disease using 16 normal and 5 stenotic vessel segments (cross-sectional area ranging from 0.8 to 8.7 mm2). Two independent observers analyzed the same vessel segment twice. Intraobserver variability expressed as the standard error of estimate in percent of the mean angiographic vessel area (SEE) amounted to 2.1% for observer 1 and 4.4% for observer 2, respectively. Interobserver variability expressed as SEE was 4.1% for measurement 1 and 3.6% for measurement 2, respectively.

Aged↗
PubMed1996

Development of interpretive criteria and quality control limits for macrolide and clindamycin susceptibility testing of Streptococcus pneumoniae.

A six-laboratory collaborative study was conducted to develop MIC and zone diameter quality control limits and interpretive criteria for antimicrobial susceptibility testing of Streptococcus pneumoniae with azithromycin, clarithromycin, dirithromycin, and clindamycin. The MICs of all of the agents plus erythromycin for 302 clinical isolates of pneumococci that had been selected with an emphasis on resistant strains were determined by use of the National Committee for Clinical Laboratory Standards (NCCLS)-recommended broth microdilution procedure. The zone diameters of the isolates were also determined for the same agents except erythromycin by the NCCLS disk diffusion test procedure. Repeated testing of S. pneumoniae ATCC 49619 with different sources and lots of media and disks allowed development of MIC and zone diameter quality control ranges for these agents. Interpretive criteria for the MIC of azithromycin were established and were as follows: susceptible, < or = 0.5 microgram/ml; intermediate, 1 microgram/ml; and resistant, > or = 2 micrograms/ml. The interpretive criteria advocated for the MICs of clarithromycin and clindamycin were as follows: susceptible, < or = 0.25 microgram/ml; intermediate, 0.5 microgram/ml; and resistant, > or = 1 microgram/ml. Comparison of MICs and disk diffusion zone diameters led to the development of interpretive criteria for the zone diameters for azithromycin, clarithromycin, and clindamycin that correlated well with these MIC breakpoints. Testing of this organism collection also led to the reestablishment of the erythromycin MIC breakpoints as being identical to those of clarithromycin, which resulted in equivalent cross-susceptibility and cross-resistance for the three macrolides that are currently marketed in the United States. Thus, the susceptibility of pneumococci to azithromycin and clarithromycin can be predicted accurately by testing only erythromycin in clinical laboratories. This recommendation, as well as the interpretive and quality control criteria that are described, have been accepted by NCCLS and are included in the latest NCCLS susceptibility testing guidelines.

Anti-Bacterial Agents↗
PubMedDate not supplied

[The Beck Anxiety Inventory. Psychometric properties of a French translation].

The Beck Anxiety Inventory (Beck, Epstein, Brown, & Steer, 1988) is a 21-item checklist developed with large clinical samples to measure anxiety symptoms associated with DSM III-R (APA, 1987) anxiety disorders. Administration and scoring are rapid; the patient rates symptom intensity during the last seven days on a 0 to 3 scale. The BAI adequately covers the major cognitive, affective, and physiological symptoms of anxiety. Care was taken during scale construction to eliminate items that would be confounded with depression items. The authors demonstrate excellent reliability and appropriate convergent and discriminant validity with other measures of anxiety and depression as well as criterion-related validity with in patient samples (Beck et al., 1988). The properties of the BAI have been further studied by Beck and collaborators as well as by other groups of researchers. Since its appearance in 1988 the BAI has quickly been adopted by clinical researchers in the United States, Canada, and the United Kingdom. Five studies present psychometric data on a French translation of the BAI. The translation process involved alternative versions by three translators, a panel of experts, and pilot testing on a group of 20 volunteers. The first study with university students (N = 72) indicated good internal consistence (Cronbach's alpha = .85) and stability (r = .63) at four weeks. The second study (N = 91) demonstrated convergent and discriminant validity significant positive: correlations with measures of obsessive-compulsive symptoms, irrational beliefs, and depression; significant negative correlations with assertiveness and self-esteem, and non-significant correlations with two measures of social desirability.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMedDate not supplied

European consultation-liaison services and their user populations: the European Consultation-Liaison Workgroup Collaborative Study.

The authors identified variations in the characteristics of patients referred to 56 consultation-liaison (C-L) services in 11 European countries. The authors found differences in the types of patients referred to the services, and there were significant differences between countries. The first difference lays in whether services saw patients for deliberate self-harm and for substance abuse. German psychosomatic C-L services saw virtually no such patients, although in other C-L services these patients constituted one-quarter to one-third of the patients referred. The second difference lays in the remaining group of referred patients. This group is best characterized by two dimensions. One describes the severity of psychopathology -- ranging from organic mental conditions to somatization. The other describes the clarity of the physical diagnosis -- ranging from patients referred by surgical wards to those referred by general medicine and neurology wards.

Adult↗
PubMed1995

Bilateral spastic cerebral palsy--a collaborative study between southwest Germany and western Sweden. III: Aetiology.

In this third report from the collaborative study of children with bilateral spastic cerebral palsy born between 1975 and 1986, aetiology was analysed. Evidence for a prenatal aetiology increased with gestational age, whereas evidence for a peri-/neonatal aetiology decreased. The largest subgroup, the leg-dominated subtype, showed the same distribution of aetiology as the total group. A prenatal aetiology was found mainly among term and moderately preterm children with a four-limb-dominated subtype; a peri-/neonatal aetiology among very preterm children with a three- or four-limb-dominated subtype or among term children with a dyskinetic-spastic subtype. The findings support the hypothesis generated from the authors' epidemiological results of a peri-/neonatal aetiology being predominant among preterm, and a prenatal aetiology among term, children with bilateral spastic cerebral palsy.

Cerebral Palsy↗
PubMed2001

Tumorigenic effect of nonfunctional p53 or p21 in mice mutant in the Werner syndrome helicase.

Werner syndrome is an autosomal recessive disorder characterized by genomic instability and by the premature onset of a number of age-related diseases, including malignancy. To assess a potential collaboration between p21 or p53 cell cycle regulators and Wrn proteins, Wrn mutant mice were created and mated with p21 or p53 null mice to generate double mutants. The p21 null/Wrn mutant mice did not show an acceleration of tumorigenesis during the first year of life, suggesting that the p53-dependent G1-S cell cycle checkpoint (which operates via p21) is not involved in Wrn-abetted tumor suppression. In contrast, the p53 null/Wrn mutant mice were particularly remarkable with respect to the rapidity with which they developed tumors. These mice were also distinguished by the variety of tumors they developed compared to those that developed in p53 null mice. Such data suggest a genetic interaction between p53 and Wrn in which loss of Wrn provokes a more variable p53 response unrelated to its role in the G1-S cell cycle checkpoint.

Adenosine Triphosphatases↗
PubMed2002

The best hospital practices for controlling methicillin-resistant Staphylococcus aureus: on the cutting edge.

OBJECTIVE: A performance improvement task force of Rhode Island infection control professionals was created to develop an epidemiologic model of statewide consistent infection control practices that could reduce the spread of methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: This model encompasses screening protocols, isolation techniques, methods of cohorting positive patients, decolonization issues, postexposure follow-up, microbiology procedures, and standardized surveillance methodologies. These "best practice guidelines" include three categories of recommendations that define priority levels based on the availability of scientific data. SETTING: From 1995 through 2000, several Rhode Island hospitals experienced a fivefold increase in nosocomial acquisition of MRSA PARTICIPANTS: Rhode Island infection control professionals are a highly interactive group in the unique position of sharing patients and ultimately experiencing similar trends and problems. INTERVENTION: The task force collaborated on developing the best hospital infection control practices to prevent and control the spread of MRSA in Rhode Island. RESULTS: The task force met with local infectious disease physicians and representatives from the Rhode Island Department of Health, the Hospital Association of Rhode Island, and Rhode Island Quality Improvement Partners. Discussions identified numerous and diverse MRSA control practices, issues of consensus, and approaches to resolving controversial methods of reducing the spread of MRSA. The guidelines regarding the best hospital practices for controlling MRSA were finalized 8 months later. CONCLUSION: These guidelines were distributed to all chief executive officers of Rhode Island hospitals by the Rhode Island Department of Health in December 2001. They were issued separate and apart from any regulations, with the intent that hospitals will adopt them as best hospital practices in an attempt to control MRSA.

Cross Infection↗
PubMed2005

Incidence of acute respiratory distress syndrome in German children and adolescents: a population-based study.

OBJECTIVE: The objective of this study was to determine the epidemiology of acute respiratory distress syndrome (ARDS) in children and adolescents aged 1 mo to 18 yrs. DESIGN: The authors conducted a population-based prospective multicenter survey from February 1 to 28,1997, June 1 to 30, 2001, and April 1 to 30, 2004. SETTING: This study was conducted at 94 intensive care units (ICUs) in 1997, 92 ICUs in 2001 and 2004 in the district of Cologne, Germany with a population of 4.15 (1997), 4.28 (2001), and 4.35 million (2004), respectively. The survey was not confined to children's hospitals, but addressed all ICUs. PATIENTS: This study consisted of children and adolescents aged 1 mo to 18 yrs. Term neonates and premature babies with a corrected age below 43 gestational weeks were excluded. ARDS was defined according to the consensus criteria (acute-onset pulmonary process of noncardiogenic origin, Pao(2)/FIo(2) ratio <200, bilateral alveolar infiltration in chest radiograph). RESULTS: All ICUs at pediatric hospitals and all but seven adult ICUs collaborated. Incidence of ARDS was assessed as the number of patients entering ARDS criteria within the three study periods divided by the total population in this age group. During the study period, 12 pediatric patients were diagnosed as having ARDS. In five cases, onset was before the study period, representing a calculated prevalence of 5.5 x 10(-5) [3.1 x 10(-5); 9.6 x 10(-5)] cases per year and an incidence of 3. 2 x 10(-5) [1.5 x 10(-5); 6.6 x 10(-5)] cases per year in the age group under investigation. CONCLUSION: This is the first population-based evaluation of the incidence of ARDS in the pediatric age group. It shows that the incidence of ARDS in this age group is low. This makes randomized studies on pediatric ARDS aiming on the end point "outcome" nearly impossible.

Adolescent↗
PubMed1991

Longitudinal changes in fat distribution in the Western Collaborative Group Study: a 23-year follow-up.

Anthropometric measurements for a total of 1,150 surviving subjects aged 65-86 and examined twice 23 years apart were analyzed with the following objectives: (1) to determine longitudinal changes on a large battery of anthropometric measures, (2) to examine the persistence of individual differences in the distribution of fat and relative weight, and (3) to investigate the relationship between changes in weight and changes in fat distribution. Significant changes toward an increase in size with age were observed in younger subjects below the age of 50 when first examined. In older subjects, age greater than or equal to 50, we observed a decrease in stature of 1.2 cm per decade, an overall decrease in weight of 1.6 kg, and no significant changes in trunk skinfold thickness. Longitudinal changes were most pronounced in the redistribution of fat and were also independent of weight changes. The relationships between measures of abdominal fat and overall obesity were stronger at follow-up than 23 years earlier.

Adipose Tissue↗
PubMed2004

[National database of German arthritis centers. Tool for health services research].

The national database of the German Collaborative Arthritis Centers is a joint venture of German rheumatology. Since 1993, all outpatients with inflammatory rheumatic diseases treated in 1 of 24 arthritis centers have been registered once a year with a clinical record form and a patient questionnaire. The aim is to continuously monitor the current state and trends in rheumatologic health care and to gain knowledge on the outcomes and burdens of diseases as well as medical, social, and economic consequences beyond the limited perspective of randomized controlled trials. Data collected for 10 years about 145,000 patients with inflammatory rheumatic diseases are available making it possible to analyze even very rare diseases with sufficient numbers of cases. Selected results concerning the health care situation in specialized and nonspecialized care, practice variations in rheumatology, and the burden of illness in various diseases are reported.

Adult↗
PubMed1995

The role of the floor plate in axon guidance.

The data reviewed above have implicated the floor plate in directing axonal growth towards the midline, in directing the behavior of axons at the midline, and finally, in directing the longitudinal growth of axons alongside the midline. In the case of growth to the midline, there is clear evidence for the existence of two types of cues that collaborate to direct growth--short-range cues that can direct axons along the edge of the spinal cord and a long-range chemoattractant secreted by the floor plate cells whose main function may be to direct later-extending commissural axons that must migrate through the complex environment of the developing motor column. Determining the precise contribution of these cues will require identifying them and perturbing them in vivo. The cues that direct growth along the edge are unknown; their identification in the spinal cord would be of quite general significance, since the growth of axons parallel to (but not in contact with) the pial surface is a widespread feature of early axon growth at all axial levels of the neural tube. A strong candidate for the long-range chemoattractant is netrin-1, a homologue of the UNC-6 protein of C. elegans and a distant relative of laminin, which is expressed by floor plate cells and which can both promote and orient commissural axon outgrowth. Netrin-1 may also influence growth of other populations of neurons that exhibit stereotyped behaviors near the ventral midline. Much less is known about the exact role of the floor plate in directing axon growth at the midline, though it is clearly required for accurate guidance. In the absence of the floor plate, a range of errors has been found, the most prominent of which are aberrant midline crossings and errors in longitudinal growth near the ventral midline. The severity of these errors varies with species, which could result from either the variable importance of the floor plate in the different species or the fact that, so far, quite different manipulations of the ventral midline region have been performed in different species. The most specific perturbation of the ventral midline occurs in the zebrafish cyc-1 mutant, where the selective loss of the floor plate leads to stereotyped misrouting events. Perhaps surprisingly, virtually all axons that grow to the midline turn longitudinally (although sometimes in the wrong direction).(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed2002

[Cyclothymic obsessive-compulsive disorder. Clinical characteristics of a neglected and under-recognized entity].

OBJECTIVE: Clinical research is largely focused on depressive comorbidity in obsessional compulsive disorder (OCD). However some recent publications have suggested that bipolar comorbidity occurs in authentic OCD and its presence has a differential impact on the clinical picture and course of OCD. METHOD: Recent data from the collaborative survey conducted with AFTOC (French Association of patients suffering from OCD) have revealed a high rate of bipolar comorbidity in OCD: 30% for hypomania and 50% for cyclothymia. RESULTS: The present paper presents further comparative analyses between OCD with (n = 302) versus without cyclothymia (n = 272). The sub-group "Cyclothymic OCD" is characterized by a different clinical picture (higher frequency of aggressive, impulsive, religious and sexual obsessions, and compulsions of control, hoarding, repetition), episodic course, higher rate of major depressive episodes (with more intensity and recurrence) associated with higher rates of suicide attempts and psychiatric admissions, and less favorable response to anti-OCD treatments. CONCLUSION: These data suggested that cyclothymic OCD could represent a specific distinct variant form of OCD. More vigilance is needed toward this entity which is largely under-recognized in clinical practice.

Adolescent↗
PubMed2006

Chronic disease management systems registries in rural health care.

UNLABELLED: Health care quality is being addressed from a variety of policy perspectives. The 2001 Institute of Medicine report, Crossing the Quality Chasm, calls for sweeping action involving a five-part strategy for change in the U.S. health care system. This agenda for change includes use of evidence-based approaches to address common conditions, the majority of which are chronic. A Chronic Disease Management System (CDMS), or registry, is a tool that helps providers efficiently collect and analyze patient information to promote quality care for the rural population. CDMSs can provide a technological entry point for the impending use of Electronic Medical Records. A CDMS is a patient-centered electronic database tool that helps providers diagnose, treat, and manage chronic diseases. The purpose of this brief is to discuss the different types of CDMSs used by a sample of 14 state organizations and 19 local rural clinics in Maine, Nebraska, New Mexico, South Carolina, Washington, and Wisconsin. As part of a larger study examining the challenges and innovations in implementing disease management programs in rural areas, we conducted interviews with national, state, and local contacts. During interviews, respondents helped us understand the usefulness and functionalities of commonly used CDMSs in rural facilities. Our focus was on the use of CDMSs in the management of diabetes, a disease prevalent in rural populations. KEY FINDINGS: (1) CDMSs are readily available to rural clinics and are being implemented and maintained by clinic staff with minimal expenditures for technology. (2) Use of a standardized system in a collaborative helps provide data comparisons and share costs involved with technical assistance services across the group.

Chronic Disease↗
PubMed2000

Familial vs sporadic rheumatoid arthritis (RA). A prospective study in an early RA inception cohort.

OBJECTIVES: To study potential differences in demographic, process and outcome variables between familial and sporadic rheumatoid arthritis (RA) in an early RA inception cohort. METHODS: In 1998, we ascertained the familial status of all collaborative patients in a large early RA inception cohort at our department. Familial RA was defined by the presence of at least two siblings fulfilling the American College of Rheumatology criteria for RA. Baseline demographic data and prospectively recorded disease activity variables, therapies and radiological damage during the first 6 yr of disease were included in the analysis. A regression analysis was performed to assess whether familial clustering is a prognostic factor. RESULTS: We identified 142 patients with sporadic and 36 with familial RA. The most striking difference between these groups was the larger sibship size in multicase families (8.2 +/- 2.5 vs 5. 5 +/- 2.8; P < 0.0001). Age at onset was similar in both groups, although males with familiar RA were younger at disease onset than those with sporadic RA (median 50 vs 57 yr; P=0.03). No differences were found in gender, presence of rheumatoid factor (RF), antinuclear factor and HLA-DR typing or in disease activity, interventions and outcome over 6 yr of follow-up. Early radiological damage and disease activity, but not familial history of RA were prognostic for X-ray damage. CONCLUSION: We show that sibship size is the only relevant risk factor for familial RA. No differences in genotypic and phenotypic characteristics, disease severity or radiological damage were observed among familial and sporadic RA. Familial history of RA is not a poor prognostic factor. This prospective study confirms previous cross-sectional findings in the Dutch population.

Adult↗
PubMed2005

Development of the QuickDASH: comparison of three item-reduction approaches.

BACKGROUND: The purpose of this study was to develop a short, reliable, and valid measure of physical function and symptoms related to upper-limb musculoskeletal disorders by shortening the full, thirty-item DASH (Disabilities of the Arm, Shoulder and Hand) Outcome Measure. METHODS: Three item-reduction techniques were used on the cross-sectional field-testing data derived from a study of 407 patients with various upper-limb conditions. These techniques were the concept-retention method, the equidiscriminative item-total correlation, and the item response theory (Rasch modeling). Three eleven-item scales were created. Data from a longitudinal cohort study in which the DASH questionnaire was administered to 200 patients with shoulder and wrist/hand disorders were then used to assess the reliability (Cronbach alpha and test-retest reliability) and validity (cross-sectional and longitudinal construct) of the three scales. Results were compared with those derived with the full DASH. RESULTS: The three versions were comparable with regard to their measurement properties. All had a Cronbach alpha of > or = 0.92 and an intraclass correlation coefficient of > or = 0.94. Evidence of construct validity was established (r > or = 0.64 with single-item indices of pain and function). The concept-retention method, the most subjective of the approaches to item reduction, ranked highest in terms of its similarity to the original DASH. CONCLUSIONS: The concept-retention version is named the QuickDASH. It contains eleven items and is similar with regard to scores and properties to the full DASH. A comparison of item-reduction approaches suggested that the retention of clinically sensible and important content produced a comparable, if not slightly better, instrument than did more statistically driven approaches.

Arm↗
PubMedDate not supplied

Conventional and chained standard gambles in the assessment of coronary heart disease prevention and treatment. Canadian Collaborative Cardiac Assessment Group.

The authors compared the abilities of descriptive and valuational health-related quality-of-life measures to discriminate healthy participants (n=39) from those on diets for dyslipidemia (n=35) and angina patients (n=30). On the rating scale, the time tradeoff, and the General Health Perception subscale of the SF-36 Health Survey, the participants with dyslipidemia or angina reported lower mean scores than the healthy participants. No differences were detected between these groups on conventional or chained standard gamble (SG) scales. The distribution of the conventional and the chained SG scores was very skewed, with the vast majority of scores being equal or very close to the maximum score. It is concluded that in this study the discriminant ability of the chained SG was comparable to that of the conventional SG and inferior to descriptive and non-risky valuational scaling techniques. This may be explained by the distortion of probabilities, by a misunderstanding of the SG chained assessment, and by a strong certainty effect.

Adult↗