Lack of effect of combination antibiotic therapy on mortality in patients with pneumococcal sepsis

In order to determine whether combination antibiotic therapy decreases mortality after severe pneumococcal infection, a retrospective study of a cohort of 1,840 adult patients with severe sepsis or septic shock enrolled in two multicenter clinical trials between 1994 and 1999 was conducted. Among 107 patients with monobacterial pneumococcal sepsis, the case-fatality rate was 20% (five of 25) for patients who received antibiotic monotherapy compared with 19.5% (16 of 82) for patients who received combination therapy (adjusted hazard ratio, 1.1; 95% CI, 0.4-3.1). Similarly, monotherapy did not increase the risk of death (adjusted hazard ratio, 1.0; 95% CI, 0.2-4.8) among bacteremic patients (n=75). However, the latter analysis may have been underpowered (power, 58%) to detect a difference in mortality. Overall, in contrast to recently published reports, these results suggest that combination antibiotic therapy does not decrease mortality after severe pneumococcal sepsi

A calcareous nannofossil and organic geochemical study of marine palaeoenvironmental changes across the Sinemurian/Pliensbachian (early Jurassic, ~191Ma) in Portugal

The Sinemurian/Pliensbachian boundary (~ 191 Ma) is acknowledged as one of the most important steps in the radiation of planktonic organisms, especially primary producers such as dinoflagellates and coccolithophores. To date, there is no detailed study documenting changes in planktonic assemblages related to palaeoceanographic changes across this boundary. The aim of this study is to characterize the palaeoenvironmental changes occurring across the Sinemurian/Pliensbachian boundary at the São Pedro de Moel section (Lusitanian Basin, Portugal) using micropalaeontology and organic geochemistry approaches. Combined calcareous nannofossil assemblage and lipid biomarker data document for a decrease in primary productivity in relation to a major sea-level rise occurring above the boundary. The Lusitanian Basin was particularly restricted during the late Sinemurian with a relatively low sea level, a configuration that led to the recurrent development of black shales. After a sharp sea-level fall, the basin became progressively deeper and more open during the earliest Pliensbachian, subsequently to a major transgression. This sea-level increase seems to have been a global feature and could have been related to the opening of the Hispanic Corridor that connected the Tethys and palaeo-Pacific oceans. The palaeoceanographic and palaeoclimatic changes induced by this opening may have played a role in the diversification of coccolithophores with the first occurrence or colonization of Tethyan waters by placolith-type coccoliths

Remote control of macrophage production by cancer

The communication between tumor and host cells involves signals that act across extended distances in the body. Recent evidence indicates that the hormone angiotensin II is overproduced by lung adenocarcinoma to remotely expand bone marrow-derived hematopoietic stem cells. This process amplifies the supply of tumor-associated macrophages, which promote disease progression

Development of a monitoring instrument to assess the performance of the Swiss primary care system.

The Swiss health system is customer-driven with fee-for-service paiement scheme and universal coverage. It is highly performing but expensive and health information systems are scarcely implemented. The Swiss Primary Care Active Monitoring (SPAM) program aims to develop an instrument able to describe the performance and effectiveness of the Swiss PC system. Based on a Literature review we developed a conceptual framework and selected indicators according to their ability to reflect the Swiss PC system. A two round modified RAND method with 24 inter-/national experts took place to select primary/secondary indicators (validity, clarity, agreement). A limited set of priority indicators was selected (importance, priority) in a third round. A conceptual framework covering three domains (structure, process, outcome) subdivided into twelve sections (funding, access, organisation/ workflow of resources, (Para-)Medical training, management of knowledge, clinical-/interpersonal care, health status, satisfaction of PC providers/ consumers, equity) was generated. 365 indicators were pre-selected and 335 were finally retained. 56 were kept as priority indicators.- Among the remaining, 199 were identified as primary and 80 as secondary indicators. All domains and sections are represented. The development of the SPAM program allowed the construction of a consensual instrument in a traditionally unregulated health system through a modified RAND method. The selected 56 priority indicators render the SPAM instrument a comprehensive tool supporting a better understanding of the Swiss PC system's performance and effectiveness as well as in identifying potential ways to improve quality of care. Further challenges will be to update indicators regularly and to assess validity and sensitivity-to-change over time

Increasing the frequency of hand washing by healthcare workers does not lead to commensurate reductions in staphylococcal infection in a hospital ward

Hand hygiene is generally considered to be the most important measure that can be applied to prevent the spread of healthcare-associated infection (HAI). Continuous emphasis on this intervention has lead to the widespread opinion that HAI rates can be greatly reduced by increased hand hygiene compliance alone. However, this assumes that the effectiveness of hand hygiene is not constrained by other factors and that improved compliance in excess of a given level, in itself, will result in a commensurate reduction in the incidence of HAI. However, several researchers have found the law of diminishing returns to apply to hand hygiene, with the greatest benefits occurring in the first 20% or so of compliance, and others have demonstrated that poor cohorting of nursing staff profoundly influences the effectiveness of hand hygiene measures. Collectively, these findings raise intriguing questions about the extent to which increasing compliance alone can further reduce rates of HAI. In order to investigate these issues further, we constructed a deterministic Ross-Macdonald model and applied it to a hypothetical general medical ward. In this model the transmission of staphylococcal infection was assumed to occur after contact with the transiently colonized hands of HCWs, who, in turn, acquire contamination only by touching colonized patients. The aim of the study was to evaluate the impact of imperfect hand cleansing on the transmission of staphylococcal infection and to identify, whether there is a limit, above which further hand hygiene compliance is unlikely to be of benefit. The model demonstrated that if transmission is solely via the hands of HCWs, it should, under most circumstances, be possible to prevent outbreaks of staphylococcal infection from occurring at a hand cleansing frequencies <50%, even with imperfect hand hygiene. The analysis also indicated that the relationship between hand cleansing efficacy and frequency is not linear - as efficacy decreases, so the hand cleansing frequency required to ensure R0<1 increases disproportionately. Although our study confirmed hand hygiene to be an effective control measure, it demonstrated that the law of diminishing returns applies, with the greatest benefit derived from the first 20% or so of compliance. Indeed, our analysis suggests that there is little benefit to be accrued from very high levels of hand cleansing and that in most situations compliance >40% should be enough to prevent outbreaks of staphylococcal infection occurring, if transmission is solely via the hands of HCWs. Furthermore we identified a non-linear relationship between hand cleansing efficacy and frequency, suggesting that it is important to maximise the efficacy of the hand cleansing process

The effect of surveillance and appreciative inquiry on puerperal infections : a longitudinal cohort study in India

Peer reviewedPublisher PD