Reduction of Risk from Bacterial Transmission in the Emergency Department through Implementation of Standardized EKG machine cleaning protocols: An Evidence-Based Approach.

Purpose Electrocardiograms (EKGs) are a frequently performed test in the emergency department (ED). Despite an increased awareness of infection prevention, there is currently no standard policy on the routine cleaning of EKG machines at The University of Vermont Medical Center (UVMMC). The purpose of this project was to: 1) establish baseline data on type and amount of bacterial presence on EKG machines, and compliance with cleaning of machines between use, 2) Determine if feedback to staff on their compliance of cleaning EKGs after each use alters practice, 3) Establish an Emergency Medicine policy for the cleaning of medical equipment, and 4) Implement a sustainable change to the daily practice in the Emergency Department that will improve the quality of care patients receive. Methods EKG machines in the emergency department were swabbed to determine presence of bacteria. A cleaning campaign was initiated within the emergency department to promote and encourage the cleaning of EKG machines after each patient use. The photographs of the plates were laminated and placed in a central location in the ED, where they could be reviewed by clinical staff. An e-mail was sent to all ED staff reminding them that the machines should be cleaned after each use, with a copy of the agar plate images attached. The same content was brought up in each of the daily huddles across a two-week period, as well as included in the ED newsletter. In addition to this, brightly colored signs were placed on each of the machines to serve as a reminder. Results The initial swabs from the EKG machines showed high levels of bacteria, with an overall decrease in bacterial presence after the cleaning campaign was initiated. Conclusions Findings indicate that bacterial presence decreased following the cleaning campaign, however there are limitations to these findings. The bacterial type was not able to be determined, making the environmental swabs of the EKG machines indeterminate. Future work is needed to determine bacterial type in order to establish more reliable results. A measure of baseline compliance with cleaning EKG machines after each use would be helpful to allow for a comparison with post intervention results in order to determine causation versus simply correlation. Keywords. EKG Machines, Infection Prevention, Emergency Department, Cleaning Protoco

Understanding decisions about antibiotic prescribing in ICU: an application of the Necessity Concerns Framework

Background: Antibiotics are extensively prescribed in intensive care units (ICUs), yet little is known about how antibiotic-related decisions are made in this setting. We explored how beliefs, perceptions and contextual factors influenced ICU clinicians’ antibiotic prescribing. / Methods: We conducted 4 focus groups and 34 semistructured interviews with clinicians involved in antibiotic prescribing in four English ICUs. Focus groups explored factors influencing prescribing, whereas interviews examined decision-making processes using two clinical vignettes. Data were analysed using thematic analysis, applying the Necessity Concerns Framework. / Results: Clinicians’ antibiotic decisions were influenced by their judgement of the necessity for prescribing/not prescribing, relative to their concerns about potential adverse consequences. Antibiotic necessity perceptions were strongly influenced by beliefs that antibiotics would protect patients from deterioration and themselves from the ethical and legal consequences of undertreatment. Clinicians also reported concerns about prescribing antibiotics. These generally centred on antimicrobial resistance; however, protecting the individual patient was prioritised over these societal concerns. Few participants identified antibiotic toxicity concerns as a key influencer. Clinical uncertainty often complicated balancing antibiotic necessity against concerns. Decisions to start or continue antibiotics often represented ‘erring on the side of caution’ as a protective response in uncertainty. This approach was reinforced by previous experiences of negative consequences (‘being burnt’) which motivated prescribing ‘just in case’ of an infection. Prescribing decisions were also context-dependent, exemplified by a lower perceived threshold to prescribe antibiotics out-of-hours, input from external team members and local prescribing norms. / Conclusion: Efforts to improve antibiotic stewardship should consider clinicians’ desire to protect with a prescription. Rapid molecular microbiology, with appropriate communication, may diminish clinicians’ fears of not prescribing or of using narrower-spectrum antibiotics

Dietary intakes of adolescent girls in relation to weight status

Background: To examine macronutrient and micronutrient intake of adolescent girls of Tehran, capital of Iran to discover any malnutrition in relation to weight status and dieting. Methods: A cross-sectional study was conducted. Four hundred 11- to 17-year-old students were selected by multistage cluster sampling from secondary and high schools of Tehran. The information about dietary intakes was taken by food frequency questionnaire and 24-hour recall form. The students' body mass indices (BMIs) were measured and were classified according to National Center for Health Statistics/Center for Disease Control and Prevention (2000) growth charts. Participants were also questioned about body image and dieting. Results: 6.7 of adolescent girls were classified as being obese, 14.6 overweight, 75.4 normal and 3.2 underweight. Students 11-13 year old, had mean intakes lower than estimated average requirement (EAR) for folic acid, vitamin E, calcium, magnesium, phosphorus, potassium and sodium, and 14-18 year old students had mean intakes lower than EAR for niacin, pyridoxine, folic acid, pantothenic acid, vitamin E, calcium, magnesium, phosphorus, potassium, sodium and zinc. Obese and overweight adolescents had less carbohydrate, thiamin, niacin, iron and selenium intake. The participants, who were dieting, used significantly less amounts of proteins, carbohydrates, thiamin, niacin, iron, selenium, sodium and zinc. Conclusion: Knowing the harmful consequences of nutrient deficiency especially in adolescents, nutrition education must be emphasized in schools to promote nutritional literacy

Impact of comorbid conditions on asthmatic adults and children

Comorbid conditions (comorbidities) can complicate the diagnosis and management of asthma. In different age groups, comorbid conditions can present varying challenges, including diagnostic confusion due to mimicking asthma symptoms, exacerbation of asthma symptoms, therapy for comorbid conditions affecting asthma or therapy for asthma affecting these conditions. This review aims to summarise some common comorbid conditions with asthma, such as rhinitis, vocal cord dysfunction, gastro-oesophageal reflux, psychiatric disorders, obesity and obstructive sleep apnoea, and discuss their prevalence, symptoms, diagnosis and treatment, highlighting any differences in how they impact children and adults. Overall, there is a lack of data on the impact of treating comorbid conditions on asthma outcomes and further studies are needed to guide age-appropriate asthma management in the presence of these conditions.This article is freely available via Open Access. Click on the Publisher URL to access it via the publisher's site.A.K. reports personal fees from AstraZeneca, Behring, Boehringer Ingelheim, GlaxoSmithKline, Griffols, Teva, Novartis, Novo Nordisk, Paladdin, Pfizer, Purdue, Sanofi and Trudel, outside the submitted work. D.M.G.H. reports personal fees from AstraZeneca, Chiesi and Pfizer and grants and personal fees from Boehringer Ingelheim, GlaxoSmithKline and Novartis, outside the submitted work. S.J.S. reports fees from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis, Propeller Health, Regeneron and Sanofi, outside the submitted work all paid to the University of Colorado School of Medicinepublished version, accepted version, submitted versio

Understanding patients' perceptions of asthma control: a qualitative study.

Asthma control is suboptimal for many sufferers despite the existence of effective treatments. Patients' self-management is influenced by their perceptions of asthma and its treatment. This study explored sufferers' perceptions of asthma control and their influence on self-management behaviours.Participants (n=42) recruited from primary and secondary care asthma clinics in London in the UK each underwent a qualitative interview exploring perceptions and experiences of asthma control. Purposive sampling ensured variation in disease severity, degree of asthma control, age and socioeconomic status. Grounded theory was employed in thematic analysis of transcribed interviews.Five themes relating to perceptions of asthma control and self-management were identified: personal meaning of control, intermittent prevention, compromising control to avoid medication, pharmacological agents overemphasised in control and the role of asthma review in control. Within the first theme, some participants had an internal barometer of the level of symptoms that indicated their asthma was getting "out of control" that was set much higher than Asthma Control Test criteria.The findings provide new insights into patients' perceptions of asthma control. Symptoms indicative of poor control were often tolerated as part of living with asthma. Identification of barriers and drivers to self-management highlight potential targets for strategies aimed at optimising asthma management.Asthma U

How informed is declared altruism in clinical trials? A qualitative interview study of patient decision-making about the QUEST trials (Quality of Life after Mastectomy and Breast Reconstruction).

BACKGROUND: Randomised controlled trials (RCTs) often fail to recruit sufficient participants, despite altruism being cited as their motivation. Previous investigations of factors influencing participation decisions have been methodologically limited. This study evaluated how women weigh up different motivations after initially expressing altruism, and explored their understanding of a trial and its alternatives. The trial was the 'Quality of Life after Mastectomy and Breast Reconstruction' (QUEST) trial. METHODS: Thirty-nine women participated in qualitative interviews 1 month post-surgery. Twenty-seven women (10 trial decliners and 17 acceptors) who spontaneously mentioned 'altruism' were selected for thematic analysis. Verbatim transcripts were coded independently by two researchers. Participants' motivations to accept or decline randomisation were cross-referenced with their understanding of the QUEST trials and the process of randomisation. RESULTS: The seven emerging themes were: (1) altruism expressed by acceptors and decliners; (2) overriding personal needs in decliners; (3) pure altruism in acceptors; (4) 'hypothetical altruism' amongst acceptors; (5) weak altruism amongst acceptors; (6) conditional altruism amongst acceptors; and (7) sense of duty to participate. Poor understanding of the trial rationale and its implications was also evident. CONCLUSIONS: Altruism was a motivating factor for participation in the QUEST randomised controlled trials where the main outcomes comprised quality of life and allocated treatments comprised established surgical procedures. Women's decisions were influenced by their understanding of the trial. Both acceptors and decliners of the trial expressed 'altruism', but most acceptors lacked an obvious treatment preference, hoped for personal benefits regarding a treatment allocation, or did not articulate complete understanding of the trial. TRIAL REGISTRATION: QUEST A, ISRCTN38846532 ; Date assigned 6 January 2010. QUEST B, ISRCTN92581226 ; Date assigned 6 January 2010

Basophil activation test in the diagnosis and monitoring of mastocytosis patients with wasp venom allergy on immunotherapy

Background There is need for an accurate diagnostic test in mastocytosis patients with wasp venom allergy (WVA) and monitoring of these patients during immunotherapy (IT). In this study, we aimed to evaluate sensitivity and specificity of the Basophil Activation Test (BAT) as a diagnostic and monitoring test in patients with mastocytosis and WVA. Methods Seventeen patients with mastocytosis and WVA and six mastocytosis patients without WVA were included. BAT was performed before the start of IT (first visit) and at 6 weeks (second visit) and 1 year (third visit), after reaching the maintenance dose. Of 17 patients included, 11 completed the third visit. In mastocytosis patients with WVA, dose-dependent wasp-venom induced upregulation of CD63 and CD203c expression on basophils was observed compared with mastocytosis patients without WVA. Serum specific IgE, IgG4, and tryptase levels were measured in all patients. Results BAT had a sensitivity of 87% and specificity of 100% in diagnosing WVA in mastocytosis patients. Basophil allergen threshold sensitivity with respect to CD63 and CD203c was significantly decreased in the second visit compared with the first visit and increased significantly in the third visit compared with the second visit. Specific IgE levels increased significantly in the second visit compared with first and decreased significantly in the third visit compared with the second. Specific IgG4 levels rose significantly in the second visit compared with the first and on the third visit compared with the second. Tryptase levels did not change significantly during the study. Conclusions BAT represents a diagnostic test with 100% specificity in allergic patients with mastocytosis and these patients are better to be monitored for a longer period during IT. (c) 2013 International Clinical Cytometry Societ