Proactive evaluation of clinical risk: a FMECA analysis in pediatric chemotherapy

In 2010-2011, we used FMECA to prospectively assess risk-management in chemotherapy of children with cancer, in a third level Italian children's Hospital (Ospedale Pediatrico Bambino Gesù; OPBG). We designed a flow chart representing the entire process; we described potential failure points for each step of the process, as well as their potential underlying causes. We calculated the risk priority number (RPN) of each failure point based on the severity of the failure, the frequency of occurrence, and the likelihood of detecting the failure prior to completion of the process. All FMECA activities were supported by a web-based tool. The highest RPN values were observed for failure points of the paper-based chemotherapy medication orders sent from clinicians to Pharmacy, the transcription of the orders into the Pharmacy paper-based work-sheet for medication preparation, and the selection of medications to be used for chemotherapy preparation. Causes of these failures were mostly related to illegible or incomplete handwriting. As a consequence of these results, the implementation of an electronic ordering process for children's chemotherapy medications was proposed as risk-reducing action.

Advancement in the routine identification of anaerobic bacteria by MALDI-TOF mass spectrometry

We evaluated matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) Biotyper as a tool for the identification of anaerobic bacteria compared with 500 base-pair (bp) 16S ribosomal ribonucleic acid (rRNA) gene sequencing analysis, which is considered to be the "gold standard" method. A total of 484 anaerobic bacteria were retrieved from the clinical specimens of 318 pediatric patients. Molecular identification resulted in 18 genera and 51 species. The most prevalent genus was Clostridium (76.85 %), with 70 % C. difficile isolates. The concordance and sensitivity determined by MALDI-TOF MS for C. difficile, the most prevalent species isolated, was 94.08 %, whereas the specificity was 100 %. For the other anaerobes, the sensitivity and specificity were 94.07 % and 81.82 %, respectively, with a concordance of 93.15 %. Low performance was observed for Propionibacterium acnes and Fusobacterium nucleatum, for which a dedicated pretreatment procedure should likely be set up. MALDI-TOF MS was shown to be a valid alternative for the fast and reliable identification of the most clinically relevant anaerobic bacteria; moreover, it is less time-consuming, the cost for reagents is minimized, and it does not require dedicated personnel.

Novel Tandem Duplication in Exon 1 of the SNURF/SNRPN Gene in a Child with Transient Excessive Eating Behaviour and Weight Gain

A deletion in 15q11.2 involving the SNURF/SNRPN gene is the typical finding in patients with Prader-Willi syndrome. Apart from translocations disrupting this gene, no other mutation types have been described so far. We report a patient in whom a small duplication in exon 1 of the SNURF/SNRPN gene was diagnosed which is predicted to interrupt only SNURF expression. The patient was investigated due to overgrowth, increased appetite and developmental delay in childhood. This duplication was inherited from her father who carries the duplication on his paternal chromosome 15 and also had transient excessive eating behaviour as an adolescent. RNA studies showed that the duplication introduces a premature stop codon in SNURF.

Trend of healthcare-associated infections in children: annual prevalence surveys in a research hospital in Italy, 2007-2010

BACKGROUND

Annual prevalence surveys of healthcare-associated infections (HAIs) between 2007 and 2010 were conducted in the largest tertiary care children's hospital in Italy. During this period, actions to improve HAI prevention were implemented, including strengthened isolation measures; adoption of care bundles for invasive procedures; hand hygiene promotion using the World Health Organization multimodal strategy; and promotion of appropriate antimicrobial use.

AIM

To determine the impact of these measures on HAI rates.

METHODS

A total of 1506 patients were surveyed. Information on patient demographics, mechanical ventilation, central line and urinary catheterization in the preceding 48 h, and surgery in the previous 30 days were abstracted from medical charts. The type and date of onset of HAIs, and microbiological data were recorded. Univariate and multivariate logistic analysis were used to evaluate changes in HAI rates over time, and the influence of ward type and patient characteristics.

FINDINGS

There were significant (P < 0.001) reductions in the prevalence of patients developing HAI (from 7.6% to 4.3%) and in the prevalence of total HAIs (from 8.6 to 4.3 per 100 patients). Factors independently associated with increased HAI risk were hospitalization in intensive care ward, length of stay >30 days, presence of invasive device, and age 6-11 years.

CONCLUSION

This HAI prevention strategy was influential in decreasing infections among hospitalized children. Repeated prevalence surveys are an effective tool for monitoring HAI frequency, increasing awareness among the healthcare personnel, and contributing to the establishment of effective infection control.

Systematic screening of FBN1 gene unclassified missense variants for splice abnormalities

Defects at the level of pre-mRNA splicing are a common source of genetic mutation but such mutations are not always easy to identify from DNA sequence data alone. Clinical practice has only recently begun to incorporate analysis for this type of abnormality. Some base changes at the DNA level currently viewed as unclassified variants or missense mutations may influence RNA splicing. To address this problem for fibrillin 1 (FBN1) gene missense mutations we have carried out RNA analysis and in silico analysis with splice site prediction programs on 40 cases with 36 different mutations. Direct analysis of RNA from blood was performed by cDNA preparation, PCR amplification of specific FBN1 fragments, gel electrophoresis and sequencing of the PCR products. Of the 36 missense base changes, direct RNA analysis identified 2 which caused an abnormality of splicing. In silico analysis using five splice site prediction programs did not always accurately predict the splicing seen by direct RNA analysis. In conclusion, some apparent missense mutations have an effect on splicing which can be identified by direct RNA analysis, however, in silico analysis of splice sites is not always accurate, should be carried out with more than one prediction program and results should be used with caution.

Point prevalence study of antibiotic use in a paediatric hospital in Italy

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Functional splicing assay shows a pathogenic intronic mutation in neurofibromatosis type 1 (NF1) due to intronic sequence exonization

Genomic variations with no apparent effect ("neutral polymorphisms") may have a significant effect on splicing. The effect of this type of mutation is difficult to spot, unless a functional assay is undertaken. In our study, DNA sequencing of a patient with clinically defined neurofibromatosis type 1 (NF1) showed only a single polymorphism in intron 30 due to an A>G transition 279 nucleotides from the 3' splice site. Using a minigene splicing assay we conclusively show that this change produces a cryptic exon with a 3' SS defined by the nucleotide change and the unexpected activation of a very weak 5'SS. Further site directed mutagenesis studies aimed at identifying the signals involved in the cryptic exon inclusion were carried out. Interestingly we find that particular characteristics of the cryptic 5' SS are essential for its inclusion. Significantly an additional single nucleotide change disrupting the cryptic 5'ss consensus sequence rescues the effect of the pathogenetic mutation resulting in normal splicing.

[Hospital infection surveillance in 5 Roman intensive care units]

The A.A. carried out a survey on hospital acquired infection (HAI) in the intensive care units (ICU) of five roman hospitals. The study monitored the following site-specific infection rates: pneumonia (PNE), blood stream infections (BSI), urinary tract infections (UTI), surgical site infections (SSI). According to CDC definitions all patients developing infection 48 hours or more after ward admission were included. Furthermore risk factors (i.e. age, sex, SAPS II), invasive procedures (i.e. endotracheal intubation, vascular and urinary catheterisation), microbiological isolates and their antibiotic susceptibility were screened. The overall 503 patients characteristics (i.e., age, length of stay, case-mix...) showed the wards as general ICU's. Although the SAPS II score was similar, mortality (18.2%-42.9%) and general infection rates (15.4%-40.4%) among the five ICU's were considerably variable (p < 0.05), as HAI episodes distribution by type: PNE (37-88%), BSI (6-42%), UTI (6-24%), SSI (3-7%) (p < 0.05). Also device-associated infection rates such as Ventilator-associated PNE (11.6-24.6@1000), Vascular catheter-associated BSI (3.4-19.2@1000). Urinary catheter-associated UTI (2.6-14.0@1000) and invasive procedures management were different. Among the infected patients the most commonly isolated microorganisms were P. aeruginosa and Staphylococcus spp., which presented a considerable antibiotic resistance. The study showed: 1) sampling (i.e. blood cultures, tracheal aspirate and urine samples) and laboratory methodology indispensable for a correct HAI diagnosis were not standardized in the five ICU's; 2) hospital infection control policy was not carried out in all ICU's. The study showed a lack of standardization which limits the comparability of the general roman ICU's.