Making health care safer II: an updated critical analysis of the evidence for patient safety practices

OBJECTIVES

To review important patient safety practices for evidence of effectiveness, implementation, and adoption.

DATA SOURCES

Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders.

REVIEW METHODS

The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains: • How important is the problem? • What is the patient safety practice? • Why should this practice work? • What are the beneficial effects of the practice? • What are the harms of the practice? • How has the practice been implemented, and in what contexts? • Are there any data about costs? • Are there data about the effect of context on effectiveness? We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were "strongly encouraged" for adoption, and those practices that were "encouraged" for adoption.

RESULTS

From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least "moderate," and 25 practices had at least "moderate" evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be "strongly encouraged" for adoption, and an additional 12 practices were classified as those that should be "encouraged" for adoption.

CONCLUSIONS

The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.

The vibrationally mediated photodissociation of Cl2

The photodissociation of vibrationally excited Cl(2)(v = 1) has been investigated experimentally using the velocity mapped ion imaging technique. The experimental measurements presented here are compared with the results of time-dependent wavepacket calculations performed on a set of ab initio potential energy curves. The high level calculations allow prediction of all the dynamical information regarding the dissociation, including electronic polarization effects. Using a combination of theory and experiment it was found that there was negligible cooling of the vibrational degree of freedom of the parent molecule in the molecular beam. The results presented are compared with those following the photodissociation of Cl(2)(v = 0). Although the same electronic states are found to be important for Cl(2)(v = 1) as for Cl(2)(v = 0), significant differences were found regarding many of the observables. The overall level of agreement between theory and experiment was found to be reasonable and confirms previous assignments of the photodissociation mechanism.

Longitudinal in vivo SPECT/CT imaging reveals morphological changes and cardiopulmonary apoptosis in a rodent model of pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) has a complex pathogenesis involving both heart and lungs. Animal models can reflect aspects of the human pathology and provide insights into the development and underlying mechanisms of disease. Because of the variability of most animal models of PAH, serial in vivo measurements of cardiopulmonary function, morphology, and markers of pathology can enhance the value of such studies. Therefore, quantitative in vivo SPECT/CT imaging was performed to assess cardiac function, morphology and cardiac perfusion utilizing (201)Thallium ((201)Tl) in control and monocrotaline-treated rats. In addition, lung and heart apoptosis was examined with (99m)Tc-Annexin V ((99m)Tc-Annexin) in these cohorts. Following baseline imaging, rats were injected with saline or monocrotaline (50 mg/kg, i.p.) and imaged weekly for 6 weeks. To assess a therapeutic response in an established pulmonary hypertensive state, a cohort of rats received resveratrol in drinking water (3 mg/kg/day) on days 28-42 post-monocrotaline injection to monitor regression of cardiopulmonary apoptosis. PAH in monocrotaline-treated rats was verified by conventional hemodynamic techniques on day 42 (right ventricular systolic pressure (RSVP) = 66.2 mmHg in monocrotaline vs 28.8 mmHg in controls) and in terms of right ventricular hypertrophy (RV/LVS = 0.70 in monocrotaline vs 0.32 in controls). Resveratrol partially reversed both RVSP (41.4 mmHg) and RV/LVS (0.46), as well as lung edema and RV contractility +dP/dt(max). Serial (99m)Tc-Annexin V imaging showed clear increases in pulmonary and cardiac apoptosis when compared to baseline, which regressed following resveratrol treatment. Monocrotaline induced modest changes in whole-heart perfusion as assessed by (201)TI imaging and cardiac morphological changes consistent with septal deviation and enlarged RV. This study demonstrates the utility of functional in vivo SPECT/CT imaging in rodent models of PAH and further confirms the efficacy of resveratrol in reversing established monocrotaline-induced PAH presumably by attenuation of cardiopulmonary apoptosis.

Electronic polarization effects in the photodissociation of Cl2

Velocity mapped ion imaging and resonantly enhanced multiphoton ionization time-of-flight methods have been used to investigate the photodissociation dynamics of the diatomic molecule Cl(2) following excitation to the first UV absorption band. The experimental results presented here are compared with high level time dependent wavepacket calculations performed on a set of ab initio potential energy curves [D. B. Kokh, A. B. Alekseyev, and R. J. Buenker, J. Chem. Phys. 120, 11549 (2004)]. The theoretical calculations provide the first determination of all dynamical information regarding the dissociation of a system of this complexity, including angular momentum polarization. Both low rank K = 1, 2 and high rank K = 3 electronic polarization are predicted to be important for dissociation into both asymptotic product channels and, in general, good agreement is found between the recent theory and the measurements made here, which include the first experimental determination of high rank K = 3 orientation.

Predictive clinicopathological features derived from systematic autopsy examination of patients who died with A/H1N1 influenza infection in the UK 2009-10 pandemic

BACKGROUND

From April 2009 to January 2010, the pandemic of A/H1N1 influenza affected the UK. There were > 30,000 infections and 457 deaths (all ages). Reports from other countries had indicated that certain comorbidities were associated with a higher risk of death from H1N1 infection, and there was a need to identify these factors in the UK population as knowledge of them could lead to improved treatment in the current epidemic and reduced mortality in future epidemics.

OBJECTIVES

To gather all the available clinical pathology information from autopsies performed on patients dying with known or suspected influenza A/H1N1 infection, across the UK. To evaluate comorbidities present in these deceased patients; correlate them with the H1N1-related pathology and treatment-associated pathology, determine their relative contributions and estimate the significant features associated with death.

METHODS

To obtain the autopsy reports, standard request letters were sent by e-mail to all histopathologists in the UK on the Royal College of Pathologists list, all the coroners' jurisdictions in England, Wales and Northern Ireland, and to procurators fiscal in Scotland. The letters asked for autopsy reports of the autopsied deceased who included: those with H1N1 infection, proven before or after death, and those in whom swine flu was unproven but most likely to have been present; those in whom H1N1 was a minor pathology, as well as those in whom it was the immediate cause of death; those whose cause of death mentioned 'swine flu', 'swine influenza' or 'H1N1 infection'; and those of any age from infancy to old age.

RESULTS

Sixty-eight autopsy reports were received: 19 children (0-15 years) and 49 adults (16 + years). All but two autopsies were medico-legal, and only two (3% of the total) were consented. This sample thus represents 15% of the known 457 deaths from H1N1. Median age for children at death was 6 years, for adults it was 41 years. Deaths in children were associated with congenital diseases (47%, 9/19), particularly of the heart and central nervous system. The autopsied children were not obese. Death in adults were associated with pregnancy (three cases in the study, but nationally 12/457 H1N1-associated deaths were noted), obesity (50% of adults had a body mass index ≥ 30 kg/m²) and chronic respiratory disease (12%, 6/49 adults). Diabetes did not emerge as a risk factor for death, but learning difficulties did. Nearly all the deaths (94%, 64/68) were a consequence of H1N1 infection in the respiratory tract. In more than one-third (41%, 28/68) of the deaths, bacterial secondary infection was the significant complication; the pneumococcus was the most common agent identified (25%, 7/28).

LIMITATIONS

This review is an incomplete medical study of what happened during the epidemic, and the small sample number (68 reports from 457 deaths) limits further speculation. We have no true measure of whether the cases selected for autopsy are representative of the total deaths in terms of pathology and comorbidities.

CONCLUSIONS

The major comorbidities associated with death from H1N1 infection were obesity, chronic respiratory disease and pregnancy. Young age at death was confirmed. Congenital disease in children and learning difficulties in adults were also important, but diabetes was not. This methodology of gathering data for research has potential for use in other public health questions, but is dependent on the co-operation of the medico-legal services. These results reinforce the need to enquire further into the pathogenesis of severe and fatal H1N1 disease, and the circumstances of clinical presentation and rapid evaluation in a time of epidemic influenza.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Manufacturing polymer/carbon nanotube composite using a novel direct process

A direct process for manufacturing polymer carbon nanotube (CNT)-based composite yarns is reported. The new approach is based on a modified dry spinning method of CNT yarn and gives a high alignment of the CNT bundle structure in yarns. The aligned CNT structure was combined with a polymer resin and, after being stressed through the spinning process, the resin was cured and polymerized, with the CNT structure acting as reinforcement in the composite. Thus the present method obviates the need for special and complex treatments to align and disperse CNTs in a polymer matrix. The new process allows us to produce a polymer/CNT composite with properties that may satisfy various engineering specifications. The structure of the yarn was investigated using scanning electron microscopy coupled with a focused-ion-beam system. The tensile behavior was characterized using a dynamic mechanical analyzer. Fourier transform infrared spectrometry was also used to chemically analyze the presence of polymer on the composites. The process allows development of polymer/CNT-based composites with different mechanical properties suitable for a range of applications by using various resins.

Lymphomatosis cerebri presenting as a rapidly progressive dementia with a high methylmalonic acid

We report a case of a patient with a rapidly progressive dementing illness and gait disturbance, in whom initial screening demonstrated a high methylmalonic acid level only, suggestive of a functional vitamin B(12) deficiency. Despite B(12) replacement therapy, he continued to decline. Further investigations demonstrated extensive signal change on magnetic resonance imaging involving grey and white matter within the corpus callosum, deep grey matter, brainstem and cerebellar peduncles, and patchy post-contrast enhancement. Laboratory testing revealed a raised erythrocyte sedimentation rate, raised anti-nuclear, intrinsic factor and lupus anticoagulant antibody titres, and a IgG kappa paraprotein. Cerebrospinal fluid was unremarkable. Bone marrow trephine biopsy showed monoclonal gammopathy of unknown significance. The patient initially responded to steroids, and underwent a brain biopsy, which was uninformative. However, 3 weeks following admission, he died due to an aspiration pneumonia. Autopsy findings were consistent with a diffuse primary central nervous system small cell B-cell lymphoma. This has been rarely reported in the medical literature, but our case exhibits typical clinical features, although patchy enhancement on imaging and the high methylmalonic acid have not been previously described. We hypothesise that his functional B(12) deficiency may have resulted from rapid cell turnover, perhaps in conjunction with the presence of intrinsic factor antibodies.

Radioimmunotherapy with radioactive nanoparticles: biological doses and treatment efficiency for vascularized tumors with or without a central hypoxic area

PURPOSE

Radioactive atoms attached to monoclonal antibodies are used in radioimmunotherapy to treat cancer while limiting radiation to healthy tissues. One limitation of this method is that only one radioactive atom is linked to each antibody and the deposited dose is often insufficient to eradicate solid and radioresistant tumors. In a previous study, simulations with the Monte Carlo N-Particle eXtended code showed that physical doses up to 50 Gy can be delivered inside tumors by replacing the single radionuclide by a radioactive nanoparticle of 5 nm diameter containing hundreds of radioactive atoms. However, tumoral and normal tissues are not equally sensitive to radiation, and previous works did not take account the biological effects such as cellular repair processes or the presence of less radiosensitive cells such as hypoxic cells.

METHODS

The idea is to adapt the linear-quadratic expression to the tumor model and to determine biological effective doses (BEDs) delivered through and around a tumor. This BED is then incorporated into a Poisson formula to determine the shell control probability (SCP) which predicts the cell cluster-killing efficiency at different distances "r" from the center of the tumor. BED and SCP models are used to analyze the advantages of injecting radioactive nanoparticles instead of a single radionuclide per vector in radioimmunotherapy.

RESULTS

Calculations of BED and SCP for different distances r from the center of a solid tumor, using the non-small-cell lung cancer as an example, were investigated for 90Y2O3 nanoparticles. With a total activity of about 3.5 and 20 MBq for tumor radii of 0.5 and 1.0 cm, respectively, results show that a very high BED is deposited in the well oxygenated part of the spherical carcinoma.

CONCLUSIONS

For either small or large solid tumors, BED and SCP calculations highlight the important benefit in replacing the single beta-emitter 90Y attached to each antibody by a 90Y2O3 nanoparticle.

Randomized, controlled trial of telcagepant for the acute treatment of migraine

BACKGROUND

The neuropeptide calcitonin gene-related peptide (CGRP) plays a key role in migraine pathophysiology. In this large phase 3 clinical trial, we sought to confirm the efficacy of telcagepant, the first orally bioavailable CGRP receptor antagonist.

METHODS

Adults with migraine with or without aura (International Headache Society criteria) treated a moderate or severe attack with oral telcagepant 50 mg (n = 177), 150 mg (n = 381), 300 mg (n = 371), or placebo (n = 365) in a randomized, double-blind trial. The 5 co-primary endpoints were pain freedom, pain relief, and absence of photophobia, absence of phonophobia, and absence of nausea, all at 2 hours postdose. The key secondary endpoint was 2-24 hour sustained pain freedom. The prespecified primary efficacy analyses evaluated the 150 mg and 300 mg groups; the 50-mg group was included on an exploratory basis to further characterize the dose response but was not prespecified for analysis. Tolerability was assessed by adverse experience reports.

RESULTS

Telcagepant 300 mg was more effective (p <or= 0.001) than placebo on all primary endpoints and the key secondary endpoint, as was telcagepant 150 mg (p <or= 0.05). Telcagepant 300 mg showed a slight numeric advantage over telcagepant 150 mg on most measures. Telcagepant 50 mg values were numerically intermediate between placebo and telcagepant 150 mg and 300 mg. The percentages of patients with adverse experiences were 32.2% for telcagepant 50 mg, 32.0% for telcagepant 150 mg, 36.2% for telcagepant 300 mg, and 32.2% for placebo.

CONCLUSIONS

This study confirmed previous findings that telcagepant 300 mg was effective at relieving pain and other migraine symptoms at 2 hours and providing sustained pain freedom up to 24 hours. In this study, telcagepant 150 mg was also effective. Telcagepant was generally well tolerated.

[Study of dental attrition in a medieval adult population from Southwest France]

INTRODUCTION

The aim of the authors was to study dental attrition in a medieval sample of paired mandibles and maxillas from the Southwest France (IX to XV century).

MATERIALS AND METHODS

We selected 58 adult individuals with maxillas and mandibles in good state of conservation, 29 women and 29 men from the medieval collection of Vilarnau-d'Amont (Western Pyrenees, France). Attrition was graded according to the Brabant index.

RESULTS

We found a high prevalence of attrition in this sample. The first molars (M1) were the maxillary and mandibular teeth most concerned by attrition. The most frequent attrition level was level 2, with dentin exposure. We did not find any significant difference of tooth wear between maxillary and mandibular teeth, even if maxillary teeth seemed to be more worn. There was symmetry of attrition between the left and right side. There was no significant difference between men and women.

DISCUSSION

Working on paired mandibles and maxillas showed that attrition in the middle age was a global phenomenon, intermaxillary and symmetric. It was much more severe than today, rapidly evolving and generalized because of the abrasive quality of food, cooking, chewing habits, and intensity of chewing pressure.