[Experiences of women in cesium brachytherapy]

The objective of the present study was to determine the main difficulties and problems experienced by patients submitted to sealed internal radiotherapy as well as to provide guidance for nurses to better perceive the difficulties experienced by the patients and act as an element of support while giving care. The problems and difficulties observed and reported by the patients were mainly related to the impositions of treatment, such as isolation, prohibition of visits, hospitalization, bed confinement, restriction of movements, use of the intracavity system, measures of radiological protection, use of a delay bladder tube, and limited personal hygiene. Fear related to treatment and anesthesia, partial or absent orientation and skin lesions were the complaints voiced by most of the patients in the present study. The role of the nurse is important in planning nursing care in sealed internal radiotherapy, especially when nurses understand the problems and difficulties experienced by women submitted to this treatment.

On fighting versus accepting stressful circumstances: primary and secondary control among HIV-positive men in prison

The primacy of primary control over secondary control and ethnic differences in control processes were tested in HIV-positive male state prison inmates. They rated their perceptions of control and psychological distress at an initial interview (N = 95) and 3 months later (N = 78). Regression analyses revealed that primary control had primacy as it had greater adaptive value. However, secondary control did not function as a backup to primary control, and temporal differences in control were not found. No mean differences due to ethnicity (African American vs. White) were found, but there was a strong ethnic difference in the effects of primary control. White participants showed the expected negative relationship between distress and primary control, but African American participants did not. The idea that the benefits of primary control would be the same across various subcultures was not supported.

Trends in the prevalence of methicillin-resistant Staphylococcus aureus associated with discontinuation of an isolation policy

The number of patients with methicillin-resistant Staphylococcus aureus (MRSA) before and after discontinuing placement of patients into private rooms was determined. The mean monthly number of patients with MRSA decreased from 34 to 22, and the proportion of S aureus isolates that were MRSA decreased from 34% to 20%. We found no evidence that failure to isolate patients with MRSA resulted in an increased prevalence of MRSA.

Prevention of community-acquired and nosocomial pneumonia

Pneumonia is an important cause of morbidity and mortality in the United States. The provision of effective prophylaxis for pneumonia has become a major goal for both public health officials and individual physicians. Prophylaxis for community-acquired pneumonia is pathogen-specific and is directed toward the most common microorganisms that cause it. The 23-valent pneumococcal polysaccharide vaccine; the trivalent influenza vaccine; the Haemophilus b conjugate vaccine; and either trimethoprim-sulfamethoxazole, dapsone, or aerosolized pentamidine are recommended to prevent Streptococcus pneumoniae, influenza viruses, H. influenzae type b, and Pneumocystis carinii respectively. Except for the microorganisms listed above, the prevention of nosocomial pneumonia is not pathogen-specific. Rather, prevention of nosocomial pneumonia requires the use of infection control procedures, including patient and staff education; isolation of patients with highly contagious respiratory pathogens; vigorous hand washing; cleaning and sterilizaton of respiratory equipment; and use of sterile water in nebulizers and humidifiers. It also requires procedures to limit pooling and aspiration of secretions, such as positioning and rotation of the bed-bound patient; frequent suctioning of respiratory secretions using gloves and sterile suction catheters; and limiting enteral alimentation. Finally, selective decontamination of the digestive tract may be considered for intubated patients.

Outcome for patients colonised with Burkholderia cepacia in a Birmingham adult cystic fibrosis clinic and the end of an epidemic

BACKGROUND

There has been increasing concern since 1979 about the emergence of Pseudomonas cepacia (Burkholderia cepacia) in patients with cystic fibrosis in the UK and elsewhere. Colonisation of the sputum has been shown to be associated with increased morbidity and mortality. Evidence suggests person to person transmission and some centres have segregated those colonised with B cepacia from other patients with cystic fibrosis. The outcome of patients colonised by B cepacia has been studied, together with the effects of strict segregation.

METHODS

The outcome in 18 patients with sputum colonised by B cepacia was compared with that in age, sex, and severity matched controls with no evidence of B cepacia colonisation by a retrospective case note study.

RESULTS

No difference between cases or controls were found in the 24 month period prior to colonisation by B cepacia in lung function, number of days in hospital, or outpatient visits. Colonisation led to an increased rate of loss of lung function and utilisation of hospital services. There was an increase in the numbers of transplants and deaths amongst the cases. Since 1992 there have been only three new cases of B cepacia colonisation and the incidence and prevalence of the organism has fallen dramatically since segregation commenced.

CONCLUSIONS

B cepacia appears to be linked to the decline in colonised individuals. There was no evidence that colonisation occurred in patients declining for other reasons. B cepacia colonisation confers a worse prognosis than Pseudomonas aeruginosa alone. Segregation appears to limit the spread of the organism from infected individuals to other patients with cystic fibrosis.

Prevention and management of tuberculosis in HIV positive patients living in countries with a low prevalence of Mycobacterium tuberculosis

We have re-examined the evidence on which current British Thoracic Society recommendations for primary and secondary prophylaxis and therapy of tuberculosis are based. We suggest that in a country such as the UK with a low prevalence of tuberculosis, primary prophylaxis should be offered primarily to tuberculin positive or anergic patients from high-incidence groups, including immigrants from high-prevalence countries, intravenous drug users and those with previous tuberculosis, that secondary prophylaxis be withheld from all but very high-risk patients and that four drug regimens which include ethambutol should be used for patients originating from, or who have lived in areas of the world with more than 2% primary isoniazid resistance.

Hospital care of tuberculosis patients referred for directly observed therapy in New York City: identifying factors in prolonged stays

Individuals hospitalized and treated for tuberculosis (TB) who were then enrolled into TB directly observed therapy at four study hospitals in New York City (NYC) were identified. Review of hospital medical records determined whether the hospitalizations were warranted and whether lengths of stay were prolonged. Most hospitalizations were appropriate but over 70 percent of cases analyzed had prolonged stays. Of these, almost half were to document bacteriologic response to anti-TB treatment. Some were prolonged due to misunderstanding of state recommendations. Focused educational efforts could significantly reduce lengths of stay and save up to $9.7 million annually in NYC hospitalization costs.

Tuberculosis in the workplace: OSHA's compliance experience

OBJECTIVE

Inspections of 272 facilities were performed between May 1992 and October 1994 to determine compliance with applicable Occupational Safety and Health Administration (OSHA) requirements for prevention of tuberculosis (TB) transmission.

DESIGN

Retrospective record review of two data sources: (1) OSHA's Computerized Integrated Management Information System and (2) an inspector-completed questionnaire on inspection results.

SETTING/PARTICIPANTS

Inspections of five types of facilities: healthcare institutions, correctional facilities, homeless shelters, long-term-care facilities for the elderly, and others, including drug treatment centers that the Centers for Disease Control and Prevention (CDC) identified as having a higher than expected rate of TB.

METHODS

The OSHA Compliance Memorandum, based on the 1990 CDC Guidelines, which outlined elements of a TB prevention program, was used in performing 272 inspections of facilities between May 1992 and October 1994. Elements of compliance were recorded and reviewed from the IMIS database and inspectors' questionnaires.

RESULTS

Regulated facilities were not fully compliant with OSHA guidance. Generally, healthcare facilities performed better than other facilities. Most facilities (79%) were compliant with administrative elements of a comprehensive TB control program, such as early identification of known or suspected infectious TB patients and skin testing of workers. Only 29% of inspected facilities were found to have acceptable respiratory protection programs for the prevention of occupational TB.

CONCLUSION

Facilities have not been fully compliant with the OSHA memorandum describing protection of workers from TB. Facility compliance was better with some traditionally recognized TB infection control elements, but was weaker in the area of respiratory protection programs. This may reflect a lack of familiarity with the latter type of hazard protection.

An investigation into nurses' perceptions of secluding patients on closed psychiatric wards

Seclusion continues to be used in the care of acutely disturbed psychiatric patients despite often emotionally charged debate about its appropriateness within mental health services. Powerful legal and moral arguments about the use of seclusion emphasize an urgent need to critically examined its role into the care of mentally ill people. This paper examines the use of seclusion on closed psychiatric wards in the management of acutely disturbed patients. Seven psychiatric nurses working in two closed wards in an Australian teaching hospital were interviewed in relation to their perceptions of the role of seclusion. Data were analysed using grounded theory methodology revealing the core conceptual category 'controlling' and two sub-categories 'watching out for' and 'watching over'. Seclusion was found to be used as an adjunctive treatment in the care of individuals considered to be 'out of control'. Clinicians expressed comfort with the use of seclusion, citing a strict protocol that provided parameters for its use. Whilst expert therapeutic interventions were described by clinicians, they are contextualized within a framework of power and control - a framework that stands in stark contrast to contemporary philosophies of nursing care, providing impetus for a reconsideration of the use of constraining practices in the care of mentally ill people.

Positive tuberculin skin test reactions among house staff at a public hospital in the era of resurgent tuberculosis

BACKGROUND

The number and significance of tuberculin skin test reactions were compared with self-reported baseline values among house staff working in a public hospital. High-risk medical specialties, locations, and infection control practices were examined.

METHODS

House staff interviews, tuberculin skin test applications, review of employee health service records, and environmental monitoring of high-risk areas were performed.

RESULTS

Among house staff self-reported as having negative tuberculin skin test status, 46.2% (95% CI 27.0% to 65.4%) of internal medicine house staff, compared with 4.8% (95% CI 4.3% to 13.9%) of house staff from other areas (p < 0.005), had positive results on a repeat tuberculin skin testing before graduation. These differences were not entirely explained by the use of surgical masks, year of training, or previous vaccination with bacille Calmette-Guérin. Most skin test reactions (69%) occurred among house staff who had not been vaccinated with bacille Calmette-Guérin. Increased skin reactivity probably represented excess conversions from unprotected exposure. Tuberculosis transmission was facilitated by delays in diagnosis, inadequate isolation facilities, and suboptimal ventilation. House staff did not comply with recommended tuberculosis surveillance because of time constraints, fear, and misunderstandings about tuberculin skin test interpretations in light of previous bacille Calmette-Guérin vaccination.

CONCLUSIONS

House staff in high-exposure settings with suboptimal environmental controls are at increased risk for tuberculosis infection. Participation in surveillance programs can be increased by enlisting the participation and advocacy of respected medical colleagues, screening house staff differentially according to exposure and job classifications, and more accurately interpreting subsequent test results from baseline two-step testing.

Nosocomial mumps: report of an outbreak and its control

BACKGROUND

Mumps is a relatively uncommon disease in the United States, and nosocomial transmission of mumps is rare.

METHODS

When a recently arrived Mexican immigrant became ill with mumps in a pediatric hospital in the United States, control measures and careful secondary case surveillance were instituted. Outbreak control included isolation of the patient with symptoms, seclusion of patients potentially incubating mumps virus, and immunization of susceptible patients and health care workers.

RESULTS

A 3-year-old patient showed symptoms of mumps 18 days after onset of illness in the index patient. Two employees, a physical therapist and a nurse, became ill with mumps 20 and 28 days after the onset of illness in the index patient. No other hospital or community cases of mumps were identified.

CONCLUSIONS

Outbreak control measures were incompletely successful in stopping the spread of mumps. Preadmission immunization of all patients and mumps-specific screening and vaccination of hospital employees might be indicated in such a situation, but such measures are neither easy nor inexpensive.