The role of angiogenic biomarkers and uterine artery Doppler in pregnant women with systemic lupus erythematosus or antiphospholipid syndrome

OBJECTIVE

To evaluate the usefulness of the uterine artery mean pulsatility index (mPI-UtA) and the sFlt-1/PlGF ratio in women with systemic lupus erythematosus (SLE) or antiphospholipid syndrome (APS) for the prediction of placental dysfunction-related adverse outcomes (AO), namely pre-eclampsia (PE) and intrauterine growth restriction (IUGR), and for differential diagnosis between PE and SLE flares.

STUDY DESIGN

Observational prospective cohort study of 57 pregnant women with SLE or APS.

MAIN OUTCOME MEASURES

mPI-UtA and sFlt-1/PlGF ratio in maternal serum were obtained at four gestational age periods (11-14, 19-22, 24-29 and 32-34 weeks). Comparisons among pregnancies with normal outcome, SLE flare and AO were performed.

RESULTS

Overall, we had 44 ongoing pregnancies (36 with SLE and 8 with APS) of which most (n = 35, 80%) were uncomplicated. The overall rate of AO was 9% (n = 4), that was diagnosed at a mean (SD) gestational age of 34.1 (7.5) weeks. Five SLE patients (14%) suffered a SLE flare. No differences for these markers were found between normal pregnancies and those affected by SLE flare. mUtA-PI values were significantly higher in the AO group when compared with normal and SLE flare groups, at 19-22 weeks (1.52, 0.95 and 0.76) and 32-34 weeks (1.13, 0.68 and 0.65), respectively. The sFlt-1/PlGF ratio was significantly higher in the AO group at 24-29 weeks (191.1, 3.1 and 9.2), respectively.

CONCLUSION

Our preliminary results indicate that mPI-UtA and sFlt1/PlGF ratio may be useful to predict AO in women with SLE, and to make the differential diagnosis with a lupus flare.

Differentiating between hospitals according to the "maturity" of quality improvement systems: a new classification scheme in a sample of European hospitals

Aim:

This study, part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project focusing on cross-border patients in Europe, investigated quality policies and improvement in healthcare systems across the European Union (EU). The aim was to develop a classification scheme for the level of quality improvement (maturity) in EU hospitals, in order to evaluate hospitals according to the maturity of their quality improvement activities.

Methods:

A web-based questionnaire survey designed to measure quality improvement in EU hospitals was used as the basis for the classification scheme. Items included for the development of an evaluation tool—the maturity index—were considered important contributors to quality improvement. The four-stage quality cycle (plan, do, check and act) was used to determine the level of maturity of the various items. Psychometric properties of the classification scheme were assessed, and validation analyses were performed.

Results:

A total of 389 hospitals participated in a questionnaire survey; response rates varied by country. For a final sample of 349 hospitals, it was possible to construct a quality improvement maturity index which consisted of seven domains and 113 items. The results of independent analyses sustained the validity of the index, which was useful in differentiating between hospitals in the research sample according to the maturity of their quality improvement system (defined as the total of all quality improvement activities).

Discussion:

Further research is recommended to develop an instrument which for use in the future as a practical tool to evaluate the maturity of hospital quality improvement systems.

Quality requirements for cross-border care in Europe: a qualitative study of patients', professionals' and healthcare financiers' views

BACKGROUND

In the past decade the issue of patient mobility has emerged on the European health policy agenda. Although the volume of patients crossing borders to obtain healthcare is low, it is increasing continuously and, due to its legal, financial and medical implications, has generated considerable interest among health policy and other decision makers. However, there is little information available on the safety and patient-centredness of cross-border care and neither governments nor citizens have an explicit basis for comparing healthcare delivery in Europe.

METHODS

This study investigated the viewpoints of patients, professionals and healthcare financiers on the safety and patient-centredness of cross-border care. Qualitative interviews were carried out during 2005 and early 2006 with 40 patients, 30 professionals (doctors, nurses and managers) and 3 healthcare-financing bodies.

RESULTS

Although cross-border care has become a common issue in many European countries, there remain uncertainties on the side of each of the parties addressed--patients, professionals and financiers--with regard to the provision of cross-border care. One of the most striking results of this project is the current lack of research on systematic knowledge on the quality of cross-border care.

CONCLUSION

Many of the issues identified through this research may have a potential impact on the quality and safety of cross-border care and will support further investigation and help shape the health policy agenda on patients crossing borders in European Union countries.

Impact of quality strategies on hospital outputs

CONTEXT

This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on patients crossing borders, a study to investigate quality improvement strategies in healthcare systems across the European Union (EU).

AIM

To explore the association between the implementation of quality improvement strategies in hospitals and hospitals' success in meeting defined quality requirements that are considered intermediate outputs of the care process.

METHODS

Data regarding the implementation of seven quality improvement strategies (accreditation, organisational quality management programmes, audit and internal assessment of clinical standards, patient safety systems, clinical practice guidelines, performance indicators and systems for obtaining patients' views) and four dimensions of outputs (clinical, safety, patient-centredness and cross-border patient-centredness) were collected from 389 acute care hospitals in eight EU countries using a web-based questionnaire. In a second phase, 89 of these hospitals participated in an on-site audit by independent surveyors. Pearson correlation and linear regression models were used to explore associations and relations between quality improvement strategies and achievement of outputs.

RESULTS

Positive associations were found between six internal quality improvement strategies and hospital outputs. The quality improvement strategies could be reasonably subsumed under one latent index which explained about half of their variation. The analysis of outputs concluded that the outputs can also be considered part of a single construct. The findings indicate that the implementation of internal as well as external quality improvement strategies in hospitals has beneficial effects on the hospital outputs studied here.

CONCLUSION

The implementation of internal quality improvement strategies as well as external assessment systems should be promoted.

Implementation of patient safety strategies in European hospitals

CONTEXT

This study is part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on cross-border care, investigating quality improvement strategies in healthcare systems across the European Union (EU).

AIM

To explore to what extent a sample of acute care European hospitals have implemented patient safety strategies and mechanisms and whether the implementation is related to the type of hospital.

METHODS

Data were collected on patient safety structures and mechanisms in 389 acute care hospitals in eight EU countries using a web-based questionnaire. Subsequently, an on-site audit was carried out by independent surveyors in 89 of these hospitals to assess patient safety outputs. This paper presents univariate and bivariate statistics on the implementation and explores the associations between implementation of patient safety strategies and hospital type using the chi(2) test and Fisher exact test.

RESULTS

Structures and plans for safety (including responsibilities regarding patient safety management) are well developed in most of the hospitals that participated in this study. The study found greater variation regarding the implementation of mechanisms or activities to promote patient safety, such as electronic drug prescription systems, guidelines for prevention of wrong patient, wrong site and wrong surgical procedure, and adverse events reporting systems. In the sample of hospitals that underwent audit, a considerable proportion do not comply with basic patient safety strategies--for example, using bracelets for adult patient identification and correct labelling of medication.

Volume and diagnosis: an approach to cross-border care in eight European countries

OBJECTIVES

Mobility of patients is a pertinent issue on the European Union's agenda. This study aimed to estimate the volume and main diagnoses of cross-border care in eight European countries, in order to provide policy makers with background information about the nature of patient mobility in Europe.

METHODS

This article reports the combined findings from three independent studies that compiled self-reported information on admissions data and main diagnoses from more than 200 hospitals in eight European countries.

RESULTS

The average volume of cross-border patients accounted for less than 1% of total admissions in the hospitals studied here. Diseases of the circulatory system (mainly acute myocardial infarction) and fractures were the most common reasons for hospitalisation of European patients abroad. Deliveries and other diagnoses related to pregnancy, pneumonia, appendicitis and other diseases of the digestive system, aftercare procedures, and disorders of the eye and adnexa were also common diagnoses for this population.

CONCLUSIONS

Hospitals should reinforce their efforts to adapt the care provided to the needs of foreign patients in treatment areas that cover the most frequent pathologies identified in this population.

Do European hospitals have quality and safety governance systems and structures in place?

Internal systems for quality and safety were assessed in 89 hospitals in six European states, by external teams using standardised criteria and procedures, as part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) project. The assessments were made primarily to identify the current use of quality management systems in the sample hospitals, and also to demonstrate a potential tool for comparable assessment of hospitals in general. The large majority of the hospitals had a formal, documented infrastructure to manage quality and safety, but a significant minority had no designated mission, programme or coordination. In two-thirds of hospitals, the governing body was active in defining policy and programmes for improvement, and received reports on quality, safety and patient satisfaction at least once a year. The brief on-site assessments identified systematic variations, within and between countries, in structures and processes of governance and to document the uptake of best practice. Unacceptable variations in practice could be reduced, to the benefit of consumers and providers, by developing and publishing basic organisational standards relevant to all European states. The simple assessment criteria designed for this project could be developed into a practical tool for self-assessment, peer review or benchmarking of hospitals across national borders. This assessment, combined with explicit, relevant and achievable standards, could provide a vehicle to promote the voluntary uptake of best practice and consistency in quality and safety among hospitals in Europe.

Application of quality improvement strategies in 389 European hospitals: results of the MARQuIS project

CONTEXT

This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project investigating the impact of quality improvement strategies on hospital care in various countries of the European Union (EU), in relation to specific needs of cross-border patients.

AIM

This paper describes how EU hospitals have applied seven quality improvement strategies previously defined by the MARQuIS study: organisational quality management programmes; systems for obtaining patients' views; patient safety systems; audit and internal assessment of clinical standards; clinical and practice guidelines; performance indicators; and external assessment.

METHODS

A web-based questionnaire was used to survey acute care hospitals in eight EU countries. The reported findings were later validated via on-site survey and site visits in a sample of the participating hospitals. Data collection took place from April to August 2006.

RESULTS

389 hospitals participated in the survey; response rates varied per country. All seven quality improvement strategies were widely used in European countries. Activities related to external assessment were the most broadly applied across Europe, and activities related to patient involvement were the least widely implemented. No one country implemented all quality strategies at all hospitals. There were no differences between participating hospitals in western and eastern European countries regarding the application of quality improvement strategies.

CONCLUSIONS

Implementation varied per country and per quality improvement strategy, leaving considerable scope for progress in quality improvements. The results may contribute to benchmarking activities in European countries, and point to further areas of research to explore the relationship between the application of quality improvement strategies and actual hospital performance.

In vitro effect of the presence of human albumin or human serum on the bactericidal activity of daptomycin against strains with the main resistance phenotypes in Gram-positives

OBJECTIVES

Bactericidal activity depends on antibiotic-bacteria couples, resistance phenotype and theoretically on protein binding. This work explores the influence of protein binding on the bactericidal activity of two antibiotics, daptomycin versus vancomycin, that exhibit, respectively, different C(max) (56 versus 25.5 mg/L), protein binding (91.7% versus 36.9%) and thus theoretical free-drug fractions (4.7 versus 16.1 mg/L).

METHODS

The effect of the presence of physiological concentrations of human albumin (4 g/dL) or human serum (90%) on the bactericidal activity of daptomycin was studied against Gram-positive isolates with troublesome resistance phenotypes [multidrug-resistant Streptococcus pneumoniae (MDRSP), methicillin-resistant Staphylococcus aureus (MRSA), heterogeneous vancomycin-intermediate MRSA (MRSA-hVI) and vancomycin-resistant Enterococcus faecium]. Killing curves (final inocula of approximately 10(7) cfu/mL) were performed using daptomycin and vancomycin concentrations similar to the C(max) obtained in serum.

RESULTS

Daptomycin was rapidly bactericidal (> or =3 log(10) initial inocula reduction) against S. pneumoniae and S. aureus, regardless of the strain tested or the presence of albumin or human serum (that slightly delayed bactericidal activity). Against vancomycin-susceptible or -resistant enterococci, daptomycin exhibited rapid bactericidal activity, delayed to 8 and 24 h, respectively, by human albumin. Vancomycin exhibited much slower bactericidal activity against MDRSP and methicillin-susceptible or -resistant S. aureus, but was never bactericidal against MRSA-hVI and vancomycin-susceptible or -resistant E. faecium.

CONCLUSIONS

Daptomycin exhibited rapid bactericidal activity against the strains of the three Gram-positive species tested, regardless of resistance phenotype or the presence of physiological concentrations of albumin.

Evaluation of the continuation of care between psychiatric hospitalization units and the outpatient clinics in the community

INTRODUCTION

Continuum of care between health institutions is one of the basic elements of healthcare quality. In this article we present a study that was conducted in an acute psychiatric hospitalization unit for adolescent population. The present study analyzes the perception of professionals from community psychiatric care centers on the continuum of care provided to the patients hospitalized in this unit.

METHOD

A self-administered and anonymous questionnaire was mailed to each of the mental health centers that refer patients to the unit. The instrument used is a self-created questionnaire, based on previous tools developed for primary healthcare institutions. The data were analyzed and action plans were defined for the improvement of those areas with a lower score.

RESULTS

The response rate was 71.4 %. All the items have an average rate higher than 3 on a scale of 1 to 5. The items with a higher score are the possibility to exchange opinions with the professionals of the unit and the knowledge of the doctor responsible for the patient during the hospitalization. The items with a lower level of satisfaction are the referral procedure and the unit's resources.

CONCLUSION

The study provides data on the perception that professionals from mental health out-patient centers have about the coordination with the Unit. This data has been found to be useful to define improvement initiatives that will improve the continuum of care.

Intramembrane charge movements and excitation- contraction coupling expressed by two-domain fragments of the Ca2+ channel

To investigate the molecular basis of the voltage sensor that triggers excitation-contraction (EC) coupling, the four-domain pore subunit of the dihydropyridine receptor (DHPR) was cut in the cytoplasmic linker between domains II and III. cDNAs for the I-II domain (alpha1S 1-670) and the III-IV domain (alpha1S 701-1873) were expressed in dysgenic alpha1S-null myotubes. Coexpression of the two fragments resulted in complete recovery of DHPR intramembrane charge movement and voltage-evoked Ca(2+) transients. When fragments were expressed separately, EC coupling was not recovered. However, charge movement was detected in the I-II domain expressed alone. Compared with I-II and III-IV together, the charge movement in the I-II domain accounted for about half of the total charge (Q(max) = 3 +/- 0.23 vs. 5.4 +/- 0.76 fC/pF, respectively), and the half-activation potential for charge movement was significantly more negative (V(1/2) = 0.2 +/- 3.5 vs. 22 +/- 3.4 mV, respectively). Thus, interactions between the four internal domains of the pore subunit in the assembled DHPR profoundly affect the voltage dependence of intramembrane charge movement. We also tested a two-domain I-II construct of the neuronal alpha1A Ca(2+) channel. The neuronal I-II domain recovered charge movements like those of the skeletal I-II domain but could not assist the skeletal III-IV domain in the recovery of EC coupling. The results demonstrate that a functional voltage sensor capable of triggering EC coupling in skeletal myotubes can be recovered by the expression of complementary fragments of the DHPR pore subunit. Furthermore, the intrinsic voltage-sensing properties of the alpha1A I-II domain suggest that this hemi-Ca(2+) channel could be relevant to neuronal function.

Determination of lumbar muscular activity in helicopter pilots: a new approach

BACKGROUND

Discomfort in the lumbar region is a frequent complaint of helicopter pilots. Two factors that helicopter crewmembers relate to back pain are exposure to vibration and poor posture during flight, because during flight the seat and controls force the pilot to adopt an asymmetric posture. Repeated exposure to these adverse flight conditions could cause pathological changes in the spine. The purpose of this study was to compare right and left sided lumbar muscular activity in helicopter pilots under real flight conditions, using surface electromyography (SEMG) to demonstrate the effects of asymmetrical posture on the musculoskeletal system. An attempt was also made to correlate lumbar muscular activity with environmental factors and such variables as type of flight, type of helicopter, duration of flight, age, physical fitness, and height.

METHODS

Right- and left-sided lumbar electrical activity were measured using two-channel SEMG during 35 flights in 2 types of helicopter and a cockpit mock-up.

RESULTS

There was a statistically significant increase in right-sided lumbar activity when related to the duration of flight.

CONCLUSIONS

The data showed that when the pilot used the manual controls during flight, he did not maintain a symmetrical posture and contracted one side more than the other. We think the relationship between the greatest right-sided contraction and flight duration is due to maintaining an asymmetric posture over a long period. We also noted a tendency towards greater right lumbar musculature activity in older pilots.

Comparison of Ca(2+) sparks produced independently by two ryanodine receptor isoforms (type 1 or type 3)

The molecular determinants of a Ca(2+) spark, those events that determine the sudden opening and closing of a small number of ryanodine receptor (RyR) channels limiting Ca(2+) release to a few milliseconds, are unknown. As a first step we investigated which of two RyR isoforms present in mammalian embryonic skeletal muscle, RyR type 1(RyR-1) or RyR type 3 (RyR-3) has the ability to generate Ca(2+) sparks. Their separate contributions were investigated in intercostal muscle cells of RyR-1 null and RyR-3 null mouse embryos. A comparison of Ca(2+) spark parameters of RyR-1 null versus RyR-3 null cells measured at rest with fluo-3 showed that neither the peak fluorescence intensity (DeltaF/F(o) = 1.25 +/- 0.7 vs. 1.55 +/- 0.6), spatial width at half-max intensity (FWHM = 2.7 +/- 1.2 vs. 2.6 +/- 0.6 microm), nor the duration at half-max intensity (FTHM = 45 +/- 49 vs. 43 +/- 25 ms) was significantly different. Sensitivity to caffeine (0.1 mM) was remarkably different, with sparks in RyR-1 null myotubes becoming brighter and longer in duration, whereas those in RyR-3 null cells remained unchanged. Controls performed in double RyR-1/RyR-3 null cells obtained by mice breeding showed that sparks were not observed in the absence of both isoforms in >150 cells imaged. In conclusion, 1) RyR-1 and RyR-3 appear to be the only intracellular Ca(2+) channels that participate in Ca(2+) spark activity in embryonic skeletal muscle; 2) except in their responsiveness to caffeine, both isoforms have the ability to produce Ca(2+) sparks with nearly identical properties, so it is rather unlikely that a single RyR isoform, when others are also present, would be responsible for Ca(2+) sparks; and 3) because RyR-1 null cells are excitation-contraction (EC) uncoupled and RyR-3 null cells exhibit a normal phenotype, Ca(2+) sparks result from the inherent activity of small clusters of RyRs regardless of the participation of these RyRs in EC coupling.

Involvement of the carboxy-terminus region of the dihydropyridine receptor beta1a subunit in excitation-contraction coupling of skeletal muscle

Skeletal muscle knockout cells lacking the beta subunit of the dihydropyridine receptor (DHPR) are devoid of slow L-type Ca(2+) current, charge movements, and excitation-contraction coupling, despite having a normal Ca(2+) storage capacity and Ca(2+) spark activity. In this study we identified a specific region of the missing beta1a subunit critical for the recovery of excitation-contraction. Experiments were performed in beta1-null myotubes expressing deletion mutants of the skeletal muscle-specific beta1a, the cardiac/brain-specific beta2a, or beta2a/beta1a chimeras. Immunostaining was used to determine that all beta constructs were expressed in these cells. We examined the Ca(2+) conductance, charge movements, and Ca(2+) transients measured by confocal fluo-3 fluorescence of transfected myotubes under whole-cell voltage-clamp. All constructs recovered an L-type Ca(2+) current with a density, voltage-dependence, and kinetics of activation similar to that recovered by full-length beta1a. In addition, all constructs except beta2a mutants recovered charge movements with a density similar to full-length beta1a. Thus, all beta constructs became integrated into a skeletal-type DHPR and, except for beta2a mutants, all restored functional DHPRs to the cell surface at a high density. The maximum amplitude of the Ca(2+) transient was not affected by separate deletions of the N-terminus of beta1a or the central linker region of beta1a connecting two highly conserved domains. Also, replacement of the N-terminus half of beta1a with that of beta2a had no effect. However, deletion of 35 residues of beta1a at the C-terminus produced a fivefold reduction in the maximum amplitude of the Ca(2+) transients. A similar observation was made by deletion of the C-terminus of a chimera in which the C-terminus half was from beta1a. The identified domain at the C-terminus of beta1a may be responsible for colocalization of DHPRs and ryanodine receptors (RyRs), or may be required for the signal that opens the RyRs during excitation-contraction coupling. This new role of DHPR beta in excitation-contraction coupling represents a cell-specific function that could not be predicted on the basis of functional expression studies in heterologous cells.

[Transient bacteremia caused by Corynebacterium urealyticum: apropos of 2 cases]

BACKGROUND

Corynebacterium urealyticum is a pathogen mainly isolated from the urinary tract and seldom from the blood. We present two cases of bacteremia caused by multiresistant C. urealyticum isolated in two and three blood cultures respectively.

PATIENTS AND METHODS

The two cases were studied. C. urealyticum was isolated from blood cultures and clinical charts were reviewed retrospectively. No history of prior antibiotic therapy was observed in either patient. Blood cultures were processed using BACTEC NC 730 system (Becton Dickinson). The API Coryne system (BioMérieux) was used to identify both strains.

RESULTS

Despite both patients having not received any antibiotic treatment, they improved clinically and microbiologically. Therefore, the episodes were considered as transitory bacteremias.

CONCLUSION

Although C. urealyticum is not common, we believe that it is necessary to identify any diphtheromorphic microorganism in blood, when they are clinically significant.