Soliciting views of various communities on health research: a prelude to engagement in specific research projects

BACKGROUND

Members of the public are increasingly engaged in health-service and biomedical research and provide input into the content of research, design and data sharing. As there is variation among different communities on how research is perceived, to engage all sectors of the general public research institutions need to customize their approach.

OBJECTIVE

This paper explores how research institutions and community leaders can partner to determine the best ways to engage different sectors of the public in research.

DESIGN

Following a literature review, a research institution engaged with four different sectors of the public through their respective representative community-based organizations (CBOs) by interviews with leaders, community member focus groups and a joint project.

SETTING

San Diego and Imperial Counties, California, United States of America (USA).

CONCLUSION

Before embarking on more specific research projects, investigators can gain valuable insights about different communities' attitudes to, and understanding of, health services and biomedical research by interacting directly with members of the community, collaborating with community leaders, and jointly identifying steps of engagement tailored to the community.

Case study in designing a research fundamentals curriculum for community health workers: a university-community clinic collaboration

Community health workers (CHWs) are increasingly incorporated into research teams. Training them in research methodology and ethics, while relating these themes to a community's characteristics, may help to better integrate these health promotion personnel into research teams. An interactive training course on research fundamentals for CHWs was designed and implemented jointly by a community agency serving a primarily Latino, rural population and an academic health center. A focus group of community members and input from community leaders comprised a community-based participatory research model to create three 3-hour interactive training sessions. The resulting curriculum was interactive and successfully stimulated dialogue between trainees and academic researchers. By choosing course activities that elicited community-specific responses into each session's discussion, researchers learned about the community as much as the training course educated CHWs about research. The approach is readily adaptable, making it useful to other communities where CHWs are part of the health system.

Neonatal group B streptococcal infection at the University Hospital of the West Indies, Jamaica: a 10-year experience

AIM

To describe the incidence, clinical presentation and outcome of neonatal group B streptococcal (GBS) infection at the University Hospital of the West Indies (UHWI).

METHODS

A 10-year retrospective review of all inborn neonates admitted to the neonatal unit of UHWI with GBS infection between 1 January 1991 and 31 December 2000 was conducted. Differences in maternal and neonatal characteristics between early- and late-onset disease (EOD, LOD) were determined.

RESULTS

There were 32,029 live births and 29 neonates were admitted for GBS infection, an incidence of 0.91/1000 live births (95% CI 0.58-1.23/1000). Twenty-one (72%) neonates had EOD, a rate of 0.66/1000 live births (95% CI 0.38-0.94/1000) and eight (28%) had LOD, a rate of 0.23/1000 (95% CI 0.08-0.42/1000). Seventeen of the 21 (81%) cases of EOD occurred within the 1st 24 hours of life. The most common clinical diagnosis was septicaemia (17, 61%), followed by pneumonia (8, 28%) and meningitis (3, 11%). All five (100%) babies whose mothers' membranes were ruptured for >18 hours had EOD. The babies of all six (100%) women with intrapartum pyrexia went on to have EOD. A greater proportion of babies (63%) with LOD were preterm and of low birthweight. The most common presenting symptom was respiratory distress which occurred more frequently in neonates with EOD, p=0.006. One neonate died, giving a case fatality rate of 3.6%.

CONCLUSION

Although the incidence of GBS infection is relatively low at UHWI, further reduction in the incidence might be achieved by implementation of measures to prevent perinatal transmission.

Urinary tract infection in neonates with serious bacterial infections admitted to the University Hospital of the West Indies

OBJECTIVE

The aim of this study was to describe the epidemiology of urinary tract infection in neonates, with serious bacterial infections, admitted to the University Hospital of the West Indies.

METHODS

Admission records of all neonates admitted to the neonatal unit of the University Hospital of the West Indies between January 1995 and December 2000 for sepsis evaluation were reviewed. Infants who had positive bacterial cultures were identified using laboratory records. Those satisfying the criteria for urinary tract infection were selected for detailed analysis. Demographic, clinical and laboratory data were collected using a pre-coded questionnaire. Descriptive analyses were performed.

RESULTS

Fifty-one (38%) of 135 babies with positive bacterial isolates had confirmed urinary tract infection. Male:female ratio was 6:1. Common presenting features included fever (32%), poor feeding (30%) and irritability (22%). The mean white cell count was 14 +/- 6.26. E coli and Klebsiella species were most frequently identified. Factors associated with a diagnosis of urinary tract infection included male gender (p < 0.001), age > 48 hours (p < 0.05) and a presenting complaint of poor feeding (p < 0.003). Imaging studies of the renal tract detected abnormalities in 5 (10.4%) neonates.

CONCLUSIONS

Urinary tract infection is an important cause of serious bacterial infection in neonates affecting 1 in 3 babies with proven bacterial infection and may be the first indicator of underlying structural abnormalities. The absence of specific distinguishing clinical features makes it necessary to include urine cultures in the sepsis evaluation of neonates presenting with symptoms suggestive of sepsis.

Illustrating the root-cause-analysis process: creation of a safety net with a semiautomated process for the notification of critical findings in diagnostic imaging

The ACR has set a standard for the communication of critical findings on imaging examinations. Despite this standard, for a variety of reasons, it remains possible that appropriate follow-up is not initiated. The authors review the theory and application of root-cause analysis to such a failure of communication within their institution, including the development and implementation of a semiautomated notification system for critical unexpected findings on imaging examinations.

Neonatal sepsis in very low birthweight infants at the University Hospital of the West indies

A retrospective review was conducted on the charts of all very low birthweight (VLBW) infants with culture proven sepsis admitted to the neonatal unit of the University Hospital of the West Indies (UHWI) during the period January 1, 1995 to December 31, 2000. During the study period, 22 VLBW infants were admitted to the neonatal unit with culture proven sepsis, 16 (73%) survived and 6 (27%) died As birthweight and gestational age increased, outcome improved There was no difference in survival based on age at presentation. Neonates with early onset disease had a significantly longer mean duration of rupture of membranes than those with late onset disease (p = 0.009) and babies with late onset disease had a significantly lower mean Hb level than those with early onset disease (p = 0.000). Predominant isolates were Klebsiella sp (10, 37%), Streptococcus Group D (4, 15%), Escherichia coli (3, 11%) and Group B Streptococcus (3, 11%). Klebsiella sp accounted for 8/13 (62%) of late onset infections. Complications included anaemia, thrombocytopenia, bleeding and multi-organ failure. Strategies aimed at prevention, such as limiting the excessive use of broad-spectrum empiric antibiotics and the periodic review and continuous reinforcement of infection control policies will help decrease the mortality and morbidity associated with nosocomial infection in the VLBW infant.

Predictors of poor outcome in neonates with bacterial sepsis admitted to the University Hospital of the West Indies

To determine factors that affect outcome in neonates with culture-proven sepsis, the charts of all neonates with culture-proven sepsis admitted to the University Hospital of the West Indies between January 1995 and December 2000 were reviewed retrospectively. Neonates who survived without developing any complications (favourable outcome group) were compared with those who died and/or developed severe complications during the course of treatment (poor outcome group). Chi-square tests were done to determine factors associated with poor outcome; univariate and multivariate logistic regression analyses were also performed. One hundred and thirty-five neonates had culture-proven sepsis, of which 89 (66%) were term infants and 46 (34%) were preterm. Male to female ratio was 1.6:1. One hundred and twenty-six (93%) survived and 9 (7%) died. Case fatality rates were higher for premature infants (15%) than for term infants (2%). Twenty-four (18%) of the neonates with culture proven sepsis had a poor outcome. Gram negative organisms accounted for 19 (70%) of the cases with poor outcome. Prematurity (p < 0.001), very low birthweight (p < 0.001) and female gender (p < 0.05) were factors associated with poor outcome. Strategies aimed at decreasing morbidity and mortality in neonates with sepsis must include measures that will decrease the incidence of prematurity and low birthweight.

Efficiency of a semiautomated coding and review process for notification of critical findings in diagnostic imaging

OBJECTIVE

When a significant unexpected finding such as malignancy is noted on a study, the standard of care generally holds that the radiologist communicate the findings to the referring physician and document the communication in the radiology report. Despite this standard, for a variety of reasons it remains possible that the direct care provider might receive such notification but not initiate an appropriate workup. On the basis of prior root cause analysis, we developed and instituted a semiautomated process for notification of critical diagnostic imaging findings. We now report our 12-month experience with the process.

MATERIALS AND METHODS

A diagnostic code was attached to every radiology report. When a significant unexpected finding occurred, our radiologists, in addition to contacting the appropriate clinician, gave the report the designation code 8. On a weekly basis, a list of code 8 cases was passed to the cancer registrar at our institution, who tracked the cases to ensure that they were appropriately followed up.

RESULTS

In the 12-month period after initiation of this system, we performed 37,736 radiologic examinations at our institute. Of these, 395 cases were given code 8. All code 8 cases were followed up by the tumor registrar. In 35 cases, no workup was documented after 2 weeks. Of these, eight cases would have been completely lost to follow-up if this safety net had not been in place.

CONCLUSION

Failures of communication, documentation errors, and various system failures may lead to an untoward outcome for the patient. We devised a simple system to ensure that significant unexpected findings on imaging received appropriate attention. An additional level of redundancy has increased the probability of optimal patient outcome.

Neonatal sepsis in Jamaican neonates

AIM

To determine the incidence and causative organisms of bacterial sepsis in neonates at The University Hospital of the West Indies.

METHODS

A retrospective review of all neonates with culture-proven sepsis admitted to the hospital between January 1995 and December 2000 was conducted. Incidence rates and antimicrobial susceptibility patterns were determined.

RESULTS

There were 4702 admissions to the neonatal unit during the study period. Of these, 135 had culture-proven sepsis and 115 were inborn, giving an incidence of 6.7/1000 live births. There were 89 positive blood cultures, 51 positive urine cultures and two positive CSF cultures. The single most common organism was Klebsiella spp (28%). Other organisms included Escherichia coli (16%), group B Streptococcus (11%) and Enterobacter spp (10%). The aminoglycoside resistance rate of Klebsiella spp was 46% and seven isolates had multiple resistance to antibiotics. There was a case fatality rate of 6.7%.

CONCLUSION

Physicians involved in newborn care at The University Hospital of the West Indies need to recognise the important role Klebsiella now plays in neonatal sepsis and its contribution to neonatal mortality. Empirical antibiotic regimens for gram-negative sepsis must take into consideration the high rates of aminoglycoside resistance that are now prevalent.

Clinical study of 35 patients with dysarthria-clumsy hand syndrome

OBJECTIVES

Although dysarthria-clumsy hand syndrome (DCHS) is a well known and infrequent lacunar syndrome, there are few data regarding the spectrum of associated clinical characteristics, anatomical site of lesion, and aetiopathogenetic mechanisms. We report a clinical description of this subtype of lacunar stroke based on data collected from a prospective acute stroke registry.

METHODS

From 2500 acute stroke patients included in a hospital based prospective stroke registry over a 12-year period, 35 patients were identified as having DCHS.

RESULTS

DCHS accounted for 1.6% of all acute stroke patients (35/2110), 1.9% of acute ischaemic stroke (35/1840), and 6.1% of lacunar syndromes (35/570) admitted consecutively to a neurology department and included in the stroke registry over this period. The results supported the lacunar hypothesis in 94.3% of patients (n = 33). Atherothrombotic and cardioembolic infarction occurred in only one patient each (2.9%). No patient with DCHS had an intracerebral haemorrhage. Outcome was good (mortality in hospital 0%, symptom free at discharge 45.7%). After multivariate analysis, absence of limitation at discharge, limb weakness but not cerebellar-type ataxia, and internal capsule (40%), pons (17%), and corona radiata (8.6%) location were significantly associated with DCHS.

CONCLUSIONS

DCHS is a rare cerebrovascular syndrome, and supports the criteria of the lacunar hypothesis. The majority of patients in this study had internal capsule infarcts. The prognosis is good with striking similarity compared with other types of lacunar strokes. There are important differences between DCHS and non-lacunar strokes. Internal capsule and pons are the most frequent cerebral sites.

Factors influencing hepatitis B vaccine uptake in injecting drug users

BACKGROUND

Hepatitis B infection in injecting drug users is an important public health problem. Active immunization against hepatitis B is immunogenic and safe, but uptake rates in targeted vaccination programmes are low. This study was undertaken to identify factors associated with the uptake of hepatitis B vaccination in injecting drug users attending a needle exchange service.

METHODS

A retrospective cross-sectional survey of case-note data of injecting drug users who had no markers of hepatitis B infection or immunity was undertaken within a drop-in needle exchange service for injecting drug users in a large urban area in England. A qualitative study using semi-structured interviews with needle exchange staff was also conducted.

RESULTS

Of 207 injecting drug users, 180 (87 per cent) had been offered vaccine, 123 (59 per cent) accepted at least one dose and 55 (27 per cent) received three or more doses. Vaccine was less likely to be offered to those sharing injecting equipment or known to have hepatitis C. Needle sharing was also associated with failure to accept vaccine, as was increasing age and the length of contact with the service.

CONCLUSIONS

Those who are most at risk are least likely to be offered vaccine and accept it. This calls into doubt the effectiveness of hepatitis B vaccination strategies targeted at high-risk groups and adds weight to arguments for universal vaccination.

Non-opsonic phagocytosis of Trichophyton mentagrophytes arthroconidia by human neutrophils in vitro

A non-opsonic mechanism of binding and phagocytosis by human neutrophils of Trichophyton mentagrophytes arthroconidia is described. This was in direct contrast to the complement dependency of Candida albicans phagocytosis. Both serum complement and specific antibody to T. mentagrophytes promoted maximal phagocytosis (61% and 40% of neutrophils, respectively, contained arthroconidia). Increasing the ratio of arthroconidia to neutrophils did not increase non-opsonic phagocytosis (18-26%). Phagocytosis of arthroconidia exposed to trypsin in the absence of opsonin was not affected (18%). However, proteinase and chitinase reduced the level of non-opsonic and opsonic phagocytosis to negligible levels (6.3% and 4.5%, respectively). When mannose was added to neutrophils, mannose receptors on the phagocyte membrane were partially blocked when arthroconidia were opsonised, but this did not reduce the level of non-opsonic phagocytosis. The non-opsonic mechanism proposed here may have direct relevance in skin sites poor in opsonins.

The human LFA-3 gene is located at the same chromosome band as the gene for its receptor CD2

Lymphocyte function-associated antigen 3 (LFA-3) is a widely distributed cell surface glycoprotein that has been assigned a role in cell-cell adhesion on the basis of its capacity to bind to the T-lymphocyte CD2 antigen. The amino acid sequences of the extracellular domains of these two antigens, predicted from their cDNA sequences, show significant similarities, and both are members of the immunoglobulin supergene family. In this communication, a probe prepared from LFA-3 cDNA has been used in Southern blot analyses of somatic cell hybrids and in in situ hybridization to assign the LFA-3 gene to the human chromosome band 1p13. This is the same location previously assigned to CD2. Thus the LFA-3 and CD2 genes have probably arisen by duplication of a common evolutionary precursor. These genes therefore represent a further instance in which related members of the immunoglobulin superfamily are located in adjacent regions of the genome.