Costs and resource utilization patterns in surgical site infections: a pre-COVID-19 perspective from France, Germany, Spain, and the UK.

BACKGROUND: Surgical site infections (SSIs), mainly caused by Staphylococcus aureus, pose a significant economic burden in Europe, leading to increased hospitalization duration, mortality, and treatment costs, particularly with drug-resistant strains such as meticillin-resistant S. aureus. AIM: To conduct a case-control study on the economic impact of S. aureus SSI in adult surgical patients across high-volume centres in France, Germany, Spain, and the UK, aiming to assess the overall and procedure-specific burden across Europe. METHODS: The SALT study is a multinational, retrospective cohort study with a nested case-control analysis focused on S. aureus SSI in Europe. The study included participants from France, Germany, Italy, Spain, and the UK who underwent invasive surgery in 2016 and employed a micro-costing approach to evaluate health economic factors, matching S. aureus SSI cases with controls. FINDINGS: In 2016, among 178,904 surgical patients in five European countries, 764 developed S. aureus SSI. Matching 744 cases to controls, the study revealed that S. aureus SSI cases incurred higher immediate hospitalization costs (€8,810), compared to controls (€6,032). Additionally, S. aureus SSI cases exhibited increased costs for readmissions within the first year post surgery (€7,961.6 versus €5,298.6), with significant differences observed. Factors associated with increased surgery-related costs included the cost of hospitalization immediately after surgery, first intensive care unit (ICU) admission within 12 months, and hospital readmission within 12 months, as identified through multivariable analysis. CONCLUSION: The higher rates of hospitalization, ICU admissions, and readmissions among S. aureus SSI cases highlight the severity of these infections and their impact on healthcare costs, emphasizing the potential benefits of evidence-based infection control measures and improved patient care to mitigate the economic burden.

Recommendations for the diagnosis and treatment of Clostridioides difficile infection: An official clinical practice guideline of the Spanish Society of Chemotherapy (SEQ), Spanish Society of Internal Medicine (SEMI) and the working group of Postoperative Infection of the Spanish Society of Anesthesia and Reanimation (SEDAR).

This document gathers the opinion of a multidisciplinary forum of experts on different aspects of the diagnosis and treatment of Clostridioides difficile infection (CDI) in Spain. It has been structured around a series of questions that the attendees considered relevant and in which a consensus opinion was reached. The main messages were as follows: CDI should be suspected in patients older than 2 years of age in the presence of diarrhea, paralytic ileus and unexplained leukocytosis, even in the absence of classical risk factors. With a few exceptions, a single stool sample is sufficient for diagnosis, which can be sent to the laboratory with or without transportation media for enteropathogenic bacteria. In the absence of diarrhoea, rectal swabs may be valid. The microbiology laboratory should include C. difficile among the pathogens routinely searched in patients with diarrhoea. Laboratory tests in different order and sequence schemes include GDH detection, presence of toxins, molecular tests and toxigenic culture. Immediate determination of sensitivity to drugs such as vancomycin, metronidazole or fidaxomycin is not required. The evolution of toxin persistence is not a suitable test for follow up. Laboratory diagnosis of CDI should be rapid and results reported and interpreted to clinicians immediately. In addition to the basic support of all diarrheic episodes, CDI treatment requires the suppression of antiperistaltic agents, proton pump inhibitors and antibiotics, where possible. Oral vancomycin and fidaxomycin are the antibacterials of choice in treatment, intravenous metronidazole being restricted for patients in whom the presence of the above drugs in the intestinal lumen cannot be assured. Fecal material transplantation is the treatment of choice for patients with multiple recurrences but uncertainties persist regarding its standardization and safety. Bezlotoxumab is a monoclonal antibody to C. difficile toxin B that should be administered to patients at high risk of recurrence. Surgery is becoming less and less necessary and prevention with vaccines is under research. Probiotics have so far not been shown to be therapeutically or preventively effective. The therapeutic strategy should be based, rather than on the number of episodes, on the severity of the episodes and on their potential to recur. Some data point to the efficacy of oral vancomycin prophylaxis in patients who reccur CDI when systemic antibiotics are required again.

Climate oscillations effects on market prices of commercially important fish in the northern Alboran Sea.

Climate oscillations affect fish population dynamics, ecological processes and fisheries activities in marine ecosystems. In the western Mediterranean, several atmospheric indices associated with pressure oscillations have been identified as the main drivers of the abundance or availability of certain resources exploited by fisheries. The main aim of this study was to explore the association between the potential effects of the North Atlantic Oscillation (NAO) and the Arctic Oscillation (AO) on the first sale price of fresh fish at the fish market of the most representative commercial species of the fisheries in the Alboran Sea (Mediterranean Sea). We used the Pearson correlation test to investigate correlations between the atmospheric oscillation indices and the fish market price of the selected species. The results suggest that inter- and intra-annual atmospheric oscillations may have an effect on bonito (Sarda sarda), European anchovy (Engraulis encrasicolus) and catsharks (Scyliorhinus spp.) abundance and catchability in the Alboran Sea and, therefore, an impact on their fish market presence and price variability according to the law of supply and demand.

Information on nosocomial infections in the mainstream media: an opinion document.

This paper seeks to explore the reasons for the low impact of nosocomial infection in the mainstream media and the responsibilities of physicians and journalists in terms of this situation. To this end, a small group of 13 experts met for round-table discussions, including physicians with expertise in nosocomial infection, medical lawsuits and ethics, as well as journalists from major mainstream Spanish media outlets. The various participants were asked a series of questions prior to the meeting, which were answered in writing by one of the speakers and discussed during the meeting by the whole group, the aim being to obtain consensual conclusions for each of them. The document was subsequently reviewed, edited and forwarded to all co-authors for their agreement. The opinions expressed are the personal opinions of the participants and not necessarily those of the institutions in which they work or with which they collaborate.

[Supply medicinal products improvement in outpatient care in a hospital pharmacy service]. / Mejora de la dispensación a pacientes externos de un servicio de farmacia hospitalaria.

INTRODUCTION: Pharmaceutical care to outpatients is currently one of the main occupations of hospital pharmacy services (PEX). There are several questionnaires to measure the satisfaction of the PEX of a pharmacy service, and the results of these questionnaires can generate improvement actions that result in satisfaction. OBJECTIVES: To verify if a satisfaction questionnaire for outpatients is valid for the generation of improvements in the care provided, and if after its implementation, the same questionnaire is able to detect changes in satisfaction. MATERIAL AND METHOD: Prospective study of a single center carried out in a tertiary hospital in 2015 and 2016. A questionnaire previously validated with 16 Likert-type items was used. Demographic and classification data were collected. A descriptive analysis was performed and the internal consistency was calculated using the Cronbach's α value. RESULTS: A total of 258 questionnaires were collected in 2015 and 493 in 2016. There were no differences in the baseline characteristics of the patients and users of the service. The items with the lowest satisfaction scores in 2015 (comfort of the waiting room, dispensing privacy, drug pick-up time and medication pick-up time) guided the improvement actions to be implemented. In 2016 there was an improvement in the waiting time until collection in 12.3% (p = 0.002); in the comfort of the waiting room 4.9% (p = 0.304); business hours for medication collection, 10.7% (p = 0.013); and in the confidentiality of the dispensation 4% (p = 0.292). The remaining scores fluctuated minimally, with no statistical significance at all. A 5.1% improvement in overall satisfaction was found (p < 0.001). Satisfaction values obtained as a whole were high. CONCLUSIONS: The satisfaction questionnaire is a valid instrument for generating actions to improve the care received in an outpatient unit of a pharmacy service. This same questionnaire is a tool to monitor the changes implemented to improve the care received.

[Adjusted Clinical Groups Method (ACG) to allocate resources according to the disease burden of each health center]. / Clasificación según nivel de morbilidad e intensidad del uso de recursos de una población con patologías crónicas en Atención Primaria de Salud utilizando “Adjusted Clinical Groups” (ACG).

BACKGROUND: Health care must be provided with strong primary health care models, emphasizing prevention and a continued, integrated and interdisciplinary care. Tools should be used to allow a better planning and more efficient use of resources. AIM: To assess risk adjustment methodologies, such as the Adjusted Clinical Groups (ACG) developed by The Johns Hopkins University, to allow the identification of chronic condition patterns and allocate resources accordingly. MATERIAL AND METHODS: We report the results obtained applying the ACG methodology in primary care systems of 22 counties for three chronic diseases, namely Diabetes Mellitus, Hypertension and Heart Failure. RESULTS: The outcomes show a great variability in the prevalence of these conditions in the different health centers. There is also a great diversity in the use of resources for a given condition in the different health care centers. CONCLUSIONS: This methodology should contribute to a better distribution of health care resources, which should be based on the disease burden of each health care center.

Clasificación según nivel de morbilidad e intensidad del uso de recursos de una población con patologías crónicas en Atención Primaria de Salud utilizando “Adjusted Clinical Groups” (ACG) / Adjusted Clinical Groups Method (ACG) to allocate resources according to the disease burden of each health center

Background: Health care must be provided with strong primary health care models, emphasizing prevention and a continued, integrated and interdisciplinary care. Tools should be used to allow a better planning and more efficient use of resources. Aim: To assess risk adjustment methodologies, such as the Adjusted Clinical Groups (ACG) developed by The Johns Hopkins University, to allow the identification of chronic condition patterns and allocate resources accordingly. Material and Methods: We report the results obtained applying the ACG methodology in primary care systems of 22 counties for three chronic diseases, namely Diabetes Mellitus, Hypertension and Heart Failure. Results: The outcomes show a great variability in the prevalence of these conditions in the different health centers. There is also a great diversity in the use of resources for a given condition in the different health care centers. Conclusions: This methodology should contribute to a better distribution of health care resources, which should be based on the disease burden of each health care center.

Antifungal stewardship in a tertiary-care institution: a bedside intervention.

Antifungal stewardship (AFS) programmes are needed in tertiary-care hospitals. Our aim is to describe a bedside non-restrictive AFS programme, and to evaluate its economic impact. During the first year of the AFS a bundle of non-interventional measures were implemented. During the second year an infectious diseases specialist visited 453 patients receiving candins, liposomal amphotericin B, voriconazole or posaconazole. Monthly costs were studied with an interrupted time series (ITS) analysis. The main prescribing departments were haematology (35%), medical departments (23%), and intensive care units (20%). Reasons to start antifungal therapy were: targeted therapy (36%), prophylaxis (32%), empirical therapy (20%) and pre-emptive therapy (12%). At the initial visit, diagnostic advice was provided in 40% of cases. The most common therapeutic recommendations were to de-escalate the antifungal drug (17%) or to suspend it (7%). Annual total antifungal expenditure was reduced from US$3.8 million to US$2.9 million over the first 2 years, generating net savings of US$407,663 and US$824,458 per year after considering the cost of additional staff required. The ITS analyses showed a significant economic impact after the first 12 months of the intervention (p 0.042 at month 13), which was enhanced in the following 24 months (p 0.006 at month 35). The number of defined daily doses decreased from 66.4 to 54.8 per 1000 patient-days. Incidence of candidaemia was reduced from 1.49 to 1.14 (p 0.08) and related mortality was reduced from 28% to 16% (p 0.1). A collaborative and non-compulsory AFS program based on bedside intervention is an efficacious and cost-effective approach that optimizes the use of AF drugs.

Routine aspiration of subglottic secretions after major heart surgery: impact on the incidence of ventilator-associated pneumonia.

Aspiration of subglottic secretions (ASS) is recommended in patients requiring mechanical ventilation for ≥48h. We assessed the impact of the introduction of ASS routinely in all patients after major heart surgery in an ecological study comparing ventilator-acquired pneumonia (VAP) incidence, days of mechanical ventilation, and cost of antimicrobial agents before and after the implementation of ASS. Before and after the intervention the results (per 1000 days) were: VAP incidence, 23.92 vs 16.46 (P = 0.04); cost of antimicrobials, €71,384 vs €63,446 (P = 0.002); and days of mechanical ventilation, 507.5 vs 377.5 (P = 0.009). From the moment of induction of anaesthesia all patients undergoing major heart surgery should routinely receive ASS.

Hazard assessment of sediments from a wetland system for treatment of landfill leachate using bioassays.

Four bioassays were used in this study for the hazard assessment of sediments from sediment traps and several ponds in a treatment wetland for landfill leachate at Atleverket, Sweden. In the 6-day solid phase microbiotest with the sediment-dwelling crustacean Heterocypris incongruens both acute and chronic effects were observed with a gradual decrease and loss of toxicity with treatment in the wetland system. Some samples showed a low toxicity in porewater and only one sample was weakly toxic in the whole sediment test when assessed with Aliivibrio fischeri (Vibro fischeri). No genotoxicity was detected in the umu test. The toxicity response in the H4IIE- luc test evaluating the presence of dioxin-like compounds was considerably higher in the samples from the sediment traps. The hazard of the sediment therefore appears to be highest in the sediment traps and pond 1 with the methods employed. The result indicates that the wetland system has a design supporting the concentration and sequestration of toxic substances in the first part of the wetland. Based upon the results we suggest that hazard assessment of sediments from other treatment wetlands for landfill leachate should be conducted.

Habilidad de cuidado de los profesionales de enfermería de unainstitución prestadora de servicios de salud / The Care ability of nursing professionals in a health care providing institution

Objetivo: Medir la habilidad de cuidado de los profesionales de enfermería que laboran en una InstituciónPrestadora de Servicios de Salud de tercer nivel de la ciudad de Sincelejo, Colombia, en el 2009. Metodología:Estudio descriptivo, cuantitativo de corte transversal: la muestra estuvo conformada por 30 enfermeros del áreaasistencial, a quienes se les aplicó el Inventario de Habilidad de Cuidado, que mide tres categorías: conocimiento,valor y paciencia. La información se procesó a través del programa Statistical Package for the Social Sciences (SPSS).Resultados: En la caracterización de los cuidadores se reportó que la edad estuvo comprendida entre 20 a 30 añosen el 53,3%, el sexo femenino predominó en el 80,0% de los participantes, el estado civil casado ocupó un 60,0%,eltiempo de experiencia laboral superó los 60 meses en el 67,0% y el 93,0% expresó no padecer enfermedades crónicas.En cuanto a la habilidad de cuidado, el 46,6% se ubicó en la categoría media, el 40,0% en la baja y el 13,3% en la alta.Conclusiones: Los resultados muestran la necesidad de fortalecer en los cuidadores profesionales las capacidadesde afrontamiento ante situaciones cotidianas del acto de cuidar, en las dimensiones conocimiento, valor ypaciencia.

Objetive: To measure the caring ability of nursing professionals that work in a third level Health Care ProvidingInstitution in Sincelejo, Colombia. Methodology: This being a descriptive cross-sectional quantitative study, thesample consisted of 30 nurses from the care area, which were administered the Care Ability Inventory, whichmeasures three categories: knowledge, value and patience. The information was processed through the StatisticalPackage for the Social Sciences: SPSS software. Results: The caregivers characterization reported that the age wasbetween 20 to 30 years in the 53,3%, females predominated in 80,0% of the participants, the marital status, married,occupied 60,0%, work experience history surpassed 60 months 67,0% and 93,0% declared not suffering any chronicillnesses. In the caring ability aspect, 46,6% were placed in the medium category, 40,0% in the low and 13,3% in thehigh. Conclusions: The results show the need to strengthen the capacity of professional caregivers to face theeveryday situations in the act of caring, in the aspects of knowledge, value and patience.

Prospective, randomised study of selective versus routine culture of vascular catheter tips: patient outcome, antibiotic use and laboratory workload.

In order to assess the value of vascular catheter tip culture in patients with negative blood cultures, all tip samples from hospitalised patients were prospectively randomised (1:1) to two different routines for processing catheters: culture of all tips (routine A) vs culture only of tips from patients with concomitant bacteraemia or fungaemia (routine B). Over a nine-month period, 426 catheters from 318 patients were randomly assigned to routine A and 429 catheters from 322 patients to routine B (n=40 [corrected] patients). We compared the outcome and costs from both groups. No statistically significant differences were found with respect to demographic data, mortality, hospital stay or antimicrobial use. In non-bacteraemic/fungaemic cases (N=517), days on antimicrobial therapy after catheter withdrawal were significantly higher in patients from group A [10.0 days (interquartile range, IQR): 6.0-14.0] vs 8.0 days (IQR: 4.7-12.2), P=0.03], as was the number of daily defined doses (DDDs) of antimicrobials [10.8 DDDs (IQR: 2.4-26.9) vs 7.5 DDDs (IQR: 1.5-20.0), P=0.03]. Median antimicrobial cost per treated patient was significantly higher in group A: €222.30 (IQR: €20.30-€1,030.60) vs €109.10 (IQR: €10.90-€653.20), P=0.05. If all vascular catheter tips were processed according to routine B, the microbiology laboratory workload would decrease by 77% for the total number of catheters processed. Microbiology laboratories should not routinely culture catheter tips in patients without bacteraemia or fungaemia.

[Impact of a short stay unit in a tertiary hospital]. / Impacto de una unidad de corta estancia en un hospital de tercer nivel.

OBJECTIVE: To analyze the health care activity indicators of a short-stay unit (SSU) and compare them with those of other services in a Conventional Hospital. MATERIAL AND METHODS: A descriptive, retrospective study was conducted of the patients admitted to SSU during 2003-2007. Number of admissions, mean stay (MS), mortality and destination were analyzed. Mean stay and number of admissions of the main diagnosis-related groups (DRGs) in the SSU were compared with other services of conventional hospitalization. RESULTS: A total of 15.3% of the patients who came to the Emergency Service were admitted to the SSU. Mean stay was significantly lower in the SSU than in the rest of the hospital (year 2003, SSU 3.2 days, rest of the hospital 10.2 days; year 2007, SSU 3.3 days, rest of the hospital 8.6 days). The 4 most common DRGs (71.3% of all those admitted to the SSU) were COPD, respiratory infection/bronchitis, simple pneumonia/pleuritis and heart failure/shock. Mean stay for the 4 DRGs in the SSU was significantly lower (p<0.01) than in Internal Medicine, Pneumology and Cardiology (heart failure/shock). CONCLUSIONS: The SSU handles its most prevalent diseases with greater agility compared to other conventional hospitalization services.

Assessment of the impact of eating disorders on quality of life using the disease-specific, Health-Related Quality of Life for Eating Disorders (HeRQoLED) questionnaire.

OBJECTIVE: To evaluate and compare the quality of life (QOL) in patients with eating disorders (ED) and general population, using the disease-specific Health-Related Quality of Life for Eating Disorders (HeRQoLED) questionnaire. METHODS: A total of 358 patients with ED completed the HeRQoLED questionnaire as well as the SF-12 and the Eating Attitudes Test (EAT-26) at baseline; 273 patients completed the same instruments after 1 year of multidisciplinary treatment. A total of 305 individuals recruited from the general population completed the HeRQoLED once. Comparison of means was used to assess change. Multivariate models were created to determine variables predictive of change in HeRQoLED scores. RESULTS: Patients with anorexia nervosa had higher baseline scores (indicating worse perception of QOL) on the HeRQoLED questionnaire and experienced smaller improvements than patients with other diagnoses after 1 year of treatment. After adjustment by relevant variables, body-mass index (BMI) and EAT-26 scores were associated with changes in QOL. SF-12 scores showed significant improvement in the physical health component but not in mental health. General population had lower baseline scores on the HeRQoLED. CONCLUSIONS: As measured by the disease-specific HeRQoLED and generic instruments, QOL in patients with ED improved after 1 year of treatment, though it did not reach the values of the general population.

[Preliminary study aimed at the construction of a questionnaire for referral from primary care to mental health services]. / Estudio preliminar dirigido a la construcción de un cuestionario de derivación de la atención primaria a los servicios de salud mental.

The high prevalence of psychiatric morbidity in primary care, the growing perception of the need for specialized help by the least severe patients and the lack of accuracy in referrals, contribute to the increasing overload in mental health services. So it seems necessary to design diagnostic tools in order to improve the detection of more severe patients and to help in the referral decision. With this purpose in mind, we have designed the multidimensional heteroadministrated Scale Referral Criteria for Mental Health (CRMH). This paper presents the preliminary results of a pilot study on its application in a sample of 198 patients by a group of Primary Care Physicians (PCP). The data show the detection of a high percentage of potential psychiatric patients (46.9%) and 4% of patients who having the possibility of being referred. The results also illustrate the low ability of PCP to detect these disorders. CRMH has a moderate correlation with the General Health Questionnaire (GHQ) and with detection of psychopathology by PCP. Other factors, apart from clinical severity evaluated through CRMH, possibly belonging to doctor-patient relationship, which should be analyzed, seem to influence the mental health referral. In a future article, we will present the validation of this scale in our care setting.

Validation in Spanish population of the family objective and subjective burden interview (ECFOS-II) for relatives of patients with schizophrenia.

INTRODUCTION: The family burden experienced by caregivers of people with schizophrenia is one of the most relevant consequences of this disorder. This paper aims to show the validity and reliability of the Spanish version of the Family Burden Interview Schedule (FBIS) designed to assess objective and subjective family burden for people with schizophrenia. DESIGN: cross sectional study. PARTICIPANTS: 356 patients fulfilling DSM-IV criteria for schizophrenia from four Spanish geographic areas (Barcelona, Madrid, Pamplona and Granada) and 205 main caregivers of these patients were assessed. MATERIAL: caregivers were assessed with the Family Burden Interview Schedule (FBIS) Spanish version (ECFOS-II), which assesses family burden in eight different modules: activities of daily living, disrupted behaviors restraint, expenses, caregiver's routine, concern, help, repercussions on health, and assessment of general burden. Patients were also assessed with PANSS, DAS-sv and GAF. STATISTICAL ANALYSIS: in order to assess internal consistency, parametrical tests of Cronbach's alpha were undertaken. To compute test-retest reliability Cohen's kappa and Weighted kappa were used. A principal component analysis was undertaken for assessing construct validity. Convergent validity was assessed with Spearman and Pearson correlation coefficients respectively, relating the instrument with the psychopathological (PANSS) and disability scale (DAS-sv) and general functioning (GAF). Moreover, a description of the viability of the ECFOS-II was described by a questionnaire especially designed for this purpose. RESULTS: Cronbach's alpha coefficient was 0.85 for the global assessment. Test-retest coefficients were very high, both for Cohen's kappa and for Weighted kappa, most values being between 0.61 and 1. Principal component analysis detected four factors that coincide with the modules of the original schedule. In the convergent validity we found that these factors are related with the symptom, disability and global functioning characteristics of the patients. CONCLUSIONS: ECFOS-II results in a valid and reliable instrument for assessing family burden experienced by caregivers of people with schizophrenia.

Assessment of service use patterns in out-patients with schizophrenia: a Spanish study.

OBJECTIVE: The objective is to describe and characterize patterns of service use by out-patients with schizophrenia in Spain. METHOD: A representative treated prevalence sample of cases with schizophrenia was selected from four Spanish health areas. The evaluation included health service use, clinical severity, functioning and disability. Statistical analysis was based on hierarchical clustering methods. RESULTS: A total of 356 patients were included in the analysis. Five patterns of health service use were defined: heavy out-patient mental health users; mental health and general health service users; heavy hospital service users; nursing service users; low users of mental health services. Patients in each group showed differences in clinical and disability status. Patterns of health service use showed consistency, but also variability, among the geographical areas. CONCLUSION: Development and organization of mental health services should take into account the combinations of services patients most frequently use.

[Estimating the costs associated with nosocomial urinary tract infection. A case-control study]. / Estimación de los costes asociados a la infección urinaria nosocomial. Un estudio de casos y controles.

BACKGROUND: Nosocomial infection (NI) is associated with increased resource use. The current study addressed the cost excess attributable to nosocomial urinary tract infection (NUTI). METHODS: Case-control study conducted in a cohort population. For matching, the Diagnostic Related Group (DRG) to which the episode of case patient was ascribed was used. Then, a further search was conducted in the hospital discharge database with the following parameters: DRG, gender, age, admission date, department, comparison of length of stays, main diagnosis, co-morbidities, number of secondary diagnoses and procedures. Matching was achieved for 64 episodes (71%), and upon them an estimation of costs was performed. RESULTS: The mean length of stay for cases were 15.3 (median: 12) and 12.3 (median: 11) days for cases and controls, respectively (p = 0.0001). The excess of length of stay attributable to NUTI was 3 days (95% CI 1.6-4.7), longer for patients admitted to Medical Departments (5.3 days) than for patients admitted to Surgical Departments (2 days) (p = 0,03). The use of diagnostic resources was significantly higher for bacteriological testing only. The use of antibiotics and fluid therapy was higher among infected patients. Out of the total excess of the estimated costs per episode, 132,047 ptas, 93% corresponded to the increase in hospital stay. Ten patients (15.6%) were responsible for 68% of the total of extra-costs. In 17 occasions (26.6%), the control patient used more resources than the infected patient. CONCLUSIONS: Nosocomial urinary tract infection is associated with a resource use directly related to its presence. For the most part, it is related to the prolongation of hospital stay.

Disparity vergence double responses processed by internal error.

Disparity vergence eye movements occasionally exhibit two high-velocity components to a single step stimulus (Alvarez, T. L., Semmlow, J. L. & Yuan, W. (1998). Journal of Neurophysiology, 79, 37-44). This research investigates the neural strategy used to trigger the second component of double high-velocity vergence eye movements. Vergence doubles evoked by an experimental protocol that induces post-movement visual error were compared to doubles that occur normally. The second component of a visually evoked response double occurred later, and with slower dynamics, than that of a naturally occurring double. These differences in timing and dynamics indicate that natural double responses are mediated, at least in part, by a mechanism other than visual feedback. The faster dynamics and timing of natural doubles suggest that an internal monitoring process triggers these movements.