Understanding of advance care planning in primary care: a gap analysis.

BACKGROUND: Although primary care is a well suited context for conducting advance care planning (ACP), there are many barriers to initiating discussions regarding future health preference and end-of-life conversations. METHODS: This qualitative study conducted 30 detailed individual interviews with senior administrators, medical and nurse practitioners of a local health district, NSW Ambulance, e-Health NSW, general practitioners and practice nurses to find out about barriers to ACP in South Western Sydney. RESULTS: Thematic analysis was conducted on the interviews. Six major themes were identified: Prevalence; Empowerment of roles and responsibilities; Lack of training/knowledge/confidence; Fragmentation of care; Patient/family readiness; and Prognostication. Half of the participants were willing to use a prognostic tool to identify when a patient was likely to be at the end of their life and provide a prompt to initiate ACP. CONCLUSION: In addition to addressing training and acknowledging resource constraints, these findings suggest that if a prognostic tool was validated and practical in a primary care setting, it may provide valuable assistance to encourage everyone in society to begin discussing this issue and completing ACP.

Antimicrobial prescribing practices following publication of guidelines for the prevention of infections associated with combat-related injuries.

BACKGROUND: Timely and limited antibiotic prophylaxis (postinjury antimicrobial therapy) targeting specific traumatic injuries is a well-recognized measure to lessen posttraumatic infection. Modern military combat injuries raise significant challenges because of complex multiple injuries and limited data derived directly from well-controlled trials to base recommendations. Expert consensus review of available evidence led to published guidance for selection and duration of antimicrobial therapy for combat-related trauma infection prevention. This analysis evaluates antibiotic-prescribing practices by military physicians in the operational theater relative to the published guidance. METHODS: Trauma history and infectious disease-specific inpatient care information is captured through the Joint Theater Trauma Registry along with a supplemental infectious disease module. Injury patterns are classified based on documented International Classification of Diseases-9th Revision codes with a composite assessment of each patient's injury pattern. Antimicrobial use categorized as prophylaxis is prescribed within the first 48 hours postinjury. Adherence to published guidance is reported along with patient characteristics and injury severity to assess for potential explanations of nonadherence. RESULTS: During June to November 2009, 75% of the 610 eligible trauma patients received antimicrobial prophylaxis. Adherence to the recommended antibiotic agent on the day of injury was in the range of 46% to 50% for the most common extremity injury patterns and <10% in penetrating abdominal injuries. Antibiotics were given in 39% of patients sustaining injuries that are recommendations to not receive antimicrobial prophylaxis. CONCLUSIONS: This first evaluation of combat trauma-related antibiotic prophylaxis shows adherence levels comparable or superior to reported rates in civilian settings despite the austere, frequently mass casualty environment. Areas for interval surveillance and education-based strategies for improved adherence to practice guidance are identified.

Multi-drug resistant Bacteroides fragilis recovered from blood and severe leg wounds caused by an improvised explosive device (IED) in Afghanistan.

This report summarizes the case of a 23 year-old otherwise healthy male that was injured in an improvised explosive device (IED) blast in support of Operation Enduring Freedom (OEF). He sustained bilateral open tibia and fibula fractures in the setting of being exposed to water contaminated with raw sewage. Despite long-term carbapenem therapy, the patient's wounds were repeatedly noted to have purulent drainage during surgical debridement and cultures from these wounds were persistently positive for Bacteroides fragilis. Apparent clinical failure persisted despite the addition of metronidazole to his regimen and an eventual trial of tigecycline. Susceptibility testing of the B. fragilis isolate was performed and resistance to penicillin, clindamycin,metronidazole, cefoxitin, meropenem, imipenem, piperacillin/tazobactam, and tigecycline was confirmed. The presence of a nimE gene on a potentially transferrable plasmid was also confirmed by plasmid sequencing. The only antibiotics that displayed in vitro susceptibility were moxifloxacin and linezolid. These antibiotics were initiated in combination with aggressive irrigation and serial surgical debridement. Conversion to left-sided internal fixation became feasible and his left lower extremity was salvaged without residual evidence of infection. The patient completed an eight week course of combination moxifloxacin and linezolid therapy without adverse event. This B. fragilis isolate displayed simultaneous high-level resistance to multiple antibiotics routinely utilized in anaerobic infections. This was evidenced by clinical failure, in vitro susceptibility testing, and demonstration of genes associated with resistance mechanisms. This case warrants review not only due to the rarity of this event but also the potential implications regarding anaerobic infections in traumatic wounds and the success of a novel treatment regimen utilizing combination therapy with moxifloxacin and linezolid.

Disseminated nocardia cyriacigeorgica presenting as right lung abscess and skin nodule.

Nocardia species are ubiquitous in the environment and can be found worldwide. Direct inhalation remains the most commonly attributed route of infection with Nocardia asteroides complex, causing 50% of invasive infections. Improved molecular methods have identified a significant proportion of N. asteroides complex isolates to be Nocardia cyriacigeorgica. We report a case of a 58-year-old male working as a contractor in Bagram Air Force Base, Afghanistan, with disseminated N. cyriacigeorgica involving the lung, brain, and dermis. Diagnosis was facilitated by early identification of branched, filamentous bacteria using Fite and gram staining along secA DNA sequencing of clinical isolates. Our patient is the first confirmed case of N. cyriacigeorgica infection in Afghanistan.

The effect of injurious compression on the elastic, hyper-elastic and visco-elastic properties of porcine peripheral nerves.

The aim of this study was to characterise the viscoelastic and hyper-elastic properties of the ulnar nerve before and after compression has been induced, in order to aid the understanding of how the mechanical properties of nerves are altered during nerve compression, a contributing factor to cubital tunnel syndrome. Ulnar nerves were dissected from porcine legs and tensile tested to 10% strain. The Young's modulus and Yeoh hyper-elastic model were used to evaluate the materials elastic and hyper-elastic properties respectively. Dynamic mechanical analysis (DMA) was used to evaluate the viscoelastic properties over a range of frequencies between 0.5 Hz and 38 Hz. The nerves were then compressed to 40% for 60 s and the same tests were carried out after compression. The nerves were stiffer after compression, the mean Young's modulus before was 0.181 MPa and increased to 0.601 MPa after compression. The mean shear modulus calculated from the Yeoh hyper-elastic model was also higher after compression increasing from 5 kPa to 7 kPa. After compression, these properties had significantly increased (p < 0.05). The DMA results showed that the nerves exhibit frequency dependent viscoelastic behaviour across all tested frequencies. The median values of storage modulus before compression ranged between 0.605 and 0.757 MPa across the frequencies and after compression between 1.161 MPa and 1.381 MPa. There was a larger range of median values for loss modulus, before compression, median values ranged between 0.073 MPa and 0.216 MPa and after compression from 0.165 MPa to 0.410 MPa. There was a significant increase in both storage and loss modulus after compression (p < 0.05). The mechanical properties of the nerve change following compression, however the response to decompression in vivo requires further evaluation to determine whether the observed changes persist, which may have implications for clinical recovery after surgical decompression in entrapment neuropathy.

Is HIV becoming more virulent? Initial CD4 cell counts among HIV seroconverters during the course of the HIV epidemic: 1985-2007.

BACKGROUND: Whether human immunodeficiency virus (HIV) seroconverters have been presenting with progressively lower CD4 cell counts over the course of the HIV epidemic is controversial. Additional data on whether HIV might have become more virulent on a population level (measured by post-seroconversion CD4 cell counts) may provide important insights regarding HIV pathogenesis. METHODS: To determine whether post-seroconversion CD4 cell counts have changed over time, we evaluated 2174 HIV seroconverters as part of a large cohort study during the period 1985-2007. Participants were documented antiretroviral-naive HIV seroconverters who had a CD4 cell count measured within 6 months after receiving a diagnosis of HIV infection. Multiple linear regression models were used to assess trends in initial CD4 cell counts. RESULTS: The mean initial CD4 cell count decreased during the study period from 632 cells/mm(3) in 1985-1990 to 553 cells/mm(3) in 1991-1995, 493 cells/mm(3) in 1996-2001, and 514 cells/mm(3) in 2002-2007. During those periods, the percentages of seroconverters with an initial CD4 cell count <350 cells/mm(3) were 12%, 21%, 26%, and 25%, respectively. In the multiple linear model, the mean decrease in CD4 cell count from 1985-1990 was 65 cells/mm(3) in 1991-1995 (P < .001)), 107 cells/mm(3) in 1996-2001 (P < .001), and 102 cells/mm(3) in 2002-2007 (P < .001). Similar trends occurred with regard to CD4 cell percentage and total lymphocyte count. Similar decreases in initial CD4 cell counts were observed among African American and white persons during the epidemic. DISCUSSION: A significant decrease in initial CD4 cell counts among HIV seroconverters in the United States has occurred during the HIV epidemic. These data provide an important clinical correlate to suggestions that HIV may have adapted to the host, resulting in a more virulent infection.

Infectious disease teleconsultative support of deployed healthcare providers.

Specialty teleconsultation is being provided to deployed healthcare providers in the current wars in Iraq and Afghanistan through the use of the Army Knowledge Online (AKO) e-mail service. We reviewed 374 teleconsults received by the infectious disease (ID) service between January 2005 and June 2008. The patients were 65% male, 12% female, 33% the gender was not stated or the consult did not involve an individual, and 41% were U.S. Army. The average response time was under 5 hours. Ninety-one percent of consults originated from the U.S. Central Command area of responsibility. Consults included questions pertaining to therapy (42%), diagnosis (21%), prevention (13%), or mixed categories (24%). Bacterial infections were the most common (32%), followed by parasitic infections (16%). Tuberculosis and methicillin-resistant Staphylococcus aureus accounted for 13% and 8% of consults, respectively. Data from this program should be useful in focusing predeployment provider training. It also provides the military ID community situational awareness of problems encountered in theater.

Antimicrobial susceptibilities of geographically diverse clinical human isolates of Leptospira.

Although antimicrobial therapy of leptospirosis has been studied in a few randomized controlled clinical studies, those studies were limited to specific regions of the world and few have characterized infecting strains. A broth microdilution technique for the assessment of antibiotic susceptibility has been developed at Brooke Army Medical Center. In the present study, we assessed the susceptibilities of 13 Leptospira isolates (including recent clinical isolates) from Egypt, Thailand, Nicaragua, and Hawaii to 13 antimicrobial agents. Ampicillin, cefepime, azithromycin, and clarithromycin were found to have MICs below the lower limit of detection (0.016 microg/ml). Cefotaxime, ceftriaxone, imipenem-cilastatin, penicillin G, moxifloxacin, ciprofloxacin, and levofloxacin had MIC(90)s between 0.030 and 0.125 microg/ml. Doxycycline and tetracycline had the highest MIC(90)s: 2 and 4 microg/ml, respectively. Doxycycline and tetracycline were noted to have slightly higher MICs against isolates from Egypt than against strains from Thailand or Hawaii; otherwise, the susceptibility patterns were similar. There appears to be possible variability in susceptibility to some antimicrobial agents among strains, suggesting that more extensive testing to look for geographic variability should be pursued.

Pulmonary blastomycosis diagnosed in Hawai'i.

Blastomycosis, a fungal infection caused by Blastomyces dermatitidis, was once thought to be endemic only to the Central and Great Lakes regions of the United States of America. We present the first reported case series of patients documenting the diagnosis of blastomycosis in the Pacific region. In both cases, exposure to endemic areas was retrospectively identified.

Telemedicine via satellite to support offshore oil platforms.

On any one day, approximately 15,000-28,000 oil industry personnel are employed in the North Sea oil and gas industry. First aid in this remote environment is provided by non-medical staff on the rigs. Remote specialist advice via videoconferencing should improve the quality of offshore health care and reduce avoidable medical evacuations. Satellite communications and videoconferencing equipment was installed on the 'Alwyn North' oil platform, with medical advice provided via a call centre in Milan. Over a nine-month period, trial telemedicine links were conducted approximately twice per week. The three onshore physicians were very satisfied on each occasion with communications and diagnostic data image quality, including the ultrasound screening carried out by the rig provider. Remote specialist advice via videoconferencing should reduce unnecessary and/or untimely patient evacuation to hospital or onshore for medical assessment.

The delivery of a minor injuries telemedicine service by Emergency Nurse Practitioners.

We conducted a retrospective review to assess the potential for Emergency Nurse Practitioners (ENPs) to deliver telemedicine advice for minor injuries. Over a one-year study period, 835 patients from 15 minor injury units in community hospitals presented to the minor injuries telemedicine service and were seen via videoconferencing by a doctor at the Aberdeen emergency department. A case review showed that overall, ENPs were considered capable of treating 470 of 788 new presentations (60%). If children under 14 years of age and shoulder injuries were excluded, this figure rose to 84%. Assessment of all minor injuries via a telemedicine network by medical staff is unnecessary. An ENP-led service offers a realistic and attractive alternative.

A five-year review of ground-to-air emergency medical advice.

We reviewed five years' experience of providing ground-to-air medical advice for commercial passenger aircraft. A total of 273 events occurred in-flight where further advice was sought. The most common age group resulting in calls were from those aged 21-30 years, who generated 38 calls (16%). The 273 cases included gastrointestinal conditions (26%), neurological (22%) and cardiovascular events (14%). Most incidents were managed conservatively in-flight with oxygen and/or other medications. Aircraft diversion occurred on 9% of occasions; cardiovascular and neurological emergencies were the major cause of this. Collaboration between aviation providers should be considered to develop a common database of in-flight emergencies so that contents of medical kits can be standardized in order to improve the quality of care in the air.

Provision of telehealth to the Scottish Police College.

A telemedicine service was established for the Scottish Police College with medical advice provided from the Aberdeen Royal Infirmary. Use of the service from November 2004 to February 2006 was audited. A total of 192 patients presented to the service during the 16-month study period. There were 97 teleconsultations. The remaining 95 patients (49%) were not seen by telemedicine due to technical problems. The complaints dealt with were 68% injuries and 32% minor illness (n = 97). The outcome of the teleconsultation was: advice alone 76%; referral to a general practitioner 10%; and A&E referral 14% (n = 97). The treatment advised was: over-the-counter medicine 85%; prescription 5%; and nil 10% (n = 97). Even with a 24% connection rate, the service overall was perceived as beneficial and the Police College wished to continue to use the service, if the technology difficulties could be resolved.

A low-cost decision support network for electrocardiograph transmission from oil rigs in the North Sea.

A telemedicine service consisting of electrocardiogram (ECG) interpretation and advice on the management of chest pain offshore was offered to oil rig installations in the North Sea. A total of 14 subscribing oil rigs were supplied with thrombolytic drugs and rig paramedics were trained in their delivery. Electrocardiographs could be recorded using a standard ECG machine and then digitized using a scanner for transmission as an email attachment. Several oil companies invested in ECG equipment which allowed direct recording of the patient's ECG in electronic form for transmission by email. Uptake of the telemedicine service was very rapid. The majority of rig medics found the system very easy to use. During a 36-month study period from August 2004, 47 cases of chest pain were dealt with by telemedicine. Of these 47 cases, only six patients (13%) were airlifted to shore. The 41 remaining ECGs did not to have acute changes requiring immediate evacuation. The use of email for ECG transmission proved to be highly effective in managing chest pain offshore.

Feasibility of a telemedicine 'booth' for supporting remote care in Scotland.

Access to health care in remote settings is becoming increasingly difficult in Scotland. We have investigated the feasibility of a telemedicine 'booth'. Two telemedicine booths were constructed for display at the Royal Highland Show in Edinburgh. One was equipped for patient use and one for the doctor. The booths contained videoconferencing and physiological monitoring equipment connected via an IP link at a bandwidth of 1.1 Mbit/s. The picture resolution was 4CIF (704 x 576 pixels). A total of 238 members of the public used the booth for a teleconsultation with a doctor. Ninety-three percent completed questionnaires. Of the 221 respondents, 75% saw the booth as an opportunity to access specialist advice; 84% felt that the booth would save them attending a hospital or clinic; 60% felt that it would improve the way they looked after their own health. The concept of a telemedicine booth appears both feasible and acceptable to the public.

The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives.

BACKGROUND: Quality improvement collaboratives (QICs) are a widely applied strategy for implementing change in health care organizations. Alternative collaborative methodologies were compared to gain insight into the elements important for QIC success. METHODS: A modified version of a previously described QIC evaluation tool was used to assess the methods and characteristics of the Medication Error Prevention Initiative (MEPI) and to compare MEPI with two other long-term ongoing QICs--the Vermont-Oxford Network's Neonatal Intensive Care QIC and the Northern New England Cardiovascular Disease Study Group, and the shorter-term Breakthrough Series QICs of the Institute for Healthcare Improvement (IHI). RESULTS: The modified QIC assessment tool was a useful framework for QIC assessment and comparison. The MEPI differed in scope of topic, team members, and the method for learning about and making improvements. CONCLUSIONS: Long-term QIC methods such as those used by MEPI may be particularly applicable when QICs address broad, complex, comprehensive, or organizationwide improvement needs.

A case of Enterococcus faecalis prosthetic joint infection: a rare and difficult infection to treat.

Enterococcus faecalis septic arthritis in native and prosthetic joints is a very rare infection. A case of an African American man with Enterococcus faecalis prosthetic joint infection is presented as well as a brief review of the literature.

Fatal pulmonary Mycobacterium abscessus infection in a patient using etanercept.

A case of fatal pulmonary Mycobacterium abscessus infection in a 56-year-old man is reported. The patient had a longstanding history of seropositive, nodular rheumatoid arthritis with severe joint manifestations that had been treated with a regimen of prednisone, leflunomide, and etanercept. He presented to our facility with complaint of productive cough, persistent fevers, pleuritic chest discomfort, and dyspnea at rest. The patient was admitted to hospital, placed in isolation, a left-sided chest tube was inserted (left pneumothorax identified), and sputum acid-fast bacteria stains and cultures were obtained. Fluorochrome stains demonstrated numerous acid-fast bacteria, and M. abscessus was recovered from the culture media. He was treated with a regimen of amikacin, cefoxitin, and clarithromycin. He initially responded well, and was discharged home with this regimen. He remained afebrile with decreased cough and sputum production until 15 days after discharge when he was again admitted to hospital, with acute onset dyspnea and right-sided chest discomfort (right pneumothorax identified). He ultimately expired, due to overwhelming pulmonary infection, 20 days after readmission to hospital. Autopsy revealed acid fast bacilli in the setting of numerous, bilateral, necrotic, granulomatous, cavitary pulmonary lesions. Based on its mechanism of action, we propose an association between the use of etanercept, a tumor necrosis factor alpha (TNF-alpha) inhibitor, and this case of fatal pulmonary mycobacterial infection. We recommend that physicians exercise cautious clinical judgment when initiating etanercept therapy in persons with underlying lung disease, especially in communities in which mycobacterial organisms are highly prevalent. We also advise physicians to maintain a high level of vigilance for late onset granulomatous infection in persons using etanercept.

Correlating Cleaning Thoroughness with Effectiveness and Briefly Intervening to Affect Cleaning Outcomes: How Clean Is Cleaned?

OBJECTIVES: The most efficient approach to monitoring and improving cleaning outcomes remains unresolved. We sought to extend the findings of a previous study by determining whether cleaning thoroughness (dye removal) correlates with cleaning efficacy (absence of molecular or cultivable biomaterial) and whether one brief educational intervention improves cleaning outcomes. DESIGN: Before-after trial. SETTING: Newly built community hospital. INTERVENTION: 90 minute training refresher with surface-specific performance results. METHODS: Dye removal, measured by fluorescence, and biomaterial removal and acquisition, measured with culture and culture-independent PCR-based assays, were clandestinely assessed for eight consecutive months. At this midpoint, results were presented to the cleaning staff (intervention) and assessments continued for another eight consecutive months. RESULTS: 1273 surfaces were sampled before and after terminal room cleaning. In the short-term, dye removal increased from 40.3% to 50.0% (not significant). For the entire study period, dye removal also improved but not significantly. After the intervention, the number of rooms testing positive for specific pathogenic species by culturing decreased from 55.6% to 36.6% (not significant), and those testing positive by PCR fell from 80.6% to 53.7% (P = 0.016). For nonspecific biomaterial on surfaces: a) removal of cultivable Gram-negatives (GN) trended toward improvement (P = 0.056); b) removal of any cultivable growth was unchanged but acquisition (detection of biomaterial on post-cleaned surfaces that were contaminant-free before cleaning) worsened (P = 0.017); c) removal of PCR-based detection of bacterial DNA improved (P = 0.046), but acquisition worsened (P = 0.003); d) cleaning thoroughness and efficacy were not correlated. CONCLUSION: At this facility, a minor intervention or minimally more aggressive cleaning may reduce pathogen-specific contamination, but not without unintended consequences.