Meticillin-resistant Staphylococcus aureus (MRSA) environmental contamination in a radiology department.

AIM: To explore the potential risk to patients and healthcare workers of acquiring meticillin-resistant Staphylococcus aureus (MRSA) in clinical and non-clinical areas within a radiology department. MATERIALS AND METHODS: High-risk sites in clinical and non-clinical areas within the Department of Radiology were identified and 125 environmental swabs were obtained by an infection control nurse specialist. Decontamination methods and protocols were reviewed and compared against international decontamination best practice. RESULTS: One of 125 samples was culture positive for MRSA. The positive sample was isolated from the surface of the bore of the magnetic resonance imaging (MRI) unit. A hypochlorite cleaning agent was applied using a long-handled brush to clean the bore of the MRI unit. A repeat environmental screen found the MRI unit to be culture negative for MRSA. CONCLUSION: This study has demonstrated that standard decontamination measures are adequate to prevent environmental contamination with MRSA in a radiology department. However, the MRI unit requires special attention because of its long bore and difficult access.

Hospital infection society prevalence survey of Healthcare Associated Infection 2006: comparison of results between Northern Ireland and the Republic of Ireland.

As part of the Third Healthcare Associated Infection (HCAI) Prevalence Survey of the United Kingdom and Ireland, HCAI point prevalence surveys were carried out in Northern Ireland (NI) and the Republic of Ireland (RoI). Here we explore the potential benefits of comparing results from two countries with different healthcare systems, which employed similar methodologies and identical HCAI definitions. Forty-four acute adult hospitals in the RoI and 15 in NI participated with a total of 11 185 patients surveyed (NI 3644 patients and RoI 7541). The overall HCAI prevalence was 5.4 and 4.9 in NI and the RoI, respectively. There was no significant difference in prevalence rates of HCAI, device-related HCAI or HCAI associated with bloodstream infection but there was a difference in meticillin-resistant Staphylococcus aureus-related HCAI (P = 0.02) between the two countries. There were significantly more urinary tract infections and Clostridium difficile infections recorded in NI (P = 0.002 and P < 0.001). HCAIs were more prevalent in patients aged >65 years and in the intensive care unit in both countries. HCAIs were also more prevalent if patients were mechanically ventilated, had had recent non-implant surgery (RoI) or had more recorded HCAI risk factors. This is the first time that HCAI prevalence rates have been directly compared between NI and the RoI. By closely examining similarities and differences between HCAI prevalence rates in both countries it is hoped that this will influence healthcare planning and at the same time reassure the public that HCAI is important and that measures are being taken to combat it.

Drama therapy for schizophrenia or schizophrenia-like illnesses.

BACKGROUND: Medication is the mainstay of treatment for schizophrenia or schizophrenia-like illnesses, but many people continue to experience symptoms in spite of medication (Johnstone 1998). In addition to medication, creative therapies, such as drama therapy may prove beneficial. Drama therapy is a form of treatment that encourages spontaneity and creativity. It can promote emotional expression, but does not necessarily require the participant to have insight into their condition or psychological-mindset. OBJECTIVES: To review the effects of drama therapy and related approaches as an adjunctive treatment for schizophrenia compared with standard care and other psychosocial interventions. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group's Register (October 2006), hand searched reference lists, hand searched Dramatherapy (the journal of the British Association of Dramatherapists) and Arts in Psychotherapy and contacted relevant authors. SELECTION CRITERIA: We included all randomised controlled trials that compared drama therapy, psychodrama and related approaches with standard care or other psychosocial interventions for schizophrenia. DATA COLLECTION AND ANALYSIS: We reliably selected, quality assessed and extracted data from the studies. We excluded data where more than 50% of participants in any group were lost to follow up. For continuous outcomes we calculated a weighted mean difference and its 95% confidence interval. For binary outcomes we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and a number needed to treat (NNT). MAIN RESULTS: The search identified 183 references but only five studies (total n=210) met the inclusion criteria. All of the studies were on inpatient populations and compared the intervention with standard inpatient care. One study had drama therapy as the intervention, one had role-playing, one had a social drama group and two used psychodrama. Two of the included studies were Chinese and it is difficult to know whether psychodrama and indeed inpatient psychiatric care in China is comparable with the drama interventions and inpatient care in the other included studies. There were no significant findings about the value of drama interventions for keeping inpatients engaged in treatment. Due to poor reporting very little data from the five studies could be used and there were no conclusive findings about the harms or benefits of drama therapy for inpatients with schizophrenia. AUTHORS' CONCLUSIONS: Randomised studies are possible in this field. The use of drama therapy for schizophrenia and schizophrenia-like illnesses should continue to be under evaluation as its benefits, or harms, are unclear.

Art therapy for schizophrenia or schizophrenia-like illnesses.

BACKGROUND: Many people with schizophrenia or schizophrenia-like illnesses continue to experience symptoms in spite of medication. In addition to medication, creative therapies, such as art therapy, may be helpful. Art therapy allows exploration of the patient's inner world in a non-threatening way through a therapeutic relationship and the use of art materials. It was mainly developed in adult psychiatric inpatient units and was designed for use with people for whom verbal psychotherapy would be impossible. OBJECTIVES: To review the effects of art therapy as an adjunctive treatment for schizophrenia compared with standard care and other psychosocial interventions. SEARCH STRATEGY: We updated the search of the Cochrane Schizophrenia Group's Register (February 2005), hand searched reference lists and 'Inscape' (the Journal of the British Association of Art Therapists), and contacted relevant authors. SELECTION CRITERIA: We included all randomised controlled trials that compared art therapy with standard care or other psychosocial interventions for schizophrenia. DATA COLLECTION AND ANALYSIS: We reliably selected, quality assessed and extracted data from the studies. We excluded data where more than 50% of participants in any group were lost to follow up. For continuous outcomes we calculated a weighted mean difference and its 95% confidence interval. For binary outcomes we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and a number needed to treat (NNT). MAIN RESULTS: The search identified 61 reports but only two studies (total n=137) met the inclusion criteria. Both compared art therapy plus standard care with standard care alone. More people completed the therapy if allocated to the art therapy group compared with standard care in the short (n=90, 1 RCT, RR 0.97 CI 0.41 to 2.29), medium (n=47, 1 RCT, RR 0.34 CI 0.15 to 0.80) and long term (n=47, 1 RCT, RR 0.96 CI 0.57 to 1.60). Data from one mental state measure (SANS) showed a small but significant difference favouring the art-therapy group (n=73, 1 RCT, WMD -2.3 CI -4.10 to -0.5). In the short term, a measure of social functioning (SFS) showed no clear difference between groups in endpoint scores (n=70, 1 RCT, WMD 7.20 CI -2.53 to 16.93) and quality of life, as measured by the PerQoL, did not indicate effects of art therapy (n=74, 1 RCT, WMD 0.1 CI -2.7 to 0.47). AUTHORS' CONCLUSIONS: Randomised studies are possible in this field. Further evaluation of the use of art therapy for serious mental illnesses is needed as its benefits or harms remain unclear.

Psychosocial interventions for conversion disorder.

BACKGROUND: Conversion disorder is an alteration or loss of physical functioning suggestive of a physical disorder that is thought to be due to a psychological stressor or conflict. The fact that many theories about the cause of conversion disorder focus on psychological and social factors would suggest that a psychosocial intervention might be of most benefit. OBJECTIVES: To investigate the efficacy of psychosocial interventions on people diagnosed with conversion disorder compared with standard care, a biological intervention or another psychosocial intervention. SEARCH STRATEGY: We searched the Cochrane Depression, Anxiety and Neurosis Group Trials Register (May 2004), various databases on OVID (February 2004), handsearched reference lists and textbooks on conversion disorder and contacted relevant authors. SELECTION CRITERIA: We included all randomised controlled trials that compared psychosocial interventions for conversion disorder with standard care or other interventions (biological or psychosocial). DATA COLLECTION AND ANALYSIS: We reliably selected, quality assessed and extracted data from the studies. For dichotomous outcomes we calculated a relative risk with its associated 95% confidence interval and a number needed to treat. For continuous data we calculated a weighted mean difference. MAIN RESULTS: The search identified 260 references, 217 were clearly not relevant to this review and excluded on the basis of their titles and abstracts, 40 more were excluded after reading the full papers (the reasons are given in the excluded studies tables) and only three studies (total n =119) met the inclusion criteria. One study was concerned with paradoxical injunction therapy and the other two studied the value of hypnosis. The three studies had different interventions and control groups so the results could not be combined. All of the studies were of poor methodological quality and it is therefore difficult to place much value on the results of the studies. We were unable to include some data because of poor reporting. AUTHORS' CONCLUSIONS: Randomised studies are possible in this field. The use of psychosocial interventions for conversion disorder requires more research and it is not possible to draw any conclusions about their potential benefits or harms from the included studies.

Art therapy for schizophrenia or schizophrenia-like illnesses.

BACKGROUND: Medication is the mainstay of treatment for schizophrenia or schizophrenia-like illnesses. Many people, however, continue to experience symptoms in spite of medication. In addition to medication, creative therapies, such as art therapy may be helpful. Art therapy allows exploration of the patient's inner world in a non-threatening way through a therapeutic relationship and the use of art materials. It was mainly developed in adult psychiatric inpatient units and was designed for use with people in whom verbal psychotherapy would be impossible. OBJECTIVES: To review the effects of art therapy as an adjunctive treatment for schizophrenia compared with standard care and other psychosocial interventions. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group's Register (May 2002), hand searched reference lists and 'Inscape' (the Journal of the British Association of Art Therapists), and contacted relevant authors. SELECTION CRITERIA: All randomised controlled trials that compared art therapy with standard care or other psychosocial interventions for schizophrenia. DATA COLLECTION AND ANALYSIS: Studies were reliably selected, quality assessed and data extracted. Data were excluded where more than 50% of participants in any group were lost to follow up. For binary outcomes we calculated a fixed effects risk ratio (RR) and its 95% confidence interval (CI). MAIN RESULTS: The search identified 57 reports but only two studies (total n=137) met the inclusion criteria. Both compared art therapy plus standard care with standard care alone. Fewer people allocated to art therapy left the study before 20 weeks compared with those given standard care alone (n=47, 1 RCT, RR 0.34 CI 0.15 to 0.8, NNT 3 CI 1.5 to 7). Measures of change in mental state, interpersonal relationships and social networking were reported but the data were too problematic to interpret with confidence. Much data was lost due to poor reporting or inappropriate use of scales. REVIEWER'S CONCLUSIONS: Randomised studies have been proven to be possible in this field. The use of art therapy for serious mental illnesses should continue to be under evaluation as its benefits, or harms, are unclear.

Effectiveness of oral or nebulized dexamethasone for children with mild croup.

OBJECTIVE: To assess the efficacy of oral dexamethasone or nebulized dexamethasone sodium phosphate in children with mild croup. METHODS: Double-blind, placebo-controlled study of 264 children between 6 months and 6 years of age with symptoms of croup for fewer than 48 hours. Patients were excluded if they received racemic epinephrine or corticosteroid treatment. Other exclusion criteria included corticosteroid treatment during the 14 days prior to enrollment or complicating medical condition. Subjects randomly received oral dexamethasone (0.6 mg/kg), nebulized dexamethasone sodium phosphate (160 microg), or placebo. Telephone follow-up was obtained on days 1, 2, 3, 4, and 7. MAIN OUTCOME MEASURES: The primary outcome measure was treatment failure, defined as receiving corticosteroid or racemic epinephrine treatment during the 7 days after enrollment in the study. Secondary outcome measures included seeking additional care and the parental assessments of the patients' condition obtained during follow-up (worse, same, better, or gone). RESULTS: Eighty-five patients received oral dexamethasone, 91 received nebulized dexamethasone, and 88 received placebo. There were 3 treatment failures in the oral dexamethasone-treated group, 12 in the nebulized dexamethasone-treated group, and 10 in the placebo-treated group (P =.05). Ten children in the oral dexamethasone-treated group sought additional care compared with 27 and 29 in the nebulized dexamethasone-treated and placebo-treated groups, respectively (P =.002). Parents of children in the oral dexamethasone-treated group reported greater improvement on day 1 (P<.001) compared with the nebulized dexamethasone-treated and placebo-treated groups. CONCLUSIONS: Children with mild croup who receive oral dexamethasone treatment are less likely to seek subsequent medical care and demonstrate more rapid symptom resolution compared with children who receive nebulized dexamethasone or placebo treatment.

Delayed diagnosis in pediatric blunt trauma.

OBJECTIVE: Identification of injuries of a traumatized patient is a mandate for the emergency department (ED) and the trauma team. Delayed diagnosis of injury in trauma patients leads to increased morbidity, mortality, dissatisfaction, and risk of litigation. Comparing children admitted for blunt trauma, with and without delay, this study examines risk factors for delayed diagnosis. METHODS: Delays in diagnosis from 1991 to 1996 were identified during prospective collection of trauma registry data. Controls were randomly selected from the trauma registry. Charts from both groups were retrospectively reviewed. RESULTS: Fifty-eight patients had 65 delays in diagnosis. Significant independent delay variables included: female, motor vehicle crash (MVC)-related mechanism, altered consciousness, higher injury severity score, and multiple injuries (P < 0.05). Trauma team activation, documentation of tertiary survey, and length of hospitalization were greater in patients with delay injuries (P < 0.05). Logistic regression identified MVC-related mechanism, female, facial, and extremity injuries as a combination of predictors. CONCLUSIONS: Delays occurred in 1% of patients. Trauma team care itself did not protect all patients from delay. Injury severity at presentation alone is not an adequate predictor of delayed diagnosis in the pediatric patient. A combination of variables was identified as negative predictors of delay. Further study is needed to validate these criteria, and determine if earlier diagnosis would effect quality.

Maximizing the sensitivity and specificity of pediatric trauma team activation criteria.

BACKGROUND: Care of the severely injured child requires the rapid assembly of personnel trained in pediatric trauma care. Trauma team activation criteria, which are highly sensitive and maximally specific for identifying the child who requires resuscitation, are necessary to provide rapid care to all who need it, while using resources efficiently. OBJECTIVE: To determine the sensitivity and specificity of the standard trauma team activation (TTA) criteria for identifying patients who receive resuscitation in the emergency department. METHODS: A one-year study was conducted of all patients transported by emergency medical out-of-hospital services for a trauma-related complaint. For all patients, out-of-hospital medical control operators recorded whether patients met TTA criteria and, if so, which criteria were met. Criteria included standard physiologic, anatomic, and mechanism parameters. Sensitivity and specificity for the outcome of resuscitation (volume restoration, assisted ventilation or intubation, chest tube insertion/needle decompression, operative intervention) were calculated. RESULTS: A total of 492 patients met the case definition. Two-thirds were male, the mean age was 8 years (+/-4.8 SD), and the Injury Severity Score was > or =15 in 9.3%. Trauma team activation criteria were met by 179 patients (36. 4%) and, of these, 107 met mechanism criteria only. A resuscitative intervention was received by 54 (10.9%) of the total and none in the mechanism-only group. Sensitivity and specificity of the TTA criteria for predicting receipt of a resuscitation procedure were 98. 1% and 71.2%, respectively. When mechanism criteria were excluded, the sensitivity remained 98.1% and the specificity increased to 95. 7%. CONCLUSIONS: Criteria for TTA that include patients who meet mechanism criteria only are not specific for identifying patients who receive a resuscitative intervention. Use of anatomic and physiologic criteria only results in an increase in specificity, thereby reducing overtriage while retaining a high sensitivity.

Linking emergency department patients to primary care: phone vs face-to-face interaction.

OBJECTIVE: To compare the patient compliances and time analyses of two methods of assigning primary care providers (PCPs) to ED patients who are without a PCP: phone interview vs face-to-face interaction. METHODS: Prospective observational cohort study following an intervention, performed in a pediatric ED, serving a population of 1.7 million, with a census of 80,000 pediatric ED visits per year. Over one year, a consecutive sampling of 1,062 patients evaluated in the ED and without a PCP were approached to participate in our study (536 enrolled, 526 declined). Patients enrolled were addressed by a nurse practitioner/social worker (NP/SW) who arranged an appointment with a PCP, either in person (in ED) or by phone after discharge. The primary outcome measure was compliance with the arranged appointment. Secondarily, the authors analyzed the time necessary for each approach in person-hours. RESULTS: Of the 536 enrolled, 81 were excluded because data collection was incomplete at the time of the study's completion, leaving 455 study patients. Seventy-six percent of the study patients were between the ages of 1 month and 12 years. Contact was made by phone for 151 (33%) patients and face-to-face for 304 (67%). Sixty-two percent of the phone patients kept their appointments, compared with 52% of face-to-face patients (p = 0.048, RR = 1.20, 1.02 < RR < 1.41). Phone interaction was also more time effective. CONCLUSION: Linking ED patients without a medical provider to PCPs via phone is as effective as a face-to-face interaction.

A pilot study of the predictive value of plasma tumor necrosis factor alpha and interleukin 1 beta for Streptococcus pneumoniae bacteremia in febrile children.

OBJECTIVE: To determine the value of tumor necrosis factor alpha (TNF) and interleukin 1 beta (IL1) levels in predicting Streptococcus pneumoniae bacteremia in nontoxic-appearing, febrile children who do not have a bacterial source for their fever on physical examination. METHODS: A prospective, nested case-control study was conducted in a children's hospital ED. All febrile children < 3 years old who were believed to be immunocompetent and not in shock, had no obvious bacterial source for their fever on physical examination, and had a blood culture obtained were eligible. Plasma obtained at the time of the blood culture was available for analysis by enzyme-linked immunosorbent assays for TNF and IL1. Children who had positive blood cultures for Streptococcus pneumoniae were the cases. The controls were selected from children who had negative blood cultures. RESULTS: During a 1-year period, 12 cases and 65 controls were identified. There was no significant difference in age, height or duration of fever, or illness acuity between the groups. The following were used as threshold values for positive test: white blood cell (WBC) count > 15.0 x 10(9) cells/L, TNF > 21.5 ng/mL, and IL1 > 9.0 ng/mL. Using an estimated prior probability of bacteremia of 4%, the positive predictive value (PPV) and the negative predictive value (NPV) for bacteremia were 11.7% and 98.6% using the WBC count, 11.1% and 98.6% using the IL1 level, and 9.0% and 98.9% using the TNF level. The combination of WBC count with either TNF or IL1 gave an NPV of 100%, with PPVs of 8.5% for TNF and 9.9% for IL1. CONCLUSIONS: Like the WBC count, TNF and IL1 are good negative but poor positive predictors of Streptococcus pneumoniae bacteremia in nontoxic-appearing, febrile children. At present, the addition of plasma TNF or IL1 levels would add little to emergency physicians' ability to predict Streptococcus pneumoniae bacteremia. However, as the quantification of these cytokines becomes more rapid, available, and standardized, and more knowledge of TNF and IL1 levels during various illnesses is gained, their utility in the clinical setting for ruling out bacteremia should be further assessed.

An update on pediatric trauma.

Trauma care for children is examined from a demographic perspective. Critical issues, such as "who should care for acutely injured children" and "where should they receive care" are addressed. Specific issues regarding blunt trauma and indications for and outcome of emergency department thoracotomy are discussed also. A strategy for injury prevention is reviewed.

Development of a polymerase chain reaction assay to detect the presence of Streptococcus pneumoniae DNA.

In this study, we have developed a chemically sensitive and specific polymerase chain reaction (PCR) assay to detect the presence of Streptococcus pneumoniae genomic DNA. The target DNA sequence was a 322-base pair segment of the S. pneumoniae DNA polymerase I gene (pol I). PCR products of pure cultures of a set of pneumococcal serotypes commonly associated with human infection could be amplified in water and in blood cultures of clinical isolates containing S. pneumoniae. We were able to detect 2 fg of purified S. pneumoniae DNA. There were no false-positive reactions when the assay was performed on samples containing the following clinically encountered bacteria: Haemophilus influenzae type B, Neisseria meningitidis, Escherichia coli, Klebsiella pneumoniae, Pseudomonas spp. nontypeable H. influenzae, Staphylococcus aureus, coagulase-negative staphylococci, and Streptococcus pyogenes. The addition of EDTA and citrate-anticoagulated whole blood to the PCR reaction mixture inhibited the PCR assay, whereas the addition of lithium heparin, sodium heparin, and sodium polyanetholesulfonate-anticoagulated whole blood to PCR reaction mixture did not interfere with the ability to detect the presence of S. pneumoniae DNA.

Smoke inhalation injury.

Smoke inhalation injury in children still represents a significant cause of pulmonary disease and mortality. Carbon monoxide and other toxic products of combustion are major determinants of severity. Early hypoxemia is a contributor to over 50% of deaths. There are several clinical entities: upper airway obstruction, bronchospasm, consolidation, pulmonary edema, ARDS, and late pneumonia. Intensive care has improved outcome from burns, but pulmonary injury is still an important cause of mortality. New therapies such as high frequency ventilation may improve the outcome. Primary prevention is the most important way to reduce the poor outcome from significant exposure.

Transfusion therapy for severe anemia.

PURPOSE: We evaluated the safety and efficacy of a new transfusion regimen for children with severe anemia. PATIENTS AND METHODS: Twenty-two consecutive patients with severe anemia (hemoglobin < 5 g/dl) of gradual onset requiring transfusion of packed red blood cells (PRBC) were studied. The transfusion regimen consisted of continuous infusion of PRBC at the rate of 2 cc/kg/h until the desired volume was given. Throughout the transfusion, the patients were closely monitored for any clinical signs of heart failure. The rise in hematocrit per 1 cc of PRBC/kg transfused was computed for each patient. RESULTS: No patient developed any signs of cardiac failure or increase in the heart rate during or after the completion of transfusion. All patients had a decrease in the heart rate by the completion of transfusion. The mean decrease in the heart rate was 28% of the pretransfusion heart rate (range 12-44%). Excluding the four patients with sickle cell anemia, the remaining 18 patients had a mean increase in the hematocrit of 1.04% per 1 cc/kg of PRBC (range 0.85-1.28). CONCLUSION: We conclude that for children with severe anemia of gradual onset requiring transfusion therapy, continuous transfusion of PRBC at the rate of 2 cc/kg/h is a safe and effective regimen resulting in an increase in the hematocrit of approximately 1% for each 1 cc/kg of PRBC transfused in all patients, except patients with sickle cell anemia.