[Intraoperative OCT in retinal detachment with macular involvement]. / Intraoperative OCT bei Netzhautablösung mit Makulabeteiligung.

BACKGROUND: Intraoperative optical coherence tomography (iOCT) has recently been introduced for the visualization of retinal structures within the operating microscope. OBJECTIVE: The aim of this study was to analyze the behavior of the retina and morphological features during surgery for retinal detachment with macular involvement. METHODS: A retrospective analysis of 41 consecutive eyes with macula-off retinal detachment, which were treated with pars plana vitrectomy (PPV) using iOCT. A qualitative analysis of morphological features of the retina at defined moments during surgery was carried out. RESULTS: The visualization of macular detachment with iOCT was successful in 63% of cases and in the other cases the height of retinal detachment surpassed the maximum depth of the scan by iOCT. With perfluorodecalin 53.7% of eyes showed subretinal fluid and 22% of eyes showed a wave-like configuration of the outer retinal layers. In 61% of the eyes persisting subretinal fluid could be detected under the final tamponade. The amount of subretinal fluid could not be detected intraoperatively with the naked eye. In one case a macular hole could be newly identified intraoperatively and in three cases macular detachment could not be found at the start of surgery, although a detachment had been expected. CONCLUSION: The use of iOCT rarely leads to changes or extension of the intervention; however, it provides real-time information on intraretinal and subretinal fluid, which is sometimes in contrast to the clinical assessment. The relevance of persistent subretinal fluid and folds of the outer retinal layers after surgery remains unclear. It can be speculated whether this could serve as a prognostic factor for the postoperative outcome.

[Orbital firearm injuries]. / Orbitale Schussverletzungen.

BACKGROUND: Injuries caused by firearms are fortunately rare in the field of ophthalmology. The treatment of an affected patient is a special challenge both ophthalmologically and emotionally. METHODS: We report on seven consecutive cases of patients with an orbital gunshot injury who presented in a university hospital over a period of 11 years. The course of events leading to the injury with the weapon involved, the type of projectile, the injury pattern, cranial imaging, treatment and course were evaluated. RESULTS: A total of seven cases of injuries caused by firearms could be documented and evaluated in the period 2007-2018. All seven patients were male. The average age was 44 ± 27.5 years. Of the injuries five were caused by a suicide attempt and two by an accident. Firearms were used except for one injury caused by a crossbow. There was a retained projectile in four of the cases, the bullet went through the body in two cases and one of the cases presented with a ricochet shot. The final visual acuity was unilateral amaurosis in 1 case and bilateral amaurosis in another case, 1/35 (measured at 1 m) in 1 case, while it varied between 0.2 and 0.7 in the other 4 cases. No patient died as a direct consequence of the firearm injury. CONCLUSION: Injuries caused by firearms are relatively rare in Germany and mostly have a suicidal background. The pattern of the injury of the ocular structures is very variable. A reconstruction attempt is principally recommended. In the care of patients interdisciplinary cooperation between ophthalmologists and neurosurgeons, orofacial surgeons, ear nose and throat (ENT) surgeons and psychiatrists is necessary.

Testing of the WHO Infection Prevention and Control Assessment Framework at acute healthcare facility level.

BACKGROUND: Monitoring and evaluation are an essential part of infection prevention and control (IPC) implementation. The authors developed an IPC assessment framework (IPCAF) to support implementation of the World Health Organization (WHO) guidelines on core components of IPC programmes in acute healthcare facilities. AIM: To evaluate the usability and reliability of the IPCAF tool for global use. METHODS: The IPCAF is a questionnaire with a scoring system to measure the level of IPC implementation according to the eight WHO core components. The tool was pre-tested qualitatively, revised and translated selectively. A convenience sample of hospitals was invited to participate in the final testing. At least two IPC professionals from each hospital independently completed the IPCAF and a usability questionnaire online. The tool's internal consistency and interobserver reliability or intraclass correlation coefficient (ICC) were assessed, and usability questions were summarized descriptively. FINDINGS: In total, 46 countries, 181 hospitals and 324 individuals participated; 52 (16%) and 55 (17%) individual respondents came from low- and lower-middle income countries, respectively. Fifty-two percent of respondents took less than 1 h to complete the IPCAF. Overall, there was adequate internal consistency and a high ICC (0.92, 95% confidence interval 0.89-0.94). Ten individual questions had poor reliability (ICC <0.4); these were considered for revision according to usability feedback and expert opinion. CONCLUSIONS: The WHO IPCAF was tested using a robust global study and revised as necessary. It is now an effective tool for IPC improvement in healthcare facilities.

BabyGel pilot: a pilot cluster randomised trial of the provision of alcohol handgel to postpartum mothers to prevent neonatal and young infant infection-related morbidity in the community.

BACKGROUND: Alcohol-based hand rub (ABHR) is widely used in both health and social facilities to prevent infection, but it is not known whether supplying it for regular perinatal use can prevent newborn sepsis in African rural homes. Our study piloted a cluster randomised trial of providing ABHR to postpartum mothers to prevent neonatal infection-related morbidity in the communities. METHODS: We conducted a pilot parallel cluster randomised controlled trial across ten villages (clusters) in rural Eastern Uganda. Pregnant women of over 34 weeks' gestation were recruited over a period of 3 months. Both clusters received the standard of care of antenatal health education, Maama Kit, and clinic appointments. In addition, women in the intervention villages received ABHR, instructions on ABHR use, a poster on the 'three moments of hand hygiene', and training. We followed up each mother-baby pair for 3 months after birth and measured rates of consent, recruitment, and follow-up (our target rate was more than 80%). Other measures included ABHR use (the acceptable use was more than four times a day) and its mode of distribution (village health workers (VHWs) or pharmacy), acceptability of study protocol and electronic data capture, and the use of WHO Integrated Management of Childhood Illness (IMCI) tool to screen for newborn infection. RESULTS: We selected 36% (10/28) of villages for randomisation to either intervention or control. Over 12 weeks, 176 pregnant women were screened and 58.5% (103/176) were eligible. All, 100% (103/103), eligible women gave consent and were enrolled into the trial (55 intervention and 48 control). After birth, 94.5% (52/55) of mothers in the intervention and 100% (48/48) of mothers in the control villages were followed up within 72 h. Most, 90.9% (50/55), of the mothers in the intervention villages (96.2% of live births) and 95.8% (46/48) of mothers in the control villages (95.9% of live births) were followed up at 3 months. In intervention villages, the average hand rub use was 6.6 times per day. VHWs accounted for all ABHR stock, compared to the pharmacy that could not account for 5 l of ABHR. The screening tool was positive for infection among a third of babies, i.e. 29.2% (14/48) in the intervention villages versus 31.4% (16/51) in the control villages.VHWs completed the first four questions of IMCI screening tool with ease and accuracy. There were no adverse reactions with the ABHR. CONCLUSION: It is feasible to conduct a cluster-randomised controlled trial (cRCT) of the provision of ABHR to postpartum mothers to prevent neonatal infection-related morbidity in the community in resource-poor settings. Our results indicate that home recruitment promotes excellent follow-up and retention of participants in community trials. The intervention was safe. This pilot study informed the substantial changes necessary in the larger cRCT, including a change in the primary outcome to a composite outcome considering multiple methods of infection detection. A large BabyGel cluster randomised controlled trial is now required. TRIAL REGISTRATION: ISRCTN67852437, registered March 02, 2015. TRIAL FUNDING: Medical Research Council/WellcomeTrust/DfID (Global Health Trials Scheme).

Optimising informed consent for participants in a randomised controlled trial in rural Uganda: a comparative prospective cohort mixed-methods study.

BACKGROUND: Poor participant understanding of research information can be a problem in community interventional studies with rural African women, whose levels of illiteracy are high. This study aimed to improve the informed consent process for women living in rural eastern Uganda. We assessed the impact of alternative consent models on participants' understanding of clinical trial information and their contribution to the informed consent process in rural Uganda. METHODS: The study applied a parallel mixed-methods design for a prospective comparative cohort, nested within a pilot study on the community distribution of an alcohol-based hand rub to prevent neonatal sepsis (BabyGel pilot trial). Women of at least 34 weeks' pregnancy, suitable for inclusion in the BabyGel pilot trial, were recruited into this study from their homes in 13 villages in Mbale District. As part of the informed consent process, information about the trial was presented using one of three consent methods: standard researcher-read information, a slide show using illustrated text on a flip chart or a video showing the patient information being read as if by a newsreader in either English or the local language. In addition, all women received the patient information sheet in their preferred language. Each information-giving method was used in recruitment for 1 week. Two days after recruitment, women's understanding of the clinical trial was evaluated using the modified Quality of Informed Consent (QuIC) tool. They were also shown the other two methods and their preference assessed using a 5-point Likert scale. Semi-structured interviews were administered to each participant. The interviews were audio-recorded, transcribed and translated verbatim, and thematically analysed. RESULTS: A total of 30 pregnant women in their homes participated in this study. Their recall of the trial information within the planned 48 h was assessed for the majority (90%, 27/30). For all three consent models, women demonstrated a high understanding of the study. There was no statistically significant difference between the slide-show message (mean 4.7; standard deviation, SD 0.47; range 4-5), video message (mean 4.9; SD 0.33; range 4-5) and standard method (mean 4.5; SD 0.53; range 4-5; all one-way ANOVA, p = 0.190). The slide-show message resulted in the most objective understanding of question items with the highest average QuIC score of 100 points. For women who had been recruited using any of the three models, the slide show was the most popular method, with a mean score for all items of not less than 4.2 (mean 4.8; SD 0.6; range 4-5). Most women (63%, 19/30) preferred the slide-show message, compared with 17% (5/30) and 20% (6/30) for the standard and video messages, respectively. The reasons given included the benefits of having pictures to aid understanding and the logical progression of the information. CONCLUSION: Our results from this small study suggest that slide-show messages may be an effective and popular alternative way of presenting trial information to women in rural Uganda, many of whom have little or no literacy. TRIAL REGISTRATION: ISRCTN, ISRCTN67852437 . Registered on 18 March 2018.

Preventing neonatal sepsis in rural Uganda: a cross-over study comparing the tolerance and acceptability of three alcohol-based hand rub formulations.

BACKGROUND: Neonatal sepsis causes 0.5 million deaths annually, mostly in low resource settings. Babies born in African rural homes without running water or toilet facilities are especially vulnerable. Alcohol-based hand rub (ABHR) may be used by mothers and carers as an alternative to hand washing with soap to prevent neonatal infection. However, no definite study has established the preferred formulation of hand rub for the mothers. This study aimed to assess the effects of addition of bitterants and perfume towards the acceptability of the alcohol-based hand rubs by the mothers in their homes after childbirth. METHODS: This was a 3-way blinded cross-over study design. Mothers with children aged ≤3 months were recruited from immunisation clinics at 3 local health facilities in rural eastern Uganda and received 3-different ABHR formulations (in the order plain, bitterant and perfumed) packed in 100 ml bottles. Each ABHR was used for 5 consecutive days followed by a 2-day 'washout' period (evaluation period). Overall satisfaction with each hand rub was evaluated at the end of each week using a 7-point Likert scale. RESULTS: A total of 43 women were recruited, whose ages ranged from 16 to 45 years (mean 26.2 years old). None of the participants normally used a hand protective lotion/cream. The three formulations were used for a mean of 5 (range 3-7) days. A significantly greater volume of the "bitterant" and "perfumed" formulations (mean 91 and 83 ml respectively) were used in comparison to the "plain" formulation (mean 64 ml). Overall satisfaction was high with all the hand rubs, but the perfumed formulation had a significantly higher overall satisfaction score [mean 6.7, range 4-7] compared with the plain [6.4, 3-7] and bitterant [6.2, 2-7] formulations. CONCLUSIONS: All the 3 ABHR formulations were well accepted with little to choose between them. The ABHR with added perfume scored highest on overall satisfaction and was used significantly more often than plain ABHR. ABHR with bitterant additive did, however, score highly and may be a preferable choice to those with concern over alcohol misuse. TRIAL REGISTRATION: ISRCTN67852437 , prospectively registered on 18/03/2018.

Global hand hygiene improvement progress: two surveys using the WHO Hand Hygiene Self-Assessment Framework.

The World Health Organization (WHO) conducted two global surveys in 2011 and 2015 using the Hand Hygiene Self-Assessment Framework. In 2011, 2119 health facilities from 69 countries participated, and in 2015, 807 health facilities from 91 countries participated. In total, 86 facilities submitted results for both surveys; their overall score increased significantly (P<0.001) from 335.1 [standard deviation (SD) 7.5] to 374.4 (SD 90.5). In terms of WHO regions, the scores for the Eastern Mediterranean, Europe and Western Pacific regions all improved significantly (P<0.01). This represents a snapshot of the current position of global hand hygiene improvement efforts, outlining facility progress and highlighting the value of such an assessment tool.

Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study.

Healthcare-associated infections (HAIs) affect at least 300,000 patients annually in the UK and represent a significant, yet largely preventable, burden to healthcare systems. Hand hygiene by healthcare workers (HCWs) is the leading prevention measure, but compliance with good practice is generally low. The UK National Patient Safety Agency surveyed the public, inpatients, and HCWs, particularly frontline clinical staff and infection control nurses, in five acute care hospitals to determine whether they agreed that a greater level of involvement and engagement with patients would contribute to increased compliance with hand hygiene and reduce HAIs. Fifty-seven percent (302/530) of the public were unlikely to question doctors on the cleanliness of their hands as they assumed that they had already cleaned them. Forty-three percent (90/210) of inpatients considered that HCWs should know to clean their hands and trusted them to do so, and 20% (42/210) would not want HCWs to think that they were questioning their professional ability to do their job correctly. Most HCWs surveyed (178/254, 71%) said that HAI could be reduced to a greater or lesser degree if patients asked HCWs if they had cleaned their hands before touching them. Inviting patients to remind HCWs about hand hygiene through the provision of individual alcohol-based hand-rub containers and actively supporting an 'It's OK to ask' attitude were perceived as the most useful interventions by both patients and HCWs. However, further work is required to refute the myth among HCWs that patient involvement undermines the doctor- or HCW-patient relationship.

Patient safety: a literature [corrected] review on the impact of nursing empowerment, leadership and collaboration.

BACKGROUND: Nurses are ideally placed to drive the safety and quality agenda within health care because of their unique proximity to patients. There have been some attempts to look at the links between nursing care and quality outcomes, but relatively little on the connection between nursing and patient safety. Therefore, exploring the evidence on this issue was indicated, excluding links to nurse staffing and environment. AIMS: The aim of this study was to identify to what extent and in what way nursing leadership, collaboration and empowerment can have a demonstrable impact on patient safety. METHODS: A search of electronic databases was undertaken from 1998 to 2008. One thousand seven hundred eighty-eight titles and abstracts were retrieved, and the full text of 65 relevant papers was obtained and reviewed. Data extraction was undertaken if papers met the following inclusion criteria: a measure of impact from a study or audit, patient safety and nursing focused, and identified one of the following issues (leadership, advocacy, interdisciplinary working, empowerment and collaboration). Eleven papers were selected and critically reviewed. FINDING: Of the 11 papers, 7 were undertaken in the USA, 2 in Canada, 1 in the UK and 1 in Iceland. Selected papers comprised of one systematic review, one cohort study, four qualitative studies, three cross-sectional studies, one survey and an evaluation. The quality of papers was variable and provided limited evidence of impact or effectiveness in terms of nurses directly influencing patient safety. CONCLUSION: Gaps currently exist in relation to knowledge on the extent and nature of the role of nurses in patient safety improvement. Considerable work is required before comprehensive solutions can be further developed. Huge potential exists for improvement through nursing empowerment, leadership and the development of tools to strengthen and support nurses' influential role in the quality and safety movement; therefore, the need for investment into well-designed research studies to address these gaps is obvious, required and timely.

African partnerships for patient safety: a vehicle for enhancing patient safety across two continents. [corrected].

African Partnerships for Patient Safety (APPS) aims to develop sustainable partnerships between hospitals in Africa and Europe to create a network of beacon hospitals for patient safety. The three core APPS objectives are focused on building strong patient safety partnerships between hospitals in Africa and Europe, implementing patient safety improvements in each partnership hospital on 12 patient safety action areas, and facilitating spread of patient safety improvements. APPS is working with six first wave hospital partnerships and will capture and report learning from implementation. A range of APPS resources will shortly be available to hospitals working on patient safety systems.

Infection control as a major World Health Organization priority for developing countries.

Healthcare-associated infection affects hundreds of millions of people worldwide and is a major global issue for patient safety. It complicates between 5 and 10% of admissions in acute care hospitals in industrialised countries. In developing countries, the risk is two to twenty times higher and the proportion of infected patients frequently exceeds 25%. A growing awareness of this problem prompted the World Health Organization to promote the creation of the World Alliance for Patient Safety. Prevention of healthcare-associated infection is the target of the Alliance First Global Patient Safety Challenge, 'Clean Care is Safer Care', launched in October 2005. After 2 years, a formal statement has been signed by 72 ministries of health as a pledge of their support to implement actions to reduce healthcare-associated infection; of these, 30 are developing countries. Additional countries, mostly from the developing world, have planned to sign by the end of 2008 and will represent in total more than three-quarters of the world's population. Given the emphasis of the proposed strategy on simple and affordable solutions, the impact of the Challenge is expected to be high in developing countries. The combined efforts expected under the Challenge have the potential to save millions of lives, prevent morbidities and long-term disability for hundreds of millions of patients, and lead to major cost savings through the improvement of basic infection control measures in any healthcare setting, regardless of resources available or level of development.

Hand hygiene compliance in healthcare workers.

The 'clean-your-hands' campaign has now been introduced into hospitals in England but it was initially piloted in six acute trusts. The campaign was multi-modal and aimed to improve hand hygiene compliance. This review reports the findings from one of the trusts involved in the pilot. The campaign consisted of a toolkit that included placing alcohol hand rub beside patients, along with posters and supporting marketing materials. A guide to implementation and a strategy aimed at increasing patient information and empowerment was also initiated. In order to assess the success of the campaign, audits of hand hygiene in healthcare workers were conducted over a six-month period. Additionally, data were obtained from staff surveys, patient surveys, usage levels of alcohol hand rub and interviews with the on-site lead. The local campaign indicated that a multi-modal campaign induced a marked increase in hand hygiene compliance (from 32% to 63%), with 74% of staff reporting increased compliance throughout the campaign. Usage of alcohol hand rub increased by 184%. The majority of patients indicated that the public should be actively involved in helping healthcare staff to improve their hand hygiene.

Relaxation of imprinted expression of ZAC and HYMAI in a patient with transient neonatal diabetes mellitus.

Transient neonatal diabetes mellitus (TNDM) is a rare disease believed to result from overexpression of a paternally expressed gene controlled by a differentially methylated CpG island on chromosome 6q24. Two genes partially overlap the island: the cell-cycle-control gene ZAC and the untranslated gene HYMAI, the function of which is currently unknown. Proof that either gene is involved in TNDM would require demonstration that imprinted expression is relaxed in TNDM patients; this has hitherto been lacking because of the rarity of the disease and the lack of imprinted expression in the lymphoblastoid cells that are generally the only resource available for study. Here, we show, for the first time, the aberrant expression of imprinted genes in a TNDM patient. In TNDM fibroblasts, the monoallelic expression of both ZAC and HYMAI is relaxed, providing strong supportive evidence that the presence of two unmethylated alleles of this locus is indeed associated with the inappropriate gene expression of neighbouring genes.

Chickenpox.

Although often dismissed as a minor childhood illness, chickenpox is potentially very serious if contracted by certain vulnerable adults, pregnant women or neonates. This Update examines the course of the illness and implications for nurses.