Investigation of the Effect of Turn Residues on Tetrapeptide Aldol Catalysts with ß-Turn Propensity.

Peptide catalysts for a wide diversity of reaction types contain a common motif-residues that bias the sequence toward ß-turn secondary structure. In this work, we explore what role that secondary structure plays in the catalysis of aldol reactions for primary amine tetrapeptide aldol catalysts. Using a lead tetrapeptide ß-turn catalytic sequence, we varied the i + 1 and i + 2 residues to amino acids that would affect the ß-turn propensity. We then studied the correlation between secondary structure, aldol rate enhancement, and stereoselectivity of the reaction between hydroxyacetone and 4-nitrobenzaldehyde. Using the i + 3 amide chemical shift as a measure of ß-turn character, we found a rough correlation between the peptide structure and reaction kinetics but minimal effect on stereoselectivity. These trends may help aid the design of future catalytic sequences.

'Draw your pelvis' test for assessing pelvic schema in people with Parkinson's disease: a validity and reliability study.

Aim: Body schema (i.e., the mental representation of the body and its parts) is important for cognitive and motor functions, with the pelvis constituting a core element in such schema. Although people with Parkinson's disease exhibit misperceptions and deficits in body schema, there are currently no published tools available for assessing pelvic schema in this population. This study aimed to develop and establish feasibility, reliability, and validity of a novel drawing test - 'Draw Your Pelvis' - for assessing pelvic schema in people with Parkinson's disease. Materials and methods: Twenty people with idiopathic Parkinson's disease (Hoehn &Yahr stages I-III; M age: 65.75 ± 10.13) volunteered and were asked to manually draw a picture of their pelvis. Drawings were assessed and scored by 13 blinded raters over two sessions. Intra- and inter-rater reliability and content and criterion validity were investigated. Results: The 'Draw Your Pelvis' test is shown to be feasible and quick to administer, with excellent inter-rater reliability for consistency (0.954-0.968) and absolute agreement (0.946-0.961). It also demonstrates good-excellent (0.614-0.950) intra-rater reliability, and is content valid. Conclusions: The 'Draw Your Pelvis' test holds potential for clinicians and researchers in assessing pelvic schema and its deficits in people with Parkinson's disease. In addition, this test could be used for investigating the effect of therapeutic interventions on body schema in this population. Future studies should explore this test in additional populations.

Psychometric properties of clock and pelvic drawings in Parkinson's disease: A validity and cross-sectional study.

OBJECTIVES: Parkinson's disease (PD) is characterized by visuospatial and body schema deficits. People with PD often exhibit hypometric movements and graphic hypometria (i.e., small drawing dimensions). The goal of the current study was to explore graphic-metric representation in people with PD by assessing pelvic and clock drawing dimensions (i.e., height and width) and by investigating associations between pelvic drawing dimensions and participant characteristics. METHODS: Twenty people (16 males, 4 females; M age: 65.75 ± 10.13 years) with idiopathic PD (Hoehn &Yahr Stages I-III) volunteered to participate in this study. Draw Your Pelvis and Clock Drawing tests were used for assessing drawing dimensions, which were then correlated with PD severity, stage and duration, cognitive level, side of symptoms onset, and pelvic schema score. Bivariate and multiple linear regression analyses were also used. RESULTS: Excellent (.844-.999) interrater reliability was shown for measuring pelvic and clock drawing dimensions. Pelvic drawing dimensions did not significantly (P > .05) differ in magnitude, whereas clock drawing height was significantly (p < .01) greater than width, both suggesting graphic dysmetria (i.e., distorted graphic dimensions). Pelvic drawing width was negatively associated with PD severity and stage, was positively associated with pelvic schema score, and predicted all three parameters. CONCLUSION: Measuring pelvic drawing dimensions, and specifically pelvic drawing width, holds potential as an adjunct diagnostic measure in PD assessments and for detecting pelvic schema deficits or misperceptions. This test can be used by physical therapists in the clinic for assessing disease severity, stage, and pelvic schema in people with PD. The knowledge gained from this study contributes to a greater understanding of graphic-metric representation and associated deficits in people with PD. Future studies should explore the relationship between pelvic drawing dimensions and pelvic mentally imaged estimates, and their role in motor planning, control, and execution in people with PD.

Integrating motivational interviewing and narrative therapy to teach behavior change to family medicine resident physicians.

INTRODUCTION: Motivational interviewing is a useful skill to address the common problem of patient ambivalence regarding behavior change by uncovering and strengthening a person's own motivation and commitment to change. The Family Medicine Milestones underline the need for clear teaching and monitoring of skills in communication and behavior change in Family Medicine postgraduate training settings. METHODS: This article reports the integration of a motivational interviewing curriculum into an existing longitudinal narrative therapy-based curriculum on patient-centered communication. OUTCOMES: Observed structured clinical examination for six participants indicate that intern physicians are able to demonstrate moderate motivational interviewing skill after a brief 2-h workshop. Participant self-evaluations for 16 participants suggest a brief 2-h curriculum was helpful at increasing importance of learning motivational interviewing by participants, and that participants desire further training opportunities. CONCLUSION: A brief motivational interviewing curriculum can be integrated into existing communication training in a Family Medicine residency training program.

Decisional practices and patterns of intraoperative glucose management in an academic medical center.

OBJECTIVE: To understand the decisional practices of anesthesia providers in managing intraoperative glucose levels. DESIGN: This is a retrospective cohort study. SETTING: Operating rooms in an academic medical center. PATIENTS: Adult patients undergoing surgery. INTERVENTION: Intraoperative blood glucose management based on an institutional protocol. MEASUREMENTS: Glucose management data was extracted from electronic medical records to determine compliance to institutional glucose management protocol that prescribes hourly glucose measurements and insulin doses to maintain glucose levels between 100 to 140mg/dL. Effect of patient and surgery specific factors on compliance to glucose management protocol was explored. MAIN RESULTS: In 1903 adult patients compliances to hourly glucose measurements was 72.5% and correct insulin adjustments was 12.4%. Insulin was under-dosed compared to the prescribed value by a mean of 0.85U/h (95% CI 0.76-0.95). Multivariate analysis showed that compliance to hourly glucose measurements decreased with increasing length of the procedure (OR=0.92 per hour, 95% CI 0.89-0.95) but increased with ASA status codes (OR=1.25 per ASA unit, 95% CI=1.06-1.49). Greater compliance to correct insulin adjustment was found in diabetic patients compared with non-diabetic patients (OR=1.31, 95% CI 1.09-1.55). On average, providers administered progressively more insulin with an additional 0.11U/h (95% CI=0.00-0.21] for every additional 10kg/m(2) of BMI and 0.20U/h (95% CI=0.01-0.39) less in diabetic patients than in non-diabetic patients. With the above practice pattern, the mean±SD of glucose level was 158±36mg/dL. Hypoglycemic (<60mg/dL) incident rate was 0.1% (9/8301 measurements) while hyperglycemic (>180mg/dL) incident rate was 28%. Glucose levels were within the target range (100-140mg/dL) only 28% of the time. CONCLUSIONS: Low compliance and considerable variability in initiating and following institutional glucose management protocol were observed.

Intraoperative blood glucose management: impact of a real-time decision support system on adherence to institutional protocol.

Poor perioperative glycemic management can lead to negative surgical outcome. Improved compliance to glucose control protocol could lead to better glucose management. An Anesthesia Information Management System based decision support system-Smart Anesthesia Manager™ (SAM) was used to generate real-time reminders to the anesthesia providers to closely adhere to our institutional glucose management protocol. Compliance to hourly glucose measurements and correct insulin dose adjustments was compared for the baseline period (12 months) without SAM and the intervention period (12 months) with SAM decision support. Additionally, glucose management parameters were compared for the baseline and intervention periods. A total of 1587 cases during baseline and 1997 cases during intervention met the criteria for glucose management (diabetic patients or non-diabetic patients with glucose level >140 mg/dL). Among the intervention cases anesthesia providers chose to use SAM reminders 48.7 % of the time primarily for patients who had diabetes, higher HbA1C or body mass index, while disabling the system for the remaining cases. Compliance to hourly glucose measurement and correct insulin doses increased significantly during the intervention period when compared with the baseline (from 52.6 to 71.2 % and from 13.5 to 24.4 %, respectively). In spite of improved compliance to institutional protocol, the mean glucose levels and other glycemic management parameters did not show significant improvement with SAM reminders. Real-time electronic reminders improved intraoperative compliance to institutional glucose management protocol though glycemic parameters did not improve even when there was greater compliance to the protocol.

Aligning institutional priorities: engaging house staff in a quality improvement and safety initiative to fulfill Clinical Learning Environment Review objectives and electronic medical record Meaningful Use requirements.

BACKGROUND: House staff quality improvement projects are often not aligned with training institution priorities. House staff are the primary users of inpatient problem lists in academic medical centers, and list maintenance has significant patient safety and financial implications. Improvement of the problem list is an important objective for hospitals with electronic health records under the Meaningful Use program. METHODS: House staff surveys were used to create an electronic problem list manager (PLM) tool enabling efficient problem list updating. Number of new problems added and house staff perceptions of the problem list were compared before and after PLM intervention. RESULTS: The PLM was used by 654 house staff after release. Surveys demonstrated increased problem list updating (P = .002; response rate 47%). Mean new problems added per day increased from 64 pre-PLM to 125 post-PLM (P < .001). CONCLUSIONS: This innovative project serves as a model for successful engagement of house staff in institutional quality and safety initiatives with tangible institutional benefits.

The Effect of Intraoperative Blood Glucose Management on Postoperative Blood Glucose Levels in Noncardiac Surgery Patients.

BACKGROUND: Postoperative hyperglycemia has been associated with poor surgical outcome. The effect of intraoperative glucose management on postoperative glucose levels and the optimal glycemic threshold for initiating insulin are currently unknown. METHODS: We performed a retrospective cohort study of surgery patients who required intraoperative glucose management with data extracted from electronic medical records. In patients who required glucose management, intraoperative glucose levels and insulin therapy were compared against postoperative glucose levels during 3 periods: first postoperative level within 1 hour, within the first 12 hours, and 24 hours of the postoperative period. Logistic regression models that adjusted for patient and surgical factors were used to determine the association between intraoperative glucose management and postoperative glucose levels. RESULTS: In 2440 patients who required intraoperative glucose management, an increase in mean intraoperative glucose level by 10 mg/dL was associated with an increase in postoperative glucose levels by 4.7 mg/dL (confidence interval [CI], 4.1-5.3; P < 0.001) for the first postoperative glucose measurement, 2.6 mg/dL (CI, 2.1-3.1; P < 0.001) for the mean first 12-hour postoperative glucose, and 2.4 mg/dL (CI, 2.0-2.9; P < 0.001) for the mean first 24-hour postoperative glucose levels (univariate analysis). Multivariate analysis showed that these effects depended on (interacted with) body mass index and diabetes status of the patient. Both diabetes status (regression coefficient = 12.2; P < 0.001) and intraoperative steroid use (regression coefficient = 10.2; P < 0.001) had a positive effect on elevated postoperative glucose levels. Intraoperative hyperglycemia (>180 mg/dL) was associated with postoperative hyperglycemia during the first 12 hours and the first 24 hours. However, interaction with procedure duration meant that this association was stronger for shorter surgeries. When compared with starting insulin for an intraoperative glucose threshold of 140 mg/dL thus avoiding hyperglycemia, initiation of insulin for a hyperglycemia threshold of 180 mg/dL was associated with an increase in postoperative glucose level (7 mg/dL; P < 0.001) and postoperative hyperglycemia incidence (odds ratio = 1.53; P = 0.01). CONCLUSIONS: A higher intraoperative glucose level is associated with a higher postoperative glucose level. Intraoperative hyperglycemia increases the odds for postoperative hyperglycemia. Adequate intraoperative glucose management by initiating insulin infusion when glucose level exceeds 140 mg/dL to prevent hyperglycemia is associated with lower postoperative glucose levels and fewer incidences of postoperative hyperglycemia. However, patient- and procedure-specific variable interactions make the relationship between intraoperative and postoperative glucose levels complicated.

Anesthesia information management system-based near real-time decision support to manage intraoperative hypotension and hypertension.

BACKGROUND: Intraoperative hypotension and hypertension are associated with adverse clinical outcomes and morbidity. Clinical decision support mediated through an anesthesia information management system (AIMS) has been shown to improve quality of care. We hypothesized that an AIMS-based clinical decision support system could be used to improve management of intraoperative hypotension and hypertension. METHODS: A near real-time AIMS-based decision support module, Smart Anesthesia Manager (SAM), was used to detect selected scenarios contributing to hypotension and hypertension. Specifically, hypotension (systolic blood pressure <80 mm Hg) with a concurrent high concentration (>1.25 minimum alveolar concentration [MAC]) of inhaled drug and hypertension (systolic blood pressure >160 mm Hg) with concurrent phenylephrine infusion were detected, and anesthesia providers were notified via "pop-up" computer screen messages. AIMS data were retrospectively analyzed to evaluate the effect of SAM notification messages on hypotensive and hypertensive episodes. RESULTS: For anesthetic cases 12 months before (N = 16913) and after (N = 17132) institution of SAM messages, the median duration of hypotensive episodes with concurrent high MAC decreased with notifications (Mann Whitney rank sum test, P = 0.031). However, the reduction in the median duration of hypertensive episodes with concurrent phenylephrine infusion was not significant (P = 0.47). The frequency of prolonged episodes that lasted >6 minutes (sampling period of SAM), represented in terms of the number of cases with episodes per 100 surgical cases (or percentage occurrence), declined with notifications for both hypotension with >1.25 MAC inhaled drug episodes (δ = -0.26% [confidence interval, -0.38% to -0.11%], P < 0.001) and hypertension with phenylephrine infusion episodes (δ = -0.92% [confidence interval, -1.79% to -0.04%], P = 0.035). For hypotensive events, the anesthesia providers reduced the inhaled drug concentrations to <1.25 MAC 81% of the time with notifications compared with 59% without notifications (P = 0.003). For hypertensive episodes, although the anesthesia providers' reduction or discontinuation of the phenylephrine infusion increased from 22% to 37% (P = 0.030) with notification messages, the overall response was less consistent than the response to hypotensive episodes. CONCLUSIONS: With automatic acquisition of arterial blood pressure and inhaled drug concentration variables in an AIMS, near real-time notification was effective in reducing the duration and frequency of hypotension with concurrent >1.25 MAC inhaled drug episodes. However, since phenylephrine infusion is manually documented in an AIMS, the impact of notification messages was less pronounced in reducing episodes of hypertension with concurrent phenylephrine infusion. Automated data capture and a higher frequency of data acquisition in an AIMS can improve the effectiveness of an intraoperative clinical decision support system.

Reducing wastage of inhalation anesthetics using real-time decision support to notify of excessive fresh gas flow.

BACKGROUND: Reduced consumption of inhalation anesthetics can be safely achieved by reducing excess fresh gas flow (FGF). In this study the authors describe the use of a real-time decision support tool to reduce excess FGF to lower, less wasteful levels. METHOD: The authors applied a decision support tool called the Smart Anesthesia Manager™ (University of Washington, Seattle, WA) that analyzes real-time data from an Anesthesia Information Management System to notify the anesthesia team if FGF exceeds 1 l/min. If sevoflurane consumption reached 2 minimum alveolar concentration-hour under low flow anesthesia (FGF < 2 l/min), a second message was generated to increase FGF to 2 l/min, to comply with Food and Drug Administration guidelines. To evaluate the tool, mean FGF between surgical incision and the end of procedure was compared in four phases: (1) a baseline period before instituting decision rules, (2) Intervention-1 when decision support to reduce FGF was applied, (3) Intervention-2 when the decision rule to reduce flow was deliberately inactivated, and (4) Intervention-3 when decision rules were reactivated. RESULTS: The mean ± SD FGF reduced from 2.10 ± 1.12 l/min (n = 1,714) during baseline to 1.60 ± 1.01 l/min (n = 2,232) when decision rules were instituted (P < 0.001). When the decision rule to reduce flow was inactivated, mean FGF increased to 1.87 ± 1.15 l/min (n = 1,732) (P < 0.001), with an increasing trend in FGF of 0.1 l/min/month (P = 0.02). On reactivating the decision rules, the mean FGF came down to 1.59 ± 1.02 l/min (n = 1,845). Through the Smart Anesthesia Messenger™ system, the authors saved 9.5 l of sevoflurane, 6.0 l of desflurane, and 0.8 l isoflurane per month, translating to an annual savings of $104,916. CONCLUSIONS: Real-time notification is an effective way to reduce inhalation agent usage through decreased excess FGFs.

Smart Anesthesia Manager™ (SAM)--a real-time decision support system for anesthesia care during surgery.

Anesthesia information management systems (AIMS) are being increasingly used in the operating room to document anesthesia care. We developed a system, Smart Anesthesia Manager™ (SAM) that works in conjunction with an AIMS to provide clinical and billing decision support. SAM interrogates AIMS database in near real time, detects issues related to clinical care, billing and compliance, and material waste. Issues and the steps for their resolution are brought to the attention of the anesthesia provider in real time through "pop-up" messages overlaid on top of AIMS screens or text pages. SAM improved compliance to antibiotic initial dose and redose to 99.3 ± 0.7% and 83.9 ± 3.4% from 88.5 ± 1.4% and 62.5 ± 1.6%, respectively. Beta-blocker protocol compliance increased to 94.6 ± 3.5% from 60.5 ± 8.6%. Inadvertent gaps (>15 min) in blood pressure monitoring were reduced to 34 ± 30 min/1000 cases from 192 ± 58 min/1000 cases. Additional billing charge capture of invasive lines procedures worth $144,732 per year and 1,200 compliant records were achieved with SAM. SAM was also able to reduce wastage of inhalation anesthetic agents worth $120,168 per year.

A collaborative, systems-level approach to eliminating healthcare-associated MRSA, central-line-associated bloodstream infections, ventilator-associated pneumonia, and respiratory virus infections.

To achieve sustainable reductions in healthcare-associated infections (HAIs), the University of Washington Medical Center (UWMC) deployed a collaborative, systems-level initiative. With the sponsorship of senior leadership, multidisciplinary teams were established to address healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA), central-line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and respiratory virus infections. The goal of the initiative was to eliminate these four HAIs among medical center inpatients by 2012. In the first 24 months of the project, the number of healthcare-associated MRSA cases decreased 58%; CLABSI cases decreased 54%. Staff and provider compliance with infection prevention measures improved and remained strong, for example, 96% compliance with hand hygiene, 98% compliance with the recommended influenza vaccination program, and 100% compliance with the VAP bundle. Achieving these results required an array of coordinated, systems-level interventions. Critical project success factors were believed to include creating organizational alignment by declaring eliminating HAIs as an organizational breakthrough goal, having the organization's executive leadership highly engaged in the project, coordination by an experienced and effective project leader and manager, collaboration by multidisciplinary project teams, and promoting transparency of results across the organization.

Improving documentation of a beta-blocker quality measure through an anesthesia information management system and real-time notification of documentation errors.

BACKGROUND: Continuation of perioperative beta-blockers for surgical patients who are receiving beta-blockers prior to arrival for surgery is an important quality measure (SCIP-Card-2). For this measure to be considered successful, name, date, and time of the perioperative beta-blocker must be documented. Alternately, if the beta-blocker is not given, the medical reason for not administering must be documented. METHODS: Before the study was conducted, the institution lacked a highly reliable process to document the date and time of self-administration of beta-blockers prior to hospital admission. Because of this, compliance with the beta-blocker quality measure was poor (-65%). To improve this measure, the anesthesia care team was made responsible for documenting perioperative beta-blockade. Clear documentation guidelines were outlined, and an electronic Anesthesia Information Management System (AIMS) was configured to facilitate complete documentation of the beta-blocker quality measure. In addition, real-time electronic alerts were generated using Smart Anesthesia Messenger (SAM), an internally developed decision-support system, to notify users concerning incomplete beta-blocker documentation. RESULTS: Weekly compliance for perioperative beta-blocker documentation before the study was 65.8 +/- 16.6%, which served as the baseline value. When the anesthesia care team started documenting perioperative beta-blocker in AIMS, compliance was 60.5 +/- 8.6% (p = .677 as compared with baseline). Electronic alerts with SAM improved documentation compliance to 94.6 +/- 3.5% (p < .001 as compared with baseline). CONCLUSIONS: To achieve high compliance for the beta-blocker measure, it is essential to (1) clearly assign a medical team to perform beta-blocker documentation and (2) enhance features in the electronic medical systems to alert the user concerning incomplete documentation.

Automated electronic reminders to improve redosing of antibiotics during surgical cases: comparison of two approaches.

BACKGROUND: Timely re-dosing of antibiotic for prolonged surgical cases is an important measure in reducing the risk of surgical site infections. For the anesthesia team, which generally administers the antibiotic re-doses, it is difficult to keep track of and remember the exact timing requirements. We explored the efficacy of two types of electronic reminders to aid the anesthesia team in performing timely antibiotic re-doses. METHODS: The first electronic reminder was a timer-triggered "blinking button" feature in the Anesthesia Information Management System (AIMS). The second was generated with a real-time decision support system, the Smart Anesthesia Messenger (SAM). The AIMS reminder was applied for the first five months of the study, whereas the SAM reminder was applied for the second five months. A retrospective analysis was performed to evaluate the efficacy of the reminder messages in improving the antibiotic re-dose success rate. RESULTS: In a total of 940 cases, the anesthesia team was reminded of the need for antibiotic re-dosing with AIMS, whereas in 922 cases, the SAM system gave the reminder. The AIMS reminders achieved a timely re-dose success rate of 62.5% ± 1.6%, whereas the SAM reminders achieved a significantly higher success rate: 83.9% ± 3.4% (p < 0.001). CONCLUSIONS: Compared with the simple reminders generated with AIMS, the relevant, informative messages generated with SAM were more effective in improving compliance with timely antibiotic re-doses.

Feedback mechanisms including real-time electronic alerts to achieve near 100% timely prophylactic antibiotic administration in surgical cases.

BACKGROUND: Administration of prophylactic antibiotics during surgery is generally performed by the anesthesia providers. Timely antibiotic administration within the optimal time window before incision is critical for prevention of surgical site infections. However, this often becomes a difficult task for the anesthesia team during the busy part of a case when the patient is being anesthetized. METHODS: Starting with the implementation of an anesthesia information management system (AIMS), we designed and implemented several feedback mechanisms to improve compliance of proper antibiotic delivery and documentation. This included generating e-mail feedback of missed documentation, distributing monthly summary reports, and generating real-time electronic alerts with a decision support system. RESULTS: In 20,974 surgical cases for the period, June 2008 to January 2010, the interventions of AIMS install, e-mail feedback, summary reports, and real-time alerts changed antibiotic compliance by -1.5%, 2.3%, 4.9%, and 9.3%, respectively, when compared with the baseline value of 90.0% ± 2.9% when paper anesthesia records were used. Highest antibiotic compliance was achieved when using real-time alerts. With real-time alerts, monthly compliance was >99% for every month between June 2009 and January 2010. CONCLUSIONS: Installation of AIMS itself did not improve antibiotic compliance over that achieved with paper anesthesia records. However, real-time guidance and reminders through electronic messages generated by a computerized decision support system (Smart Anesthesia Messenger, or SAM) significantly improved compliance. With such a system a consistent compliance of >99% was achieved.

Use of serum and plasma glucose measurements as a benchmark for improved hospital-wide glycemic control.

OBJECTIVE: To demonstrate the benefit of an institutionally implemented glucose control intervention based on serum and plasma glucose values in the acute inpatient setting. METHODS: In a retrospective analysis, all serum and plasma glucose values from the laboratory information system database from 1999 through 2005 were used to assess implementation of 2 new hospital-wide intravenous and subcutaneous protocols aimed at lowering blood glucose values without increasing the number of hypoglycemic events. In our analysis, we used both a per-patient hyperglycemic index (HGI), an area-under-the-curve analysis, and hospital-wide geometric mean blood glucose to assess glucose control. Bedside capillary blood glucose measurements were not included. RESULTS: More than 630,000 serum and plasma glucose results were available for analysis. The percentage of results above the protocol target of 180 mg/dL decreased from 16.4% before the intervention to 10.0% after the intervention (P<.00001), and we found no change in the proportion of "critical" hypoglycemic results (<50 mg/dL). The hospital-wide geometric mean decreased significantly and coincided with a significant decrease in the fraction of patients with poor glucose control (based on the HGI) from 27.6% to 18.7% (P<.00001). The geometric mean blood glucose was found to be an excellent marker for the HGI (r2 = 0.99). CONCLUSION: We are the first to report improvements in glucose control over an extended period with use of both hospital-wide intravenous and subcutaneous insulin protocols in an academic hospital setting. Furthermore, hospital-wide mean blood glucose levels are excellent surrogates for the more comprehensive calculation of per-patient HGI.

Importancia de los suministros en la central de esterilización. El protagonismo del agua / The importance of supplies in the sterilisation centre

Con motivo de la Directiva Europea de Productos Sanitarios 93/42/CEE y su aplicación en España mediante el RD 414/97 se han llevado a cabo, en los últimos diez años, numerosos reemplazos de esterilizadores e instalación de quipos adaptados al nuevo marco legal. Sin embargo, como presenta este artículo quedan aún bastantes puntos de mejora en cuanto a la calidad de los suministros relacionados con el correcto funcionamiento de los equipos (AU)

Following the publishing of the European Guideline for Health Products 93/42 /CEE and its application in Spain by RD 414/967 over the last ten years, many sterilisers have been replaced and equipment which has been adapted to the new legal regulations has been installed. However, as this article states, there are still many areas for improvement as far as the quality of material supplied is concerned, especially with regard to the correct operating of the equipment (AU)