Preventing healthcare-associated transmission of the Middle East Respiratory Syndrome [MERS]: Our Achilles heel

Middle East Respiratory Syndrome [MERS] coronavirus is the most recent among the Coronaviridae family to jump species and infect humans. Major health-care associated MERS outbreaks have occurred in the Middle East and Korea that affected both patients and healthcare workers. These outbreaks were characterized by intra and inter-hospital spread and were exacerbated specifically by overcrowding, delayed diagnosis and appropriate use of personal protective equipment. Recent experience with this virus emphasizes the importance of compliance with infection control practices and with other interventions addressing patient triage, placement and flow within and between healthcare facilities. Our Achilles heel remains compliance with the best infection prevention practices and their harmonization with patient flow. Both infection prevention compliance and maintenance of patient flow are critical in preventing healthcare-associated transmission of many of these emerging infectious diseases, including MERS

impact of onset time on the isolated pathogens and outcomes in ventilator associated pneumonia

Several guidelines base the empirical therapy of ventilator-associated pneumonia [VAP] on the time of onset. However, there is emerging evidence that the isolated microorganisms may be similar regardless of onset time. This study evaluated the characteristics and outcomes of VAP with different onset times. All of the mechanically ventilated patients admitted to the ICU of a 900-bed tertiary-care hospital between 01/08/2003 and 31/12/2010 were prospectively followed for VAP development according to the National Healthcare Safety Network criteria. The patients were categorized into four groups: EO if VAP occurred within 4 days of intubation and hospital admission; LO if VAP occurred after 4 days of admission; EL if VAP occurred within 4 days of intubation, but after the fourth hospitalization day; and LL if VAP occurred after the fourth day of intubation and hospitalization. Out of the 394 VAP episodes, 63 [16%] were EO episodes, 331 [84.0%] were LO episodes, 40 [10.1%] were EL episodes and 291 [73.1%] were LL episodes. The isolated microorganisms were comparable among the four groups, with a similar rate of potentially multidrug resistant organisms in the EO-VAP [31.7%], LO-VAP [40.8%], EL-VAP [37.5%] and LL-VAP [43.3%] samples. The hospital mortality was 24% for EO-VAP cases, 28% for LO-VAP cases, 40% for EL-VAP cases and 49% for LL-VAP cases. However, in the adjusted multivariate analysis, neither LO-VAP, EL-VAP nor LL-VAP was associated with an increased risk of hospital mortality compared with EO-VAP [OR, 0.86 95% CI, 0.34-2.19; 1.22; 95% CI, 0.41-3.68, and 0.95; 95% CI, 0.43-2.10, respectively]. In this study, the occurrence of potential multidrug resistant pathogens and the mortality risk were similar regardless of VAP timing from hospital admission and intubation. The bacterial isolates obtained from the VAP cases did not follow an early vs. late-onset pattern, and thus, these terms may not be clinically helpful

Determinants of functional status among survivors of severe sepsis and septic shock: one-year follow-up

Sepsis is a leading cause of intensive care unit [ICU] admissions worldwide and a major cause of morbidity and mortality. Limited data exist regarding the outcomes and functional status among survivors of severe sepsis and septic shock. This study aimed to determine the functional status among survivors of severe sepsis and septic shock a year after hospital discharge. Adult patients admitted between April 2007 and March 2010 to the medical-surgical ICU of a tertiary hospital in Saudi Arabia, were included in this study. The ICU database was investigated for patients with a diagnosis of severe sepsis or septic shock. Survival status was determined based on hospital discharge. Patients who required re-admission, stayed in ICU for less than 24 hours, had incomplete data were all excluded. Survivors were interviewed through phone calls to determine their functional status one-year post-hospital discharge using Karnofsky performance status scale. A total of 209 patients met the eligibility criteria. We found that 38 [18.1%] patients had severe disability before admission, whereas 109 [52.2%] patients were with severe disability or died one-year post-hospital discharge. Only one-third of the survivors had good functional status one-year post-discharge [no/mild disability]. After adjustment of baseline variables, age [adjusted odds ratio [aOR] = 1.03, 95% confidence interval [CI] = 1.01-1.04] and pre-sepsis functional status of severe disability [aOR = 50.9, 95% CI = 6.82-379.3] were found to be independent predictors of functional status of severe disability one-year post-hospital discharge among survivors. We found that only one-third of the survivors of severe sepsis and septic shock had good functional status one-year post-discharge [no/mild disability]. Age and pre-sepsis severe disability were the factors that highly predicted the level of functional status one-year post-hospital discharge

[Effect of Aloe vera gel on TGF- beta gene expression in incisional skin wound in BALB/c mice]

Aloe vera [Aloe barbadensis M.] as a medicinal herb is practiced in wound healing. This study was carried out to assess the effect of Aloe vera gel [mucilage] on TGF- beta gene expression in incisional skin wound in BALB/c mice. In this experimental study, 36 BALB/c male mice with weight range 22 +/- 2 gr were allocated equally into negative control [no wound], sham-operated [wound treated with physiological serum] and teratment [wound treated with Aloe vera gel]. Two equal full-thickness skin wounds of 10 +/- 2mm were made on either side of the vertebral column in the sacral region. The animals in the teratment group were received daily, 2 gram of Aloe vera gel [without any bandage] as a thin layer for a period of 16 days. On 8th and 16th post wounding day, TGF- beta gene expression in incisional wounds and Malonyldialdehyde [as end-product of lipid peroxidation] in serum samples was measured using RT-PCR and spectrophotometry methods, respectively. TGF- beta gene expression in incisional skin wound increased in Aloe vera gel treated group in compared to negative control and sham-operated groups [P<0.05]. Malonyldialdehyde concentration was significantly reduced in Aloe vera treated group in comparision with negative control and sham-operated groups. Aloe vera gel can induce growth factor TGF- beta gene expression and reducing the lipid peroxidation content can play an important role in incisional skin wound healing process

Association of compliance of ventilator bundle with incidence of ventilator-associated pneumonia and ventilator utilization among critical patients over 4 years

Several studies showed that the implementation of the Institute for Healthcare Improvement [IHI] ventilator bundle alone or with other preventive measures are associated with reducing Ventilator-Associated Pneumonia [VAP] rates. However, the association with ventilator utilization was rarely examined and the findings were conflicting. The objectives were to validate the bundle association with VAP rate in a traditionally high VAP environment and to examine its association with ventilator utilization. The study was conducted at the adult medical-surgical intensive care unit [ICU] at King Abdulaziz Medical City, Saudi Arabia, between 2010 and 2013. VAP data were collected by a prospective targeted surveillance as per Centers for Disease Control and Prevention [CDC]/National Healthcare Safety Network [NHSN] methodology while bundle data were collected by a cross-sectional design as per IHI methodology. Ventilator bundle compliance significantly increased from 90% in 2010 to 97% in 2013 [P for trend < 0.001]. On the other hand, VAP rate decreased from 3.6 [per 1000 ventilator days] in 2010 to 1.0 in 2013 [P for trend = 0.054] and ventilator utilization ratio decreased from 0.73 in 2010 to 0.59 in 2013 [P for trend < 0.001]. There were negative significant correlations between the trends of ventilator bundle compliance and VAP rate [cross-correlation coefficients -0.63 to 0.07] and ventilator utilization [cross-correlation coefficients -0.18 to -0.63]. More than 70% improvement of VAP rates and approximately 20% improvement of ventilator utilization were observed during IHI ventilator bundle implementation among adult critical patients in a tertiary care center in Saudi Arabia. Replicating the current finding in multicenter randomized trials is required before establishing any causal link

Drug-resistant ventilator associated pneumonia in a tertiary care hospital in Saudi Arabia

There is a wide geographic and temporal variability of bacterial resistance among microbial causes of ventilator-associated pneumonia [VAP]. The contribution of multi-drug resistant [MDR] pathogens to the VAP etiology in Saudi Arabia was never studied. We sought to examine the extent of multiple-drug resistance among common microbial causes of VAP. We conducted a retrospective susceptibility study in the adult intensive care unit [ICU] of King Abdulaziz Medical City, Riyadh, Saudi Arabia. Susceptibility results of isolates from patients diagnosed with VAP between October 2004 and June 2009 were examined. The US National Healthcare Safety Network definition of MDR was adopted. A total of 248 isolates including 9 different pathogens were included. Acinetobacter spp. was highly [60-89%] resistant to all tested antimicrobials, including carbapenems [three- and four-class MDR prevalence were 86% and 69%, respectively]. Pseudomonas aeruginosa was moderately [13-31%] resistant to all tested antimicrobials, including antipseudomonal penicillins [three- and four-class MDR prevalence were 13% and 10%, respectively]. With an exception of ampicillin [fully resistant], Klebsiella spp. had low [0-13%] resistance to other tested antimicrobials with no detected MDR. Staphylococcus aureus was fully susceptible to vancomycin with 42% resistance to oxacillin. There were significant increasing trends of MDR Acinetobacter spp. However not P. aeruginosa during the study. Resistant pathogens were associated with worse profile of ICU patients but not patients' outcomes. Acinetobacter in the current study was an increasingly resistant VAP-associated pathogen more than seen in many parts of the world. The current finding may impact local choice of initial empiric antibiotics.

Risk factors, management and outcomes of patients admitted with near fatal asthma to a tertiary care hospital in Riyadh

Near-fatal asthma [NFA] has not been well studied in Saudi Arabia. We evaluated NFA risk factors in asthmatics admitted to a tertiary-care hospital and described NFA management and outcomes. This was a retrospective study of NFA patients admitted to an ICU in Riyadh [2006-2010]. NFA was defined as a severe asthma attack requiring intubation. To evaluate NFA risk factors, randomly selected patients admitted to the ward for asthma exacerbation were used as controls. Collected data included demographics, information on prior asthma control and various NFA treatments and outcomes. Thirty NFA cases were admitted to the ICU in the five-year period. Compared to controls [N= 120], NFA patients were younger [37.5 +/- 19.9 vs. 50.3 +/- 23.1 years, P= 0.004] and predominantly males [70.0% vs. 41.7%, P= 0.005] and used less inhaled steroids/long-acting 32-agonists combination [13.6% vs. 38.7% P = 0.024. Most [73.3%] NFA cases presented in the cool months [October-March]. On multivariate analysis, age [odds ratio [OR] 0.96; 95% confidence interval [Cl], 0.92-0.99, P= 0.015] and the number of ED visits in the preceding year [OR, 1.25; 95% Cl, 1.00-1.55] were associated with NFA. Rescue NFA management included ketamine [50%] and theophylline [19%] infusions. NFA outcomes included: neuromyopathy [23%], mechanical ventilation duration = 6.4 +/-4.7 days, tracheostomy [13%] and mortality [0%]. Neuromuscular blockade duration was associated with neuromyopathy [OR, 3.16 per one day increment; 95% Cl, 1.27-7.83]. In our study, NFA risk factors were younger age and higher number of ED visits. NFA had significant morbidity. Reducing neuromuscular blockade duration during ventilator management may decrease neuromyopathy risk

Building capacity for quality and safety in critical care: a roundtable discussion from the second international patient safety conference in April 9-11, 2013, Riyadh, Saudi Arabia

This paper summarizes the roundtable discussion from the Second International Patient Safety Conference held in April 9-11, 2013, Riyadh, Saudi Arabia. The objectives of the roundtable discussion were to: [1] Review the conceptual framework for building capacity in quality and safety in critical care.2] Examine examples of leading international experiences in building capacity.3] Review the experience in Saudi Arabia in this area.4] Discuss the role of building capacity in simulation for patient safety in critical care and [5] Review the experience in building capacity in an ongoing improvement project for severe sepsis and septic shock

Knowledge of thromboprophylaxis guidelines pre- and post-didactic lectures during a venous thromboembolism awareness day at a tertiary-care hospital

Didactic lectures are frequently used to improve compliance with practice guidelines. This study assessed the knowledge of health-care providers [HCPs] at a tertiary-care hospital of its evidence-based thromboprophylaxis guidelines and the impact of didactic lectures on their knowledge. The hospital launched a multifaceted approach to improve thromboprophylaxis practices, which included posters, a pocket-size guidelines summary and didactic lectures during the annual thromboprophylaxis awareness days. A self-administered questionnaire was distributed to HCPs before and after lectures on thromboprophylaxis guidelines [June 2010]. The questionnaire, formulated and validated by two physicians, two nurses and a clinical pharmacist, covered various subjects such as risk stratification, anticoagulant dosing and the choice of anticoagulants in specific clinical situations. Seventy-two and 63 HCPs submitted the pre- and post-test, respectively [62% physicians, 28% nurses, from different clinical disciplines]. The mean scores were 7.8 +/- 2.1 [median = 8.0, range = 2-12, maximum possible score = 15] for the pre-test and 8.4 +/- 1.8 for the post-test, P = 0.053. There was no significant difference in the pre-test scores of nurses and physicians [7.9 +/- 1.7 and 8.2 +/- 2.4, respectively, P = 0.67]. For the 35 HCPs who completed the pre- and post-tests, their scores were 7.7 +/- 1.7 and 8.8 +/- 1.6, respectively, P = 0.003. Knowledge of appropriate anticoagulant administration in specific clinical situations was frequently inadequate, with approximately two-thirds of participants failing to adjust low-molecular-weight heparin doses in patients with renal failure. Education via didactic lectures resulted in a modest improvement of HCPs' knowledge of thromboprophylaxis guidelines. This supports the need for a multifaceted approach to improve the awareness and implementation of thromboprophylaxis guidelines

Trauma profile at a tertiary intensive care unit in Saudi Arabia

Trauma is a leading cause of death worldwide and in Saudi Arabia. This study describes the injury profiles and ICU outcomes of patients in a tertiary trauma care referral center in Riyadh, Saudi Arabia. A retrospective analysis of ICU data collected prospectively over 5 years in a 21-bed medical and surgical intensive care unit [ICU] in a tertiary care teaching hospital. We collected ICU data on all patients admitted secondary to motor vehicle accidents [MVAs], excluding patients younger than 18 years, brain dead patients and readmissions. We collected data on age, gender, and Glasgow coma scale score at admission, injury severity scores at admission, injury severity scores, Acute Physiology and Chronic Health Evaluation II [APACHE II] score, and other data. Multivariate logistic regression was used to identify predictors of mortality. During the study period, of 1659 patients, MVA was the most common cause of injury [78.4%], followed by pedestrian accident [12.7%]. ICU mortality included 221 patients [13.3%] during the study period. Severe head injury, age >60 years, Glascow coma scale score, injury severity scores, APACHE II and international normalized ratio were independent predictors of mortality. MVA is very common in our country and leads to significant mortality and morbidity. Public education and strict law enforcement are needed to reduce these adverse events

-hospital mortality among a cohort of cirrhotic patients admitted to a Tertiary hospital

To determine the mortality rate in a cohort of hospitalized patients with cirrhosis and examine their resuscitation status at admission. A retrospective chart review was conducted of patients with cirrhosis who were admitted to a tertiary care hospital in Riyadh, Saudi Arabia, from January 1, 2009, to December 31, 2009. We reviewed 226 cirrhotic patients during the study period. The hospital mortality rate was 35%. A univariate analysis revealed that worse outcomes were seen in patients with advanced age or who had worse child-turcotte-pugh [CPT] scores, worse model for end-stage liver disease [MELD] scores, low albumin and high serum creatinine. Using a multivariate analysis, we found that advanced age [P=0.004] and high MELD [P=0.001] scores were independent risk factors for the mortality of cirrhotic patients. The end-of-life decision were made in 34% of cirrhotic patients, and the majority of deceased patients were "no resuscitation" status [90% vs. 4%, P<0.001]. The relatively high mortality in cirrhotic patients admitted for care in a tertiary hospital, Saudi Arabia was comparable to that reported in the literature. Furthermore, end-of-life discussions should be addressed early in the hospitalization of cirrhotic patients

Intensive insulin therapy versus conventional insulin therapy for critically ill trauma patients admitted to ICU

The objective of our study was to evaluate the beneficial effect of IIT in reducing mortality and morbidity in critically ill trauma patients admitted to ICU. Nested cohort study within a Randomized Controlled Trial. All trauma patients with GCS

Assessment the diagnostic accuracy of sentinel lymph nodes lymphoscintigraphy using technetium-99m phytate in breast cancer

Technetium-99m phytate [[99m]Tc-ph] is a readily available radiopharmaceutical and has been suggested as a suitable agent for sentinel lymph node [SLN] detection. In this study, the diagnostic accuracy and false-negative rate of radionuclide SLN mapping using [99m]Tc-ph were investigated. Forty three women [mean age 52.3 years, range 31-74 years], who all had been diagnosed with breast cancer were enrolled in the study. All patients had no palpable axillary lymph nodes and had not undergone exploratory tumor resection or any drug treatment, previously. [99m]Tc-ph was injected peri-tumorally at four sites. Following SLN scintigraphic imaging, the patients were operated. Intraoperatively SLN were detected by a scintillation probe and a blue dye technique. Modified radical mastectomies with radical axillary dissection were performed with excision of the lymph nodes, to evaluate the accuracy of the SLN technique. Intraoperative scinti-mapping identified SLN in 40 of the 43 patients [detection rate: 93%]. Scintigraphically, none of the patients had internal mammary drainage or contralateral axillary involvement. The blue dye detection rate in 23 patients under study was 87% and all lymph nodes detected by the blue dye technique were also detected as "hot" spots in the lymphoscintigraphy. Using pathology as the gold standard, the sensitivity and negative predictive value of scintigraphic lymphatic mapping in detection of SLN by [99m]Tc-ph were 90% and 90.9%, respectively. The same values for blue dye lymphatic mapping were 84.6% and 77.7%, respectively. [99m]Tc-ph used for SLN mapping is readily available, has low cost and gives better results than the blue dye technique. Long-term follow-up is required to assess accurately the incidence of failure in patients with negative SLN and the overall diagnostic accuracy and efficacy of the SLN mapping using [99m]Tc-ph as the radioactive tracer

introduction to medical simulation

While medical simulation is no panacea, it offers numerous potential strategies for comprehensive and practical training, safer patient care, and for those keen to attract and retain staff. It is a technique, rather than just a technology that promotes experiential and reflective learning. It is also a key strategy to teach Crisis Resource Management skills. Simulation can benefit the individual learner, the multidisciplinary team, and the hospital as a whole. It has been described as a key driver of patient safety, and even as the "patient safety laboratory" of the future. As such is endorsed by many professional societies in many nations. While challenges remain [and are outlined] there are great opportunities for clinicians, administrators, and educators alike

Anatomy of the hoof in sheep, a study to find proper hoof trimming indices

An anatomic study on ovine hoof to find a proper hoof trimming method was done. Fore and hind limbs of 15, two years old ewes. were studied all legs were transferred to vet college and divided by fore and hind limbs, left and right and lateral and medial digits. Toe height to ground and to the solar surface, heel height, sole length, toe length, toe length to the sensitive tissue, sole thickness in toe and heel region [cm] were measured. Toe angle was mathematically measured from toe height and toe length and toe to heel height was measured as well. All data were compared by t-test. Toe angle was significant in forelimbs [55. 09 +/- 8. 1] and hind limbs [50. 43 +/- 6. 9] and heel height was significantly different [3. 02 +/- 0. 33, 2. 36 +/- 0. 44] in the fore and hind limbs respectively. Although no statistical difference was recorded in the other results but some descriptive changes were recorded. Hoof grows to make an edge in the solar hoof wall that is slightly longer in hind limbs. Sole thickness in toe and heel regions of fore and hind limb was recorded as 0. 41 +/- 0. 12, 0. 82 +/- 0. 18 and 0. 37 +/- 0. 13, 0. 68 +/- 0. 17 respectively that was significantly higher in hind limbs. Hoof growth pattern in sheep is different from cow. Toe angle in fore and hind limb is slightly higher than cows. Lateral wall growth in solar region makes weight bearing surface of the hoof different from cows. 1. 2 of horny tissue of the hoof protects from sensitive underlying tissue that can make a satisfactory hoof trimming

[Demographic charectrestics and risk factors in 320 thyroid cancer patients]

Thyroid cancer is a rare disease which includes less than 1% percent of all human cancers. The aim of this study is to evaluate the demographic characteristics and risk factors among patients with thyroid malignancy at the Cancer institute and Imam Khomeini hospital in Tehran Iran. This is a retrospective descriptive study of the charts of 320 patients admitted with the diagnosis of thyroid malignancy based on pathologic reports in the above- mentioned hospitals from 1992 to 2002. From the 320 patients diagnosed with thyroid malignancy 68.1% were papillary cancer, 10.9% were follicular cancer, 10.6% were anaplastic cancer, 9.06% were medullary cancer and 1.2% were lymphoma. The average of the patients was 50.2 years, ranging from 12 to 98 years; 60.6% were female and 39.4%were male; 22.8% of the patients had histories of thyroid nodule and 5% had received radiation therapy. From the anatomic point of view 57.5% of the cancers were in the right lobe of thyroid, 38.1% were in left lobe and 4.4% in the isthmus. None of the patients had positive family history of thyroid malignancy. Thyroid malignancy is more prevalent in the fifth decade of life and more common among females. Therefore, among patients in this group, alarming symptoms, such as anterior neck mass, thyroid nodule and voice change, should be evaluated more seriously