A statewide quality improvement collaborative to reduce neonatal central line-associated blood stream infections.

OBJECTIVE: The objective of this study was to reduce central line-associated blood stream infections (CLABSIs) among 13 collaborating regional neonatal intensive care units by 25%. We tested the hypothesis that change could be attributed to the quality improvement collaborative by testing for 'special cause' variation. STUDY DESIGN: Our prevention project included five features: (1) leadership commitment, (2) potentially best practices, (3) collaborative processes, (4) audit and feedback tools and (5) quality improvement techniques. Baseline (1 January 2006 to 30 August 2006) data were compared with the intervention (1 September 2006 to 30 June 2007) and post-intervention (1 July 2007 to 30 December 2007) periods and analyzed using statistical process control (SPC) methods. RESULT: We detected special cause variation, suggesting that the collaborative was associated with reduced infection rates, from 4.32 to 3.22 per 1000 line days (a 25% decrease) when comparing the baseline with the follow-up period. CONCLUSION: The collaborative's process was associated with fewer infections. SPC suggested that systematic changes occurred. The remaining challenges include sustaining or even further reducing the infection rate.

EEG bispectrum predicts movement during thiopental/isoflurane anesthesia.

OBJECTIVE: The objective of our study was to test the efficacy of the bispectral index (BIS) compared with spectral edge frequency (SEF), relative delta power, median frequency, and a combined univariate power spectral derivative in predicting movement to incision during isoflurane/oxygen anesthesia. METHODS: A total of 42 consenting patients were assigned to 3 groups, isoflurane 0.75, 1.0, and 1.25 minimal alveolar concentration (MAC). Anesthesia was induced with thiopental and maintained with the appropriate end-tidal concentration of isoflurane. The electroencephalogram (EEG) was recorded using a microcomputer system, and data were analyzed off-line. The EEG during the 2 min before incision was analyzed. Following skin incision, each patient was carefully observed for 60 sec to detect occurrence of purposeful movement. RESULTS: For all groups combined, there was a statistically significant difference for BIS (p < 0.0001) and also for relative delta power (p < 0.016) between movers and nonmovers. There was a statistically significant difference between movers and nonmovers at 1.25 MAC isoflurane for BIS (p < 0.01). There were no other significant differences for any other EEG variable at any concentration of isoflurane. No EEG variable showed a relationship to isoflurane concentration. CONCLUSIONS: When bispectral analysis of the EEG was used to develop a retrospectively determined index, there was an association of the index with movement. Thus, it may be a useful predictor of whether patients will move in response to skin incision during anesthesia with isoflurane/oxygen.

Sex hormone binding globulin: effect of synthetic steroids on the assay and effect of oral contraceptives.

The effect that synthetic steroid components of different oral contraceptives have on the assay system for measurement of sex hormones binding globulin (SHBG)-binding capacity, has been examined. Interference with the assay was not demonstrable at therapeutic levels of the drugs. d-Norgestrel was the only steroid studied which bound to SHBG with an affinity comparable to the endogenous sex hormones; it also tended to decrease SHBG-finding capacity, whereas preparations containing low levels of norethisterone increased the binding capacity. We suggest that measurement of changes in SHBG-binding capacity in subjects taking oral contraceptives may prove useful in indicating changes in sex hormone balance, particularly in view of the well-recognised side-effect of these drugs.

PIP: This study examines the effect of synthetic steroid components of 7 commonly prescribed oral contraceptives on the assay of sex hormone binding globulin (SHBG). The 7 oral contraceptives and the number of patients taking each preparation are: 1) Minovlar (n=10); 2) Ortho-Novum 1/50 (n=2); 3) Gynovlar 21 (n=8); 4) Minilyn (n=5); 5) Eugynon-50 (n=2); 6) Eugynon-30 (n=10) and 7) Microgynon (n=3). The blood SHBG-binding capacity of these 40 women was measured. The method of Rosner was used in the SHBG-binding capacity assay. Serum samples from each woman were treated with charcoal to remove the endogenous and exogenous steroids; the samples were assayed for SHBG-binding capacity before and after the charcoal treatment. Binding studies were also done. The results show that the synthetic compounds do not cause significant interference with the assay system when used at therapeutic levels. Of the synthetic steroids studied, d-Norgestrel was the only 1 which bound to SHBG with an affinity comparable to the endogenous sex hormones. D-Norgestrel also tended to decrease SHBG-binding capacity. This finding supports the observation that d-Norgestrel has androgenic activity due to its structure, as there is an apparent relation between the in vivo androgenic activity of steroids and their ability to bind to SHBG; the more potent the androgen, the greater its binding to SHBG. It is probable that d-Norgestrel exerts a direct inhibiting effect on SHBG synthesis, as do endogenous androgens. The ideal oral contraceptive preparation is one which maintains the existing sex hormone balance, avoiding the undesirable effects of excess estrogen administration on the one hand and excess androgenicity on the other. Measurement of SHBG-binding capacity would be a useful tool for determining changes in sex hormone balance. As women vary in their requirement, measurement of SHBG-binding capacity before and during contraceptive therapy may be a better indicator of hormonal balance in an individual woman.