Evaluation of use of electronic patient controlled analgesia pumps to improve patient safety in an academic medical center.

Patient controlled analgesia (PCA) and Patient-controlled epidural analgesia (PCEA) pumps are methods of pain control with complex smart infusion devices and are widely used in hospitals. Smart PCA/PCEA pumps can be programmed with the dose and rate of medications within pre-set ranges. However, adverse effects have been reported associated with these pumps' use. In this paper, we describe a prevalence observational study where observers used an electronic data collection tool to record pump settings and medications with PCA pumps, corresponding medication orders to identify errors. The results showed that there were many labeling and tubing change tag errors, which were a violation of hospital policy. A few potential harmful medication errors were identified but no critical errors. Study results suggest the importance of a standard process of PCA pump use. Next steps include implementing a safety bundle for improving PCA practice to support safe and effective pain management.

Development of a web-based observational tool for detecting intravenous medication errors with smart infusion pumps.

Computerized smart infusion pumps have been widely implemented to decrease the rate of intravenous (IV) medication errors in hospitals. However, these devices have not always achieved their potential, and important IV errors still persist. Findings from a previous study [1] that assessed the frequency of IV medication errors and the impact of smart infusion pumps identified major issues related to use of smart infusion pumps in a single facility, but generalizability of these results is uncertain. Additionally, lack of standardized methodology for measuring these errors remains an issue. In this study, we developed an observational tool to capture IV medication errors through iterative participatory design with interdisciplinary experts and then tested the tool by using incident cases regarding smart pump errors. We found that the tool could capture all smart infusion pump errors and is ready for testing for use as standard data collection tool in different hospital settings.

Evaluation of intravenous medication errors with smart infusion pumps in an academic medical center.

While some published research indicates a fairly high frequency of Intravenous (IV) medication errors associated with the use of smart infusion pumps, the generalizability of these results are uncertain. Additionally, the lack of a standardized methodology for measuring these errors is an issue. In this study we iteratively developed a web-based data collection tool to capture IV medication errors using a participatory design approach with interdisciplinary experts. Using the developed tool, a prevalence study was then conducted in an academic medical center. The results showed that the tool was easy to use and effectively captured all IV medication errors. Through the prevalence study, violation errors of hospital policy were found that could potentially place patients at risk, but no critical errors known to contribute to patient harm were noted.

Efficacy of parenteral vaccination against porcine circovirus type 2 (PCV2) in seropositive piglets.

This study investigated if parenteral administration of a prototype adjuvanted vaccine against porcine circovirus type 2 (PCV2) could override maternally derived antibodies and induce acquired immunity in young piglets. Piglets with high levels of maternal PCV2 antibodies at 1 wk of age were randomly grouped into vaccinates and controls on the basis of body weight and inoculated with the vaccine or a control preparation twice, with an interval of 3 wk. Both groups were challenged 3 wk after the booster vaccination and euthanized 3 wk after challenge. The pigs were evaluated for clinical disease, histologic lesions in sections of gastric and left inguinal lymph nodes stained with hematoxylin and eosin, and the amount of PCV2 antigen in the lymph nodes by immunohistochemical study. The PCV2 antibody titers were monitored by competitive enzyme-linked immunosorbent assay throughout the experiment. The vaccinates showed significantly less decline (P < 0.05) in PCV2 antibody titers after the booster vaccination. Clinical disease did not develop in any of the piglets. The vaccinates and controls did not differ in either histologic lesions or amount of PCV2 antigen in the lymph nodes. This study demonstrated some evidence of priming of young piglets in the presence of maternal antibodies. Further studies are recommended to determine the optimum concentration of PCV2 antigen and a suitable adjuvant for the vaccine to achieve the full potential of the strategy of inducing acquired immunity in young piglets that have maternally derived antibodies.

Cette étude visait à déterminer si l'administration parentérale d'un prototype de vaccin avec adjuvant dirigé contre le circovirus porcin de type 2 (PCV2) pouvait outrepasser les anticorps maternels et induire une immunité acquise chez les jeunes porcelets. Les porcelets avec des niveaux élevés d'anticorps maternels anti-PCV2 à 1 sem d'âge étaient regroupés de manière aléatoire en vaccinés et témoins basés sur le poids corporel et inoculés avec le vaccin ou une préparation témoin deux fois à un intervalle de trois semaines. Les deux groupes ont été soumis à une infection défi 3 sem après la vaccination de rappel et euthanasiés 3 sem après l'infection. Les porcs ont été évalués pour la présence de maladie clinique, de lésions histologiques dans des sections de noeuds lymphatiques gastriques et inguinal gauche colorés avec de l'hématoxyline et éosine, et la quantité d'antigène PCV2 dans les noeuds lymphatiques par étude immunohistochimique. Les titres d'anticorps anti-PCV2 ont été suivis par épreuve immuno-enzymatique compétitive tout au long de l'expérience. Les animaux vaccinés ont présenté une diminution significativement moindre (P < 0,05) des titres d'anticorps anti-PCV2 après le rappel de vaccin. La maladie clinique ne s'est développée chez aucun des porcelets. Les animaux vaccinés et les témoins n'ont pas différé quant aux lésions histologiques et à la quantité d'antigènes de PCV2 dans les noeuds lymphatiques. Cette étude a démontré quelques évidences d'amorçage de l'immunité chez les jeunes porcelets en présence d'anticorps maternels. Des études supplémentaires sont recommandées afin de déterminer la concentration optimale d'antigène de PCV2 et un adjuvant adéquat pour le vaccin dans le but d'atteindre le plein potentiel de la stratégie d'induire une immunité acquise chez les jeunes porcelets possédant des anticorps maternels.(Traduit par Docteur Serge Messier).

Sharps injury reduction using a sharps container with enhanced engineering: a 28 hospital nonrandomized intervention and cohort study.

BACKGROUND: The decrease in reported sharps injuries (SI) in the United States has markedly slowed. Additional devices and strategies need investigation. Sharps containers are associated with SI, and more than 90% of these injuries are related to container design. This study addresses the hypothesis that containers with enhanced engineering can reduce SI. METHODS: In a before/after intervention study from 2006 to 2008, we examined the impact of conversion to a sharps container with enhanced engineering (the Device) on SI categories in 14 Ascension Health hospitals (study group). The Device's safety features included large horizontal aperture, sensitive counterbalanced door, large atrium, and passive overfill prevention. Study group results were also compared with a control cohort of 14 contemporaneous size-matched, Ascension Health hospitals (control group). RESULTS: The Device was associated with significant reductions in after-procedure (-30%), disposal-related (-57%), and container-associated (-81%) SI in the study group. No significant reductions occurred in container-associated sharps injuries in the control group. Hospitals using the Device had significantly fewer total SI than control hospitals. CONCLUSION: Enhanced aperture design can significantly reduce container-associated sharps injuries. Other factors contributing to reduced injuries may include 1-hand deposit, safe closure, hand restriction, and preassembly. These results, from a country where sharps safety devices are widespread, are particularly applicable to countries where safety devices are not extensively used.

In situ detection of urease-positive Helicobacter pylori-like organisms on swine gastric mucosa.

The objective of this study was to improve the visual localization of urease activity of Helicobacter pylori-like organisms (HPLO) on swine gastric mucosa by in vitro optimization of the urea concentration and pH indicator of a urease test reagent. Five 21-day-old conventional pigs were infected orally with HPLO (3 pigs) or Brucella broth alone (2 pigs). At 17 d after infection the pigs were euthanized and their stomachs excised and tested for HPLO by a modified urease test formulation sprayed onto the gastric mucosa, as well as confirmatory culture and isolation of HPLO from urease-positive sites. This study showed improved detection of HPLO in porcine gastric mucosa with the use of a modified urease test formulation containing 5% urea and the pH indicator bromocresol purple compared with the use of a conventional formulation of 2% urea and phenol red. This test can readily be applied to achieve a presumptive diagnosis of HPLO in cases of gastritis or gastric esophageal ulceration in pigs.

Ring tests to evaluate the performance of Porcine circovirus-2 (PCV-2) polymerase chain reaction (PCR) assays used in North American diagnostic laboratories.

Two laboratory studies involving 11 laboratories were undertaken to assess the performance of North American Porcine circovirus-2 (PCV-2) polymerase chain reaction (PCR) assays. Laboratories received identical submissions containing randomly coded positive and negative control samples, and serially diluted PCV-2-spiked samples. In study 1 and 2, respectively, spiked samples contained measured amounts of PCV-2 virus or DNA. All but 1 assay detected DNA in the most concentrated spiked sample. There were no statistical differences in the proportion of positive or negative samples reported by quantitative (n = 7) versus non-quantitative (n = 6) assays. Across both studies, the false positive rate was 17% (4 out of 23), and 17% (2 out of 12) of assays cross-reacted with PCV-1. The most sensitive assay detected PCV-2 DNA levels about 100 000 times lower the least sensitive assay. This study demonstrated that the PCR assays available in North American diagnostic labs vary considerably in their detection limits and quantification.

In utero transmission of porcine torque teno viruses.

Sera and selected tissue homogenates collected from gnotobiotic swine never exposed to the environment or other swine tissues were tested for the presence of porcine torque teno virus (TTV) DNAs by nested and non-nested polymerase chain reactions (PCR) using primers specific for the untranslated region of porcine genogroups (g) 1 and 2. Twenty-three of 105 (21.9%) gnotobiotic piglets were g1- and/or g2-TTV DNA positive. Twenty-three of 27 (85.2%) sow sera, collected at the time of Caesarian derivation of the litters contained either or both TTV genogroup DNAs. These data demonstrate that porcine TTV may be transmitted to piglets by the in utero route and that the incidence of fetal infection is high.

Development and validation of a SYBR green real-time PCR for the quantification of porcine circovirus type 2 in serum, buffy coat, feces, and multiple tissues.

The emergence of multiple genotypes of PCV2, as demonstrated by phylogenetic analysis of whole genome or capsid sequences, makes it necessary to have quantitative diagnostic assays that perform equally well on all strains. The objectives of this study were to develop and validate a novel real-time polymerase chain reaction (PCR) assay targeting the highly conserved rep gene (ORF1) and investigate the effects of diagnostic specimen choice on its performance. The assay was tested in naturally infected conventional pigs, experimentally infected gnotobiotic pigs, and plasmid-spiked negative serum, lung tissue, and feces and found to have a linear detection range of 2.2x10(3) to 2.2x10(10) copies of PCV2 per mL. The assay successfully detected and quantified PCV2 DNA in serum, buffy coat, feces, and multiple lymphoid (bronchial, mesenteric, and superficial inguinal lymph nodes; thymus; tonsil; ileal Peyer's patches; and spleen), and non-lymphoid (myocardium; lung; kidney; liver; and gluteal muscle) tissues from naturally infected pigs. Across all tissues and sera of naturally infected pigs, the mean PCV2 concentration was 3.0logs higher in wasting versus non-wasting pigs. PCV2 concentration measured by tissue culture and immunohistochemical staining in homogenized liver samples of experimentally infected gnotobiotic pigs were compared to the concentrations estimated by quantitative PCR. Similar trends were noted with increasing PCV2 concentration detected in subclinically infected to severely PMWS-affected pigs across all assays. Our diagnostic assay was developed with a conserved target sequence, and performed efficiently in quantification of PCV2 in a variety of tissues from naturally and experimentally infected pigs.

Porcine circovirus-2 DNA concentration distinguishes wasting from nonwasting pigs and is correlated with lesion distribution, severity, and nucleocapsid staining intensity.

The emergence of severe porcine circoviral disease in North America is associated with Porcine circovirus-2 genotype b (PCV-2b), which has led to speculation that PCV-2b is more virulent than PCV-2a. The objectives of this study were to 1) correlate the PCV-2 DNA concentration and lesions in wasting (WST) and age-matched healthy (HLTH) pigs from 2 clinically affected farms, and unaffected (UNFCT) pigs from a farm with no prior clinical or diagnostic history of PCVD; and 2) to determine the initial estimates of sensitivity and specificity of PCV-2 quantitative polymerase chain reaction (qPCR). PCV-2b was confirmed in all 3 farms. Compared with HLTH pigs, WST pigs demonstrated significantly more prevalent thymic atrophy, failure of normal pulmonary collapse, and ascites (P < 0.017 for all). The HLTH and UNFCT pigs had significantly more pronounced lymphoid germinal centers and proliferative paracortical T-dependent zones, compared with WST pigs (P < 0.017). Across all tissues, PCV-2 DNA concentrations were significantly higher in WST compared with HLTH and UNFCT pigs (P < 0.017 for all). The PCV-2 DNA concentrations were strongly correlated with PCV-2 nucleocapsid staining intensity in lymph node, spleen, Peyer's patches, lung, liver, and kidney (0.60 < or = r < or = 0.84). In the current study, the PCV-2 DNA log10 cutoff concentrations best able to distinguish WST from HLTH and UNFCT pigs were between 7.0 and 8.0 per gram for tissues, and between 4.0 and 5.0 per milliliter for sera. The presence of PCV-2b in UNFCT pigs is evidence that PCV-2b by itself is not sufficient to induce severe disease.

Quantitative polymerase chain reaction for Porcine circovirus-2 in swine feces in a Porcine circovirus disease-affected commercial herd and a nonaffected commercial herd.

This study examined if pigs in a Porcine circovirus disease (PCVD)-affected herd (n = 100) had shed more Porcine circovirus-2 (PCV-2) in their feces than pigs in a PCVD-nonaffected herd (n = 101), and if differences in shedding among production stages within and between the herds existed. The PCV-2 shedding was quantified by real-time polymerase chain reaction. The highest median PCV-2 shedding was found in the nursery of the PCVD-affected herd and in the grower of the PCVD-nonaffected herd. The PCV-2 shedding was significantly higher in earlier stages (newly weaned, nursery, and pregrower) in the PCVD-affected herd (Wilcoxon rank sum; P < 0.001) compared with the PCVD-nonaffected herd. Porcine circovirus-2 DNA was not detected in a significant proportion of lactating sows (parity > or = 3) in the PCVD-nonaffected herd (Fisher's exact test; P = 0.001). The results of this study suggest there may be an association between the presence of PCV-2 in the feces of lactating sows and increased PCV-2 shedding in younger pigs.

Age-dependent seroprevalence of antibodies against a Helicobacter pylori-like organism and Helicobacter pylori in commercially reared swine.

OBJECTIVE: To determine the prevalence of antibodies against a swine-origin Helicobacter pylori-like organism (HPLO) and H pylori in conventionally reared swine. ANIMALS: 640 conventionally reared swine of various ages from 16 high-health farms in Canada, 20 sows from Ohio, and 35 gnotobiotic swine. PROCEDURES: Blood was collected from the cranial vena cava. Sera were collected and tested via ELISA for antibodies against antigen prepared from a swine-origin HPLO and human H pylori strain 26695. RESULTS: Antibodies reactive with a swine HPLO, H pylori, or both were detected in 483 of 640 swine from all 16 farms in western Canada. Seroprevalence varied with age and was low (5.6%) in suckling ( 4 weeks old to adulthood. CONCLUSIONS AND CLINICAL RELEVANCE: Findings suggested that colonization by a swine-origin HPLO, H pylori, or both and resultant seroconversion, like that of H pylori infection in humans, were common in commercial swine operations. Furthermore, data indicated that gastric infection was acquired at an early age. The relationships to gastric colonization by HPLOs and clinical manifestations of disease such as gastritis and gastroesophageal ulceration remain to be determined.

Nested polymerase chain reaction detection and duration of porcine circovirus type 2 in semen with sperm morphological analysis from naturally infected boars.

A nested polymerase chain reaction (nPCR) protocol was applied to porcine semen to demonstrate the porcine circovirus type 2 (PCV2) shedding patterns and duration in naturally infected boars. Sperm morphology analysis was performed on a subset of samples to determine if the presence of PCV2 DNA in semen was associated with reduced semen quality. Semen was collected serially from 43 boars representing 6 breeds, aged 33.9 to 149.3 weeks. Of the 903 semen samples collected, 30 samples (3.3%) were positive for PCV2 DNA by nPCR from 13 boars. Boars shedding PCV2 DNA in semen ranged between 35.9 and 71.0 weeks of age, and shedding occurred during a period of up to 27.3 weeks. A semen nPCR test was 2.6 times more likely to be positive when collected from pigs that were < or =52 weeks of age, and 3.0 times more likely to be positive when collected from pigs that were < or =26 weeks from time of entry into the stud main unit (generalized estimating equations: P = 0.02; 95% confidence interval [CI] of the odds ratio 1.2 to 5.5, and P = 0.01; 95% CI of the odds ratio 1.3 to 6.9, respectively). These results demonstrate a sporadic and long-term shedding pattern of PCV2 DNA in semen from naturally infected boars. PCV2 DNA in semen does not appear to have detrimental effects on sperm morphology; however, boar age and, possibly, breed may contribute to the persistence of PCV2-shedding in semen.

Detection of Porcine circovirus type 2 viremia and seroconversion in naturally infected pigs in a farrow-to-finish barn.

Porcine serum was assayed by 2 polymerase chain reaction (PCR) protocols (nested PCR [nPCR] and non-nested PCR) and a competitive enzyme-linked immunosorbent assay to determine when Porcine circovirus type 2 (PCV2) viremia and a rise in the serum level of PCV2-specific antibody occurred in pigs raised in a large Canadian farrow-to-finish barn. Eight serial blood samples were collected from each of 40 pigs from 5 to 156 (+/- 1.5) d of age; 6 pigs were removed from the study for various reasons at various times. Viremia was not detected in the samples collected before 72 d of age but was detected in those collected on or after 72 d: of 33 pigs, 7 (21%) had only 1 serum sample positive for PCV2 DNA by nPCR after day 72; 11 (33%) were intermittently positive by nPCR, non-nested PCR, or both between 72 and 156 d; and the remaining 15 (45%) were repeatedly positive (in 2 to 4 samples). The level of serum antibody against PCV2 declined after weaning and increased between 72 and 107 d of age, only after PCV2 was detected in serum. Our results show that PCV2 viremia persists in the presence of elevated levels of PCV2-specific antibody.