Evaluation of lay health workers' needs to effectively support anti-tuberculosis treatment adherence in Malawi.

OBJECTIVE: To identify barriers and facilitators to efforts by lay health workers (LHWs) to support anti-tuberculosis treatment adherence in Malawi to inform the design of a knowledge translation intervention for improving adherence. DESIGN: Qualitative study utilizing focus groups and interviews conducted with LHWs providing tuberculosis (TB) care in Zomba District, Malawi. RESULTS: Participants identified lack of knowledge, both general (understanding of TB and its treatment) and job-specific (understanding of tasks such as completion of treatment forms), as the key barrier to LHWs in their role as adherence supporters. Lack of knowledge among LHWs providing TB care was reported to lead to a lack of confidence, conflicting messages given to patients, poor interactions with patients and errors in documentation. In addition to lack of knowledge, a number of system barriers were identified as limiting LHWs' ability to function optimally, including a lack of physical resources, workload, communication delays and ineffective guardians. CONCLUSION: Our findings suggest a gap between LHW knowledge and their responsibilities as adherence supporters. The results have informed the development of an educational outreach intervention and point-of-care tool, to be evaluated in a randomized trial in Zomba District.

La extracción de un hemograma antes de la valoración médica retrasa la administración de antibióticos en los pacientes con fiebre neutropénica en urgencias / Complete blood counts testing before physician assessment delays antibiotics in Emergency Febrile Neutropenia patients

Objetivo: La fiebre neutropénica (FN) se asocia a una alta mortalidad y requiere un tratamiento antibiótico precoz. Los procedimientos en urgencias, como las pautas preestablecidas de extracción de analíticas en el triaje, pueden disminuir los retrasos. Se evalua si el disponer de un hemograma con anterioridad a la primera valoración médica se asocia con una reducción del tiempo puerta-antibiótico. Método: Se revisaron los datos de 83 pacientes con FN ingresados en un hospital terciario durante 11 meses. El tiempo puerta-antibiótico se calculó como aquél correspondiente entre el momento del triaje y el de la administración del tratamiento. El principal factor de predicción fue la disponibilidad de los resultados del hemograma antes de la visita médica. Resultados: Se incluyó 72 pacientes [36% varones, edad de 58 (DE 14) años], todos clasificados con categorías altas de gravedad (I, II ó III) de triaje. El 50% tuvieron los resultados disponibles del hemograma cuando fueron valorados por primera vez por el urgenciólogo; y en ellos fue mayor el de tiempo puerta antibiótico que en los que no tuvieron un hemograma disponible (224 vs 83 minutos, p < 0,05). El 90% de los pacientes fueron diagnosticados de FN en urgencias y el 93% fueron tratados con antibióticos intravenosos. En un análisis de regresión logística, la valoración médica previa a los resultados del hemograma se asoció con un tiempo puerta-antibiótico más corto(-84 minutos; p = 0,051), mientras que los casos atendidos en fin de semana se asociaron con un mayor tiempo puerta-antibiótico (+151 minutos, p = 0,002).Conclusión: El tiempo puerta-antibiótico es un indicador factible de la calidad en la atención de los pacientes con FN. La mayoría de los pacientes son diagnosticados y tratados en urgencias. Los hallazgos del estudio no sugieren que disponer de los resultados de un hemograma en el momento de la primera valoración médica reduzca el tiempo puerta-antibiótico (AU)

Objective: Febrile neutropenia (FN) has high mortality and requires prompt antibiotic therapy. Emergency Department(ED) processes, such as standing orders for blood tests at triage, may reduce delays. We evaluated whether having complete blood counts (CBC) available prior to first physician assessment was associated with shorter door-to-antibiotic(DTA) time. Methods: Electronic and chart data was reviewed on 83 FN patients admitted to a tertiary care center over 11 months. DTA time was calculated from triage to delivery of drug. The main predictor was CBC result available before physician encounter. Results: Among 72 patients included, 36% were male, with a mean age of 58±14. All were given high acuity triagecodes, 50% had CBC results available when first assessed by the ED physician; their mean DTA time was longer than those who did not have a CBC available (224 min vs 83, p < 0.05). Although 90% of patients were diagnosed as “FN” in the ED, 93% were treated with IV antibiotics. In multivariable regression analysis, seeing a physician before CBC results was associated with shorter DTA time (–84 min, p = 0.0514), while weekend cases were associated with a longer DTAtime (+151 min, p = 0.0023).Conclusion: DTA time is a feasible measure of quality of care for FN patients. Most patients are diagnosed and treated inED. Our findings do not suggest that having a CBC result available at the first physician assessment reduces DTA time (AU)

The gatekeeper mutation T315I confers resistance against small molecules by increasing or restoring the ABL-kinase activity accompanied by aberrant transphosphorylation of endogenous BCR, even in loss-of-function mutants of BCR/ABL.

In Philadelphia chromosome-positive (Ph+) leukemia BCR/ABL induces the leukemic phenotype. Targeted inhibition of BCR/ABL by kinase inhibitors leads to complete remission. However, patients with advanced Ph+ leukemia relapse and acquire resistance, mainly due to point mutations in BCR/ABL. The 'gatekeeper mutation' T315I is responsible for a general resistance to small molecules. It seems not only to decrease the affinity for kinase inhibitors, but to also confer additional features to the leukemogenic potential of BCR/ABL. To determine the role of T315I in resistance to the inhibition of oligomerization and in the leukemogenic potential of BCR/ABL, we investigated its influence on loss-of-function mutants with regard to the capacity to mediate factor independence. Here, we show that T315I (i) requires autophosphorylation at tyrosine 177 in the BCR-portion to mediate resistance against the inhibition of oligomerization; (ii) restores the capacity to mediate factor-independent growth of loss-of-function mutants due to an increase in or activation of ABL-kinase; (iii) leads to phosphorylation of endogenous BCR, suggesting aberrant substrate activation by BCR/ABL harboring the T315I mutation. These data show that T315I confers additional leukemogenic activity to BCR/ABL, which might explain the clinical behavior of patients with BCR/ABL-T315I-positive blasts.

Emergency department overcrowding following systematic hospital restructuring: trends at twenty hospitals over ten years.

OBJECTIVE: Hospital restructuring often results in fewer inpatient beds, increased ambulatory services, and closures of hospitals or emergency departments (EDs). The authors sought to determine the impact of systematic hospital restructuring on ED overcrowding. METHODS: Time series analyses of average monthly overcrowding for EDs in Toronto, Ontario, Canada, from 1991 and 2000 (n = 20 hospitals, 120 months) were conducted. Autoregression models evaluated the rate of increase of overcrowding before and during systematic restructuring. A secondary analysis included total ED visits, patient age, and sex distribution as covariates. Seasonality was assessed by means of spectral analysis. RESULTS: Severe and moderate overcrowding averaged 3% and 14% of the time each month, respectively, over the whole period. Before restructuring (n = 74 months), severe and moderate overcrowding averaged 0.5% and 9% per month, respectively; during restructuring (n = 46 months), the monthly averages were 6% and 23%, respectively. Neither severe nor moderate overcrowding was increasing before restructuring. During restructuring, however, both increased significantly (severe 0.2% per month [p < 0.0001]; moderate 0.5% per month [p < 0.0001]). Similar results were found after controlling for ED utilization. Female gender independently predicted increased overcrowding; older age predicted reduced moderate overcrowding; number of total visits was not a predictor. Spectral analysis revealed significant seasonality in overcrowding. CONCLUSIONS: Hospital restructuring was associated with increased ED overcrowding, even after controlling for utilization and patient demographics. Restructuring should proceed slowly to allow time for monitoring of its effects and modification of the process, because the impact of incremental reductions in hospital resources may be magnified as maximum operating capacity is approached.

The Canadian C-spine rule for radiography in alert and stable trauma patients.

CONTEXT: High levels of variation and inefficiency exist in current clinical practice regarding use of cervical spine (C-spine) radiography in alert and stable trauma patients. OBJECTIVE: To derive a clinical decision rule that is highly sensitive for detecting acute C-spine injury and will allow emergency department (ED) physicians to be more selective in use of radiography in alert and stable trauma patients. DESIGN: Prospective cohort study conducted from October 1996 to April 1999, in which physicians evaluated patients for 20 standardized clinical findings prior to radiography. In some cases, a second physician performed independent interobserver assessments. SETTING: Ten EDs in large Canadian community and university hospitals. PATIENTS: Convenience sample of 8924 adults (mean age, 37 years) who presented to the ED with blunt trauma to the head/neck, stable vital signs, and a Glasgow Coma Scale score of 15. MAIN OUTCOME MEASURE: Clinically important C-spine injury, evaluated by plain radiography, computed tomography, and a structured follow-up telephone interview. The clinical decision rule was derived using the kappa coefficient, logistic regression analysis, and chi(2) recursive partitioning techniques. RESULTS: Among the study sample, 151 (1.7%) had important C-spine injury. The resultant model and final Canadian C-Spine Rule comprises 3 main questions: (1) is there any high-risk factor present that mandates radiography (ie, age >/=65 years, dangerous mechanism, or paresthesias in extremities)? (2) is there any low-risk factor present that allows safe assessment of range of motion (ie, simple rear-end motor vehicle collision, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness)? and (3) is the patient able to actively rotate neck 45 degrees to the left and right? By cross-validation, this rule had 100% sensitivity (95% confidence interval [CI], 98%-100%) and 42.5% specificity (95% CI, 40%-44%) for identifying 151 clinically important C-spine injuries. The potential radiography ordering rate would be 58.2%. CONCLUSION: We have derived the Canadian C-Spine Rule, a highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients. If prospectively validated in other cohorts, this rule has the potential to significantly reduce practice variation and inefficiency in ED use of C-spine radiography.

Canadian CT head rule study for patients with minor head injury: methodology for phase II (validation and economic analysis).

Prospective validation on a new set of patients is an essential test of a new decision rule. However, many clinical decision rules are not prospectively assessed to determine their accuracy, reliability, clinical sensibility, or potential impact on practice. This validation process is important because many statistically derived rules or guidelines do not perform well when tested in a new population. The methodologic standards for a validation study are similar to those described in the article on phase I for derivation studies in the August 2001 issue of Annals of Emergency Medicine. The goal of phase II is to prospectively assess the accuracy, reliability, and acceptability of the decision rule in a new set of patients with minor head injury. This will determine the clinical utility of the rule and is essential if such a rule is to be widely adopted into clinical practice.

Problems for clinical judgement: 4. Surviving in the report card era.

Health care report cards involve comparisons of health care systems, hospitals or clinicians on performance measures. They are going to be an important feature of medical care in Canada in the new millennium as patients demand more information about their medical care. Although many clinicians are aware of this growing trend, they may not be prepared for all of its implications. In this article, we provide some historical background on health care report cards and describe a number of strategies to help clinicians survive and thrive in the report card era. We offer a number of tips ranging from knowing your outcomes first to proactively getting involved in developing report cards.

The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation).

Head injuries are among the most common types of trauma seen in North American emergency departments, with an estimated 1 million cases seen annually. "Minor" head injury (sometimes known as "mild") is defined by a history of loss of consciousness, amnesia, or disorientation in a patient who is conscious and talking, that is, with a Glasgow Coma Scale score of 13 to 15. Although most patients with minor head injury can be discharged without sequelae after a period of observation, in a small proportion, their neurologic condition deteriorates and requires neurosurgical intervention for intracranial hematoma. The objective of the Canadian CT Head Rule Study is to develop an accurate and reliable decision rule for the use of computed tomography (CT) in patients with minor head injury. Such a decision rule would allow physicians to be more selective in their use of CT without compromising care of patients with minor head injury. This paper describes in detail the rationale, objectives, and methodology for Phase I of the study in which the decision rule was derived. [Stiell IG, Lesiuk H, Wells GA, McKnight RD, Brison R, Clement C, Eisenhauer MA, Greenberg GH, MacPhail I, Reardon M, Worthington J, Verbeek R, Rowe B, Cass D, Dreyer J, Holroyd B, Morrison L, Schull M, Laupacis A, for the Canadian CT Head and C-Spine Study Group. The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med. August 2001;38:160-169.]

Problems for clinical judgement: 3. Thinking clearly in an emergency.

The resuscitation of a patient in extremis is frequently characterized by chaos and disorganization, and is one of the most stressful situations in medicine. We reviewed selected studies from the fields of anesthesia, emergency medicine and critical care that address the process of responding to a critically ill patient. Individual clinicians can improve their performance by increased exposure to emergencies during training and by the incorporation of teamwork, communication and crisis resource management principles into existing critical care courses. Team performance may be enhanced by assessing personality factors when selecting personnel for high-stress areas, explicit assignment of roles, ensuring a common "culture" in the team and routine debriefings. Over-reliance on technology and instinct at the expense of systematic responses should be avoided. Better training and teamwork may allow for clearer thinking in emergencies, so that knowledge can be translated into effective action and better patient outcomes.

Problems for clinical judgement: 1. Eliciting an insightful history of present illness.

This article presents the results of a review of studies of psychology that describe how ordinary human reasoning may lead patients to provide an unreliable history of present illness. Patients make errors because of mistakes in comprehension, recall, evaluation and expression. Comprehension of a question changes depending on ambiguities in the language used and conversational norms. Recall fails through the forgetting of relevant information and through automatic shortcuts to memory. Evaluation can be mistaken because of shifting social comparisons and faulty personal beliefs. Expression is influenced by moods and ignoble failures. We suggest that an awareness of how people report current symptoms and events is an important clinical skill that can be enhanced by knowledge of selected studies in psychology. These insights might help clinicians avoid mistakes when eliciting a patient's history of present illness.

Problems for clinical judgement: 2. Obtaining a reliable past medical history.

Ordinary human reasoning may lead patients to provide an unreliable history of past experiences because of errors in comprehension, recall, evaluation and expression. Comprehension of a question may change depending on the definition of periods of time and prior questions. Recall fails through the loss of relevant information, the fabrication of misinformation and distracting cues. Evaluations may be mistaken because of the "halo effect" and a reluctance to change personal beliefs. Expression is influenced by social culture and the environment. These errors can also occur when patients report a history of present illness, but they tend to be more prominent with experiences that are more remote. An awareness of these specific human fallibilities might help clinicians avoid some errors when eliciting a patient's past medical history.

Complex emergencies: expected and unexpected consequences.

Complex emergencies emerged as a new type of disaster following the end of the Cold War, and have become increasingly common in recent years. Human activity including civil strife, war, and political repression often coexist with and contribute to natural phenomena such as famine. They frequently result in high mortality, population displacement, and the disruption of civil society and its infrastructure. This article reviews the context of recent complex emergencies, and their expected health consequences, such as diarrhea, measles, malnutrition and outbreaks of infectious disease, and the disruption of mechanisms of disease control and surveillance. However, the complex nature of these emergencies also may have unexpected consequences, such as hindering understanding of their causes or limiting the attention paid to them by the public. This paper discusses the context and consequences of complex emergencies from the health standpoint, and explores some of their unexpected effects.

Rape in war: the humanitarian response.

Women and children are vulnerable to sexual violence in times of conflict, and the risk persists even after they have escaped the conflict area. The impact of rape goes far beyond the immediate effects of the physical attack and has long-lasting consequences. We describe the humanitarian community's response to sexual violence and rape in times of war and civil unrest by drawing on the experiences of Médecins Sans Frontières/Doctors Without Borders and other humanitarian agencies. Health care workers must have a keen awareness of the problem and be prepared to respond appropriately. This requires a comprehensive intervention protocol, including antibiotic prophylaxis, emergency contraception, referral for psychological support, and proper documentation and reporting procedures. Preventing widespread sexual violence requires increasing the security in refugee camps. It also requires speaking out and holding states accountable when violations of international law occur. The challenge is to remain alert to these often hidden, but extremely destructive, crimes in the midst of a chaotic emergency relief setting.