Impact of a multidimensional infection control strategy on catheter-associated urinary tract infection rates in the adult intensive care units of 15 developing countries: findings of the International Nosocomial Infection Control Consortium (INICC).

PURPOSE: We aimed to evaluate the impact of a multidimensional infection control strategy for the reduction of the incidence of catheter-associated urinary tract infection (CAUTI) in patients hospitalized in adult intensive care units (AICUs) of hospitals which are members of the International Nosocomial Infection Control Consortium (INICC), from 40 cities of 15 developing countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, India, Lebanon, Macedonia, Mexico, Morocco, Panama, Peru, Philippines, and Turkey. METHODS: We conducted a prospective before-after surveillance study of CAUTI rates on 56,429 patients hospitalized in 57 AICUs, during 360,667 bed-days. The study was divided into the baseline period (Phase 1) and the intervention period (Phase 2). In Phase 1, active surveillance was performed. In Phase 2, we implemented a multidimensional infection control approach that included: (1) a bundle of preventive measures, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of CAUTI rates, and (6) feedback of performance. The rates of CAUTI obtained in Phase 1 were compared with the rates obtained in Phase 2, after interventions were implemented. RESULTS: We recorded 253,122 urinary catheter (UC)-days: 30,390 in Phase 1 and 222,732 in Phase 2. In Phase 1, before the intervention, the CAUTI rate was 7.86 per 1,000 UC-days, and in Phase 2, after intervention, the rate of CAUTI decreased to 4.95 per 1,000 UC-days [relative risk (RR) 0.63 (95% confidence interval [CI] 0.55-0.72)], showing a 37% rate reduction. CONCLUSIONS: Our study showed that the implementation of a multidimensional infection control strategy is associated with a significant reduction in the CAUTI rate in AICUs from developing countries.

Immunodeficiency-related lymphoproliferative disorders: prospective data from the United Kingdom Children's Cancer Study Group Registry.

Clinical data and biological samples were prospectively collected in 42 children with lymphoproliferative disease (LPD) secondary to organ/bone marrow transplant-related immunosuppression (30: 11 liver, 10 heart/lung, 8 kidney and 1 bone marrow), other drug-induced immunosuppression (2), congenital immunodeficiency (8) or human immunodeficiency virus (HIV)-related immune dysfunction (2). Ages ranged from 10 months to 17 years and there were 15 girls. Pathology was centrally reviewed and showed polymorphic features in 5 cases, monomorphic in 23, mixed pattern in 5 patients and 9 other types. Using the Revised European-American Classification of Lymphoid Neoplasms, 5 were B lymphoblastoid, 24 were high-grade B and 14 were other subtypes. Using the Pittsburgh classification, 9 were lymphadenopathic, 10 were systemic, 25 were lymphomatous and, with the Murphy grouping for non-Hodgkin's lymphoma (NHL), 10 were localized and 32 non-localized. Twenty-four out of 38 evaluable cases were Epstein-Barr virus positive. Thirty-five patients were evaluable for clonality; 24 were monoclonal and 11 were polyclonal. Reduced immunosuppression in solid organ transplant patients resulted in resolution of disease in 14/24, which was sustained in 11. Nineteen patients received chemotherapy, 14/18 evaluable responded, which was sustained in 8 cases. Seven out of 29 solid organ transplant and 10/13 other immune-deficient patients died. In the largest group of patients, solid organ transplants, no significant clinical or biological characteristics that predicted outcome were identified. In the transplant group close monitoring of response during reduction in immunosuppression is essential and the early use of B NHL chemotherapy may be effective.

Detection of the PAX3-FKHR fusion gene in paediatric rhabdomyosarcoma: a reproducible predictor of outcome?

Rhabdomyosarcoma has 2 major histological subtypes, embryonal and alveolar. Alveolar histology is associated with the fusion genes PAX3-FKHR and PAX7-FKHR. Definition of alveolar has been complicated by changes in terminology and subjectivity. It is currently unclear whether adverse clinical behaviour is better predicted by the presence of these fusion genes or by alveolar histology. We have determined the presence of the PAX3/7-FKHR fusion genes in 91 primary rhabdomyosarcoma tumours using a combination of classical cytogenetics, FISH and RT-PCR, with a view to determining the clinical characteristics of tumours with and without the characteristic translocations. There were 37 patients with t(2;13)/PAX3-FKHR, 8 with t(1;13) PAX7-FKHR and 46 with neither translocation. One or other of the characteristic translocations was found in 31/38 (82%) of alveolar cases. Univariate survival analysis revealed the presence of the translocation t(2;13)/PAX3-FKHR to be an adverse prognostic factor. With the difficulties in morphological diagnosis of alveolar rhabdomyosarcoma on increasingly used small needle biopsy specimens, these data suggest that molecular analysis for PAX3-FKHR will be a clinically useful tool in treatment stratification in the future. This hypothesis requires testing in a prospective study. Variant t(1;13)/PAX7-FKHR appears biologically different, occurring in younger patients with more localised disease.

Fetal echocardiography and congenital heart disease.

Fetal echocardiography has proved a useful tool for prenatal detection of cardiac lesions and the diagnosis--and, in some cases, the treatment--of fetal arrhythmias. It is particularly indicated for mothers from high risk groups. Management of diagnosed heart disease leads either to termination of pregnancy or to optimal postnatal care for the baby and the mother.

Survival of patients with colorectal cancer diagnosed in a randomized controlled trial of faecal occult blood screening.

BACKGROUND: Analysis of survival of subjects with colorectal cancer diagnosed by different modalities can provide insight into the mechanism by which screening has an effect. It can also give an indication of the feasibility of using prognostic indicators as surrogate outcome measures to predict mortality in future studies. METHODS: This paper examines the survival of individuals with colorectal cancer diagnosed in the Nottingham trial and explores the role of selected prognostic factors as possible surrogate outcome measures. RESULTS: Survival was significantly better in subjects with screen-detected cancers than in controls, even after adjusting for tumour stage and accounting for lead-time bias. Survival was inversely related to stage of tumour, with patients with stage A tumours having the best survival. Subjects with well or moderately differentiated tumours had a significantly better survival than those with poorly differentiated tumours. CONCLUSION: Screening for colorectal cancer by means of faecal occult blood testing improved survival among subjects with screen-detected cancers. Differences in prognostic factors largely explain the differences in survival between both non-responders and subjects with interval cancers and those in the control group, but not the improved prognosis for patients with screen-detected cancers. The use of such factors as surrogate outcome measures may therefore be inappropriate.

Willingness to pay: a method for measuring preferences for maternity care?

BACKGROUND: The aim of this study was to assess the feasibility of the use of "willingness to pay" as a measure of the benefits of intrapartum care. METHODS: A questionnaire was mailed to 150 pregnant women booking at Aberdeen Maternity Hospital in the northeast of Scotland, giving information on options for intrapartum care compiled from a recent randomized trial of care in a midwife-managed delivery unit versus care in a consultant-led labor ward. Women were asked which type of care they preferred and what would be their maximum willingness to pay for their preferred option. Data were also collected on demographic and clinical characteristics. RESULTS: Most women (55%) expressed a preference for care in a midwives unit. However, strength of preference, as reflected in willingness to pay, was greater among those in the smaller group, who expressed a preference for care in a consultant-led labor ward. The willingness-to-pay results were not associated with ability to pay. CONCLUSIONS: These data should be used together with cost data to decide on provision of care. Given the strength of preference of the minority group, and if the cost implications are not too great, a flexible service that takes account of women's wishes should be provided, even if this goes against the trend for care of those at low risk. By analyzing choice of care by income groups and social class groupings, it is possible to examine whether willingness-to-pay results are associated with indicators of ability to pay. In this case, they were not. Willingness to pay has an advantage in allowing respondents to account for more than just health gain when valuing different types of care.

Assessing community values in health care: is the 'willingness to pay' method feasible?

In this paper an economics approach to assessing community values in health care priority setting is examined. The approach is based on the concept of 'willingness to pay' (WTP). Eighty two parents were interviewed with regard to three aspects of provision of child health services. For each aspect a choice of two courses of action was presented. Parents were asked which course of action they preferred and what was the maximum amount of money they would be prepared to pay for this rather than their less preferred option. WTP responses are acceptable to the majority of respondents and appear to 'behave' in accordance with a priori expectations. A method of assessing the influence of ability to pay on preferences and WTP is outlined. Preferences and WTP do not appear to have been unduly distorted by ability to pay. Use of WTP data does have the potential to provide health care purchasers and providers with information on intensity as well as direction of the preferences of members of the community.

Estimating the economic benefits of avoiding food-borne risk: is 'willingness to pay' feasible?

In this paper, the results of a pilot study of willingness to pay (WTP) to avoid poultry-borne illness are reported. Through this, the problems of devising an economic measure of the 'intangible' benefits of prevention of food-borne risk are explored. The study is the first to allow those against a prevention policy (irradiation of poultry-meat) to register their WTP not to have the policy implemented. The study demonstrates that it is feasible to obtain answers to WTP questions from a self-selected sample. Future studies should ensure greater representativeness of respondents, that better information about benefits is provided to respondents and that an appropriate method of aggregation of benefits is used.