Patient-driven hand hygiene audit process at a regional cancer center.

A patient-driven hand hygiene compliance audit strategy was piloted in a Canadian provincial cancer agency during routine provision of cancer outpatient care by health care providers (physicians, nurses, and health care aides) under conditions where the deployment of an independent external auditor was not feasible. The results of the audit suggest the feasibility of this approach as a routine institutional performance metric.

Outcome of local excision of rectal carcinoma.

PURPOSE: This study was designed to determine the results of patients with rectal adenocarcinoma treated with local excision. METHODS: A retrospective, chart review was conducted for all patients treated with local excision for rectal adenocarcinoma from 1984 to 1998. RESULTS: Sixty-four patients were retained for analysis. The median follow-up was 37 (range, 9-125) months. There were 15 local failures with a median time to local failure of 12 months. Seven patients were salvaged with further operation (4 by repeat local excision, 4 by abdominoperineal resection, and 1 by low anterior resection). The incidence of local recurrence increased with advancing stage of the carcinoma (T1, 13 percent; T2, 24 percent; T3, 71 percent), histologic grade of differentiation, (well, 12 percent; moderately, 24 percent; poorly, 44 percent), and margin status (negative, 16 percent; close (within 2 mm), 33 percent; positive, 50 percent). Sixteen percent of carcinomas < or = 3 cm failed compared with 47 percent for carcinomas > 3 cm. Nine percent (1/11) of T2 patients treated with adjuvant radiation therapy recurred locally compared with 36 percent (5/14) without radiation therapy. Three of four T3 patients who received radiation therapy failed locally compared with two of three who did not. Using the Kaplan-Meier method, the overall survival at five years was 71 percent, and disease-free survival was 83 percent. Actuarial local failure was 27 percent and freedom from distant metastasis was 86 percent. The sphincter preservation rate was 90 percent at five years. CONCLUSIONS: Local excision alone is an acceptable option for well-differentiated, T1 carcinomas, < or = 3 cm. Adjuvant radiation is recommended for T2 lesions. The high local recurrence rate in patients after local excision of T3 lesions with or without adjuvant radiotherapy would mandate a radical resection.

Assessment of the cytotoxicity of photocrosslinked dextran and hyaluronan-based hydrogels to vascular smooth muscle cells.

The cytotoxicity of polysaccharide-based hydrogels and solutions was studied in vitro after 48h of indirect exposure of the materials with vascular smooth muscle cells. Dextran and/or hyaluronan were derivatized using glycidyl methacrylate, and hydrogels were formed in the presence of photoinitiators and ultraviolet radiation in multiwell inserts to avoid direct contact with cell monolayers. Observation of cell morphology indicated that dextran hydrogels, a blend of non-derivatized hyaluronan into dextran hydrogel. and a hyaluronan solution were highly cytocompatible. However, hydrogels made of derivatized hyaluronan were cytotoxic when compared to unexposed sham controls that contained multiwell inserts but no hydrogels. Results from quantitative assays for proliferation and viability corroborated the qualitative observations, and scrape wound assays revealed a significant increase in smooth muscles cell migration/proliferation after indirect exposure to several of the polysaccharide-based materials. Results from this study demonstrate that hydrogels made of dextran and hyaluronan solution show good cytocompatibility in vitro. making these degradable matrices interesting candidates for drug delivery purposes.

Seven principles for teaching procedural and technical skills.

The authors developed a cognitive-theory-based checklist of seven important principles for teaching technical skills. They then used the checklist in a workshop for doctors who teach procedural and technical skills. Participants in the workshop found the principle-based approach to be more effective than the traditional "see one, do one, teach one" approach.

The value of specialization--is there an outcome difference in the management of fistulas complicating diverticulitis.

PURPOSE: The value of specialization has frequently been challenged by many health care institutions and providers. This review was conducted to determine whether there were any outcome differences in the management of fistulas complicating diverticulitis. METHODS: We conducted an historical cohort study using hospital charts of all cases of fistulas complicating diverticulitis that were operated on in four university-affiliated hospitals between 1975 and 1995. There were 122 patients, with 37 under the care of fully trained colorectal surgeons and 85 under the care of general surgeons. RESULTS: There were no significant differences in patient demographics, preoperative comorbidities, or the number of preoperative diagnostic investigations between the two groups. The colorectal surgeons performed more intraoperative ureteral stenting (Colorectal Surgery 55.5 percent vs. General Surgery 24.4 percent, P = 0.001). The general surgeons performed more initial diverting Hartmann's and colostomy procedures (Colorectal Surgery 5.4 percent vs. General Surgery 27 percent, P = 0.013). The patients in the General Surgery group had longer preoperative lengths of stay (median Colorectal Surgery 3 (range, 1-28) days vs. General Surgery 8 (range, 0-29) days; P < 0.001), longer postoperative lengths of stay (median Colorectal Surgery 11 (range, 5-40) days vs. General Surgery 14 (range, 2-80) days; P = 0.001), and longer total lengths of stay (median Colorectal Surgery 14 (range, 6-62) days vs. General Surgery 24 (range, 6-100) days; P < 0.001). The patients in the General Surgery group experienced a higher rate of wound infections (Colorectal Surgery 5.4 percent vs. General Surgery 12.9 percent), and a larger proportion of them experienced complications (Colorectal Surgery 27 percent vs. General Surgery 41.2 percent). CONCLUSIONS: We conclude that specialization in colon and rectal surgery contributed to an improved outcome, with a lower rate of diverting procedures, a shorter hospital stay, and a lower rate of complications.

The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial.

PURPOSE: Colorectal surgery is associated with postoperative ileus, which contributes to delayed discharge. This study was designed to investigate the effect of thoracic epidural anesthesia and analgesia on gastrointestinal function after colorectal surgery under standardized controlled postoperative care. METHODS: Forty-two patients diagnosed with either colonic cancer, diverticulitis, polyps, or adenoma, and scheduled for elective colorectal surgery, were randomly assigned to either postoperative patient-controlled analgesia (PCA) with intravenous morphine (n = 21) or epidural analgesia with a mixture of bupivacaine and fentanyl (n = 21). Postoperative early oral feeding and assistance to mobilization were offered to all patients. Pain visual analog scale (1-100 mm), passage of flatus and bowel movements, length of hospital stay, and readiness for discharge were recorded. RESULTS: Pain visual analog scale (visual analog scale, 1-100 mm) at rest, on coughing, and daily on mobilization was significantly lower in the epidural group compared with the patient-controlled analgesia group. Median values for the visual analog scale group were 7 (95 percent confidence interval, 2-18) mm, 19 (95 percent confidence interval, 4-38) mm, and 10 (95 percent confidence interval, 5-33) mm, respectively, and, for the patient-controlled analgesia group, were 24 (95 percent confidence interval, 18-51) mm, 59 (95 percent confidence interval, 33-74) mm, and 40 (95 percent confidence interval, 29-79) mm, respectively (P < 0.01). Intake of protein and calories and time out of bed were similar in both groups. Mean time intervals +/- standard deviation from surgery to first flatus and first bowel movement occurred earlier in the epidural group, 1.9 +/- 0.6 days and 3.1 +/- 1.7 days, respectively, compared with patient-controlled analgesia, 3.6 +/- 1.5 days and 4.6 +/- 1.6 days, respectively (P < 0.01). Postoperative complications occurred in 33 percent of the patient-controlled analgesia group and 28 percent of the epidural group. There was no significant difference in length of hospital stay between the two groups with a mean of 7.3 +/- 3.7 days in the patient-controlled analgesia group and 8.5 +/- 4.2 days in the epidural group. Readiness for discharge was similar in both groups. CONCLUSION: Thoracic epidural analgesia has distinct advantages over patient-controlled analgesia morphine in providing superior quality of analgesia and shortening the duration of postoperative ileus. However, discharge home was not faster, indicating that other perioperative factors influence the length of hospital stay.

Quality of life after coronary revascularization in the United States and Canada.

Cardiac procedures are performed less frequently in Canada than in the United States (US), yet rates of cardiac death and myocardial infarction are similar. We therefore sought to compare long-term symptoms and quality of life in Canadian and American patients undergoing initial coronary revascularization. The 161 patients enrolled in the Bypass Angioplasty Revascularization Investigation at the Montreal Heart Institute were compared with 934 patients enrolled at 7 US sites. Patients' outcomes were documented for 5 years after random assignment to percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery. Functional status was assessed using the Duke Activity Status Index. Canadian patients were significantly younger and had more angina at study entry. Death and nonfatal myocardial infarction were not significantly different between Canadian and US patients after adjustment for baseline risk. Canadian patients had significantly greater improvements in functional status at 1-year follow-up (Duke Activity Status Index score + 13.5 vs. + 6.0, p = 0.002), but this difference progressively narrowed over 5 years. Angina was equally prevalent in Canadian and US patients at 1 year (16% vs. 19%), but significantly more prevalent in Canadian patients at 5 years (36% vs. 16%, p = 0.001). Repeat revascularization procedures were performed less often over 5 years among Canadian patients (26% vs. 34%, p = 0.08), especially coronary artery bypass graft surgery after initial percutaneous transluminal coronary angioplasty (18% vs. 32%, p = 0.03). These results suggest more anginal symptoms are required in Canada before coronary revascularization, but as a result Canadians receive greater improvements in quality of life after the procedure.

Postoperative hypocalcemic tetany caused by fleet phospho-soda preparation in a patient taking alendronate sodium: report of a case.

This case report describes a patient who was previously prescribed alendronate (Fosamax) and presented with postoperative hypophosphatemia and hypocalcemic tetany after bowel preparation with Fleet Phospho-Soda. This report suggests that patients taking bone metabolism regulators may not be able to respond appropriately to hypocalcemic stressors.

Ileoanal anastomosis with reservoirs: complications and long-term results.

OBJECTIVE: To determine the rate of complications of ileoanal pouch anastomosis, their treatment and their influence on a successful outcome. DESIGN: A computerized database and chart review. SETTING: Three academic tertiary care health centres. PATIENTS: All 239 patients admitted for surgery between 1981 and 1994 with a diagnosis of ulcerative colitis and familial adenomatosis coli. INTERVENTIONS: Sphincter-saving total proctocolectomy and construction of either S-type of J-type ileoanal reservoir. OUTCOME MEASURES: Indications, early and late complications, incidence of pouch excision. RESULTS: Of the 239 patients, 228 (95.4%) were operated on for ulcerative colitis and 11 (4.6%) for familial polyposis coli. One patient in each group was found to have a carcinoma not previously diagnosed. Twenty-eight patients had poor results: in 17 (7.1%) the ileostomy was never closed or was re-established because of pelvic sepsis or complex fistulas, sclerosing cholangitis or severe diarrhea; 11 (4.6%) patients required excision of the pouch because of anal stenosis, perirectal abscess-fistula or rectovaginal fistula. Three patients died--of suicide, and complications of liver transplantation and HIV infection. Thus, 208 patients maintained a functioning pouch. The early complication rate (within 30 days of operation) was 57.7% (138 patients) and the late complication rate was 52.3% (125 patients). Pouchitis alone did not lead to failure or pouch excision. Emptying difficulties in 25 patients with anal stenosis were helped in 2 by resorting to intermittent catheterization. Patients with indeterminate colitis had a higher rate of anorectal septic complications, and all patients having Crohn's disease after pouch construction had complicated courses. CONCLUSIONS: The complication rate associated with ileoanal pouch anastomosis continues to be relatively high despite increasing experience with this technique. Overall, however, a satisfactory outcome was obtained in 87% of patients.

Some thaumatin-like proteins hydrolyse polymeric beta-1,3-glucans.

Thaumatin and 12 purified thaumatin-like (TL) proteins were surveyed for their capacity to hydrolyse beta-1,3-glucans by using an in-gel glucanase assay. Six TL proteins identified by N-terminal amino acid microsequencing were found to be active on carboxymethyl(CM)-pachyman: a barley leaf stress-related permatin, two tomato fruit osmotins, a cherry fruit and two tobacco stigma proteins. TL enzymes ranged in specific activity from 0.07 to 89 nkat mg-1 with CM-pachyman as substrate. Hydrolytic activities were not restricted to TL proteins strongly binding to water-insoluble beta-1,3-glucans since the two osmotins were active without tight binding to pachyman. Some TL proteins hydrolysed crude fungal walls and one barley TL enzyme even lysed fungal spores. No activity was observed on laminarin in the in-gel hydrolase assay. Thin-layer chromatography revealed that the six enzymes acted as endo-beta-1, 3-glucanases leading to the formation of various oligoglucosides. Thus far, the TL enzymes (EC 3.2.1.x) appeared different from the well-known beta-1,3-glucanases (EC 3.2.1.39). No activity was found with thaumatin, zeamatin, tobacco leaf PR-R protein and four stress-related TL proteins from barley and pea. This is the first demonstration that diverse TL proteins are enzymatically active. The functions of some TL proteins must be reassessed because they display endo-beta-1,3-glucanase activity on polymeric beta-1, 3-glucans.

Do surgical residents rated as better teachers perform better on in-training examinations?

BACKGROUND: There have been no attempts to objectively compare resident teaching ability with resident knowledge level. METHODS: Resident teaching ability, as rated by medical students and junior surgical residents, was compared with resident knowledge level, estimated by in-training examination results, for 18 PGY5 and PGY4 surgical residents at McGill University (September 1996 to July 1997). RESULTS: There was a trend to suggest that greater teaching ability is associated with higher in-training examination scores; this did not achieve statistical significance. PGY4 residents were rated as better teachers than PGY5 residents. Resident self-evaluation revealed a high degree of interest in teaching; inadequate time was the principal deterrent to resident teaching; enjoyment and learning during teaching were found to be the most common incentives. CONCLUSIONS: Our results suggest an association between resident level of knowledge and teaching ability. The principal deterrent to teaching--inadequate time--must be addressed to effectively assist surgical resident teaching.

Several thaumatin-like proteins bind to beta-1,3-glucans.

Pathogenesis-related proteins from intercellular fluid washings of stressed barley (Hordeum vulgare L.) leaves were analyzed to determine their binding to various water-insoluble polysaccharides. Three proteins (19, 16, and 15 kD) bound specifically to several water-insoluble beta-1,3-glucans. Binding of the barley proteins to pachyman occurred quickly at 22 degreesC at pH 5.0, even in the presence of 0.5 M NaCl, 0.2 M urea, and 1% (v/v) Triton X-100. Bound barley proteins were released by acidic treatments or by boiling in sodium dodecyl sulfate. Acid-released barley proteins could bind again specifically and singly to pachyman. Water-soluble laminarin and carboxymethyl-pachyman competed for the binding of the barley proteins to pachyman. The N-terminal sequence of the 19-kD barley beta-1,3-glucan-binding protein showed near identity to the barley seed protein BP-R and high homology to other thaumatin-like (TL) permatins. The 16-kD barley protein was also homologous to TL proteins, whereas the 15-kD barley protein N-terminal sequence was identical to the pathogenesis-related Hv-1 TL protein. Antifungal barley protein BP-R and corn (Zea mays) zeamatin were isolated by binding to pachyman. Two extracellular proteins from stressed pea (Pisum sativum L.) also bound to pachyman and were homologous to TL proteins.

Detection of enzymes active on various beta-1,3-glucans after denaturing polyacrylamide gel electrophoresis.

Enzymes were assayed for glucanase activity after denaturing sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) in gels containing beta-1,3-glucans embedded as substrate. Lentinan, curdlan, paramylon, baker's yeast alkali-insoluble glucan, baker's yeast alkali-soluble glucan and carboxymethyl (CM)-pachyman were compared to oligomeric laminarin, which is the usual substrate for assaying beta-1,3-glucanase activities. Detecting enzyme activities by aniline blue fluorescent staining was also compared with the staining of released reducing sugars by 2,3,5-triphenyltetrazolium chloride (TTC). For the nonreduced proteins, the Driselase extract exhibited one major band at 32.5 kDa and one less intense band at 23 kDa for most substrates with the two detection procedures. No Lyticase enzyme was detected in either detection procedures for all tested substrates. For barley enzymes, no activity was revealed after aniline blue staining while one undescribed 19 kDa glucanase activity was best shown after TTC staining with curdlan, paramylon and CM-pachyman as substrates. In the case of reduced proteins, the Lyticase extract yielded three bands (33, 36 and 46 kDa) on several substrates with both detection procedures. This was the same for the barley leaf extract (32, 36 and 39 kDa). The Driselase extract showed one 42 kDa band. Many enzymes active on beta-1,3-glucans are thus best revealed when proteins are denatured and reduced and when protein renaturation after SDS-PAGE involves a pH 8.0 treatment and the inclusion of 1 mM cysteine in buffers. However, some enzymes are only detected when proteins are denatured without reduction. Finally, the use of various polymeric beta-1,3-glucan substrates different from oligomeric laminarin is necessary to detect new types of enzymes such as the 19 kDa barley glucanase.

Psychometric properties of the Health Utilities Index Mark 2 system in paediatric oncology patients.

This study examined the reliability and validity of the Health Utilities Index (HUI) Mark 2 system, a health-related quality of life (QoL) instrument, in children with cancer. The sample consisted of 61 mothers of paediatric oncology patients, aged 4.1-17.3 years, who were either on treatment (n = 20) or off treatment (n = 41). The test-retest reliability was very good for the HUI Mark 2 system global score and all of its dimensions except pain. The HUI Mark 2 dimensions of emotion, pain and self-care as well as its overall score showed moderate convergent validity with other measures. In addition, the HUI Mark 2 system demonstrated good discriminant validity. However, the content validity of the HUI Mark 2 system when considered as a multiattribute descriptive health profile is questionable because it falls to assess domains such as neuropsychological and psychosocial functioning. Overall, the results indicate that the HUI Mark 2 system is reliable and valid as a measure of health-related QoL for paediatric oncology patients.

Lipid uptake by silicone enteral access feeding devices.

BACKGROUND/PURPOSE: Deterioration of long-term enteral access devices remains a significant patient care and financial problem. Because it is known that lipids, particularly medium-chain triglycerides oil (MCT oil), can soften and break certain types of polymeric materials, the authors evaluated the effect of liquid enteral feeding formulas containing different amounts of MCT oil on silicone feeding tubes. METHODS: Commercially available and widely used gastrostomy silicone catheters of two sizes (20F and 15F) were sectioned in 5-cm-long samples and cleaned. Five groups of five pieces were immersed for 8 weeks in pure MCT oil and in four commercial formulas having similar protein, carbohydrate, and fat contents. These formulas were chosen because they contained similar percentages of fat (37% to 45%), although they contained differing amounts of MCT oil. Sodium azide 0.05% was added as a bactericide. Samples were maintained at 37 degrees C in an incubator-shaker. After incubation, specimens were rinsed, dried, and weighed. Selected samples were extracted with a chloroform-methanol solution (2:1). Super-critical fluid chromatography (SFC) and infrared (IR) spectroscopy were performed. A tensile tester was used to generate force-elongation curves for the remaining samples. A statistical analysis (ANOVA, alpha = .05) was conducted to compare data from test groups with results from 20 samples of control silicone material. RESULTS: Data demonstrate that silicone is significantly affected by liquid formulas and pure MCT oil. SFC and IR findings indicated that fractions of MCT oil, corn oil, and canola oil were absorbed by the material. The most dramatic weight gain (3.7%) was observed for specimens immersed in pure MCT oil. An average increase (9.6%) of silicone compliance was measured along with oil migration in the tubing. CONCLUSIONS: Lipid uptake contributes significantly to deterioration of the silicone tested, leading to device failure. Surface damage can create a potential nidus for microorganisms, particularly fungi. Lipid type and rate of administration should be taken into account when long-term enteral feedings are given. These data contribute to the understanding of the causes of the physico-chemical deterioration of long-term enteral feeding devices and provide helpful information for the design and manufacture of improved products.

Fistulas complicating diverticulitis.

This study was undertaken to assess the appropriate management of patients with diverticulitis complicated by fistula formation. A retrospective chart review was conducted on patients with symptoms of a fistula who presented between 1975 to 1995. There were 42 patients (32 women, 76%; 10 men, 24%) who ranged in age from 46 to 89 years (mean 69.8 +/- 9.8). Six patients had multiple fistulas. The types of fistulas included colovesical (48%), colovaginal (44%), colocutaneous (4%), colotubal (2%), and coloenteric (2%). Operative procedures consisted of resection and primary anastomosis in 38 patients and a Hartmann's operation in one. Three patients were managed conservatively with antibiotics (two due to poor performance status, the third due to resolution of symptoms). There were no operative deaths. The postoperative course was uncomplicated in 69%, while 12 patients (31%) experienced 19 complications (40%). These consisted of urinary tract infection (9.5%), atelectasis (7.1%), prolonged ileus (4.8%), arrhythmias (4.8%) and renal failure, myocardial infarction, pseudomembranous colitis, peroneal nerve palsy, unexplained fever, pulmonary edema (2.4% each). There were no anastomotic leaks and no deaths. Hospital stay ranged from 6 to 31 days (mean 12.3 +/- 7.6). Fistulas due to diverticulitis were safely managed by resection and primary anastomosis without mortality and with acceptable morbidity in this series. Patients deemed to be poor operative risks can be managed with a course of nonoperative treatment.

Long-term prognostic value of clinically evident noncoronary vascular disease in patients undergoing coronary revascularization in the Bypass Angioplasty Revascularization Investigation (BARI).

In the general population, peripheral atherosclerosis is a strong predictor of cardiovascular disease and death. In patients with known coronary artery disease, it is unclear whether the presence of additional noncoronary atherosclerosis is of further prognostic value. In the Bypass Angioplasty Revascularization Investigation, 5-year outcome was compared between patients with and without clinically evident noncoronary atherosclerosis. Within the subgroup with noncoronary atherosclerosis, surgery, and angioplasty treatment strategies were compared. Noncoronary atherosclerosis was defined as claudication, peripheral vascular surgery, abdominal aortic aneurysm, history of cerebral ischemia, or carotid disease. Among 1,816 patients, 303 (17%) had noncoronary atherosclerosis. These patients were more likely to have a history of congestive heart failure, diabetes, and hypertension, and were more likely to smoke. Coronary angiographic variables were similar between the 2 groups. Five-year survival was 75.8% for patients with noncoronary atherosclerosis and 90.2% for those without (p < 0.001). The adjusted relative risk of death was 1.7 for any noncoronary atherosclerosis, 1.5 for lower extremity disease alone, 1.7 for cerebral disease alone, and 2.3 for both conditions. Among the 303 patients with noncoronary atherosclerosis, the adjusted relative risk of death for surgery versus angioplasty was 0.87 (p = 0.40). However, the study has limited power to detect a treatment effect in this small subgroup. Thus, patients with combined coronary and clinically evident noncoronary atherosclerosis are a high-risk group with significantly worse long-term outcome compared patients with isolated coronary disease.

Communication during the recruitment phase of a multicenter trial: the recruitment hotline.

The Bypass Angioplasty Revascularization Investigation (BARI) is a randomized trial that compares the safety and efficacy of angioplasty and bypass surgery in selected patients with multivessel coronary disease. During recruitment, the Clinical Coordinating Center (CC) required an organized manner of responding to the many questions expected from the 18 clinical sites. Thus a dedicated telephone line was established to provide the clinical sites with information quickly and ensure consistent dissemination of information. In addition, the hotline functioned as a backup mechanism for patient randomization in the event of a computer failure at one of the sites. During the first 13 months of recruitment, 1332 calls were received. The average number of daily calls peaked at 7.3 with 14 calls being the highest in any one day. Calls gradually declined as the clinical sites became more familiar with the protocol, data collection forms, and computer systems. Most questions were answered by the data management staff; however a substantial number (37%) required faculty level input. For questions that could not be answered immediately, the median time for a return call was 25 min. The BARI hotline was an efficient way to provide accurate and consistent feedback to all sites and to identify areas that required protocol clarification. It allowed rapid identification of differences in protocol interpretation across sites so that these variations could be addressed. Review of specific questions by the Operations Committee resulted in decisions on how to apply the protocol to particularly difficult or exceptional cases. While the system was labor-intensive, its benefits outweighed this disadvantage. Recommended modifications to lower costs would result in a system that could be easily adapted for use in other clinical trials.