Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.

OBJECTIVES: To assess the relationship between changes in clinician attitude and changes in postoperative outcomes following a checklist-based surgical safety intervention. DESIGN: Pre- and post intervention survey. SETTING: Eight hospitals participating in a trial of a WHO surgical safety checklist. PARTICIPANTS: Clinicians actively working in the designated study operating rooms at the eight hospitals. SURVEY INSTRUMENT: Modified operating-room version Safety Attitudes Questionnaire (SAQ). MAIN OUTCOME MEASURES: Change in mean safety attitude score and correlation between change in safety attitude score and change in postoperative outcomes, plus clinician opinion of checklist efficacy and usability. RESULTS: Clinicians in the preintervention phase (n=281) had a mean SAQ score of 3.91 (on a scale of 1 to 5, with 5 representing better safety attitude), while the postintervention group (n=257) had a mean of 4.01 (p=0.0127). The degree of improvement in mean SAQ score at each site correlated with a reduction in postoperative complication rate (r=0.7143, p=0.0381). The checklist was considered easy to use by 80.2% of respondents, while 19.8% felt that it took a long time to complete, and 78.6% felt that the programme prevented errors. Overall, 93.4% would want the checklist used if they were undergoing operation. CONCLUSIONS: Improvements in postoperative outcomes were associated with improved perception of teamwork and safety climate among respondents, suggesting that changes in these may be partially responsible for the effect of the checklist. Clinicians held the checklist in high regard and the overwhelming majority would want it used if they were undergoing surgery themselves.

A surgical safety checklist to reduce morbidity and mortality in a global population.

BACKGROUND: Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery. METHODS: Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization's Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation. RESULTS: The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001). CONCLUSIONS: Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.

Assessment of nutritional status of pediatric cancer patients.

The study was done to identify which parameters are most useful to be used for nutrition assessment in pediatric cancer patients. The study included 70 pediatric cancer patients (48 males and 22 females) age 4-10 years. Patients were classified into 3 groups based on type of cancer (Lymphoma, leukemia and rhabdomyosarcoma). The period of the study was divided into 3 stages according to treatment (initial, during and at the end of the 6 months period). The patients were subjected to nutrition assessment through using 24 hours dietary recall and anthropometric measurements. Also the relationship between nutrient intake and socioeconomic status of the patients was studied. The results showed positive between each of triceps skinfold (TSF), arm circumference (AC), arm muscle circumference (AMC), height (Ht) and weight categories (as a percent of ideal body weight). These parameters can be used to assess nutritional status of pediatric cancer patients throughout the stages of treatment. The results of the 24 hours dietary recall showed a decrease in protein and caloric intake of all the patients by the end of the 6 months period. All the patients had low intake of vitamins A and C and calcium. A positive correlation was found between the intake of these 3 nutrients and socioeconomic level of the patients.

Integration of hepatitis B immunization in the Expanded Program on Immunization of the Child Survival Project.

The Expanded Program on Immunization (EPI) is a component of the Child Survival Project (CSP) whose objectives are to reduce the incidence rates of six childhood diseases (Measles, Diphtheria, Pertussis, Tetanus, Tuberculosis, Poliomyelitis) and to reduce the number of infant deaths from those diseases by increasing effective vaccination coverage. In 1991, the CSP/EPI developed a national plan to introduce national immunization of infants against hepatitis B in an attempt to control the magnitude and seriousness of the damage which viral hepatitis causes in terms of morbidity, mortality and serious sequelae as hepatitis B is an endemic disease in Egypt causing an important public health problem which requires urgent control. This presentation will discuss the integrated effort undertaken to plan and implement the program, the different challenges it faces, control studies being performed as well as the proposed objectives of the hepatitis B vaccination program.

PIP: The Expanded Program on Immunization (EPI) is a component of the Child Survival Project (CSP). Its objective is to reduce the incidence rates of measles, diphtheria, pertussis, tetanus, tuberculosis, and poliomyelitis by increasing effective vaccination coverage. In 1991, CSP/EPI developed a national plan to introduce national immunization of infants against hepatitis B, which is an endemic disease in Egypt. Hepatitis B virus (HBV) causes acute hepatitis and chronic liver disease. Studies have shown that by maturity most of the population has been infected with hepatitis A and greater than 50% with hepatitis B. The recommended series of 3 intramuscular doses of hepatitis B vaccine induces a protective antibody response (anti HBs) in 90% of healthy adults and 95% of infants, children, and adolescents. Several studies have shown that the currently licensed vaccines produce high rates of seroconversion ( 95%) and induce adequate levels of anti HBs when administered to infants at 2 months, 4 months, and 6 months of age. Scheduling was adjusted to coincide with the currently adopted 2, 4, and 6 month vaccination schedule for oral poliomyelitis virus (OPV) and diphtheria-pertussis-tetanus (DPT) to allow a delay of vaccination from 2 to 3 months following birth. Long term studies of healthy adults and children indicate the immunologic memory remains intact for at least 9 years and confers protection against HBV infection even though anti HBs levels may decline below detectable levels. Safety of hepatitis B vaccines has been verified through experience with millions of doses administered worldwide after licensure. Pain at the injection site (3-29%) and a temperature greater than 37.7 degrees Celsius have been the most frequently reported side effects among adults and children. Nearly 90% of children and 96% of newborns had no reactions to the vaccine. Any presumed risk of adverse events must be balanced against the expected risk of acute and chronic liver disease associated with hepatitis B virus infection.

Comparative results of the immunogenicity of Edmonston-Zagreb and Schwartz measles vaccines administered to 60 Egyptian infants.

The present study was conducted on sixty 9-11 month infants attending a primary care clinic in a rural Giza governorate area. Patients were divided into two groups: the first group comprised 42 infants who were vaccinated with the Edmonston Zagreb measles vaccine strain, whereas the second group comprised 18 infants who were vaccinated with the Schwartz measles vaccine strain. Estimation of measles antibody titer by neutralization testing was determined by the microtiter technique prior to and 4 weeks post vaccination. The overall serconversion rate was 85%. Three infants failed vaccination. The Edmonston-Zagreb strain was superior to the Schwartz strain in inducing immunity to non immune infants. The nutritional status of the study group was abnormal in almost 1/2 (29/60) infants and borderline in 1/3 (20/60).

Pediatric non-Hodgkin's lymphoma abdominal presentations: a comparative study between two treatment regimens at the National Cancer Institute Cairo.

Abdominal presentations of pediatric NHL are rarely amenable to complete surgical resection. Chemotherapy is the hallmark of treatment for pediatric NHL. Treatment of various types of this disease including intra-abdominal NHL in children with various protocols have not exceeded 54 per cent two-year disease-free survival. We have attempted to study and compare the effects of two treatment regimen upon two groups of previously untreated children up to the age of 16 years who presented to the Pediatric Oncology Unit at the NCI. The first group included 18 children who presented between 1983 and 1985 and were treated by a modified St Jude regimen: while the second group of patients was comprised of 19 children who presented between 1985 and 1987 and were treated by a multi-national protocol: the MCP 842. The two groups will be compared with respect to various patient characteristics, response to therapy and their two-year disease-free survival as well as overall survival.

Prolonged disease-free survival in pediatric non-Hodgkin's lymphoma using ifosfamide-containing combination chemotherapy.

Pediatric non-Hodgkin's lymphoma (NHL) constitutes 16 per cent of pediatric malignancies reported to the National Cancer Institute (NCI) in Cairo. The adopted treatment for these cases was, from 1982 to July 1985, a modified St Jude's regimen consisting of: vincristine, cyclophosphamide, adriamycin, prednisone and intrathecal methotrexate for the first 6 weeks for induction, followed by cranial irradiation for cranial prophylaxis. Patients in remission received maintenance therapy for 18 months. Of 32 patients complete remission (CR) was achieved in 24 patients (75 per cent); partial remission (PR) in one patient (3 per cent); five patients showed no response (15 per cent) while two patients died during the induction phase. At 60+ months follow-up, 60 per cent of cases are still alive, disease-free, and overall survival is 66 per cent. A new protocol was adopted in 1985, consisting of alternating cycles: A and B, for 4-8 cycles. Cycle A: cyclophosphamide, high dose ara-C, adriamycin, and vincristine. Cycle B: ifosfamide, methotrexate, VP 16, with intrathecal methotrexate. The response in 39 cases is: CR in 31 cases (82 per cent); PR in four cases (10 per cent); no response in three cases (8 per cent). At 60+ months, the disease-free survival is 60 per cent, and overall survival 80 per cent. This new protocol has the advantage of: short duration of therapy and so better patient compliance, no maintenance therapy or cranial irradiation with its sequelae in the future. Moreover, it has a better overall survival.

The immune status and response to measles vaccine amongst Egyptian infants. A preliminary report.

This study was carried out on 18 infants attending a primary care clinic in the Giza Governorate. Following a comprehensive history and physical exam estimation of measles antibody titer by neutralization testing was carried out on 10 infants prior to vaccination and on 8 infants prior to as well as one month following vaccination against measles utilizing the Edmondston-Zagreb strain. Our results indicate that at the currently adopted age of 9 months for vaccination, infants are susceptible to measles. Good response to vaccination with acquisition of immunity was noted despite border-line levels of growth and development. The occasional patient with persistent maternal antibodies to measles responded well to vaccination.

Childhood non-Hodgkin's lymphoma in Egypt: preliminary results of treatment with a new ifosfamide-containing regimen.

Pediatric non-Hodgkin's lymphoma (NHL) constitutes 16% of pediatric malignancies reported to the National Cancer Institute (NCI) in Cairo. Since July 1985, we have treated 39 previously untreated pediatric NHL cases younger than 16 years of age (mean, 7.6 years) with a new protocol consisting of alternating cycles: regimen A comprised cyclophosphamide, high-dose ara-C, Adriamycin and vincristine; regimen B consisted of ifosfamide, methotrexate and VP16, with intrathecal methotrexate. Diagnoses included 20 abdominal masses, 16 peripheral lymphadenopathies and 6 bony lesions. Histopathology according to the working formulation revealed 21 cases of small non-cleaved lymphoma, 6 lymphoblastic, 5 large-cell and 7 unclassified diffuse lymphomas. Responses were complete in 31 cases (82%) and partial in 4 cases (10%), and no response was obtained in 4 cases (8%). Overall survival was 82% in limited disease and 60% in extensive disease at 28+ months. This short-term ifosfamide-containing regimen proved its efficacy, with results matching those of other regimens used in the United States and Europe.

Pediatric Hodgkin's disease in Egypt.

A consecutive group of 242 children with Hodgkin's disease attending the National Cancer Institute, Cairo during the years 1975-1980 were studied. Males predominated representing 76.85% of cases. Age distribution was similar to other African countries with an earlier presentation than the US. The most common histopathologic types was the mixed cellularity 60.74% of patients. Late Stages III and IV represented 63.22%, with a high tumor burden. Celiotomy in 154 cases detected more tissue involvement than clinical assessment. Its results coincided with lymphography in 68% of the cases. It showed 7 cases with schistosomal hepatic fibrosis. As schistosomal infestation is still prevalent in rural areas of Egypt, celiotomy seems mandatory in the cases studied to accomplish proper staging.