Profile and generalist physician knowledge about neurology in emergency department: headache management.

BACKGROUND: Neurological complaints are frequent in emergency department routine. Among them, headache is a common disorder, which requires a certain degree of knowledge on Neurology because of its extensive differential diagnosis. OBJECTIVE: To assess general practice physicians' level of knowledge about headaches, in addition to outlining the profile of professionals who attend in emergency departments, as well as the profile of their respective workplaces in terms of neurological approach. METHODS: We included in evaluation physicians who attend emergency care units for adult public as general practitioners. A questionnaire was applied with questions regarding participants' general knowledge on headache, neurological approach, demographic profile, and workplace profile. RESULTS: 159 physicians answered the questionnaire. The professionals' profile corresponded to recently graduated individuals (mean of 6.31 years). Knowledge about headache management was regular. Those who do not have any specialization or are not majoring a specialization were statistically significantly more confident in neurological patients care (p=0.006). Only 18.24% reported access to Magnetic Resonance Imaging and 35.85% had no access to any type of neuroimaging. CONCLUSIONS: General practice physicians often do not feel confident when performing neurological exams, demonstrating low knowledge about the topic. The profile of professionals working in these departments is predominantly of newly graduates, which may affect in some way on care quality. There was also a lack of structure for adequate care.

Profile and generalist physician knowledge about neurology in emergency department: headache management / Perfil e conhecimento em neurologia do médico generalista no setor de emergência: abordagem de cefaleias

Abstract Background: Neurological complaints are frequent in emergency department routine. Among them, headache is a common disorder, which requires a certain degree of knowledge on Neurology because of its extensive differential diagnosis. Objective: To assess general practice physicians' level of knowledge about headaches, in addition to outlining the profile of professionals who attend in emergency departments, as well as the profile of their respective workplaces in terms of neurological approach. Methods: We included in evaluation physicians who attend emergency care units for adult public as general practitioners. A questionnaire was applied with questions regarding participants' general knowledge on headache, neurological approach, demographic profile, and workplace profile. Results: 159 physicians answered the questionnaire. The professionals' profile corresponded to recently graduated individuals (mean of 6.31 years). Knowledge about headache management was regular. Those who do not have any specialization or are not majoring a specialization were statistically significantly more confident in neurological patients care (p=0.006). Only 18.24% reported access to Magnetic Resonance Imaging and 35.85% had no access to any type of neuroimaging. Conclusions: General practice physicians often do not feel confident when performing neurological exams, demonstrating low knowledge about the topic. The profile of professionals working in these departments is predominantly of newly graduates, which may affect in some way on care quality. There was also a lack of structure for adequate care.

Resumo Introdução: Queixas neurológicas são frequentes na rotina de setores de emergência. Entre elas, a cefaleia é um distúrbio comum, que por seu diagnóstico diferencial amplo, exige certo grau de conhecimento em Neurologia. Objetivo: Avaliar o nível de conhecimento em cefaleias de médicos generalistas, além de traçar o perfil dos profissionais que atendem em setores de emergência nesta função, assim como de seus respectivos locais de trabalho em termos de abordagem neurológica. Métodos: Foram incluídos na avaliação médicos que atendem em unidades de pronto-atendimento para público adulto, na função de generalista. Um questionário foi aplicado com perguntas referentes ao conhecimento geral dos participantes sobre cefaleia, abordagem neurológica, perfil demográfico e perfil do local de trabalho. Resultados: 159 médicos responderam ao questionário. O perfil dos profissionais presentes na amostra correspondeu a indivíduos graduados recentemente (média de 6,31 anos). O conhecimento a respeito da abordagem de cefaleias foi regular. Aqueles que não possuem nenhuma especialização, nem estão cursando uma residência, se mostraram, de forma estatisticamente significativa, mais seguros no atendimento de pacientes neurológicos (p=0,006). Apenas 18,24% referiram ter acesso à Ressonância Magnética e 35,85% não tiveram acesso a nenhum tipo de neuroimagem. Conclusão: Médicos generalistas frequentemente não sentem segurança ao realizar atendimento e exame neurológicos, demonstrando pouco conhecimento acerca do assunto. O perfil dos profissionais que atuam nesses setores é predominantemente de recém graduados, o que pode impactar de alguma forma na qualidade de atendimento. Verificou-se também falta de estrutura para um atendimento adequado.

A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care.

BACKGROUND: Catheter-associated urinary tract infection (UTI) is a common device-associated infection in hospitals. Both technical factors--appropriate catheter use, aseptic insertion, and proper maintenance--and socioadaptive factors, such as cultural and behavioral changes in hospital units, are important in preventing catheter-associated UTI. METHODS: The national Comprehensive Unit-based Safety Program, funded by the Agency for Healthcare Research and Quality, aimed to reduce catheter-associated UTI in intensive care units (ICUs) and non-ICUs. The main program features were dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). Multilevel negative binomial models were used to assess changes in catheter use and catheter-associated UTI rates. RESULTS: Data were obtained from 926 units (59.7% were non-ICUs, and 40.3% were ICUs) in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico. The unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1000 catheter-days. In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P=0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P<0.001) and catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days (incidence rate ratio, 0.68; 95% CI, 0.56 to 0.82; P<0.001). Catheter use and catheter-associated UTI rates were largely unchanged in ICUs. Tests for heterogeneity (ICU vs. non-ICU) were significant for catheter use (P=0.004) and catheter-associated UTI rates (P=0.001). CONCLUSIONS: A national prevention program appears to reduce catheter use and catheter-associated UTI rates in non-ICUs. (Funded by the Agency for Healthcare Research and Quality.).

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

BACKGROUND: Several studies demonstrating that central line-associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections. METHODS: We conducted a collaborative cohort study to evaluate the impact of the national "On the CUSP: Stop BSI" program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented. RESULTS: A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16-18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50-0.65) at 16-18 months after implementation. CONCLUSION: Coincident with the implementation of the national "On the CUSP: Stop BSI" program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.

Regulation of protein kinase C-related protein kinase 2 (PRK2) by an intermolecular PRK2-PRK2 interaction mediated by Its N-terminal domain.

Protein kinase C-related protein kinases (PRKs) are effectors of the Rho family of small GTPases and play a role in the development of diseases such as prostate cancer and hepatitis C. Here we examined the mechanism underlying the regulation of PRK2 by its N-terminal region. We show that the N-terminal region of PRK2 prevents the interaction with its upstream kinase, the 3-phosphoinositide-dependent kinase 1 (PDK1), which phosphorylates the activation loop of PRK2. We confirm that the N-terminal region directly inhibits the kinase activity of PRK2. However, in contrast to previous models, our data indicate that this inhibition is mediated in trans through an intermolecular PRK2-PRK2 interaction. Our results also suggest that amino acids 487-501, located in the linker region between the N-terminal domains and the catalytic domain, contribute to the PRK2-PRK2 dimer formation. This dimerization is further supported by other N-terminal domains. Additionally, we provide evidence that the region C-terminal to the catalytic domain intramolecularly activates PRK2. Finally, we discovered that the catalytic domain mediates a cross-talk between the inhibitory N-terminal region and the activating C-terminal region. The results presented here describe a novel mechanism of regulation among AGC kinases and offer new insights into potential approaches to pharmacologically regulate PRK2.

Regulation of the interaction between protein kinase C-related protein kinase 2 (PRK2) and its upstream kinase, 3-phosphoinositide-dependent protein kinase 1 (PDK1).

The members of the AGC kinase family frequently exhibit three conserved phosphorylation sites: the activation loop, the hydrophobic motif (HM), and the zipper (Z)/turn-motif (TM) phosphorylation site. 3-Phosphoinositide-dependent protein kinase 1 (PDK1) phosphorylates the activation loop of numerous AGC kinases, including the protein kinase C-related protein kinases (PRKs). Here we studied the docking interaction between PDK1 and PRK2 and analyzed the mechanisms that regulate this interaction. In vivo labeling of recombinant PRK2 by (32)P(i) revealed phosphorylation at two sites, the activation loop and the Z/TM in the C-terminal extension. We provide evidence that phosphorylation of the Z/TM site of PRK2 inhibits its interaction with PDK1. Our studies further provide a mechanistic model to explain different steps in the docking interaction and regulation. Interestingly, we found that the mechanism that negatively regulates the docking interaction of PRK2 to the upstream kinase PDK1 is directly linked to the activation mechanism of PRK2 itself. Finally, our results indicate that the mechanisms underlying the regulation of the interaction between PRK2 and PDK1 are specific for PRK2 and do not apply for other AGC kinases.