The standard of newly qualified dental graduates - foundation trainer perceptions.

Background There have been anecdotal concerns that the skill mix of recently qualified graduates is very different to those qualifying several years ago, in particular that the clinical skills on qualification are less. If true, such changes may have ramifications for providers of undergraduate training, postgraduate training, particularly at foundation training level, and ultimately the public.Aim The aim of this study was to assess changes in perceived standards of newly qualified graduates as reported by foundation trainers.Method A cross-sectional survey was conducted using a self-completed internet-based survey tool sent to all foundation trainers (FTs) in England, Northern Ireland and Wales.Results A total of 312 responses were obtained covering all postgraduate deaneries. There was mixed opinion regarding standards of new graduates, with 51% reporting that the overall standard of those entering foundation training was 'unsatisfactory'. Standards in key clinical areas were considered unsatisfactory by large proportions of respondents. Eighty-five percent considered standards to be unsatisfactory in 'crown and bridge', 75% in 'extraction of teeth', 74% in endodontics, 67% in removable prosthodontics, and 62% in treatment planning. Experienced trainers identified a decline in standards in particular clinical areas.Conclusions A large proportion of foundation trainers consider the current standard of new graduates to be unsatisfactory for entering foundation training. There are a number of key clinical areas of concern and a perception of declining standards.

Are the UK clinical guidelines for H1N1 influenza infection valid in the hospital setting?

The diagnosis of pandemic influenza is clinical. This prospective study questions the validity of the Department of Health guidelines in 77 children admitted to hospital. The positive predictive value for the guidelines was 0.39. Although H1N1 was identified in a sizeable minority of cases using the guidelines, virology testing is still required.

Growth and skeletal development in families with NOGGIN gene mutations.

INTRODUCTION: There is a scarcity of data on height as well as bone densitometry in humans with NOGGIN mutations. METHODS: In 2 families with symphalangism, anthropometry, bone densitometry and genetic analysis of the NOGGIN gene were performed. RESULTS: In family A, the height standard deviation scores of the affected father and son were -0.4 and 3.5, respectively. In family B, the height standard deviation scores of the affected father, twin daughters and another daughter were 1.7, 1.8, 2.4 and 1.8, respectively. In the children, percentage predicted bone mineral content (BMC) for height at the appendicular sites (total femur, femoral neck) was lower than at an axial site lumbar spine. In the 2 fathers, median bone mineral density at total femur and femoral neck was -0.3 standard deviation scores (-0.7, 0.2) and at lumbar spine the scores were -0.4 and 0.9. The children had median tibial and radial speed of sound velocities of -2.1 (-0.9 to -6.4) and -1.4 (-0.2 to -4.9), respectively. DNA analysis revealed a novel missense mutation in family A and family B, resulting in a Met190Val substitution and a Pro42Arg substitution, respectively. CONCLUSION: Heterozygous gene mutations in NOGGIN are associated with tall stature in children but not necessarily in adults. The appendicular BMC and speed of sound may be low in affected children but normalises by adulthood. However, axial BMC seems normal in childhood and is high in adulthood.

HeatBalance, a computer program to determine optimum incubator air temperature and humidity. A comparison against nurse settings for infants less than 29 weeks gestation.

BACKGROUND: Very immature newborn infants need close control of their thermal environment. Decisions on incubator temperature and humidity settings can be difficult and available charts are not readily applicable to these babies. A computer program (HeatBalance) using basic principles to calculate heat gains and losses has been developed. The program recommends incubator temperature and humidity settings to keep babies in thermal balance. AIM: The aim of this study was to compare the effect of the program on temperature control of infants <29 weeks gestation with that achieved by experienced nurses. METHOD: Twenty consecutive babies were studied over the first 5 days of life, all nursed in incubators using air mode control. The first 10 had temperature and humidity set by the nurses while the next 10 had incubator settings determined by the program. Nurses could alter the parameters if the babies were too hot or cold. Incubator temperature and humidity data along with central and peripheral temperatures from the babies were collected autonomicallly onto a cotside computer system. RESULTS: There were no differences between the groups in mean central temperatures or the periods of time the babies were either too hot (central temperature T(c)>37.5) or too cold (T(c)<36.5). In the control group, the nurses often altered incubator temperature because of changes in the infant's temperature on the monitors. On each day of the study, the nurses deviated from the HeatBalance recommendations between 11% and 22% of the time. CONCLUSIONS: The HeatBalance program and the nurses achieved similar results in temperature stability for these immature infants. Whichever method was used to determine the initial incubator settings, this study highlighted the importance of continuous monitoring of central and peripheral temperatures in these infants.

The role of intraoperative Gram stain in revision total joint arthroplasty.

The ability to identify intraoperatively patients with an infected prosthesis at the time of a revision procedure assists the surgeon in selecting appropriate management. The results of 413 intraoperative Gram stains were compared with the results of operative cultures, permanent histology, and the surgeon's intraoperative assessment to determine the ability of Gram stains to identify periprosthetic infection. Gram staining correctly identified the presence of infection in 10 of the 68 cases that met study criteria for infection (sensitivity of 14.7%). Four false-positive Gram stains were encountered. Intraoperative Gram stains do not have adequate sensitivity to be helpful in identifying periprosthetic infection and should not be performed on a routine basis. They may be helpful, however, in cases in which gross purulence is encountered to assist in the selection of initial antibiotic therapy. The use of intraoperative Gram staining alone is inadequate for ruling out infection at the time of revision total joint arthroplasty.

Total purchasing. Tracking down care.

Purchasers have a duty to monitor the quality of services purchased on patients' behalf; a purchasing general practice is best placed to do this effectively, especially by means of a tracker nurse. The tracker nurse should be diplomatic and experienced to earn the respect of professional staff in provider units, some of whom may see the process as threatening. The purchaser must introduce the concept of care monitoring gently but firmly, agreeing terms of confidentiality. Good practice should be highlighted and used as an example to others. Monitoring must follow the whole pathway of care, at the time and place it is given.

Three-year outbreak of pseudobacteremia with Burkholderia cepacia traced to a contaminated blood gas analyzer.

Between November 1990 and June 1993, Burkholderia cepacia was isolated from the blood cultures of 13 neonates born at the Ottawa General Hospital. Eight of the 13 neonates appeared symptomatic, and only 4 were treated with appropriate antimicrobial therapy, but all improved clinically. In August 1993, the blood gas analyzer in the neonatal intensive-care unit was found to be contaminated heavily with B cepacia. Eight available patient isolates were identical to the isolates recovered from the blood gas analyzer by ribotyping analysis. Infection control measures were implemented to prevent future contamination of the analyzer, and no further cases have been identified.

Elimination of an outbreak of gram-negative bacteremia in a hemodialysis unit.

BACKGROUND: The purpose of this study was to identify the cause of an unusual outbreak of gram-negative bacteremia in patients undergoing long-term hemodialysis. METHODS: We performed direct observation and investigation of current dialysis techniques and facilities including microbiologic sampling in a long-term hemodialysis unit in a tertiary care center. We also performed a retrospective review of medical charts and laboratory data of 10 patients undergoing long-term hemodialysis who experienced 11 episodes of gram-negative bacteremia between March 4 and June 28, 1993. RESULTS: All of these patients underwent dialysis by jugular venous access. Containers used to collect flush solution after priming of dialysis tubing remained unemptied for extended periods of time, and quantitative culture revealed more than 200 colony-forming units/ml gram-negative bacilli, including species isolated in blood cultures. Dialysis tubing and connector were left submerged in flush solution collection containers during priming, and the process of disinfecting tubing before patient connection had recently been discontinued. Control measures included emptying of flush containers after each use and daily decontamination. All dialysis tubing was to be disinfected before patient connection. CONCLUSION: Outbreak was due to contamination during dialysis setup. After institution of appropriate control measures, no new cases have occurred.

Underestimation of surgical site infection rates in obstetrics and gynecology.

BACKGROUND: With the increasing volume of same-day operations and shortened hospital stays, it becomes more likely that a significant percentage of surgical site infections will occur after these patients' discharges. METHODS: To document the true incidence of postdischarge surgical site infection, surveillance was undertaken in a group of obstetric and gynecologic patients. The study consisted of two parts. (1) A questionnaire was mailed to each surgeon, inquiring about clinical evidence of infection. The infection control service continued to do surveillance of wound infection in the usual manner, and the results of the two methods were compared. (2) A questionnaire was provided to patients undergoing operation, inquiring about signs and symptoms of wound infection. RESULTS: A total of 469 surgical procedures were included, with a total of 24 infections detected (5.2%). Of these, 14 infections (58.3%) were detected by the usual surveillance method. An additional 10 infections (41.7%) were detected after patient discharge by the physician questionnaire. Only two of the 24 infections were detected by the patient questionnaire. CONCLUSIONS: Failure to include postdischarge surgical site surveillance results in a substantial underestimation of the true surgical site infection rate. Physician input and strong support have prompted a regular biannual postdischarge surgical site surveillance program in this patient population.

Group A streptococcal endometritis: Report of an outbreak and review of the literature.

Two cases of group A streptococcus (gas) postpartum endometritis were diagnosed within 24 h following uncomplicated vaginal delivery. Investigation by the infection control service identified all 10 obstetric personnel who performed any invasive procedure on both cases. These personnel were questioned about a recent history of sore throat, skin lesions, vaginal or rectal symptoms. Throat and rectal cultures were obtained for gas from all 10 personnel. A carrier was identified among the personnel screened. This nurse was removed from direct patient care and treated with a two-week course of oral clindamycin and rifampin with documentation of carrier eradication of gas at the end of therapy, 30 days, 60 days and six months post-treatment. All three isolated strains were identical by restriction endonuclease analysis and by M and T typing. Rapid implementation of infection control measures were successful in arresting this outbreak, with no further cases of gas occurring in the subsequent year.

Plumbing system shock absorbers as a source of Legionella pneumophila.

BACKGROUND: Water distribution systems have been demonstrated to be a major source of nosocomial legionellosis. We describe an outbreak in our institution in which a novel source of Legionella pneumophila was identified in the plumbing system. METHODS: After an outbreak of 10 cases of legionellosis in our hospital, recommended measures including superheating of the hot water to 80 degrees C, hyperchlorination to 2 ppm, and flushing resulted in no new cases in the following 5 years. Recently, despite these control measures, three new cases occurred. Surveillance cultures of shower heads and water tanks were negative; cultures of tap water samples remained positive. This prompted a search for another reservoir. Shock absorbers installed within water pipes to decrease noise were suspected. RESULTS: One hundred twenty-five shock absorbers were removed and cultured. A total of 13 (10%) yielded heavy growth of L. pneumophila (serogroup 1). Since their removal, no new cases have been found and the percentage of positive results of random tap water culture has dropped from 20% to 5%. CONCLUSIONS: This is the first report that identifies shock absorbers as a possible reservoir for L. pneumophila. We recommend that institutions with endemic legionellosis assess the water system for possible removal of shock absorbers.

Colonization of intravascular catheters in the intensive care unit.

A prospective study of intravascular catheters (arterial, Swan-Ganz, and central venous) in two hospitals with similar intensive care units revealed an overall 25 percent colonization rate (more than 15 colony counts). Arterial catheters had the lowest colonization rate and central venous catheters had the highest. Arterial, Swan-Ganz, and central venous catheters are possible sources of nosocomial infections and septicemia. They should be inserted only when necessary. A critical review of our data and the literature suggests that future studies should examine the potential benefits of assiduous insertion technique, improved dressing care, intravascular delivery systems, and the choice of catheter.

Abortion.

PIP: Professor Peter Hungerford (25 August, p 496) says that he is fed up with semantic arguments about abortion which ignore reality. He then invokes two major fantasies of the last decade, those of sexual equality and the woman's right to choose. The second of these has become an article of faith to many pro-abortionists and its credentials should be examined. Whence does this right derive? A woman takes part in a more or less pleasurable activity with a man and then, without her volition, with no conscious effort on her part at all, the miraculous occurs and a new life comes into being. How does she have the right to destroy this new life? The argument is usually to the effect that it belongs to her and could not survive without her: "It's mine and I can do what I like with it." Of course, it is true that a fetus cannot survive without the support of its mother; no more could Professor Hungerford or I survive without the support of our fellow men who provide us with food, drink, and clothing, but that does not give them the right to kill us. The claim to possession, the assumption that the fetus is owned by its mother involves, I believe, a semantic error. In a sense, the fetus is "hers" in that it is growing inside her, even though she did not create it. Likewise, her husband is hers because joined to her by marriage and her country is hers because she lives there, although she does not own either of them and certainly has no right to destroy them. The life growing inside the mother is not hers in the same way that a cardigan she has bought or knitted for herself is hers. It is the consideration of semantics that protects us from the "realities" of such as Professor Hungerford.^ieng