Effect of an antibiotic checklist on length of hospital stay and appropriate antibiotic use in adult patients treated with intravenous antibiotics: a stepped wedge cluster randomized trial.

OBJECTIVES: Quality indicators (QIs) have been developed to define appropriate antibiotic use in hospitalized patients. We evaluated whether a checklist based on these QIs affects appropriate antibiotic use and length of hospital stay. METHODS: An antibiotic checklist for patients treated with intravenous antibiotics was introduced in nine Dutch hospitals in a stepped wedge cluster randomized trial. Prophylaxis was excluded. We included a random sample before (baseline), and all eligible patients after (intervention) checklist introduction. Baseline and intervention outcomes were compared. Primary endpoint was length of stay (LOS), analysed by intention to treat. Secondary endpoints, including QI performances, QI sum score (performance on all QIs per patient), and quality of checklist use, were analysed per protocol. RESULTS: Between 1 November 2014 and 1 October 2015 we included 853 baseline and 5354 intervention patients, of whom 993 (19%) had a completed checklist. The LOS did not change (baseline geometric mean 10.0 days (95% CI 8.6-11.5) versus intervention 10.1 days (95% CI 8.9-11.5), p 0.8). QI performances increased between +3.0% and +23.9% per QI, and the percentage of patients with a QI sum score above 50% increased significantly (OR 2.4 (95% CI 2.0-3.0), p<0.001). Higher QI sum scores were significantly associated with shorter LOS. Discordance existed between checklist-answers and actual performance. CONCLUSIONS: Use of an antibiotic checklist resulted in a significant increase in appropriateness of antibiotic use, but not in a reduction of LOS. Low overall checklist completion rates and discordance between checklist-answers and actual provided care might have attenuated the impact of the checklist.

[Long-term complications of bariatric surgery]. / Langetermijncomplicaties van bariatrische chirurgie: het mes snijdt aan twee kanten.

The prevalence of morbid obesity is increasing, with a corresponding increase in the demand for bariatric surgery, a proven effective treatment option. Bariatric surgery has potentially severe complications, including micro- and macronutrient deficiencies. Additionally, stenosis and ulceration of the anastomosis, reflux oesophagitis, cholelithiasis, steatohepatitis and altered pharmacokinetics and -dynamics may occur. Doctors in both the hospital setting and general practice will be increasingly confronted with the occasionally adverse long-term effects of bariatric surgery. Early detection, efficient follow-up and a multidisciplinary team approach are crucial in preventing and adequately treating the complications of bariatric surgery.

Risk estimations and treatment decisions in early stage breast cancer: agreement among oncologists and the impact of the 70-gene signature.

BACKGROUND: Clinical decision-making in patients with early stage breast cancer requires adequate risk estimation by medical oncologists. This survey evaluates the agreement among oncologists on risk estimations and adjuvant systemic treatment (AST) decisions and the impact of adding the 70-gene signature to known clinico-pathological factors. METHODS: Twelve medical oncologists assessed 37 breast cancer cases (cT1-3N0M0) and estimated their risk of recurrence (high or low) and gave a recommendation for AST. Cases were presented in two written questionnaires sent 4 weeks apart. Only the second questionnaire included the 70-gene signature result. RESULTS: The level of agreement among oncologists in risk estimation (κ=0.57) and AST recommendation (κ=0.57) was 'moderate' in the first questionnaire. Adding the 70-gene signature result significantly increased the agreement in risk estimation to 'substantial' (κ=0.61), while agreement in AST recommendations remained 'moderate' (κ=0.56). Overall, the proportion of high risk was reduced with 7.4% (range: 6.9-22.9%; p<0.001) and the proportion of chemotherapy that was recommended was reduced with 12.2% (range: 5.4-29.5%; p<0.001). CONCLUSION: Oncologists' risk estimations and AST recommendations vary greatly. Even though the number of participating oncologists is low, our results underline the need for a better standardisation tool in clinical decision-making, in which integration of the 70-gene signature may be helpful in certain subgroups to provide patients with individualised, but standardised treatment.

Predicting communication skills with a paper-and-pencil test.

AIM: This study was conducted to investigate the value of a written knowledge test of communication skills for predicting scores on a performance test of communication skills. METHOD: A paper-and-pencil test of knowledge about communication skills and a performance test of communication skills, consisting of four stations with standardised patients, were administered to students of two classes of the medical schools of Maastricht and Leiden, the Netherlands. The results on these tests were compared. RESULTS: From the results of both instruments, the classes of the participating students could be recognised equally well: 60% correct qualifications of the classes by the knowledge test and 64% by the multiple station examination. Between the two tests an overall, disattenuated correlation of 0.60 was found (N=133, P < 0.01), suggesting moderate predictive value of the knowledge test for the performance test of communication skills. The correlation is stronger for students from Maastricht medical school than for their colleagues in Leiden. Correlation between the knowledge of communication skills test and other available test results of the participating Maastricht students is close to zero, suggesting that the test measures a distinct quality of students' competence. DISCUSSION: The paper-and-pencil test of knowledge of communication skills has predictive value for the performance of these skills, but this value seems to be less pronounced than similar findings for clinical procedural skills. The stronger relationship between 'knowing how' and 'showing' in the Maastricht student group might be indicative of an effect of the training format.

Longitudinal and concentrated communication skills programmes: two dutch medical schools compared.

AIM OF THE STUDY: The communication skills of students of the Dutch medical schools of Maastricht and Leiden were compared, to assess the effectiveness of these schools' different approaches to communication skills training. Both schools have a six-year undergraduate medical curriculum, divided into four preclinical years and two years of clinical clerkships. The Maastricht problem-based curriculum offers an integrated clinical skills training programme, including communication skills, which runs throughout the first four years. Communication skills training in Leiden is concentrated in courses in the preclinical phase, at the beginning of the clinical phase and preceding two clerkships. METHOD: Communication skills of fourth-year and sixth-year students (N = 161) of both universities were assessed using four OSCE stations in which students did entire consultations with standardised patients. Trained observers rated these consultations, using a checklist. RESULTS: Maastricht students of both year groups obtained significantly higher checklist scores for their communication skills than their Leiden colleagues. The Leiden students' scores increase between years 4 and 6, whereas those of the Maastricht students showed no significant change. DISCUSSION: The higher scores obtained by the Maastricht students indicate a greater overall effectiveness of a longitudinal, integrated approach compared with concentrated courses. Absence of formal training in the clinical phase in Maastricht leads to stabilisation of communication skills, whereas the increase in the Leiden students' scores between years 4 and 6 offers evidence that formal communication skills training during the clinical phase does pay off. These findings suggest that the preferred approach to communication skills training would be an integrated, longitudinal programme, which continues during the clinical years.

Recombinant human alpha-glucosidase from rabbit milk in Pompe patients.

Pompe's disease is a fatal muscular disorder caused by lysosomal alpha-glucosidase deficiency. In an open-label study, four babies with characteristic cardiomyopathy were treated with recombinant human alpha-glucosidase (rhGAA) from rabbit milk at starting doses of 15 mg/kg or 20 mg/kg, and later 40 mg/kg. The enzyme was generally well tolerated. Activity of alpha-glucosidase normalised in muscle. Tissue morphology and motor and cardiac function improved. The left-ventricular-mass index decreased significantly. We recommend early treatment. Long-term effects are being studied.

Chronic extrinsic allergic alveolitis in a family with idiopathic pulmonary fibrosis: the importance of histological diagnosis.

We report a patient who presented with progressive exertional dyspnoea, chronic cough and radiographic signs of interstitial lung disease. Since several of his family members were known to have familial idiopathic pulmonary fibrosis he was also suspected to suffer from this disease. After thorough investigation, including histological examination of lung biopsies obtained by thoracoscopy, a diagnosis of chronic extrinsic allergic alveolitis was made. Current knowledge of familial idiopathic pulmonary fibrosis is discussed. This case report underlines the importance of a histological diagnosis in interstitial lung disease.