Prospective Interventional Cohort Study Research Articles

Antisperm antibodies and testicular blood flow after inguinal hernia mesh repair.

Testicular flow studies after hernia mesh repair mostly showed different outcomes. The reason of infertility in some men after hernia repair is immunological factors. Aim of the study was to investigate the influence of mesh hernia repair on antisperm antibodies production and testicular blood flow and a connection among these parameters. A prospective interventional longitudinal cohort study was made on 82 male patients without exclusion criteria who had an inguinal hernia. Patients underwent laparoscopic TAPP or open tension-free hernia repair. Vascular ultrasound and antisperm antibodies were measured in the preoperative and postoperative periods. Main outcome measures were resistive index (RI), peak systolic velocity (PSV) cm/s, and end-diastolic velocity (EDV) cm/s in testicular blood flow measurement and the quantitative value of antisperm antibodies (ASA) in serum (IU/ml). ASA significantly increased postoperatively only in patients who underwent open tension-free hernia repair (p < 0.001). ASA stayed in normal range in all patients except the one with postoperative complication. Friedman analysis showed significant change of the RI only on intratesticular (p < 0.001) and capsular artery level (0.02) in patients who underwent laparoscopic technique. PSV significantly changed on intratesticular (p < 0.001) and capsular artery level (p = 0.015) in the laparoscopic hernia repair. PSV showed significant change on intratesticular (p < 0.001) and testicular artery levels (p < 0.001) in the open tension-free hernia repair. EDV showed significant change only on testicular artery level (p = 0.032) in the patients who had open tension-free hernia repair. These blood flow parameters significantly increased in the early postoperative period and returned on basal value in the late postoperative period. Parameters of flow did not show any significant correlation with ASA. Mesh hernia repairs without complication caused only a transitory change in testicular blood flow and no clinical significant autoimmune reaction.

Effects of a screening and treatment protocol with haloperidol on post-cardiotomy delirium: a prospective cohort study

Post-cardiotomy delirium is common and associated with increased morbidity and mortality. No gold standard exists for detecting delirium, and evidence to support the choice of treatment is needed. Haloperidol is widely used for treating delirium, but indication, doses and therapeutic targets vary. Moreover, doubt has been raised regarding overall efficacy. The purpose of this study was to assess the effect of a combination of early detection and standardized treatment with haloperidol on post-cardiotomy delirium, with the hypothesis that the proportion of delirium- and coma-free days could be increased. Length of stay (LOS), complications and 180-day mortality are reported. Prospective interventional cohort study. One hundred and seventeen adult patients undergoing cardiac surgery were included before introduction of a screening and treatment protocol with haloperidol for delirium, and 123 patients were included after. Nurses screened patients using validated tools (the Delirium Observation Screening (DOS) scale and confusion assessment method for the intensive care unit (CAM-ICU)). In case of delirium, a checklist to eliminate precipitating/ inducing factors and a protocol for standardized dosing with haloperidol was applied. Group comparison was done using non-parametric tests and analysis of fractions, and associations between delirium and predefined covariates were analysed with logistic regression. Incidence of delirium after cardiac surgery was 21 (14-29) and 22 (15-30) %, onset was on postoperative day 1 (1-4) and 1 (1-3), duration was 1 (1-4) day and 3 (1-5) days, respectively, with no significant difference (Period 1 vs 2, all values are given as the median and 95% confidence interval). The proportion of delirium- and coma-free days was 67 (61-73) and 65 (60-70) %, respectively (ns). There was no difference in LOS or complication rate. Delirium was associated to increasing age, increased length of stay and complications. We observed no increase in the proportion of delirium- and coma-free days after introduction of a combination of early detection and standardized treatment with haloperidol on post-cardiotomy delirium. Most patients were not severely affected, and the few who were, proved difficult to treat, indicating that a simple treatment protocol with haloperidol was ineffective.

Intervention for promoting breast milk use in neonatal intensive care unit: a pilot study

Objective: The health benefits provided by breast milk are significant in preterm infants. Despite recommendations, rates of breastfeeding in preterm infants are lower than in term infants. The aim of this study was to evaluate the efficacy of a multidisciplinary intervention in promoting any breastfeeding in preterm infants at discharge.Methods: A prospective non-randomized interventional cohort study was conducted. One hundred and twenty-two preterm infants constituted the historical group. A multidisciplinary intervention was performed including staff training and setting up and implementation of a written breastfeeding procedure.Results: One hundred and ten preterm infants were enrolled in the intervention group. The percentage of infants fed human milk at discharge was 69 and 62 in the intervention group and in the historical group, respectively. The percentage change from any breastfeeding at full enteral feeding attainment to formula feeding at discharge was lower in the intervention group than in the historical group (−9 versus −23). Belonging to the intervention group and having at least one stress factor during pregnancy were independently associated with any breast milk feeding at discharge.Conclusions: The multidisciplinary intervention performed appears to be effective in promoting any breastfeeding in preterm infants at discharge.

Wii Fit Balance Board Playing Improves Balance and Gait in Parkinson Disease

To assess the effect of exercise training by using the Nintendo Wii Fit video game and balance board system on balance and gait in adults with Parkinson disease (PD). A prospective interventional cohort study. An outpatient group exercise class. Ten subjects with PD, Hoehn and Yahr stages 2.5 or 3, with a mean age of 67.1 years; 4 men, 6 women. The subjects participated in supervised group exercise sessions 3 times per week for 8 weeks by practicing 3 different Wii balance board games (marble tracking, skiing, and bubble rafting) adjusted for their individualized function level. The subjects trained for 10 minutes per game, a total of 30 minutes training per session. Pre-and postexercise training, a physical therapist evaluated subjects' function by using the Berg Balance Scale, Dynamic Gait Index, and Sharpened Romberg with eyes open and closed. Postural sway was assessed at rest and with tracking tasks by using the Wii balance board. The subjects rated their confidence in balance by using the Activities-specific Balance Confidence scale and depression on the Geriatric Depression Scale. Balance as measured by the Berg Balance Scale improved significantly, with an increase of 3.3 points (P= .016). The Dynamic Gait Index improved as well (mean increase, 2.8; P= .004), as did postural sway measured with the balance board (decreased variance in stance with eyes open by 31%; P= .049). Although the Sharpened Romberg with eyes closed increased by 6.85 points and with eyes opened by 3.3 points, improvements neared significance only for eyes closed (P= .07 versus P= .188). There were no significant changes on patient ratings for the Activities-specific Balance Confidence (mean decrease,-1%; P= .922) or the Geriatric Depression Scale (mean increase, 2.2; P= .188). An 8-week exercise training class by using the Wii Fit balance board improved selective measures of balance and gait in adults with PD. However, no significant changes were seen in mood or confidence regarding balance.

AB0960 Efficacy and safety of oral low dose glucocorticoids in patients with estrogen hormone dependent primary osteoarthritis

BackgroundEstrogen hormone dependent osteoarthritis (EDPOA) is presented in peri-menopausal age women. Their manifestations are polyarticular pain with common co-morbidities (carpal tunnel syndrome, insomnia, fatigue, depression and fibromyalgia). Based on dual...

A prospective interventional cohort study of 175 patients treated by the SpineCor orthosis, following the Scoliosis Research Society Criteria

Background The mainstay of the conservative treatment still remains the orthosis, which was demonstrated to provide a reduction of curve progression, possibly a decrease in the need for surgery, and sometimes a correction of the existing deformity. The effectiveness of the SpineCor orthosis compared with the natural history of the disease has already been shown for milder and moderate curves[1]. Aim To provide confirmation on the demonstrated effectiveness of the Dynamic SpineCor orthosis for adolescent idiopathic scoliosis, following the standardized criteria proposed by the SRS Committee on Bracing and Nonoperative Management[2], and to confirm the stability of the results two years after the end of the treatment. Method

Comprehensive care of elderly patients with hip fracture: the orthogeriatric model

Introduction: Hip fractures in the elderly are a major source of morbidity and mortality. Interdisciplinary hospital care models proposed for the treatment of these patients include consultant teams, integrated orthopedic-geriatric care, and comprehensive geriatric-led care settings. A prospective interventional cohort study was conducted in 4 public hospitals in the Emilia-Romagna Region of Italy to compare the outcomes of these different care models. This report presents the preliminary results obtained with an orthogeriatric model in one of these centers, a large teaching hospital in Bologna. Materials and methods: Beginning in February 2008, all patients older than 75 years admitted to the University of Bologna’s Sant’Orsola-Malpighi Hospital for hip fractures were cared for in an orthogeriatric unit. The unit consisted of 10 beds in the orthopedic ward that were managed by a geriatric specialist and a multidisciplinary team, which met daily and included an orthopedic surgeon, a physiatrist, a nurse case-manager, staff nurses, a physical therapist, and a social worker. The management protocol included a thorough geriatric work-up to identify comorbidities and risk factors, systematic assessment and prevention of pain and acute disorientation, early verticalization and moblization, postacute rehabilitation therapy, family support, and regular follow-up after discharge. Preliminary results were compared with those achieved in the same orthopedic ward prior to the creation of the Orthogeriatric Unit. Results: During 2008, 226 elderly patients (mean age 86.2 + 5.5 years), 73.4% of whom were women, were admitted to the Orthogeriatric Unit for hip fractures. The mean Charlson comorbidity index of this cohort was 3.0 + 1.8). Half the patients had Activity of Daily Living scores &lt; 4, and cognitive impairment was common (mean score on Short Portable Mental Status Questionnaire: 5.9 + 3.2). Compared with figures obtained in the hospital’s orthopedic ward prior to 2008, in-hospital mortality dropped from 5.98% to 3.98%. The mean overall length of hospitalization was not significantly reduced, but the mean stay in the Orthogeriatric unit decreased by almost 2 days (to 10.46 days from 12.44 days in the traditional orthopedic unit). Discussion: Compared with traditional care models, the orthogeriatric model may allow better integration of the health-care resources available for the management of hip fractures in the elderly, and this improvement may have positive effects on the outcome of these cases.

Persistent nasal methicillin-resistant staphylococcus aureus carriage in hemodialysis outpatients: a predictor of worse outcome

BackgroundNasal colonization with methicillin-resistant Staphylococcus aureus (MRSA) is a well defined risk factor for subsequent bacteremia and death in various groups of patients, but its impact on outcome in patients receiving long-term hemodialysis (HD) is under debate.MethodsThis prospective interventional cohort study (performed 2004 to 2010) enrolled 289 HD outpatients of an urban dialysis-unit. Nasal swab cultures for MRSA were performed in all patients upon first admission, at transfer from another dialysis facility or readmission after hospitalisation. Nasal MRSA carriers were treated in a separate ward and received mupirocin nasal ointment. Concomitant extra-nasal MRSA colonization was treated with 0.2% chlorhexidine mouth rinse (throat) or octenidine dihydrochloride containing antiseptic soaps and 2% chlorhexidine body washes (skin). Clinical data and outcome of carriers and noncarriers were systematically analyzed.ResultsThe screening approach identified 34 nasal MRSA carriers (11.7%). Extra-nasal MRSA colonization was observed in 11/34 (32%) nasal MRSA carriers. History of malignancy and an increased Charlson Comorbidity Index were significant predictors for nasal MRSA carriers, whereas traditional risk factors for MRSA colonization or markers of inflammation or malnutrition were not able to discriminate. Kaplan-Meier analysis demonstrated significant survival differences between MRSA carriers and noncarriers. Mupirocin ointment persistently eliminated nasal MRSA colonization in 26/34 (73.5%) patients. Persistent nasal MRSA carriers with failure of this eradication approach had an extremely poor prognosis with an all-cause mortality rate >85%.ConclusionsNasal MRSA carriage with failure of mupirocin decolonization was associated with increased mortality despite a lack of overt clinical signs of infection. Further studies are needed to demonstrate whether nasal MRSA colonization represents a novel predictor of worse outcome or just another surrogate marker of the burden of comorbid diseases leading to fatal outcome in HD patients.

Intraocular Pressure Lowering Is Associated with an Increase in the Photopic Negative Response (PhNR) Amplitude in Glaucoma and Ocular Hypertensive Eyes

The aim of our study was to determine whether IOP lowering in glaucomatous and ocular hypertensive (OHT) eyes leads to an improvement in the full-field photopic negative response (PhNR) of the electroretinogram. A prospective nonrandomized interventional cohort study was conducted. Patients with OHT or glaucomatous optic neuropathy were recruited, and photopic full-field electroretinograms (ERG) were performed at baseline and then repeated 1 to 2 months later. The change in PhNR amplitude was compared between those eyes that had a significant lowering in IOP (defined as >25% decrease from baseline or to a predetermined target IOP) during follow-up and those that did not. From a cohort of 30 eyes, 18 eyes had a significant reduction in IOP during follow-up (n = 18) and 12 eyes had no significant change in IOP (<25% reduction in IOP, n = 12). A significant increase in PhNR amplitude and the PhNR/b-wave amplitude ratios was observed in the reduced IOP group, but not in the IOP stable group for the two flash intensities used (2.25 and 3.00 cd.s/m(2)). The full-field PhNR amplitude provides a potentially reversible measure of inner retinal function that improves after IOP lowering. Further study now is required to assess its use as a measure of optic nerve health in glaucoma patients.

Long-term Results of a 12-Week Comprehensive Ambulatory Cardiac Rehabilitation Program

To evaluate the long-term outcome of a 12-week outpatient cardiac rehabilitation (CR) program. In a prospective single-center interventional cohort study, 201 consecutive patients (133 patients after acute coronary syndrome, 32 patients after heart surgery, and 36 patients with heart failure) attending a 12-week comprehensive outpatient CR program were evaluated for exercise capacity, cardiovascular risk factors (CvRFs), and quality of life at entry, end, and 1.4 years after completion of the program (followup). Physical exercise capacity improved significantly from program entry to program end and remained at this level at followup (P ≤ .006). CvRFs at followup were significantly reduced with regard to smoking prevalence and blood lipids (P < .001). At program end and followup, MacNew heart disease-specific emotional, physical, and social quality of life were improved significantly compared with those at program entry (P < .001). Use of cardioprotective medication remained equally high over the entire study period. However, significantly fewer patients reached blood pressure (<140/90 mm Hg, P = .034) and body mass index (<30 kg/m, P = .017) goals at followup than at program end. The 12-week comprehensive outpatient CR program was successful at reducing important CvRFs long-term.

Increasing Use of the Vaccine Against Zoster Through Recommendation and Administration by Ophthalmologists at a City Hospital

To increase the vaccination rate and identify barriers to administration of the vaccine against herpes zoster by having ophthalmologists screen and provide the vaccine. Prospective interventional cohort study. Academic City Hospital, Bellevue Hospital. A total of 100 eligible patients based on recommended Centers for Disease Control (CDC) criteria and ability to speak English and Spanish who received the herpes zoster vaccine were compared with 66 patients who declined the vaccine. The vaccine was administered after written informed consent was obtained to complete a screening questionnaire evaluating the participants' eligibility and interest in receiving the vaccine. Barriers to administration of the vaccine were evaluated. A total of 170 consenting patients, including 100 patients who were vaccinated, 66 patients who declined vaccination, and 4 patients who were ineligible, were analyzed. The proportion of subjects who would consider receiving the vaccine if recommended by a doctor among those who received the shingles vaccine, 98.0% (95% CI: 95%-100%), was significantly greater than the proportion in the group that declined, 74.2% (95% CI: 64%-85%) (P ≤ .0001). The most common reason that patients declined the vaccine was wanting to speak with their primary care physician, 46.9% (95% CI: 33%-61%). Ophthalmologists can screen, educate, and prescribe the vaccine against herpes zoster in order to increase utilization of this vaccine. Nonfinancial or access barriers of this vaccine among underserved eligible patients include absence of recommendation by their primary care doctor.

Efficacy and safety of oral low-dose glucocorticoids in patients with estrogen-dependent primary osteoarthritis

Estrogen-dependent osteoarthritis (EDPOA) is a disease of perimenopausal-age women. Their manifestations are polyarticular pain with common co-morbidities (carpal tunnel syndrome, insomnia, fatigue, depression, and fibromyalgia). Based on dual role of glucocorticoids, its trophic action on the chondrocyte and its anti-inflammatory effect, we conducted a prospective interventional cohort study where we evaluate the efficacy and safety of oral low-dose GC in one hundred women with EDPOA. The pain intensity, number of tender joints as well as impact in co-morbidities were analyzed. We conclude that the use of low-dose GC in patients with EDPOA can be an effective and a safe therapeutic option.

A prospective cohort study on the role of nonspecialist staff in preventing relapses and improving clinic attendance of patients with schizophrenia

Background:The Sri Lankan government employs graduates from local universities (trained in nonpsychiatry disciplines) as Mental Health Development Officers (MHDOs) to fulfill the role of a psychiatric social worker.Materials and Methods:This was a prospective interventional cohort study on preventing relapses of schizophrenia by active involvement of MHDOs. The intervention (randomly selected) and control groups each had 25 follow-up patients with schizophrenia (1:1 match for sex, ethnicity, age, and duration of illness). The intervention was to develop a close liaison with the patient/family and build an individualized client oriented follow-up through the MHDOs. The follow-up period was 1 year.Results:The intervention group had better clinic attendance, less relapses, and defaults. The number needed to follow-up to avert a relapse or a default was 12.5 and 5 respectively.Conclusions:Low-cost strategies involving nonspecialist staff can reduce relapses and defaults in patients with schizophrenia.

Evaluation of the effect of intravitreal ranibizumab on choroidal thickness in eyes treated for diabetic macular edema

Purpose: To evaluate the effect of intravitreal Ranibizumab on central choroidal thickness (CCT) in eyes treated for diabetic macular edema (DME). Materials and Methods: This prospective non-randomized interventional cohort study included 20 eyes of 20 diabetic patients, recruited between March 2013 and March 2014. Eyes with DME (thickness from 290 to 600 μm) underwent intravitreal injection of Ranibizumab (three consecutive injections, 1 month apart). Prior to injection, all patients had a complete ophthalmic examination, including manifest refraction, slit-lamp bio-microscopy, intraocular pressure measurement, and a detailed fundus examination. Prior to injection and 1 month from the third injection, the central macular thickness and CCT were assessed again by SD-OCT. After each injection, patients were followed to diagnose and treat any complications from injections. Results: Twenty eyes of 20 diabetic retinopathy (DR) patients, 9 females and 11 males with a mean age of 49.7 ± 4.1 years, were included. The pre-injection mean CCT was 234.35 ± 38.36 μm. In the NPDR group, it was 238.2 ± 41.36 μm; and in the PDR group, it was 228.5 ± 35.26 μm. This was not significantly different (P = 0.851). After injections, the mean CCT in all patients, in the NPRD group and in the PDR group showed a decrease to 215.5 ± 39.08, 224.9 ± 40.72 and 201.31 ± 34.02 μm, respectively (P = 0.362). There was a statistically significant difference between the pre-injection and the post-injection CCT (P < 0.001). The improvement in the CCT after treatment was not significantly correlated with the pre-injection CCT or the pre-injection CMT (P = 0.346, P = 0.096 respectively). No significant correlation was found between post-injection CCT and CMT in all patients (P = 0.436) or in the different groups separately (P = 0.191, P = 0.817, respectively). No injection-related complication was observed in either group. Conclusion: Intravitreal injection of Ranibizumab was effective in significantly decreasing the CCT as well as the CMT after three consecutive injections, 1 month apart regardless of the level of DR. Whether the number of injections can influence the amount of this reduction or not should be evaluated in future studies. No correlation was found between the reduction in CMT and that of the CCT after intravitreal injection with 0.5 mg of Ranibizumab.

332 Impact of Emergency Department Clinical Pharmacist Response to an Automated Electronic Notification System on Timing and Appropriateness of Antimicrobials in Severe Sepsis or Septic Shock in the Emergency Department

Study Objectives: To determine the effect of an emergency department (ED) clinical pharmacist response to an automated electronic notification system on the timing and appropriateness of antimicrobials in patients with severe sepsis or septic shock in the ED. Methods: The study was conducted in an ED at a tertiary care academic medical center with 80,000 visits annually. This was a prospective interventional cohort (01/21/2010 - 006/20/2010) study with a historical control cohort (01/21/2009-06/20/2009). Potentially eligible patients were identified by an electronic notification system. The electronic notification system criteria/algorithm were previously validated in our ED to detect potential patients with severe sepsis and septic shock. The prospective cohort was identified by application of the electronic notification system criteria via radio page in real-time. The historical control cohort was identified by applying the electronic notification system criteria retrospectively to the ED electronic tracking board which retains and stores all patient information for all ED visits on a Microsoft SQL Server 2005 database. Patients were eligible for the study if they met electronic notification system criteria, had severe sepsis or septic shock (per Surviving Sepsis Campaign Guidelines) and presented to the ED while the pharmacist was present (approximately 80 hours/week). A radio page was sent to an ED clinical pharmacist when a patient met electronic notification system criteria. The pharmacist evaluated the patient for the presence of severe sepsis or septic shock, recommended empiric antimicrobials, and facilitated their procurement and administration. Primary outcome measures were: 1) time from ED room assignment to appropriate antimicrobial administration; and 2) proportion of patients with appropriate antimicrobials administered within 3 hours of ED room assignment. Appropriate antimicrobials were defined as having activity against any isolated pathogen or following national or institutional guidelines in culture negative patients. Determination of severe sepsis or septic shock in all electronic notification system patients and assessment of appropriateness of antimicrobials was done by chart review after completion of the study by blinded reviewers. Results: The electronic notification system was triggered 1232 and 1202 times during the intervention and control cohort study periods, respectively. Of these, 160 (13%) and 143 (12%) patients met inclusion criteria in the intervention and control groups respectively. Baseline demographic characteristics and ED length of stay were similar between groups. There was no significant difference in mean time from ED arrival to meeting electronic notification system criteria. Patients in the intervention group had a shorter median time to appropriate antimicrobial administration than in the control group (173 [IQR 182] versus 217IQR 301] minutes, P = 0.03). There were significantly more patients who received appropriate antimicrobials in the ED (73% versus 61% P=0.03). The proportion of patients who received appropriate antimicrobials within 3 hours of ED presentation (room time) was higher in the intervention group compared to controls (47% versus 35%, P=0.048). Conclusion: An ED pharmacist response to an automated electronic notification system resulted in faster time to appropriate antimicrobial administration and a higher rate of appropriate empiric antimicrobial use within 3 hours of presentation. This method is one means of improving the care of patients with severe sepsis and septic shock in the ED.

Combining Zonal Refractive and Diffractive Aspheric Multifocal Intraocular Lenses

To assess visual performance with the combination of a zonal refractive aspheric multifocal intraocular lens (MIOL) (Lentis Mplus, Oculentis GmbH) and a diffractive aspheric MIOL (Acri.Lisa 366, Acri.Tech GmbH). This prospective interventional cohort study comprised 80 eyes from 40 cataract patients (mean age: 65.5±7.3 years) who underwent implantation of the Lentis Mplus MIOL in one eye and Acri.Lisa 366 MIOL in the fellow eye. The main outcome measures were refraction; monocular and binocular uncorrected and corrected distance, intermediate, and near visual acuities; monocular and binocular defocus curves; binocular photopic contrast sensitivity function compared to a monofocal intraocular lens (IOL) control group (40 age-matched pseudophakic patients implanted with the AR-40e [Abbott Medical Optics]); and quality of vision questionnaire. Binocular uncorrected visual acuities were 0.12 logMAR (0.76 decimal) or better at all distances measured between 6 m and 33 cm. The Lentis Mplus provided statistically significant better vision than the Acri.Lisa at distances between 2 m and 40 cm, and the Acri.Lisa provided statistically significant better vision than the Lentis Mplus at 33 cm. Binocular defocus curve showed little drop-off at intermediate distances. Photopic contrast sensitivity function for distance and near were similar to the monofocal IOL control group except for higher frequencies. Moderate glare (15%), night vision problems (12.5%), and halos (10%) were reported. Complete independence of spectacles was achieved by 92.5% of patients. The combination of zonal refractive aspheric and diffractive aspheric MIOLs resulted in excellent uncorrected binocular distance, intermediate, and near vision, with low incidence of significant photic phenomena and high patient satisfaction.

Abstract 226: Nurses' Retention of BLS and ACLS Skills Improves Survival from In-Hospital Cardiac Arrest

OBJECTIVE: To evaluate whether nurses' retention of BLS and ACLS skills improves survival from in-hospital cardiac arrest (IHCA). METHODS: A prospective interventional cohort study was performed. All of 24 registered nurses in a general ward were assigned to 6 groups after training of BLS and ACLS. At immediately and 9 months after training, the 6 groups were evaluated by skill performance tests based on the American Heart Association 2005 BLS and ACLS tools in simulated environment. Survival from IHCA after resuscitation efforts by nurses as first responders was classified after-training term (2010) and before-training term (2008-2009) and examined the outcome. RESULTS: The evaluation in 9 month after training resulted that core skills of chest compression were well-retained. Delivering 30 compressions and 2 ventilations, pressing first shock button of AED &lt; 90 seconds from AED arrival and management of drug use were also well-retained in 6 groups, whereas both first 2 ventilations with bag-valve-mask were done in only one group. Checking carotid pulse or checking breathing was little done for at least 5 seconds but no more than 10 seconds. As concerns survival from IHCA, 53 patients (67.8 yr, M/F=35/18) received resuscitation efforts by nurses as first responders in 2008-2009, and 6 patients (77.4 yr, M/F=4/2) received resuscitation in ward in 2010. The outcome of in-ward cardiac arrest after training improved significantly compared with that of IHCA before training. The return of spontaneous circulation rate increased from 38% to 83% (P=0.04), 7-day survival increased from 19% to 83% (P=0.003), 30-day survival increased from 15% to 67% (P=0.01), and cerebral performance category 1 at hospital discharge increased from 11% to 50% (P=0.04). CONCLUSIONS: Registered nurses had well retained BLS and ACLS skills for 9 months. The nurses' retention of those skills improved survival from IHCA. Contrary to other skills, the skills of assessment for breathing and circulation were little retained. This assessment may not affect on the outcome, and thus, our results may support validity that “look, listen and feel for breathing” was removed from assessment step of the 2010 algorithm, as well as that “A-B-C” changed to “C-A-B”.

Ortogeriatria: un nuovo modello di assistenza ai pazienti anziani con frattura di femore e comorbilità

Summary Introduction Hip fractures in the elderly are a major source of morbidity and mortality. Interdisciplinary hospital care models proposed for the treatment of these patients include consultant teams, integrated orthopedic-geriatric care, and comprehensive geriatric-led care settings. A prospective interventional cohort study was conducted in 4 public hospitals in the Emilia-Romagna Region of Italy to compare the outcomes of these different care models. This report presents the preliminary results obtained with an orthogeriatric model in one of these centers, a large teaching hospital in Bologna. Materials and methods Beginning in February 2008, all patients older than 75 years admitted to the University of Bologna's Sant’Orsola-Malpighi Hospital for hip fractures were cared for in an orthogeriatric unit. The unit consisted of 10 beds in the orthopedic ward that were managed by a geriatric specialist and a multidisciplinary team, which met daily and included an orthopedic surgeon, a physiatrist, a nurse case-manager, staff nurses, a physical therapist, and a social worker. The management protocol included a thorough geriatric work-up to identify comorbidities and risk factors, systematic assessment and prevention of pain and acute disorientation, early verticalization and moblization, postacute rehabilitation therapy, family support, and regular follow-up after discharge. Preliminary results were compared with those achieved in the same orthopedic ward prior to the creation of the Orthogeriatric Unit. Results During 2008, 226 elderly patients (mean age 86.2 ± 5.5 years), 73.4% of whom were women, were admitted to the Orthogeriatric Unit for hip fractures. The mean Charlson comorbidity index of this cohort was 3.0 ± 1.8). Half the patients had Activity of Daily Living scores ≤ 4, and cognitive impairment was common (mean score on Short Portable Mental Status Questionnaire: 5.9 ± 3.2). Compared with figures obtained in the hospital's orthopedic ward prior to 2008, in-hospital mortality dropped from 5.98% to 3.98%. The mean overall length of hospitalization was not significantly reduced, but the mean stay in the Orthogeriatric unit decreased by almost 2 days (to 10.46 days from 12.44 days in the traditional orthopedic unit). Discussion Compared with traditional care models, the orthogeriatric model may allow better integration of the health-care resources available for the management of hip fractures in the elderly, and this improvement may have positive effects on the outcome of these cases.

Prevention of adverse drug reactions in intensive care patients by personal intervention based on an electronic clinical decision support system

We investigated the effect of written drug information for senior clinicians on the incidence of drug-drug interactions (DDIs) and DDI-related adverse events in intensive care patients. A prospective controlled intervention cohort study was conducted in a medical intensive and intermediate care unit in a university hospital. From 1,062 consecutive intensive care patients, those 265 (control: 136, intervention: 129) with > or =8 concurrently prescribed drugs were included in the study (to include high-risk patients with polypharmacy). The DDI information for senior clinicians during an intervention period of 3 months was based on a computerised clinical decision support system (CDSS) containing information on risk and management of 9,453 drug combinations. The number of patients with at least one DDI at the end of the respective study phase decreased by 18% (relative risk reduction) from 90 (66%) patients in controls to 70 (54%) in the intervention group (p = 0.02). The relative risk of a patient suffering from at least one DDI-related adverse event decreased by 43% from 60 (44%) patients in controls to 32 (25%) in the intervention group (p < 0.01). Among these events, the incidence of QT(C) prolongation was reduced by 64% from 15 (11%) patients in the control group to 5 (4%) in the intervention group (p = 0.04), and the incidence of hypokalemia by 80% from 14 (10%) to 2 (2%, p < 0.01). Written drug information based on a CDSS considerably decreased DDIs and DDI-related adverse events in routine practice.

Multidisciplinary pain management based on a computerized clinical decision support system in cancer pain patients

A prospective controlled intervention cohort study in cancer pain patients (n=50 per group) admitted to radiation oncology wards (62 beds, 3 wards) was conducted in a 1621-bed university hospital. We investigated the effect of an intervention consisting of daily pain assessment using the numeric visual analog scale (NVAS) and pain therapy counseling to clinicians based on a computerized clinical decision support system (CDSS) to correct deviations from pain therapy guidelines. Effects on guideline adherence (primary outcome), pain relief (NVAS) at rest and during physical activity (both groups: cross-sectional assessment on day 5; intervention group: every day assessment), co-analgesic prescription, and acceptance rates of recommendations (secondary outcomes) were assessed. The number of patients with at least one deviation from guidelines at discharge was decreased by the intervention from 37 (74%) in controls to 7 (14%, p<0.001). In the intervention group, pain (NVAS) decreased during hospital stay at rest from 3.0 (Δ0.5 (Q75%−Q25%)=3.0) on admission to 1.5 (Δ0.5=1.0) at discharge (p<0.01) and during physical activity from 7.0 (Δ0.5=4.0) on admission to 2.5 (Δ0.5=3.8) at discharge (p<0.001). At discharge, the number of patients treated with co-analgesics increased from 23 (46%) in controls to 33 (66%) in the intervention group (p=0.04). From 279 recommendations issued in the intervention 85% were fully accepted by the physicians. Deviations from well-established guidelines are frequent in pain therapy. A multidisciplinary pain management increased adherence to pain management guidelines.