Nasal carriage of methicillin resistant Staphylococcus aureus in a cardiovascular tertiary care centre and its detection by Lipovitellin Salt Mannitol Agar.
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Ecological niches of Staphylococcus aureus are the anterior nares. Carriage of Staphylococcus aureus in the nose appears to play a key role in the epidemiology and pathogenesis of infection. Numerous studier have shown that elimination of nasal carriage using Mupirocin also eliminated hand carriage and the spread of infections in hospitals. Lipovitellin-Salt-Mannitol Agar was used for screening, isolation and presumptive identification of Staphylococcus aureus from nasal carriers. From November; 97 to August'98, 724 nasal swabs were cultured and 18.23% of health care workers were found to be nasal carriers of Staphylococcus aureus. Of these 12.15% were carriers of MRSA. The carrier rate was highest in December' 97 (32.07%). All MRSA carriers were treated with local application of Mupirocin for three days. A study of the antibiogram of the clinical isolates during the corresponding period showed 100% susceptibility of MRSA to Vancomycin. Susceptibility of MRSA to Clindamycin, Netilmycin, Rifampicin & Ofloxacin was 86.6%, 69.5%, 66% & 64.7% respectively. (+info)
Use of the Internet by patients before and after cardiac surgery: telephone survey.
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BACKGROUND: Little is known about to what extent patients who underwent medical treatment access the Internet and whether they benefit from consulting the Internet. OBJECTIVE: To understand if cardiopathic patients use the Internet for health-related information and whether they find retrieved information understandable and useful. METHODS: Telephone interviews, using a semi-structured questionnaire, were conducted with 82 patients who had undergone off-pump coronary-artery bypass grafting at the Center for Less Invasive and Robotic Heart Surgery in Buffalo, New York, USA. Study design was multidisciplinary, combining expertise of medical and communication science. Sources of medical information were identified (doctor, Internet, magazines, newspapers, television, radio, family members). Accessibility, quality, and readability of Internet medical information from the patients point of view were investigated. RESULTS: Out of 82 patients, 35 (35/82, 42.7%) were Internet users. Internet users had a significantly higher education level than Internet non-users (college education: 42.9% of users, 10.6% of non-users; P <.001). Among the Internet users, 18 (18/35, 51.4%) had used the Internet for retrieving medical information; 17 (17/35, 48.6%) had not. No statistically significant differences in demographic data were found when comparing these 2 sub-groups of patients. Family-members involvement was high (15/18, 83.3%). Internet medical information was rated helpful in most cases; readability was acceptable for only 3 patients (3/18, 16.7%). To improve on-line medical information, all patients interviewed suggested sites designed by their physicians. CONCLUSIONS: Although 1 in 5 patients in our sample has used the Internet to retrieve medical information, the majority of them experiences difficulties comprehending the information retrieved. Health-care providers should provide Internet medical information that is adequate for the non-medical public's needs. (+info)
Grown-up congenital heart (GUCH) disease: current needs and provision of service for adolescents and adults with congenital heart disease in the UK.
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This report addresses the needs and problems of grown-up congenital heart (GUCH) patients and makes recommendations on organisation of national medical care, training of specialists, and education of the profession. The size of the national population of patients with grown-up congenital heart disease (GUCH) is uncertain, but since 80-85% of patients born with congenital heart disease now survive to adulthood (age 16 years), an annual increase of 2500 can be anticipated according to birth rate. Organisation of medical care is haphazard with only three of 18 cardiac surgical centres operating on over 30 cases per annum and only two established specialised units fully equipped and staffed. Not all grown-ups with congenital heart disease require the same level of expertise; 20-25% are complex, rare, etc, and require life long expert supervision and/or intervention; a further 35-40% require access to expert consultation. The rest, about 40%, have simple or cured diseases and need little or no specialist expertise. The size of the population needing expertise is small in comparison to coronary and hypertensive disease, aging, and increasing in complexity. It requires expert cardiac surgery and specialised medical cardiology, intensive care, electrophysiology, imaging and interventions, "at risk" pregnancy services, connection to transplant services familiar with their basic problem, clinical nurse specialist advisors, and trained nurses. An integrated national service is described with 4-6 specialist units established within adult cardiology, ideally in relation or proximity to university hospital/departments in appropriate geographic location, based in association with established paediatric cardiac surgical centres with designated inpatient and outpatient facilities for grown-up patients with congenital heart disease. Specialist units should accept responsibility for educating the profession, training the specialists, cooperative research, receiving patients "out of region", sharing particular skills between each other, and they must liaise with other services and trusts in the health service, particularly specified outpatient clinics in district and regional centres. Not every regional cardiac centre requires a full GUCH specialised service since there are too few patients. Complex patients need to be concentrated for expertise, experience, and optimal management. Transition of care from paediatric to adult supervision should be routine, around age 16 years, flexibly managed, smooth, and explained to patient and family. Each patient should be entered into a local database and a national registry needs to be established. The Department of Health should accept responsibility of dissemination of information on special needs of such patients. The GUCH Patients' Association is active in helping with lifestyle and social problems. Easy access to specialised care for those with complex heart disease is crucial if the nation accepts, as it should, continued medical responsibility to provide optimal medical care for GUCH patients. (+info)
Continuous systemic perfusion via collaterals at moderate hypothermia in aortic arch repairs in neonates.
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AIM: To present our experience with modified cannulation with continuous, moderately hypothermic systemic perfusion in extensive aortic arch repair. The technique has fewer complications and preserves cerebral blood flow autoregulation. METHOD: Nine neonates, 6 with the hypoplastic left heart syndrome and 3 with the interrupted aortic arch with ventricular septal defect, were surgically treated with this technique between June and December 2001. Before extracorporeal circulation, 3.5-mm polytetrafluoroethylene tube was sutured onto the innominate artery and the arterial perfusion cannula inserted into the tube. Aortic arch repair was then performed with extracorporeal circulation. Right radial artery and femoral artery pressures were continuously monitored. Perfusion flows were built up gradually, with strict attention to the upper body (right radial artery) pressures not to exceed normal values. Procedures were carried out at moderate hypothermia (>28 degrees C), preferably with the beating heart. RESULTS: No morbidity or mortality attributable to continuous perfusion occurred. Mean+/-SD extracorporeal circulation duration was 114+/-26 min. Maximum perfusion rate (actual/required flow for body surface area) was 1.65 at normal perfusion pressures. Right radial artery pressure at full flow (2.2 L/m2/min) was 56.1+/-6.7 mm Hg, whereas femoral artery pressure was 34.2+/-8.2 mm Hg. Decrease in right radial-to-femoral artery pressure was 21.9+/-5.6 mm Hg. The lowest nasopharyngeal temperature was 28.5 degrees C. There were no neurologic complications. CONCLUSION: Continuous, moderately hypothermic systemic perfusion via collaterals seems to be a method of choice in aortic arch repair in neonates. As there is no need for deep hypothermic total circulatory arrest, its numerous sequelae, such as increased postoperative bleeding and permanent neurologic deficit, can be avoided. (+info)
Right ventricle failure and outcome of simple and complex arterial switch operations in neonates.
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AIM: To analyze the causes and role of right ventricle failure in the morbidity and mortality after arterial switch operation for transposition of the great arteries in neonates. METHOD: Between January 1999 and December 2001, 62 neonates underwent arterial switch operation. The simple transposition group was comprised of 39 patients with transposition of the great arteries and intact ventricular septum. The complex transposition group included 23 patients with large ventricular septal defects, accompanied with left ventricle outflow tract obstruction in 6 cases and dextrocardia in 1 case. Arterial switch operation was performed on elective basis in all but 3 patients who underwent emergency operation. RESULTS: Patients with complex heart defects had significantly lower body weight (p = 0.008) than patients with simple trasposition of great arteries. The usual coronary artery pattern (ie, the left anterior descending artery and circumflex artery arising from the right aortic sinus; the right coronary artery arising from the left aortic sinus) was found in 74% of the neonates in the simple transposition group and 65% of the neonates in the complex transposition group. Age, weight, coronary artery anatomy, cardiopulmonary bypass, duration of aortic cross-clamp, bleeding, and the need for delayed chest closure did not influence the outcome of surgery. Low cardiac output after surgery was more common in the complex transposition group (p = 0.0001), although it was not a predictor of fatal outcome. Preoperative hypoxia coupled with acidosis (odds ratio (OR), 5.70; 95% confidence intervals (CI), 4.45-7.44), and emergency operations (OR, 3.62; 95% CI, 2.22-5.59) were strong predictors of unfavourable outcome. We lost 4 patients out of 62 (6.5%) because of right ventricle failure caused by persistent pulmonary hypertension. Right ventricle failure on the second postoperative day, e.g., sustained increased central venous pressure > 15 mm Hg (p < 0.001) and high velocity tricuspid regurgitation > 4 m/s (p = 0.002), indicated bad prognosis. CONCLUSION: Difficult coronary anatomy was not a risk factor for morbidity and mortality after arterial switch operation. Poor preoperative health condition, hypoxia (despite effective balloon atrioseptostomy), and acidosis contributed to persistent pulmonary hypertension. Operation on the emergency basis and tricuspid valve insufficiency with right ventricle failure were strong predictors of unfavorable outcome. (+info)
Geography and service supply do not explain socioeconomic gradients in angiography use after acute myocardial infarction.
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BACKGROUND: Socioeconomic status appears to be an important predictor of coronary angiography use after acute myocardial infarction. One potential explanation for this is that patients with lower socioeconomic status live in neighbourhoods near nonteaching hospitals that have no catheterization capacity, few specialists and lower volumes of patients with acute myocardial infarction. This study was conducted to determine whether the impact of socioeconomic status on angiography use would be lessened by considering variations in the supply of services. METHODS: We examined payment claims for physician services, hospital discharge abstracts and vital status data for 47 036 patients with acute myocardial infarction admitted to hospitals in Ontario between April 1994 and March 1997. Neighbourhood income of each patient was obtained from Canada's 1996 census. Using multivariate hierarchical logistic regression and adjusting for baseline patient and physician factors, we examined the interaction among hospital and regional characteristics, socioeconomic status and angiography use in the first 90 days after admission to hospital for acute myocardial infarction. RESULTS: Within each hospital and geographic subgroup, crude rates of angiography rose progressively with increases in neighbourhood income. After adjusting for sociodemographic, clinical and physician characteristics, hospitals with on-site angiography capacity (adjusted odds ratio [OR] 1.88, 95% confidence interval [CI] 1.52-2.33), those with university affiliations (adjusted OR 1.60, 95% CI 1.27-2.01) and those closest to tertiary institutions (adjusted OR 1.57, 95% CI 1.32-1.87) were all associated with higher 90-day angiography use after acute myocardial infarction. However, the relative impact of socioeconomic status on 90-day angiography use was similar whether or not hospitals had on-site procedural capacity (interaction term p = 0.68), had university affiliations (interaction term p = 0.99), were near tertiary facilities (interaction term p = 0.67) or were in rural or urban regions (interaction term p = 0.90). INTERPRETATION: Socioeconomic status was as important a predictor of angiography use in hospitals with ready access to cardiac catheterization facilities as it was in those without. The socioeconomic gradient in the use of angiography after acute myocardial infarction cannot be explained by the distribution of specialists or tertiary hospitals. (+info)
Waiting times, revascularization modality, and outcomes after acute myocardial infarction at hospitals with and without on-site revascularization facilities in Canada.
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OBJECTIVES: This study was designed to determine whether admission to a Canadian hospital with on-site revascularization (invasive hospital) affected revascularization choice, timing, and outcome compared with community (non-invasive) hospitals. BACKGROUND: Health care systems in Canada are characterized by relative restraint in diffusion of tertiary cardiovascular services, with capacity for revascularization procedures concentrated in large regional referral centers. METHODS: We used linked administrative data and a clinical registry to follow-up 15,166 Ontario patients who underwent revascularization within the year after their index acute myocardial infarction (MI). Outcomes included recurrent urgent cardiac hospitalization, hospital bed-days, and death within the same year after the index admission. We adjusted for age, gender, socioeconomic status, illness severity, attending physician specialty, and academic hospital affiliation. RESULTS: After adjusting for baseline factors, patients admitted to invasive hospitals were more likely to receive angioplasty than bypass surgery (adjusted odd ratio: 1.85; 95% confidence interval: 1.68 to 2.04, p < 0.001). The converse pattern was seen for patients admitted to community hospitals. Median revascularization waiting times were significantly shorter at invasive hospitals (12 vs. 48 days, p < 0.001). Patients admitted to invasive hospitals had fewer cardiac re-admissions (41.5 vs. 68.9 events per 100 patients, p < 0.001) before their first revascularization and consumed fewer hospital bed-days (379 vs. 517 per 100 patients, p < 0.001). There were no differences in outcomes beyond revascularization. CONCLUSIONS: Outcome advantages associated with timely post-MI revascularization highlight the importance of organizing revascularization referral networks and facilitating access to revascularization for patients with acute coronary syndromes admitted to community hospitals in Canada. (+info)
The relation between experience and outcome in heart transplantation.
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BACKGROUND: Current policies related to organ transplantation in the United States are designed to ensure that centers and physicians with experience in transplantation perform these procedures. It is essential to confirm the validity of such policies, since they may limit access to transplantation services. METHODS: To determine the relation between experience with heart transplantation and mortality after the procedure, we merged data from the registry of the International Society for Heart and Lung Transplantation with data from a survey that provided additional information about patients and transplantation centers. Our study included 1123 patients who received a heart transplant at one of 56 hospitals in the United States from 1984 through 1986. We used univariate and bivariate techniques, as well as logistic regression, to analyze our data. RESULTS: We observed an institutional learning curve for heart transplantation. Patients who received one of a center's first five transplants had higher mortality rates than patients who received a subsequent transplant (20 percent vs. 12 percent; P = 0.002; relative risk = 2.2; 95 percent confidence interval, 1.6 to 3.4). In addition, we found a correlation between the training of key personnel on the transplantation team and mortality at new transplantation centers. For example, new centers staffed by cardiologists with previous training in heart transplantation had lower mortality rates among heart-transplant recipients than centers without experienced cardiologists (7 percent vs. 16 percent; P = 0.001; relative risk = 2.7; 95 percent confidence interval, 1.3 to 5.9). By contrast, the previous training of the surgeons who performed transplantations was not related to the mortality rate associated with the procedure. CONCLUSIONS: Experience with heart transplantation is associated with a better outcome for patients after that procedure. Opportunities exist to refine transplantation policies on the basis of the experience of a center and its transplantation team and to develop similar policies for other forms of organ transplantation. (+info)