Determination of temperature variation during the individual steps of the production of hospital diets of modified consistency

Background & aim: Many disease outbreaks of food origin are caused by foods prepared in Food Service and Nutrition Units of hospitals, affecting hospitalized patients who, in most cases, are immunocompromised and therefore at a higher risk of severe worsening of their clinical status. The aim of this study was to determine the variations in temperature and the time-temperature factor of hospital diets. Methods: The time and temperature for the preparation of 4 diets of modified consistency were determined on 5 nonconsecutive days in a hospital Diet and Nutrition Unit at the end of preparation and during the maintenance period, portioning and distribution at 3 sites, i.e., the first, the middle and the last to receive the diets. Results and discussion: All foods reached an adequate temperature at the end of cooking, but temperature varied significantly from the maintenance period to the final distribution, characterizing critical periods for microorganism proliferation. During holding, temperatures that presented a risk were reached by 16.7% of the meats and 59% of the salads of the general diet, by 16.7% of the garnishes in the bland diet and by 20% of the meats and garnishes in the viscous diet. The same occurred at the end of distribution for 100% of the hot samples and of the salads and for 61% of the desserts. None of the preparations remained at risk temperature for a time exceeding that established by law. Conclusion: The exposure to inadequate temperature did not last long enough to pose risks to the patient.

Reference distribution of the bioelectrical impedance vector in healthy term newborns

Bioelectrical impedance vector analysis (BIVA) is a new method that is used for the routine monitoring of the variation in body fluids and nutritional status with assumptions regarding body composition values. The aim of the present study was to determine bivariate tolerance intervals of the whole-body impedance vector and to describe phase angle (PA) values for healthy term newborns aged 7-28 d. This descriptive cross-sectional study was conducted on healthy term neonates born at a low-risk public maternity. General and anthropometric neonatal data and bioelectrical impedance data (800 mu A-50 kHz) were obtained. Bivariate vector analysis was conducted with the resistance-reactance (RXc) graph method. The BIVA software was used to construct the graphs. The study was conducted on 109 neonates (52.3% females) who were born at term, adequate for gestational age, exclusively breast-fed and aged 13 (SD 3.6) d. We constructed one standard, reference, RXc-score graph and RXc-tolerance ellipses (50, 75 and 95 %) that can be used with any analyser. Mean PA was 3.14 (SD 0.43)degrees (3.12 (SD 0.39)degrees for males and 3.17 (SD 0.48)degrees for females). Considering the overlapping of ellipses of males and females with the general distribution, a graph for newborns aged 7-28 d with the same reference tolerance ellipse was defined for boys and girls. The results differ from those reported in the literature probably, in part, due to the ethnic differences in body composition. BIVA and PA permit an assessment without the need to know body weight and the prediction error of conventional impedance formulas.

The rise of multiple births in Brazil

Aim: The aim of this study was to assess the rise in multiple births and its influence on trends of low birth weight (LBW) rates in Porto Alegre, Brazil. Methods: This is a registry-based study of live births from 1994 to 2005 obtained from the national live birth information system. Chi-square tests for trends were assessed for LBW and multiple birth rates. The impact of multiple births on LBW trends was assessed by sequential modelling, including year and further adjustment for multiple births. Risk factors for multiple births were assessed using the Poisson regression. Results: A total of 263 252 live births were studied. The LBW rate increased from 9.70% to 9.88% (p < 0.001) and the multiple birth rate rose from 1.95% to 2.53% (p < 0.001). LBW rate increased among twins, from 57.14% to 63.46% (p = 0.001). The twin birth rate rose by 24.7%, while the rate of triplets or higher-order increased by 150%. Multiple births may be responsible for 23.9% of the increase in the LBW rate over the period. Mothers with higher levels of schooling, older mothers and mothers delivering in private hospitals were more likely to deliver multiple births. Conclusions: It seems that both the increase in multiple births and in the LBW among multiple births contributed to this rise in overall LBW rate.

Molecular characteristics of extended-spectrum beta-lactamase-producing Escherichia coli from Rio de Janeiro, Brazil

Twenty-five extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli clinical isolates from Rio de Janeiro, Brazil were characterized by isoelectric focusing, PCR and sequencing of bla(ESBL) genes, plasmid-mediated quinolone resistance determinants, phylogenetic groups, replicon typing, pulsed-field electrophoresis, and multilocus sequencing typing. Twenty-three (92%) ESBL-producing E. coli isolates were positive for bla(CTX-M) genes, aac(6`)-lb-cr, and qnrB. Genetic relatedness of ESBL producers clustered seven (28%) CTX-M-15-producing isolates as sequence type (ST) 410, clonal complex (CC) 23, and two (8%) as clone O25-ST131. Our results illustrate the predominance of phylo-group A (52%), ST410 (CC 23) and CTX-M-15 among ESBL-producing E. coli isolates from hospitals in Rio de Janeiro.

Underuse of beta-blockers following myocardial infarction: a tale of two cities

Aims: To measure factors associated with underuse of beta-blocker therapy after myocardial infarction (MI). Methods: The Newcastle and Perth collaborating centres of the World Health Organization (WHO) MONICA project (to MONItor trends and determinants of Cardiovascular disease) systematically evaluated all patients admitted to hospital in their respective regions with possible MI. A total of 1766 patients in Newcastle and 4503 patients in Perth, discharged from hospital after confirmed MI from 1985 to 1993, were studied, Rates of beta-blocker use before and after hospital discharge were evaluated and correlates of beta-blocker use determined. Results: Beta-blocker use was similar in Newcastle and Perth before MI (21% of patients in each centre). During hospital admission, beta-blocker therapy was initiated nearly twice as frequently in Perth compared with Newcastle (66 vs 36%, respectively) and more patients were discharged from hospital on beta-blockers in Perth (68%) than in Newcastle (45%). The main factors associated with underuse of beta-blockers in multivariate analysis were geographical centre (odds ratio (OR) for Newcastle compared with Perth 0.3 95% confidence interval (CI) 0.3-0.3), a history of previous MI (OR 0.6, 95% CI 0.5-0.7), admission to hospital in earlier years (OR 0.4, 95% CI 0.3-0.4 for years 1985-87 compared with years 1991-93), diabetes (OR 0.6, 95% CI 0.5-0.8) and the concomitant use of diuretics (OR 0.5, 95% CI 0.4-0.6) and calcium antagonists (OR 0.6, 95% CI 0.5-0.8). Conclusions: Underuse of beta-blockers after MI was strongly related to hospital prescribing patterns and not to community use of beta-blockers. Underuse occurred in patients with diabetes and in patients with left ventricular dysfunction, patients who stand to benefit most from beta-blocker use following MI.

Auditing complications of laparoscopy in a major tertiary hospital in Australia

Objective To review complications in both diagnostic and operative laparoscopic procedures at a university-affiliated major teaching hospital and to assess possible risk factors for complications. Design and setting A retrospective review of all laparoscopic procedures at the Royal Women's Hospital Brisbane, Australia, from 1990 to 1997 inclusive. A non-medical or nursing independent assessor reviewed charts. Data were collected on a standard form. Incomplete charts were excluded from analysis. Results There was a total of 1505 procedures. Analysis was based on 1435 complete data records. The overall complication rate was 2.86% with infection (1.3%) being the most common. The rate of gastrointestinal injury was 0.14%. Compared with women who had diagnostic laparoscopies, a higher rate of complication was found in women who had undergone operative laparoscopic procedures. However, this difference did not reach statistical significance. The complication rate was unrelated to seniority of the surgeon. Conclusion Complications can occur in any laparoscopic procedure. Regular reviews, especially in teaching hospitals, will provide feedback to clinicians to improve quality of care.

Randomised controlled trial of telemedicine for new neurological outpatient referrals

Objective-To test the hypothesis that telemedicine for new patient referrals to neurological outpatients is as efficient and acceptable as conventional face to face consultation. Methods-A randomised controlled trial between two groups: face to face (FF) and telemedicine (TM). This study was carried out between a neurological centre and outlying clinics at two distant hospitals linked by identical medium cost commercial interactive video conferencing equipment with ISDN lines transmitting information at 384 kbits/s. The same two neurologists carried out both arms of the study. Of the 168 patients who were suitable for the study, 86 were randomised into the telemedicine group and 82 into the face to face group. Outcome measures were (I) consultation process: (a) number of investigations; (b) number of drugs prescribed; (c) number of patient reviews and (2) patient satisfaction: (a) confidence in consultation; (b) technical aspects of consultation; (c) aspects surrounding confidentiality. Diagnostic categories were also measured to check equivalence between the groups: these were structural neurological, structural non-neurological, nonstructural, and uncertain. Results-Diagnostic categories were similar (p>0.5) between the two groups. Patients in the telemedicine group had significantly more investigations (p=0.001). There was no difference in the number of drugs prescribed (p>0.5). Patients were generally satisfied with both types of consultation process except for concerns about confidentiality and embarrassment in the telemedicine group (p=0.017 and p=0.005 respectively). Conclusion-Telemedicine for new neurological outpatients is possible and feasible but generates more investigations and is less well accepted than face to face examination.

Experience with a low-cost telemedicine system in three developing countries

The Swinfen Charitable Trust was established in 1998 with the aim of helping the poor, sick and disabled in the developing world. It does this by setting up simple telemedicine links based on email to support doctors in isolated hospitals. The first telemedicine link was established to support the lone orthopaedic surgeon at the Centre for the Rehabilitation of the Paralysed (CRP) in Savar, near Dhaka in Bangladesh, in July 1999. An evaluation of the 27 referrals made during the first year of operation showed that the telemedical advice had been useful and cost-effective. Based on the success of the Bangladesh project, the Swinfen Charitable Trust supplied: digital cameras and tripods to more hospitals in other developing countries. These are Patan Hospital in Nepal (March 2000), Gizo Hospital in the Solomon Islands (March 2000), Helena Goldie Hospital: on New Georgia in the Solomon Islands (September 2000) and LAMB Hospital in Bangladesh (September 2000).

Cost implications of outpatient teleneurology

A randomized controlled trial was conducted to compare the costs of realtime teleneurology with the cost of conventional neurological care. Two district hospitals in Northern Ireland were equipped with videoconferencing units and were connected to the regional neurological centre by ISDN at 384 kbit/s. Of 168 patients randomized to the study, 141 kept their appointments (76 male, 65 female). Sixty-five patients were randomized to a conventional consultation while 76 were randomized to a teleconsultation. The average age was 44 years of those seen conventionally and 42 years of those seen by telemedicine. The groups had similar diagnoses. The telemedicine group required more investigations and reviews than the conventional group. The average cost of the conventional consultation was pound 49 compared with pound 72 for the teleconsultation. Realtime teleneurology was not as cost-effective as conventional care.

Congenital thyrotoxicosis in premature infants

OBJECTIVES Graves' disease (GD) complicates 0.1% to 0.2% of pregnancies, but congenital thyrotoxicosis is rare occurring in one in 70 of these pregnancies independent of maternal disease status. Antenatal prediction of affected infants is imprecise; however, maternal history, coupled with a high maternal serum TSH receptor binding immunoglobulin index (TBII) predict adverse neonatal outcome. Mortality is reported to be as high as 25% in affected infants and would therefore be expected to be higher in premature infants. This study illustrates that in sick, premature, extreme low birth weight (ELBW) or intrauterine growth retarded (IUGR) infants, the diagnosis maybe overlooked especially in the absence of antenatal risk assessment and management of thyrotoxicosis in this setting is complex. DESIGN and PATIENTS The records of premature neonates born at the three main maternity units in Brisbane, between January 1996 and July 1998 diagnosed with congenital thyrotoxicosis were reviewed. Data were recorded on gestational age, birth weight (B Wt), maternal thyroid history and current status, and neonatal course. Thyroid function and TBII status was assessed using standard biochemical assays. RESULTS Seven neonates from five pregnancies were identified (four female, three male). Mean gestational age was 30 week (25-36 week) and median B Wt was 1.96 kg (0.50-2.62 kg). Only one mother received formal antenatal counselling by a paediatric endocrine service and had a TBII (54%) measured prior to delivery. Three of five mothers had elevated TBII measured after diagnosis in their offspring (57%, 65%, 83%) and in one mother, a TBII was not performed. All mothers were biochemically euthyroid at delivery. Mean age at diagnosis was 9 days (1-16 days) and mean age at commencement of treatment was 12 days (7-26 days). Two infants received propylthiouracil and five received a combination of carbimazole and propranolol. Pour became biochemically hypothyroid, in three this resolved with cessation of the antithyroid drug (ATD), and one required ongoing T4 supplementation. Only one infant required treatment for cardiac failure and there were no deaths in this cohort. CONCLUSIONS This is a large series of extremely small and premature infants with neonatal thyrotoxicosis. Presentation was nonspecific. The diagnosis was delayed because of low birth weight, prematurity, multiple birth and/or an unrecognized maternal history of Graves' disease. The treatment of neonatal thyrotoxicosis was difficult in these extreme law birth weight infants yet no infant died and significant morbidity was confined to high output cardiac failure in one infant. With antenatal recognition of past or active Graves' disease, assessment of maternal TSH receptor binding immunoglobulin index prior to delivery and postnatal monitoring of cord TSH and venous fT4 and TSH on days 4 and 7 rapid treatment of affected infants may have further reduced neonatal morbidity.

Lipid-lowering therapy following major cardiac events: progress and deficits

Objective: To assess hospital prescribing of lipid-lowering agents in a tertiary hospital, and examine continuation of, or changes to, such therapy in the 6-18 months following discharge. Design: Retrospective data extraction from the hospital records of patients admitted from October 1998 to April 1999. These patients and their general practitioners were then contacted to obtain information about ongoing management after discharge. Setting: Tertiary public hospital and community. Participants: 352 patients admitted to hospital with acute myocardial infarction or unstable angina, and their GPs. Main outcome measures: Percentage of eligible patients discharged on lipid-lowering therapy and percentage of patients continuing or starting such therapy 6-18 months after discharge. Results: 10% of inpatients with acute coronary syndromes did not have lipid-level estimations performed or arranged during admission. Documentation of lipid levels in discharge summaries was poor. Eighteen per cent of patients with a total serum cholesterol level greater than 5.5 mmol/L did not receive a discharge prescription for a cholesterol-lowering agent. Compliance with treatment on follow-up was 88% in the group discharged on treatment. However, at follow-up, 70% of patients discharged without therapy had not been commenced on lipid-lowering treatment by their GPs. Conclusions: Prescribing of lipid-lowering therapy for secondary prevention following acute coronary syndromes remains suboptimal. Commencing treatment in hospital is likely to result in continuing therapy in the community. Better communication of lipid-level results, treatment and treatment aims between hospitals and GPs might encourage optimal treatment practices.

Survivors and victims: A case study of organisational restructuring in the public health sector

This paper examines a process of major organizational restructuring in an Australian hospital within a context of decentralization of health services and relocation of clients, brought about by changes in government policy. The change process differed from the abrupt downsizing often found in the private sector in that the organization initiated significant job losses concomitantly with the development of new facilities around the State, while attempting to deal with employee issues related to downsizing. The paper focuses on the process involved in the downsizing, from the perspective of both the "survivors" and "victims" of the change. It draws on interviews and focus groups with managers, union officials and employees, as well a survey of employees to assess the outcomes and effectiveness of the restructuring process. Using a stakeholder analysis framework, the paper examines the complex issues and perspectives raised by the downsizing process.

Patients' interactions with health providers - A linguistic category model approach

Two studies investigated interactions between health providers and patients, using Semin and Fiedler's linguistic category model. In Study 1 the linguistic category model was used to examine perceptions of the levels of linguistic intergroup bias in descriptions of conversations with health professionals in hospitals. Results indicated a favourable linguistic bias toward health professionals in satisfactory conversations but low levels of linguistic intergroup bias in unsatisfactory conversations. In Study 2, the language of patients and health professionals in videotaped interactions was examined for levels of linguistic intergroup bias. Interpersonally salient interactions showed less linguistic intergroup bias than did intergroup ones. Results also indicate that health professionals have high levels of control in all types of medical encounters with patients. Nevertheless, the extent to which patients are able to interact with health professionals as individuals, rather than only as professionals is a key determinant of satisfaction with the interaction.

Standardised audit of hip fractures in Europe

The objectives of this study were to evaluate the outcomes of our patients admitted with hip fractures, and to benchmark these results with other hospitals, initially in Europe and subsequently in Australia. The Standardised Audit of Hip Fractures in Europe (SAHFE) questionnaires was used as the data gathering instrument. The participants were all patients admitted to Redcliffe Hospital with a fractured neck of femur prior to surgery. This paper reports the results of the first 70 consecutive patients admitted to Redcliffe Hospital with a fractured neck of femur from November 1st 2000. The main outcome measures were mobility, independence, residence prior to fracture; type of fracture and surgical repair; and time to surgery, survival rates and discharge destination. Results: 43 patients were admitted from home, but only 13 returned home directly from the orthopaedic ward. It is hoped that most of the 26 transferred to the rehabilitation ward will ultimately return home. 7 patients died, these were aged 82 to 102, and all had premorbid disease. Delays in surgery were apparent for 13 patients, mainly due to administrative problems. Conclusions: We support the recommendation in the Fifteenth Scottish Intercollegiate Guidelines Network Publication on the management of hip fractures, that all units treating this condition should enter an audit to evaluate their management. (author abstract)

Guideline-discordant care in acute myocardial infarction: predictors and outcomes

Objectives: To determine (i) factors which predict whether patients hospitalised with acute myocardial infarction (AMI) receive care discordant with recommendations of clinical practice guidelines; and (ii) whether such discordant care results in worse outcomes compared with receiving guideline-concordant care. Design: Retrospective cohort study. Setting: Two community general hospitals. Participants: 607 consecutive patients admitted with AMI between July 1997 and December 2000. Main outcome measures: Clinical predictors of discordant care; crude and risk-adjusted rates of inhospital mortality and reinfarction, and mean length of hospital stay. Results: At least one treatment recommendation for AMI was applicable for 602 of the 607 patients. Of these patients, 411(68%) received concordant care, and 191 (32%) discordant care. Positive predictors at presentation of discordant care were age > 65 years (odds ratio [OR], 2.5; 95% Cl, 1.7-3.6), silent infarction (OR, 2.7; 95% Cl, 1.6-4.6), anterior infarction (OR, 2.5; 95% Cl, 1.7-3.8), a history of heart failure (OR, 6.3; 95% Cl, 3.7-10.7), chronic atrial fibrillation (OR, 3.2; 95% Cl, 1.5-6.4); and heart rate greater than or equal to 100 beats/min (OR, 2.1; 95% Cl, 1.4-3.1). Death occurred in 12.0% (23/191) of discordant-care patients versus 4.6% (19/411) of concordant-care patients (adjusted OR, 2.42; 95% Cl, 1.22-4.82). Mortality was inversely related to the level of guideline concordance (P = 0.03). Reinfarction rates also tended to be higher in the discordant-care group (4.2% v 1.7%; adjusted OR, 2.5; 95% Cl, 0.90-7.1). Conclusions: Certain clinical features at presentation predict a higher likelihood of guideline-discordant care in patients presenting with AMI Such care appears to increase the risk of inhospital death.