Cultural competency of health-care providers in a Swiss University Hospital: self-assessed cross-cultural skillfulness in a cross-sectional study.

BACKGROUND: As the diversity of the European population evolves, measuring providers' skillfulness in cross-cultural care and understanding what contextual factors may influence this is increasingly necessary. Given limited information about differences in cultural competency by provider role, we compared cross-cultural skillfulness between physicians and nurses working at a Swiss university hospital. METHODS: A survey on cross-cultural care was mailed in November 2010 to front-line providers in Lausanne, Switzerland. This questionnaire included some questions from the previously validated Cross-Cultural Care Survey. We compared physicians' and nurses' mean composite scores and proportion of "3-good/4-very good" responses, for nine perceived skillfulness items (4-point Likert-scale) using the validated tool. We used linear regression to examine how provider role (physician vs. nurse) was associated with composite skillfulness scores, adjusting for demographics (gender, non-French dominant language), workplace (time at institution, work-unit "sensitized" to cultural-care), reported cultural-competence training, and cross-cultural care problem-awareness. RESULTS: Of 885 questionnaires, 368 (41.2%) returned the survey: 124 (33.6%) physicians and 244 (66.4%) nurses, reflecting institutional distribution of providers. Physicians had better mean composite scores for perceived skillfulness than nurses (2.7 vs. 2.5, p < 0.005), and significantly higher proportion of "good/very good" responses for 4/9 items. After adjusting for explanatory variables, physicians remained more likely to have higher skillfulness (β = 0.13, p = 0.05). Among all, higher skillfulness was associated with perception/awareness of problems in the following areas: inadequate cross-cultural training (β = 0.14, p = 0.01) and lack of practical experience caring for diverse populations (β = 0.11, p = 0.04). In stratified analyses among physicians alone, having French as a dominant language (β = -0.34, p < 0.005) was negatively correlated with skillfulness. CONCLUSIONS: Overall, there is much room for cultural competency improvement among providers. These results support the need for cross-cultural skills training with an inter-professional focus on nurses, education that attunes provider awareness to the local issues in cross-cultural care, and increased diversity efforts in the work force, particularly among physicians.

A Salmonella agona outbreak in a pediatric hospital in the city of Rio de Janeiro, Brazil

Six Salmonella Agona strains from an outbreak of 15 days duration which occurred in a public hospital in Rio de Janeiro, Brazil, were analyzed. The outbreak involved six infants (mean age, 24 days; mean body weight, 1612 g), all of them with severe clinical signs and symptoms. Two of them had surgical implications, two were preterm and two had respiratory distress at birth. The Salmonella strains were resistant to nine antimicrobial agents (ampicillin, cephalotin, cefriaxone, gentamicin, amykacin, trimethoprim-sulfamethoxazole, chloramphenicol, and tetracyclin). Analysis of the plasmid pattern of the wild strains and of the transconjugants confirmed that these were identical strains.

Le soignant face au patient lombalgique chronique: l'expérience clinique de l'Unité Rachis à l'Hôpital orthopédique [The health professional's approach to chronic lumbago: clinical experience at the Spinal Cord Unit at the orthopedic hospital]

The treatment of back pain patients refers to the biopsychosocial model of care. This model includes illness in patient's personal and relational life. In this context, it is not only the physical symptom of the patient which is focused but also his psychological distress often hidden by algic complain. Clinical interviews conducted with back pain patients have highlighted psychosocial aspects able to influence the relationship between health care user and provider. Taking account of psychosocial aspects implies an interdisciplinary approach that identify and assesses patients' needs through adequate tools. As a result, the different health care providers implied with back pain patients have to collaborate in a structured network.

New and emerging treatment of Staphylococcus aureus infections in the hospital setting.

Methicillin-resistant Staphylococcus aureus (MRSA), both hospital-acquired and community-acquired, is a dangerous pathogen that is involved in an increasing number of serious infections with high risk for morbidity and mortality. Community-acquired MRSA strains have epidemic potential and can be particularly virulent. Vancomycin has been the standard hospital treatment for the past 40 years, but vancomycin-resistant isolates of S. aureus have emerged in the USA, and vancomycin-intermediate isolates are increasingly being reported worldwide. New antimicrobial agents with activity against multidrug-resistant S. aureus and other resistant pathogens are urgently needed. Despite great strides, further advances in our understanding of the molecular and biochemical mechanisms responsible for antimicrobial resistance are still required. Several agents have been recently approved for the treatment of serious Gram-positive infections, including linezolid, daptomycin, and tigecycline. The novel investigational cephalosporin, ceftobiprole, is one of the first penicillinase-resistant agents to target penicillin-binding protein 2a (or PBP2a), an acquired PBP with low beta-lactam-affinity that confers intrinsic beta-lactam resistance to S. aureus and other staphylococci. This mechanism of PBP binding, including inhibition of PBP2a, confers broad-spectrum activity against clinically important Gram-negative and Gram-positive pathogens, including MRSA. Phase III clinical trials comparing ceftobiprole with vancomycin alone and in combination with ceftazidime for the treatment of complicated skin and skin structure infections showed ceftobiprole to have efficacy similar to the efficacy of these comparators as evidenced by non-inferior clinical cure and microbiological eradication rates.

L'oficina judicial a Catalunya: mitjà real d'una justícia eficaç pel ciutadà del segle XXI

En aquest estudi es pretenia assolir la pràctica d'un sistema que només s'ha plantejat teòricament, doncs l'experiència acumulada, ja abans de la reforma orgànica de 2003, parteix de la figura dels serveis comuns, amb un criteri d'eficiència, racionalitat i economia per invertir en l'Administració de justícia catalana. Assumir i donar resposta jurídica concreta a tots els reptes tècnics pot fer-se des d'una perspectiva dogmàtica, tot i que el temps transcorregut també permet advertir exigències pràctiques a l'àmbit de la dogmàtica processal, el context socio-cultural i, naturalment, les necessitats laborals. En aquest sentit, els objectius s'introdueixen cap a la garantia d'un apropament material, conceptual i quotidià de l'Administració de justícia al ciutadà, establert com a eix inextricable del sistema, tenint present la de vegades despesa incomprensible en una realitat històricament menystinguda i deficitària, malgrat l'esforç pressupostari fet els darrers anys que, malgrat tot, no ha evitat discordances greus per manca de racionalitat i eficiència en el consum diari dels operadors implicats. Es pretén aconseguir, per mitjà del nou sistema d'oficina judicial estructurat, un avenç efectiu i econòmic a l'estat de la Justícia al país, especialment envers la dilació dels tràmits, a més de reclamar reformes legals, de caire processal especialment, que no es prestin a mers paràmetres d'ajust formal, sinó que incideix substantivament en millores per altre part reclamades fa temps per la doctrina científica. S'han aconseguit les fites definides des del punt de vista teòric, així com s'ha afrontat tots el problemes conceptuals i hipòtesis pràctiques més significatives, establint pautes de resposta sota la prèvia determinació de les qüestions debatudes i els conflictes habituals que correspon enfrontar. D'aquesta manera, s'ha estudiat la normativa en presència i la jurisprudència que hi dona actualitat pràctica, sense oblidar la doctrina d'autors. S'ha repassat el funcionament existent a l'oficina judicial i les previsions de la mateixa en un futur immediat, remarcant les noves tecnologies en ús i projectades, de igual manera que les bondats i crítiques de tots els operador jurídics actuants.

Estudi sobre l'aplicació en l'àmbit judicial de les mesures de protecció integral contra la violència de gènere aprovades pel legislador l'any 2004

Amb el següent estudi volem conèixer l’impacte penal que ha tingut l’aprovació de la LO 1/2004, de 28 de desembre, de mesures de protecció integral contra la violència de gènere, en matèria de maltractament ocasional en l’àmbit de la parella (art. 153 CP). Presentem el treball empíric que hem dut a terme, el qual consisteix en una anàlisi quantitativa de les sentències dictades pels jutges de Barcelona pel delicte de maltractament ocasional quan es produeix en la parella i de les executòries corresponents a cadascuna de les sentències, per tal de conèixer, a més de les penes imposades en sentències, les penes que efectivament s’executen per la comissió d’aquest delicte. Hem constatat que una gran part de la violència domèstica fa referència al maltractament ocasional de l’home contra la dona parella o ex parella. És un delicte que sí es castiga, ja que els jutges dicten en la majoria dels casos sentències condemnatòries i opten per la imposició en sentència de la pena privativa de llibertat. A més, com des de l’aprovació de LO 1/2004 és obligatori, la pena imposada va acompanyada de penes accessòries, particularment de la prohibició de aproximació i de comunicació. Generalment, en execució, la pena de presó es suspèn amb regles de conducta, sobre tot amb l’obligació de realitzar programes formatius o de tractament. Així doncs, la comissió d’un delicte de maltractament ocasional en l’àmbit de la parella té conseqüències penals importats, a més de les conseqüències que pugui tenir en altres àmbits.

La mesura substitutiva de la pena de presó prevista a l’Art 89 Codi penal: aplicació judicial i pràctica penitenciària a Catalunya en el cas de dones penades

L’objecte de la recerca és analitzar l’aplicació a Catalunya de la mesura d’expulsió prevista a l’article 89 del Codi penal en el cas de les dones penades, fer-ne la valoració corresponent i, si s’escau, plantejar alternatives d’actuació. La recerca constata les dificultats d’aplicació del principi constitucional de reinserció i d’altres de previstos a la legislació penitenciària en relació amb el col•lectiu de penats estrangers en situació irregular. La pràctica penitenciària observada a Catalunya en els darrers anys ha fet una aposta clara per l’acolliment dels penats estrangers en el territori, en general, amb independència de la seva situació administrativa. Aquesta pràctica ha generat una important expectativa de romandre en el territori per part de bona part d’aquests penats. Per la seva banda, els jutges i tribunals han obviat en general i sota diversos arguments i fonaments el mandat del legislador en les diverses ocasions en què aquest ha fet l’aposta per l’expulsió dels penats estrangers en situació irregular. Aquesta posició oficial majoritària contrària a l’expulsió ha coincidit plenament amb el desig de la majoria de la població reclusa estrangera clarament contrària a la seva expulsió. Les diverses opcions legals que poden implicar el retorn del penat al seu país de residència resulten estranyament aplicades per part dels tribunals i en menor mesura per la mateixa Administració penitenciària. Aquesta no-actuació i la manca d’alternatives legals provoquen situacions divergents de caràcter negatiu que atempten clarament contra el principi d’igualtat, contra la finalitat reinsertadora de les penes i poden resultar generadores d’inseguretat pública. Conscients i coneixedors de les dificultats actuals, els autors estableixen diverses vies d’actuació en la línia de superar aquesta situació. Es proposa una reforma en profunditat de l’art. 89 del Codi penal i s’obre la via favorable a l’establiment d’una nova llibertat condicional per a penats estrangers en situació irregular i que han assolit el compliment de la meitat de la pena privativa imposada.

La medida sustitutiva de la pena de prisión prevista en el artículo 89 del Código penal: aplicación judicial y práctica penitenciaria en Cataluña en el caso de mujeres penadas

En los últimos años se constata el difícil ensamblaje del colectivo de penados extranjeros en situación irregular dentro del actual marco penal-penitenciario. El instrumento consistente en sustituir en estos casos la pena por la expulsión ha resultado un fracaso. Resulta necesario buscar alternativas.

Evaluation of the impact of a therapeutic drug monitoring program in a Swiss University Hospital

Background and objective: Therapeutic Drug Monitoring (TDM) has been introduced early 1970 in our hospital (CHUV). It represents nowadays an important routine activity of the Division of Clinical Pharmacology and Toxicology (PCL), and its impact and utility for clinicians required assessment. This study thus evaluated the impact of TDM recommendations in terms of dosage regimen adaptation. Design: A prospective observational study was conducted over 5 weeks. The primary objective was to evaluate the application of our TDM recommendations and to identify potential factors associated to variations in their implementation. The secondary objective was to identify pre-analytical problems linked to the collection and processing of blood samples. Setting: Four representative clinical units at CHUV. Main outcome measure: Clinical data, drug related data (intake, collection and processing) and all information regarding the implementation of clinical recommendations were collected and analyzed by descriptive statistics. Results: A total of 241 blood measurement requests were collected, among which 105 triggered a recommendation. 37% of the recommendations delivered were applied, 25 % partially applied and 34% not applied. In 4% it was not applicable. The factors determinant for implementation were the clinical unit and the mode of transmission of the recommendation (written vs oral). No clear difference between types of drugs could be detected. Pre-analytical problems were not uncommon, mostly related to completion of request forms and delays in blood sampling (equilibration or steady-state not reached). We have identified 6% of inappropriate and unusable drug level measurements that could cause a substantial cost for the hospital. Conclusion: This survey highlighted a better implementation of TDM recommendations in clinical units where this routine is well integrated and understood by the medical staff. Our results emphasize the importance of communication with the nurse or the physician in charge, either to transmit clinical recommendations or to establish consensual therapeutic targets in specific conditions. Development of strong partnerships between clinical pharmacists or pharmacologists and clinical units would be beneficial to improve the impact of this clinical activity.

Estudi d'utilització d'antifúngics sistèmics a l'Hospital Universitari Vall d'Hebron

Objectius: Descriure les principals característiques de la utilització dels antifúngics sistèmics a l’Hospital Universitari Vall d’Hebron (HUVH) i avaluar la seva adequació. Metodologia: Estudi de prescripció-indicació en pacients majors de 16 anys amb seguiment prospectiu de 40 casos incidents consecutius. Limitats a 10 els casos de fluconazole, es realitza una anàlisi descriptiva ponderada. S’avalua l’adequació segons les recomanacions de la Infectious Diseases Society of America (IDSA). Resultats: El fluconazole va ser el fàrmac més emprat (74,8%; IC del 95%: 60,7-88,9), seguit del voriconazole. L’ús més habitual va ser l’empíric-anticipat (53,4%; IC del 95%: 28,6-78,1) i la indicació més freqüent la profilaxi d’infecció fúngica invasiva (25,0%; IC del 95%: 2,4-47,5). Es van considerar adequades el 71,7% (IC del 95%: 49,1-94,3) de les indicacions, el 100% (IC del 95%: 100-100) dels fàrmacs seleccionats, el 51,2% (IC del 95%: 21,8-80,6) de les dosis i el 61,7% (IC del 95%: 32,6-90,7) de les durades. Conclusions: Els resultats suggereixen que a l’HUVH es fa una prescripció raonada dels antifúngics sistèmics però caldria millorar el seu ús empíricanticipat i específic. Cal interpretar-los amb cautela per la manca de precisió i la dificultat per valorar la situació clínica

Proportion of out of hospital adult non traumatic cardiac arrest presenting as a convulsion

Introduction: The majority of convulsions are due to an epilepticseizure or a convulsive syncope. In some cases, this is the firstsymptom of an out of hospital cardiac arrest (OH-CA).Objective: This study was aimed to measure the proportion of adultnon traumatic OH-CA presenting as a convulsion.Methodology: We prospectively collected all incoming calls with anout-of-hospital non traumatic seizure as the chief complaint in patients>18 years during a 24-months period. Among these calls, we collectedcases identified as OH-CA by paramedics.Results: During the 24-months period, the EMS dispatch centerreceived 561 calls for an out-of-hospital non traumatic convulsion in anadult. Twelve cases were ultimately classified as CA. In this group, onebystander spontaneously reported that the patient was known forepilepsy. The incidence of OH-CA presenting as convulsions wastherefore 2.1% of all calls for convulsion. Over the same period, theEMS dispatch center received 1035 calls related to an adult nontraumatic OH-CA. Therefore the rate of OH-CA presenting as aconvulsion represented 1.2% of all adult non traumatic OH-CA.Conclusion: Only 12 cases out of the 531 calls for non traumatic adultconvulsions were confirmed OH-CA (2.1%). Nevertheless, this unusualpresentation of OH-CA must be recognized by dispatchers, even whena patient is reported by bystander as a known epileptic. Dispatchersshould keep bystanders on line or call them back before paramedics'arrival, and have them confirm the progressive return of a normalpattern of breathing and state of consciousness; if not, they shouldencourage when necessary bystander to initiate CPR. For dispatchers,a past medical history of epilepsy should not be regarded as sufficientinformation to rule-out OH-CA. It is mandatory that known epilepticpatients should be monitored in the same way as non-epileptic patients.

Thrombolyse de l'accident vasculaire cérébral ischémique aigu: rôles du praticien et de l'hôpital périphérique [Thrombolysis of acute ischemic cerebral vascular accident: roles of the physician and the peripheral hospital]

Thrombolysis administered intravenously within 3 hours (or within 6 hours intra-arterially) after symptoms onset improves the functional outcome of acute ischemic stroke patients. In Switzerland this treatment is only performed by specialized centers. At the level of a community hospital or a general practitioner, the management is based on the appropriate selection of patients in whom thrombolysis could be indicated, followed by their immediate transfer to a reference medical center. Because of the very short therapeutic window, specific criteria have to be used. We present the guidelines of Les Cadolles Hospital in Neuchâtel established in collaboration with the Department of Neurology of the University Hospital of Lausanne and a retrospective analysis of emergency admissions for suspected stroke at Les Cadolles between January 1st 2001 and December 31st 2002.

Short term evolution of a highly transmissible methicillin-resistant Staphylococcus aureus clone (ST228) in a tertiary care hospital.

Staphylococcus aureus is recognized as one of the major human pathogens and is by far one of the most common nosocomial organisms. The genetic basis for the emergence of highly epidemic strains remains mysterious. Studying the microevolution of the different clones of S. aureus is essential for identifying the forces driving pathogen emergence and spread. The aim of the present study was to determine the genetic changes characterizing a lineage belonging to the South German clone (ST228) that spread over ten years in a tertiary care hospital in Switzerland. For this reason, we compared the whole genome of eight isolates recovered between 2001 and 2008 at the Lausanne hospital. The genetic comparison of these isolates revealed that their genomes are extremely closely related. Yet, a few more important genetic changes, such as the replacement of a plasmid, the loss of large fragments of DNA, or the insertion of transposases, were observed. These transfers of mobile genetic elements shaped the evolution of the ST228 lineage that spread within the Lausanne hospital. Nevertheless, although the strains analyzed differed in their dynamics, we have not been able to link a particular genetic element with spreading success. Finally, the present study showed that new sequencing technologies improve considerably the quality and quantity of information obtained for a single strain; but this information is still difficult to interpret and important investments are required for the technology to become accessible for routine investigations.