Enhancing patient safety: A national standard for cyber resiliency in healthcare

With support from Public Safety Canada's Cyber Security Cooperation Program, HealthCareCAN and the Digital Governance Council developed a new standard to support cyber resiliency in Canada's healthcare system. With a clear framework and enhanced cybersecurity capabilities, healthcare organizations will be better protected from cybercrime, allowing them to respond more effectively to evolving threats and defend critical infrastructure. Health and information technology leaders can derive practical guidance and next steps from this three-year national project to enhance cyber resilience and improve safety within their organizations.

Opening the door: midwives' perceptions of two models of psychosocial assessment in pregnancy- a mixed methods study

Background

One in five women experience psychological distress in the perinatal period. To support women appropriately, Australian guidelines recommend routine depression screening and psychosocial risk assessment by midwives in pregnancy. However, there is some evidence that current screening processes results in higher rates of false positives. The Perinatal Integrated Psychosocial Assessment (PIPA) Project compared two models of psychosocial assessment and referral – Usual Care and the PIPA model – with a view to improving referral decisions. This paper describes midwives’ perspectives on psychosocial assessment, depression screening and referral at the antenatal booking appointment and compares midwives’ experiences with, and perspectives on, the two models of care under investigation.

Methods

A two-phase, convergent mixed methods design was used. Midwives providing antenatal care completed a self-report survey in phase one prior to implementation of the new model of psychosocial assessment (n = 26) and again in phase two, following implementation (n = 27). Sixteen midwives also participated in two focus groups in phase two. Quantitative and qualitative data were compared and integrated in the presentation of results and interpretation of findings.

Results

Midwives supported psychosocial assessment believing it was a catalyst for ‘Opening the door” to conversations with women. Midwives were comfortable asking the questions and tailored their approach to build rapport and trust. Overall. midwives expressed favourable views towards the PIPA model. A greater proportion of midwives relied mostly or entirely on the suggested wording for the psychosocial questions in the PIPA model compared to Usual Care (44.4% vs 12.0%, χ²=5.17, p=.023, φ =-.36). All midwives reported finding the referral or action message displayed at the end of the PIPA psychosocial assessment to be ‘somewhat’ or ‘very’ helpful, compared to 42.3% in Usual Care (χ² = 18.36, p < .001, φ = −.64). Midwives were also more likely to act on or implement the message often or all of the time) in the PIPA model (PIPA = 69.2% vs Usual Care = 32.0%, (χ² = 5.66, p < .017, φ = −.37).

Conclusion

The study identified benefits of the new model and can inform improvements in psychosocial screening, referral and related care processes within maternity settings. The study demonstrates that psychosocial assessment can, over time, become normalised and embedded in practice.

History of mood or anxiety disorders and risk of gestational diabetes mellitus in a population-based cohort

AIM

To examine the association between mood and anxiety disorders and the development of gestational diabetes mellitus in a retrospective population-based cohort study.

METHODS

Clinical data from a provincial perinatal health registry were linked to physician claims, hospitalization records and emergency visits to identify any diagnoses of mood or anxiety disorders in the 2 years prior to pregnancy and a subsequent diagnosis of gestational diabetes during pregnancy. The study population included all singleton pregnancies in the Canadian province of Alberta from 1 April 2000 to 31 March 2010. Generalized estimating equations were used to determine the adjusted odds ratio of gestational diabetes, comparing women with and without a history of mood or anxiety disorders.

RESULTS

Among 373 674 pregnancies from 253 911 women, 25.7% had a history of mood or anxiety disorders, and 3.8% developed gestational diabetes. The multivariate-adjusted odds of developing gestational diabetes were higher among women with a history of mood or anxiety disorders (odds ratio 1.10, 95% CI 1.06-1.14).

CONCLUSIONS

Women with a history of mood or anxiety disorders had a moderately increased risk of developing gestational diabetes.

Does non-pharmacological therapy for antenatal depression reduce risks for the infant?

Depression during pregnancy has been associated with an increased risk of adverse outcomes for the infant such as preterm birth. These risks are not reduced with pharmacological treatment, but the effect of non-pharmacological therapies is unknown. We performed a systematic review to assess the risk of adverse perinatal outcomes in non-pharmacologically treated depressed women compared to non-depressed women. We found no studies that met our inclusion criteria, highlighting a critical need for research on this topic.

Evaluation of a two rubber band technique for finger ring removal

INTRODUCTION

Rings are required to be removed from a finger in many clinical situations. Rings that are difficult to remove is a problem encountered frequently. Many techniques have been reported for this problem. This study looks at the effectiveness of a single technique for removing difficult rings from fingers.

METHODS

A two rubber band technique was used in this study of 69 difficult to remove rings. Success of the technique and time to removal were recorded.

RESULTS

Difficult rings were removed in 92.5% of cases, in a mean time of 10.7 seconds. No fingers or rings suffered damage during the study.

CONCLUSIONS

This two rubber band technique is a rapid, safe and effective method for removing rings that cannot be removed easily.

A prospective review of appetite loss and recovery time in primary joint replacement patients

INTRODUCTION

Appetite loss is commonly reported by patients following major surgery, including total joint arthroplasty (TJA). A number of studies have examined related problems, particularly in relation to physiological responses to surgery. However, no published paper has looked specifically at the duration of appetite loss in total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients.

METHODS

A simple, established appetite screening tool was administered preoperatively and at 2-week intervals postoperatively in 50 TJA patients until appetite levels returned to preoperative levels. The results were examined for various descriptive parameters and compared using the chi-squared test.

RESULTS

Thirty-three patients underwent TKA and 17 THA. There were 27 female and 23 male patients. No patients were lost to follow-up. The median time for return of appetite in both male and female patients was 4 weeks (interquartile range [IQR]: male, 2-4; female, 4-6). The median time for return of appetite was 4 weeks both in TKA patients (IQR 4-6) and in those undergoing THA (IQR 4-4). The time to return of appetite was not significantly associated with either the gender of the patients (p=0.13) or the type of joint replacement (p=0.49).

CONCLUSIONS

The study provides a clear time frame for return of appetite in uncomplicated primary joint replacements. This is a commonly noted patient problem that has not previously been specifically reviewed.

Clinical and economic impact of a switch from high- to low-volume renal replacement therapy in patients with acute kidney injury

High-intensity renal replacement therapy protocols in intensive care patients with acute kidney injury have failed to translate to improved patient outcomes when compared with lower-intensity protocols. This retrospective study explored the clinical and economic impacts of switching from a 30-35 ml.kg(-1) .h(-1) (high-volume) to a 20 ml.kg(-1) .h(-1) (low-volume) protocol. Patients (n = 366) admitted 12 months before (n = 187) and after (n = 179) the switch were included in the study. There was no difference in in-hospital mortality (77/187 (41%) vs 75/179 (42%), respectively, p = 0.92), intensive care unit mortality (55/187 (29%) vs 61/179 (34%), respectively, p = 0.40), duration of organ support or extent of renal recovery between the high- and low-volume cohorts. A 25% reduction in daily replacement fluid usage was observed, equating to a cost saving of over £27 000 per annum. In conclusion, a switch from high- to low-volume continuous haemodiafiltration had minimal effects on clinical outcomes and resulted in marked cost savings.

Migrant women's utilization of prenatal care: a systematic review

Our objectives were to determine whether migrant women in Western industrialized countries have higher odds of inadequate prenatal care (PNC) compared to receiving-country women and to summarize factors that are associated with inadequate PNC among migrant women in these countries. We conducted searches of electronic databases (MEDLINE, EMBASE, and PsycINFO), reference lists, known experts, and an existing database of the Reproductive Outcomes And Migration international research collaboration for articles published between January, 1995 and April, 2010. Title and abstract review and quality appraisal were conducted independently by 2 reviewers using established criteria, with consensus achieved through discussion. In this systematic review of 29 studies, the majority of studies demonstrated that migrant women were more likely to receive inadequate PNC than receiving-country women, with most reporting moderate to large effect sizes. Rates of inadequate PNC among migrant women varied widely by country of birth. Only three studies explored predictors of inadequate PNC among migrant women. These studies found that inadequate PNC among migrant women was associated with being less than 20 years of age, multiparous, single, having poor or fair language proficiency, education less than 5 years, an unplanned pregnancy, and not having health insurance. We concluded that migrant women as a whole were more likely to have inadequate PNC and the magnitude of this risk differed by country of origin. Few studies addressed predictors of PNC utilization in migrant women and this limits our ability to provide effective PNC in this population.

Experimental pathology of intravenous Polyurethane cannulae containing disinfectant

Cannula tubing (1.6 mm external, 1 mm internal diameter) manufactured from medical grade polyurethane containing 2%, 2,4,4'-tri-chloro-2'-hydroxydiphenylether ('Irgasan', Ciba-Geigy) was found to have no effect other than that seen with control ('Irgasan'-free) tubing in the following test systems: (i) haemolysis, (ii) endothelial cell cultures, (iii) paravertebral muscle of rabbits, (iv) jugular vein of rabbits, (v) cannulation of baboons and (vi) clotting times of human platelet-rich plasma. However, the results from (iv) showed a significant amount of damage from both inpregnated and control cannulae and (v) showed that all detectable 'Irgasan' had been eluted from the portions of tubing retained within the animal before the end of the experiment, more rapidly than predicted from in-vitro studies. The rate of elution of 'Irgasan' in vivo needs to be further investigated, and consideration should be given to developing a plastic-disinfectant combination with a slower rate of loss of disinfectant.

Current hypotheses on synergistic microbial gangrene

We have reviewed spreading infections of the dermis, with special reference to the importance of synergy in their causation. Evidence for this is accumulating from both clinical studies and from studies in laboratory animals. Necrotizing fasciitis (rapid spread over 24 h) can be caused by beta-haemolytic streptococci, sometimes with Staphylococcus aureus, or by mixed infections of aerobes and anaerobes, often of gut origin. Animal studies provide good evidence that S. aureus can potentiate the beta-haemolytic streptococcal infection in necrotizing fasciitis. There is also evidence that mixtures of aerobes and anaerobes can act synergistically, but animal models for necrotizing fasciitis have not been developed. Anaerobic cellulitis (variable rate of spread from hours to days) can be caused by mixed aerobes and anaerobes or by mixed clostridia. Animal studies provide good evidence for synergy in the former. Meleney's synergistic postoperative gangrene (slow spread over weeks) may be cutaneous amoebiasis: the animal model of Brewer and Meleney relates to the more rapid infections of anaerobic cellulitis.

Memorandum on the infections hazards of the common communion cup with especial reference to AIDS

Bacteriological studies on the communion cup have shown that there is a low level of contamination with mouth organisms on the rim. The death rate of bacteria on the cup surface would not be significant, but the wine had a bactericidal effect on most but not all organisms tested. However droplets of saliva did not readily mix with the wine. In considering the spread of AIDS, extensive studies of people infected with human immunodeficiency virus (HIV) in hospital or at home have shown that the established routes of spread are the injection of blood or blood products, sexual intercourse or at birth. There are only very rare examples of spread by other means. The virus is rarely isolated from the saliva and a study of homosexuals indulging in oral sexual intercourse suggests that it is very poorly infectious when taken into the mouth or swallowed. It is concluded that the risk of transmission of HIV by the common communion cup can be neglected under ordinary circumstances. Suggestions are made for improving the hygiene of the communion service which may be useful under special circumstances: there is no evidence that disease is spread in this way under normal conditions.

Self-disinfecting plastics for intravenous catheters and prosthetic inserts

A disinfectant (2,4,4'-trichloro-2'-hydroxydiphenyl ether: Irgasan, Ciba-Geigy) was incorporated into plastic washers fabricated from ethylvinyl acetate (EVA), polyethylene, polypropylene or TPX. Plastics containing 0.2 and 2% Irgasan gave zones of inhibition on nutrient and blood agar plates seeded with micro-organisms (Staphylococcus aureus, Staph. epidermidis, Escherichia coli, Proteus mirabilis or Candida albicans) even after thorough washing. Exceptionally, C. albicans was inhibited only by 2% Irgasan, and EVA gave good inhibition only against the staphylococci. Similar washers of each plastic were implanted subcutaneously into the flanks of rabbits; before insertion each was washed, had thread woven into it and was surrounded by a plasma clot containing 2 X 10(8) Staph. aureus. All the plastics without Irgasan gave rise to abscesses, none of the plastics impregnated with 2% Irgasan did, though from 2 out of 12 sites small numbers of Staph. aureus were isolated at post mortem. Using either clinical or bacteriological criteria, the results were highly significant (P less than 0.00001 and P less than 0.001 respectively), demonstrating the effectiveness of this technique in preventing plastic-associated infection.

Antibody production to milk proteins in the jejunal mucosa of children with Cow's milk protein intolerance

A direct immunofluorescent technique with fluorescein-labeled antigens was used to examine the jejunal mucosa for specific antibody reduction in 23 children aged 2--25 months referred for diagnostic biopsy. Plasma cells containing antibodies to beta-lactoglobulin (beta LG) or bovine serum albumin (BSA) were present in 11 of 16 biopsies from patients with cow's milk protein intolerance (CMPI) but only one of eight controls, all on a diet containing cow's milk. Antibody-containing cells (ACC) constituted approximately 0.5--5% of the total (IgA + IgM) plasma cell population. Their presence did not correlate with either histologic abnormality or IgA plasma cell count. Double immunofluorescence with rhodamine-labeled antigens and fluorescein-labeled class-specific anti-human immunoglobulin sera showed the ACC to be approximately 70% IgA cells and 30% IgE cells.

Eczema and atopy in early childhood: low IgA plasma cell counts in the jejunal mucosa

Twenty-one children aged between 2 and 54 months, 14 with eczema and 7 with allergies in first-degree relatives, were referred for diagnostic jejunal mucosal biopsy for a variety of symptoms. A partial villous atrophy was found in 19 of the 21 biopsies obtained; the other 2 were normal. We report a highly significant (P less than 0.0001) lower IgA cell count in biopsies with partial villous atrophy compared with the results of our previous study of IgA and IgM plasma cells in the mucosal biopsies in children without eczema or a history of atopy matched for age and histological appearances. The IgM cell count was also lower.

IgE plasma cells in human jejunum demonstrated by immune electron microscopy

An immune electron microscopy technique has been employed to detect IgE plasma cells in histologically normal human jejunal biopsies. Anti-IgE-labelled plasma cells have been found in the lamina propria of three out of eight biopsies studied. Thus this report ends speculation regarding the presence of IgE plasma cells in human jejunum and supports other data indicating local IgE production in mucosal tissues.

Protein A-like activity and streptococcal cross-reactions

Recognition of the protein A-like activity of some strains of group A streptococci has thrown doubt on much previous work suggesting antigenic cross-reactions between these streptococci and mammalian tissues. The strains used in our previous studies have now been examined by the mixed reverse passive antiglobulin reaction (MRPAH) for the 'non-specific' absorption of purified Fc portion of human IgG. They were found to have only traces of activity. The strain of Staphylococcus aureus used to control 'non-specific' absorption by bacterial cell walls was strongly positive. Protein A-like material as detected in this way was not therefore responsible for our earlier results.

The use of the peroxidase reaction to obliterate staining of eosinophils by fluorescein-labelled conjugates

The staining of eosinophils by fluorescein conjugates can be obliterated by utilising the peroxidase activity of the eosinophil. The brown reaction product of 3,4,3',4'-tetraaminobiphenyl hydrochloride (DAB) with hydrogen peroxide was more effective than Lendrum's stain. A satisfactory alternative to the possibly carcinogenic DAB was 2,7-fluorenediamine.

Plasma cell counts on human jejunal biopsy specimens examined by immunofluorescence and immunoperoxidase techniques: a comparative study

Ten human jejunal biopsy specimens were examined by both immunofluorescence (IF) and immunoperoxidase (IP) methods to compare both plasma cell counts and the distribution of extracellular immunoglobulins. Each specimen was cut into at least two portions, one fixed in 5% formaldehyde in phosphate-buffered saline before being snap-frozen and sectioned on a cryostat for IF, the other being fixed in half-strength Zenker and embedded in paraffin wax by standard methods for IP. Plasma cell counts were comparable in the eight biopsy specimens for which they could be estimated, geometric mean values being IgA 22.9 (IF), 19.3 (IP) and IgM 9.5 (IF), 10.6 (IP). Two specimens showing subtotal villous atrophy had too much extracellular IgA for plasma cell counts to be feasible. For these the IF methods had the advantage that the extracellular immunoglobulin was more readily distinguishable from background staining.

Jejunal mucosal morphometry in children with and without gut symptoms and in normal adults

Nineteen diagnostic peroral biopsy specimens from 18 children without diarrhoea, vomiting, or abdominal pain ('control' children) were compared with those taken from 23 children with diarrhoea of varying aetiology to establish the morphometric characteristics of jejunal mucosa in childhood. Comparison was also made with normal jejunal mucosa from adults. Statistical analysis of each characteristic individually showed no significant difference between the 'control' children and those with diarrhoea, but there were significant differences between the mucosae of 'control' children and those of adults; the villi tended to be shorter and the crypts longer in children. Thirty-seven per cent of specimens from the 'control' children showed a partial villous atrophy, that is, they were abnormal by adult criteria. Discriminant analysis of the features measured showed effective separation of the following groups: normal histology from partial villous atrophy in children, healthy adults from 'control' children, and normal histology in adults from normal histology in children.

Tetrabenazine for involuntary movement disorders

The use of tetrabenazine to treat the movement disorder of Huntington's chorea and other dyskinesias is described. Tetrabenazine produced moderate to marked improvement in the movement disorder in 79% of a series of 40 Australian patients. The most commonly reported side effects were depression, drowsiness and Parkinsonism.

Histopathologic changes and the immune response within the jejunal mucosa in infants and children

Jejunal biopsies obtained from 45 children referred for a variety of clinical conditions were examined histologically and by standard immunofluorescence methods. The number of plasma cells was recorded per "mucosal tissue unit". The results showed that most of the immunoglobulin A (IgA) counts in infants under 3 yr with normal mucosa were low and that there was a rise in the number of IgA plasma cells starting after this age. Despite this, under pathologic conditions (partial villous atrophy with increased inflammatory cell infiltration--PVA) a significant rise in IgA plasma cells occurred in all age groups. Patients with coeliac disease tended to show the highest IgA as well as IgM plasma cell counts. In all other patients, IgM counts did not change significantly with age or histologic abnormalities.

Streptococcal cross-reacting antigen and the bundle of His

Five sera raised in rabbits against three strains of Streptococcus pyogenes (grown in semi-synthetic media) were shown by immunofluorescence to have antibodies reacting with both myocardial and conducting fibres. The pattern of staining on the conducting fibres was different to that on myocardial fibres and suggested the presence of larger amounts of cross-reacting antigen. Most work was done on ox heart, but the results were confirmed on human heart and rabbit heart. Absorption studies, carried out with three sera on ox heart only, showed that absorption with the homologous organism abolished in parallel the staining of both types of fibre. Absorption with heterologous organisms was less effective indicating the existence of more than one cardiac cross-reacting antigen. Absorption with myocardium, suggested that the conducting fibres contained streptococcal cross-reacting antigens additional to those found in the contractile fibres.

Anti-streptococcal antibodies reacting with brain tissue. II. Utrastructural studies

The reaction of rabbit anti-Streptococcus pyogenes type 24 with mouse brain has been studied at the ultrastructural level using horseradish peroxidase labelled antiglobulin. It is shown that these antibodies, and by inference those found in Sydenham's chorea, react with the fibrous astrocyte. The cross-reacting antigen is the glial filament or a closely associated cytoplasmic constituent.

Anti-streptococcal antibodies reacting with brain tissue. I. Immunofluourescent studies

Serum JD from a 14-year old girl with Sydenhams chorea contained antibodies which gave immunofluorescent staining of the limiting membrane of the brain, ependymal tissue and fibrous astrocytes. These antibodies could be completely absorbed by Str. pyogenes type 24 (NCTC 8305) but only partially if at all by type 6 matt (NCTC 8302) or type 6 glossy (NCTC 8709). In contrast, staining by the same serum of the choroid plexus, the periphery of hepatocytes, the periphery of the cells of the gastric mucosa, and tubules in the kidney could be absorbed out by the type 6 matt and type 24 strains (but not by the type 6 glossy or Staph. aureus NCTC 6571). A rabbit anti-streptococcal serum (3/74) raised against disintegrated washed cells of Str. pyogenes type 24 stained and the same structures in the brain to high titre, but not the choroid plexus and not the other structures stained by serum JD. These staining reactions of 3/74 could be absorbed out by Str. pyogenes type 24 but not by Str. pyogenes type 6 matt or type 6 glossy. None of these staining patterns given by serum JD or by 3/74 could be absorbed by human uterine smooth muscle. Serum 3/74 stained heart muscle but this reaction could be absorbed without affecting the brain staining reactions. Sera from 4 other patients with Sydenham's chorea were found to give staining of the ependyma and the limiting membrane, 2 only very weakly.

The non-passage of mycobacteria from Freund's complete adjuvant granuloma depots to arthritic joints

The intra-articular injection of antigen after immunization with that antigen in FCA, the mycobacterial component of which consisted of live M. avium or dead 125I-M. tuberculosis, resulted in identical chronic disease, experimental allergic arthritis. In the former case live mycobacteria could be isolated from the subcutaneous granuloma which developed at the injection site, and from arthritic joints into which 10 mug wet weight (equivalent of 2 mug dry weight) had been injected with this antigen. However, no mycobacteria could be isolated from other inflamed or normal joints. With 125I-labelled mycobacteria radioactive counting and radioautography clearly showed M. tuberculosis present in the subcutaneous granuloma but not in either injected or uninjected joints. The quantity of mycobacteria which could have been detected if present was estimated to be less than 1 mug dry weight. These results strongly suggest that mycobacteria do not travel from the granuloma depot to the arthritic joint, and that any mechanism one may consider to explain the chronicity of EAA cannot involve the physical presence of mycobacteria in the knee joint.

Immunology of bovine heart valves. II. Reaction with connective tissue components

Images

A cross-reaction between Str. pyogenes and human fibroblasts, endothelial cells and astrocytes

Antisera were raised in rabbits to whole streptococci of group A grown in a semi-synthetic medium, containing tryptic digest of casein. Twelve of these sera were tested for their ability to react with a variety of human tissues by the immunofluorescence technique. One serum, raised against a type 6 glossy strain, contained no detectable antibodies to the sarcolemmal/subsarcolemmal region of the myocardium, but gave strong staining of fibroblasts, endothelial cells, smooth muscle and the pia-arachnoid. In addition there was staining of astrocytes, best demonstrated in sections of an astrocytoma, and of the stratum granulosum of the skin. This reaction was prevented by absorption with the homologous organism but not with Staph. aureus. In addition the titre of the serum against fibroblasts was not affected by the presence of 10 mg/ml tryptic digest of casein in the diluent. Antisera to two other strains of streptococci (type 6 matt and type 24) gave this staining reaction in addition to the sarcolemmal/subsarcolemmal staining reaction.

Release of formaldehyde from polynoxylin and noxythiolin

Polynoxylin and noxythiolin (Anaflex and Noxyflex) have been recommended for the treatment of certain bacterial infections. Both compounds were shown to release formaldehyde. Detailed studies with noxythiolin showed that it decomposed in solution to liberate most of its formaldehyde, and that solutions of formaldehyde of the appropriate strength gave zones of inhibition on seeded plates comparable in size with those given by noxythiolin. It is suggested that the effects observed with these compounds are caused by the formaldehyde released.