Jane Garbutt

Meta-analysis of randomized controlled trials comparing laparoscopic and open appendectomy

We performed a meta-analysis to determine whether laparoscopic or open appendectomy gives better outcomes for patients with suspected acute appendicitis. Studies were selected from the MEDLINE database, personal files, and meeting abstracts. Eleven of 21 randomized controlled trials were included in the meta-analysis. Pooled effect size estimates were calculated using a random effects model. Laparoscopic appendectomy reduced time to full functioning by 5.48 days (95% confidence interval [CI] 3.70 to 7.26; p < 0.001), improved postoperative pain at 24 hours measured by a visual analog scale from 0 to 10 by 1.19 points (95% CI -2.14 to -0.24 points; p=0.014), and decreased the absolute risk for wound infection by 3.2% (95% CI -5.6% to -0. 8%; p=0.009). Operating time was increased by 17.12 min (95% CI 14.19 to 20.03; p < 0.0001). There was no difference between the two surgeries for length of hospital stay, readmission rate, and intra-abdominal abscess formation. Laparoscopic appendectomy improves patient outcomes.

A Randomized, Placebo-Controlled Trial of Antimicrobial Treatment for Children With Clinically Diagnosed Acute Sinusitis

Objective. Although antimicrobial treatment for children with acute sinusitis is used commonly, it is unclear whether it offers significant clinical benefit. The purpose of this study was to evaluate the effectiveness of antimicrobial treatments for acute sinusitis as they are used in community pediatric practice. Methods. We conducted a randomized, placebo-controlled trial in 3 community pediatric practices in St Louis, Missouri. A total of 188 patients who were between the ages of 1 and 18 years and who had had 10 to 28 days of persistent sinus symptoms and a clinical diagnosis of acute sinusitis were randomized to receive 14 days of amoxicillin (40 mg/kg/d in 3 daily doses), amoxicillin-clavulanate (amoxicillin 45 mg/kg/d in 2 daily doses), or placebo. Change in sinus symptoms was assessed both by a quantitative symptom score (the S5 score) and subjectively by the parent. Secondary outcomes included adverse effects of treatment and recurrence or relapse of sinus symptoms. Outcomes were assessed by telephone interviews over a 2-month period. Results. Of the 161 patients who were included in the analysis, 58 received amoxicillin, 48 received amoxicillin-clavulanate, and 55 received placebo. Day 14 improvement rates were 79%, 81%, and 79%, respectively. There were no differences in the 14-day change in S5 score among treatment groups. The rates of adverse events (amoxicillin, 19%; amoxicillin-clavulanate, 11%; placebo, 10%), relapse (amoxicillin, 12%; amoxicillin-clavulanate, 13%; placebo, 13%), and recurrence (amoxicillin, 9%; amoxicillin-clavulanate, 13%; placebo, 13%) of sinus symptoms were similar among treatment groups. Conclusion. Neither amoxicillin nor amoxicillin-clavulanate offered any clinical benefit compared with placebo for children with clinically diagnosed acute sinusitis.

The Attitudes and Experiences of Trainees Regarding Disclosing Medical Errors to Patients

Purpose To measure trainees’ attitudes and experiences regarding medical error and error disclosure. Method In 2003, the authors carried out a cross-sectional survey of 629 medical students (320 in their second year, 309 in their fourth year), 226 interns (159 in medicine, 67 in surgery), and 283 residents (211 in medicine, 72 in surgery), a total 1,138 trainees at two U.S. academic health centers. Results The response rate was 78% (889/1,138). Most trainees (74%; 652/881) agreed that medical error is among the most serious health care problems. Nearly all (99%; 875/884) agreed serious errors should be disclosed to patients, but 87% (774/889) acknowledged at least one possible barrier, including thinking that the patient would not understand the disclosure (59%; 525/889), the patient would not want to know about the error (42%; 376/889), and the patient might sue (33%; 297/889). Personal involvement with medical errors was common among the fourth-year students (78%; 164/209) and the residents (98%; 182/185). Among residents, 45% (83/185) reported involvement in a serious error, 34% (62/183) reported experience disclosing a serious error, and 63% (115/183) had disclosed a minor error. Whereas only 33% (289/880) of trainees had received training in error disclosure, 92% (808/881) expressed interest in such training, particularly at the time of disclosure. Conclusions Although many trainees had disclosed errors to patients, only a minority had been formally prepared to do so. Formal disclosure curricula, coupled with supervised practice, are necessary to prepare trainees to independently disclose errors to patients by the end of their training.

BRIEF REPORT: Hospitalized Patients' Attitudes About and Participation in Error Prevention

BACKGROUND AND OBJECTIVE: Although many patient safety organizations and hospital leaders wish to involve patients in error prevention, it is unknown whether patients will take the recommended actions or whether error prevention involvement affects hospitalization satisfaction.DESIGN AND PARTICIPANTS: Telephone interviews with 2,078 patients discharged from 11 Midwest hospitals.RESULTS: Ninety-one percent agreed that patients could help prevent errors. Patients were very comfortable asking a medication’s purpose (91%), general medical questions (89%), and confirming their identity (84%), but were uncomfortable asking medical providers whether they had washed their hands (46% very comfortable). While hospitalized, many asked questions about their care (85%) and a medication’s purpose (75%), but fewer confirmed they were the correct patient (38%), helped mark their incision site (17%), or asked about handwashing (5%). Multivariate logistic regression revealed that patients who felt very comfortable with error prevention were significantly more likely to take 6 of the 7 error-prevention actions compared with uncomfortable patients.CONCLUSIONS: While patients were generally comfortable with error prevention, their participation varied by specific action. Since patients who were very comfortable were most likely to take action, educational interventions to increase comfort with error prevention may be necessary to help patients become more engaged.

Association Between Resistance to Vancomycin and Death in Cases of Enterococcus faecium Bacteremia

We conducted a retrospective cohort study to determine the association between resistance to vancomycin and mortality among hospitalized patients with Enterococcus faecium bacteremia. We compared outcomes for patients infected with vancomycin-resistant versus vancomycin-susceptible E. faecium among 69 patients with bacteremia defined according to the National Nosocomial Infections Surveillance system. The univariate odds ratio (OR) for death associated with vancomycin resistance was 2.1 (P=.172). After controlling for severity of illness, we found that vancomycin resistance was not associated with mortality (OR, 1.74; 95% confidence interval, 0.5-6.12; P=.39). Vancomycin resistance does not independently increase mortality among patients with E. faecium bacteremia.

Household Versus Individual Approaches to Eradication of Community-Associated Staphylococcus aureus in Children: A Randomized Trial

BACKGROUND Community-associated Staphylococcus aureus infections often affect multiple members of a household. We compared 2 approaches to S. aureus eradication: decolonizing the entire household versus decolonizing the index case alone. METHODS An open-label, randomized trial enrolled 183 pediatric patients (cases) with community-onset S. aureus skin abscesses and colonization of anterior nares, axillae, or inguinal folds from 2008 to 2009 at primary and tertiary centers. Participants were randomized to decolonization of the case alone (index group) or of all household members (household group). The 5-day regimen included hygiene education, twice-daily intranasal mupirocin, and daily chlorhexidine body washes. Colonization of cases and subsequent skin and soft tissue infection (SSTI) in cases and household contacts were ascertained at 1, 3, 6, and 12 months. RESULTS Among 147 cases with 1-month colonization data, modified intention-to-treat analysis revealed S. aureus eradication in 50% of cases in the index group and 51% in the household group (P = 1.00). Among 126 cases completing 12-month follow-up, S. aureus was eradicated from 54% of the index group versus 66% of the household group (P = .28). Over 12 months, recurrent SSTI was reported in 72% of cases in the index group and 52% in the household group (P = .02). SSTI incidence in household contacts was significantly lower in the household versus index group during the first 6 months; this trend continued at 12 months. CONCLUSIONS Household decolonization was not more effective than individual decolonization in eradicating community-associated S. aureus carriage from cases. However, household decolonization reduced the incidence of subsequent SSTI in cases and their household contacts. CLINICAL TRIALS REGISTRATION NCT00731783.

Prevalence of and Risk Factors for Community-Acquired Methicillin-Resistant and Methicillin-Sensitive Staphylococcus aureus Colonization in Children Seen in a Practice-Based Research Network

OBJECTIVE. We sought to define the prevalence of and risk factors for methicillin-resistant Staphylococcus aureus nasal colonization in the St Louis pediatric population. METHODS. Children from birth to 18 years of age presenting for sick and well visits were recruited from pediatric practices affiliated with a practice-based research network. Nasal swabs were obtained, and a questionnaire was administered. RESULTS. We enrolled 1300 participants from 11 practices. The prevalence of methicillin-resistant S aureus nasal colonization varied according to practice, from 0% to 9% (mean: 2.6%). The estimated population prevalence of methicillin-resistant S aureus nasal colonization for the 2 main counties of the St Louis metropolitan area was 2.4%. Of the 32 methicillin-resistant S aureus isolates, 9 (28%) were health care-associated types and 21 (66%) were community-acquired types. A significantly greater number of children with community-acquired methicillin-resistant S aureus were black and were enrolled in Medicaid, in comparison with children colonized with health care-associated methicillin-resistant S aureus. Children with both types of methicillin-resistant S aureus colonization had increased contact with health care, compared with children without colonization. Methicillin-sensitive S aureus nasal colonization ranged from 9% to 31% among practices (mean: 24%). The estimated population prevalence of methicillin-sensitive S aureus was 24.6%. Risk factors associated with methicillin-sensitive S aureus colonization included pet ownership, fingernail biting, and sports participation. CONCLUSIONS. Methicillin-resistant S aureus colonization is widespread among children in our community and includes strains associated with health care-associated and community-acquired infections.

Socioeconomic, Family, and Pediatric Practice Factors That Affect Level of Asthma Control

BACKGROUND. Multiple issues play a role in the effective control of childhood asthma. OBJECTIVE. To identify factors related to the level of asthma control in children receiving asthma care from community pediatricians. PATIENTS AND METHODS. Data for 362 children participating in an intervention study to reduce asthma morbidity were collected by a telephone-administered questionnaire. Level of asthma control (well controlled, partially controlled, or poorly controlled) was derived from measures of recent impairment (symptoms, activity limitations, albuterol use) and the number of exacerbations in a 12-month period. Data also included demographic characteristics, asthma-related quality of life, pediatric management practices, and medication usage. Univariable and multivariable analyses were used to identify factors associated with poor asthma control and to explore the relationship between control and use of daily controller medications. RESULTS. Asthma was well controlled for 24% of children, partially controlled for 20%, and poorly controlled for 56%. Medicaid insurance, the presence of another family member with asthma, and maternal employment outside the home were significant univariable factors associated with poor asthma control. Medicaid insurance had an independent association with poor control. Seventy-six percent of children were reported by parents as receiving a daily controller medication. Comparison of guideline recommended controller medication with current level of asthma control indicated that a higher step level of medication would have been appropriate for 74% of these children. Significantly lower overall quality-of-life scores were observed in both parents and children with poor control. CONCLUSIONS. Despite substantial use of daily controller medication, children with asthma continue to experience poorly controlled asthma and reduced quality of life. Although Medicaid insurance and aspects of family structure are significant factors associated with poorly controlled asthma, attention to medication use and quality-of-life indicators may further reduce morbidity.

SKIN INFECTION IN CHILDREN COLONIZED WITH COMMUNITY-ASSOCIATED METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

OBJECTIVES The relationship between community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) nasal colonization and subsequent infection in children is unknown. We sought to define risk factors for skin and soft tissue infection (SSTI) in community children. METHODS A prior study measured S. aureus nasal colonization prevalence for 1300 community children. To detect subsequent SSTI in these children or a household member, surveys were administered 6 and 12 months following enrollment. RESULTS SSTIs were reported by 56/708 (8.1%) respondents during the initial 6-month interval. SSTI developed in 6/26 (23%) initially colonized with MRSA, 16/194 (8%) with methicillin-sensitive S. aureus colonization, and 34/474 (7%) not colonized with S. aureus (MRSA vs. not MRSA, univariate analysis, p = 0.014). In multivariable analysis, factors associated with SSTI included history of SSTI in the child during the year preceding enrollment (p < 0.01) and SSTI in household contacts during the follow-up interval (p<0.01); MRSA nasal colonization approached statistical significance (p = 0.08). CONCLUSIONS In the current era of community MRSA transmission, SSTI is a disease of households, with recurrences in index cases and occurrences among household contacts. Children with MRSA colonization may be at risk for subsequent SSTI. Further study of MRSA transmission dynamics in households and preventive strategies should receive high priority.

Safe Medication Prescribing: Training and Experience of Medical Students and Housestaff at a Large Teaching Hospital

Purpose To assess medical students’ and housestaffs knowledge, attitudes, and behaviors regarding safe prescribing. Method In 2003, 214 housestaff (interns and residents) and 77 medical students in medicine and surgery at Barnes-Jewish Hospital, St. Louis, Missouri, were asked to complete an anonymous, self-administered questionnaire about safe prescribing. Questions asked about training in and attitudes about safe-prescribing and current prescribing behaviors. Fisher exact test was used to compare attitudes and behaviors among subgroups. Results Of the 175 (60%) respondents, 73 (59%) of 123 housestaff and eight (15%) of 52 students agreed that their safe-prescribing training was adequate (p < .001), and 145 (83%) total respondents agreed that prescribing errors were unacceptable. Respondents reported always doing the following: 156 (89%) checked prescribing information before prescribing new drugs, 131 (75%) checked for drug allergies, 103 (59%) double-checked dosage calculations, 98 (56%) checked for renal impairment, and 53 (30%) checked for potential drug–drug interactions. Conclusion Routine use of safe medication prescribing behaviors among housestaff and medical students was poor. Contributing factors may have included inadequate training and a culture that does not support safe prescribing. Effective strategies to increase safe medication prescribing need to be identified and implemented.