Pasquale Iozzo

Effect of High-Fidelity Simulation on Medical Students' Knowledge about Advanced Life Support: A Randomized Study

High-fidelity simulation (HFS) is a learning method which has proven effective in medical education for technical and non-technical skills. However, its effectiveness for knowledge acquisition is less validated. We performed a randomized study with the primary aim of investigating whether HFS, in association with frontal lessons, would improve knowledge about advanced life support (ALS), in comparison to frontal lessons only among medical students. The secondary aims were to evaluate the effect of HFS on knowledge acquisition of different sections of ALS and personal knowledge perception. Participants answered a pre-test questionnaire consisting of a subjective (evaluating personal perception of knowledge) and an objective section (measuring level of knowledge) containing 100 questions about algorithms, technical skills, team working/early warning scores/communication strategies according to ALS guidelines. All students participated in 3 frontal lessons before being randomized in group S, undergoing a HFS session, and group C, receiving no further interventions. After 10 days from the end of each intervention, both groups answered a questionnaire (post-test) with the same subjective section but a different objective one. The overall number of correct answers of the post-test was significantly higher in group S (mean 74.1, SD 11.2) than in group C (mean 65.5, SD 14.3), p = 0.0017, 95% C.I. 3.34 – 13.9. A significantly higher number of correct answers was reported in group S than in group C for questions investigating knowledge of algorithms (p = 0.0001; 95% C.I 2.22–5.99) and team working/early warning scores/communication strategies (p = 0.0060; 95% C.I 1.13–6.53). Students in group S showed a significantly higher score in the post-test subjective section (p = 0.0074). A lower proportion of students in group S confirmed their perception of knowledge compared to group C (p = 0.0079). HFS showed a beneficial effect on knowledge of ALS among medical students, especially for notions of algorithms and team working/early warning scores/communication.

Use of a Real-Time Training Software (Laerdal QCPR®) Compared to Instructor-Based Feedback for High-Quality Chest Compressions Acquisition in Secondary School Students: A Randomized Trial

High-quality chest compressions are pivotal to improve survival from cardiac arrest. Basic life support training of school students is an international priority. The aim of this trial was to assess the effectiveness of a real-time training software (Laerdal QCPR®) compared to a standard instructor-based feedback for chest compressions acquisition in secondary school students. After an interactive frontal lesson about basic life support and high quality chest compressions, 144 students were randomized to two types of chest compressions training: 1) using Laerdal QCPR® (QCPR group– 72 students) for real-time feedback during chest compressions with the guide of an instructor who considered software data for students’ correction 2) based on standard instructor-based feedback (SF group– 72 students). Both groups had a minimum of a 2-minute chest compressions training session. Students were required to reach a minimum technical skill level before the evaluation. We evaluated all students at 7 days from the training with a 2-minute chest compressions session. The primary outcome was the compression score, which is an overall measure of chest compressions quality calculated by the software expressed as percentage. 125 students were present at the evaluation session (60 from QCPR group and 65 from SF group). Students in QCPR group had a significantly higher compression score (median 90%, IQR 81.9–96.0) compared to SF group (median 67%, IQR 27.7–87.5), p = 0.0003. Students in QCPR group performed significantly higher percentage of fully released chest compressions (71% [IQR 24.5–99.0] vs 24% [IQR 2.5–88.2]; p = 0.005) and better chest compression rate (117.5/min [IQR 106–123.5] vs 125/min [115–135.2]; p = 0.001). In secondary school students, a training for chest compressions based on a real-time feedback software (Laerdal QCPR®) guided by an instructor is superior to instructor-based feedback training in terms of chest compression technical skill acquisition. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000383460

No-touch methods of terminal cleaning in the intensive care unit: results from the first large randomized trial with patient-centred outcomes

Environmental contamination may play a major role in intensive care unit (ICU)-acquired infections, despite current terminal cleaning standards [1]. Anderson et al. [2] recently performed the first large randomized trial investigating a no-touch method of terminal cleaning with a patient-centred outcome, and provided more robust data on the role of environmental contamination for healthcare-associated infections. The authors evaluated three different enhanced terminal disinfection methods (ultraviolet, UV light, UV light plus bleach, and bleach) compared to the reference standard for prevention of transmission of multidrug resistant organisms (MDROs) and Clostridium difficile to patients exposed to a room whose prior occupant was either colonized or infected with a MDRO. The addition of UV light to the reference disinfection strategy (based on quaternary ammonium) reduced the transmission of the targeted MDROs (methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci) by 30%, while no significant difference was observed when UV light was compared to bleach or to the combination of bleach and UV. Moreover, the authors did not observe a difference in colonization and infection by C. difficile when UV light was added to bleach (the standard disinfection method for C. difficile). We agree with them that this would represent the minimum effect of the UV strategy and that, in a real-life scenario with considerably less cleaning compliance, the benefit from UV-based enhanced terminal cleaning would have been more incisive. Notably, killing of C. difficile spores appeared to be timeand dosedependent in a previously published study [3]. ICU-acquired infections are a major health problem worldwide [4]. Environmental contamination may pose an even higher challenge in this setting due to a number of factors: a higher prevalence of colonization and infection by MDROs, understaffing, the presence of sophisticated equipment with high-touch surfaces and specific cleaning procedures [1]. The benefit of no-touch methods for terminal cleaning may be theoretically higher in these circumstances. Unfortunately, the study did not provide data on Acinetobacter since only one exposed patient acquired this organism. The role of Gram-negative bacteria may be more relevant in the ICUs. In a meta-analysis of studies investigating the risk of acquiring bacteria from prior bed occupants, the odds ratio for acquisition of Acinetobacter was the highest, corresponding to 4.91 (95% CI 2.79–8.64) [5]. The study by Anderson et al. highlights how terminal cleaning may be considered the basis to build an effective strategy to reduce healthcare-associated infections.

What is the risk of acquiring bacteria from prior intensive care unit bed occupants

Contamination of inanimate surfaces and equipment may play a role in cross-transmission of bacteria in the intensive care unit (ICU), despite current standards of terminal cleaning [1–3]. This is particularly relevant due to the high prevalence of multidrug-resistant (MDR) colonization of critically ill patients and the virulence and invasiveness of bacteria, which frequently present multidrug resistance to antimicrobials (e.g. Staphylococcus aureus, Acinetobacter baumanii, Klebsiella pneumoniae). Moreover, colonization has been identified as a risk factor for subsequent infections in critically ill patients [4, 5]. We searched Medline, Scopus, and CINHAL databases for either prospective or retrospective studies reporting data on ICU-acquired bacterial species and carriage status of the same species by the prior bed occupant. An exclusion criterion was the non-ICU setting due to differences in terminal cleaning procedures and the hospital environment of the patients. We applied no language restrictions and did not consider gray literature. We performed a random-effect meta-analysis (Mantel-Haenszel method) of included studies and calculated the odds ratio (OR) for acquiring specific microorganisms as well as from the pooled data (Fig. 1). We assessed the heterogeneity among studies by the I statistic. The full search strategy can be found as Additional file 1. Our search strategy found a total of 2264 articles from inception to 1 January 2017 (1247 Medline, 654 Scopus, 363 CINHAL). Two authors (VR and AC) independently performed the search and extracted the data. In case of disagreement, it was solved by consensus with another author (SMR). We used Review Manager 5.3. We selected six studies for inclusion (two prospective cohort study, one post-hoc analysis of a prospective interventional cross-over study, and three retrospective studies) for a total of 33,494 patients. The list of included studies and references is available as Additional file 2. Among 3838 patients admitted to ICU beds with prior infected/colonized occupants, 230 acquired bacteria compared to 954 among 29,656 in the control group. The overall pooled OR of acquiring a bacterial pathogen from prior ICU bed occupants was 2.13 (95% confidence interval 1.62–2.81). We observed a substantial heterogeneity among included studies (I = 61%, P = 0.01). Figure 1 shows the forest plot of meta-analysis of studies with subgroup analyses according to microorganisms and pooled data. Patients admitted to ICU beds of prior occupants who were carrying bacterial pathogens should be considered at increased risk of ICU-acquisition compared to other ICU patients. It should be highlighted that these results refer to acquisition of bacteria and not to infection. However, it may be argued that acquiring bacteria may lead to colonization and nosocomial infections during the ICU stay due to disruption of natural barriers for invasive procedures (e.g., insertion of central venous catheters, arterial lines), use of broadspectrum antibiotics, and impaired immunological function. A possible explanation for these results is that bacteria frequently encountered in the ICU, especially MDR, may have the ability to survive standard terminal * Correspondence: vinrussotto@gmail.com Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy Full list of author information is available at the end of the article

Two episodes of Taravana syndrome in a breath-hold diver with hyperhomocysteinemia

Taravana syndrome is a rare dysbaric disease characterized by neurologic signs and symptoms. Differently from others decompression illness, it has unspecified pathophysiology and unclear predisposing factors. Our cases suggest that thrombophilic state due to hyperhomocysteinemia could increase the risk to develop Taravana syndrome.

Procalcitonin for the diagnosis of invasive candidiasis: what is the evidence?

AbstractsProcalcitonin is a widely used marker for the evaluation of infection and sepsis and to guide antibiotic therapy. During the last decade, several studies evaluated its role and diagnostic performance as a surrogate marker for the identification of Candida spp. in suspected invasive candidiasis. A low serum level and a favorable negative predictive value are the main findings for procalcitonin in this setting. The aim of this report is to provide an updated brief summary of the evidence supporting the use of PCT for the management of invasive candidiasis.

What Healthcare Workers Should Know about Environmental Bacterial Contamination in the Intensive Care Unit

Intensive care unit- (ICU-) acquired infections are a major health problem worldwide. Inanimate surfaces and equipment contamination may play a role in cross-transmission of pathogens and subsequent patient colonization or infection. Bacteria contaminate inanimate surfaces and equipment of the patient zone and healthcare area, generating a reservoir of potential pathogens, including multidrug resistant species. Traditional terminal cleaning methods have limitations. Indeed patients who receive a bed from prior patient carrying bacteria are exposed to an increased risk (odds ratio 2.13, 95% confidence intervals 1.62–2.81) of being colonized and potentially infected by the same bacterial species of the previous patient. Biofilm formation, even on dry surfaces, may play a role in reducing the efficacy of terminal cleaning procedures since it enables bacteria to survive in the environment for a long period and provides increased resistance to commonly used disinfectants. No-touch methods (e.g., UV-light, hydrogen peroxide vapour) are under investigation and further studies with patient-centred outcomes are needed, before considering them the standard of terminal cleaning in ICUs. Healthcare workers should be aware of the role of environmental contamination in the ICU and consider it in the broader perspective of infection control measures and stewardship initiatives.

Rapid detection of carbapenem resistance: targeting a zero level of inadequate empiric antibiotic exposure?

Resistance to carbapenems is an increasingly encountered phenomenon in the ICU, complicating empiric and targeted antimicrobial therapy. Infections due to carbapenem-resistant microorganisms are characterized by high morbidity and mortality [1, 2]. Recently, there has been an increasing interest in rapid detection techniques, based on real time on-demand easy-to-use PCR, to detect genes responsible for carbapenem resistance. One of these techniques is the Cepheid Xpert Carba-R assay, which is able to detect and differentiate five of the most frequent genes associated with non-susceptibility to carbapenems in Gram-negative bacteria (bla KPC, bla VIM, bla OXA-48, bla IMP-1, bla NDM). The diagnostic performance of this assay seems to be high when compared to classic microbiological cultures and gene identification with in-house PCR in a clinical setting, especially in intra-abdominal infections using samples from rectum or abdominal drainage material [3, 4]. Originally, assays for screening of patients carrying multidrug-resistant organisms were used to guide infection control programs, to restrict access to patients’ health-care zones, or for outbreak surveillance. However, several studies reported an association between detection from surveillance techniques and subsequent infection etiology, improving the rate of adequate empiric antimicrobial treatment [5].

Real-time feedback systems for cardiopulmonary resuscitation training: time for a paradigm shift

Among the new tools to improve the quality of cardiopulmonary resuscitation (CPR), real-time feedback systems (FS) have been largely studied during the last decade (1). These systems permit the real-time analysis of CPR.

Protocol of a multicenter international randomized controlled manikin study on different protocols of cardiopulmonary resuscitation for laypeople (MANI-CPR)

Introduction Out-of-hospital cardiac arrest is one of the leading causes of death in industrialised countries. Survival depends on prompt identification of cardiac arrest and on the quality and timing of cardiopulmonary resuscitation (CPR) and defibrillation. For laypeople, there has been a growing interest on hands-only CPR, meaning continuous chest compression without interruption to perform ventilations. It has been demonstrated that intentional interruptions in hands-only CPR can increase its quality. The aim of this randomised trial is to compare three CPR protocols performed with different intentional interruptions with hands-only CPR. Methods and analysis This is a prospective randomised trial performed in eight training centres. Laypeople who passed a basic life support course will be randomised to one of the four CPR protocols in an 8 min simulated cardiac arrest scenario on a manikin: (1) 30 compressions and 2 s pause; (2) 50 compressions and 5 s pause; (3) 100 compressions and 10 s pause; (4) hands-only. The calculated sample size is 552 people. The primary outcome is the percentage of chest compression performed with correct depth evaluated by a computerised feedback system (Laerdal QCPR). Ethics and dissemination . Due to the nature of the study, we obtained a waiver from the Ethics Committee (IRCCS Policlinico San Matteo, Pavia, Italy). All participants will sign an informed consent form before randomisation. The results of this study will be published in peer-reviewed journal. The data collected will also be made available in a public data repository. Trial registration number NCT02632500.