A short, preoperative team briefing prior to cardiac surgery – where each person on the team speaks – improves communication and reduces errors and costs, according to a pilot study conducted at Mayo Clinic.

Mayo researchers believe this is the first such study to use real-time observations to measure the effect of preoperative briefings on specific disruptions to surgery. Disruptions were categorized as patient-related issues, equipment or resource issues, procedural knowledge issues and miscommunication events. Results from the Mayo Clinic pilot are published online in the Journal of the American College of Surgeons.

“The goal of the briefings was to get everyone used to talking when there wasn’t a problem, so they would be more likely to speak up when problems occur,” says Thoralf Sundt, M.D., Mayo Clinic cardiac surgeon who volunteered his surgery team for the study. “We know that miscommunication is a major cause of sentinel events, an unexpected death or serious injury.”

Fifty-six surgical staff members filled out questionnaires and participated in focus groups to develop the format for the briefings. Among the participants were surgical assistants and technicians, registered nurses, nurse anesthetists, and perfusionists, who operate the heart-lung machine during most cardiac surgeries.

The briefings were conducted in the operating room immediately prior to the first surgical procedure of the day, before the patient arrived in the room. Each team member discussed his or her role in the procedure and any concerns specific to the patient. The briefings lasted from one to eight minutes.

“The briefing was not a checklist review,” says Dr. Sundt. Checklists are most helpful in preventing predictable errors, such as confirming if and when medications are administered prior to surgery. No checklist can cover the unexpected scenarios that might occur in surgery.

“Because of the complexity of what we do, errors do happen,” says Dr. Sundt. “Each team member needs to feel comfortable enough to identify errors. Then we catch them and correct them.”

Pre-procedure briefings are not common in operating rooms, but they are standard in other high-risk industries such as aviation and in the military, according to Douglas Wiegmann, Ph.D., the lead researcher on the Mayo study.

“This approach reflects a change in culture in the surgical field – that everyone has a unique contribution to the outcome and care of the patient,” says Dr. Wiegmann, who has since moved to the University of Wisconsin as an associate professor of human factors engineering.

While staff are expected to speak up during surgery, they don’t or don’t always, according to Dr. Wiegmann. Other research has shown that information conveyed in the operating room is often shared in a tense, ad hoc manner that is not conducive to comfortable communication. Previous Mayo Clinic research found that only 32 percent of nonphysician caregivers in cardiovascular surgery thought that surgeon communication was effective. In the same study, 59 percent of nonphysician respondents thought that surgeon attitudes and personalities negatively impacted teamwork.

To measure the briefings’ effectiveness, a trained observer monitored six surgeries where briefings were conducted and 10 surgeries where no briefing occurred. The observer was a medical student who was familiar with cardiac surgery and trained to record errors and flow disruptions.

When the briefings were conducted:

  • Miscommunication events were reduced by 53 percent. None of the miscommunication events observed during the study resulted in adverse events. Examples include the surgeon asking for a medication to be given and the anesthesiologist not hearing the request. There were significantly fewer delays, with fewer interruptions to clarify procedures. And, nurses made fewer trips outside the operating room to retrieve supplies.
  • Waste of medical supplies was reduced because the team better anticipated specific needs for each surgery.

Dr. Sundt says his team has embraced the briefings and continues to conduct them prior to the first procedure of the day. Other surgical teams have since requested implementation of the briefings.

“It’s time well spent that tunes us in to the specific patient’s needs,” says Dr. Sundt. In addition to specific concerns about the surgery, the briefings include information about the patient’s prior procedures, other diagnoses, risks and emotional concerns, such as the patient’s biggest worry regarding surgery.

“It sets the tone for the day. Now, I’m uncomfortable when we don’t do it,” says Dr. Sundt, who was initially skeptical about the benefits of the briefings.

There are barriers to conducting briefings for every procedure. “The structure of the operating room is not conducive to this,” says Dr. Sundt. With multiple surgical suites, surgery times overlap, creating difficulty in assembling the team prior to each procedure. During long, complex surgeries, shift and staff changes occur.

Additional study and pilots are needed to determine ways to incorporate the briefings more broadly, researchers say.

Source: Mayo Clinic


ImmunoVaccine Technologies Inc. (IVT), a Canadian vaccine development company, announced a research partnership with FIT Biotech, a Finland-based , clinical stage company that develops DNA vaccines. This research will formulate FIT Biotech’s GTU(R) MultiHIV DNA plasmid with IVT’s DepoVax(TM) vaccine delivery system to advance a therapeutic HIV vaccine.

“DepoVax(TM) will act as a vector to deliver FIT Biotech’s GTU(R) MultiHIV DNA vaccine and our goal is to develop a more sophisticated and efficient HIV vaccine candidate,” commented Dr. Marc Mansour, Vice President R&D at IVT.

The development of an HIV vaccine is complicated by the ability of the virus to mutate rapidly. FIT Biotech has addressed this challenge by designing a synthetic DNA plasmid, known as GTU(R) MultiHIV that covers the antigenic variability within HIV strains. GTU(R) MultiHIV and is comprised of the multi-epitope/multivalent HIV antigens. As FIT Biotech’s lead vaccine candidate, GTU(R) MultiHIV has the potential to trigger an immune response that slows the progression of HIV in infected individuals.

IVT’s pre-clinical research demonstrates that DepoVax(TM) effectively delivers DNA plasmids into draining lymph nodes with as little as one dose. The DepoVax(TM) platform uses liposomes to encapsulate a target antigen, like GTU(R) MultiHIV, and adjuvant. DepoVax(TM) also relies on a hydrophobic carrier to create a depot effect that significantly enhances vaccine induced cell-mediated and humoral immunity.

This pre-clinical research partnership will combine the complementary technologies of DepoVax(TM) and GTU(R) MultiHIV. Both IVT and FIT Biotech will examine the novel vaccine’s capabilities of inducing cell-mediated and humoral immunity against HIV virus.

“By testing DepoVax(TM) in combination with GTU(R) MultiHIV plasmid, we are working towards developing a superior vaccine candidate for therapeutic use against HIV and AIDS,” said Kalevi Reijonen, President and CEO at FIT Biotech.

The WHO reports that 33 million people are living with HIV and the epidemic is rapidly expanding with 2.7 million people newly infected in 2007. Nearly all of them will develop AIDS-related complications, creating an urgent need for effective HIV therapeutic vaccines. Therapeutic vaccination offers the most hope for HIV infected individuals because it maintains a low viral load and has the potential to modify the course of the infection and its progression towards the AIDS disease.

Source: ImmunoVaccine Technologies Inc.


New multi-country research study finds neither newborns nor their mothers are receiving appropriate treatment and care to end this needless tragedy

Global and national programs to prevent vertical (mother-to-child) transmission are in disarray and governments are falling seriously short of their goals, leading to hundreds of thousands of needless HIV infections annually, according to new on-the-ground research from six countries published in the latest Missing the Target report — “Failing Women, Failing Children: HIV, Vertical Transmission and Women’s Health” — from the International Treatment Preparedness Coalition (ITPC), to be released during the 62nd World Health Assembly (WHA) in Geneva.

Although the drugs have been available for over a decade, two-thirds of HIV-positive pregnant women in the developing world do not receive any antiretroviral drugs (ARVs) to prevent HIV transmission to infants. Worse, most of those who get drugs are treated with a therapy known to be just over 40% effective, rather than the triple-dose combination therapy that successfully prevents almost 98% of newborn HIV infections in the developed world.

“The statistics clearly show that governments of developing countries are failing to provide effective drug therapy to prevent HIV infections in newborns. Worse still, our research findings point to an unacceptable absence of a comprehensive program to prevent vertical transmission,” said Aditi Sharma, coordinator of the Treatment Monitoring and Advocacy Project of ITPC. “Unless governments begin to address the fundamental barriers specific to women that stop them accessing health care services, the world will continue to miss the target of eradicating vertical transmission of HIV.”

Research conducted by civil society activists in Argentina, Cambodia, Moldova, Morocco, Uganda and Zimbabwe shows that efforts to prevent vertical transmission are failing to reach the very group it was designed for — HIV-positive pregnant women. One of the key reasons for this is that the national programs have been narrowly focused on providing antiretroviral prophylaxis and not on the other essentials — prevention, counseling, care and treatment for women and children.

“On paper, the existing global program is a model of sound design, human rights principles and a comprehensive approach. In practice, it is a shameful demonstration of double standards and another instance of women’s programming for which everyone and no one at the UN is in charge,” said Stephen Lewis, co-director of AIDS-Free World, who co-authored the report’s preface.

Findings from each country demonstrate the many symptoms of the failure:

  • In Cambodia, 88 percent of HIV-positive mothers receive no ARV prophylaxis at all;
  • Shortages of ARVs and health workers plus poor infrastructure make women’s access to health services particularly difficult for Uganda’s rural and post-conflict areas;
  • Over 30 percent of pregnant women in Argentina get no HIV test prior to going into labor;
  • In Moldova knowledge about prevention of vertical transmission and awareness of the risks of mixed infant feeding is very poor;
  • In Morocco, almost a third of women have no access to any prenatal exam and a third of births are not assisted by health care professionals;
  • Zimbabwe’s situation provides stark evidence of the importance of a comprehensive approach to women’s health. “The program to prevent vertical transmission has been severely compromised since early 2008 because of the collapse of the health delivery system,” explains Caroline Mubaira, of the Zimbabwe research team. “Before the economic and political turmoil, the prevention of vertical transmission program was among the best in the southern African region. When it was operating well, structures were in place and they were supported by policy. Staff were trained and the Minister of Health provided constant feedback and gathered data about the status of the program at each stage of the comprehensive care provision”;
  • In every country, the researchers found rampant fear of stigma among women and discrimination by health care workers. Governments are failing to address the health needs of women and there is inadequate integration between vertical transmission and maternal and child health, HIV treatment and sexual and reproductive health services;
  • The report also warns of a “significant and dangerous inconsistency” in infant feeding guidance given to HIV-positive mothers.

“The ITPC report adds to the growing evidence of the vital need to tackle gender inequities in order to provide universal access to health care,” says Lorena Di Giano, an AIDS activist and Missing the Target team leader from Argentina.

In its recommendations, ITPC calls on UN agencies to radically improve coordination at all levels, and for governments, donors and UN agencies to publish a joint action plan to provide comprehensive vertical transmission services to those in need.

“UN agencies were instrumental in helping set the vital goal of universal access to HIV prevention, treatment and care,” said Gregg Gonsalves, co-founder of ITPC. “Along with governments, they too bear responsibility for the daily toll of preventable infections in newborns and the needless deaths of women, men and children.”

Specific report recommendations include:

  • At UNGASS in June 2010, UNAIDS, WHO and UNICEF should report progress based on all four prongs of the comprehensive strategy — not just the provision of prophylaxis.
  • Governments, with support from donors, should increase mothers’ access to the triple-dose ARV regimen, currently provided to only eight percent of those treated to prevent transmission to newborns.
  • WHO and UNICEF need to urgently work with governments to revise national infant-feeding policies consistent with global guidelines and latest research, and regularly assess implementation.

The report, published by the Treatment Monitoring and Advocacy Project (TMAP) of ITPC, is based on research conducted in the six countries between November 2008 and January 2009. The full report is available at www.aidstreatmentaccess.org and www.itpcglobal.org.

Source: International Treatment Preparedness Coalition


H1N1: What You Should Know

  • Author: Health Informer
  • Filed under: Health News
  • Date: May 24,2009

As a Dallas-based physician, there has been a recent flurry of panic about the H1N1 (swine influenza). School districts closed down. Intramural sports statewide were cancelled. Some even suggested closing the border with Mexico, where approximately three quarters of a million people routinely cross back and forth every day. The panic certainly was fueled by the media reports. Likewise, the media can serve to educate the public about health issues.

For that reason, I have created this column to respond to frequently asked questions about H1N1 and reassure the public that pork is safe and will continue to be safe to consume.

What is H1N1 (swine flu)?

H1N1 (previously referred to as “swine flu”) is a respiratory illness. This new virus was first detected in people in the United States in April 2009. Other countries, including Mexico and Canada, have reported people sick with this new virus. This virus is spreading from person-to-person, probably in much the same way that regular seasonal influenza viruses spread.

Why was the H1N1 virus originally called “swine flu”?

This virus was originally referred to as “swine flu” because laboratory testing showed that some of the genes in this new virus were similar to influenza viruses that have occurred in pigs. But further study has shown that this H1N1 virus is very different from what normally circulates in North American pigs. In fact, this strain is unique and was not previously recognized in either people or pigs.

How is H1N1 spread?

Flu viruses generally spread from person to person, often through the moisture in coughs and sneezes. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and deposited on the mouth or nose of another individual. Influenza viruses may also be spread when a person touches respiratory droplets on another person or an object and then touches their own or another’s mouth or nose. You cannot get H1N1 from handling raw pork or eating cooked pork.

Is the H1N1 virus spread through animals?

It appears that the virus is spreading from humans to humans. No evidence indicates that any of the human illnesses resulted from contact with pigs or other animals.

Isn’t it better to be cautious?

According to the most reputable health organizations, including the World Health Organization, U.S. Centers for Disease Control and Prevention, U.S. Departments of Agriculture and U.S. Health and Human Services, the H1N1 flu strain cannot be transmitted by eating pork; it is not a food safety issue. To be cautious, you need to take measures to avoid coming into contact with the virus, such as frequent hand washing. Visit elcerdoesbueno.com for more information.

It doesn’t seem clear to me.

The facts are clear. The Centers for Disease Control (CDC) has not found any evidence to indicate that any of the illnesses resulted from contact with pigs. The CDC web site states, “Swine influenza viruses are not spread by food. You cannot get swine influenza from eating pork or pork products. Eating properly handled and cooked pork products is safe.”

When should I seek medical care?

Signs that you should seek immediate attention include: difficulty in breathing or chest pain, discoloration of the lips, vomiting and inability to keep liquids down, dizziness, absence of urination or seizures.

Can pork be part of a healthy diet?

Absolutely. Lean cuts such as tenderloin and pork chops rival chicken as an ideal protein source. Pork provides many under-consumed nutrients such as potassium, phosphorous and vitamin B12, a vitamin found only in animal foods.

Source: Dr. Gonzalo Venegas – has been practicing medicine since 1984. He is president of The Venegas Medical Foundation and is active in community organizations including LULAC, The Mexico Institute, Casa Guanajuato and Emmanuel Medical Mission.


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