The benefits of combining women’s and children’s healthcare

Medical Tribune August 2008 P2-3

Associate Professor Tay Eng-Hseon reflects on the advantages offered by centers such as KK Women’s and Children’s Hospital, Singapore

A mother and her child share a special relationship that begins even before birth. Having a combined hospital to attend to both of their needs provides continuity of care for the new family, and can help to develop and strengthen this bond. The ability to deliver specialist pediatric care on-site removes the potential need to separate a mother from her newborn baby within moments of delivery, enabling the family unit to remain intact within the same hospital. And as the child continues to grow, mothers can enjoy the convenience of having their own health needs attended to at the same place as those of their children. Joint visits such as this can help to reinforce the social support network and cohesion within a family.

Combining women’s and children’s healthcare is also beneficial from a medical standpoint as well as a social one. Delivery of crossover services becomes quicker, easier and more efficient within a single site. Many times at KK Women’s and Children’s Hospital (KKH) we have witnessed a neonatologist supervise the birth of a child before handing over to the pediatric urologist or cardiac surgeon, thereby allowing treatment to continue promptly without interruption or the need for further travel, with the associated delays and costs that this entails.

KKH treats a more specific section of the community than a general hospital, and this has proved to be beneficial from a practical point of view as well. With the field of potential patients narrowed we can reduce the range of equipment that we need, keep a more specific selection of drugs at the pharmacy, and standardize the hospital wards to a greater degree. We can also provide more specialized training for physicians, who can gain hands-on experience of a wide spectrum of conditions within their discipline.

Specializing in this way also has benefits for research, enabling a greater focus which in turn improves the ease of execution. Consequently KKH has participated in several large-scale international trials, including those of the rotavirus and cervical cancer vaccines. Entry into trials such as these can be competitive, but the ability to accrue large numbers of subjects quickly and easily has enabled our hospital to stay ahead of the competition. Furthermore we can provide a different patient perspective to centers in Europe and the US, and for these particular studies KKH was the main provider of Asian subjects.

Until 1997, pediatric hospital care in Singapore was spread between Tan Tock Seng, Singapore General and National University Hospitals. The visionary decision to consolidate these services into KKH – previously a dedicated women’s hospital – has enabled the hospital to expand into new areas and provide further dimensions of care to its patients. Examples include the development of highly specialized breast surgery and plastic and reconstructive surgery teams, and the opening of the Women Wellness Centre and Department of Child Development. Promoting mental health within the same vicinity as physical health also has the added benefit of reducing the stigma that can be associated with conventional psychiatric settings.

In a large specialist center such as KKH, the progression to higher-level services is a natural one, and it would not be surprising to see the private sector develop along these lines in future. High-end secondary and tertiary care such as this can only be feasible when there is access to a high volume of primary care patients, however, otherwise the demand will not match the capacity for supply and an expensive excess will develop.

In Singapore, patients from all corners of the country can reach the hospital within 30 minutes, making the concentration of care into one specialist centre very feasible. By virtue of its size and position within a dense population, KKH delivers a third of the 38,000-odd babies born each year in Singapore and provides care for around 80 percent of the country’s children. This model of centralized combined healthcare might not be feasible in all countries, however, and smaller hospitals in more sparsely-populated areas may not be able to match the volume of patients needed to sustain a dedicated center.

By focusing and centralizing our services we have been able to enhance our international reputation and provide regional leadership, and over the years we have attracted many foreign doctors on training fellowships. Other countries have begun looking into our model of hospital structure, and there has been a lot of interest from China in particular. For now women’s and children’s hospitals remain a rarity within Asia but, as KKH demonstrates, this system can provide many important benefits to both doctors and patients at all levels of care.

Laquinimod shows promise for multiple sclerosis

Medical Tribune August 2008 P3

The novel immunomodulatory agent laquinimod appears to reduce disease activity in relapsing-remitting multiple sclerosis and could be a promising new treatment for the condition.

A randomized phase IIb trial involving 306 patients found that, compared to patients who took placebo, those who took oral laquinimod (.6 mg daily) had a 40.4 percent reduction in the number of gadolinium enhancing lesions seen on magnetic resonance imaging at weeks 24, 28, 32 and 36. The drug was well tolerated, with a similar adverse event rate to placebo.

The drug is due to undergo further assessment in a phase III clinical trial.

[Lancet 2008 Jun 21;371(9630):2085-92]

Nanotubes can be used to ‘cook’ tumor cells

Medical Tribune August 2008 P3

Cancer cells can be killed using nanotechnology to deliver a highly specific heat source, a study has shown.

Researchers at the University of Texas Southwestern Medical Center, US, coupled single-walled carbon nanotubes to monoclonal antibodies and targeted these to lymphoma cells in vitro. Exposure to near-infrared light caused the nanotubes to emit heat, thereby ablating the tumor cells while leaving other cells unaffected.

Describing the specificity of the technique as “excellent”, the researchers conclude that the next step is to evaluate the use of these nanotube-antibody constructs in vitro.

[Proc Natl Acad Sci U S A 2008 Jun 24;105(25):8697-702]

New type of cardiac stem cell discovered

Medical Tribune August 2008 P3

Scientists at Harvard have identified a new type of precursor cell which develop into cardiomyocytes.

The cells are located in the epicardium and can be identified through their expression of the Wt1 gene, the researchers reported in Nature. A subset of these cells gave rise to fully functioning cardiomyocytes during normal development of the mouse heart. Other epicardial cells had been previously shown to differentiate into endothelial and smooth muscle cells but not cardiomyocytes.

Identifying these progenitor cells could enable future research to harness their potential for cardiac repair and regeneration, the study authors conclude.

[Nature 2008 Jun 22. Epub ahead of print]

Heel ultrasound predicts osteoporotic fracture risk

Medical Tribune August 2008 P5
David Brill

A simple formula combining clinical information with quantitative ultrasound data from the heel can be used to predict whether a woman is at risk for osteoporotic fractures, a study has shown.

The prediction rule, which assigns patients a risk score from 0 to 14, was tested in 6,174 Swiss women aged 70 to 85 who were followed up for 2.8 years.

Rates of osteoporotic fracture were 6.1 percent among women defined as high-risk and 1.8 for those defined as low-risk, when using a cut-off score of 4.5. The sensitivity of the formula using this score was 90 percent.

“The whole idea of this study was to end up with a tool that can be used by primary care physicians on a daily basis,” said Dr. Idris Guessous, lead author of the study which was published in Radiology.

Ultrasound is inexpensive and portable, he added, and could be used as a diagnostic screening tool in countries where costly bone mineral density (BMD) scans are not available. Resource-permitting, the two modalities could be used in combination for select high-risk women he said.

Dr. Lau Tang Ching – consultant rheumatologist at Tan Tock Seng Hospital, Singapore – said that ultrasound could be useful for assessing nursing home patients who would have difficulty visiting hospital for a BMD scan.

He added, however, that he would like to have seen the authors report the continuous score spectrum for fracture risk prediction, rather than using the single cut-off point of 4.5.

“It would also be good if the test characteristics of the ultrasound machine were compared with dual X-ray absorptiometry BMD or with other well established predictors of low BMD such as the Osteoporosis Self-Assessment Test,” said Lau.

The researchers used a quantitative ultrasound device which requires an operator to position the subject’s foot in a water bath. The measurement procedure is otherwise automatic.

“What is really specific to this study is the way that clinical risk factors – history of fractures or recent fall – are combined with this ultrasound technique, so there are two domains that are included in the score,” said Guessous, who is a senior research fellow at Lausanne University Hospital in Switzerland.

“I stress this point because this score may not only highlight the quality of the bone itself, which is a major risk factor for fractures, but it also highlights the risk of fall for a woman.

“Depending on which factors the woman is at risk for you may better target your intervention, so eventually women who are at more risk of falling than having a bad quality of bone may end up having other interventions like hip protectors or rebalancing techniques, than just receiving bisphosphonate drugs,” he said.

Healthcare systems urged to vaccinate workers

Medical Tribune August 2008 P7
David Brill

Widespread vaccination programs should be introduced for all healthcare workers and backed by the WHO, according to an infectious diseases expert from Mexico City.

Describing healthcare as “a very risky activity,” Dr. Samuel Ponce de Leon told the ICID that death and disease among personnel can have serious consequences for systems that are already short of important resources.

“Healthcare workers are an endangered species and a very reluctant one to be protected. A total of 57 countries, mostly in sub-Saharan Africa but also some Asian countries, face crippling healthcare worker shortages.

“Every health system, hospital, institute and outpatient clinic, private or public, should establish a program to vaccinate all healthcare workers as part of a comprehensive healthcare program,” he said, adding that “the WHO should establish obligatory regulation to protect healthcare workers.”

Hepatitis B, influenza, measles, rubella, tetanus and diphtheria – just some of the diseases faced by healthcare workers – should form the very minimum components of vaccination programs, according to Ponce de Leon.

Workers risk catching a wide range of infectious diseases from their patients if they are not vaccinated, and can be responsible for passing these on to other patients, medics and the community at large.

Compliance to healthcare worker vaccination schemes is typically poor, he said, suggesting that poor communication and lack of knowledge are typically responsible. Workers may also be reluctant to give up their time, have a fear of needles, or perceive vaccination as dangerous or unnecessary.

“Healthcare workers should be clear that compliance to be vaccinated is an ethical duty,” he said.

Despite the obstacles, vaccine uptake can be successfully promoted said Ponce de Leon, citing the example of a hospital campaign in Korea which boosted influenza vaccination rates among workers from 27 to 52 percent. [Infect Control Hosp Epidemiol 2006 Jun;27(6):612-7]

Beyond the basic schedule, vaccination programs could be extended to include hepatitis A, varicella and pneumoccocus, he said.

He added that avian influenza is also an area to consider but several issues remain unresolved as to what the best vaccine is and when best to use it.

Hygiene and education key to reducing catheter-related infections

Medical Tribune August 2008 P7
David Brill

Some 250,000 catheter-related bloodstream infections (BSIs) occur each year in the US, with mortality as high as 35 percent and avoidable costs totaling around US$6.25 billion.
Pic: hospital patient with a catheter line

However the number of infections can be dramatically reduced by following a range of simple steps, according to Trish Perl who is Professor of medicine, pathology and epidemiology at Johns Hopkins Hospital (JHH) in Baltimore.

Since introducing measures to reduce the rates of catheter-related BSIs, JHH has seen a 75 percent decrease across all of their adult intensive care units in the past 6 years, she said. The hospital published a report in 2004 in which they estimate that 43 BSIs, 8 deaths and nearly US$2 million dollars in costs have been prevented each year by the intervention strategy. [Crit Care Med 2004 Oct;32(10):2014-20]

Perl outlined three major contamination sites that can cause BSIs: the skin and insertion site, the catheter hub and the infusate. Each of these points provides a focal target for prevention strategies, she said, noting that the former two are of the greatest concern in developed countries whereas the latter is more of a problem in the developing world.

“It remains important to cleanse your hands … that recommendation actually has the strongest evidence,” said Perl, adding that employing maximal barrier precautions and educating health care workers who place catheters can also help to avoid skin-derived infections.

“These three recommendations are highly, highly supported by the evidence and should be in place in all settings. Knowledge and adherence to guidelines for all persons placing lines has also been shown to decrease your BSI rates,” she said.

Suggested maximal barrier precautions include wearing sterile gloves and gowns and tight-fitting non-sterile masks and hats, and covering the patient’s body with a sterile drape. Consideration should also be given to the site of catheter insertion, as the subclavian vein is associated with lower infection rates than the internal jugular and femoral veins she said.

Beyond the insertion site, catheter hubs and infusates are also an important source of infections said Perl, citing a study of four pediatric hospitals in Mexico City which found that 70 percent of injection ports and 7 percent of infusates were contaminated. [Infect Control Hosp Epidemiol 2004 Mar;25(3):226-30]

“Coated catheters have been shown to decrease BSI rates but given the cost we need to determine the high-risk patients and ensure that other prevention strategies are in place,” she said, adding that the use of antiseptic ports and caps and new stopcock models seem to cut infection rates.

BSI rates also seem to increase when nursing staff levels are low, and ensuring adequate levels of care at all times may also be an important prevention strategy.

Perl noted, however, that certain newer models of needleless connectors have actually led to increased infection rates.

“I think we have to really start considering whether or not the technology can actually contribute to BSIs,” she said.

Perl concluded by adding that future infection control programs should use standard definitions, so that feedback can be easily provided to the healthcare workers who are responsible for the placement of catheters.