David N. Fisman

Background.: Extreme fatigue in medical trainees likely compromises patient safety, but regulations that limit trainee work hours have been controversial. It is not known whether extreme fatigue compromises trainee safety in the healthcare workplace, but evidence of such a relationship would inform the current debate on trainee work practices. Our objective was to evaluate the relationship between fatigue and workplace injury risk among medical trainees and nontrainee healthcare workers.Design.: Case-crossover study.Setting.: Five academic medical centers in the United States and Canada.Participants.: Healthcare workers reporting to employee healthcare clinics for evaluation of needlestick injuries and other injuries related to sharp instruments and devices (sharps injuries). Consenting workers completed a structured interview about work patterns, time at risk of injury, and frequency of fatigue.Results.: Of 350 interviewed subjects, 109 (31%) were medical trainees. Trainees worked more hours per week (P< .001) and slept less the night before an injury (P< .001) than did other healthcare workers. Fatigue increased injury risk in the study population as a whole (incidence rate ratio [IRR], 1.40 [95% confidence interval {CI}, 1.03-1.90]), but this effect was limited to medical trainees (IRR, 2.94 [95% CI, 1.71-5.07]) and was absent for other healthcare workers (IRR, 0.97 [95% CI, 0.66-1.42]) (P= .001).Conclusions.: Long work hours and sleep deprivation among medical trainees result in fatigue, which is associated with a 3-fold increase in the risk of sharps injury. Efforts to reduce trainee work hours may result in reduced risk of sharps-related injuries among this group.

Background: Genital herpes (GH) is a common sexually transmitted infection. Novel tools for the control of GH (for example, tests and vaccines) are emerging, but optimal assessment of the cost effectiveness of such interventions requires scaled, preference based estimates of the impact of GH on health related quality of life. Methods: We provided self administered interviews to 39 individuals with recurrent GH recruited from an STD clinic and a GH support group in southern Ontario, Canada. Health preference estimates were generated using visual analogue scales (VAS), a time-tradeoff approach (TTO) and the Health Utilities Index Mark-II (HUI-II). Quality of life was also assessed with the Recurrent Genital Herpes Quality of Life scale (RGHQoL). Results: Average (SD) health values for asymptomatic and symptomatic genital herpes were 0.89 (0.21) and 0.89 (0.22) using TTO, and 0.76 (0.30) and 0.71 (0.30) using VAS. Health utility estimates generated with HUI-II for transient symptomatic and asymptomatic health states were 0.93 (0.08) and 0.80 (0.16). Log transformed health value estimates exhibited convergent validity when compared to RGHQoL, as did health utility estimates for symptomatic GH. Utility scores for symptomatic GH increased (improved) with increasing age; no other subject characteristic was predictive of preference weights. Conclusions: Preference based measures of health related quality of life can be elicited with relative ease in the context of genital herpes, and preference weights are correlated with quality of life scores generated using the RGHQoL. Generation of preference weights will permit direct comparison of the economic attractiveness of herpes prevention interventions with that of other commonly available health interventions.

Outbreaks of invasive infections caused by group A β-hemolytic streptococcus (GAS) may occur in long-term care settings and are associated with a high case-fatality rate in debilitated adults. Targeted antibiotic treatment only to residents and staff known to be at specific risk of GAS may be an ineffective outbreak control measure. We describe two institutional outbreaks in which mass antibiotic treatment was used as a control measure. In the first instance, mass treatment was used after targeted antibiotic treatment was not successful. In the second instance, mass treatment was used to control a rapidly evolving outbreak with a high case-fatality rate. Although no further clinical cases were seen after the introduction of mass antibiotic treatment, persistence of the outbreak strain was documented in one institution >1 year after cases had ceased. Strain persistence was associated with the presence of a chronically colonized resident and poor infection control practices.