Trans-radial cerebral angiography for stereotactic radiosurgery treatment of arteriovenous malformations.

OBJECTIVES: The popularity of trans-radial access (TRA) for cerebral angiography is growing. Potential benefits of TRA over traditional trans-femoral access (TFA) are multitude. This study aimed to evaluate discharge outcomes and patient opinion of TRA compared to TFA in patients undergoing cerebral angiography prior to stereotactic radiosurgery (SRS) treatment for cerebral arteriovenous malformations. METHODS: Consecutive patients treated at the National Centre for Stereotactic Radiosurgery (Sheffield, United Kingdom) over a 22-month period were included. All patients underwent cerebral angiography with either TRA or TFA as part of treatment planning prior to SRS. TRA patients who had previously undergone TFA in other centres were surveyed for their experience of cerebral angiography using a questionnaire. SRS staff at our centre was approached for their opinion. RESULTS: 492 patients were included (median age = 43 years, 57.5% male, median lesions treated = 1). More patients underwent angiography with TFA (75.2%) than TRA (24.8%). No difference was found in accumulated dose for angiography between the groups (p>0.05). There was 17.6% reduction in overnight stay between TRA and TRF, the proportion of patients requiring overnight admission was higher for the TFA (35.2%) than TRA (17.6%, p<0.05). 101 patients were surveyed, with a response rate of 47%. Most respondents (79%) indicated preference for TRA over TFA. CONCLUSIONS: Use of TRA in pre-SRS cerebral angiography is feasible and improves both patient and staff experience. The adoption of TRA could have important implications for department resources and costs by reducing the proportion of overnight admissions.

Research and innovation as a catalyst for food system transformation.

BACKGROUND: Food systems are associated with severe and persistent problems worldwide. Governance approaches aiming to foster sustainable transformation of food systems face several challenges due to the complex nature of food systems. SCOPE AND APPROACH: In this commentary we argue that addressing these governance challenges requires the development and adoption of novel research and innovation (R&I) approaches that will provide evidence to inform food system transformation and will serve as catalysts for change. We first elaborate on the complexity of food systems (transformation) and stress the need to move beyond traditional linear R&I approaches to be able to respond to persistent problems that affect food systems. Though integrated transdisciplinary approaches are promising, current R&I systems do not sufficiently support such endeavors. As such, we argue, we need strategies that trigger a double transformation - of food systems and of their R&I systems. KEY FINDINGS AND CONCLUSIONS: Seizing the opportunities to transform R&I systems has implications for how research is done - pointing to the need for competence development among researchers, policy makers and society in general - and requires specific governance interventions that stimulate a systemic approach. Such interventions should foster transdisciplinary and transformative research agendas that stimulate portfolios of projects that will reinforce one another, and stimulate innovative experiments to shape conditions for systemic change. In short, a thorough rethinking of the role of R&I as well as how it is funded is a crucial step towards the development of the integrative policies that are necessary to engender systemic change - in the food system and beyond.

"Motherhood is like a roller coaster lots of ups, then downs, something chaotic "; UK & Israeli women's experiences of motherhood 6-12 months postpartum.

Background: The motherhood myth has been associated with perceptions of idealised motherhood which makes it difficult for women to express related struggles or distress. This is a second follow-up study focusing on the experiences of mothers from the United Kingdom (UK) and Israel. Methods: Forty-one women were interviewed about their experience of motherhood, body-image, feeding and well-being. Interviews were analysed thematically. Data were driven by the following questions: 1. how do Israeli and UK women experience motherhood 6-12 months postpartum? 2. Are these experiences associated with body satisfaction and well-being? 3. Whether perceptions of motherhood remained stable or changed from early (<6 months) to 12 months postpartum. Results: Three meta-themes were derived from the data relating to motherhood as ideal, good enough or burdened. Such experiences were associated with body acceptance and well-being. The ideal mother was associated with lack of preoccupation with body image whereas the good enough mother aspired to reclaim her mind and her old body. Our findings suggested that the burdened mothers' struggles in relating to motherhood often correlated to a negative body image. Israeli women perceived motherhood as ideal in the early and later postpartum whereas UK mothers continued to relate to their motherhood as ideal 6-12 months postpartum. Conclusions: Perceptions of motherhood varied between Israeli and UK mothers suggesting a diversity positively associated with culture and country. Encouraging mothers to openly share their perceptions of motherhood could lead to improvements in maternal well-being and more positive interactions with the newborn.

Genomic and Biochemical Characterization of Acinetobacter Podophage Petty Reveals a Novel Lysis Mechanism and Tail-Associated Depolymerase Activity.

The increased prevalence of drug-resistant, nosocomial Acinetobacter infections, particularly from pathogenic members of the Acinetobacter calcoaceticus-baumannii complex, necessitates the exploration of novel treatments such as phage therapy. In the present study, we characterized phage Petty, a novel podophage that infects multidrug-resistant Acinetobacter nosocomialis and Acinetobacter baumannii Genome analysis reveals that phage Petty is a 40,431-bp ϕKMV-like phage, with a coding density of 92.2% and a G+C content of 42.3%. Interestingly, the lysis cassette encodes a class I holin and a single-subunit endolysin, but it lacks canonical spanins to disrupt the outer membrane. Analysis of other ϕKMV-like genomes revealed that spaninless lysis cassettes are a feature of phages infecting Acinetobacter within this subfamily of bacteriophages. The observed halo surrounding Petty's large clear plaques indicated the presence of a phage-encoded depolymerase capable of degrading capsular exopolysaccharides (EPS). The product of gene 39, a putative tail fiber, was hypothesized to possess depolymerase activity based on weak homology to previously reported phage tail fibers. The 101.4-kDa protein gene product 39 (gp39) was cloned and expressed, and its activity against Acinetobacter EPS in solution was determined. The enzyme degraded purified EPS from its host strain A. nosocomialis AU0783, reducing its viscosity, and generated reducing ends in solution, indicative of hydrolase activity. Given that the accessibility to cells within a biofilm is enhanced by degradation of EPS, phages with depolymerases may have enhanced diagnostic and therapeutic potential against drug-resistant Acinetobacter strains.IMPORTANCE Bacteriophage therapy is being revisited as a treatment for difficult-to-treat infections. This is especially true for Acinetobacter infections, which are notorious for being resistant to antimicrobials. Thus, sufficient data need to be generated with regard to phages with therapeutic potential, if they are to be successfully employed clinically. In this report, we describe the isolation and characterization of phage Petty, a novel lytic podophage, and its depolymerase. To our knowledge, it is the first phage reported to be able to infect both A. baumannii and A. nosocomialis The lytic phage has potential as an alternative therapeutic agent, and the depolymerase could be used for modulating EPS both during infections and in biofilms on medical equipment, as well as for capsular typing. We also highlight the lack of predicted canonical spanins in the phage genome and confirm that, unlike the rounding of lambda lysogens lacking functional spanin genes, A. nosocomialis cells infected with phage Petty lyse by bursting. This suggests that phages like Petty employ a different mechanism to disrupt the outer membrane of Acinetobacter hosts during lysis.

Attenuation of ketamine-induced impairment in verbal learning and memory in healthy volunteers by the AMPA receptor potentiator PF-04958242.

There is a need to develop treatments for cognitive impairment associated with schizophrenia (CIAS). The significant role played by N-methyl-d-aspartate receptors (NMDARs) in both the pathophysiology of schizophrenia and in neuronal plasticity suggests that facilitation of NMDAR function might ameliorate CIAS. One strategy to correct NMDAR hypofunction is to stimulate α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (AMPARs) as AMPAR and NMDAR functioning are coupled and interdependent. In rats and nonhuman primates (NHP), AMPAR potentiators reduce spatial working memory deficits caused by the nonselective NMDAR antagonist ketamine. The current study assessed whether the AMPAR potentiator PF-04958242 would attenuate ketamine-induced deficits in verbal learning and memory in humans. Healthy male subjects (n=29) participated in two randomized treatment periods of daily placebo or PF-04958242 for 5 days separated by a washout period. On day 5 of each treatment period, subjects underwent a ketamine infusion for 75 min during which the effects of PF-04958242/placebo were assessed on ketamine-induced: (1) impairments in verbal learning and recall measured by the Hopkins Verbal Learning Test; (2) impairments in working memory on a CogState battery; and (3) psychotomimetic effects measured by the Positive and Negative Syndrome Scale and Clinician-Administered Dissociative Symptoms Scale. PF-04958242 significantly reduced ketamine-induced impairments in immediate recall and the 2-Back and spatial working memory tasks (CogState Battery), without significantly attenuating ketamine-induced psychotomimetic effects. There were no pharmacokinetic interactions between PF-04958242 and ketamine. Furthermore, PF-04958242 was well tolerated. 'High-impact' AMPAR potentiators like PF-04958242 may have a role in the treatment of the cognitive symptoms, but not the positive or negative symptoms, associated with schizophrenia. The excellent concordance between the preclinical (rat, NHP) and human studies with PF-04958242, and in silico modeling of AMPAR-NMDAR interactions in the hippocampus, highlights the translational value of this study.

Characterization of core-shell MOF particles by depth profiling experiments using on-line single particle mass spectrometry.

Materials with core-shell structures have distinct properties that lend themselves to a variety of potential applications. Characterization of small particle core-shell materials presents a unique analytical challenge. Herein, single particles of solid-state materials with core-shell structures were measured using on-line aerosol time-of-flight mass spectrometry (ATOFMS). Laser 'depth profiling' experiments verified the core-shell nature of two known core-shell particle configurations (<2 µm diameter) that possessed inverted, complimentary core-shell compositions (ZrO2@SiO2 versus SiO2@ZrO2). The average peak area ratios of Si and Zr ions were calculated to definitively show their core-shell composition. These ratio curves acted as a calibrant for an uncharacterized sample ­ a metal-organic framework (MOF) material surround by silica (UiO-66(Zr)@SiO2; UiO = University of Oslo). ATOFMS depth profiling was used to show that these particles did indeed exhibit a core-shell architecture. The results presented here show that ATOFMS can provide unique insights into core-shell solid-state materials with particle diameters between 0.2-3 µm.

Contrasting impacts of defoliation on root colonization by arbuscular mycorrhizal and dark septate endophytic fungi of Medicago sativa.

Individual plants typically interact with multiple mutualists and enemies simultaneously. Plant roots encounter both arbuscular mycorrhizal (AM) and dark septate endophytic (DSE) fungi, while the leaves are exposed to herbivores. AMF are usually beneficial symbionts, while the functional role of DSE is largely unknown. Leaf herbivory may have a negative effect on root symbiotic fungi due to decreased carbon availability. However, evidence for this is ambiguous and no inoculation-based experiment on joint effects of herbivory on AM and DSE has been done to date. We investigated how artificial defoliation impacts root colonization by AM (Glomus intraradices) and DSE (Phialocephala fortinii) fungi and growth of Medicago sativa host in a factorial laboratory experiment. Defoliation affected fungi differentially, causing a decrease in arbuscular colonization and a slight increase in DSE-type colonization. However, the presence of one fungal species had no effect on colonization by the other or on plant growth. Defoliation reduced plant biomass, with this effect independent of the fungal treatments. Inoculation by either fungal species reduced root/shoot ratios, with this effect independent of the defoliation treatments. These results suggest AM colonization is limited by host carbon availability, while DSE may benefit from root dieback or exudation associated with defoliation. Reductions in root allocation associated with fungal inoculation combined with a lack of effect of fungi on plant biomass suggest DSE and AMF may be functional equivalent to the plant within this study. Combined, our results indicate different controls of colonization, but no apparent functional consequences between AM and DSE association in plant roots in this experimental setup.

Suppression of stimulated Brillouin scattering in optical fibers using a linearly chirped diode laser.

The output of high power fiber amplifiers is typically limited by stimulated Brillouin scattering (SBS). An analysis of SBS with a chirped pump laser indicates that a chirp of 2.5 × 10(15) Hz/s could raise, by an order of magnitude, the SBS threshold of a 20-m fiber. A diode laser with a constant output power and a linear chirp of 5 × 10(15) Hz/s has been previously demonstrated. In a low-power proof-of-concept experiment, the threshold for SBS in a 6-km fiber is increased by a factor of 100 with a chirp of 5 × 10(14) Hz/s. A linear chirp will enable straightforward coherent combination of multiple fiber amplifiers, with electronic compensation of path length differences on the order of 0.2 m.

Guided entropy mode Rayleigh scattering in optical fibers.

Rayleigh scattering in optical fibers has the potential to degrade the performance of low-noise opto-electronic systems. In this Letter, we measure the Rayleigh gain spectrum of optical fibers. Our data show the gain bandwidth and the offset frequency of the Rayleigh gain peak. Both the gain bandwidth and the peak frequency are 3 orders of magnitude lower than the corresponding values for bulk silica. Our data suggest that the narrower gain bandwidth and frequency shift that we observe are due to guided entropy modes in the fiber. This effect is fundamental and will be present in any medium in which light is guided so that transverse intensity gradients exist.

Personal protective equipment training & lived experience for healthcare staff during COVID-19.

Objectives: To describe the lived experience of healthcare staff during the Coronavirus Disease 2019 (COVID-19) pandemic relating to the use of personal protective equipment (PPE) and investigate risks associated with PPE use, error mitigation and acceptability of mindfulness incorporation into PPE practice. Methods: A qualitative human factors' study at two Irish hospitals occurred in late 2020. Data was collected by semi-structured interview and included role description, pre-COVID-19 PPE experience, the impact of COVID-19 on lived experience, risks associated with PPE use, contributory factors to errors, error mitigation strategies and acceptability of incorporating mindfulness into PPE practice. Results: Of 45 participants, 23 of whom were nursing staff (51%), 34 (76%) had previously worn PPE and 25 (56%) used a buddy system. COVID-19 lived experience impacted most on social life/home-work interface (n=36, 80%). Nineteen staff (42%) described mental health impacts. The most cited risk concerned 'knowledge of procedures' (n=18, 40%). Contributory factors to PPE errors included time (n=15, 43%) and staffing pressures (n=10, 29%). Mitigation interventions included training/education (n=12, 40%). The majority (n=35, 78%) supported mindfulness integration into PPE practice. Conclusions: PPE training should address healthcare staff lived experiences and consider incorporation of mindfulness and key organisational factors contributing to safety.

Antimicrobial usage in an intensive care unit: a prospective analysis.

Antimicrobial therapies in the Intensive Care Unit (ICU) need to be appropriate in both their antimicrobial cover and duration. We performed a prospective observational study of admissions to our semi-closed ICU over a three-month period and recorded the indications for antimicrobial therapy, agents used, duration of use, changes in therapy and reasons for changes in therapy. A change in therapy was defined as the initiation or discontinuation of an antimicrobial agent. There were 51 patients admitted during the three-month study period and all received antimicrobial therapy. There were 135 changes in antimicrobial therapy. 89 (66%) were made by the ICU team and 32 (24%) were made by the primary team. Changes were made due to a deterioration or lack of clinical response in 41 (30%) cases, due to the completion of prescribed course in 36 (27%) cases, and in response to a sensitivity result in 25 (19%) cases. Prophylactic antibiotic courses (n=24) were of a duration greater than 24 hours in 15 (63%) instances. In conclusion, the majority of changes in antimicrobial therapy were not culture-based and the duration of surgical prophylaxis was in excess of current recommended guidelines.

Structure of the human CR1 gene. Molecular basis of the structural and quantitative polymorphisms and identification of a new CR1-like allele.

Structural and quantitative polymorphisms have been described in human CR1. In the former, the S allotype is larger than the F allotype by 40-50 kD, the size of a long homologous repeat (LHR). In the latter, homozygotes for a 7.4-kb Hind III fragment express fourfold more CR1 per erythrocyte than do homozygotes for the allelic 6.9-kb restriction fragment. The basis for these genomic polymorphisms has been determined by restriction mapping the entire S allele and part of the F allele. The S allele is 158 kb and contains 5 LHRs of 20-30 kb, designated -A, -B/A, -B, -C, and -D, respectively, 5' to 3'. Extensive homology was found among the LHRs in their restriction maps, exon organization, and the coding and noncoding sequences. The presence of LHR-B/A in the S allele but not in the F allele accounts for the longer transcripts and polypeptide associated with the former allotype. At least 42 exons are present in the S allele, with distinct exons for the leader sequence, the transmembrane and cytoplasmic regions and most of the SCRs comprising the extracellular portion of CR1. Consistent with the mapping of the ligand binding site to the first two SCRs in each LHR, the second SCRs in LHR-A, -B/A, -B, and -C are encoded by two exons, reflecting a specialized function for this unit. The allelic 7.4/6.9-kb Hind III fragments extend from the 3' region of LHR-C to LHR-D. The 6.9-kb restriction fragment is the result of a new Hind III site generated by a single base change in the intron between the exons encoding the second SCR of LHR-D. A second cluster of genomic clones has been identified by hybridization to CR1 probes. Although they contain regions of hybridization to the cDNA and genomic probes derived from CR1, these cannot be overlapped with the structural gene owing to their distinct restriction maps. Three genomic polymorphisms previously identified by CR1 cDNA probes map to this region. These additional clones may represent part of a duplicated allele located nearby within the CR1 locus.

The advancement of a new human factors report--'The Unique Report'--facilitating flight crew auditing of performance/operations as part of an airline's safety management system.

This paper presents the findings of research relating to the specification of a new human factors report, conducted as part of the work requirements for the Human Integration into the Lifecycle of Aviation Systems project, sponsored by the European Commission. Specifically, it describes the proposed concept for a unique report, which will form the basis for all operational and safety reports completed by flight crew. This includes all mandatory and optional reports. Critically, this form is central to the advancement of improved processes and technology tools, supporting airline performance management, safety management, organisational learning and knowledge integration/information-sharing activities. Specifically, this paper describes the background to the development of this reporting form, the logic and contents of this form and how reporting data will be made use of by airline personnel. This includes a description of the proposed intelligent planning process and the associated intelligent flight plan concept, which makes use of airline operational and safety analyses information. Primarily, this new reporting form has been developed in collaboration with a major Spanish airline. In addition, it has involved research with five other airlines. Overall, this has involved extensive field research, collaborative prototyping and evaluation of new reports/flight plan concepts and a number of evaluation activities. Participants have included both operational and management personnel, across different airline flight operations processes. Statement of Relevance: This paper presents the development of a reporting concept outlined through field research and collaborative prototyping within an airline. The resulting reporting function, embedded in the journey log compiled at the end of each flight, aims at enabling employees to audit the operations of the company they work for.

Multiple daily amphetamine administration: behavioral and neurochemical alterations.

In rats, multiple daily amphetamine injections (2.5 milligrams per kilogram of body weight, injected subcutaneously every 4 hours for 5 days) resulted in a progressive augmentation in response, characterized by a more rapid onset and an increased magnitude of stereotypy. By contrast, offset times of both the stereotypy and the poststereotypy hyperactivity periods were markedly shortened. When the animals were retested with the same dose of amphetamine 8 days after the long-term treatment was discontinued, the time of offset of the stereotypy and hyperactivity phases had recovered to values found with short-term amphetamine treatment, whereas the more rapid onset of stereotypy persisted. Brain monoamine and amphetamine concentrations and tyrosine hydroxylase activity were determined in comparably treated rats at times corresponding to the behavioral observations. The behavioral data indicate that enhanced responsiveness to amphetamine following its repeated administration may contribute to the development of amphetamine psychosis.

Multiple daily amphetamine administration: behavioral and neurochemical alterations.

In rats, multiple daily amphetamine injections (2.5 milligrams per kilogram of body weight, injected subcutaneously every 4 hours for 5 days) resulted in a progressive augmentation in response, characterized by a more rapid onset and an increased magnitude of stereotypy. By contrast, offset times of both the stereotypy and the poststereotypy hyperactivity periods were markedly shortened. When the animals were retested with the same dose of amphetamine 8 days after the long-term treatment was discontinued, the time of offset of the stereotypy and hyperactivity phases had recovered to values found with short-term amphetamine treatment, whereas the more rapid onset of stereotypy persisted. Brain monoamine and amphetamine concentrations and tyrosine hydroxylase activity were determined in comparably treated rats at times corresponding to the behavioral observations. The behavioral data indicate that enhanced responsiveness to amphetamine following its repeated administration may contribute to the development of amphetamine psychosis.

Direct high-temperature ohmic heating of metals as liquid pipes.

When a sufficiently high electric current is passed through a liquid metal, the electromagnetic pressure pinches off the liquid metal and interrupts the flow of current. For the first time the pinch effect has been overcome by use of centrifugal acceleration. By rotation of a pipe of liquid metal, tin or bismuth or their alloys, at sufficiently high speed, it can be heated electrically without intermission of the electric current. One may now heat liquid metallic substances, by resistive (ohmic) heating, to 5000 degrees K and perhaps higher temperatures.

A review and critical appraisal of measures of therapist-patient interactions in mental health settings.

OBJECTIVES: To assemble and to appraise critically the current literature on tests and measures of therapist-patient interactions in order to make recommendations for practice, training and research, and to establish benchmarks for standardisation, acceptability and routine use of such measures. DATA SOURCES: Major electronic databases (including PsycINFO) were searched from inception to 2002. REVIEW METHODS: A comprehensive conceptual map of the subject area of therapist-patient interactions was developed through data extraction from, and analysis of, studies selected from the literature searches. The results of these searches were assessed and appraised to produce a set of possible therapist-patient measures. These measures were then evaluated. RESULTS: The contextual map included the various concepts and domains that had been used in the context of the literature on therapist-patient interactions, and was used to guide the successive stages of the review. Three developmental processes were identified as necessary for the provision of an effective therapeutic relationship: 'establishing a relationship', 'developing a relationship' and 'maintaining a relationship'. Eighty-three therapist-patient measures having basic information on reliability and validity were identified for critical appraisal. The areas of the conceptual map that received most coverage (i.e. over 50% measures associated with them) were framework, therapist and patient engagement, roles, therapeutic techniques and threats to the relationship. These areas relate to the three key developmental processes outlined above. Of the 83 measures matching the content domain, 43 met the minimum standard. A total of 30 measures displayed adequate responsiveness or precision. None of the 43 measures that met the minimum standard was fully addressed in terms of acceptability and feasibility evidence. The majority of these measures had three or fewer components described. Therefore, out of a total of 83 measures matching the content domain, no measure could be said to have met an industry standard. CONCLUSIONS: The findings indicate that the therapist-patient interaction can be measured using a wide range of instruments of varying value. However, due care should be taken in ensuring that the measure is suitable for the context in which it is to be used. Following on from this work, it is suggested that specific research networks for the development of therapist-patient measures should be established, that research activity should prioritise investment in increasing the evidence base of existing measures rather than attempting to develop new ones, and that research activity should focus on improving these existing measures in terms of acceptability and feasibility issues.

Inhibition of c-Jun N-terminal kinase pathway attenuates cerebral vasospasm after experimental subarachnoid hemorrhage through the suppression of apoptosis.

BACKGROUND: Recent studies have demonstrated that apoptosis in cerebral arteries could play an essential role in cerebral vasospasm after subarachnoid hemorrhage (SAH) and that SP600125, an inhibitor of c-Jun N-terminal kinase (JNK) could suppress apoptosis. The present study examined whether SP600125 could reduce cerebral vasospasm through the suppression of apoptosis. METHOD: Fifteen dogs were assigned to 3 groups: control, SAH, and SAH + SP600125 (30 micromol/l). SAH was induced by the injection of autologous blood into the cisterna magna on day 0 and day 2. Angiograms were evaluated on day 0 and day 7. The activation of the JNK pathway and caspase-3 were also evaluated using Western blot. To determine the distribution, TUNEL staining and immunohistochemistry for phosphorylated c-jun and cleaved caspase-3 were performed. FINDINGS: Severe vasospasm was observed in the basilar artery of the SAH dogs. SP600125 reduced angiographic and morphological vasospasm and reduced the expression of cleaved caspase-3, thereby suppressing apoptosis. CONCLUSIONS: These results demonstrate that SP600125 attenuates cerebral vasospasm through the suppression of apoptosis, which may provide a novel therapeutic target for cerebral vasospasm.

Quality of life after infection in total joint replacement.

PURPOSE: To compare the health-related quality of life and functional outcomes of patients with and without periprosthetic infection after total joint replacement (TJR). METHODS: 62 uncomplicated TJRs and 34 TJRs complicated with deep infection were compared using a visual analogue scale for satisfaction, the Western Ontario and McMaster Universities Osteoarthritis Index, Assessment of Quality of Life, and Short Form-36. RESULTS: Patients with complicated TJR had significantly poorer satisfaction in outcome (p<0.0001) and disease-specific functional outcomes (p<0.0001). Six of the 8 health-related quality-of-life scores were also significantly poorer (p<0.05). These results persisted after controlling for age, sex, and follow-up period in a multiple regression analysis. CONCLUSION: Infection following TJR reduces patient satisfaction and seriously impairs functional health status and health-related quality of life. When hospitals are balancing the costs of preventative measures with the costs of treating infection in TJR, the effect on patients' quality of life must be considered. Our findings argue strongly for allocation of health care resources to minimise the occurrence of infection after TJR.