Meta-analysis of the potential economic impact following introduction of absorbable antimicrobial sutures.

BACKGROUND: Despite several randomized trials, systematic reviews and meta-analyses that have demonstrated the effectiveness of antimicrobial (triclosan-coated or -impregnated) sutures (TCS), the clinical and economic impact of using these sutures compared with conventional non-antimicrobial-coated absorbable sutures (NCS) remains poorly documented. METHODS: An independent systematic review and meta-analysis of all published evidence from January 2005 to September 2016 comparing TCS with NCS was conducted. Surgical-site infection (SSI) was the primary outcome. The results of the meta-analysis were used in a decision-tree deterministic and stochastic cost model, using the National Health Service (NHS England)-based cost of inpatient admissions for infections and differential costs of TCS versus NCS. RESULTS: Thirty-four studies were included in the final assessment from an initial 163 identified citations; 20 of 34 studies were randomized, and 17 of 34 reported blinding of physicians and assessors. Using a random-effects model, the odds ratio for SSI in the TCS compared with NCS control groups was statistically significant (odds ratio 0·61, 95 per cent c.i. 0·52 to 0·73; P < 0·001). There was significant heterogeneity (I2 = 49 per cent). Using random-effects event estimates of SSI for TCS and NCS for each individual wound type, the mean savings per surgical procedure from using antimicrobial sutures were significant: £91·25 (90 per cent c.i. 49·62 to 142·76) (€105·09 (57·15 to 164·41); exchange rate 15 November 2016) across all wound types. CONCLUSION: The reviewed literature suggested that antimicrobial sutures may result in significant savings across various surgical wound types.

Does time to endoscopic sinus surgery impact outcomes in chronic rhinosinusitis? Retrospective analysis using the UK clinical practice research data.

BACKGROUND: Patients with chronic rhinosinusitis (CRS) refractory to medical management may elect endoscopic sinus surgery (ESS). Recent data showed that clinical outcomes of patients treated earlier outperformed those of patients treated later in the disease continuum. In this study, CRS-related healthcare utilisation of patients treated early versus late was analysed using the UK-based Clinical Practice Research Database. METHODS: Two cohorts ("Early Cohort": ESS within 12 months of first CRS diagnosis, versus "Late Cohort": ≥ 5 years from diagnosis to ESS) were matched for age, gender, asthma, polyposis. Healthcare needs related to CRS were analysed post-operatively for 5 years. RESULTS: Patients in the Late cohort used significantly more CRS-related care than patients in the Early cohort visits and 0.54 prescriptions per patient per year. A sub-analysis of patients with and without asthma indicated that patients in the Late cohort without asthma had healthcare needs equivalent to patients in the Early cohort with asthma. CONCLUSION: Delayed surgical intervention for CRS is associated with greater post-operative healthcare needs than ESS within 12 months of first CRS diagnosis.

Use of a biomimetic strategy to engineer bone.

Engineering trabecular-like, three-dimensional bone tissue throughout biodegradable polymer scaffolds is a significant challenge. Using a novel processing technique, we have created a biodegradable scaffold with geometry similar to that of trabecular bone. When seeded with bone-marrow cells, new bone tissue, the geometry of which reflected that of the scaffold, was evident throughout the scaffold volume and to a depth of 10 mm. Preseeded scaffolds implanted in non-healing rabbit segmental bone defects allowed new functional bone formation and bony union to be achieved throughout the defects within 8 weeks. This marks the first report of successful three-dimensional bone-tissue engineering repair using autologous marrow cells without the use of supplementary growth factors. We attribute our success to the novel scaffold morphology.

Postoperative infections in craniofacial reconstructive procedures.

The rate of, and possible risk factors for, postoperative craniofacial infection is unclear. To investigate this problem, we reviewed 349 cases of craniofacial skeletal procedures performed from 1996 to 1999 at our institution. Infection rate was determined and correlated with the use of implants, operative site, and cause of deformity. The inclusion criteria consisted of all procedures requiring autologous or prosthetic implantation in craniofacial skeletal sites, as well as all procedures involving bone or cartilage resection, osteotomies, debridement, reduction and/or fixation. Procedures that did not involve bone or cartilage surgery were excluded. The criteria for diagnosis of infection included clinical confirmation and one or more of 1) intravenous or oral antibiotic treatment outside of the prophylactic surgical regimen; 2) surgical intervention for drainage, irrigation, and or debridement; and 3) microbiological confirmation. Among the 280 surgical cases that fit the inclusion criteria and had complete records, there were 23 cases of postoperative infection (8.2%). The most common site for postoperative infection was the mandible (infection rate = 16.7%). Multiple logistic regression analysis revealed gunshot wound to be the most significant predictor of postoperative infection. Additionally, porous polyethylene implantation through a transoral route was correlated with a significant risk of postoperative infection.

Optimizing the sterilization of PLGA scaffolds for use in tissue engineering.

There are few suitable techniques available to sterilize biodegradable polyester three-dimensional tissue engineering scaffolds because they are susceptible to degradation and/or morphological degeneration by high temperature and pressure. We used a novel polyllactide-co-glycolide) scaffold (Osteofoam) to determine the optimal sterilization procedure--i.e. a sterile product with minimal degradation and deformation. Initial studies, found that an argon plasma created at 100W for 4min was optimal for sterilizing Osteofoam scaffolds without affecting their morphology. The RFGD plasma sterilization method was compared to two well-established techniques--ethylene oxide (ETO) and gamma-irradiation (gamma)--which were in turn compared to disinfection in 70% ethanol. Disinfection in 70% ethanol serves as a useful control because it affects neither the morphology nor the molecular weight of the polymer: yet, ethanol is unsuitable as a sterilization method because it does not adequately eliminate hydrophilic viruses and bacterial spores. The three sterilization techniques, ETO, gamma and RFGD plasma, were compared in terms of their immediate and long-term effects on the dimensions, morphology, molecular weight and degradation profile of the scaffolds. Scaffolds shrank to 60% of their initial volume after ETO sterilization whereas their molecular weight (Mw) decreased by approximately 50% after gamma-irradiation. Thus, both ETO and gamma-irradiation posed immediate problems as sterilization techniques for 3-D biodegradable polyester scaffolds. During the in vitro degradation study, all sterilized samples showed advanced morphological and volume changes over time relative to ethanol (EtOH) disinfected samples, with the greatest changes observed for gamma-irradiated samples. ETO, RFGD plasma sterilized and EtOH disinfected samples showed similar changes in Mw and mass over the 8-week time frame. Overall, of the three sterilization techniques studied, RFGD plasma was the best.

Engineering three-dimensional bone tissue in vitro using biodegradable scaffolds: investigating initial cell-seeding density and culture period.

New three-dimensional (3D) scaffolds for bone tissue engineering have been developed throughout which bone cells grow, differentiate, and produce mineralized matrix. In this study, the percentage of cells anchoring to our polymer scaffolds as a function of initial cell seeding density was established; we then investigated bone tissue formation throughout our scaffolds as a function of initial cell seeding density and time in culture. Initial cell seeding densities ranging from 0.5 to 10 x 10(6) cells/cm(3) were seeded onto 3D scaffolds. After 1 h in culture, we determined that 25% of initial seeded cells had adhered to the scaffolds in static culture conditions. The cell-seeded scaffolds remained in culture for 3 and 6 weeks, to investigate the effect of initial cell seeding density on bone tissue formation in vitro. Further cultures using 1 x 10(6) cells/cm(3) were maintained for 1 h and 1, 2, 4, and 6 weeks to study bone tissue formation as a function of culture period. After 3 and 6 weeks in culture, scaffolds seeded with 1 x 10(6) cells/cm(3) showed similar tissue formation as those seeded with higher initial cell seeding densities. When initial cell seeding densities of 1 x 10(6) cells/cm(3) were used, osteocalcin immunolabeling indicative of osteoblast differentiation was seen throughout the scaffolds after only 2 weeks of culture. Von Kossa and tetracycline labeling, indicative of mineralization, occurred after 3 weeks. These results demonstrated that differentiated bone tissue was formed throughout 3D scaffolds after 2 weeks in culture using an optimized initial cell density, whereas mineralization of the tissue only occurred after 3 weeks. Furthermore, after 6 weeks in culture, newly formed bone tissue had replaced degrading polymer.

Processing cell-seeded polyester scaffolds for histology.

Biodegradable 3-dimensional scaffolds of various morphologies are currently being developed for tissue engineering. Poly(lactide-co-glycolide)s (PLGAs) of various lactide to glycolide ratios are frequently used for such applications. Tissue engineering involves an in vitro stage during which cells are seeded onto scaffolds and allowed to settle and/or grow for various time periods. To assess cell distribution and/or tissue formation throughout the scaffolds during this in vitro stage, techniques such as confocal microscopy and magnetic resonance imaging have been applied. However, such cultured scaffolds have been refractory to histological evaluation because of numerous technical difficulties. We describe a method to prepare histological sections of cell cultured PLGA scaffolds for tissue engineering. The technique involves in situ labeling of cultured scaffolds, infiltration of the scaffolds with a 10% poly(vinyl alcohol) solution under a low vacuum, and cryosectioning of samples onto acid-treated glass coverslips. Sections obtained with this technique show cell distribution and cell-tissue morphology on the pore wall structures of entire centimeter-thick scaffolds. This rapid and easy technique allows for fast evaluation of tissues grown on biodegradable scaffolds.

Closed-unit staffing speaks volumes.

Providing the right staff mix for a highly fluctuating patient census challenges most nurse managers. Read how one hospital implemented a closed-unit staffing model to better serve its patients and control staffing costs.

In vitro degradation of a novel poly(lactide-co-glycolide) 75/25 foam.

Macroporous poly(lactide-co-glycolide) PLGA 75/25 foams were prepared for application in bone tissue engineering. Their in vitro degradation behaviour was followed over a 30 week period at 37 degrees C and at one of three pHs: (1) pH 5.0, which mimics the acidic environment produced by activated macrophages, (2) pH 7.4, which reproduces normal physiological conditions and (3) an intermediate pH 6.4. The degradation of the PLGA 75/25 foams was studied by measuring changes in mass, molecular weight and morphology. The degradation profile of foams maintained at pH 5.0, 6.4 and 7.4 was similar until week 16, after which foams maintained at pH 6.4 and 7.4 had comparable degradation patterns whereas foams maintained at pH 5.0 degraded faster. For example, mass loss was less than 3% for foams maintained at all three pHs until week 16; however, by week 30, foams maintained at pH 6.4 and 7.4 had lost 30% of their mass whereas foams maintained at pH 5.0 had lost 90% of their mass. Foams maintained at pH 6.4 and 7.4 showed a similar constant decrease in molecular weight over the entire degradation study. Foams maintained at pH 5.0 had a similar rate of molecular weight loss as those maintained at pH 6.4 and 7.4 until week 16, after which the rate of molecular weight loss of foams maintained at pH 5.0 was accelerated. The morphology of the foams maintained at pH 6.4 and 7.4 was unchanged for 25 weeks. Foams maintained at pH 5.0 collapsed after week 18. Thus the PLGA 75/25 foams, described herein, maintained their 3-D morphology at physiological pH for over 6 months, which is an important feature for tissue engineering applications.

Coexpression of P2X2 and P2X3 receptor subunits can account for ATP-gated currents in sensory neurons.

Cation-selective P2X receptor channels were first described in sensory neurons where they are important for primary afferent neurotransmission and nociception. Here we report the cloning of a complementary DNA (P2X3) from rat dorsal root ganglia that had properties dissimilar to those of sensory neurons. We also found RNA for (P2X1)(ref. 7), (P2X2)(ref. 8) and P2X4 (ref. 9) in sensory neurons; channels expressed from individual cDNAs did not reproduce those of sensory ganglia. Coexpression of P2X3 with P2X2, but not other combinations, yielded ATP-activated currents that closely resembled those in sensory neurons. These properties could not be accounted for by addition of the two sets of channels, indicating that a new channel had formed by subunit heteropolymerization. Although in some tissues responses to ATP can be accounted for by homomeric channels, our results indicate that ATP-gated channels of sensory neurons may form by a specific heteropolymerization of P2X receptor subunits.