Barriers and facilitators for surgical site infection surveillance for adult cardiac surgery in a high-income setting: an in-depth exploration.

BACKGROUND: Surgical site infection (SSI) surveillance aims to facilitate a reduction in SSIs through identifying infection rates, benchmarking, triggering clinical review and instituting infection control measures. Participation in surveillance is, however, variable suggesting opportunities to improve wider adoption. AIM: To gain an in-depth understanding of the barriers and facilitators for SSI surveillance in a high-income European setting. METHODS: Key informant interviews with 16 surveillance staff, infection prevention staff, nurses and surgeons from nine cardiac hospitals in England. Data were analysed thematically. FINDINGS: SSI surveillance was reported to be resource intensive. Barriers to surveillance included challenges associated with data collection: data being located in numerous places, multiple SSI data reporting schemes, difficulty in finding denominator data, lack of interface between computerized systems, 'labour intensive' or 'antiquated' methods to collect data (e.g., using postal systems for patient questionnaires). Additional reported concerns included: relevance of definitions, perceived variability in data reporting, lack of surgeon engagement, unsupportive managers, low priority of SSIs among staff, and a 'blame culture' around high SSI rates. Facilitators were increased resources, better use of digital technologies (e.g., remote digital wound monitoring), integrating surveillance within routine clinical work, having champions, mandating surveillance, ensuring a closer relationship between surveillance and improved patient outcomes, increasing the focus on post-discharge surveillance, and integration with primary care data. CONCLUSION: Using novel interviews with 'front-line' staff, identified opportunities for improving participation in SSI surveillance. Translating these findings into action will increase surveillance activity and bring patient safety benefits to a larger pool of surgical patients.

Randomised controlled trial to evaluate a physiotherapy-led functional exercise programme after total hip replacement.

BACKGROUND: At present, there is an insufficient evidence base to evaluate the effectiveness of physiotherapy following total hip replacement (THR). This study evaluated the effectiveness of a physiotherapy-supervised functional exercise programme between 12 and 18 weeks following THR. These time-points coincide with increased functional demand in patients. DESIGN: Adequately powered assessor-blinded randomised controlled trial. SETTING: Patients were recruited at a pre-operative assessment clinic and randomised following surgery. PARTICIPANTS: Sixty-three subjects were randomised to either the usual care group (control, n=31) or the functional exercise+usual care group (n=32). INTERVENTIONS: Patients in the functional exercise group attended a physiotherapy-supervised functional exercise class twice weekly from 12 to 18 weeks following THR. Patients in the control group followed the usual care protocol with no exercise intervention. MAIN OUTCOME MEASUREMENT: The main outcome measurement tool was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, and the secondary outcomes included walking speed, hip abduction dynamometry, Short Form 12 physical and mental health scores, and visual analogue pain scale score. RESULTS: At 18 weeks post surgery, WOMAC function and walking speed improved significantly more in the functional exercise group [mean difference -4.0, 95% confidence interval (CI) -7.0 to 1.0 (P<0.01); mean difference 21.9m, 95% CI 0.60 to 43.3 (P<0.04)] than the control group, but there was no significant difference in hip abductor strength. CONCLUSION: This study demonstrated that patients who undertake a physiotherapy-led functional exercise programme between 12 and 18 weeks after THR may gain significant functional improvement compared with patients receiving usual care. Clinical trial registration number NCT01683201.

Impact of obesity on the risk of wound infection following surgery: results from a nationwide prospective multicentre cohort study in England.

We sought to assess the impact of body mass index on the risk of surgical site infection in a prospective cohort study of 206 National Health Service (NHS) hospitals in England between 2007 and 2011. Body mass index was available for 159,720 of 350,089 operations among patients undergoing abdominal hysterectomy, coronary artery bypass graft, hip replacement, knee replacement, or large-bowel surgery. Among these patients, the risk of surgical site infection ranged from 0.65% for knee replacement to 11.04% for large-bowel surgery. Overall, 127,512 (79.8%) patients were overweight or obese (body mass index of ≥25 kg/m(2)). Obesity was associated with a 1.1-fold to 4.4-fold increase in the adjusted odds of developing surgical site infection as compared with normal weight, depending on the type of surgery. The population-attributable fraction (PAF) for body mass index was greatest in overweight (body mass index of 25.0-29.9 kg/m(2)) patients undergoing coronary artery bypass graft, accounting for 15% of their overall risk of surgical site infection (PAF 0.15; 95% CI 0.09-0.22). Being overweight or obese substantially increased the likelihood of patients developing surgical site infection. Given the increasingly high proportion of the surgical population who are overweight, this is likely to place a considerable additional burden on the NHS. Strategies for mitigating this excess risk need to be found.

Economic evaluation of robot-assisted hysterectomy: a cost-minimisation analysis.

OBJECTIVE: The aim of this study was to carry out an economic evaluation of robot-assisted hysterectomy compared with the current standard of care in Ireland. DESIGN: Cost-minimisation analysis of robot-assisted hysterectomy compared with a combination of traditional open and conventional laparoscopic surgery. SETTING: The publicly funded healthcare system in Ireland. POPULATION: The target population was women requiring hysterectomy that could be completed using robot-assisted surgery. METHODS: A simulation-based economic evaluation model including data derived from a systematic review and local databases was used to estimate surgical costs. MAIN OUTCOME MEASURES: Incremental cost of robot-assisted surgery compared to current routine care. RESULTS: The incremental cost of robot-assisted hysterectomy is an estimated €3291 (95% confidence interval €2509-€4183) more than the existing mix of open and traditional laparoscopic surgery. The additional cost of robot-assisted surgery is primarily driven by the increased cost of surgical equipment, the robot, maintenance of the robot, and the cost of theatre staff due to longer operative times. The only significant factor reducing the cost of surgery is a shorter hospital stay relative to open surgery. CONCLUSIONS: Robot-assisted hysterectomy is more costly than the current mix of open and traditional laparoscopic surgery. Without longer-term or functional outcome data, the additional expense associated with robot-assisted hysterectomy may not be justified in a budget-constrained health system.

Clinical characteristics of ovarian cancer classified by BRCA1, BRCA2, and RAD51C status.

We evaluated homologous recombination deficient (HRD) phenotypes in epithelial ovarian cancer (EOC) considering BRCA1, BRCA2, and RAD51C in a large well-annotated patient set. We evaluated EOC patients for germline deleterious mutations (n = 899), somatic mutations (n = 279) and epigenetic alterations (n = 482) in these genes using NGS and genome-wide methylation arrays. Deleterious germline mutations were identified in 32 (3.6%) patients for BRCA1, in 28 (3.1%) for BRCA2 and in 26 (2.9%) for RAD51C. Ten somatically sequenced patients had deleterious alterations, six (2.1%) in BRCA1 and four (1.4%) in BRCA2. Fifty two patients (10.8%) had methylated BRCA1 or RAD51C. HRD patients with germline or somatic alterations in any gene were more likely to be high grade serous, have an earlier diagnosis age and have ovarian and/or breast cancer family history. The HRD phenotype was most common in high grade serous EOC. Identification of EOC patients with an HRD phenotype may help tailor specific therapies.

Alveolar rhabdomyosarcoma originating between the fourth and fifth metatarsal--case report and literature review.

We report a case of alveolar rhabdomyosarcoma arising between the fourth and fifth metatarsal. A 13-year-old boy presented to outpatients with a history of pain and swelling in the lateral aspect of his left forefoot. Plain radiographs and MRI showed a soft tissue mass displacing the fourth metatarsal. Percutaneous biopsy revealed an alveolar rhabdomyosarcoma. Staging scans showed advanced metastatic disease. The patient was treated with chemotherapy. This highly malignant lesion remains challenging to diagnose, and difficult to treat successfully.

The "silver-haired" general medical services patient. Clinical activity of the non-means tested over-70's during their first six months.

The objective was to examine the impact on general practice clinical activity of the granting of medical cards to all patients over 70 years of age on 01.07.01 under the General Medical Services (GMS) scheme. Retrospective case-control study. Chart review of 50 "new GMS" patients who received medical cards on 01.07.01 compared with 50 "old GMS" patients with means tested medical cards on this date. Single-handed mixed urban/rural general practice in Ireland. 1. Attendance rates. 2. Health status as measured by total number of chronic diseases, prevalence of hypertension, diabetes and cardiovascular disease. 3. Quality of preventive care comprising influenza and pneumococcal vaccine uptake rates; hypertension control; hyperlipidaemia control; level of screening activity for hypertension, diabetes, hyperlipidaemia, prostate specific antigen (among men) and smoking behaviour. Comparisons were made both before and after free GMS care for all between the "old GMS" and "new GMS" patient groups. Behaviour of the "new GMS" group was also compared, both before and after GMS eligibility. Prior to universal eligbility "old GMS" patients attended more often (p=0.0002), had more documented chronic illness (p=0.0002), consumed more medications (p=0.0002), were more likely to be diagnosed hypertensive (p=0.0336) and to have prostate specific antigen (PSA) measurement (men only) (p=0.048) than "new GMS" patients. Within the first 6 months of free GMS care for all, the "new GMS" patients attended significantly more often than before with the percentage of high consulters increasing from 24% to 52% (p=0.0039), took more medications (from 1.72 to 2.2), showed improvement in all quality of care parameters (with the exception of PSA screening which remained static) and had improved attendance for influenza 40% to 62% (p=0.0277) and pneumococcal vaccines 2% to 26% (p=0.00054). More "new GMS" patients were diagnosed as hypertensive (24% to 38%) to a prevalence no longer significantly different from the "old GMS" group. Free general practice care has impacted positively on this "new GMS" patient group of over 70's. Our data suggests that the low consultation rate of this group when fee paying may have resulted in less exposure to practice screening activities. The apparent better health status among this group may in fact be a façade masking undiagnosed chronic disease, notably hypertension.

A stereotactic method for the three-dimensional registration of multi-modality biologic images in animals: NMR, PET, histology, and autoradiography.

The objective of this work was to develop and then validate a stereotactic fiduciary marker system for tumor xenografts in rodents which could be used to co-register magnetic resonance imaging (MRI), PET, tissue histology, autoradiography, and measurements from physiologic probes. A Teflon fiduciary template has been designed which allows the precise insertion of small hollow Teflon rods (0.71 mm diameter) into a tumor. These rods can be visualized by MRI and PET as well as by histology and autoradiography on tissue sections. The methodology has been applied and tested on a rigid phantom, on tissue phantom material, and finally on tumor bearing mice. Image registration has been performed between the MRI and PET images for the rigid Teflon phantom and among MRI, digitized microscopy images of tissue histology, and autoradiograms for both tissue phantom and tumor-bearing mice. A registration accuracy, expressed as the average Euclidean distance between the centers of three fiduciary markers among the registered image sets, of 0.2 +/- 0.06 mm was achieved between MRI and microPET image sets of a rigid Teflon phantom. The fiduciary template allows digitized tissue sections to be co-registered with three-dimensional MRI images with an average accuracy of 0.21 and 0.25 mm for the tissue phantoms and tumor xenografts, respectively. Between histology and autoradiograms, it was 0.19 and 0.21 mm for tissue phantoms and tumor xenografts, respectively. The fiduciary marker system provides a coordinate system with which to correlate information from multiple image types, on a voxel-by-voxel basis, with sub-millimeter accuracy--even among imaging modalities with widely disparate spatial resolution and in the absence of identifiable anatomic landmarks.

Ion-molecule reactions of gas-phase chromium oxyanions. CrxOyHz-+ O2.

Chromium oxyanions, Cr(x)O(y)H(z)(-), were generated in the gas-phase using a quadrupole ion trap secondary ion mass spectrometer (IT-SIMS), where they were reacted with O(2). Only CrO(2)(-) of the Cr(1)O(y)H(z)(-) envelope was observed to react with oxygen, producing primarily CrO(3)(-). The rate constant for the reaction of CrO(2)(-) with O(2) was approximately 38% of the Langevin collision constant at 310 K. CrO(3)(-), CrO(4)(-), and CrO(4)H(-) were unreactive with O(2) in the ion trap. In contrast, Cr(2)O(4)(-) was observed to react with O(2) producing CrO(3)(-) + CrO(3) via oxidative degradation at a rate that was approximately 15% efficient. The presence of background water facilitated the reaction of Cr(2)O(4)(-) + H(2)O to form Cr(2)O(5)H(2)(-); the hydrated product ion Cr(2)O(5)H(2)(-) reacted with O(2) to form Cr(2)O(6)(-) (with concurrent elimination of H(2)O) at a rate that was 6% efficient. Cr(2)O(5)(-) also reacted with O(2) to form Cr(2)O(7)(-) (4% efficient) and Cr(2)O(6)(-) + O (2% efficient); these reactions proceeded in parallel. By comparison, Cr(2)O(6)(-) was unreactive with O(2), and in fact, no further O(2) addition could be observed for any of the Cr(2)O(6)H(z)(-) anions. Generalizing, Cr(x)O(y)H(z)(-) species that have low coordinate, low oxidation state metal centers are susceptible to O(2) oxidation. However, when the metal coordination is >3, or when the formal oxidation state is > or =5, reactivity stops.

Amelanotic subungual melanoma mimicking pyogenic granuloma in the hand.

Between six and eight per cent of cases of malignant melanoma lack pigmentation on macroscopic examination, making accurate early diagnosis difficult. Delays in diagnosis and misdiagnosis are common in cases of subungual melanoma. We report a patient with an amelanotic subungual malignant melanoma who presented with a lesion that closely resembled a pyogenic granuloma. Since amelanotic melanoma usually presents as a vascular or ulcerating nodule, it should be considered in the differential diagnosis of a wide range of superficial lesions that occur in the hand.

Intramedullary hip screw versus sliding hip screw for unstable intertrochanteric femoral fractures in the elderly.

We report a randomised, prospective study comparing a standard sliding hip screw and the intramedullary hip screw for the treatment of unstable intertrochanteric fractures in the elderly. One hundred and two patients were randomised on admission to two treatment groups. Fifty-two patients were treated with a compression hip screw (CHS), and fifty had intramedullary fixation with an intramedullary hip screw (IMHS). Patients were followed for 1 year and had a clinical and radiological review at 3, 6 and 12 months. The mean duration of operation and fluoroscopy screening time was significantly greater for insertion of the intramedullary hip screw. There was no difference between the groups with regard to transfusion requirements or time to mobilise after surgery. There were two technical complications in the CHS group and three in the IMHS group. There was no significant difference between the two groups in radiological or functional outcome at 12 months. It remains to be shown whether the theoretical advantages of intramedullary fixation of extracapsular hip fractures bring a significant improvement in eventual outcome.

Inappropriate medical management of spinal epidural abscess.

A 67 year old man with longstanding rheumatoid disease was referred to the regional spinal surgery unit with acute onset of paraparesis due to an extensive spinal epidural abscess of the lumbar spine. Ten months previously, he had started antibiotic treatment at another hospital for an epidural abscess arising at the level of the L2-3 disc space. Despite completing seven months of medical treatment with appropriate antibiotics, he had a recrudescence of acute back pain shortly after restarting methotrexate treatment. Urgent anterior spinal decompression with excision of the necrotic vertebral bodies of L1-3 was performed. The indications for the surgical management of spinal epidural abscess are reviewed.

Ophthalmoscopic contact lenses for transpupillary thermotherapy.

Ophthalmoscopic contact lenses for transpupillary thermotherapy (TTT) must provide effective visualization of retinal treatment sites and transmission of infrared diode laser radiation. Selection and proper use of retinal laser lenses requires knowledge of their lateral magnification, laser beam magnification factor, field of view and resolution. Optical performance is analyzed for Goldmann-type lenses and a series of inverted image lenses of differing magnification. Goldmann lenses have the highest resolution, but inverted image lenses of comparable magnification have 2.5 times or more their field of view. Inverted image lenses of similar magnification can differ in resolution. They require 2-4% more incident laser power to produce the same retinal irradiance as a Goldmann lens, but this difference is small in comparison to other clinical variables. Tilting an ophthalmoscopic contact lens up to 15 degrees causes little distortion in the circularity of the retinal spot formed by a laser beam or difference in retinal irradiance across the spot. Inverted image lenses produce higher anterior segment irradiances than Goldmann-type lenses, but anterior segment injuries are less likely in TTT than conventional visible light, short-pulse retinal photocoagulation because of the comparatively low irradiances used in TTT and the decreased absorption of diode laser infrared radiation in ocular media and melanin.

The tolerability of efavirenz after nevirapine-related adverse events.

Eight patients who were infected with human immunodeficiency virus, and who had each sustained an adverse drug reaction while following a regimen including nevirapine, were switched to a regimen including efavirenz. None of the patients experienced adverse events identical to that which necessitated discontinuation of nevirapine. This study demonstrates that adverse events related to nevirapine are not a class-specific effect.