Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections.

BACKGROUND: Surgical-site infection (SSI) is associated with significant healthcare costs. To reduce the high rate of SSI among patients undergoing colorectal surgery at a cancer centre, a comprehensive care bundle was implemented and its efficacy tested. METHODS: A pragmatic study involving three phases (baseline, implementation and sustainability) was conducted on patients treated consecutively between 2013 and 2016. The intervention included 13 components related to: bowel preparation; oral and intravenous antibiotic selection and administration; skin preparation, disinfection and hygiene; maintenance of normothermia during surgery; and use of clean instruments for closure. SSI risk was evaluated by means of a preoperative calculator, and effectiveness was assessed using interrupted time-series regression. RESULTS: In a population with a mean BMI of 30 kg/m2 , diabetes mellitus in 17·5 per cent, and smoking history in 49·3 per cent, SSI rates declined from 11·0 to 4·1 per cent following implementation of the intervention bundle (P = 0·001). The greatest reductions in SSI rates occurred in patients at intermediate or high risk of SSI: from 10·3 to 4·7 per cent (P = 0·006) and from 19 to 2 per cent (P < 0·001) respectively. Wound care modifications were very different in the implementation phase (43·2 versus 24·9 per cent baseline), including use of an overlying surface vacuum dressing (17·2 from 1·4 per cent baseline) or leaving wounds partially open (13·2 from 6·7 per cent baseline). As a result, the biggest difference was in wound-related rather than organ-space SSI. The median length of hospital stay decreased from 7 (i.q.r. 5-10) to 6 (5-9) days (P = 0·002). The greatest reduction in hospital stay was seen in patients at high risk of SSI: from 8 to 6 days (P < 0·001). SSI rates remained low (4·5 per cent) in the sustainability phase. CONCLUSION: Meaningful reductions in SSI can be achieved by implementing a multidisciplinary care bundle at a hospital-wide level.

Contamination of headwater streams in the United Kingdom by oestrogenic hormones from livestock farms.

Most studies of hormonal activity in rivers have focused on inputs from sewage treatment works (STW), and their consequences for endocrine disruption in fish. It is possible that livestock is contributing to this hormonal activity in rivers. This study represents a search for evidence of steroid hormone contamination in streams associated with livestock farms. The majority of the 10 sites selected were streams running through dairy farms, although some examples of beef, sheep and pigs were included. Passive water samplers (Polar Organic Chemical Integrative Samplers-POCIS) were deployed up- (control) and down-stream of the farms for 3 to 10 weeks (mean=39 days) during the period November 2004 to January 2005. At one site, water samples were also taken automatically during rainfall events. All samples were solvent-extracted. Total oestrogenic activity in concentrates of the extracts was analysed using the Yeast Estrogen Screen (YES) calibrated against 17beta-oestradiol (E2), while oestrone (E1), E2 and 17alpha-ethinylestradiol (EE2) were analysed by liquid chromatography-mass spectrometry (LC-MS/MS). Stream water from the entirety of only one rainfall event was sampled directly, but this revealed background activity (E2 equivalents) of 0-0.3 ng/l, rising to a transient peak of 9.4 ng/l. Average oestrogenic activity at this site as estimated from the POCIS samplers was 1.8-2.7 ng E2 equiv./l. Estimated average oestrogenic activity across all sites (with one exception) lay in the range 0-26.5 ng E2 equiv./l (mean=2.0 ng/l; S.D.=5.1), based on the POCIS samples. The outlier was 292 ng/l, and this could not be specifically linked with livestock rearing. 92% of monitoring stations (at least one on each farm) contained some oestrogenic activity, and activity was higher at downstream sites in 50% of cases. Although no EE2 was detected analytically in any stream, E1 and E2 were almost ubiquitous, with E2 equivalents ranging from 0.04 to 3.6 ng/l across all sites. Furthermore, steroid concentrations downstream of livestock were higher than upstream in 60% of cases, more markedly so than for the YES data. In several cases, activity upstream was greater than downstream, and this tended to be associated with higher activity than could be accounted for by the hormone analyses. Both the YES and chemical analytical data suggest that fish in headwater streams on or near some livestock farms may be at risk of endocrine disruption.

Seasonality of the red blood cell stress response in rainbow trout (Oncorhynchus mykiss).

The beta-adrenergic stress response in red blood cells (RBCs) of rainbow trout shows seasonal changes in expression. We have explored the mechanisms underpinning this response by following, over a period of 27 months, changes in beta-adrenergic receptor (beta-AR) binding characteristics, beta-adrenergically stimulated RBC Na(+)/H(+) exchanger (betaNHE) activity, together with beta-AR and betaNHE mRNA levels and plasma steroid hormone and lactate levels. These parameters were measured at approximately monthly intervals in a single population of fish held under semi-natural conditions. Membrane-bound, high-affinity beta-ARs were present in RBCs at all sampling times, varying from 668+/-112 receptors cell(-1) to 2654+/-882 receptors cell(-1) (mean +/- S.E.M.; N=8). betaNHE activity, however, was reduced by 57% and 34% in December 1999 and February 2001, respectively, compared with an otherwise sustained influx that averaged 110.4+/-2.3 mmol l(-1) RBCs h(-1) (N=119). Only one reduction coincided with a spawning period but both were preceded by transient increases in circulating testosterone. betaNHE activity measured under standard conditions was not correlated with the number or affinity of beta-ARs nor with water temperature, but both beta-AR numbers and betaNHE activity were positively related to their respective mRNA levels (P=0.005 and 0.038, respectively). Pharmaceutical intervention in the transduction cascade linking the beta-AR and betaNHE failed to indicate any failure of the transduction elements in RBCs displaying low betaNHE activity. Similarly, we failed to demonstrate any link between seasonal cortisol fluctuations and seasonally reduced betaNHE activity. However, the betaNHE activity of age-separated RBC fractions showed that younger RBCs had a significantly higher betaNHE response than older RBCs, consistent with the seasonal reductions in betaNHE being linked to turnover of RBCs and erythropoiesis. Testosterone is known to induce erythropoiesis and we conclude that seasonal reductions in betaNHE are not caused by changes in beta-AR numbers but may be linked to testosterone-induced erythropoiesis.

High blood cortisol levels and low cortisol receptor affinity: is the chub, Leuciscus cephalus, a cortisol-resistant teleost?

In contrast to the relatively minor intra- and interspecies differences in blood cortisol levels reported for salmonid species, there is a more pronounced distinction between cortisol levels among the Salmonidae and the Cyprinidae, with both basal and stress-induced cortisol levels markedly higher in the latter. This study shows that in the chub, Leuciscus cephalus, a widely distributed European cyprinid, mean blood cortisol levels during stress (1500 ng mL(-1)) exceeded those reported for most other species of fish and, even in unstressed chub, cortisol levels (50-100 ng mL(-1)) were within the range known to cause immunosuppression, growth retardation, and reproductive dysfunction in salmonid fish. The chub appears to be atypical only with respect to plasma cortisol levels; the levels of plasma glucose and plasma lactate in unstressed and stressed chub are similar to those reported for other species. Plasma levels of 11-ketotestosterone in males and 17beta-estradiol in females are lower than those reported for salmonids but similar to those reported for other cyprinid species and display clear stress-induced reduction. Comparative analysis of the binding characteristics of the trout and chub gill cortisol receptor revealed that the total number of binding sites in gill tissue for each species was similar (B(max); approximately 50-100 fmol mg(-1) protein). However, the affinity of the binding site for cortisol displayed an eightfold difference between the species (rainbow trout: K(d) approximately 6 nM; chub: K(d) approximately 50 nM). Therefore, the potentially adverse effects of high circulating levels of cortisol found both at rest and under conditions of stress in chub may be offset by the lower affinity of the cortisol receptor, rather than the abundance of target-tissue receptor sites. This strategy is similar to that reported for some glucocorticoid-resistant rodents and New World primates.

Salmonid follicle-stimulating hormone (GtH I) mediates vitellogenic development of oocytes in the rainbow trout, Oncorhynchus mykiss.

Rainbow trout (Oncorhynchus mykiss) were subjected to unilateral ovariectomy (ULO) during early vitellogenesis to examine the endocrine responses mediating the recruitment and growth of oocytes in the secondary (vitellogenic) growth phase. ULO induced recruitment of a second population of primary oocytes into the vitellogenic growth phase that then grew at a faster rate than oocytes in the control fish. Seven days post-ULO, the concentration of plasma salmonid FSH (sFSH = GtH I) was significantly higher than in controls and was elevated for at least 54 days. Maximal concentrations of sFSH in ULO fish (Day 21 post-ULO) were twice (10 ng/ml) those in controls. The data show that sFSH plays a primary role in mediating vitellogenic development. After ULO, plasma concentrations of estradiol-17beta were significantly lower than in controls up until 21 days post-ULO. Thereafter, plasma concentrations of estradiol-17beta did not differ from those in controls. The changes in concentrations of plasma estradiol-17beta and sFSH in the ULO fish demonstrated that the secretion of sFSH is probably not controlled by negative feedback of estradiol-17beta alone; in fish, as in mammals, it is likely that intragonadal autocrine/paracrine factors, such as inhibin and activin, also participate in the regulation of sFSH secretion. Plasma concentrations of testosterone did not appear to differ between the control and ULO fish. The responses in the production of estradiol-17beta and testosterone indicate that the dynamics of sex steroid synthesis in ovarian follicles in ULO fish was different than in the ovaries of control fish.

Testosterone, 11-ketotestosterone, and estradiol-17 beta modify baseline and stress-induced interrenal and corticotropic activity in trout.

Estradiol-17 beta (E), 11-ketotestosterone (KT), and testosterone (T) were administered to immature rainbow and brown trout by implantation of steroid-containing cocoa butter pellets. This procedure elevated the levels of these hormones in the blood of the treated fish and had significant effects on plasma ACTH and cortisol levels in both unstressed and stressed rainbow trout and in stressed brown trout. E treatment significantly elevated resting levels of ACTH and cortisol and KT significantly suppressed resting ACTH levels in rainbow trout, although no effect of KT was noted on baseline cortisol levels. One hour of confinement stress increased ACTH levels in rainbow trout, but less so in T- and KT-implanted fish than in sham-implanted fish. A similar pattern was observed in stress-induced plasma cortisol levels where T and KT treatment of rainbow trout resulted in a more than 50% attenuation of plasma cortisol levels while E implantation significantly increased stress-induced plasma cortisol levels. In brown trout subjected to confinement stress for 96 hr, within 1 hr of the onset of confinement the stress-induced increase in plasma ACTH and plasma cortisol was significantly lower in T- and KT-implanted fish than in sham-implanted controls. However, these differences were not sustained at subsequent sample points during the 96-hr period of continuous confinement. Nonetheless, overall mean ACTH levels for the entire confinement period were significantly enhanced in E-implanted brown trout and significantly reduced in KT-implanted fish. Overall mean cortisol levels were significantly lower in T- and KT-implanted fish. The enhancement of stress responsiveness observed in E-treated immature fish was not observed during confinement stress in untreated mature female trout, with naturally high plasma E levels. However, untreated mature male trout displayed a significantly reduced cortisol response to confinement. It is suggested that gonadal steroids are involved in the regulation of both baseline and stress-induced activity of the pituitary-interrenal axis in salmonid fish.

Mechanisms controlling egg size and number in the rainbow trout, Oncorhynchus mykiss.

Female rainbow trout (Oncorhynchus mykiss) produce a single batch of eggs each year; synchronous growth of oocytes, all of which are ovulated at the same time, occurs in the two ovaries. To examine the regulatory mechanisms controlling egg size and number, virgin female rainbow trout were subjected to unilateral ovariectomy (ULO) during early vitellogenesis, and oocyte recruitment and growth in the remaining ovary were monitored. The study also set out to determine whether the presence of a second population of smaller oocytes in the maturing pool (induced by ULO) affected the timing of ovulation and/or the size of the eggs ovulated. Two months after ULO, there was no difference in the gonadosomatic index between ULO fish and controls. Compensatory ovarian hypertrophy resulted from the recruitment of a second population of primary oocytes into the vitellogenic pool. This population of smaller maturing oocytes in the ULO fish displayed growth rates up to twice those of the population of larger oocytes in the same ovary and of oocytes in controls. The growth rate of the population of larger oocytes in the ULO fish was not altered by the recruitment of a second maturing population. One month after ULO, fish had a lower concentration of plasma estradiol-17 beta than did controls; subsequently the concentrations of plasma estradiol-17 beta in the ULO and control groups were similar. After ULO, plasma levels of vitellogenin in the ULO fish did not differ from those in the control group throughout the study. At or close to ovulation, the fecundity of ULO fish was 75-80% that of controls. In the control group, oocytes appeared to reach a certain critical size before they were ovulated, and fish with higher fecundity ovulated later than their less fecund counterparts. ULO did not affect the timing of ovulation, and ULO fish ovulated eggs with a considerably greater size-range than did controls.

Stress-induced changes in the affinity and abundance of cytosolic cortisol-binding sites in the liver of rainbow trout, Oncorhynchus mykiss (Walbaum), are not accompanied by changes in measurable nuclear binding.

Plasma cortisol levels and the number (Nmax) and affinity (Kd) of specific hepatic cortisol-binding sites were determined in rainbow trout subjected to chronic confinement stress for 14 days. Confinement significantly elevated plasma cortisol levels to 47.3 ± 13.5 ng ml(-1) within 24h and although levels declined to 8.0 ± 3.0 ng ml(-1) after 14 days, they were significantly higher throughout than levels in unstressed control fish (< 2.0 ng ml(-1)). There was a 60% reduction in cytosolic Nmax in stressed fish during the first 24h of confinement (35.8 ± 7.9 cf. 129.0 ± 15.2 fmol mg(-1) protein), a decline which was sustained at 7 days after the onset of stress but, although numbers of binding sites in the liver of stressed fish were still lower than in unstressed fish, the difference was no longer significant after 14 days of confinement. There was an accompanying significant rise in the Kd of cortisol binding in stressed fish during confinement, from 4.0 ± 0.6 nM at time 0 to 8.4 ± 0.8 nM after 24 h confinement. This increment in Kd was sustained at a level significantly higher than in control fish throughout the 14 day confinement period, despite marked reductions in cortisol levels and increases in Nmax in stressed fish. Throughout the study, specific binding of cortisol could not be consistently detected in high-salt nuclear extracts from stressed or unstressed fish, suggesting either that high-affinity binding sites for cortisol were absent from these preparations, that receptors were present but unable to interact with ligand because they were occupied, or that receptors were present but not being extracted. These possibilities were investigated using a range of extraction procedures, by varying the temperature of incubation, by employing dexamethasone as ligand and by examining binding in purified, intact, nuclei. Estradiol was employed as a methodological control throughout and substantial amounts of specific estradiol binding were detected in all compartments and preparations. Specific cortisol-binding sites were detected in intact nuclei of both stressed and unstressed fish, at levels an order of magnitude lower than estradiol binding in the same preparations. These data demonstrate that activation of the pituitary-interrenal axis leads to significant changes in the nature of target-tissue binding of cortisol in rainbow trout, and reveal a clear difference in the subcellular distribution of binding-sites for estradiol and cortisol, which reflects the situation in mammalian tissues.

The effect of cortisol administration on hepatic and plasma estradiol-binding capacity in immature female rainbow trout (Oncorhynchus mykiss).

Implantation of a cortisol-containing pellet into the peritoneal cavity of immature female rainbow trout raised plasma cortisol levels within the range commonly observed in chronically stressed fish. In cortisol-implanted fish there was a significant decline in the concentration of hepatic estradiol-binding sites relative to sham-implanted controls. This consisted of a 35% drop in cytosolic binding sites and a 29% reduction in the number of nuclear estradiol-binding sites, by 4 weeks postimplantation. Plasma estradiol-binding capacity was also influenced by cortisol treatment. After 2 weeks there was a 33% increase in plasma estradiol-binding capacity of cortisol-implanted fish. Plasma estradiol levels were unaffected by cortisol implantation, suggesting that the effects of cortisol on estradiol-binding sites were not mediated by altering the rate of estradiol secretion. The results indicate a possible mechanism by which environmental stress may suppress vitellogenesis.

The effect of stress and exogenous cortisol on receptor-like binding of cortisol in the liver of rainbow trout, Oncorhynchus mykiss.

Cortisol binding has been identified in cytosols prepared from rainbow trout liver. Binding is of high affinity (kD = 5.1 +/- 0.2 nM, n = 23) low capacity (Nmax = 197 +/- 12 fmol mg-1 protein, n = 23), and high specificity, only dexamethasone, cortisol, and Ru38486 being efficient in displacing bound [3H]cortisol. Binding is not due to contamination by blood because plasma displayed no affinity for cortisol under the assay regime employed here and, although whole blood cytosol does specifically bind cortisol, the degree of contamination is demonstrably too low to account for the levels of binding detected in liver cytosol. No specific binding of [3H]cortisol could be detected in liver nuclear extracts, although the simultaneous assay for nuclear estradiol-binding sites was positive. Rainbow trout stressed by confinement displayed a significant reduction in cytosolic [3H]cortisol-binding capacity (with no concomitant detectable appearance of binding within nuclear extracts), 96-hr confinement eliciting a 40% depression in binding capacity relative to unstressed fish. The administration of cortisol via intraperitoneal implants also reduced, significantly, the number of hepatic-binding sites. The results are discussed with reference to anomalies in reported characteristics of teleost glucocorticoid receptors and the phenomenon of down-regulation observed in some mammalian systems.

Androgen binding in the skin of mature male brown trout, Salmo trutta L.

Specific, saturable binding of [3H]testosterone (Kd = 12.5 nM, Nmax = 1.1 pmol mg-1 protein) has been identified in skin cytosol of mature male brown trout. Binding with this affinity and capacity resembles more closely that observed in the plasma of mature male brown trout (Kd = 20.6 nM, Nmax = 6.6 pmol mg-1 protein) than that expected of a specific steroid receptor. However, the fraction of skin cytosol precipitating with 30% ammonium sulphate has a higher affinity for testosterone (Kd = 1.9 nM) and a lower capacity (Nmax = 96.3 fmol mg-1 protein) than does whole cytosol. Furthermore, the high-salt extract of crude skin nuclear pellet binds [3H]testosterone with affinity (Kd = 1.3 nM) and capacity (Nmax = 69.4 fmol mg-1 protein) similar to those of ammonium sulphate-precipitated cytosol. Specific binding in all three fractions of skin is abolished by treatment with proteolytic enzymes and a component of both cytosol and nuclear extract, which binds [3H]testosterone specifically, is retained on DNA-cellulose columns, eluting with high-salt buffer. Specifically bound [3H]testosterone is displaced most efficiently by testosterone. 5 alpha-dihydrotestosterone, estradiol-17 beta, and 11-ketotestosterone also compete but are 5- to 10-fold less potent. Consistent and reproducible binding of [3H]11-ketotestosterone to skin cytosol fractions or nuclear extract could not be demonstrated. It is concluded that testosterone binding with the above characteristics partially fulfills the criteria required of a putative steroid hormone receptor. The results are discussed with reference to the relative roles of testosterone and 11-ketotestosterone during sexual maturation.

Estrogen-binding sites in the liver of sexually mature male and female brown trout, Salmo trutta L.

Binding sites with characteristics conforming to those of a putative estrogen receptor have been identified in the liver of sexually mature male and female brown trout. [3H]Estradiol is bound with high affinity (kD in the 10(-9) M range) and limited capacity (less than 400 fmol mg-1 protein) to a proteinaceous moiety in liver cytosol. Binding is highly specific, only estradiol and estrone displace specifically bound [3H]estradiol. Cortisol, testosterone, 11-ketotestosterone, and 17 alpha, 20 beta-dihydroxyprogesterone are inactive. Labeled cytosol is retained on DNA-cellulose columns, eluting with 0.1 M NaCl. The liver of a sexually mature female brown trout contains more than twice as many binding sites as that of the male (168 +/- 15 fmol mg-1 protein cf. 69 +/- 4 fmol mg-1 protein), and no difference in kD is observed between males and females (2.6 +/- 0.2 10(-9) M and 2.9 +/- 0.3 10(-9) M, respectively). Plasma from both male and female brown trout was also found to bind [3H]estradiol, but with lower affinity (kD in 10(-8) M range) and higher capacity (4000-11,000 fmol mg-1 protein) and with less specificity. Estradiol, testosterone, and 11-ketotestosterone all displaced plasma-bound [3H]estradiol. It is concluded that cytosol and plasma binding of estradiol in brown trout are distinct, and indicative of the presence of an intracellular hepatic estrogen receptor and a plasma sex-steroid-binding protein.