Clinician-led surgical site infection surveillance of orthopaedic procedures: a UK multi-centre pilot study.

The UK Department of Health established the Healthcare-associated Infection (HAI) Surveillance Steering Group in 2000 to develop a strategy for implementing a national programme for HAI surveillance in National Health Service trusts. A subgroup of this committee examined the surveillance of surgical site infections following orthopaedic surgery. This group oversaw a pilot scheme that was set up in 12 hospitals around the UK to explore the feasibility of implementing a system of surveillance that engaged clinical staff in its operation, provided a process for continuous data collection and could be maintained as part of routine hospital operation over time. A minimum data set was established by the subgroup, and Centers for Disease Control and Prevention (CDC) definitions of infection were used. By March 2003, the surveillance had been undertaken continuously in 11 sites for one to two years, depending on the date of implementation. Only one hospital had ceased data collection. The information was collected mainly by clinical staff, with support and co-ordination usually provided by infection control teams. Data on more than 5400 procedures were available for analysis for four core procedures: arthroplasty of the hip and knee; hemi-arthroplasty of the hip; and internal fixation of trochanteric fractures of the femur. The data set permitted the calculation of risk-adjusted rates, allowing comparisons between hospitals and within a hospital over time. The methodology enhanced clinical ownership of the surveillance process, re-inforced infection control as the responsibility of all staff, and provided timely feedback and local data analysis. The use of CDC definitions permitted international comparisons of the data.

Suprabasal expression of the human papillomavirus type 16 oncoproteins in mouse epidermis alters expression of cell cycle regulatory proteins.

Human papillomavirus (HPV) survives by reactivating DNA replication in post-mitotic cells. In the present study, we describe a mouse model of HPV-dependent disease. In these mice, DNA synthesis is activated in suprabasal keratinocytes, leading to acanthosis, parakeratosis and enhanced desquamation. The full-length E6/E7 transcript and two alternately spliced products are produced and in most lines the predominant product is E6*. In the present study, we examine the effects of E6/E7 on cell cycle regulatory protein expression. E6/E7 expression in mouse epidermis is correlated with increased levels of the p53, p21, p27, cdk2, cdk4, cdk6, cyclin D1 and cyclin E regulatory proteins. Hyperproliferation is also observed in the buccal mucosa and the tongue epithelia of E6/E7 mice, and p53 levels are markedly increased in these epithelia. These results suggest that the major changes in cell cycle regulatory protein expression are in response to the presence of E7 and that E6 has a lesser impact.

Cardiovascular effects of short-term growth hormone hypersecretion.

Many studies have shown that acromegaly has relevant effects on cardiovascular system, but few data are available regarding the effects of short-term acromegaly on heart morphology and function. These data would help to clarify the natural history of acromegalic disease and could provide new insight into the mechanisms of GH action on the human heart. Therefore, we studied by Doppler echocardiography a group of 10 young subjects strictly selected as having short-term (<5 yr) uncomplicated acromegaly. The results of this study have shown that shortterm acromegaly is characterized by significantly increased left ventricular mass (P<0.005), with normal relative wall thickness, associated with Doppler indices of diastolic function in the normal range. Furthermore, stroke index and cardiac index were significantly enhanced in the patient group (P<0.01 and P<0.001, respectively), whereas systemic vascular resistance was significantly reduced (P<0.001). In conclusion, our study shows that short-term acromegaly significantly affects the heart, but, at variance with long-term disease, it is characterized by increased left ventricular mass, with eccentric remodeling and normal diastolic function. Moreover, short-term acromegaly induces a high cardiac output state with reduction of systemic vascular resistance.

[Effects of chronic subclinical hyperthyroidism from levothyroxine on cardiac morphology and function]. / Effetti dell'ipertiroidismo subclinico cronico da terapia con levotiroxina su morfologia e funzione cardiaca.

BACKGROUND: Thyroid hormones greatly affect the cardiovascular system. Although the effects of overt hyperthyroidism on the cardiovascular system have been diffusely studied, only in the last years the effects of subclinical hyperthyroidism on the heart have been investigated. Subclinical hyperthyroidism is a symptomatic or asymptomatic condition with an absent response of thyrotropin (TSH) to thyrotropin-releasing hormone in the presence of normal serum levels of thyroid hormones for the general population, though supraoptimal for the individual. The more frequent causes of endogenous subclinical hyperthyroidism are multinodular goiter, toxic, adenoma and Graves's disease, whereas the exogenous causes are induced by levothyroxine (LT4) therapy used to suppress TSH in patients with nontoxic goiter and differentiated thyroid cancer. This paper reports our experience derived from the study of 60 patients with subclinical hyperthyroidism due to TSH-suppressive therapy with LT4 compared to normal subjects. METHODS: Patients (9 males and 51 females, mean age 39 +/- 10 years) were studied by complete Doppler echocardiography, standard and 24 hour ECG Holter monitoring, exercise test with cycloergometer, and radionuclide ventriculography at rest and during fixed workload (75 W). RESULTS: Holter monitoring showed a significant increase in mean 24 hour heart rate (80 +/- 10 vs 70 +/- 9 b/min, p < 0.001) and supraventricular arrhythmias (42 vs 12 patients, p < 0.003). Echocardiography showed an increase in left ventricular mass index (94 +/- 13 vs 80 +/- 18 g/m2, p < 0.001) due to increased septal and posterior wall thickness. At rest, echocardiographic indices of systolic function (fractional shortening and mean corrected velocity of circumferential fiber shortening) were higher in patients than in controls (fractional shortening 40 +/- 6 vs 34 +/- 4%, p < 0.001; mean corrected velocity of circumferential fiber shortening 1.23 +/- 0.17 vs 1.05 +/- 0.14 circ/s, p < 0.001), while the Doppler indices of diastolic function were significantly impaired as documented by the reduced E/A ratio (1.18 +/- 0.3 vs 1.8 +/- 0.5, p < 0.001) and the prolonged isovolumic relaxation time (94 +/- 13 vs 78 +/- 12 ms, p < 0.001). Exercise tolerance was also significantly impaired in patients with subclinical hyperthyroidism: maximal exercise time (6.4 +/- 0.7 vs 9.4 +/- 1.4 min, p < 0.001) and peak workload (81 +/- 11 vs 121 +/- 17 W, p < 0.001) were significantly reduced and radionuclide ventriculography showed a decrease in ejection fraction during exercise (from 62 +/- 7 to 53 +/- 8%, p < 0.002). CONCLUSIONS: Persistent subclinical hyperthyroidism by TSH-suppressive doses of LT4 significantly affects heart morphology and function. Thus, we suggest that a complete suppression of TSH must be recommended only in patients with differentiated thyroid cancer, while in patients with begin thyroid disease it could be sufficient to maintain subnormal TSH levels.

[Carotid atherosclerosis and thrombotic stroke. Diagnostic and therapeutic perspectives]. / Aterosclerosi carotidea ed ictus aterotrombotico. Attuali prospettive diagnostiche e terapeutiche.

Carotid atherosclerotic lesions can be studied with color-Doppler ultrasonography vascular systems. Ultrasonography of the carotid plaques at major risk for the development of cerebrovascular ischemic events showed the following characteristics: irregular surface, degree of stenosis > 70%, intimal hemorrhage and ulceration. The plaques with these ultrasonography patterns have to be considered for surgical approach (TEA). The other patients with carotid atherosclerotic lesions will be initially treated with diet and changes of life style to obtain the correction of cardiovascular risk factors (i.e. hypertension, hypercholesterolemia, diabetes). Furthermore, medical therapy with antithrombotic agents will be instituted which, used with good results also in acute cerebral stroke, proved to be effective in the reduction of vascular events in patients with extracranial atherosclerotic plaques. However, it has not been clarified if the positive effect of antiaggregation therapy in carotid atherosclerosis is due to the inhibition of the progression and plaque growth or if other hemorheological factors are involved.

Left ventricular diastolic dysfunction in patients with subclinical hypothyroidism.

Although subclinical hypothyroidism is frequently diagnosed, the decision to institute a substitutive therapy with L-T4 remains controversial. Because the cardiovascular system is considered a main target for the action of thyroid hormone, we investigated whether subclinical hypothyroidism induces cardiovascular abnormalities. Twenty-six patients (mean age, 36 +/- 12 yr) were evaluated by Doppler-echocardiography, whereas a subgroup of 10 patients, randomly selected, were reevaluated after 6 months of L-T4 substitutive therapy (mean dose, 68 microg daily). Thirty subjects (matched for age, sex, and body surface area) served as controls. Mean plasma TSH was significantly higher in patients (P < 0.001), whereas mean serum free T4 and free T3 concentrations, although in the normal range, were significantly lower (P < 0.001 and P < 0.005, respectively). Blood pressure and heart rate did not differ from control values. Echocardiogram examination showed no abnormalities of the left ventricular morphology and a slight, but not significant, reduction in the systolic function in the patient group. In contrast, Doppler-derived indices of diastolic function showed significant prolongation of the isovolumic relaxation time (94 +/- 13 vs. 84 +/- 8 msec; P < 0.001), increased A wave (55 +/- 13 vs. 48 +/- 9 cm/sec; P < 0.05), and reduced early diastolic mitral flow velocity/late diastolic mitral flow velocity ratio (1.4 +/- 0.3 vs. 1.7 +/- 0.3; P < 0.001). In the subgroup of 10 patients, thyroid hormone profile was normalized by 6 months of L-T4 substitutive therapy, whereas no changes were observed in the left ventricular morphology. Systolic function was significantly enhanced, as compared with pretreatment values (P < 0.01) but did not differ from control values. Also, systemic vascular resistance was significantly decreased by L-T4 replacement therapy. Assessment of diastolic function showed significant shortening of isovolumic relaxation time (77 +/- 15 vs. 91 +/- 8; P < 0.05), reduction of A wave (51 +/- 13 vs. 60 +/- 12; P < 0.01), and increase of early diastolic mitral flow velocity/late diastolic mitral flow velocity ratio (1.7 +/- 0.4 vs. 1.3 +/- 0.3; P < 0.001). These indices, however, were comparable with those of control subjects. These findings indicate that subclinical hypothyroidism affects diastolic function and that this abnormality may be reversed by L-T4 substitutive therapy.

Doxorubicin-induced cardiomyopathy treated with carvedilol.

Even today, heart failure due to doxorubicin-induced dilated cardiomyopathy seems to have a poor prognosis, as it is often irreversible and relatively unresponsive to standard medical treatment. This paper describes the first case of a patient complaining of severe symptoms of congestive heart failure due to doxorubicin-induced dilated cardiomyopathy unresponsive to standard medical treatment (digoxin, diuretics, and angiotensin-converting enzyme inhibitor), who showed complete clinical recovery and significant improvement of left ventricular dysfunction after carvedilol treatment. It also illustrates the possibility that carvedilol may be a first-choice drug for the treatment of this disease.

Staphylococcal food poisoning from sheep milk cheese.

Cheese made from sheep milk was implicated in food-poisoning incidents in December 1984 and January 1985. Bacteriological examination of batches of cheese failed to reveal a viable pathogen but enterotoxin A produced by Staphylococcus aureus was present. This was the first time that enterotoxin was detected in a food produced in the UK which was associated with poisoning and from which viable Staph. aureus could not be isolated. Subsequent detailed examination of milk, yoghurt and cheese from the same producer revealed that contamination with Staph. aureus was associated with post-infection carriage as well as clinical illness in ewes on the farm. Strains producing enterotoxon. A were still intermittently present in the bulk milk used for cheese production nearly 2 years afterwards, apparently in the absence of clinical illness in the sheep. The possible effects of heat treatment are discussed. Any changes in legislation should cover all non-human mammalian milk used for human consumption.

A comparative study of cefotetan and metronidazole against metronidazole alone to prevent infection after appendectomy.

The role of metronidazole in reducing the incidence of infectious complications after appendectomy has been established, but the value of an additional antibiotic to act against aerobic pathogens remains controversial. Patients who received 2 grams of cefotetan intravenously at the time of appendectomy and those who did not were compared for the incidence of infection. All patients received 1 gram of metronidazole per rectum preoperatively and every 12 hours for five days postoperatively. Infection occurred in three patients who received cefotetan and 16 of those who did not (p less than 0.01). We conclude that a single dose of cefotetan, an antibiotic which is effective against aerobic and anaerobic organisms, produces a significant reduction in the incidence of infection when added to metronidazole in the management of patients after appendectomy.

Meningitis due to an unusual type of Haemophilus influenzae.

An infant was admitted to hospital with suspected meningitis. Haemophilus influenzae type 'a' was isolated from cerebrospinal fluid (C.S.F.) and blood. Haemophilus meningitis due to types other than type 'b' is rare, and only a few due to type 'a' have so far been recorded. Investigations of the family are included together with a discussion of the implications for the diagnostic bacteriologist.

Brain abscess due to Haemophilus aphrophilus: case report.

A temporal lobe abscess due to H. aphrophilus occurred in a child of 11 years, and was successfully treated by aspiration, chemotherapy, and excision of the abscess wall. The organism is an unusual cause of brain abscess and this is believed to be the first reported case in Britain.