Comparison of national strategies to reduce meticillin-resistant Staphylococcus aureus infections in Japan and England.

BACKGROUND: National responses to healthcare-associated infections vary between high-income countries, but, when analysed for contextual comparability, interventions can be assessed for transferability. AIM: To identify learning from country-level approaches to addressing meticillin-resistant Staphylococcus aureus (MRSA) in Japan and England. METHODS: A longitudinal analysis (2000-2017), comparing epidemiological trends and policy interventions. Data from 441 textual sources concerning infection prevention and control (IPC), surveillance, and antimicrobial stewardship interventions were systematically coded for: (a) type: mandatory requirements, recommendations, or national campaigns; (b) method: restrictive, persuasive, structural in nature; (c) level of implementation: macro (national), meso (organizational), micro (individual) levels. Healthcare organizational structures and role of media were also assessed. FINDINGS: In England significant reduction has been achieved in number of reported MRSA bloodstream infections. In Japan, in spite of reductions, MRSA remains a predominant infection. Both countries face new threats in the emergence of drug-resistant Escherichia coli. England has focused on national mandatory and structural interventions, supported by a combination of outcomes-based incentives and punitive mechanisms, and multi-disciplinary IPC hospital teams. Japan has focused on (non-mandatory) recommendations and primarily persuasive interventions, supported by process-based incentives, with voluntary surveillance. Areas for development in Japan include resourcing of dedicated data management support and implementation of national campaigns for healthcare professionals and the public. CONCLUSION: Policy interventions need to be relevant to local epidemiological trends, while acceptable within the health system, culture, and public expectations. Cross-national learning can help inform the right mix of interventions to create sustainable and resilient systems for future infection and economic challenges.

Confirmation of infection of an aortic graft.

The presentation of an aortic graft infection may be dramatic in the form of an aortoenteric fistula or drainage of pus from the wound. Some cases may be more subtle with presentations of fever of unknown origin. Prior to embarking upon major operative repair for these suspected lesions, it is essential to confirm the presence of infection. Under CT control, a fine needle may be inserted into the peri-graft space, and cultures may be obtained. Further confirmation may be achieved by an injection of a small amount of contrast material which will demonstrate lack of incorporation of the graft into surrounding tissues. Prior confirmation of graft infection permits a staged procedure to repair this technique is illustrated with a case history.

Rehabilitation potential of elderly patients with major amputations.

This study was undertaken to determine the rehabilitation potential of patients undergoing amputation for vascular disease. A total of 101 patients were studied with a mean age of 69 +/- 14 years, 26 of whom were over age 80. Operative indications were gangrene or ulceration in 80% with rest pain in 20%. Eighteen patients were bilateral amputees. Fifty per cent of the patient population had previous vascular operations. The operative mortality was 13% and was not affected by the age of the patients or the presence of diabetes. Most operative deaths were due to cardiac or septic respiratory complications. Twenty-four of 88 surviving patients were not considered candidates for rehabilitation and the major determining factor was the occurrence of a remote or perioperative stroke. None of these 24 patients was discharged from institutional care. Sixty-four patients were considered rehabilitation candidates with equal distribution in all age groups. Ninety-five per cent of these patients were discharged home with 80% of those patients over 80 being discharged. Eighty-seven per cent of the elderly rehabilitation candidates were fitted with prostheses which compares favourably to other age groups. Seventy-three per cent of the elderly reached their rehabilitation goals (most frequently ambulation with the aid of a walker) which is only slightly less than the younger amputation group. From this study we conclude that amputations which are done for ease of nursing care and patient comfort in debilitated patients have a high mortality rate and rehabilitation goals are unlikely to be met. We have demonstrated high success rates with rehabilitation including patients over age 80. The majority of these patients may be discharged home after a period of aggressive rehabilitation.

Intraoperative thrombolytic therapy as a treatment of small vessel thrombosis: an experimental study.

OBJECTIVE: This paper studies the effect of three doses of Streptokinase infused intra-operatively into an animal model of small vessel thrombosis. EXPERIMENTAL DESIGN: This is a controlled trial of intraoperative infusion of thrombolytic agent into a thrombosed arterial segment compared to no infusion into the contralateral limb. EXPERIMENTAL SUBJECTS: 19 New Zealand White rabbits were stratified into 3 groups. INTERVENTIONS: Thrombosis was achieved by infusing a mixture of topical thrombin and autologous blood into individual iliac arteries of the New Zealand white rabbit. A randomly selected hind limb had an infusion of one of three doses of streptokinase (A = 2,500u; B = 5,000u; C = 10,000u) in saline over 20 minute period. Preinfusion and post infusion angiography was performed. MEASUREMENTS: Angiograms were ranked by a radiologist blinded to the side of infusion and clotting parameters were assessed. RESULTS: All limbs at all doses of streptokinase infusion (SK) showed significant clot lysis when compared to the non-infused limb(C). The percentage of improved segments is as follows: iliac: SK = 100%, C = 79%; femoral SK = 79%, C = 32%; tibial SK = 52%, C = 5%. Although there was an elevation in clotting time and a reduction in fibrinogen, levels remained within normal limits. CONCLUSIONS: Streptokinase infused directly into thrombus in arteries even in low doses significantly enhances thrombolysis of vessels which are too small to be cleared by mechanical means. No significant systemic complications were encountered.

A single treadmill exercise test does not accurately quantitate claudication.

The diagnosis of vascular occlusive disease is confirmed by documenting a fall in the ankle-brachial pressure index following a treadmill exercise test. The authors hypothesize that this test does not provide a reproducible quantitative assessment of the patient's disability due to the disease. In 25 patients a series of five treadmill exercise tests were performed on the same day. There was a significant (p less than 0.05) increase in the time to the occurrence of claudication when tests 3, 4 and 5 were compared with test 1. There was also a significant (p less than 0.05) rise in the maximum time walked comparing test 3 with test 1. There was no difference in the fall in ankle-brachial pressure index with each test. The majority of patients had achieved their maximum walking distance by test no. 3. It is concluded that a single treadmill exercise test will not accurately assess disability due to intermittent claudication and it is recommended that three tests be performed for a reproducible evaluation.

Traumatic rupture of the right hemidiaphragm.

Six cases of traumatic rupture of the right hemidiaphragm are reviewed with emphasis on diagnostic features and operative treatment. In one (Case 6), a mass lesion was seen in the chest 2 years after the initial injury and was repaired through a right thoractomy incision. There were no deaths. Of the five cases operated on soon after the initial injury, two were approached initially via right thoracotomy incisions and both required second incisions for injuries below the diaphragm. Three ruptures of the right hemidiaphragm were successfully repaired through laparotomy incisions without extension of the incision into the chest. Laparotomy is the preferred approach for rupture of the right hemidiaphragm during the acute phase, because exposure is adequate and life-threatening injuries below the diaphragm can usually be dealt with through the same incision.

Eccrine spiradenoma: a report of malignant transformation.

The authors report the case of a 21-year-old man who had malignant transformation within an eccrine spiradenoma involving the big toe. Although benign eccrine spiradenoma is not an uncommon cutaneous adnexal tumour, malignant change in this tumour is rare. To the authors' knowledge only 16 cases have been reported previously. Two histologically distinct components were seen in the tumour: typical eccrine spiradenoma, constituting a small part of the tumour, and carcinoma with areas of transition. The patient was treated by below-knee amputation and superficial inguinal node dissection. There was no evidence of recurrence 2 years after surgery.

Simple method of intraoperative blood collection and reinfusion during aortic surgery.

The increasing fear of acquired immune deficiency syndrome and other blood-transmissible diseases and increasing blood-bank shortages prompted a study of the safety and feasibility of a commercially available hand-held unit for collecting and reinfusing blood. The device was used on nine patients undergoing aortic surgery and permitted a mean saving of 2.6 units of banked blood. The reinfusion of collected blood did not result in any coagulation disturbances or changes in renal function. The hemoglobin and platelet levels were comparable to those in a group of patients receiving only banked blood. The unit does not require additional personnel or technical training for its use. The authors conclude that this autotransfusion device is a safe and feasible method of reducing the requirement for banked blood during aortic surgery.

CT of the oropharynx, tongue base, and floor of the mouth: normal anatomy and range of variations, and applications in staging carcinoma.

CT scans of 35 patients were obtained during rapid drip infusion of contrast material to determine the range of normal variation in the structures of the oropharynx and the floor of the mouth. Superficial structures such as the tonsillar pillars and lingual and faucial tonsils vary so much in appearance that they are not useful indicators in the detection of subtle lesions; in fact, they are potential sources of "pseudomasses." Asymmetric obliteration of the parapharyngeal space is useful for the detection of subtle lesions of the upper tonsillar fossae; however, confident diagnosis in regard to the lower oropharynx depends on visualization of a mass lesion or loss of the more constant planes in the floor of the mouth and the tongue base. CT findings added unique and valuable information in eight of 12 cases of carcinoma, confirmed the clinical impression of the extent of the lesion in four cases, and were potentially misleading in one case. CT is a valuable adjunct to the detection and staging of an oropharyngeal malignancy.

Extra-anatomic bypass grafting: a rational approach.

To determine predictors of long-term patency in extra-anatomic bypass grafting, the authors studied retrospectively the charts of 134 patients who underwent bypass grafting (axillofemoral in 17, axillobifemoral in 32 and femorofemoral in 85). Of the study group, 64% were men; the mean age was 65 +/- 12 years (+/- SEM). The indications for grafting were limb salvage (102), claudication (27) and replacement of septic grafts (5), and for using the extra-anatomic route included high risk (83), sepsis (8) and unilateral disease (34). Operative mortality was 6% and the early graft occlusion rate 7.4%. The late death rate was 44%. At 3 years, the life-table patency rates for the various procedures were axillofemoral 52.5%, axillobifemoral 67.7% and crossfemoral 86.9%. Smoking significantly (p less than 0.05) decreased the patency rate, but diabetes did not. However, amputation was more frequent in diabetics. Indications for operation did not alter patency rates, but did affect operative mortality. The authors conclude that extra-anatomic bypass grafting is highly successful, but not as successful as anatomic bypass. When appropriate, the axillobifemoral graft is preferred to the axillounifemoral graft because of its increased patency. Crossfemoral grafts must be carefully monitored to ensure that no donor limb stenosis occurs and this procedure should not be attempted unless the disease is truly unilateral.