Introduction of a care bundle effectively and sustainably reduces patient-reported surgical site infection in patients undergoing colorectal surgery.

BACKGROUND: Surgical site infection (SSI) is one of the most common healthcare-associated infections and is particularly prevalent following colorectal surgery. It is associated with an increase in patient morbidity and healthcare costs. SSI is difficult to monitor as it frequently presents after discharge from hospital, especially if enhanced recovery programmes are in place. AIM: To develop an effective method for measuring patient-reported 30-day SSI in patients undergoing colorectal resection. To implement a new care bundle capable of delivering a sustainable reduction in SSI. METHODS: The Public Health England SSI surveillance questionnaire was used. Several data collection methods were tested including postal and telephone-based systems. A new SSI bundle was introduced in our centre incorporating four evidence-based interventions: 2% chlorhexidine skin preparation; repeat-dose antibiotics after 4 h; dual-ring wound protectors; and triclosan-coated sutures for wound closure. System changes were introduced to ensure that the change was sustainable. FINDINGS: The most reliable method of measuring patient-reported SSI was found to be postal questionnaire with telephone calls made to non-responders. Response rates to the SSI surveillance questionnaire were consistently >75%. Introduction of the new care bundle produced a significant reduction in SSI from 20% to 10% (P ≤ 0.0001) which has been sustained for six years. CONCLUSION: This is a reliable method for measuring 30-day patient-reported SSI rates. The introduction of this new care bundle has halved the rate of SSI from 20% to 10%.

Recurrent epistaxis in a nine-year-old boy: benign or malignant?

OBJECTIVE: We present the case of a rare cause of epistaxis in a paediatric patient, together with the diagnostic and management challenges associated with this condition. CASE REPORT: A previously well nine-year-old boy presented with a six-month history of intermittent unilateral epistaxis. Radiological investigation and endoscopic biopsy confirmed a highly malignant nasopharyngeal mass consistent with carcinoma. The tumour continued to grow rapidly. Whilst awaiting intervention, the patient experienced a further significant haemorrhage requiring surgical intervention. CONCLUSION: Nasopharyngeal carcinoma is a rare cause of epistaxis amongst children in the UK. Early flexible nasendoscopy can help delineate both benign and sinister causes of symptoms in this region.

Defects in lymphocyte subsets and serological memory persist a median of 10 years after high-dose therapy and autologous progenitor cell rescue for malignant lymphoma.

The number of survivors having undergone high-dose therapy (HDT) followed by auto-SCT continues to increase, although some of the long-term sequelae remain incompletely understood. The immunological status and quality of life of 37 HDT/auto-SCT survivors with lymphoma in continuous remission of ≥3 years were assessed alongside 14 age-matched controls. At a median follow-up of 10.5 years (range 2.2-20.2) following HDT/auto-SCT, the proportion of CD4(+) cells remained significantly reduced in patients compared with controls (median 43.4% vs 62.5%, respectively; P = < 0.001), predominantly a result of sustained reduction in the naive CD4(+) component (P < 0.001). Naive CD8(+) lymphocytes (P = 0.014) and transitional B cells (P = 0.008) were also significantly reduced, but differences in other lymphocyte subsets were not observed. Uptake of revaccination following HDT/auto-SCT was sporadic; between 11% and 33% of patients had serological titres outside the protective ranges for five of six routinely used vaccines. In the main, patients were found to have a good quality of life, although their EORTC QLQ-C30 questionnaire scores were significantly lower for the physical and social functioning domains compared with controls. Ten years after HDT/auto-SCT immunological deficits persist; to avoid excess risk of preventable disease, serological immunity should be assessed post HDT/auto-SCT followed by appropriate revaccination.

Isolation and characterization of Pseudomonas putida R-prime plasmids.

A number of enhanced chromosome mobilizing (ECM) plasmids derived from the wide host range plasmid R68 have been used to construct R-prime plasmids carrying a maximum of two map minutes of the Pseudomonas putida PPN chromosome, using Pseudomonas aeruginosa PAO as the recipient. For one ECM plasmid, pMO61, the ability to form R-primes did not correlate with the ability to mobilize chromosomes in intrastrain crosses, suggesting that different mechanisms are involved. Physical analysis of one R-prime showed that 3.5 kb of chromosomal DNA had been inserted between the tandem IS21 sequences carried by the parent ECM plasmid.

Characterisation of Histophilus ovis and related organisms by restriction endonuclease analysis.

The banding profiles generated by Bam H1 restriction endonuclease cleavage of bacterial DNA from clinical and reference isolates of Histophilus ovis, Haemophilus somnus and related bacteria were compared. H. ovis, H. somnus and Haemophilus agni isolates were found to have distinct similarities in banding profiles characterised by 10 common bands between 2.0 and 9.6 kilobases (kb). The close taxonomic relationship of these isolates was reinforced by these findings. The reference isolates examined in this study--Actinobacillus lignieresii, Actinobacillus seminis, H. agni, H. somnus, H. ovis, Haemophilus influenzae, Haemophilus parainfluenzae, Haemophilus parahaemolyticus--could be distinguished from each other on the basis of their characteristic banding profiles. Actinobacillus sp were observed to have more bands between 2 and 23 kb compared with the H. ovis and Haemophilus sp isolates studied. Analysis of isolates from an experimental infection trial illustrated the potential of restriction endonuclease analysis in molecular epidemiological applications. It was possible to demonstrate by this means that the post-challenge isolates had identical banding profiles to the challenge (or infecting) isolate which had a distinctly different banding profile from that of pre-challenge H. ovis isolates. Furthermore, restriction endonuclease analysis of H. ovis isolates obtained from follow-up investigations of a recurrent problem of epididymitis in unmated rams, indicated that the H. ovis isolates implicated in epididymitis, were present as a single strain in a number of sheep over a period of time. This suggested that the mechanism of transmission was by perinatal perputial contamination.

Chromosomal map of Pseudomonas putida PPN, and a comparison of gene order with the Pseudomonas aeruginosa PAO chromosomal map.

The generalized transducing phage Pf16h2 has been used to confirm linkage relationships of chromosomal markers of Pseudomonas putida previously determined from their time-of-entry in Hfr crosses, and to map new auxotrophic mutations. By means of spot matings using Hfr donors of known origin of transfer, catabolic markers forming part of a closely linked group of operons referred to as a superoperonic cluster have been shown to be chromosomally located and their map positions determined. R-prime-mediated interspecific complementation has been used to equate functionally 21 auxotrophic loci in P. putida and P. aeruginosa, and the distribution of these loci on the two genetic maps has been compared. While both maps reveal that auxotrophic markers are largely restricted to about 40% of the chromosome and that auxotrophic markers of similar phenotype are not clustered, there is evidence of at least seven chromosomal rearrangements since divergence from a presumed common ancestor.

Integration of R91-5::Tn501 into the Pseudomonas putida PPN chromosome and genetic circularity of the chromosomal map.

Derivatives of the Pseudomonas aeruginosa plasmid R91-5, loaded with the transposon Tn501, were transferred to P. putida PPN. Over 90% of exconjugants, which arose at a frequency of ca. 10(-6) per donor cell, exhibited high-frequency (greater than 10(-2) per donor cell) polarized transfer of chromosomal markers. In one instance it was demonstrated by transduction that the plasmid had been inserted into a gene required for serine biosynthesis. The integrated nature of the plasmid in this and other P. putida (R91-5::Tn501) derivatives was supported by the failure to detect covalently closed circular DNA in these strains. The transfer origins of six different Hfr donors have been characterized genetically, and time-of-entry kinetics obtained from interrupted matings have enabled the construction of a circular genetic map 103 min in length and containing 35 markers. The genetic map of P. putida PPN shows significant differences in marker order to that of P. aeruginosa PAO.

Detection of FP plasmids in hospital isolates of Pseudomonas aeruginosa.

A simple method of detection of FP plasmids with chromosome-mobilizing ability in Pseudomonas aeruginosa has been developed.

Isolates of Pseudomonas aeruginosa from Australian hospitals having R-plasmid determined antibiotic resistance.

Six hundred and fifty hospital isolates of Pseudomonas aeruginosa from Australian sources have been examined for high-level resistance to a number of antibiotics. Fifty-four strains were resistant to one or more of the antibiotics, and four of these strains carried as R-plasmid conferring resistance to streptomycin, tetracycline and sulphanilamide, and belonging to incompatibility group P-2. Possible reasons for the low incidence of R-plasmids in P. aeruginosa from Australian sources are discussed.