Traumatic wound microbiome workshop.

On May 9-10, 2011, the Walter Reed Army Institute of Research, as the Army Center of Excellence for Infectious Disease, assembled over a dozen leaders in areas related to research into the communities of microorganisms which colonize and infect traumatic wounds. The objectives of the workshop were to obtain guidance for government researchers, to spur research community involvement in the field of traumatic wound research informed by a microbiome perspective, and to spark collaborative efforts serving the Wounded Warriors and similarly wounded civilians. During the discussions, it was made clear that the complexity of these infections will only be met by developing a new art of clinical practice that engages the numerous microbes and their ecology. It requires the support of dedicated laboratories and technologists who advance research methods such as community sequencing, as well as the kinds of data analysis expertise and facilities. These strategies already appear to be bearing fruit in the clinical management of chronic wounds. There are now funding announcements and programs supporting this area of research open to extramural collaborators.

Social deprivation and prognostic benefits of cardiac surgery: observational study of 44 902 patients from five hospitals over 10 years.

OBJECTIVE: To assess the effects of social deprivation on survival after cardiac surgery and to examine the influence of potentially modifiable risk factors. DESIGN: Analysis of prospectively collected data. Prognostic models used to examine the additional effect of social deprivation on the end points. SETTING: Birmingham and north west England. PARTICIPANTS: 44 902 adults undergoing cardiac surgery, 1997-2007. MAIN OUTCOME MEASURES: Social deprivation with census based 2001 Carstairs scores. All cause mortality in hospital and at mid-term follow-up. RESULTS: In hospital mortality for all cardiac procedures was 3.25% and mid-term follow-up (median 1887 days; range 1180-2725 days) mortality was 12.4%. Multivariable analysis identified social deprivation as an independent predictor of mid-term mortality (hazard ratio 1.024, 95% confidence interval 1.015 to 1.033; P<0.001). Smoking (P<0.001), body mass index (BMI, P<0.001), and diabetes (P<0.001) were associated with social deprivation. Smoking at time of surgery (1.294, 1.191 to 1.407, P<0.001) and diabetes (1.305, 1.217 to 1.399, P<0.001) were independent predictors of mid-term mortality. The relation between BMI and mid-term mortality was non-linear and risks were higher in the extremes of BMI (P<0.001). Adjustment for smoking, BMI, and diabetes reduced but did not eliminate the effects of social deprivation on mid-term mortality (1.017, 1.007 to 1.026, P<0.001). CONCLUSIONS: Smoking, extremes of BMI, and diabetes, which are potentially modifiable risk factors associated with social deprivation, are responsible for a significant reduction in survival after surgery, but even after adjustment for these variables social deprivation remains a significant independent predictor of increased risk of mortality.

Bacteriocins as oral and gastrointestinal antibiotics: theoretical considerations, applied research, and practical applications.

Bacteriocins, specific and highly potent protein antibiotics, have been long been expected to enter the working pharmacopeia. Despite laboratory experiments demonstrating their effectiveness against a wide range of gastrointestinal pathogens, attempts to reproduce such killing activity by using live bacteriocin-producing bacteria in animal gastrointestinal systems repeatedly failed. This raised doubts about the potential of the bacteriocins as in vivo antibiotics. Thus, though some bacteriocins have been employed in food preservation and processing, none have been applied directly as medicine. Recent experiments, based on an improved theoretical understanding of microbial ecology, demonstrate the in vivo activity of bacteriocins, the potential importance of bacteriocins as antibiotics, and the role that bacteriocins play in antibiotic resistance. Meanwhile, several kinds of bacteriocins have been proposed for applications in gastrointestinal microbiology, as well as for the use of probiotics to reduce dental caries and improve oral hygiene. Unfortunately, much of the probiotic-oriented research appears to be pursued without reference to resistance and the role of the bacteriocins in a community of bacteria. This leads to continued confusion regarding the interpretation of experimental results and mistaken assessments, positive and negative, of bacteriocins' therapeutic potential. A study of microbial ecology should be incorporated in the drug development process in order to apply bacteriocins most effectively.

Balkans briefing number 7. Pristina Hospital: under new management.

This is the seventh paper in a series on the consequences for public health of the conflict in the Balkans. It describes the state of the hospital sevices in Pristina after the cease fire in June 1999 and the subsequent reconstruction programme.

The public health practitioner as investigator.

The history of public health began with the investigation of communicable diseases. Improved epidemiological methods have subsequently illuminated the causes and management of a wide range of health problems. The day-to-day challenges facing today's public health practitioners must be tackled rapidly and with limited resources, but must still subject to sound epidemiological principles.

Is health care a commodity: how will purchasing improve the National Health Service?

Through the reforms to the National Health Service in 1990 an internal market for public health care provision in the United Kingdom was introduced. As part of this new system of care, responsibility for purchasing of health care was separated from that for its provision. The new purchasing function, undertaken by district health authorities and fundholding general practices, has created the opportunity for improvements in health and higher standards of care to be achieved through new and explicit mechanisms. However, the purchasing function has not yet realized its full potential to achieve beneficial change, partly because traditional behaviours have not yet adapted to the new system of care and partly because specific aspects of the internal market are creating barriers and perverse incentives. This paper discusses these issues and identifies the important barriers which have still to be overcome if purchasing is to be the driving force for change in the new National Health Service.

Perinatal mortality and associated morbidity.

Perinatal mortality remains an important topic, with wide ranging coverage in the literature. I have considered three main themes: preexisting risk factors, clinical management, and perinatal mortality reviews. Three major studies have identified a wide range of risk factors for perinatal death. Different inclusion criteria may be responsible for some of the apparent inconsistencies between study findings, but unravelling the complex web of interrelated factors remains a major epidemiologic challenge. Recent studies of clinical management highlight the role of the delivery of health care in determining outcome. However, they also underline the difficulties of assessing contrasting approaches to clinical management in this field. There is a welcome continuing impetus to develop the systematic review of perinatal death as an indicator of effectiveness in the delivery of maternity care.

'Normal but dead': perinatal mortality in non-malformed babies of birthweight 2.5 kg and over in the northern region in 1983.

The case notes relating to 75 of the 91 perinatal deaths of nonmalformed babies of birthweight greater than or equal to 2.5 kg born in the Northern Region in 1983 were examined. The major groups involved antepartum deaths of unknown cause (40%), and deaths due to intrapartum anoxia or trauma (35%). A case-control study compared each of the 75 cases with two controls matched for place of birth, obtained by taking the next two babies born in the same maternity unit (excluding perinatal deaths, birthweight less than 2.5 kg, and malformations). Four factors were found to be significantly associated with risk of perinatal death in this group: primigravidity, parity greater than or equal to 3, not booked for antenatal care by 20 weeks, and corrected birthweight less than 3.2 kg (adjusted for gestation). Two further factors were related only to the risk of perinatal death consequent upon intrapartum events: labour post-term and malpresentation in labour. All four factors relevant to the whole group remained independently associated with risk of perinatal death after multivariate analysis by two techniques. Adjusted odds ratios (95% CI) were estimated as: primigravidity 2.1 (1.1 to 4.1); parity three or more 5.7 (1.9 to 17); not booked for antenatal care by 20 weeks 15.7 (3.0 to 81); and corrected birthweight less than 3.25 kg 2.5 (1.3 to 4.6). An avoidable factor, as defined, was detected in 50% of deaths. In 30% of deaths there was an avoidable factor (grade 2) such that absence may have been expected to lead to a different outcome had all other factors remained equal. Of the avoidable factors detected, 61% related to intrapartum management, as did 76% of the grade 2 factors. Most of these involved failure to respond to evidence of fetal distress in labour. The defined group constituted 21% of all perinatal deaths, suggesting that this is an important category, particularly as their potential for normal survival should otherwise have been high.

How will health needs be measured in districts? Implications of variations in hospital use.

Under the proposals in Working for Patients, Health Authorities will need to assess health needs in the populations for which they will become responsible, in order to ensure that optimal contracts are placed for hospital care. It seems inevitable that this process will have to be based at least in part on previous utilization data. Utilization data are known to be strongly influenced by the supply of facilities, particularly beds; unless this can be taken into account there is a likelihood that historical patterns will simply be perpetuated whether justified or not. We have used multiple regression analysis with nationally available data to investigate the effects of supply as well as of need and demand indicators on variations in hospital utilization rates. We describe how the approach may be taken by Health Authorities as the basis for a staged assessment of local levels of utilization, so that they may target further and more detailed investigation more efficiently.

An appraisal of waiting list problems.

The identification of problem waiting lists is important in effectively targeting scarce resources. This paper discusses the data available on waiting lists, and develops an information profile which can be used as a screening device to construct a short list of the 'worst' waiting lists. This profile was tested using the waiting experience of one specialty in the Northern region, and the results are presented here. Further developments to the profile are largely dependent upon improvements to the information currently collected on waiting lists.