A comprehensive qualitative investigation of the factors that affect surgical site infection prevention in cardiac surgery in England using observations and interviews.

BACKGROUND: Interview and questionnaire studies have identified barriers and challenges to preventing surgical site infections (SSIs) by focusing on compliance with recommendations and care bundles using interviews, questionnaires and expert panels. This study proposes a more comprehensive investigation by using observations of clinical practice plus interviews which will enable a wider focus. AIM: To comprehensively identify the factors which affect SSI prevention using cardiac surgery as an exemplar. METHODS: The study consisted of 130 h of observed clinical practice followed by individual semi-structured interviews with 16 surgeons, anaesthetists, theatre staff, and nurses at four cardiac centres in England. Data were analysed thematically. FINDINGS: The factors were complex and existed at the level of the intervention, the individual, the team, the organization, and even the wider society. Factors included: the attributes of the intervention; the relationship between evidence, personal beliefs, and perceived risk; power and hierarchy; leadership and culture; resources; infrastructure; supplies; organization and planning; patient engagement and power; hospital administration; workforce shortages; COVID-19 pandemic; 'Brexit'; and the war in Ukraine. CONCLUSION: This is one of the first studies to provide a comprehensive overview of the factors affecting SSI prevention. The factors are complex and need to be fully understood when trying to reduce SSIs. A strong evidence base was insufficient to ensure implementation of an intervention.

Sex differences in surgical site infections following coronary artery bypass grafting: a retrospective observational study.

BACKGROUND: Surgical site infection (SSI) following cardiac surgery poses a significant challenge for healthcare providers. Despite advances in surgical techniques and infection control measures, SSI remains a leading cause of morbidity and mortality, in addition to being a significant economic burden on healthcare services. Current literature suggests there is a reproducible difference in the incidence of SSI following cardiac surgery between sexes. We aim to assess the sex-specific predictive risk factors for sternal SSI following coronary artery bypass grafting (CABG) in addition to identifying any differences in the causative organisms between groups. METHODS: Adult patients undergoing isolated CABG between January 2012 and December 2022 in one UK hospital organization were included. In this 10-year, retrospective observational study, a total of 10,208 patients met the inclusion criteria. Pre-operative risk factors were identified using univariate analysis. To assess dependence between sex and organism or Gram stain, a Pearson Chi-squared test with Yates correction for continuity was performed. RESULTS: In total there were 8457 males of which 181 developed a sternal SSI (2.14%) and 1751 females, 128 of whom had a sternal SSI (7.31%). Male patients were found to be significantly more likely to develop an SSI secondary to a Gram-positive organism, whereas female patients were more likely to have a Gram-negative causative organism (P<0.00001). Staphylococcus was statistically more likely to be the causative organism genus in male patients. Pseudomonas aeruginosa was found to be twice as common in the female cohort compared with the male group. CONCLUSION: In our study, we found a statistically significant difference in the causative organisms and Gram stain for post-CABG sternal SSIs between males and females. Male patients predominately have Gram-positive associated SSIs, whereas female SSI pathogens are more likely to be Gram negative. The preoperative risk profiles of both cohorts are similar, including being an insulin-dependent diabetic and triple vessel coronary artery disease. Given these findings, it prompts the question, should we be tailoring our SSI treatment strategies according to sex and associated risk profiles?

Barriers and facilitators for surgical site infection surveillance for adult cardiac surgery in a high-income setting: an in-depth exploration.

BACKGROUND: Surgical site infection (SSI) surveillance aims to facilitate a reduction in SSIs through identifying infection rates, benchmarking, triggering clinical review and instituting infection control measures. Participation in surveillance is, however, variable suggesting opportunities to improve wider adoption. AIM: To gain an in-depth understanding of the barriers and facilitators for SSI surveillance in a high-income European setting. METHODS: Key informant interviews with 16 surveillance staff, infection prevention staff, nurses and surgeons from nine cardiac hospitals in England. Data were analysed thematically. FINDINGS: SSI surveillance was reported to be resource intensive. Barriers to surveillance included challenges associated with data collection: data being located in numerous places, multiple SSI data reporting schemes, difficulty in finding denominator data, lack of interface between computerized systems, 'labour intensive' or 'antiquated' methods to collect data (e.g., using postal systems for patient questionnaires). Additional reported concerns included: relevance of definitions, perceived variability in data reporting, lack of surgeon engagement, unsupportive managers, low priority of SSIs among staff, and a 'blame culture' around high SSI rates. Facilitators were increased resources, better use of digital technologies (e.g., remote digital wound monitoring), integrating surveillance within routine clinical work, having champions, mandating surveillance, ensuring a closer relationship between surveillance and improved patient outcomes, increasing the focus on post-discharge surveillance, and integration with primary care data. CONCLUSION: Using novel interviews with 'front-line' staff, identified opportunities for improving participation in SSI surveillance. Translating these findings into action will increase surveillance activity and bring patient safety benefits to a larger pool of surgical patients.

Image-based digital post-discharge surveillance in England: measuring patient enrolment, engagement, clinician response times, surgical site infection, and carbon footprint.

BACKGROUND: Surgical site infections (SSIs) can have a significant impact on patients, their families and healthcare providers. With shortening inpatient periods, the post-discharge element of surveillance is becoming increasingly important. Proactive surveillance, including digital wound images using patient smartphones, may be an efficient alternative to traditional methods for collecting post-discharge surveillance (PDS). AIM: To determine success in patient enrolment and engagement including reasons for non-response, the time for clinicians to respond to patients, SSI rates, and carbon emissions when conducting PDS using patient smartphones. METHODS: An evaluation was undertaken for a one-month period (June 2022) in two adult cardiac surgery services which routinely used patient smartphones for PDS, using the secure Islacare (Isla) system. FINDINGS: The initial patient response rate for Isla was 87.3%, and the majority of patients (73%) remained engaged throughout the 30-day period. There was no significant difference in age, gender, operation type or distance to hospital between Isla responders or non-responders, or if the hospital provided a photo at discharge or not. Patients using Isla had a shorter post-discharge stay (P = 0.03), although this was not attributed to the platform. Patients not owning a smartphone and a technical issue were the main barriers to participation. Overall, nine SSIs were recorded, eight through the Isla surveillance and one through a hospital transfer readmission. The carbon emission associated with the SSI ranged from 5 to 2615 kg CO2e. CONCLUSION: In a real-world setting, using patient smartphones is an effective method to collect PDS, including wound images.

Predictive models of surgical site infections after coronary surgery: insights from a validation study on 7090 consecutive patients.

BACKGROUND: The role of specific scoring systems in predicting risk of surgical site infections (SSIs) after coronary artery bypass grafting (CABG) has not been established. AIM: To validate the most relevant predictive systems for SSIs after CABG. METHODS: Five predictive systems (eight models) for SSIs after CABG were evaluated retrospectively in 7090 consecutive patients undergoing isolated (73.9%) or combined (26.1%) CABG. For each model, accuracy of prediction, calibration, and predictive power were assessed with area under receiver-operating characteristic curve (aROC), the Hosmer-Lemeshow test, and the Goodman-Kruskal γ-coefficient, respectively. Six predictive scoring systems for 30-day in-hospital mortality after cardiac operations were evaluated as to prediction of SSIs. The models were compared one-to-one using the Hanley-McNeil method. FINDINGS: There were 724 (10.2%) SSIs. Whereas all models showed satisfactory calibration (P = 0.176-0.656), accuracy of prediction was low (aROC: 0.609-0.650). Predictive power was moderate (γ: 0.315-0.386) for every model but one (γ: 0.272). When compared one-to-one, the Northern New England Cardiovascular Disease Study Group mediastinitis score had a higher discriminatory power both in overall series (aROC: 0.634) and combined CABG patients (aROC: 0.648); in isolated CABG patients, both models of the Fowler score showed a higher discriminatory power (aROC: 0.651 and 0.660). Accuracy of prediction for SSIs was low (aROC: 0.564-0.636) even for six scoring systems devised to predict mortality after cardiac surgery. CONCLUSION: In this validation study, current predictive models for SSIs after CABG showed low accuracy of prediction despite satisfactory calibration and moderate predictive power.

The lower saxony bank of health. rationale, principles, services, organization and architectural framework.

INTRODUCTION: This article is part of a Focus Theme of METHODS of Information in Medicine on Health Record Banking. BACKGROUND: Poor communication of health care information between health care providers (HCP) is still a major problem. One recent approach is the concept of Health Record Banking. OBJECTIVES: With this report we want to introduce the Lower Saxony Bank of Health (LSBH) to the international community. The main objective of this paper is to report and explain: 1) why this organization has been founded, 2) which basic principles have been set, 3) which services will be provided, 4) which type of organization has been chosen, and 5) which architectural framework has been selected. METHODS: To report and discuss how we plan to achieve the intended objectives. RESULTS: The LSBH was founded as an entrepreneurial company, regarding itself as a neutral third-party information broker. The bank does not store medical documents on its central servers but offers a document registry with links to documents stored at participating health care providers. Subject to valid patient consent, the LSBH grants access to these documents to authorized health care providers. To implement our services, we chose the established technical frameworks of the Integrating the Healthcare Enterprise (IHE) initiative using cross-enterprise document sharing (XDS). CONCLUSIONS: Different approaches to establish health information exchange (HIE) are in early stages and some have failed in the past. Health Record Banking can address major challenges described in the literature about HIE. The future will show if our provider-sponsored business model is sustainable. After reaching a stable network, we intend to add additional HCPs, e.g., care homes or ambulance services, to the network.

The needs of persons with lupus and health care providers: a qualitative study aimed toward the development of the Lupus Interactive Navigator™.

OBJECTIVE: Systemic lupus erythematosus is an inflammatory autoimmune disease associated with high morbidity and unacceptable mortality. A major challenge for persons with lupus is coping with their illness and complex care. Our objective was to identify the informational and resource needs of persons with lupus, rheumatologists, and allied health professionals treating lupus. Our findings will be applied toward the development of an innovative web-based technology, the Lupus Interactive Navigator (LIN™), to facilitate and support engagement and self-management for persons with lupus. METHODS: Eight focus groups were conducted: four groups of persons with lupus (n=29), three groups of rheumatologists (n=20), and one group of allied health professionals (n=8). The groups were held in British Columbia, Ontario, and Quebec. All sessions were audio-recorded and transcribed verbatim. Qualitative analysis was performed using grounded theory. The transcripts were reviewed independently and coded by the moderator and co-moderator using 1) qualitative data analysis software developed by Provalis Research, Montreal, Canada, and 2) manual coding. RESULTS: Four main themes emerged: 1) specific information and resource needs; 2) barriers to engagement in health care; 3) facilitators of engagement in health care; and 4) tools identified as helpful for the self-management of lupus. CONCLUSION: These findings will help guide the scope of LIN™ with relevant information topics and specific tools that will be most helpful to the diverse needs of persons with lupus and their health care providers.

Impact of biofilm matrix components on interaction of commensal Escherichia coli with the gastrointestinal cell line HT-29.

Commensal Escherichia coli form biofilms at body temperature by expressing the extracellular matrix components curli fimbriae and cellulose. The role of curli fimbriae and cellulose in the interaction of commensal E. coli with the intestinal epithelial cell line HT-29 was investigated. Expression of curli fimbriae by the typical commensal isolate E. coli TOB1 caused adherence and internalization of the bacteria and triggered IL-8 production in HT-29 cells. In particular, induction of IL-8 production was complex and involved curli-bound flagellin. While cellulose alone had no effect on the interaction of TOB1 with HT-29 cells, co-expression of cellulose with curli fimbriae decreased adherence to, internalization and IL-8 induction of HT-29 cells. Investigation of a panel of commensal isolates showed a partial correlation between expression of curli fimbriae and enhanced internalization and IL-8 production. In addition, a high immunostimulatory flagellin was identified. Thus, the consequences of expression of extracellular matrix components on commensal bacterial-host interactions are complex.

Seasonal cyclicity of secretogranin-II expression and its modulation by sex steroids and GnRH in the female goldfish pituitary.

The secretory vesicle protein secretogranin-II (SgII), a precursor for the bioactive peptide secretoneurin, is expressed at all levels of the goldfish reproductive axis, including the hypothalamus, pituitary and ovaries. These findings led us to hypothesize that SgII is involved in reproduction and is physiologically regulated. We investigated the effects of different sex steroids on pituitary SgII expression throughout the seasonal reproductive cycle of the female goldfish, as well as the effects of GnRH and testosterone on pituitary LHbeta subunit, GH, and SgII expression in sexually recrudescent female fish using northern blot analysis. We demonstrated that SgII expression levels vary seasonally, with levels being highest in winter and lowest in spring. Sex steroids did not alter SgII expression at any of the time periods studied. In sexually mature goldfish, injection of a GnRH agonist stimulated the expression of LHbeta and SgII specifically in the pars distalis but not the neurointermediate lobe of the pituitary. Although testosterone alone did not alter the expression of either of these genes, it did abolish the stimulatory effects of GnRH on both LHbeta and SgII expression. This represents the first study where testosterone is shown to modulate SgII expression in the pituitary.

[Demographic aging and participation of the elderly in the financing of health and social expenses]. / Vieillissement demographique et participation des personnes agees au financement des depenses de sante et des depenses sociales.

PIP: The classical indicators typically used to understand the consequences of population aging upon the ability to finance social services fail to consider the active participation of older individuals. But such participation and contribution is not negligible in countries where the financing of social programs is mainly assured through governments¿ general funds. This paper considers the actual and future importance of the participation of the elderly in funding public expenditures in Quebec, Canada. Specifically, the author attempts to determine the contribution of the elderly to the public financing of health and social expenditures taking into account overall government revenues, how that contribution will change over time and which related factors could be influenced, and up to what point can this contribution offset the projected growth in the financial burden of countries caused by an aging population. Governments¿ revenue sources and indexes related to people¿s contributions are discussed with regard to taxation on consumption and income. The contribution of the elderly to the financing of public expenditures is then considered, followed by sections on the contribution of the elderly to government revenues and the financing of social expenses, and future trends in the contribution. Demographic and health factors such as the population¿s health status and the aging of the active population also affect expenditure trends and the ability of a population to finance them.^ieng

A linker region of the yeast zinc cluster protein leu3p specifies binding to everted repeat DNA.

Yeast zinc cluster proteins form a major class of yeast transcriptional regulators. They usually bind as homodimers to target DNA sequences, with each monomer recognizing a CGG triplet. Orientation and spacing between the CGG triplet specifies the recognition sequence for a given zinc cluster protein. For instance, Gal4p binds to inverted CGG triplets spaced by 11 base pairs whereas Ppr1p recognizes a similar motif but with a spacing of 6 base pairs. Hap1p, another member of this family, binds to a direct repeat consisting of two CGG triplets. Other members of this family, such as Leu3p, also recognize CGG triplets but when oriented in opposite directions, an everted repeat. This implies that the two zinc clusters of Leu3p bound to an everted repeat must be oriented in opposite directions to those of Gal4p or Ppr1p bound to inverted repeats. In order to map the domain responsible for proper orientation of the zinc clusters of Leu3p, we constructed chimeric proteins between Leu3p and Ppr1p and tested their binding to a Leu3p and a Ppr1p site. Our results show that the linker region, which bridges the zinc cluster to the dimerization domain, specifies binding of Leu3p to an everted repeat. We propose that the Leu3p linker projects the two zinc clusters of a Leu3p homodimer in opposite directions allowing binding to everted repeats.

A novel DNA binding motif for yeast zinc cluster proteins: the Leu3p and Pdr3p transcriptional activators recognize everted repeats.

The Gal4, Put3, and Ppr1 yeast zinc cluster proteins bind as homodimers to DNA sequences composed of palindromic CGG triplets. Spacing between the triplets specifies the target site for a given zinc cluster protein. In addition, Hap1p, another zinc cluster protein, also recognizes CGG triplets but only when oriented as a direct repeat. Unexpectedly, our results show that Leu3p, another member of this family, also recognizes CGG triplets but oriented in opposite directions and spaced by 4 nucleotides (an everted repeat or inverted palindrome: CCG-N4-CGG). This constitutes a novel DNA motif for zinc cluster proteins. Moreover, the presence of this motif was shown to be essential for in vivo activation by Leu3p of a minimal reporter containing one copy of a target site for this activator. We also provide evidence that another member of this family, Pdr3p, binds to an everted repeat spaced by 0 nucleotides (CCGCGG). Thus, our results show that three CGG motifs are used by members of the zinc cluster family: palindromes, direct repeats, and everted repeats.

[Presentation of a case: encephalopathy of boxers]. / Présentation d'un cas: l'encéphalopathie des boxeurs.

A 68-year-old man presents slight memory problems and behavioural change over a period of a year. A history of boxing is identified. Neuropsychological examination confirms slight frontal cognitive damage and damage at the level of the motor signs of the upper left hemicorpus. This symptomatology should, in differential diagnosis, raise the possibility of chronic punch-drunk syndrome. Further studies should be done to better document this little-characterized clinical entity and arrive at a clearer definition of this syndrome.

[Tubal ligation and vasectomies in Quebec. Recent trends]. / Les ligatures de trompes et les vasectomies au Quebec. Evolution recente.

The author analyzes recent trends in the number of tubal ligations and vasectomies performed in Quebec, Canada, using data for cohorts born since 1941. She finds that since the early 1980s, there has been "a decrease in the proportion of sterilized females and an increase in the proportion of sterilized males.... On the whole, the number of sterilized couples in their thirties has slightly decreased.... The most recent data seem to indicate that this evolution has come to a halt." (SUMMARY IN ENG AND SPA)

[8;21 translocation and leukemia]. / Translocation 8;21 et leucémisation.

The authors report their observations on acute myeloid leukemias associated with the 8;21 translocation. Two cases have less than the required percentage of blasts for the cytological diagnosis of acute myeloid leukemia. In one case, the 8;21 translocation is superimposed on a constitutional trisomy 21. Conclusions from the 4th International Workshop on chromosomes in leukemia are highlighted, as well as certain new data relative to the biology of acute myeloid leukemias.

Enhanced DNA cross-link removal: the apparent mechanism of resistance in a clinically relevant melphalan-resistant human breast cancer cell line.

Resistance to the cytotoxic effects of alkylating agents is a major limitation to their clinical efficacy. Although a number of animal and human tumor cell models have been developed to study this problem, it has proven difficult to achieve very high levels of resistance to alkylating agents in vitro. This is consistent with the recent clinical evidence that alkylator resistance can be overcome by dose escalations of less than 10-fold. A number of mechanisms of alkylator resistance have been described, more than one of which may occur in the same model. This paper describes a human breast cancer cell subline selected for 3-fold resistance to melphalan and cross-resistant to other alkylators in which only one of the previously described mechanisms of resistance, enhanced removal of DNA interstrand cross-linking, is demonstrable. Northern blot analysis using the human incisional repair gene ERCC-1 cDNA demonstrated that this particular gene product is not the altered function in these cells, so the molecular characterization of the observed enhanced repair is pending. Because these cells are also cross-resistant to radiation and to adriamycin and epipodophyllotoxin, they may represent a clinically relevant model in which to examine the role of DNA repair of lesions resulting from alkylators and other cytotoxic agents.

[The current reproductive life of women. The Quebec case]. / La vie reproductive des femmes aujourd'hui. Le cas du Quebec.

The author reviews the current reproductive patterns of women in the province of Quebec, Canada. "Through birth control and family planning, Quebec women experience an average of two pregnancies and give birth to 1.7 children. Sexual life is not reserved any more to married women, and starts at an increasingly early age. The percentage of teenagers experiencing a pregnancy is increasing. The rate of induced abortion is the highest at age 18-24. From the age of 18, more than half of the young women use oral contraceptives. The most educated women have the smallest number of pregnancies; they start their marital and reproductive life later than other women, and declare a larger percentage of induced abortion. Less educated women resort however to sterilization at an earlier age." Data are from the Quebec Health Survey of 1987 and other official sources. (SUMMARY IN ENG AND SPA)