While person-centred care has gained increasing prominence in recent decades as a goal for healthcare systems, mainstream implementation remains tentative and there is a lack of knowledge about how ...to develop person-centred care in practice. This study therefore aimed to explore what may be required in order for person-centred care programmes to be successful. The study used an ethnographic method of data collection. This consisted of closely following an implementation programme on a medical emergency ward in a Swedish hospital. Data consisted of participant observation and informal interviews with healthcare providers and their management leaders while they were in the process of training to use person-centred care. These interlocutors were using action learning methods under the guidance of facilitators. Our findings revealed that although the programme resulted in some of the processes that are central for person-centred care being developed, organisational factors and a lack of attention to ethics in the programme counteracted these positive effects. The study highlights the importance of facilitating mechanisms to produce desired results. These include management leaders’ learning about the dynamic and collective nature of learning processes and change. They also include allowing for inter-professional dialogue to enable managers and professionals to reflect deeply on professional boundaries, disciplinary knowledge and power relations in their teams. Teamwork is essential for the development of person-centred care and documentation, in accordance with this specific implementation programme, is also indispensable. The space for inter-professional dialogue should also accommodate their various perspectives on the aims of care and organizational reality.
To evaluate three types of ventilation systems for operating rooms with respect to air cleanliness in colony-forming units (cfu/m3), energy consumption and comfort of working environment (noise and ...draught) as reported by surgical team members.
Two commonly used ventilation systems, vertical laminar airflow (LAF) and turbulent mixed airflow (TMA), were compared with a newly developed ventilation technique, temperature-controlled airflow (TcAF). The cfu concentrations were measured at three locations in an operating room during 45 orthopaedic procedures: close to the wound (<40cm), at the instrument table and peripherally in the room. The operating team evaluated the comfort of the working environment by answering a questionnaire.
LAF and TcAF, but not TMA, resulted in less than 10cfu/m3 at all measurement locations in the room during surgery. Median values of cfu/m3 close to the wound (250 samples) were 0 for LAF, 1 for TcAF and 10 for TMA. Peripherally in the room, the cfu concentrations were lowest for TcAF. The cfu concentrations did not scale proportionally with airflow rates. Compared with LAF, the power consumption of TcAF was 28% lower and there was significantly less disturbance from noise and draught.
TcAF and LAF remove bacteria more efficiently from the air than TMA, especially close to the wound and at the instrument table. Like LAF, the new TcAF ventilation system maintained very low levels of cfu in the air, but TcAF used substantially less energy and provided a more comfortable working environment than LAF. This enables energy savings with preserved air quality.
Background
Surgical‐site infection (SSI) occurs in 1–10 per cent of all patients undergoing surgery; rates can be higher depending on the type of surgery. The aim of this review was to establish ...whether (or not) surgical hand asepsis, intraoperative skin antisepsis and selected surgical dressings are cost‐effective in SSI prevention, and to examine the quality of reporting.
Methods
The authors searched MEDLINE via Ovid, CINAHL via EBSCO, Cochrane Central and Scopus databases systematically from 1990 to 2016. Included were RCTs and quasi‐experimental studies published in English, evaluating the economic impact of interventions to prevent SSI relative to surgical hand and skin antisepsis, and wound dressings. Characteristics and results of included studies were extracted using a standard data collection tool. Study and reporting quality were assessed using SIGN and CHEERS checklists.
Results
Across the three areas of SSI prevention, the combined searches identified 1214 articles. Of these, five health economic studies evaluating the cost‐effectiveness of selected surgical dressings were eligible. Study authors concluded that the interventions being assessed were cost‐effective, or were potentially cost‐saving. Still, there is high uncertainty around the decision to adopt these dressings/devices in practice. The studies' reporting quality was reasonable; three reported at least 15 of the 24 CHEERS items appropriately. Assessment of methodological quality found that two studies were considered to be of high quality.
Conclusion
With few economic studies undertaken in this area, the cost‐effectiveness of these strategies is unclear. Incorporating economic evaluations alongside RCTs will help towards evidence‐informed decisions.
Few good examples
The phenomenon of urban flooding due to rainfall exceeding the design capacity of drainage systems is a global problem and can have significant economic and social consequences. This is even more ...extreme in developing countries, where poor sanitation still causes a high infectious disease burden and mortality, especially during floods. At present, there are no software tools capable of combining hydrodynamic modelling and health risk analyses, and the links between urban flooding and the health risk for the population due to direct contact with the flood water are poorly understood. The present paper outlines a novel methodology for linking dynamic urban flood modelling with quantitative microbial risk assessment (QMRA). This provides a unique possibility for understanding the interaction between urban flooding and health risk caused by direct human contact with the flood water and hence gives an option for reducing the burden of disease in the population by use of intelligent urban flood risk management. The model linking urban flooding and health risk is applied to Dhaka City in Bangladesh, where waterborne diseases including cholera are endemic. The application to Dhaka City is supported by measurements of pathogens in the urban drainage system. The outcome of the application indicates that direct contact with polluted flood water is a plausible route of primary transmission of cholera and demonstrates the applicability and the potential for linking urban flood models with QMRA in order to identify interventions to reduce the burden of disease on the population in Dhaka City.
A population-based, cross-sectional study was performed in southeast Norway, between January 2002 and February 2008, to identify subjects with hereditary ataxia and hereditary spastic paraplegia, and ...to estimate the prevalence of these disorders. Patients were recruited through colleagues, families, searches in computerized hospital archives and the National Patients’ Association for Hereditary Ataxia and Spastic Paraplegia. Strict criteria were used for inclusion of familial and isolated subjects. A project neurologist examined all index subjects and clinical and genetic data were registered. The source population on January 1, 2008 was 2.63 million and the prevalence day was set as February 1, 2008. One hundred seventy-one subjects from 87 unrelated families with hereditary ataxia and 194 subjects from 65 unrelated families with hereditary spastic paraplegia were included. The total prevalence was estimated at 13.9/100 000. Hereditary ataxia prevalence in the region was estimated at 6.5/100 000: 4.2/100 000 for autosomal-dominant and 2.3/100 000 for autosomal recessive, 0.15/100 000 for Friedreich's ataxia and 0.4/100 000 for ataxia telangiectasia. Hereditary spastic paraplegia prevalence was 7.4/100 000: 5.5/100 000 for autosomal dominant-hereditary spastic paraplegia, 0.6/100 000 for autosomal recessive-hereditary spastic paraplegia and 1.3/100 000 for isolated subjects. Marked differences were found in the frequencies of hereditary ataxia subtypes compared with other countries, while those of the most common autosomal dominant-hereditary spastic paraplegia genotypes, SPG4, SPG3 and SPG31, were similar to those previously reported. Clear variations between age groups and counties were observed, but no gender differences. Mean age on prevalence day was 48 years, mean age at onset was 24 years. We present the largest population study performed on hereditary ataxia and hereditary spastic paraplegia prevalence and report a higher prevalence than expected. Better inclusion criteria and multiple search strategies may explain the observed differences.
Quantitative microbial risk assessments (QMRAs) often lack data on water quality leading to great uncertainty in the QMRA because of the many assumptions. The quantity of waste water contamination ...was estimated and included in a QMRA on an extreme rain event leading to combined sewer overflow (CSO) to bathing water where an ironman competition later took place. Two dynamic models, (1) a drainage model and (2) a 3D hydrodynamic model, estimated the dilution of waste water from source to recipient. The drainage model estimated that 2.6% of waste water was left in the system before CSO and the hydrodynamic model estimated that 4.8% of the recipient bathing water came from the CSO, so on average there was 0.13% of waste water in the bathing water during the ironman competition. The total estimated incidence rate from a conservative estimate of the pathogenic load of five reference pathogens was 42%, comparable to 55% in an epidemiological study of the case. The combination of applying dynamic models and exposure data led to an improved QMRA that included an estimate of the dilution factor. This approach has not been described previously.
Abstract Amplification of the MYCN proto-oncogene is associated with a poor prognosis in patients with metastatic neuroblastoma (NB). MYCN encodes the N-Myc protein, a transcriptional regulator that ...dimerizes with the Max transcription factor, binds to E-box DNA sequences, and regulates genes involved in cell growth and apoptosis. Overexpression of N-Myc leads to transcriptional activation and an increase in NB cell proliferation. Mxi1, a member of the Myc family of transcriptional regulators, also binds to Max. However, Mxi1 is a transcriptional repressor and inhibits proliferation of NB cells, suggesting that Mxi1 functions as an N-Myc antagonist. Our laboratory previously identified Mxi1-0, an alternatively transcribed Mxi1 isoform. Mxi1-0 has properties distinct from those of Mxi1; in contrast to Mxi1, Mxi1-0 is unable to suppress c-Myc-dependent transcription. We now show that Mxi1-0 expression increases in response to MYCN overexpression in NB cells, with a positive correlation between MYCN and MXI1-0 RNA levels. We also show that N-Myc expression differentially regulates the MXI1 and MXI1-0 promoters: Increased MYCN expression suppresses MXI1 promoter activity while enhancing transcription through the MXI1-0 promoter. Finally, induction of Mxi1-0 leads to increased proliferation, whereas expression of Mxi1 inhibits cell growth, indicating differential roles for these two proteins. These data suggest that N-Myc differentially regulates the expression of MXI1 and MXI1-0 and can alter the balance between the two transcription factors. Furthermore, MXI1-0 appears to be a downstream target of MYCN-dependent signaling pathways and may contribute to N-Myc-dependent cell growth and proliferation.
Abstract Neuroblastoma (NB) is the third most common malignancy of childhood, and outcomes for children with advanced disease remain poor; amplification of the MYCN gene portends a particularly poor ...prognosis. Mxi1 antagonizes N-Myc by competing for binding to Max and E-boxes. Unlike N-Myc, Mxi1 mediates transcriptional repression and suppresses cell proliferation. Mxi1 and Mxi1-0 (an alternatively transcribed Mxi1 isoform) share identical Max and DNA binding domains but differ in amino-terminal sequences. Because of the conservation of these critical binding domains, we hypothesized that Mxi1-0 antagonizes N-Myc activity similar to Mxi1. SHEP NB cells and SHEP cells stably transfected with MYCN (SHEP/MYCN) were transiently transfected with vectors containing full-length Mxi1, full-length Mxi1-0, or the common Mxi domain encoded by exons 2 to 6 (ex2-6). After incubation in low serum, parental SHEP/MYCN cell numbers were reduced compared with SHEP cells. Activated caspase-3 staining and DNA fragmentation ELISA confirmed that SHEP/MYCN cells undergo apoptosis in low serum, while SHEP/MYCN cells transfected with Mxi1 or Mxi1-0 do not. However, SHEP/MYCN cells transfected with Mxi1 or Mxi1-0 and grown in normal serum showed proliferation rates similar to SHEP cells. Mxi ex2-6 did not affect cell number in low or normal serum, suggesting that amino terminal domains of Mxi1 and Mxi1-0 are critical for antagonism. In the absence of N-Myc, Mxi1 and Mxi1-0 induce apoptosis independently through the caspase-8–dependent extrinsic pathway, while N-Myc activates the caspase-9–dependent intrinsic pathway. Together, these data indicate that Mxi1 and Mxi1-0 antagonize N-Myc but also independently impact NB cell survival.
Aims : Although pulmonary involvement is a known cause of morbidity in Niemann–Pick disease, histological features in the lung are not well characterized. The purpose of this study is to document the ...histological features seen in pulmonary involvement by types B and C Niemann–Pick disease and to correlate them with clinical and imaging data.
Methods and results : Surgical lung biopsies from six patients (four with type B and two with type C disease) were reviewed and all showed diffuse endogenous lipid pneumonia, with lesser involvement of the interstitium by fibrosis and foamy macrophage accumulation. In type B disease only, there was also fine cytoplasmic vacuolation within the cytoplasm of ciliated epithelial cells. Neither disease showed foamy changes within pneumocytes. One patient had a bronchial cast removed on whole lung lavage. Electron microscopy showed abnormal lamellar inclusions within lysosomes of affected cells in type B disease. In patients with type C disease, biopsies were undertaken as part of investigations into acute respiratory failure in the context of multiorgan systemic presentation. Three patients with type B disease had clinical disease limited to the lung, all adults (mean age of 40 years) with unexplained diffuse parenchymal lung disease and mainly ground‐glass shadowing on high‐resolution computed tomography.
Conclusions : Niemann–Pick disease should be considered for any patient with unexplained diffuse endogenous lipid pneumonia, even when disease is limited to the lungs and presentation is during adulthood.
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