Summary Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income ...countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.
Summary Surgical site infections (SSIs) are among the most preventable health-care-associated infections and are a substantial burden to health-care systems and service payers worldwide in terms of ...patient morbidity, mortality, and additional costs. SSI prevention is complex and requires the integration of a range of measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations of national guidelines have been identified. Given the burden of SSIs worldwide, the numerous gaps in evidence-based guidance, and the need for standardisation and a global approach, WHO decided to prioritise the development of evidence-based recommendations for the prevention of SSIs. The guidelines take into account the balance between benefits and harms, the evidence quality, cost and resource use implications, and patient values and preferences. On the basis of systematic literature reviews and expert consensus, we present 13 recommendations on preoperative preventive measures.
Desmosomal and phospholamban (PLN) mutations are associated with arrhythmogenic cardiomyopathy. Ultimately, most cardiomyopathic hearts develop significant cardiac fibrosis.
To compare the fibrosis ...patterns of desmosomal and p. Arg14del PLN-associated cardiomyopathies with the pattern in hearts with other hereditary cardiomyopathies.
A midventricular transversal slice was obtained from hearts of 30 patients with a cardiomyopathy with a known underlying mutation and from 8 controls. Fibrosis and fatty changes were quantitatively analyzed using digital microscopy.
Hearts from patients with desmosomal mutations (n = 6) showed fibrosis and fibrofatty replacement in the left ventricular (LV) outer myocardium, mainly in the posterolateral wall, and in the right ventricle. A similar phenotype, but with significantly more severe fibrotic changes in the LV, was found in the PLN mutation group (n = 8). Cardiomyopathies associated with lamin A/C (n = 5), sarcomeric (n = 8), and desmin (n = 3) mutations all showed a different pattern from that of the desmosomal and PLN mutation carriers. The posterolateral LV wall appeared to be the most discriminative area with fibrosis and fatty changes predominantly at the outer compact myocardium in 13 of 14 hearts with desmosomal and PLN mutations (93%), in 0 of 13 hearts with lamin A/C and sarcomeric mutations (0%), and in 1 of 3 desminopathic hearts (33%) (P < .001).
Desmosomal- and PLN-associated cardiomyopathies have a fibrosis pattern distinct from the patterns in other hereditary cardiomyopathies. The posterolateral LV wall appeared to be the most discriminative region between mutation groups. These results may provide a roadmap for cardiac imaging interpretation and may help in further unraveling disease mechanisms.
The ability of pneumococcal conjugate vaccine (PCV) to decrease transmission by blocking the acquisition of colonization has been attributed to herd immunity. We describe the role of mucosal ...immunoglobulin G (IgG) to capsular polysaccharide (CPS) in mediating protection from carriage, translating our findings from a murine model to humans. We used a flow cytometric assay to quantify antibody-mediated agglutination demonstrating that hyperimmune sera generated against an unencapsulated mutant was poorly agglutinating. Passive immunization with this antiserum was ineffective to block acquisition of colonization compared to agglutinating antisera raised against the encapsulated parent strain. In the human challenge model, samples were collected from PCV and control-vaccinated adults. In PCV-vaccinated subjects, IgG levels to CPS were increased in serum and nasal wash (NW). IgG to the inoculated strain CPS dropped in NW samples after inoculation suggesting its sequestration by colonizing pneumococci. In post-vaccination NW samples pneumococci were heavily agglutinated compared with pre-vaccination samples in subjects protected against carriage. Our results indicate that pneumococcal agglutination mediated by CPS-specific antibodies is a key mechanism of protection against acquisition of carriage. Capsule may be the only vaccine target that can elicit strong agglutinating antibody responses, leading to protection against carriage acquisition and generation of herd immunity.
The use of biosolids in agriculture continues to be debated, largely in relation to their metal contents. Our knowledge regarding the speciation and bioavailability of biosolids metals is still far ...from complete. In this study, a multi-technique approach was used to investigate copper and zinc speciation and partitioning in one contemporary and two historical biosolids used extensively in previous research and field trials. Using wet chemistry and synchrotron spectroscopy techniques it was shown that copper/zinc speciation in the biosolids was largely equivalent despite the biosolids being derived from different countries over a 50 year period. Furthermore, copper speciation was consistently dominated by sorption to organic matter whereas Zn partitioned mainly to iron oxides. These data suggest that the results of historical field trials are still relevant for modern biosolids and that further risk assessment studies should concentrate particularly on Cu as this metal is associated with the mineralisable biosolids fraction.
► Complementary techniques were used to investigate Cu and Zn speciation in biosolids. ► Historic and contemporary biosolids with differing metal contents were examined. ► Similarities in Cu/Zn speciation were observed irrespective of biosolids provenance. ► Key binding environments identified were organic matter for Cu and Fe oxides for Zn. ► Similarities show historic field trial results are still relevant for biosolids management.
Historic and contemporary biosolids show similarities in Cu/Zn speciation despite having very different total Zn/Cu contents.
Purpose
To determine the incidence rate and identify predictive factors for interval appendectomy after non-operatively treated complicated appendicitis.
Methods
Single-center retrospective cohort ...study conducted between January 2008 and June 2017. Adult patients with acute appendicitis were identified. Patients with complicated appendicitis initially treated non-operatively were included. Outcomes included abscess rate on imaging, results of additional imaging during follow-up, incidence rate of and surgical indications for interval appendectomy, and outcomes of histological reports.
Results
Of all adult patients with acute appendicitis (
n
= 1839), 9% (170/1839) was initially treated non-operatively. Median age of these patients was 55 years (IQR 42–65) and 48.8% (83/170) were men. In 36.4% (62/170) of the patients, an appendicular abscess was diagnosed. 62.4% (106/170) did not require subsequent surgery (no interval appendectomy group) and in 37.6% (64/170), an interval appendectomy was performed (interval appendectomy group). Median follow-up was 80 weeks (17–192) and 113 weeks (34–246), respectively. Most frequent reason to perform subsequent surgery was recurrent appendicitis (45% (29/64)). Increasing age was significantly associated with a lower risk of undergoing interval appendectomy (OR 0.7; CI 0.6–0.89);
p
= 0.002). In the interval appendectomy group, appendicular neoplasm was found in 11% (7/64) of the patients, in contrast to 1.5% (25/1669) of the patients that had acute surgery (
p
< 0.001).
Conclusions
One out of three patients non-operatively treated for complicated appendicitis required an interval appendectomy. The incidence of appendicular neoplasms was high in these patients compared with those that had acute surgery. Therefore, additional radiological imaging following non-operatively treated complicated appendicitis is recommended.
Environmental samples are extremely diverse but share a tendency for heterogeneity and complexity. This heterogeneity poses methodological challenges when investigating biogeochemical processes. In ...recent years, the development of analytical tools capable of probing element distribution and speciation at the microscale have allowed this challenge to be addressed. Of these available tools, laterally resolved synchrotron techniques such as X-ray fluorescence mapping are key methods for the in situ investigation of micronutrients and inorganic contaminants in environmental samples. This article demonstrates how recent advances in X-ray fluorescence detector technology are bringing new possibilities to environmental research. Fast detectors are helping to circumvent major issues such as X-ray beam damage of hydrated samples, as dwell times during scanning are reduced. They are also helping to reduce temporal beamtime requirements, making particularly time-consuming techniques such as micro X-ray fluorescence (μXRF) tomography increasingly feasible. This article focuses on μXRF mapping of nutrients and metalloids in environmental samples, and suggests that the current divide between mapping and speciation techniques will be increasingly blurred by the development of combined approaches.
Figure
Tricolour maps of elemental distributions in a barley grain: Zn (
red
), Compton (
green
) and Mn (
blue
)
Motivated by the challenge of capturing complex hierarchical chemical detail in natural material from a wide range of applications, the Maia detector array and integrated realtime processor have been ...developed to acquire X-ray fluorescence images using X-ray Fluorescence Microscopy (XFM). Maia has been deployed initially at the XFM beamline at the Australian Synchrotron and more recently, demonstrating improvements in energy resolution, at the P06 beamline at Petra III in Germany. Maia captures fine detail in element images beyond 100 M pixels. It combines a large solid-angle annular energy-dispersive 384 detector array, stage encoder and flux counter inputs and dedicated FPGA-based real-time event processor with embedded spectral deconvolution. This enables high definition imaging and enhanced trace element sensitivity to capture complex trace element textures and place them in a detailed spatial context. Maia hardware and software methods provide per pixel correction for dwell, beam flux variation, dead-time and pileup, as well as off-line parallel processing for enhanced throughput. Methods have been developed for real-time display of deconvoluted SXRF element images, depth mapping of rare particles and the acquisition of 3D datasets for fluorescence tomography and XANES imaging using a spectral deconvolution method that tracks beam energy variation.
Continuous-flow left ventricular assist devices (CF-LVADs) are increasingly used in the management of patients with end-stage heart failure; however, CF-LVAD support can be hampered by the occurrence ...of ventricular arrhythmias (VAs) (1-5). In a multivariate Cox regression model, only pre-LVAD VA remained as an independent predictor of late post-LVAD VA (adjusted hazard ratio HR: 2.13; 95% confidence interval CI: 1.06 to 4.27; p = 0.03) (Figure 1B).
This study analyzes the outcome of esophageal resection in patients 70 or more years of age, compared with patients aged less than 70 years and identifies risk factors for worse outcome in the ...elderly.
Comorbidity, postoperative morbidity, in-hospital mortality and survival rates were compared between 811 patients aged less than 70 years and 250 patients aged 70 years or more who underwent esophagectomy for esophageal cancer in a single high-volume center from 1985 to 2005.
Groups were similar regarding surgical approach, resectability, and tumor stage. More patients aged 70 years or more had cardiovascular and respiratory concomitant disease. Among patients aged 70 years or more, the prevalence of adenocarcinoma and Barrett's transformation was higher (67% versus 53% for patients aged less than 70 years, and 22% versus 15%, respectively). There were no differences in surgical complications (20% versus 17%). Nonsurgical complications occurred more in patients aged 70 years or more (35% versus 27%) and operative mortality was higher among elderly patients (8.4 versus 3.8%), as was in-hospital mortality (11.6% versus 5.4%). The disease-specific 5-year survival was lower for patients aged 70 years or more (27% versus 34%). The 1-year survival, reflecting the impact of operative morbidity and mortality, was 58% for patients aged 70 years or more and 68% for the patients aged less than 70 years (p = 0.002). Among patients aged 70 years or more, respiratory comorbidity and thoracoabdominal resection were risk factors for the occurrence of nonsurgical complications and respiratory comorbidity for in-hospital mortality.
Older patients have increased operative and in-hospital mortality and decreased 5-year survival after esophageal resection for cancer. Our results indicate that especially thoracoabdominal resection for esophageal carcinoma should be carefully considered for patients older than 70 years who suffer from respiratory disease.
PDF
