Meta-analysis of preoperative antiseptic bathing in the prevention of surgical site infection

Background

Preoperative bathing with an antiseptic solution is widely used to prevent surgical site infection, but trial results are conflicting.

Methods

Trials were identified by searches of Medline, Embase and the Cochrane controlled trials register. Studies were eligible if they compared an antiseptic solution used in preoperative bathing with a non-antiseptic washing agent or with no bathing and if they reported data on surgical site infection.

Results

Six trials with a total of 10 007 patients were included; all of them used 4 per cent chlorhexidine gluconate. Three trials with 7691 patients compared chlorhexidine with placebo. Bathing with chlorhexidine did not reduce surgical site infection rate; the relative risk (RR) was 0·91. Including only trials of high quality, the RR was 0·95. Three trials with 1443 patients compared bar soap with chlorhexidine; no differences in the surgical site infection rates were detected, and the RR was 1·02. Two trials of 1092 patients compared bathing with chlorhexidine with no washing. The surgical site wound infection rate in the two groups was similar, and the RR was 0·70.

Conclusions

The evidence does not support preoperative bathing with chlorhexidine as a means of reducing surgical site wound infection.

Left ventricular hypertrophy determined by Sokolow–Lyon criteria: a different predictor in women than in men?

The clinical usefulness of the Sokolow-Lyon voltage criteria in the assessment of electrocardiographic left ventricular hypertrophy (ECG LVH) is addressed. We prospectively studied 3,338 women and 3,330 men referred with hypertension, with an average follow-up of 11.2 years. The voltage amplitude sum SV1+max (RV5 or RV6) was calculated and ECG LVH was defined as a sum >or=3.5 mV. We adjusted survival for age, treatment status before presentation and a previous myocardial infarction or cerebrovascular accident. The risk of stroke, coronary heart disease (CHD) and cardiovascular disease (CVD) mortality increased significantly for each quantitative 0.1 mV increase in baseline electrocardiogram (ECG) voltage, in women within the range of 1.6-3.9% and in men 1.4-3.0%. After further adjustments for race, body mass index, smoking and systolic blood pressure, increasing voltage independently predicted CVD mortality in both men and women. In women, both increasing voltage and the presence of left ventricular hypertrophy (LVH) were predictors of stroke mortality, whereas in men this risk was attenuated. In men, the adjusted association between increasing voltage and CHD mortality tended to be stronger than in women. The use of different thresholds for the two genders made little difference. For stroke and CHD mortality, the population attributable fractions associated with LVH were 15.2 and 5.4% in women and 12.8 and 8.5% in men, respectively. In conclusion, the greater the baseline ECG voltage sum, the greater the associated CVD mortality risk. Women tended to have a high risk of stroke mortality owing to LVH despite adjustments.

Preoperative bathing or showering with skin antiseptics to prevent surgical site infection

BACKGROUND

Surgical site infections (SSIs) are wound infections that occur after invasive (surgical) procedures. Preoperative bathing or showering with an antiseptic skin wash product is a well-accepted procedure for reducing skin bacteria (microflora). It is less clear whether reducing skin microflora leads to a lower incidence of surgical site infection.

OBJECTIVES

To review the evidence for preoperative bathing or showering with antiseptics for the prevention of hospital-acquired (nosocomial) surgical site infection.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE (January 1966 to December 2005) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials comparing any antiseptic preparation used for preoperative full-body bathing or showering with non-antiseptic preparations in patients undergoing surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for selection, trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Six trials involving a total of 10,007 participants were included. Three of the included trials had three comparison groups. The antiseptic used in all trials was 4% chlorhexidine gluconate (Hibiscrub). Three trials involving 7691 participants compared chlorhexidine with a placebo. Bathing with chlorhexidine compared with a placebo did not result in a statistically significant reduction in SSIs; the relative risk of SSI (RR) was 0.91 (95% confidence interval (CI) 0.80 to 1.04). When only trials of high quality were included in this comparison, the RR of SSI was 0.95 (95%CI 0.82 to 0.10). Three trials of 1443 participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). Two trials of 1092 patients compared bathing with chlorhexidine with no washing. No difference was found in the postoperative SSI rate between patients who washed with chlorhexidine and those who did not wash preoperatively (RR 0.70, 95% CI 0.19 to 2.58).

AUTHORS' CONCLUSIONS

This review provides evidence of no benefit for preoperative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection. Efforts to reduce the incidence of nosocomial surgical site infection should focus on interventions where effect has been demonstrated.

[Maillard reaction products in food as pro-inflammatory and pro-arteriosclerotic factors of degenerative diseases]

Heating of food induces the formation of Maillard reaction products (MRPs) caused by the reaction of reducing sugars with proteins or amino acids. Analogous reactions occur in the human body, eventually forming "Advanced Glycation Endproducts" (AGEs). AGEs accumulate in aging tissues accelerating degenerative-inflammatory and proliferative processes. MRPs present in food can also directly cause inflammatory processes in the intestines and, once absorbed, would support and reinforce any inflammatory and degenerative process occurring in the body. The contribution of AGEs (and additional MRPs) in the development of diabetic complications as well as nephropathy, neuropathy, micro- and macroangiopathies is now well established. Which of the MRPs or AGEs in particular induce these cellular processes is currently unknown. Thus the exact knowledge of the chemical structures of the MRPs could help to minimize the formation of "harmful MRPs" that occur due to heating in food processing. Because MRPs play a decisive role in the successful marketing of edibles due to their characteristics as flavor components, it is important to increase the amount of innocuous and palatable MRPs, and minimize signal active pro-inflammatory MRPs by the use of defined preparation methods. It is practicable to use low-priced immunological methods for the quantitative determination of specific MRPs or AGEs. In the medical area, the knowledge of the signal active MRP/AGE structures provides the opportunity to measure their concentrations in body fluids and tissues and thus determine their influence on inflammatory and age-related degenerative processes (e. g., late diabetic complications, arteriosclerosis, degeneration of neurons). From a clinical perspective, the application of RAGE antagonists after an appropriate chemical diagnosis could be effective in supporting the treatment of affected patient groups, especially older diabetic and dialysis patients.

A comparison of computerised strain gauge plethysmography with D-dimer testing in screening for deep-vein thrombosis

There has been a significant increase in the amount of diagnostic testing performed to confirm or refute a diagnosis of deep-vein thrombosis (DVT), often in low-risk patients. D-dimer testing and computer-assisted strain gauge plethysmography (SGP) are rapid, inexpensive methods of excluding DVT and, in combination with a clinical probability score for DVT, both have been used to accurately exclude DVT. D-dimer testing, SGP and a combination of both in excluding DVT were compared in 243 ambulant outpatients who followed a prespecified investigation protocol. The negative-predictive value of D-dimer testing alone was 100%, 93.9% (95% CI 93.6-94.1) and 80% (95% CI 73.7-86.3) in patients with a low, moderate and high pretest probability (PTP) score for DVT respectively. The corresponding results for SGP were 95.6% (95% CI 95.5-95.7), 86.1% (95% CI 85.9-86.4) and 77.8% (95% CI 75.9-79.7) in patients with a low, moderate and high PTP score for DVT respectively. D-dimer testing provided a rapid, cost-effective method for excluding DVT in low-risk ambulant patients, which was superior to SGP. Combined use of the modalities did not improve any aspect of clinical decision making.

Adaptation to disruption of the electron transfer pathway for Fe(III) reduction in Geobacter sulfurreducens

Previous studies demonstrated that an outer membrane c-type cytochrome, OmcB, was involved in Fe(III) reduction in Geobacter sulfurreducens. An OmcB-deficient mutant was greatly impaired in its ability to reduce both soluble and insoluble Fe(III). Reintroducing omcB restored the capacity for Fe(III) reduction at a level proportional to the level of OmcB production. Here, we report that the OmcB-deficient mutant gradually adapted to grow on soluble Fe(III) but not insoluble Fe(III). The adapted OmcB-deficient mutant reduced soluble Fe(III) at a rate comparable to that of the wild type, but the cell yield of the mutant was only ca. 60% of that of the wild type under steady-state culturing conditions. Analysis of proteins and transcript levels demonstrated that expression of several membrane-associated cytochromes was higher in the adapted mutant than in the wild type. Further comparison of transcript levels during steady-state growth on Fe(III) citrate with a whole-genome DNA microarray revealed a significant shift in gene expression in an apparent attempt to adapt metabolism to the impaired electron transport to Fe(III). These results demonstrate that, although there are many other membrane-bound c-type cytochromes in G. sulfurreducens, increased expression of these cytochromes cannot completely compensate for the loss of OmcB. The concept that outer membrane cytochromes are promiscuous reductases that are interchangeable in function appears to be incorrect. Furthermore, the results indicate that there may be different mechanisms for electron transfer to soluble Fe(III) and insoluble Fe(III) oxides in G. sulfurreducens, which emphasizes the importance of studying electron transport to the environmentally relevant Fe(III) oxides.

Estrogen replacement in women of fertile years with hypopituitarism

BACKGROUND

What form of estrogen to prescribe a young hypopituitary woman with gonadal failure remains an open question despite evidence that oral estrogen therapy induces GH resistance and an increase in fat mass.

METHODS

Using an international surveillance study of hypopituitary patients, we examined two questions: 1) What estrogen is prescribed to young women of fertile years with hypopituitarism? 2) Is there a difference in body composition or IGF-I levels dependent on the type of estrogen prescribed?

RESULTS

Six hundred twenty-eight GH-deficient women, aged 18-50 yr, were identified. Three hundred thirteen had normal gonadal function, and 315 were receiving estrogen therapy; of these 14% were using transdermal estradiol, and 86% were taking an oral estrogen preparation (38% oral estradiol, 18% conjugated estrogens, and 30% ethinyl estradiol in the oral contraceptive). There was no difference in weight, waist/hip ratio, or body composition between the women taking different estrogen therapies. However, if the oral estrogen groups were combined, they showed less change in waist and hip measurement and had a greater waist/hip ratio after 1 yr of GH treatment compared with patients with normal gonadal function (0.85 vs. 0.83; P = 0.022). Patients taking ethinyl estradiol had lower age-adjusted IGF-I sd scores and required almost twice the GH dose to achieve an IGF-I sd score that remained lower than patients with normal gonadal function and patients receiving transdermal estradiol.

CONCLUSIONS

1) The majority of women of fertile years with hypo-pituitarism take oral estrogen replacement therapy. 2) Waist/hip ratio was greater in women taking oral estrogens, and there is indirect evidence that oral estrogens reduce the action of GH on fat mass. 3) Patients using the oral contraceptive had lower IGF-I levels and required twice the GH dose compared with patients receiving transdermal estradiol.

The assessment and implementation of animal welfare: theory into practice

This paper reviews the procedures and protocols necessary for the development of a practical programme for the assessment and implementation of animal welfare on farms and in other commercial situations. An effective programme must incorporate measures of both husbandry and welfare. Most current systems are based almost entirely on measures of husbandry provision, e.g. resources and management. However, what the public and the animals need are guarantees of satisfactory welfare and these guarantees must involve animal-based measurements of welfare outcomes. The development and testing of the Bristol Welfare Assurance Programme is described in outline and illustrated with detailed reference to the assessment of welfare in dairy cows. The final section describes how such a programme can be incorporated into the broader concept of quality assurance schemes that incorporate a proper concern for animal welfare into the reasonable needs of different societies for wholesome, affordable food.

A light-weight cooling vest enhances performance of athletes in the heat

During the 1990s, emphasis on the health and safety of people who exercise in hot, humid conditions increased and many organizations became aware of the need for protection against heat-related disorders. A practical, pre-cooling strategy applicable to several sporting codes, which is low cost, easy to use, light-weight and which enhances cooling of the human body prior to and following exercise, was developed and tested. Eight males and eight females participated in a maximal oxygen consumption (VO2max) test and four trials: a control (without cooling) and wearing each of three different cooling vests (A, B, C). Vests were worn during the rest, stretch, warm-up (50% VO2max) and recovery stages of the protocol, but not during the 30 min run (70% VO2max). Core and skin temperatures during exercise were reduced (by approximately 0.5 degrees C, rectal; 0.1-1.4 degrees C, abdominal skin temperature) and sweat rates were lower (by approximately 10-23%). Endurance times for running at 95% of VO2max were increased by up to 49 s. Perceptions of the thermal state and skin wetness showed changes to greater levels of satisfaction. Physiological and sensory responses were related to design features of the vests.

Effects of carvedilol on left ventricular remodelling in chronic stable heart failure: a cardiovascular magnetic resonance study

BACKGROUND

The ability of beta blockers to improve left ventricular function has been demonstrated, but data on the effects on cardiac remodelling are limited.

OBJECTIVE

To investigate, using cardiovascular magnetic resonance (CMR), the effects of carvedilol on left ventricular remodelling in patients with chronic stable heart failure and left ventricular systolic dysfunction caused by coronary artery disease.

DESIGN

Randomised, double blind, placebo controlled study.

SETTING

Chronic stable heart failure.

PATIENTS AND INTERVENTION

34 patients with chronic stable heart failure and left ventricular systolic function taking part in the CHRISTMAS trial (double blind carvedilol v placebo) underwent CMR before randomisation and after six months of treatment.

MAIN OUTCOME MEASURE

Left ventricular remodelling at six months.

RESULTS

The carvedilol and placebo groups were well balanced at baseline, with no significant intergroup differences. Over the study period, there was a significant reduction in end systolic volume index (ESV(I)) and end diastolic volume index (EDV(I)) between the carvedilol and the placebo group (carvedilol -9 v placebo +3 ml/m2, p = 0.0004; carvedilol -8 v placebo 0 ml/m2, p = 0.05). The ejection fraction increased significantly between the groups (carvedilol +3% v placebo -2%, p = 0.003).

CONCLUSIONS

Treatment of chronic stable heart failure with carvedilol results in significant improvement in left ventricular volumes and function. These effects might contribute to the benefits of carvedilol on mortality and morbidity in patients with chronic heart failure.

Development of a computerized assessment of clinician adherence to a treatment guideline for patients with bipolar disorder

The adoption of treatment guidelines for complex psychiatric illness is increasing. Treatment decisions in psychiatry depend on a number of variables, including severity of symptoms, past treatment history, patient preferences, medication tolerability, and clinical response. While patient outcomes may be improved by the use of treatment guidelines, there is no agreed upon standard by which to assess the degree to which clinician behavior corresponds to those recommendations. This report presents a method to assess clinician adherence to the complex multidimensional treatment guideline for bipolar disorder utilized in the Texas Medication Algorithm Project. The steps involved in the development of this system are presented, including the reliance on standardized documentation, defining core variables of interest, selecting criteria for operationalization of those variables, and computerization of the assessment of adherence. The computerized assessment represents an improvement over other assessment methods, which have relied on laborious and costly chart reviews to extract clinical information and to analyze provider behavior. However, it is limited by the specificity of decisions that guided the adherence scoring process. Preliminary findings using this system with 2035 clinical visits conducted for the bipolar disorder module of TMAP Phase 3 are presented. These data indicate that this system of guideline adherence monitoring is feasible.

The effects of KT3-671, a new angiotensin II (AT 1) receptor blocker in mild to moderate hypertension

AIMS

To compare the antihypertensive effect, and tolerability and safety of once daily doses of KT3-671 with that of placebo in patients with mild to moderate uncomplicated essential hypertension.

METHODS

A randomised, multicentre, double blind, parallel-group comparison of KT3-671 with placebo. Hypertensive patients [Ambulatory Blood Pressure Monitoring (ABPM), mean daytime DBP > 90 mmHg, Office sitting mean DBP 95-114 after a 7-28 day washout period] entered a 2-week, single blind, run-in phase. Patients eligible for the double-blind phase were randomised to receive KT3-671 40 mg, 80 mg, 160 mg or placebo once daily over 4 weeks. The primary end-point was trough mean sitting office DBP. The study had 90% power to detect a 5 mmHg change between treatments and placebo at the 5% level of significance. The secondary end-points were 24 hour, daytime and night time mean ABPM.

RESULTS

Office DBP was significantly lower with KT3-671 40 mg but not the other 2 dosage groups (-3.2; 95% CL -6.1 : -0.3 P < 0.03). Office SBP was significantly reduced with all dosage groups (40 mg -5.9, 95% CL -11 : -0.9; 80 mg -4.9, 95% CL -9.9 : 0.1 and 160 mg -5.7, 95% CL -10.8 : -0.7 P < 0.05). All doses of KT3-671 reduced systolic and diastolic ABPM. The number of patients with treatment related adverse events were comparable to placebo (38.8% KT3-671 vs 32.8% placebo). There was some evidence of a dose-response relationship with fall in nocturnal ABPM.

CONCLUSIONS

Oral KT3-671 was well tolerated. KT3-671 reduced office systolic BP at all doses and diastolic BP at some of the doses. Due to greater precision and power, the falls in mean ambulatory systolic and diastolic pressure were all significantly lower than placebo.

The determinants of left ventricular hypertrophy defined by Sokolow-Lyon criteria in untreated hypertensive patients

Left ventricular hypertrophy (LVH) measured by electrocardiography (ECG LVH) in hypertensive patients has been shown to be associated with an increased risk of cardiovascular sequelae. Analysis of the determinants predisposing to ECG LVH may be helpful in the prevention of LVH. The Department of Health and Social Security Hypertension Care Computer Project studied 2994 hypertensive patients in whom an electrocardiogram was recorded while not on treatment. LVH was determined as the voltage sum SV1+RV5 or RV6>or=35 mm using Sokolow-Lyon voltage criteria. The relations were determined between the presence of LVH or voltage sum and different variables. Untreated systolic (SBP) and diastolic (DBP) blood pressure and pulse pressure were positively related to the increasing ECG voltage, while body mass index (BMI) and serum cholesterol were inversely related. Blood glucose and age did not correlate significantly. Patients with the presence of ECG LVH were more often men, black people, smokers and users of alcohol. In multiple logistic regression analyses, SBP, DBP, male gender and black race were positively, whereas BMI was negatively related to the presence of LVH. The positive relation of smoking and negative relation of serum cholesterol concentration to the presence of ECG LVH were apparent in men but not in women. This study confirms the adverse association between ECG LVH and SBP and DBP, male gender, black race and decreased BMI. It also addresses the less well-known associations of blood glucose, cholesterol, smoking and alcohol consumption.

The timescale of spinodal dewetting at a polymer/polymer interface

We investigate the dynamics of spinodal dewetting in liquid-liquid polymer systems. Dewetting of poly(methyl-methacrylate) (PMMA) thin films on polystyrene (PS) "substrates" is followed in situ using neutron reflectivity. By following the development of roughness at the PS/PMMA interface and the PMMA surface we extract characteristic growth times for the dewetting process. These characteristic growth times are measured as a function of the molecular weight of the two polymers. By also carrying out experiments in the regime where the dynamics are independent of the PS molecular weight, we are able to use dewetting to probe the scaling of the PMMA thin film viscosity with temperature and molecular weight. We find that this scaling reflects bulk behaviour. However, absolute values are low compared to bulk viscosities, which we suggest may be due in part to slippage at the polymer/polymer interface.

Postnatal depression: use of health services and satisfaction with health-care providers

The objective of this study was to compare health-care use and satisfaction with health-care providers between depressed and non-depressed women in the first 4 months after childbirth. Sixteen weeks after delivery a questionnaire, which included the Edinburgh Postnatal Depression Scale (EPDS) and items about health-care use and satisfaction, was mailed to women who attended the antenatal clinic, Royal Women's Hospital, Brisbane. Completed questionnaires were returned by 574 (86.4%) of the 664 women surveyed. During the study period most women (91%) visited a general practitioner at least once and 117 (12%) saw their doctor on five or more occasions. A total of 118 (20.7%) scored above 12 on the EPDS. Depressed women were more likely to visit a psychiatrist (OR, 9.2; 95% CI, 4.3-19.6), social worker (OR, 6.1; 95% CI, 3.3-11.1), postnatal depression group (OR, 4.0; 95% CI, 1.3-12.6), paediatrician (OR, 2.5; 95% CI, 1.6-3.9), or a general practitioner (OR, 2.1; 95% CI, 1.4-3.2) than non-depressed women. Twenty-two (18.5%) of the depressed women had contact with a psychiatrist. Compared with non-depressed women, those scoring above 12 on the EPDS were less satisfied with the services of general practitioners (P=< 0.000), paediatricians (P=0.002), Nursing Mothers' Associations of Australia (P=0.043) and obstetricians (P=0.045). Postpartum depression leads to an increase use of health-care services and has a negative effect on satisfaction with some services.

Increasing joint attention, play and language through peer supported play

The purpose of the present study was to examine the effects of participation in an integrated play group on the joint attention, symbolic play and language behavior of two young boys with autism. Two 6-year-old twin brothers participated in this study, along with three typically developing girls, ages 5, 9 and 11. A multiple baseline design was used with three phases: no intervention, intervention with adult coaching, and intervention without adult coaching. After being trained, the three typically developing children implemented the integrated play group techniques in 30 minute weekly play group sessions for over 16 weeks. Results indicate that participation in the integrated play group produced dramatic increases in shared attention to objects, symbolic play acts, and verbal utterances on the part of the participants with autism. These increases were maintained when adult support was withdrawn. Implications of these findings for inclusion of children with autism are discussed.

Women's responses to screening for domestic violence in a health-care setting

BACKGROUND

interest in the health impact of domestic violence is increasing and routine screening for violence in health settings has been recommended. However, there are limited data about how women feel about such screening.

AIM

to investigate women's responses to being screened for domestic violence during a routine clinic visit.

METHOD

a cross-sectional cohort study. Women (1500) from five Queensland hospitals were asked to complete a self-report questionnaire during the visit following the consultation at which they had been screened for domestic violence. Sealable envelopes and a 'posting box' were provided to ensure anonymity of returned envelopes.

FINDINGS

of the 1313 respondents, 98% believed it was a 'good idea' to screen for domestic violence. Over 96% felt 'OK' during the process and 77% of the 30 women who felt uncomfortable still agreed that it was a good idea to screen. Women from rural and remote areas of Queensland had similar responses to those of their city counterparts.

CONCLUSION

women in Queensland found screening for domestic violence acceptable and, where health providers are suitably educated, it should be included when taking a routine health history.

Water or antiseptic for periurethral cleaning before urinary catheterization: a randomized controlled trial

BACKGROUND

Despite a lack of empiric data to support the practice, traditionally, antiseptic solutions have been used to clean the periurethral area before inserting an indwelling catheter. The purpose of this study was to compare urinary colonization rates of subjects whose periurethral area was cleaned with water versus chlorhexidine 0.1% before the insertion of an indwelling urinary catheter.

METHODS

Obstetric patients who required urinary catheterization as part of their routine care were randomly assigned to either the "water" or "chlorhexidine" group with a sealed envelope. A sterile specimen of urine was collected 24 hours after insertion of the catheter.

RESULTS

Of the 436 patients (86.2%) with complete data (water group, 219; antiseptic group, 217), 38 (8.7%) had urinary tract bacteriuria >10(6) cfu/L. Rates of urinary tract infection were similar in each group (water group, 8.2%; antiseptic group, 9.2%; odds ratio 1.13; 95% confidence interval 0.58-2.21).

CONCLUSION

The practice of periurethral cleaning with an antiseptic did not decrease the rates of bacteriuria in this population and is probably not useful.

The origin and spread of the new daisy rust in Britain

Since 1997, wild and cultivated daisies in Britain and other European countries have been suffering from a rust fungus epidemic that menaces the future cultivation of horticultural varieties. The causal fungus was first discovered in Australia 100 years ago and may have evolved there from another rust fungus on daisies previously introduced from Europe. At present, ornamental daisies can be grown successfully only when protected by fungicide sprays.