A national survey of infection control practice by New Zealand anaesthetists

Anaesthetists have an important role in preventing nosocomial infection. Failures in this role have resulted in critical reports in the media. We ascertained the current practices of New Zealand anaesthetists relating to infection control, by distributing a questionnaire to all 450 anaesthetists practising in New Zealand. Sixty-one percent responded. Just over half the respondents had never read their hospital policy on infection control and over a third had never read the Australian and New Zealand College of Anaesthetists policy document on infection control. It was found that 3.4% rarely changed gloves if they became contaminated and 2.2% occasionally used the same syringe to administer drugs to more than one patient. The majority (86.3%) of respondents split one drug ampoule between more than one patient, 41.3% used multidose vials for more than one patient and 2.2% used pre-filled syringes for more than one patient. The majority complied with the College infection control policy for performing arterial cannulation (85.7%), central venous cannulation (77.4%) and regional blockade (65.1%). Respondents ranked the overall risk of the anaesthetist contributing to the transmission of infectious agents on a scale from 0 to 10 (10=highest risk). The median response was 7, the modal response was 10 and interquartile range was 4 to 8. There was a high level of awareness of the risks of contributing to cross-infection inherent in anaesthesia, most anaesthetists reporting that they followed recommended guidelines in this context. However, these data suggest more effort is required to promote compliance with appropriate guidelines.     

Extensive Cytoreductive Surgery for Appendiceal Carcinomatosis: Morbidity, Mortality, and Survival

Background

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) are frequently used to treat appendiceal carcinomatosis. Some patients require multivisceral resection because of the volume of disease. It is unclear whether extent of CRS impacts survival in appendiceal carcinomatosis.

Methods

We analyzed 282 patients undergoing attempted CRS/HIPEC for appendiceal carcinomatosis. Patients were defined as having undergone Extensive CRS (n = 60) if they had >3 organ resections or >2 anastomoses; a subgroup of Extreme CRS patients (n = 10) had ≥5 organ resections and ≥3 anastomoses. Kaplan–Meier survival curves and multivariate Cox-regression models were used to identify prognostic factors affecting outcomes.

Results

Relative to the comparison group, patients undergoing Extensive CRS had a higher median peritoneal carcinomatosis index, operative duration, blood loss, and length of stay. No difference in completeness of cytoreduction, severe morbidity, or 60-day mortality was evident. Subgroup analysis of 10 patients undergoing extreme CRS likewise revealed no increase in severe morbidity or mortality. Median progression-free (PFS) and overall survival (OS) were 23.5 and 74 months in the comparison group; 18.5 (p = 0.086) and 51 (p = 0.85) months in the Extensive CRS group; and 40 months and not reached in the Extreme CRS subgroup. In a multivariable analysis, extent of CRS was not independently associated with PFS or OS.

Conclusions

Extensive CRS is associated with greater OR time, blood loss, and length of stay, but is not associated with higher morbidity, mortality, or inferior oncologic outcomes in patients with appendiceal carcinomatosis.     

Have Levels of Evidence Improved the Quality of Orthopaedic Research?

Background

Since 2003 many orthopaedic journals have adopted grading systems for levels of evidence (LOE). It is unclear if the quality of orthopaedic literature has changed since LOE was introduced.

Questions/purposes

We asked three questions: (1) Have the overall number and proportion of Level I and II studies increased in the orthopaedic literature since the introduction of LOE? (2) Is a similar pattern seen in individual orthopaedic subspecialty journals? (3) What is the interobserver reliability of grading LOE?

Methods

We assigned LOE to therapeutic studies published in 2000, 2005, and 2010 in eight major orthopaedic subspecialty journals. Number and proportion of Level I and II publications were determined. Data were evaluated using log-linear models. Twenty-six reviewers (13 residents and 13 attendings) graded LOE of 20 blinded therapeutic articles from the Journal of Bone and Joint Surgery for 2009. Interobserver agreement relative to the Journal of Bone and Joint Surgery was assessed using a weighted kappa.

Results

The total number of Level I and II publications in subspecialty journals increased from 150 in 2000 to 239 in 2010. The proportion of high-quality publications increased with time (p < 0.001). All subspecialty journals other than the Journal of Pediatric Orthopaedics and the Journal of Orthopaedic Trauma showed a similar behavior. Average weighted kappa was 0.791 for residents and 0.842 for faculty (p = 0.209).

Conclusions

The number and proportion of Level I and II publications have increased. LOE can be graded reliably with high interobserver agreement. The number and proportion of high-level studies should continue to increase.     

Up-regulation of TLK1B by eIF4E overexpression predicts cancer recurrence in irradiated patients with breast cancer

BACKGROUND: The overexpression of eukaryotic initiation factor 4E (eIF4E), which is a critical component of the RNA helicase complex important in the translation of messenger RNAs with long and/or complex 5' untranslated regions, appears to impact malignant transformation and predict cancer recurrence in patients with breast cancer, independent of nodal status. Tousled-like kinase (TLK1B) is a mammalian threonine kinase with a long 5' untranslated regions in the messenger RNA. In vitro, malignant cells with eIF4E overexpression appear to have corresponding TLK1B elevation. Additionally TLK1B phosphorylates histone 3, which is a protein that is involved in chromatin assembly, plays an integral role in radioresistance in cell lines. Our hypothesis is that patients with breast cancer with high eIF4E overexpression have increased TLK1B and a higher risk for recurrence after adjuvant radiation therapy. METHODS: One hundred fifty-eight patients with stage I to III breast cancer were accrued in a prospective study that was designed to detect cancer recurrence in patients who had been treated with adjuvant radiation therapy. A standardized surveillance and treatment protocol was used to maximize treatment homogeneity and to detect the study primary end point, cancer recurrence. All patients received adjuvant radiation therapy either for high-risk node-positive disease or as a part of breast conservation therapy. TLK1B and eIF4E levels were quantified by Western blot. Statistical analysis was performed and included Spearman correlation, survival analysis by the Kaplan-Meier method, log-rank test, and Cox proportional hazard model. RESULTS: Both eIF4E (15.4 +/- 0.6, mean +/- SD) and TLK1B (18.8 +/- 1.5) were increased in all breast cancer specimens. Increasing eIF4E overexpression was correlated highly with increasing TLK1B (r = 0.35; P < .0001, Spearman coefficient). Tertile distribution of patients, based on the degree of eIF4E and TLK1B increase, demonstrated that the patients in the highest eIF4E group and the highest TLK1B group had a higher rate of cancer recurrences (P = .015 and .049, log rank test, respectively). After adjustment for stage of disease, age, and estrogen/progesterone receptor status, data showed that patients in the highest TLK1B group had a 3.0-fold increase in relative risk for cancer recurrence after adjuvant radiation therapy (P = .036; 95% CI, 1.0-5.0), compared with patients in the low TLK1B group. CONCLUSION: The overexpression of eIF4E is correlated with TLK1B increase in cancer specimens from patients with stage I to III breast cancer. High TLK1B increase in tumor specimens was associated with a higher risk for cancer recurrence after adjuvant radiation therapy. Resistance to radiotherapy may be 1 mechanism whereby eIF4E overexpression in breast cancer portends a worse prognosis.     

A systematic review of comparative studies on bone graft alternatives for common spine fusion procedures

Background

The increased prevalence of spinal fusion surgery has created an industry focus on bone graft alternatives. While autologous bone graft remains the gold standard, the complications and morbidity from harvesting autologous bone drives the search for reliable and safe bone graft substitutes. With the recent information about the adverse events related to bone morhogenetic protein use, it is appropriate to review the literature about the numerous products that are not solely bone morphogenetic protein.

Purpose

The purpose of this literature review is to determine the recommendations for use of non-bone morphogenetic protein bone graft alternatives in the most common spine procedures based on a quantifiable grading system.

Study design

Systematic literature review.

Methods

A literature search of MEDLINE (1946–2012), CINAHL (1937–2012), and the Cochrane Central Register of Controlled Trials (1940–April 2012) was performed, and this was supplemented by a hand search. The studies were then evaluated based on the Guyatt criteria for quality of the research to determine the strength of the recommendation.

Results

In this review, more than one hundred various studies on the ability of bone graft substitutes to create solid fusions and good patient outcomes are detailed.

Conclusion

The recommendations for use of bone graft substitutes and bone graft extenders are based on the strength of the studies and given a grade.