Impact of case-relevant and case-irrelevant communication within the surgical team on surgical-site infection

BACKGROUND Surgical-site infections (SSIs) are the most common complications after surgery. An influence from talking and distractions during surgery on patient outcomes has been suggested, but there is limited evidence. The aim of this prospective observational study was to assess the relationship between intraoperative communication within the surgical team and SSI, and between intraoperative distractions and SSI. METHODS This prospective observational study included patients undergoing elective, open abdominal procedures. For each procedure, intraoperative case-relevant and case-irrelevant communication, and intraoperative distractions were observed continuously on site. The influence of communication and distractions on SSI after surgery was assessed using logistic regressions, adjusting for risk factors. RESULTS A total of 167 observed procedures were analysed; their mean(s.d.) duration was 4·6(2·1) h. A total of 24 SSIs (14·4 per cent) were diagnosed. Case-relevant communication during the procedure was independently associated with a reduced incidence of organ/space SSI (propensity score-adjusted odds ratio 0·86, 95 per cent c.i. 0·77 to 0·97; P = 0·014). Case-irrelevant communication during the closing phase of the procedure was independently associated with increased incidence of incisional SSI (propensity score-adjusted odds ratio 1·29, 1·08 to 1·55; P = 0·006). Distractions had no association with SSI. CONCLUSION More case-relevant communication was associated with fewer organ/space SSIs, and more case-irrelevant communication during wound closure was associated with incisional SSI.

Outcomes of Active Surveillance for Ductal Carcinoma in Situ: A Computational Risk Analysis.

BACKGROUND Ductal carcinoma in situ (DCIS) is a noninvasive breast lesion with uncertain risk for invasive progression. Usual care (UC) for DCIS consists of treatment upon diagnosis, thus potentially overtreating patients with low propensity for progression. One strategy to reduce overtreatment is active surveillance (AS), whereby DCIS is treated only upon detection of invasive disease. Our goal was to perform a quantitative evaluation of outcomes following an AS strategy for DCIS. METHODS Age-stratified, 10-year disease-specific cumulative mortality (DSCM) for AS was calculated using a computational risk projection model based upon published estimates for natural history parameters, and Surveillance, Epidemiology, and End Results data for outcomes. AS projections were compared with the DSCM for patients who received UC. To quantify the propagation of parameter uncertainty, a 95% projection range (PR) was computed, and sensitivity analyses were performed. RESULTS Under the assumption that AS cannot outperform UC, the projected median differences in 10-year DSCM between AS and UC when diagnosed at ages 40, 55, and 70 years were 2.6% (PR = 1.4%-5.1%), 1.5% (PR = 0.5%-3.5%), and 0.6% (PR = 0.0%-2.4), respectively. Corresponding median numbers of patients needed to treat to avert one breast cancer death were 38.3 (PR = 19.7-69.9), 67.3 (PR = 28.7-211.4), and 157.2 (PR = 41.1-3872.8), respectively. Sensitivity analyses showed that the parameter with greatest impact on DSCM was the probability of understaging invasive cancer at diagnosis. CONCLUSION AS could be a viable management strategy for carefully selected DCIS patients, particularly among older age groups and those with substantial competing mortality risks. The effectiveness of AS could be markedly improved by reducing the rate of understaging.

Direct Democracy and Institutional Trust: Relationships and Differences across Personality Traits

Direct democracy plays a prominent role in the explanation of institutional trust. To date, however, empirical findings on the effects of direct democracy remain inconclusive. In this article, we argue that this inconclusiveness can be partly ascribed to the diverse effects direct democracy has on individuals. In other words, direct democracy influences institutional trust, but how and to what degree depends on individuals’ personality traits. Running hierarchical analyses of unique survey data from a random sample of eligible Swiss voters, we document three findings: First, we show that the number of ballot measures is not directly associated with institutional trust. Second, we demonstrate that the Big Five personality traits affect the propensity to trust. Third, some of these traits also alter the relationship between direct democracy and institutional trust, suggesting that certain personality types are more likely to be sensitive to popular votes than others and that not everyone is equally likely to respond to political stimuli, even in highly democratic environments.

Does the use of mobile devices (tablets and smartphones) affect survey quality and choice behaviour in web surveys?

Web surveys are becoming increasingly popular in survey research including stated preference surveys. Compared with face-to-face, telephone and mail surveys, web surveys may contain a different and new source of measurement error and bias: the type of device that respondents use to answer the survey questions. This is the first study that tests whether the use of mobile devices, tablets or smartphones, affects survey characteristics and stated preferences in a web-based choice experiment. The web survey on expanding renewable energy production in Germany was carried out with 3182 respondents, of which 12% used a mobile device. Propensity score matching is used to account for selection bias in the use of mobile devices for survey completion. We find that mobile device users spent more time than desktop/laptop users to answer the survey. Yet, desktop/laptop users and mobile device users do not differ in acquiescence tendency as an indicator of extreme response patterns. For mobile device users only, we find a negative correlation between screen size and interview length and a positive correlation between screen size and acquiescence tendency. In the choice experiment data, we do not find significant differences in the tendency to choose the status quo option and scale between both subsamples. However, some of the estimates of implicit prices differ, albeit not in a unidirectional fashion. Model results for mobile device users indicate a U-shaped relationship between error variance and screen size. Together, the results suggest that using mobile devices is not detrimental to survey quality.

Übergangslösungen beim Eintritt in die Schweizer Berufsbildung: Brückenschlag oder Sackgasse?

In der Schweiz finden viele Jugendliche keinen direkten Zugang zu einer beruflichen Grundbildung; vielmehr durchlaufen sie zunächst eine so genannte Übergangslösung oder ein Brückenangebot wie z.B. ein zehntes Schuljahr. Wir beleuchten in diesem Beitrag zum einen, wie schulische, individuelle, familiäre und kontextuell-systemische Faktoren den Übertritt in solche Brückenangebote beeinflussen. Zum anderen gehen wir der Frage nach, wie sich ein verzögerter Einstieg via ein Brückenangebot auf die Chance auswirkt, einen Abschluss der Sekundarstufe II zu erwerben. Die empirische Analyse stützt sich auf die TREE-Studie, welche eine Kohorte von Schulentlassenen des Jahres 2000 längsschnittlich beobachtet. Wir modellieren dabei zunächst die interessierenden Übertrittsprozesse mittels einer multinomialen logistischen Regression, um dann mittels Propensity Score Matching deren Wirkung auf die nachobligatorischen Bildungschancen abzuschätzen.

Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke: A Matched-Pairs Analysis.

BACKGROUND AND PURPOSE Five randomized controlled trials have consistently shown that mechanical thrombectomy (MT) in addition to best medical treatment (±intravenous tissue-type plasminogen activator) improves outcome after acute ischemic stroke in patients with large artery anterior circulation stroke. Whether direct MT is equally effective as combined intravenous thrombolysis with MT (ie, bridging thrombolysis) remains unclear. METHODS We retrospectively compared clinical and radiological outcomes in 167 bridging patients with 255 patients receiving direct MT because of large artery anterior circulation stroke. We matched all patients from the direct MT group who would have qualified for intravenous tissue-type plasminogen activator with controls from the bridging group, using multivariate and propensity score analyses. Functional independence was defined as modified Rankin Scale score of 0 to 2. RESULTS From February 2009 to August 2014, 40 patients from the direct MT group would have qualified for bridging thrombolysis but were treated with MT only. Clinical and radiological characteristics did not differ from the bridging cohort, except for higher rates of hypercholesterolemia (P=0.019), coronary heart disease (P=0.039), and shorter intervals from symptom onset to endovascular intervention (P=0.01) in the direct MT group. Functional independence, mortality, and intracerebral hemorrhage rates did not differ (P>0.1). After multivariate matching analysis outcome in both groups did not differ, except for lower rates of asymptomatic intracerebral hemorrhage (P=0.023) and lower mortality (P=0.007) in the direct MT group. CONCLUSIONS In patients with large anterior circulation stroke, direct mechanical intervention seems to be equally effective as bridging thrombolysis. A randomized trial comparing direct MT with bridging therapy is warranted.

Superior outcomes of decompression with an interlaminar dynamic device versus decompression alone in patients with lumbar spinal stenosis and back pain: a cross registry study.

INTRODUCTION Surgical decompression for lumbar spinal stenosis (LSS) has been associated with poorer outcomes in patients with pronounced low back pain (LBP) as compared to patients with predominant leg pain. This cross registry study assessed potential benefits of the interlaminar coflex® device as an add-on to bony decompression alone. METHODS Patients with lumbar decompression plus coflex® (SWISSspine registry) were compared with decompressed controls (Spine Tango registry). Inclusion criteria were LSS and a preoperative back pain level of ≥5 points. 1:1 propensity score-based matching was performed. Outcome measures were back and leg pain relief, COMI score improvement, patient satisfaction, complication, and revision rates. RESULTS 50 matched pairs without residual significant differences but age were created. At the 7-9 months follow-up interval the coflex® group had higher back (p=0.014) and leg pain relief (p<0.001) and COMI score improvement (p=0.029) than the decompression group. Patient satisfaction was 90% in both groups. No revision was documented in the coflex® and one in the decompression group (2.0%). DISCUSSION In the short-term, lumbar decompression with coflex® compared with decompression alone in patients with LSS and pronounced LBP at baseline is a safe and effective treatment option that appears beneficial regarding clinical and functional outcomes. However, residual confounding of non-measured covariables may have partially influenced our findings. Also, despite careful inclusion and exclusion of cases the cross registry approach introduces a potential for selection bias that we could not totally control for and that makes additional studies necessary.

Cytomegalovirus Immunoglobulin After Thoracic Transplantation: An Overview

Cytomegalovirus (CMV) is a highly complex pathogen which, despite modern prophylactic regimens, continues to affect a high proportion of thoracic organ transplant recipients. The symptomatic manifestations of CMV infection are compounded by adverse indirect effects induced by the multiple immunomodulatory actions of CMV. These include a higher risk of acute rejection, cardiac allograft vasculopathy after heart transplantation, and potentially bronchiolitis obliterans syndrome in lung transplant recipients, with a greater propensity for opportunistic secondary infections. Prophylaxis for CMV using antiviral agents (typically oral valganciclovir or intravenous ganciclovir) is now almost universal, at least in high-risk transplants (D+/R-). Even with extended prophylactic regimens, however, challenges remain. The CMV events can still occur despite antiviral prophylaxis, including late-onset infection or recurrent disease, and patients with ganciclovir-resistant CMV infection or who are intolerant to antiviral therapy require alternative strategies. The CMV immunoglobulin (CMVIG) and antiviral agents have complementary modes of action. High-titer CMVIG preparations provide passive CMV-specific immunity but also exert complex immunomodulatory properties which augment the antiviral effect of antiviral agents and offer the potential to suppress the indirect effects of CMV infection. This supplement discusses the available data concerning the immunological and clinical effects of CMVIG after heart or lung transplantation