The source, cost and prevention of central venous catheter-related infection

Central venous catheters have become an integral part of patient management however they are associated with many complications including infection. Despite efforts being made to reduce the incidence of such infect ions the problem continues to increase and has resource implications for the Health Service. Studies relating to the source of microorganisms causing CVC-associated infection, the cost of such infections and the efficacy of an antimicrobial catheter have been undertaken. Thirty patients who required a CVC as part of their medical management and underwent cardiac surgery had the distal tips of their catheters sampled whilst in situ. Sampling took place within 1 h of catheter placement. Bacteria were isolated from 16% of the catheter distal tips sampled in situ. The guidewires used to insert the devices were also contaminated (50%). When CVC were inserted via a protective sheath, avoiding contact with the skin. the incidence of microbial contamination was reduced. These findings suggest that despite rigorous skin disinfection and strict aseptic technique, viable microorganisms are impacted onto the distal tip of CVC during the insertion procedure. Needleless intravascular access devices have been introduced in order to reduce the incidence of need1estick injury. However, it was unclear whether such connectors would act as a portal of entry for microorganisms to CVC. The efficacy of these devices was investigated. Within the controlled laboratory environment it was demonstrated that needleless devices, when challenged with microorganisms, did not allow the passage of microbes when flu id was injected. This therefore suggested that the devices should not increase the risk of catheter colonisation. When used in clinical practice however microbial contamination of the needleless connectors was 55 % in comparison to the routinely used luer connectors (23%). The cost of infections associated with CVC was determined. Twenty patients catheterised with a CVC designed for long term use who were admitted to hospital with a presumptive diagnosis of catheter-related infection were studied. The treatment given specifically for this infection was costed. The mean cost of such an infection was £ 1781.81. Throughout the UK this may amount to £1.565.906 per annum. The cost of infections associated with CVC designed for short term use was estimated to be between 5 and 7 million pounds per annum in the UK. In an attempt to reduce both the incidence and cost of catheter- related infection antimicrobial CVC have been developed. The efficacy of a novel polyurethane CVC impregnated on both the internal and external catheter surface with the quaternary ammonium compound benzalkonium chloride was investigated. Eighty eight patients received an antimicrobial catheter and 78 patients a conventional polyurethane CVC. The anti-microbial CVC resulted in a reduction in microbial colonisation of the external and internal polymer surfaces as compared to the control device. The observed reduction in microbial colonisation with the anti-microbial CVC may decrease the likelihood of subsequent infection offering a useful approach to the prevention of catheter-related infections.

Rural road accident investigation and prevention in Iran

The objectives are to examine rural road accident data in order to develop a method by which high accident rate locations and accident causes can be identified, and also to develop proposals for improvements at such locations and to identify measures which will improve road safety throughout the country. The problem of road safety in Iran is an important issue, because of the tragic and unnecessary loss of life, and the enormous cost of accidents in the country. The resources available to deal with the problems are limited and must be allocated on priority basis. This study represents an initial effort to identify the extent of the problem in order to take remedial measures. A study was made of all the available road accident data collected by agencies related to road safety in Iran, and the major organisations responsible for road safety development were visited. The Vice Minister of Roads and Transportation selected for this study a 280 Km rural road in South West Iran. Mainly because of the lack of suitable maps and plans of the roads, it was not possible to accurately identify the location of accidents. Accident scene data was subsequently collected by the highway police and personally by the author. The data for the study road was then analysed to identify 'high accident rate' locations, and also to determine, as far as was possible, the reasons for the accidents. The study suggests specific improvements for each of the high accident rate locations examined (eg. the building of dual carriageways with central guard rails to reduce the risk of collision with oncoming vehicles, pedestrian facilities to allow pedestrians to cross dangerous roadsl]. In addition recommendations are made to guide and assist the major organisations responsible for road safety in Iran. These recommendations are: (al for improving accident data collection and storage (bl for subsequent analysis for taking remedial measures with a view to accident prevention

Illness perceptions, beliefs and prevention of Type 2 Diabetes among British Pakistani mothers and young British Pakistani women

The prevalence rates of type2 diabetes mellitus (T2DM) continues to rise among British Pakistanis. The aim of this project was to explore T2DM perceptions and any preventative intentions among British Pakistani women and to discover whether they are doing anything to prevent the onset in themselves and their families. Initially a systematic review was conducted to investigate 20 existing prevention interventions and to assess their effectiveness (n=12,419). Mixed methods approach was adopted and three studies were conducted. The first study consisted of two focus groups with T2DM mothers (n=8) and three focus groups with non-T2DM mothers (n=17). The second study consisted of four focus groups young British Pakistani females (n=11). All focus groups were transcribed verbatim and analysed using thematic analysis. Following these a quantitative study was undertaken comprising of a questionnaire survey; 12 prevention-perception items (derived from the qualitative data) and the Illness-Perception Questionnaire Revised (IPQ-R) using participants from the same populations: T2DM mothers (n=41), non-T2DM mother (n=47) and young women (n=42). Results were analysed using multiple/hierarchical regression. The systematic review highlighted that the most effective prevention programmes focussed on behaviour and lifestyle with a combination of support and education to participants. The research studies demonstrated that T2DM was seen as an older person’s disease to be dealt with if/when it happens. T2DM mothers demonstrated knowledge and prevention understanding. There were non-significant relationships between prevention perceptions and T2DM illness perceptions across all three groups. The finding of this thesis emphasised that lifestyle interventions are crucial to aiding T2DM preventions as a good healthy diet and regular physical activity are the key components to T2DM prevention, and the importance of personal experience in perceived severity and lay-beliefs regarding T2DM and on family/cultural influences in British-Pakistanis. The findings of this project can be used to design culturally specific interventions towards preventing T2DM in the British Pakistani community.

The collection and use of road and traffic information for road accident investigation and prevention

DUE TO COPYRIGHT RESTRICTIONS ONLY AVAILABLE FOR CONSULTATION AT ASTON UNIVERSITY LIBRARY AND INFORMATION SERVICES WITH PRIOR ARRANGEMENT

The incidence, causes and prevention of defects in the constructiuon of new houses

DUE TO COPYRIGHT RESTRICTIONS ONLY AVAILABLE FOR CONSULTATION AT ASTON UNIVERSITY LIBRARY AND INFORMATION SERVICES WITH PRIOR ARRANGEMENT

Chlorhexidine and the prevention of surgical site infection

Surgical site infections (SSI) are a prevalent health care-associated infection (HAl). Prior to the mid-19th century, surgical sites commonly developed postoperative wound complications. It was in the 1860's, after Joseph Lister introduced carbolic acid and the principles of antisepsis that postoperative wound infection significantly decreased. Today, patient preoperative skin preparation with an antiseptic agent prior to surgery is a standard of practice. Povidone-iodine and chlorhexidine gluconate are currently the most commonly used antimicrobial agents used to prep the patient's skin. In this current study, the epidemiology, diagnosis, surveillance and prevention of SSI with chlorhexidine were investigated. The antimicrobial activity of chlorhexidine was assessed. In in-vitro and in-vivo studies the antimicrobial efficacy of 2% (w/v) chlorhexidine gluconate (CHG) in 70% isopropyl alcohol (IPA) and 10% povidoneiodine (PVP-I) in the presence of 0.9% normal saline or blood were examined. The 2% CHG in 70% IPA solutions antimicrobial activity was not diminished in the presence of 0.9% normal saline or blood. In comparison, the traditional patient preoperative skin preparation, 10% PVP-I antimicrobial activity was not diminished in the presence of 0.9% normal saline, but was diminished in the presence of blood. In an in-vivo human volunteer study the potential for reduction of the antimicrobial efficacy of aqueous patient preoperative skin preparations compromised by mechanical removal of wet product from the application site (blot) was assessed. In this evaluation, 2% CHG and 10% povidone-iodine (PVP-I) were blotted from the patient's skin after application to the test site. The blotting, or mechanical removal, of the wet antiseptic from the application site did not produce a significant difference in product efficacy. In a clinical trial to compare 2% CHG in 70% IPA and PVP-! scrub and paint patient preoperative skin preparation for the prevention of SSI, there were 849 patients randomly assigned to the study groups (409 in the chlorhexidine-alcohol and 440 in the povidone-iodine group) in the intention-to-treat analysis. The overall surgical site infection was significantly lower in the 2% CHG in 70% IPA group than in the PVP-I group (9.5% versus 16.1 %, p=0.004; relative risk, 0.59 with 95% confidence interval of 0.41 to 0.85). Preoperative cleansing of the patient's skin with chlorhexidine-alcohol is superior to povidone-iodine in preventing surgical site infection after clean-contaminated surgery.

The politics of exclusion:institutions and immigration policy in contemporary Germany

Immigration is one of the most sensitive issues of modern European politics. Nowhere is this more the case than in Germany, as a result of its history and the sheer scale of immigration it has experienced since 1945. Yet despite this background, Germany's immigration, residence and citizenship policy has been more restrictive when compared to that of many other countries; indeed, official policy long maintained that Germany was not a 'country of immigration'. But why has this been the case? The politics of exclusion provides a new analytical perspective on immigration in Germany, tracing the country's immigration and citizenship policy since the Second World War. The book argues that institutional politics are central to understanding why Germany's policy structures have experienced only incremental change over the past 20 years, and have remained comparatively restrictive. With its lively and accessible style, the book will appeal to advanced scholars and students of immigration and Germany.

Ocular and systemic markers for vascular function in those at risk of type 2 diabetes mellitus and cardiovascular disease

The devastating impact of Type 2 Diabetes Mellitus (T2DM) -related morbidity and mortality on global healthcare is escalating with higher prevalences of obesity, poor diet, and sedentary lifestyles. Therefore, the clinical need for early diagnosis and prevention in groups of high-risk individuals is necessary. The purpose of this thesis was to investigate the use of surrogate markers, namely retinal vascular function, to determine future vascular endothelial dysfunction, atherosclerosis, large vessel disease and cardiovascular risk in certain groups. This namely covered normoglycaemic and normotensive South Asians (SAs), those with Impaired-Glucose Tolerance (IGT) and individuals with a familial history (FH) of T2DM. Additionally the effect of overweight and obesity was studied. The techniques and modified protocols adopted for this thesis involved the investigation of endothelial function by means of vascular reactivity at the ocular and systemic level. Furthermore, the relationships between retinal and systemic function with circulating markers for endothelial cell function and cardiovascular risk markers were explored. The principal studies and findings of the research were: Vascular Function in Normoglycaemic Individuals with and without a FH of T2DM WE FH individuals exhibited higher levels of total cholesterol levels that correlated well with the retinal arterial dilation amplitude to flicker light stimulus. However this did not extend to noticeable differences in markers for endothelial cell damage and impaired retinal and systemic function. Vascular Function in Normoglycaemic South-Asians vs. White-Europeans without a FH and Vascular Disturbances Compared to healthy WEs (normo -glycaemic and -tensive), SA participants exhibited levels of dyslipidaemia and a state of oxidative stress that extended to impaired vascular function as detected by reduced brachial artery flow-mediated dilation, slower retinal arterial vessel dilation reaction times (Appendix 3) and steeper constriction profiles. Furthermore, gender sub-group analysis presented in a sub-chapter shows that SA males demonstrated 24-hour systemic blood pressure (BP) and heart rate variability (HRV) abnormalities and heightened cardiovascular disease (CVD) risk. Vascular Function in Individuals Newly Diagnosed with IGT as compared to Normoglycaemic Healthy Controls Newly-diagnosed WE and SA IGT patients showed a greater risk for CVD and T2DM progression by means of 24-hour BP abnormalities, dyslipidaemia, increased carotid artery intimal-media thickness (c-IMT), Framingham scores and cholesterol ratios. Additionally, pre-clinical markers for oxidative stress and endothelial dysfunction, as evident by significantly lower levels of plasma glutathione and increased levels of von-Willebrand factor in IGT individuals, extended to impaired vascular systemic and retinal function compared to normal controls. This originally shows retinal, systemic and biochemical disturbances in newly-diagnosed IGT not previously reported before. Vascular Function in Normal, Overweight and Obese Individuals of SA and WE Ethnicity In addition to the intended study chapters, the thesis also investigated the influence of obesity and overweight on vascular function. Most importantly, it was found for the first time that compared to lean individuals it was overweight and not obese individuals that exhibited signs of vascular systemic and ocular dysfunction that was evident alongside markers of atherosclerosis, CVD risk and endothelial damage.

Regulatory foci and organisational commitment

We use regulatory focus theory to derive specific predictions regarding the differential relationships between regulatory focus and commitment. We estimated a structural equation model using a sample of 520 private and public sector employees and found in line with our hypotheses that (a) promotion focus related more strongly to affective commitment than prevention focus, (b) prevention focus related more strongly to continuance commitment than promotion focus, (c) promotion and prevention focus had equally strong effects on normative commitment. Implications of these findings for the three-component model of commitment, especially the ‘dual nature’ of normative commitment, as well as implications for human resources management and leadership are discussed.

The effect of age, gender and driver status on pedestrians' intentions to cross the road in risky situations

The theory of planned behaviour (TPB) has been used successfully in the past to account for pedestrians' intentions to cross the road in risky situations. However, accident statistics show age and gender differences in the likelihood of adult pedestrian accidents. This study extends earlier work by examining the relative importance of the model components as predictors of intention to cross for four different adult age groups, men, women, drivers and nondrivers. The groups did not differ in the extent to which they differentiated between two situations of varying perceived risk. The model fit was good, but accounted for less of the variance in intention for the youngest group (17-24) than for other age groups. Differences between the age groups in intention to cross seemed to be due to differences in perceived value of crossing rather than differences in perceived risk. Women were less likely to intend to cross than men and perceived more risk, and there were important age, gender and driver status differences in the importance of the TPB variables as predictors of intention. A key implication of these findings is that road safety interventions need to be designed differently for different groups. © 2006 Elsevier Ltd. All rights reserved.

The effect of age, gender and attitudes on self-regulation in driving

Self-regulation in driving has primarily been studied as a precursor to driving cessation in older people, who minimise driving risk and compensate for physical and cognitive decline by avoiding driving in challenging circumstances, e.g. poor weather conditions, in the dark and at busy times. This research explores whether other demographic groups of drivers adopt self-regulatory behaviours and examines the effects of affective and instrumental attitudes on self-regulation across the lifespan. Quantitative data were collected from 395 drivers. Women were significantly more likely than men to engage in self-regulation, and to be negatively influenced by their emotions (affective attitude). A quadratic effect of age on self-regulation was determined such that younger and older drivers reported higher scores for self-regulation than middle-years' drivers. However, this effect was affected by experience such that when experience was controlled for, self-regulation increased with age. Nevertheless, anxious driving style and negative affective attitude were independent predictors of self-regulation behaviours. Results suggest that self-regulation behaviours are present across the driving lifespan and may occur as a result of driving anxiety or low confidence rather than as an effect of ageing.

Influence of personal mobile phone ringing and usual intention to answer on driver error

Given evidence of effects of mobile phone use on driving, and also legislation, many careful drivers refrain from answering their phones when driving. However, the distracting influence of a call on driving, even in the context of not answering, has not been examined. Furthermore, given that not answering may be contrary to an individual’s normal habits, this study examined whether distraction caused by the ignored call varies according to normal intention to answer whilst driving. That is, determining whether the effect is more than a simple matter of noise distraction. Participants were 27 young drivers (18-29 years), all regular mobile users. A Theory of Planned Behaviour questionnaire examined predictors of intention to refrain from answering calls whilst driving. Participants provided their mobile phone number and were instructed not to answer their phone if it were to ring during a driving simulation. The simulation scenario had seven hazards (e.g. car pulling out, pedestrian crossing) with three being immediately preceded by a call. Infractions (e.g. pedestrian collisions, vehicle collisions, speed exceedances) were significantly greater when distracted by call tones than with no distraction. Lower intention to ignore calls whilst driving correlated with a larger effect of distraction, as was feeling unable to control whether one answered whilst driving (Perceived Behavioural Control). The study suggests that even an ignored call can cause significantly increased infractions in simulator driving, with pedestrian collisions and speed exceedances being striking examples. Results are discussed in relation to cognitive demands of inhibiting normal behaviour and to drivers being advised to switch phones off whilst driving.

Knowledge mediation and overlapping in interfirm networks

Purpose – The literature on interfirm networks devotes scant attention to the ways collaborating firms combine and integrate the knowledge they share and to the subsequent learning outcomes. This study aims to investigate how motorsport companies use network ties to share and recombine knowledge and the learning that occurs both at the organizational and dyadic network levels. Design/methodology/approach – The paper adopts a qualitative and inductive approach with the aim of developing theory from an in-depth examination of the dyadic ties between motorsport companies and the way they share and recombine knowledge. Findings – The research shows that motorsport companies having substantial competences at managing knowledge flows do so by getting advantage of bridging ties. While bridging ties allow motorsport companies to reach distant and diverse sources of knowledge, their strengthening and the formation of relational capital facilitate the mediation and overlapping of that knowledge. Research limitations/implications – The analysis rests on a qualitative account in a single industry and does not take into account different types of inter-firm networks (e.g. alliances; constellations; consortia etc.) and governance structures. Cross-industry analyses may provide a more fine-grained picture of the practices used to recombine knowledge and the ideal composition of inter-firm ties. Practical implications – This study provides some interesting implications for scholars and managers concerned with the management of innovation activities at the interfirm level. From a managerial point of view, the recognition of the different roles played by network spanning connections is particularly salient and raises issues concerning the effective design and management of interfirm ties. Originality/value – Although much of the literature emphasizes the role of bridging ties in connecting to diverse pools of knowledge, this paper goes one step further and investigates in more depth how firms gather and combine distant and heterogeneous sources of knowledge through the use of strengthened bridging ties and a micro-context conducive to high quality relationships.

Real options in management and organizational strategy:a review of decision-making and performance implications

This paper contributes to the debate on the role of real options theory in business strategy and organizational decision-making. It analyses and critiques the decision-making and performance implications of real options within the management theories of the (multinational) firm, reviews and categorizes the organizational, strategic and operational facets of real options management in large business settings. It also presents the views of scholars and practitioners regarding the incorporation and validity of real options in strategy, international management and business processes. The focus is particularly on the decision-making and performance attributes of the real options logic concerning strategic investments, governance modes and multinational operations management. These attributes are examined from both strategic and operating perspectives of decision-making in organizations, also with an overview of the empirical evidence on real options decision-making and performance.

Monocytes in coronary artery disease and atherosclerosis:where are we now?

Despite improvements in interventional and pharmacological therapy of atherosclerotic disease, it is still the leading cause of death in the developed world. Hence, there is a need for further development of effective therapeutic approaches. This requires better understanding of the molecular mechanisms and pathophysiology of the disease. Atherosclerosis has long been identified as having an inflammatory component contributing to its pathogenesis, whereas the available therapy primarily targets hyperlipidemia and prevention of thrombosis. Notwithstanding a pleotropic anti-inflammatory effect to some therapies, such as acetyl salicylic acid and the statins, none of the currently approved medicines for management of either stable or complicated atherosclerosis has inflammation as a primary target. Monocytes, as representatives of the innate immune system, play a major role in the initiation, propagation, and progression of atherosclerosis from a stable to an unstable state. Experimental data support a role of monocytes in acute coronary syndromes and in outcome post-infarction; however, limited research has been done in humans. Analysis of expression of various cell surface receptors allows characterization of the different monocyte subsets phenotypically, whereas downstream assessment of inflammatory pathways provides an insight into their activity. In this review we discuss the functional role of monocytes and their different subpopulations in atherosclerosis, acute coronary syndromes, cardiac healing, and recovery with an aim of critical evaluation of potential future therapeutic targets in atherosclerosis and its complications. We will also discuss technical difficulties of delineating different monocyte subpopulations, understanding their differentiation potential and function.