Risk Factors for Sternal Wound Infection After Open Heart Operations Vary According to Type of Operation

BACKGROUND This study evaluated whether risk factors for sternal wound infections vary with the type of surgical procedure in cardiac operations. METHODS This was a university hospital surveillance study of 3,249 consecutive patients (28% women) from 2006 to 2010 (median age, 69 years [interquartile range, 60 to 76]; median additive European System for Cardiac Operative Risk Evaluation score, 5 [interquartile range, 3 to 8]) after (1) isolated coronary artery bypass grafting (CABG), (2) isolated valve repair or replacement, or (3) combined valve procedures and CABG. All other operations were excluded. Univariate and multivariate binary logistic regression were conducted to identify independent predictors for development of sternal wound infections. RESULTS We detected 122 sternal wound infections (3.8%) in 3,249 patients: 74 of 1,857 patients (4.0%) after CABG, 19 of 799 (2.4%) after valve operations, and 29 of 593 (4.9%) after combined procedures. In CABG patients, bilateral internal thoracic artery harvest, procedural duration exceeding 300 minutes, diabetes, obesity, chronic obstructive pulmonary disease, and female sex (model 1) were independent predictors for sternal wound infection. A second model (model 2), using the European System for Cardiac Operative Risk Evaluation, revealed bilateral internal thoracic artery harvest, diabetes, obesity, and the second and third quartiles of the European System for Cardiac Operative Risk Evaluation were independent predictors. In valve patients, model 1 showed only revision for bleeding as an independent predictor for sternal infection, and model 2 yielded both revision for bleeding and diabetes. For combined valve and CABG operations, both regression models demonstrated revision for bleeding and duration of operation exceeding 300 minutes were independent predictors for sternal infection. CONCLUSIONS Risk factors for sternal wound infections after cardiac operations vary with the type of surgical procedure. In patients undergoing valve operations or combined operations, procedure-related risk factors (revision for bleeding, duration of operation) independently predict infection. In patients undergoing CABG, not only procedure-related risk factors but also bilateral internal thoracic artery harvest and patient characteristics (diabetes, chronic obstructive pulmonary disease, obesity, female sex) are predictive of sternal wound infection. Preventive interventions may be justified according to the type of operation.

Effect of calf purchase and other herd-level risk factors on mortality, unwanted early slaughter, and use of antimicrobial group treatments in Swiss veal calf operations.

The objective of this survey was to determine herd level risk factors for mortality, unwanted early slaughter, and metaphylactic application of antimicrobial group therapy in Swiss veal calves in 2013. A questionnaire regarding farm structure, farm management, mortality and antimicrobial use was sent to all farmers registered in a Swiss label program setting requirements for improved animal welfare and sustainability. Risk factors were determined by multivariable logistic regression. A total of 619 veal producers returned a useable questionnaire (response rate=28.5%), of which 40.9% only fattened their own calves (group O), 56.9% their own calves and additional purchased calves (group O&P), and 2.3% only purchased calves for fattening (group P). A total number of 19,077 calves entered the fattening units in 2013, of which 21.7%, 66.7%, and 11.6% belonged to groups O, O&P, and P, respectively. Mortality was 0% in 322 herds (52.0%), between 0% and 3% in 47 herds (7.6%), and ≥3% in 250 herds (40.4%). Significant risk factors for mortality were purchasing calves, herd size, higher incidence of BRD, and access to an outside pen. Metaphylaxis was used on 13.4% of the farms (7.9% only upon arrival, 4.4% only later in the fattening period, 1.1% upon arrival and later), in 3.2% of the herds of group O, 17.9% of those in group O&P, and 92.9% of those of group P. Application of metaphylaxis upon arrival was positively associated with purchase (OR=8.9) and herd size (OR=1.2 per 10 calves). Metaphylaxis later in the production cycle was positively associated with group size (OR=2.9) and risk of respiratory disease (OR=1.2 per 10% higher risk) and negatively with the use of individual antimicrobial treatment (OR=0.3). In many countries, purchase and a large herd size are inherently connected to veal production. The Swiss situation with large commercial but also smaller herds with little or no purchase of calves made it possible to investigate the effect of these factors on mortality and antimicrobial drug use. The results of this study show that a system where small farms raise the calves from their own herds has a substantial potential to improve animal health and reduce antimicrobial drug use.

Annual Report Clinical Operations 2004/2005

The clinical arm of the UConn Health Center consists of the UConn Medical (UMG), our physician faculty practice, the John Dempsey Hospital (JDH) and the Correctional Managed Health Care Program (CMHC). This 2005 Clinical Annual Report was issued Sept.1, 2005 by Steven L. Strongwater, MD, Director of Clinical Operations.

Residents' risk perception due to operations of a copper smelter located near residential communities in El Paso, Texas

A face to face survey addressing environmental risk perception was conducted in January through March 2010. The 35 question survey was administered to a random sample of 73 households in El Paso, Texas. The instrument, administered in two adjacent residential communities neighboring an inactive copper smelter solicited responses about manmade and naturally occurring health risks and sources of health information that might utilized by respondents. The objective of the study was to determine if intervention which occurred in one of the communities increased residents' perception of risk to themselves and their families. The study was undertaken subsequent to increased attention from news media and public debate surrounding the request to reopen the smelter's operations. Results of the study indicated that the perception of environmental related health concerns were not significantly correlated with residence in a community receiving outreach and intervention. Both communities identified sun exposure as their greatest perceived environmental risk followed by cigarette smoking. Though industrial by products and chemical pollution were high ranking concerns, respondents indicated they felt that the decision not to reopen the smelter reduced risk in these areas. Residents expressed confidence in information received from the local health district though most indicated they received very little information from that source indicating an opportunity for public health education in this community as a strategy to address future health concerns.^

Performance tiers: Implementing comparative effectiveness analysis in the health care setting through operations research and spatial methods

This dissertation develops and tests a comparative effectiveness methodology utilizing a novel approach to the application of Data Envelopment Analysis (DEA) in health studies. The concept of performance tiers (PerT) is introduced as terminology to express a relative risk class for individuals within a peer group and the PerT calculation is implemented with operations research (DEA) and spatial algorithms. The analysis results in the discrimination of the individual data observations into a relative risk classification by the DEA-PerT methodology. The performance of two distance measures, kNN (k-nearest neighbor) and Mahalanobis, was subsequently tested to classify new entrants into the appropriate tier. The methods were applied to subject data for the 14 year old cohort in the Project HeartBeat! study.^ The concepts presented herein represent a paradigm shift in the potential for public health applications to identify and respond to individual health status. The resultant classification scheme provides descriptive, and potentially prescriptive, guidance to assess and implement treatments and strategies to improve the delivery and performance of health systems. ^

THE EVALUATION OF PUBLIC HEALTH COMPONENTS OF INTERNATIONAL DISASTER RELIEF OPERATIONS: INDOCHINESE REFUGEES IN THAILAND, 1979-1982

Refugee populations suffer poor health status and yet the activities of refugee relief agencies in the public health sector have not been subjected previously to comprehensive evaluation. The purpose of this study was to examine the effectiveness and cost of the major public health service inputs of the international relief operation for Indochinese refugees in Thailand coordinated by the United Nations High Commissioner for Refugees (UNHCR). The investigator collected data from surveillance reports and agency records pertaining to 11 old refugee camps administered by the Government of Thailand Ministry of Interior (MOI) since an earlier refugee influx, and five new Khmer holding centers administered directly by UNHCR, from November, 1979, to March, 1982.^ Generous international funding permitted UNHCR to maintain a higher level of public health service inputs than refugees usually enjoyed in their countries of origin or than Thais around them enjoyed. Annual per capita expenditure for public health inputs averaged approximately US$151. Indochinese refugees in Thailand, for the most part, had access to adequate general food rations, to supplementary feeding programs, and to preventive health measures, and enjoyed high-quality medical services. Old refugee camps administered by MOI consistently received public health inputs of lower quantity and quality compared with new UNHCR-administered holding centers, despite comparable per capita expenditure after both types of camps had stabilized (static phase).^ Mortality and morbidity rates among new Khmer refugees were catastrophic during the emergency and transition phases of camp development. Health status in the refugee population during the static phase, however, was similar to, or better than, health status in the refugees' countries of origin or the Thai communities surrounding the camps. During the static phase, mortality and morbidity generally remained stable at roughly the same low levels in both types of camps.^ Furthermore, the results of multiple regression analyses demonstrated that combined public health inputs accounted for from one to 23 per cent of the variation in refugee mortality and morbidity. The direction of associations between some public health inputs and specific health outcome variables demonstrated no clear pattern. ^

An assessment of post-disaster psychological stress in hazardous waste operations and emergency response (HAZWOPER) workers

Personnel involved in natural or man-made disaster response and recovery efforts may be exposed to a wide variety of physical and mental stressors that can exhibit long-lasting and detrimental psychopathological outcomes. In a disaster situation, huge numbers of "secondary" responders can be involved in contaminant clean-up and debris removal and can be at risk of developing stress-related mental health outcomes. The Occupational Safety and Health Administration (OSHA) worker training hierarchy typically required for response workers, known as "Hazardous Waste Operations and Emergency Response" (HAZWOPER), does not address the mental health and safety concerns of workers. This study focused on the prevalence of traumatic stress experienced by secondary responders that had received or expressed interest in receiving HAZWOPER training through the National Institute of Environmental Health Sciences Worker Education and Training Program (NIEHS WETP). ^ The study involved the modification of two preexisting and validated survey tools to assess secondary responder awareness of physical, mental, and traumatic stressors on mental health and sought to determine if a need existed to include traumatic stress-related mental health education in the current HAZWOPER training regimen. The study evaluated post-traumatic stress disorder (PTSD), resiliency, mental distress, and negative effects within a secondary responder population of 176 respondents. Elevated PTSD levels were seen in the study population as compared to a general responder population (32.9% positive vs. 8%-22.5% positive). Results indicated that HAZWOPER-trained disaster responders were likely to test positive for PTSD, whereas, untrained responders with no disaster experience and responders who possessed either training or disaster experience only were likely to test PTSD negative. A majority (68.75%) of the population tested below the mean resiliency to cope score (80.4) of the average worker population. Results indicated that those who were trained only or who possessed both training and disaster work experience were more likely to have lower resiliency scores than those with no training or experience. There were direct correlations between being PTSD positive and having worked at a disaster site and experiencing mental distress and negative effects. However, HAZWOPER training status does not significantly correlate with mental distress or negative effect. ^ The survey indicated clear support (91% of respondents) for mental health education. The development of a pre- and post-deployment training module is recommended. Such training could provide responders with the necessary knowledge and skills to recognize the symptomology of PTSD, mental stressors, and physical and traumatic stressors, thus empowering them to employ protective strategies or seek professional help if needed. It is further recommended that pre-deployment mental health education be included in the current HAZWOPER 24- and 40-hour course curriculums, as well as, consideration be given towards integrating a stand-alone post-deployment mental health education training course into the current HAZWOPER hierarchy.^

Stable isotope record, Mg/Ca ratios and age model of St. Stephens Quarry, Alabama

In the largest global cooling event of the Cenozoic Era, between 33.8 and 33.5 Myr ago, warm, high-CO2 conditions gave way to the variable 'icehouse' climates that prevail today. Despite intense study, the history of cooling versus ice-sheet growth and sea-level fall reconstructed from oxygen isotope values in marine sediments at the transition has not been resolved. Here, we analyse oxygen isotopes and Mg/Ca ratios of benthic foraminifera, and integrate the results with the stratigraphic record of sea-level change across the Eocene-Oligocene transition from a continental-shelf site at Saint Stephens Quarry, Alabama. Comparisons with deep-sea (Sites 522 (South Atlantic) and 1218 (Pacific)) d18O and Mg/Ca records enable us to reconstruct temperature, ice-volume and sea-level changes across the climate transition. Our records show that the transition occurred in at least three distinct steps, with an increasing influence of ice volume on the oxygen isotope record as the transition progressed. By the early Oligocene, ice sheets were ~25% larger than present. This growth was associated with a relative sea-level decrease of approximately 105 m, which equates to a 67 m eustatic fall.

Benthic foraminiferal biofacies and stable isotopic record of St. Stephens Quarry, Alabama

We integrate upper Eocene-lower Oligocene lithostratigraphic, magnetostratigraphic, biostratigraphic, stable isotopic, benthic foraminiferal faunal, downhole log, and sequence stratigraphic studies from the Alabama St. Stephens Quarry (SSQ) core hole, linking global ice volume, sea level, and temperature changes through the greenhouse to icehouse transition of the Cenozoic. We show that the SSQ succession is dissected by hiatuses associated with sequence boundaries. Three previously reported sequence boundaries are well dated here: North Twistwood Creek-Cocoa (35.4-35.9 Ma), Mint Spring-Red Bluff (33.0 Ma), and Bucatunna-Chickasawhay (the mid-Oligocene fall, ca. 30.2 Ma). In addition, we document three previously undetected or controversial sequences: mid-Pachuta (33.9-35.0 Ma), Shubuta-Bumpnose (lowermost Oligocene, ca. 33.6 Ma), and Byram-Glendon (30.5-31.7 Ma). An ~0.9 per mil d18O increase in the SSQ core hole is correlated to the global earliest Oligocene (Oi1) event using magnetobiostratigraphy; this increase is associated with the Shubuta-Bumpnose contact, an erosional surface, and a biofacies shift in the core hole, providing a first-order correlation between ice growth and a sequence boundary that indicates a sea-level fall. The d18O increase is associated with a eustatic fall of ~55 m, indicating that ~0.4 per mil of the increase at Oi1 time was due to temperature. Maximum d18O values of Oi1 occur above the sequence boundary, requiring that deposition resumed during the lowest eustatic lowstand. A precursor d18O increase of 0.5 per mil (33.8 Ma, midchron C13r) at SSQ correlates with a 0.5 per mil increase in the deep Pacific Ocean; the lack of evidence for a sea-level change with the precursor suggests that this was primarily a cooling event, not an ice-volume event. Eocene-Oligocene shelf water temperatures of ~17-19 °C at SSQ are similar to modern values for 100 m water depth in this region. Our study establishes the relationships among ice volume, d18O, and sequences: a latest Eocene cooling event was followed by an earliest Oligocene ice volume and cooling event that lowered sea level and formed a sequence boundary during the early stages of eustatic fall.

Taxonomic lists and abundances of the Lower Miocene bivalve assemblages of the Vives quarry (Meilhan, SW France)

Biodiversity estimates through geological times are difficult because of taphonomic perturbations that affect sedimentary records. Pristine shell assemblages, however, allow for calibration of past diversity. Diversity structures of two exceptionally preserved Miocene bivalve assemblages are quantitatively determined, compared with recent communities and used as paleoenvironmental proxy. The extremely rich assemblages were collected in Aquitanian (Early Miocene) carbonate sands of the Vives Quarry (Meilhan, SW France). Both paleontological and sedimentological data indicate a coral patch-reef environment, which deposits were affected by transport processes. Among two samples more than 28.000 shells were counted and 135 species identified. Sample Vives 1 is interpreted as a proximal debris flow and Sample Vives 2 as a sandy shoreface/foreshore environment influenced by storms. The two Vives assemblages have a similar diversity structure despite facies differences. Rarefaction curves level off at ~600 shells. The rare species account for more than 80 % of the species pool. The high values of PIE diversity index suggest a relatively high species richness and an even distribution of abundance of the most common species within the assemblages. The fossil data are compared to death shell assemblages (family level) of a modern reefal setting (Touho area, New Caledonia). The shape of the rarefaction curves and PIE indices of Meilhan fossil assemblages compare well to modern data, especially those of deep (>10 m water depth), sandy depositional environments found downward the reef slope (slope and pass settings). In addition to primary ecological signals, the similarity of the Vives samples and the Recent deep samples derives from taphonomic processes. This assumption is supported by sedimentological and paleontological observations. Sediment transports gather allochthonous and in situ materials leading to mixing of various ecological niches. Such taphonomic processes are recorded in the diversity metrics. Environmental mixing and time-averaging of the shell assemblages disturb the preservation of local-scale diversity properties but favour the sampling of the regional-scale diversity.