Researching effective approaches to cleaning in hospitals: Protocol of the REACH study, a multi-site stepped-wedge randomised trial

Background The Researching Effective Approaches to Cleaning in Hospitals (REACH) study will generate evidence about the effectiveness and cost-effectiveness of a novel cleaning initiative that aims to improve the environmental cleanliness of hospitals. The initiative is an environmental cleaning bundle, with five interdependent, evidence-based components (training, technique, product, audit and communication) implemented with environmental services staff to enhance hospital cleaning practices. Methods/design The REACH study will use a stepped-wedge randomised controlled design to test the study intervention, an environmental cleaning bundle, in 11 Australian hospitals. All trial hospitals will receive the intervention and act as their own control, with analysis undertaken of the change within each hospital based on data collected in the control and intervention periods. Each site will be randomised to one of the 11 intervention timings with staggered commencement dates in 2016 and an intervention period between 20 and 50 weeks. All sites complete the trial at the same time in 2017. The inclusion criteria allow for a purposive sample of both public and private hospitals that have higher-risk patient populations for healthcare-associated infections (HAIs). The primary outcome (objective one) is the monthly number of Staphylococcus aureus bacteraemias (SABs), Clostridium difficile infections (CDIs) and vancomycin resistant enterococci (VRE) infections, per 10,000 bed days. Secondary outcomes for objective one include the thoroughness of hospital cleaning assessed using fluorescent marker technology, the bio-burden of frequent touch surfaces post cleaning and changes in staff knowledge and attitudes about environmental cleaning. A cost-effectiveness analysis will determine the second key outcome (objective two): the incremental cost-effectiveness ratio from implementation of the cleaning bundle. The study uses the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to support the tailored implementation of the environmental cleaning bundle in each hospital. Discussion Evidence from the REACH trial will contribute to future policy and practice guidelines about hospital environmental cleaning. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in hospitals. Trial registration Australia New Zealand Clinical Trial Registry ACTRN12615000325​505

The TRAM flap for breast reconstruction : Studies on perioperative cutaneous blood flow, vasoconstriction, and indices of obesity

Breast reconstruction is performed for 10-15 % of women operated on for breast cancer. A popular method is the TRAM (transverse rectus abdominis musculocutaneous) flap formed of the patient’s own abdominal tissue, a part of one of the rectus abdominis muscles and a transverse skin-subcutis area over it. The flap can be raised as a pedicled or a free flap. The pedicled TRAM flap, based on its nondominant pedicle superior epigastric artery (SEA), is rotated to the chest so that blood flow through SEA continues. The free TRAM flap, based on its dominant pedicle deep inferior epigastric artery (DIEA), is detached from the abdomen, transferred to the chest, and DIEA and vein are anastomosed to vessels on the chest. Cutaneous necrosis is seen in 5–60 % of pedicled TRAM flaps and in 0–15 % of free TRAM flaps. This study was the first one to show with blood flow measurements that the cutaneous blood flow is more generous in free than in pedicled TRAM flaps. After this study the free TRAM flap has exceeded the pedicled flap in popularity as a breast reconstruction method, although the free flap it is technically a more demanding procedure than the pedicled TRAM flap. In pedicled flaps, a decrease in cutaneous blood flow was observed when DIEA was ligated. It seems that SEA cannot provide sufficient blood flow on the first postoperative days. The postoperative cutaneous blood flow in free TRAM flaps was more stable than in pedicled flaps. Development of cutaneous necrosis of pedicled TRAM flaps could be predicted based on intraoperative laser Doppler flowmetry (LDF) measurements. The LDF value on the contralateral skin of the flap decreased to 43 ± 7 % of the initial value after ligation of the DIEA in flaps developing cutaneous necrosis during the next week. Endothelin-1 (ET-1) is a powerful vasoconstrictory peptide secreted by vascular endothelial cells. A correlation was found between plasma ET-1 concentrations and peripheral vasoconstriction developing during and after breast reconstructions with a pedicled TRAM flap. ET-1 was not associated with the development of cutaneous necrosis. Felodipine, a vasodilating calcium channel antagonist, had no effect on plasma ET-1 concentrations, peripheral vasoconstriction or development of cutaneous necrosis in free TRAM flaps. Body mass index and thickness of abdominal were not associated with cutaneous necrosis in pedicled TRAM flaps.

Functional Outcome after Free Flap Reconstructions in Oral and Pharyngeal Cancer

Oral cancer ranks among the 10 most common cancers worldwide. Since it is commonly diagnosed at locally advanced stage, curing the cancer demands extensive tissue resection. The emergent defect is reconstructed generally with a free flap transfer. Repair of the upper aerodigestive track with maintenance of its multiform activities is challenging. The aim of the study was to extract comprehensive treatment outcomes for patients having undergone microvascular free flap transfer because of large oral cavity or pharyngeal cancer. Ninety-four patients were analyzed for postoperative survival and complications. Forty-four patients were followed-up and analyzed for functional outcome, which was determined in terms of quality of life, speech, swallowing, and intraoral sensation. Quality of life was assessed using the University of Washington Head and Neck Questionnaire. Speech was analyzed for aerodynamic parameters and for nasal acoustic energy, as well as perceptually for articulatory proficiency, voice quality, and intelligibility. Videofluorography was performed to determine the swallowing ability. Intraoral sensation was measured by moving 2-point discrimination. The 3-year overall survival was over 40%. The 1-year disease-free survival was 43%. Postoperative complications arose in over half of the patients. Flap success rate was high. Perioperative mortality varied between 2% and 11%. Unemployment and heavy drinking were the strongest predictors of survival. Sociodemographic factors were found to associate with quality of life. The global quality of life score deteriorated and did not return to the preoperative level. Significant reduction was detectable in the domains measuring chewing and speech, and in appearance and shoulder function. The basic elements necessary for normal speech were maintained. Speech intelligibility reduced and was related to the misarticulations of the /r/ and /s/ phonemes. Deviant /r/ and /s/ persisted in most patients. Hoarseness and hypernasality occurred infrequently. One year postoperatively, 98% of the patients had achieved oral nutrition and half of them were on a regular masticated diet. Overt and silent aspiration was encountered throughout the follow-up. At 12-month swallow test, 44% of the patients aspirated, 70% of whom silently. Of these patients, 15% presented with pulmonary changes referring to aspiration. Intraoral sensation weakened but was unrelated to oral functions. The results provide new data for oral reconstructions and highlight the importance of the functional outcome of the treatment for an oral cancer patient. The mouth and the pharynx encompass a unit of utmost functional complexity. Surgery should continue to make progress in this area, and methods that lead to good function should be developed. Operational outcome should always be evaluated in terms of function.

Adjuvant Arteriovenous Fistula for Infrapopliteal Bypass Patency

A lack of suitable venous graft material or poor outflow is an increasingly encountered situation in peripheral vascular surgery. Prosthetic grafts have clearly worse patency than vein grafts in femorodistal bypass surgery. The use of an adjuvant arteriovenous fistula (av-fistula) at the distal anastomosis has been postulated to improve the flow and thus increase prosthetic graft patency. In theory the adjuvant fistula might have the same effect in a compromised outflow venous bypass. A free flap transfer also augments graft flow and may have a positive effect on an ischaemic limb. The aim of this study was to evaluate the possible benefit of an adjuvant av-fistula and an internal av-fistula within a free flap transfer on the patency and outcome of an infrapopliteal bypass. The effect of the av-fistula on bypass haemodynamics was also assessed along with possible adverse effects. Patients and methods: 1. A prospective randomised multicentre trial comprised 59 patients with critical leg ischaemia and no suitable veins for grafting. Femorocrural polytetrafluoroethylene (PTFE) bypasses with a distal vein cuff, with or without an adjuvant av-fistula, were performed. The outcome was assessed according to graft patency and leg salvage. 2. Haemodynamic measurements were performed to a total of 50 patients from Study I with a prolonged follow-up. 3. Nine critically ischaemic limbs were treated with a modified radial forearm flap transfer in combination with a femorodistal bypass operation. An internal av-fistula was created within the free flap transfer to increase flap artery and bypass graft flow. 4. The effect of a previous free flap transfer on bypass haemodynamics was studied in a case report. 5. In a retrospective multicentre case-control study, 77 infrapopliteal vein bypasses with an adjuvant av-fistula were compared with matched controls without a fistula. The outcome and haemodynamics of the bypasses were recorded. Main results: 1. The groups with and without the av-fistula did not differ as regards prosthetic graft patency or leg salvage. 2. The intra- and postoperative prosthetic graft flow was significantly increased in the patients with the av-fistula. However, this increase did not improve patency. There was no difference in patency between the groups, even in the extended follow-up. 3. The vein graft flow increased significantly after the anastomosis of the radial forearm flap with an internal av-fistula. 4. A previously performed free flap transfer significantly augmented the flow of a poor outflow femoropedal bypass graft. 5. The adjuvant av-fistula increased the venous infrapopliteal bypass flow significantly. The increased flow did not, however, lead to improved graft patency or leg salvage. Conclusion: An adjuvant av-fistula does not improve the patency of a femorocrural PTFE bypass with a distal vein cuff despite the fact that the flow values increased both in the intraoperative measurements and during the immediate postoperative surveillance. The adjuvant av-fistula increased graft flow significantly also in a poor outflow venous bypass, but regardless of this the outcome was no improved. The adjuvant av-fistula rarely caused adverse effects. In a group of diabetic patients, the flow in a vascular bypass graft was augmented by an internal av-fistula within a radial forearm flap and similarly in a patient with a previous free flap transfer, a high intraoperative graft flow was achieved due to the free flap shunt effect.

Distal anterior cerebral artery aneurysms

Objective: Distal anterior cerebral artery (DACA) aneurysms represent about 6% of all intracranial aneurysms. So far, only small series on treatment of these aneurysms have been published. Our aim is to evaluate the anatomic features, microneurosurgical techniques, treatment results, and long-term outcome in patients treated for DACA aneurysms. Patients and methods: We analyzed the clinical and radiological data on 517 consecutive patients diagnosed with DACA aneurysm at two neurosurgical centers serving solely the Southern (Helsinki) and Eastern (Kuopio) Finland in 1936–2007, and used a defined subgroup of the whole study population in each part of the study. Detailed anatomic analysis was performed in 101 consecutive patients from 1998 to 2007. Treatment results were analyzed in 427 patients treated between 1980 to 2005, the era of CT imaging and microneurosurgery. Long-term treatment outcome of ruptured DACA aneurysm(s) was evaluated in 280 patients with a median follow-up of 10 years; no patients were lost to follow-up. Results: DACA aneurysms, found most often (83%) at the A3 segment of the anterior cerebral artery (ACA), were smaller (median 6 mm vs. 8 mm), more frequently associated with multiple aneurysms (35% vs. 18%), and presented more often with intracerebral hematomas (ICHs) (53% vs. 26%) than ruptured aneurysms in general. They were associated with anomalies of the ACA in 23% of the patients. Microsurgical treatment showed similar complication rates (treatment morbidity 15%, treatment mortality 0.4%) as for other ruptured aneurysms. At one year after subarachnoid hemorrhage (SAH), DACA aneurysms had equally favorable outcome (GOS≥4) as other ruptured aneurysms (74% vs. 69%) but their mortality was lower (13% vs. 24%). Factors predicting unfavorable outcome for ruptured DACA aneurysms were advanced age, Hunt&Hess≥3, rebleeding before treatment, ICH, intraventricular hemorrhage, and severe preoperative hydrocephalus. The cumulative relative survival ratio showed 16% excess mortality in patients with ruptured DACA aneurysm during the first three years after SAH compared to the matched general population. From the fourth year onwards, there was no excess mortality during the follow-up. There were four episodes of recurrent SAH, only one due to treated DACA aneurysm, with a 10-year cumulative risk of 1.4%. Conclusions: The special neurovascular features and frequent association with anterior cerebral artery anomalies must be taken into account when planning occlusive treatment of DACA aneurysms. Clipping of DACA aneurysms provides a long-lasting result, with very small rates of rebleeding. After surviving three years from rupture of DACA aneurysm, the long-term survival of these patients becomes similar to that of the matched general population.

Steady compressible flow of granular materials through a wedge-shaped hopper: The smooth wall, radial gravity problem

A continuum model based on the critical state theory of soil mechanics is used to generate stress and density profiles, and to compute discharge velocities for the plane flow of cohesionless materials. Two types of yield loci are employed, namely, a yield locus with a corner, and a smooth yield locus. The yield locus with a corner leads to computational difficulties. For the smooth yield locus, results are found to be relatively insensitive to the shape of the yield locus, the location of the upper traction-free surface and the density specified on this surface. This insensitivity arises from the existence of asymptotic stress and density fields, to which the solution tends to converge on moving down the hopper. Numerical and approximate analytical solutions are obtained for these fields and the latter is used to derive an expression for the discharge velocity. This relation predicts discharge velocities to within 13% of the exact (numerical) values. While the assumption of incompressibility has been frequently used in the literature, it is shown here that in some cases, this leads to discharge velocities which are significantly higher than those obtained by the incorporation of density variation.

Steady incompressible flow of cohesionless granular materials through a wedge-shaped hopper: Frictional 14kinetic solution to the smooth wall, radial gravity problem

Hybrid frictional-kinetic equations are used to predict the velocity, grain temperature, and stress fields in hoppers. A suitable choice of dimensionless variables permits the pseudo-thermal energy balance to be decoupled from the momentum balance. These balances contain a small parameter, which is analogous to a reciprocal Reynolds number. Hence an approximate semi-analytical solution is constructed using perturbation methods. The energy balance is solved using the method of matched asymptotic expansions. The effect of heat conduction is confined to a very thin boundary layer near the exit, where it causes a marginal change in the temperature. Outside this layer, the temperature T increases rapidly as the radial coordinate r decreases. In particular, the conduction-free energy balance yields an asymptotic solution, valid for small values of r, of the form T proportional r-4. There is a corresponding increase in the kinetic stresses, which attain their maximum values at the hopper exit. The momentum balance is solved by a regular perturbation method. The contribution of the kinetic stresses is important only in a small region near the exit, where the frictional stresses tend to zero. Therefore, the discharge rate is only about 2.3% lower than the frictional value, for typical parameter values. As in the frictional case, the discharge rate for deep hoppers is found to be independent of the head of material.

Flap‐Lag Damping in Hover and Forward Flight with a Three‐Dimensional Wake

Prediction of lag damping is difficult owing to the delicate balance of drag, induced drag and Coriolis forces in the in‐plane direction. Moreover, induced drag” is sensitive to dynamic wake, bath shed and trailing components, and thus its prediction requires adequate unsteady‐wake representation. Accordingly, rigid‐blade flap‐lag equations are coupled with a three‐dimensional finite‐state wake model; three isolatcd rotor canfigurations with three, four and five blades are treated over a range of thrust levels, tack numbers, lag frequencies and advance ratios. The investigation includes convergence characteristics of damping with respect to the number of radial shape functions and harmonics of the wake model for multiblade modes of low frequency (< 1/ rev.) to high frequency (> 1/rev.). Predicted flap and lag damping levels are then compared with similar predictions with 1) rigid wake (no unsteady induced now), 2) Loewy lift deficiency and 3) dynamic inflow. The coverage also includes correlations with the measured lag regressive‐mode damping in hover and forward flight and comparisons with similar correlations with dynamic inflow. Lag‐damping predictions with the dynamic wake model are consistently higher than the predictions with the dynamic inflow model; even for the low frequency lag regressive mode, the number of wake harmonics should at least be equal to twice the number of blades.

Ground state geometric distortions Image distal substituent effects in determining the β-facial selectivity in 7-norbornenones

The X-ray structure of Image and MNDO optimized geometries of related 7-norbornenone derivatives show a clear tilt of the carbonyl bridge away from the C=C double bond. The preferred reduction from the more hindered face of the diester reveals the electron/electrostatic origin of π - facial selectivity in these systems. X-ray structure and MNDO calculations reveal the dominance of electronic effects in determining the π-facial selectivity in 4a.

Flap-lag-torsion stability in hover and forward flight with three-dimensional wake

The contributions of full-wake dynamics in trim analysis are demonstrated for finding the control inputs and periodic responses simultaneously, as well as in Floquet eigenanalysis for finding the damping levels. The equations of flap bending, lag bending, and torsion are coupled with a three-dimensional, finite state wake, and low-frequency (<1/rev) to high frequency (>1/rev) multiblade modes are considered. Full blade-wake dynamics is used in trim analysis and Floquet eigenanalysis. A uniform cantilever blade in trimmed flight is investigated over a range of thrust levels, advance ratios, number of blades, and blade torsional frequencies. The investigation includes the convergence characteristics of control inputs, periodic responses, and damping levels with respect to the number of spatial azimuthal harmonics and radial shape functions in the wake representation. It also includes correlation with the measured lag damping of a three-bladed untrimmed rotor. The parametric study shows the dominant influence of wake dynamics on control inputs, periodic responses, and damping levels, and wake theory generally improves the correlation.

Finite element simulation of wedge indentation

A finite element simulation of frictionless wedge indentation of a copper strip has been carried out under plane strain conditions. The problem was first modelled using an one-pass contact algorithm. The difficulties associated with using this method to model wedge indentation problems are explained. An alternative procedure which alleviates some of the problems associated with the one-pass contact algorithm is proposed for modelling frictionless wedge indentation. Also, a re-meshing procedure which has to be carried out when the distortion of the elements around the indenter becomes significant, is discussed. A sample problem involving indentation of a 4 mm copper strip by a rigid wedge indenter has been modelled and the results are compared with experimental and theoretical results.

Nonsimilar mixed convection flow of a non-Newtonian fluid past a vertical wedge

The flow and heat transfer characteristics of a second-order fluid over a vertical wedge with buoyancy forces have been analysed. The coupled nonlinear partial differential equations governing the nonsimilar mixed convection flow have been solved numerically using Keller box method. The effects of the buoyancy parameter, viscoelastic parameter, mass transfer parameter, pressure gradient parameter, Prandtl number and viscous dissipation parameter on the skin friction and heat transfer have been examined in detail. Particular cases of the present results match exactly with those available in the literature.

Probing the role of the fully conserved Cys126 in triosephosphate isomerase by site-specific mutagenesis - distal effects on dimer stability

Cys126 is a completely conserved residue in triosephosphate isomerase that is proximal to the active site but has been ascribed no specific role in catalysis. A previous study of the C126S and C126A mutants of yeast TIM reported substantial catalytic activity for the mutant enzymes, leading to the suggestion that this residue is implicated in folding and stability [Gonzalez-Mondragon E et al. (2004) Biochemistry43, 3255–3263]. We re-examined the role of Cys126 with the Plasmodium falciparum enzyme as a model. Five mutants, C126S, C126A, C126V, C126M, and C126T, were characterized. Crystal structures of the 3-phosphoglycolate-bound C126S mutant and the unliganded forms of the C126S and C126A mutants were determined at a resolution of 1.7–2.1 Å. Kinetic studies revealed an approximately five-fold drop in kcat for the C126S and C126A mutants, whereas an approximately 10-fold drop was observed for the other three mutants. At ambient temperature, the wild-type enzyme and all five mutants showed no concentration dependence of activity. At higher temperatures (> 40 °C), the mutants showed a significant concentration dependence, with a dramatic loss in activity below 15 μm. The mutants also had diminished thermal stability at low concentration, as monitored by far-UV CD. These results suggest that Cys126 contributes to the stability of the dimer interface through a network of interactions involving His95, Glu97, and Arg98, which form direct contacts across the dimer interface.