Economic burden of surgical site infections at a European university hospital

OBJECTIVE: To quantify the economic burden of in-hospital surgical site infections (SSIs) at a European university hospital. DESIGN: Matched case-control study nested in a prospective observational cohort study. SETTING: Basel University Hospital in Switzerland, where an average of 28,000 surgical procedures are performed per year. METHODS: All in-hospital occurrences of SSI associated with surgeries performed between January 1, 2000, and December 31, 2001, by the visceral, vascular, and traumatology divisions at Basel University Hospital were prospectively recorded. Each case patient was matched to a control patient by age, procedure code, and National Nosocomial Infection Surveillance System risk index. The case-control pairs were analyzed for differences in cost of hospital care and in provision of specialized care. RESULTS: A total of 6,283 procedures were performed: 187 SSIs were detected in inpatients, 168 of whom were successfully matched with a control patient. For case patients, the mean additional hospital cost was SwF-19,638 (95% confidence interval [CI], SwF-8,492-SwF-30,784); the mean additional postoperative length of hospital stay was 16.8 days (95% CI, 13-20.6 days); and the mean additional in-hospital duration of antibiotic therapy was 7.4 days (95% CI, 5.1-9.6 days). Differences were primarily attributable to organ space SSIs (n = 76). CONCLUSIONS: In a European university hospital setting, SSIs are costly and constitute a heavy and potentially preventable burden on both patients and healthcare providers.

Comparison of three methods for driven pile capacity

A significant cost for foundations is the design and installation of piles when they are required due to poor ground conditions. Not only is it important that piles be designed properly, but also that the installation equipment and total cost be evaluated. To assist in the evaluation of piles a number of methods have been developed. In this research three of these methods were investigated, which were developed by the Federal Highway Administration, the US Corps of Engineers and the American Petroleum Institute (API). The results from these methods were entered into the program GRLWEAPTM to assess the pile drivability and to provide a standard base for comparing the three methods. An additional element of this research was to develop EXCEL spreadsheets to implement these three methods. Currently the Army Corps and API methods do not have publicly available software and must be performed manually, which requires that data is taken off of figures and tables, which can introduce error in the prediction of pile capacities. Following development of the EXCEL spreadsheet, they were validated with both manual calculations and existing data sets to ensure that the data output is correct. To evaluate the three pile capacity methods data was utilized from four project sites from North America. The data included site geotechnical data along with field determined pile capacities. In order to achieve a standard comparison of the data, the pile capacities and geotechnical data from the three methods were entered into GRLWEAPTM. The sites consisted of both cohesive and cohesionless soils; where one site was primarily cohesive, one was primarily cohesionless, and the other two consisted of inter-bedded cohesive and cohesionless soils. Based on this limited set of data the results indicated that the US Corps of Engineers method more closely compared with the field test data, followed by the API method to a lesser degree. The DRIVEN program compared favorably in cohesive soils, but over predicted in cohesionless material.

DESIGN AND FABRICATION OF RESONANT GAS SENSOR FOR HIGH SENSITIVITY IN THE PRESENCE OF AIR DAMPING

Gas sensors have been used widely in different important area including industrial control, environmental monitoring, counter-terrorism and chemical production. Micro-fabrication offers a promising way to achieve sensitive and inexpensive gas sensors. Over the years, various MEMS gas sensors have been investigated and fabricated. One significant type of MEMS gas sensors is based on mass change detection and the integration with specific polymer. This dissertation aims to make contributions to the design and fabrication of MEMS resonant mass sensors with capacitance actuation and sensing that lead to improved sensitivity. To accomplish this goal, the research has several objectives: (1) Define an effective measure for evaluating the sensitivity of resonant mass devices; (2) Model the effects of air damping on microcantilevers and validate models using laser measurement system (3) Develop design guidelines for improving sensitivity in the presence of air damping; (4) Characterize the degree of uncertainty in performance arising from fabrication variation for one or more process sequences, and establish design guidelines for improved robustness. Work has been completed toward these objectives. An evaluation measure has been developed and compared to an RMS based measure. Analytic models of air damping for parallel plate that include holes are compared with a COMSOL model. The models have been used to identify cantilever design parameters that maximize sensitivity. Additional designs have been modeled with COMSOL and the development of an analytical model for Fixed-free cantilever geometries with holes has been developed. Two process flows have been implemented and compared. A number of cantilever designs have been fabricated and the uncertainty in process has been investigated. Variability from processing have been evaluated and characterized.

Evaluating the relationship between moisture induced expansion and horizontal stress orientation in samples from the nonesuch formation

High horizontal stresses can cause numerous ground control problems in mines and other underground structures ultimately impacting worker safety, productivity and the economics of an underground operation. Mine layout and design can be optimized when the presence and orientation of these stresses are recognized and their impact minimized. A simple technique for correlating the principal horizontal stress direction in a sedimentary rock mass with the preferential orientation of moisture induced expansion in a sample of the same rock was introduced in the 1970s and has since gone un-reported and unused. This procedure was reexamined at a locality near the original test site at White Pine, Michigan in order to validate the original research and to consider its usefulness in mining and civil engineering applications in high horizontal stress conditions. This procedure may also be useful as an economical means for characterizing regional stress fields.

Inductive-Capacitive Resonant Circuit Sensors for Structural Health and Environmental Monitoring

Inductive-capacitive (LC) resonant circuit sensors are low-cost, wireless, durable, simple to fabricate and battery-less. Consequently, they are well suited to sensing applications in harsh environments or in situations where large numbers of sensors are needed. They are also advantageous in applications where access to the sensor is limited or impossible or when sensors are needed on a disposable basis. Due to their many advantages, LC sensors have been used for sensing a variety of parameters including humidity, temperature, chemical concentrations, pH, stress/pressure, strain, food quality and even biological growth. However, current versions of the LC sensor technology are limited to sensing only one parameter. The purpose of this work is to develop new types of LC sensor systems that are simpler to fabricate (hence lower cost) or capable of monitoring multiple parameters simultaneously. One design presented in this work, referred to as the multi-element LC sensor, is able to measure multiple parameters simultaneously using a second capacitive element. Compared to conventional LC sensors, this design can sense multiple parameters with a higher detection range than two independent sensors while maintaining the same overall sensor footprint. In addition, the two-element sensor does not suffer from interference issues normally encountered while implementing two LC sensors in close proximity. Another design, the single-spiral inductive-capacitive sensor, utilizes the parasitic capacitance of a coil or spring structure to form a single layer LC resonant circuit. Unlike conventional LC sensors, this design is truly planar, thus simplifying its fabrication process and reducing sensor cost. Due to the simplicity of this sensor layout it will be easier and more cost-effective for embedding in common building or packaging materials during manufacturing processes, thereby adding functionality to current products (such as drywall sheets) while having a minor impact on overall unit cost. These modifications to the LC sensor design significantly improve the functionality and commercial feasibility of this technology, especially for applications where a large array of sensors or multiple sensing parameters are required.

THE POTENTIAL OF INDUSTRIAL WASTE AND AGRICULTURAL FEEDSTOCK TOWARDS SUSTAINABLE BIOFUELS PRODUCTION: TECHNO-ECONOMIC AND ENVIRONMENTAL IMPACT PERSPECTIVES

This Ph.D. research is comprised of three major components; (i) Characterization study to analyze the composition of defatted corn syrup (DCS) from a dry corn mill facility (ii) Hydrolysis experiments to optimize the production of fermentable sugars and amino acid platform using DCS and (iii) Sustainability analyses. Analyses of DCS included total solids, ash content, total protein, amino acids, inorganic elements, starch, total carbohydrates, lignin, organic acids, glycerol, and presence of functional groups. Total solids content was 37.4% (± 0.4%) by weight, and the mass balance closure was 101%. Total carbohydrates [27% (± 5%) wt.] comprised of starch (5.6%), soluble monomer carbohydrates (12%) and non-starch carbohydrates (10%). Hemicellulose components (structural and non-structural) were; xylan (6%), xylose (1%), mannan (1%), mannose (0.4%), arabinan (1%), arabinose (0.4%), galatactan (3%) and galactose (0.4%). Based on the measured physical and chemical components, bio-chemical conversion route and subsequent fermentation to value added products was identified as promising. DCS has potential to serve as an important fermentation feedstock for bio-based chemicals production. In the sugar hydrolysis experiments, reaction parameters such as acid concentration and retention time were analyzed to determine the optimal conditions to maximize monomer sugar yields while keeping the inhibitors at minimum. Total fermentable sugars produced can reach approximately 86% of theoretical yield when subjected to dilute acid pretreatment (DAP). DAP followed by subsequent enzymatic hydrolysis was most effective for 0 wt% acid hydrolysate samples and least efficient towards 1 and 2 wt% acid hydrolysate samples. The best hydrolysis scheme DCS from an industry's point of view is standalone 60 minutes dilute acid hydrolysis at 2 wt% acid concentration. The combined effect of hydrolysis reaction time, temperature and ratio of enzyme to substrate ratio to develop hydrolysis process that optimizes the production of amino acids in DCS were studied. Four key hydrolysis pathways were investigated for the production of amino acids using DCS. The first hydrolysis pathway is the amino acid analysis using DAP. The second pathway is DAP of DCS followed by protein hydrolysis using proteases [Trypsin, Pronase E (Streptomyces griseus) and Protex 6L]. The third hydrolysis pathway investigated a standalone experiment using proteases (Trypsin, Pronase E, Protex 6L, and Alcalase) on the DCS without any pretreatment. The final pathway investigated the use of Accellerase 1500® and Protex 6L to simultaneously produce fermentable sugars and amino acids over a 24 hour hydrolysis reaction time. The 3 key objectives of the techno-economic analysis component of this PhD research included; (i) Development of a process design for the production of both the sugar and amino acid platforms with DAP using DCS (ii) A preliminary cost analysis to estimate the initial capital cost and operating cost of this facility (iii) A greenhouse gas analysis to understand the environmental impact of this facility. Using Aspen Plus®, a conceptual process design has been constructed. Finally, both Aspen Plus Economic Analyzer® and Simapro® sofware were employed to conduct the cost analysis as well as the carbon footprint emissions of this process facility respectively. Another section of my PhD research work focused on the life cycle assessment (LCA) of commonly used dairy feeds in the U.S. Greenhouse gas (GHG) emissions analysis was conducted for cultivation, harvesting, and production of common dairy feeds used for the production of dairy milk in the U.S. The goal was to determine the carbon footprint [grams CO2 equivalents (gCO2e)/kg of dry feed] in the U.S. on a regional basis, identify key inputs, and make recommendations for emissions reduction. The final section of my Ph.D. research work was an LCA of a single dairy feed mill located in Michigan, USA. The primary goal was to conduct a preliminary assessment of dairy feed mill operations and ultimately determine the GHG emissions for 1 kilogram of milled dairy feed.

CRITERIA FOR SUSTAINABLE PRODUCT DESIGN WITH 3D PRINTING IN THE DEVELOPING WORLD

The demand for consumer goods in the developing world continues to rise as populations and economies grow. As designers, manufacturers, and consumers look for ways to address this growing demand, many are considering the possibilities of 3D printing. Due to 3D printing’s flexibility and relative mobility, it is speculated that 3D printing could help to meet the growing demands of the developing world. While the merits and challenges of distributed manufacturing with 3D printing have been presented, little work has been done to determine the types of products that would be appropriate for such manufacturing. Inspired by the author’s two years of Peace Corps service in the Tanzania and the need for specialty equipment for various projects during that time, an in-depth literature search is undertaken to better understand and summarize the process and capabilities of 3D printing. Human-centered design considerations are developed to focus on the product desirability, the technical feasibility, and the financial viability of using 3D printing within Tanzania. Beginning with concerns of what Tanzanian consumers desire, many concerns later arise in regards to the feasibility of creating products that would be sufficient in strength and quality for the demands of developing world consumers. It is only after these concerns are addressed that the viability of products can be evaluated from an economic perspective. The larger impacts of a product beyond its use are vital in determining how it will affect the social, economic, and environmental well-being of a developing nation such as Tanzania. Thus technology specific criteria are necessary for assessing and quantifying the broader impacts that a 3D-printed product can have within its ecosystem, and appropriate criteria are developed for this purpose. Both sets of criteria are then demonstrated and tested while evaluating the desirability, feasibility, viability, and sustainability of printing a piece of equipment required for the author’s Peace Corps service: a set of Vernier calipers. Required for science educators throughout the country, specialty equipment such as calipers initially appear to be an ideal candidate for 3D printing, though ultimately the printing of calipers is not recommended due to current restrictions in the technology. By examining more specific challenges and opportunities of the products 3D printing can produce, it can be better determined what place 3D printing will have in manufacturing for the developing world. Furthermore, the considerations outlined in this paper could be adapted for other manufacturing technologies and regions of the world, as human centered design and sustainability will be critical in determining how to supply the developing world with the consumer goods it demands.

Surgical glove perforation and the risk of surgical site infection

HYPOTHESIS: Clinically apparent surgical glove perforation increases the risk of surgical site infection (SSI). DESIGN: Prospective observational cohort study. SETTING: University Hospital Basel, with an average of 28,000 surgical interventions per year. PARTICIPANTS: Consecutive series of 4147 surgical procedures performed in the Visceral Surgery, Vascular Surgery, and Traumatology divisions of the Department of General Surgery. MAIN OUTCOME MEASURES: The outcome of interest was SSI occurrence as assessed pursuant to the Centers of Disease Control and Prevention standards. The primary predictor variable was compromised asepsis due to glove perforation. RESULTS: The overall SSI rate was 4.5% (188 of 4147 procedures). Univariate logistic regression analysis showed a higher likelihood of SSI in procedures in which gloves were perforated compared with interventions with maintained asepsis (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.4-2.8; P < .001). However, multivariate logistic regression analyses showed that the increase in SSI risk with perforated gloves was different for procedures with vs those without surgical antimicrobial prophylaxis (test for effect modification, P = .005). Without antimicrobial prophylaxis, glove perforation entailed significantly higher odds of SSI compared with the reference group with no breach of asepsis (adjusted OR, 4.2; 95% CI, 1.7-10.8; P = .003). On the contrary, when surgical antimicrobial prophylaxis was applied, the likelihood of SSI was not significantly higher for operations in which gloves were punctured (adjusted OR, 1.3; 95% CI, 0.9-1.9; P = .26). CONCLUSION: Without surgical antimicrobial prophylaxis, glove perforation increases the risk of SSI.

The association of preoperative anemia and perioperative allogeneic blood transfusion with the risk of surgical site infection

BACKGROUND: The purpose of the study was to investigate allogeneic blood transfusion (ABT) and preoperative anemia as risk factors for surgical site infection (SSI). STUDY DESIGN AND METHODS: A prospective, observational cohort of 5873 consecutive general surgical procedures at Basel University Hospital was analyzed to determine the relationship between perioperative ABT and preoperative anemia and the incidence of SSI. ABT was defined as transfusion of leukoreduced red blood cells during surgery and anemia as hemoglobin concentration of less than 120 g/L before surgery. Surgical wounds and resulting infections were assessed to Centers for Disease Control standards. RESULTS: The overall SSI rate was 4.8% (284 of 5873). In univariable logistic regression analyses, perioperative ABT (crude odds ratio [OR], 2.93; 95% confidence interval [CI], 2.1 to 4.0; p < 0.001) and preoperative anemia (crude OR, 1.32; 95% CI, 1.0 to 1.7; p = 0.037) were significantly associated with an increased odds of SSI. After adjusting for 13 characteristics of the patient and the procedure in multivariable analyses, associations were substantially reduced for ABT (OR, 1.25; 95% CI, 0.8 to 1.9; p = 0.310; OR, 1.07; 95% CI, 0.6 to 2.0; p = 0.817 for 1-2 blood units and >or=3 blood units, respectively) and anemia (OR, 0.91; 95% CI, 0.7 to 1.2; p = 0.530). Duration of surgery was the main confounding variable. CONCLUSION: Our findings point to important confounding factors and strengthen existing doubts on leukoreduced ABT during general surgery and preoperative anemia as risk factors for SSIs.

Making epothilones fluoresce: design, synthesis, and biological characterization of a fluorescent N12-aza-epothilone (azathilone)

A green fluorescent 12-aza-epothilone (azathilone) derivative has been prepared through the attachment of the 4-nitro-2,1,3-benzoxadiazole (NBD) fluorophore to the 12-nitrogen atom of the azamacrolide core structure. While less potent than natural epothilones or different N12-acylated azathilone derivatives, NBD-azathilone (3) promotes tubulin assembly, inhibits cancer cell proliferation in vitro and arrests the cell cycle at the G2/M transition. Most significantly, the binding of 3 to cellular microtubules (MTs) could be directly visualized by confocal fluorescence microscopy. Based on competition binding experiments with laulimalide-stabilized MTs in vitro, the N12-Boc substituted azathilone 1, Epo A, and NBD-azathilone (3) all interact with the same tubulin-binding site. Computational studies provided a structural model of the complexes between beta-tubulin and 1 or 3, respectively, in which the NBD moiety of 3 or the BOC moiety of 1 directly and specifically contribute to MT binding. Collectively, these data demonstrate that the cellular effects of 3 and, by inference, also of other azathilones are the result of their interactions with the cellular MT network.

Design of the blood group AB glycotope

Although the nature of the blood groups A and B has been comprehensively studied for a long time, it is still unclear as to what exactly is the epitope that is recognized by antibodies having AB specificity, i.e. monoclonal and polyclonal antibodies which are capable of interacting equally well with the antigens GalNAcalpha 1-3(Fucalpha 1-2)Gal (A trisaccharide) and Galalpha 1-3(Fucalpha 1-2)Gal (B trisaccharide), but do not react with their common fragment Fucalpha 1-2Gal. We have supposed that besides Fucalpha 1-2Gal, A and B antigens have one more shared epitope. The trisaccharides A and B are practically identical from the conformational point of view, the only difference being situated at position 2 of Galalpha residue, i.e. trisaccharide A has a NHAc group, whereas trisaccharide B has a hydroxyl group (see formulas). We have hypothesized that the AB-epitope should be situated in the part of the molecule that is opposite to the NHAc group of GalNAc residue. In order to test this hypothesis we have synthesized a polymeric conjugate in such a way that de-N-acetylated A-trisaccharide is attached to a polymer via the nitrogen in position C-2 of the galactosamine residue. In this conjugate the supposed AB-epitope should be maximally accessible for antibodies from the solution, whereas the discrimination site of antigens A and B by the antibodies should be maximally hidden due to the close proximity of the polymer. Interaction with several anti-AB monoclonal antibodies revealed that a part of them really interacted with the synthetic AB-glycotope, thus confirming our hypothesis. Moreover, similar antibodies were revealed in the blood of healthy blood group 0 donors. Analysis of spatial models was performed in addition to identify the hydroxyl groups of Fuc, Galalpha, and Galbeta residues, which are particularly involved in the composition of the AB-glycotope.

Climatic and environmental changes during the Weichselian Lateglacial Interstadial in the Weerterbos region, the Netherlands

Lake sediment records from the Weerterbos region, in the southern Netherlands, were studied to reconstruct summer temperature and environmental changes during the Weichselian Lateglacial Interstadial. A sediment core obtained from a small lacustrine basin was analysed for multiple proxies, including lithological changes, oxygen isotopes of bulk carbonates, pollen and chironomids. It was found that the oxygen isotope record differed strongly from the other proxies. Based on a comparison with three additional lake sediment records from the same region, it emerged that the oxygen isotope records were strongly affected by local environmental conditions, impeding the distinction of a regional palaeoclimate signal. The chironomid-inferred July air temperature reconstruction produced inferred interstadial temperatures ranging between ∼15° and 18°C, largely consistent with previously published results from the northern part of the Netherlands. A temporary regressive phase in the pollen record, which can be tentatively correlated with the Older Dryas, preceded the expansion of birch woodland. Despite differences between the four pollen records from the Weerterbos region, a comparable regressive vegetation phase that was possibly the result of a shift to drier conditions could be discerned in all of the profiles. In addition, a temporary temperature decline of ∼1.5°C was inferred from the chironomid record during this regressive phase. The multi-proxy approach used here enabled a direct comparison of inferred changes in temperature, vegetation and environmental conditions at an individual site, while the multi-site approach provided insight into the factors influencing the pollen and isotope records from these small-scale depressions.

Computational and experimental methodology for site-matched investigations of the influence of mineral mass fraction and collagen orientation on the axial indentation modulus of lamellar bone

Relationships between mineralization, collagen orientation and indentation modulus were investigated in bone structural units from the mid-shaft of human femora using a site-matched design. Mineral mass fraction, collagen fibril angle and indentation moduli were measured in registered anatomical sites using backscattered electron imaging, polarized light microscopy and nano-indentation, respectively. Theoretical indentation moduli were calculated with a homogenization model from the quantified mineral densities and mean collagen fibril orientations. The average indentation moduli predicted based on local mineralization and collagen fibers arrangement were not significantly different from the average measured experimentally with nanoindentation (p=0.9). Surprisingly, no substantial correlation of the measured indentation moduli with tissue mineralization and/or collagen fiber arrangement was found. Nano-porosity, micro-damage, collagen cross-links, non-collagenous proteins or other parameters affect the indentation measurements. Additional testing/simulation methods need to be considered to properly understand the variability of indentation moduli, beyond the mineralization and collagen arrangement in bone structural units.

Evaluation of a novel photography-based home assessment protocol for identification of environmental risk factors for falls in elderly persons

PRINCIPLES To evaluate the validity and feasibility of a novel photography-based home assessment (PhoHA) protocol, as a possible substitute for on-site home assessment (OsHA). METHODS A total of 20 patients aged ≥65 years who were hospitalised in a rehabilitation centre for musculoskeletal disorders affecting mobility participated in this prospective validation study. For PhoHA, occupational therapists rated photographs and measurements of patients' homes provided by patients' confidants. For OsHA, occupational therapists conducted a conventional home visit. RESULTS Information obtained by PhoHA was 79.1% complete (1,120 environmental factors identified by PhoHA vs 1416 by OsHA). Of the 1,120 factors, 749 had dichotomous (potential hazards) and 371 continuous scores (measurements with tape measure). Validity of PhoHA to potential hazards was good (sensitivity 78.9%, specificity 84.9%), except for two subdomains (pathways, slippery surfaces). Pearson's correlation coefficient for the validity of measurements was 0.87 (95% confidence interval [CI 0.80-0.92, p <0.001). Agreement between methods was 0.52 (95%CI 0.34-0.67, p <0.001, Cohen's kappa coefficient) for dichotomous and 0.86 (95%CI 0.79-0.91, p <0.001, intraclass correlation coefficient) for continuous scores. Costs of PhoHA were 53.0% lower than those of OsHA (p <0.001). CONCLUSIONS PhoHA has good concurrent validity for environmental assessment if instructions for confidants are improved. PhoHA is potentially a cost-effective method for environmental assessment.