Cefuroxime prophylaxis is effective in noninstrumented spine surgery : a double-blind, placebo-controlled study

Rapport de synthèse : Plusieurs investigateurs ont démontré que l'utilisation d'une antibiothérapie prophylactique lors d'interventions neurochirurgicales en terrain non infecté (chirurgie propre) réduisait le taux d'infection. Toutefois, ces taux d'infections sont très variables en fonction des types de chirurgie et de la durée des interventions. Les craniotomies, la mise en place ou le remplacement de shunt ventriculo-cardiaque, l'extirpation de méningiomes intracrâniens et les interventions d'une durée de plus de quatre heures sont grevées d'un taux d'infections post-opératoires plus élevé. Si une prophylaxie antibiotique est maintenant reconnue et utilisée dans ce type de chirurgie, il n'a jamais été démontré que cette pratique amène un bénéfice dans les cas de chirurgie pour hernie discale. Des études ont montré que de nombreux organismes potentiellement pathogènes pouvaient être collectés et cultivés à proximité voire dans le champ opératoire. Malgré ces observations, le taux d'infections post-opératoires reste peu important (entre 1-4% selon les centres). Il n'est actuellement pas possible de distinguer le rôle respectif d'une antibiothérapie prophylactique et des pratiques d'asepsie habituelles (y compris l'usage de solutions de rinçage antiseptiques) dans la faible incidence des infections post-opératoires en ce qui concerne la chirurgie des hernies discales. Lorsque des opérations de chirurgie dite «propre » sont grevées d'un taux de complications aussi bas, une prophylaxie antibiotique n'est généralement pas recommandée, en raison d'un rapport coût-bénéfice défavorable. Le but de cette étude est d'évaluer la nécessité d'une antibiothérapie prophylactique par une céphalosporine de seconde génération (cefuroxime 1,5 g intraveineuse) dans la prévention des infections post-opératoires au cours d'une chirurgie pour hernie discale. Il s'agit d'un essai clinique prospectif, contrôlé contre placebo en insu réciproque, à répartition aléatoire. L'étude a été conduite dans les services de neurochirurgie de l'Hôpital Universitaire de Genève et du Centre Hospitalier Universitaire Vaudois de Lausanne. L'ensemble des patients admis dans ces deux services pour une opération de hernie discale et ayant donné leur consentement ont été inclus dans l'étude qui s'est déroulé sur une période de 6 ans. Mille trois cent soixante-neuf patients opérés pour une hernie discale ont été inclus dans cet essai et 132 patients ont été exclus de l'analyse pour diverses raisons. Au total 1'237 patients ont été analysés, respectivement 613 et 624 patients dans le groupe cefuroxime et le groupe placebo. Les patients des deux groupes présentaient des caractéristiques identiques. Nous n'avons objectivé aucun effet secondaire indésirable attribuable à la cefuroxime ou au placebo. Huit (1.3%) patients du groupe cefuroxime et 18 patients (2.8%) du groupe placebo ont développé une infection du site opératoire (P=0.073). Neuf des patients infectés dans le groupe placebo présentaient une infection profonde du site opératoire (spondylodiscite, abcès épidural) et aucun dans le groupe cefuroxime (P<0.01). Tous les patients avec infection profonde du site opératoire ont été traités par antibiothérapie par voie intraveineuse pour au moins 4 semaines et il a été procédé à une reprise chirurgicale chez deux patients. Ces résultats montrent qu'il faut traiter 69 patients avec une antibiothérapie prophylactique de cefuroxime pour prévenir une infection du site opératoire. En conclusion, l'administration d'une dose de cefuroxime 1.5 g intraveineuse comme prophylaxie lors d'opération de hernie discale, permet de réduire significativement le risque d'infection profonde du site opératoire.

Effect of growth regulators on 'Brookfield' apple gas diffusion and metabolism under controlled atmosphere storage

The objective of this work was to evaluate the effect of growth regulators on gas diffusion and on metabolism of 'Brookfield' apple, and to determine their correlation with quality characteristics of fruit stored in controlled atmosphere. A completely randomized design was used with four replicates. After eight months of storage, the effects of water (control), aminoethoxyvinylglycine (AVG), AVG + ethephon, AVG + naphthaleneacetic acid (NAA), ethephon + NAA, sole NAA, 1-MCP, ethylene absorption by potassium permanganate (ABS), AVG + ABS, and of AVG + 1-MCP - applied at different rates and periods - were evaluated on: gas diffusion rate, ethylene production, respiratory rate, internal ethylene concentration, internal CO2 content, mealiness, and intercellular space. Fruit from the control and sole NAA treatments had the highest mealiness occurrence. Growth regulators significantly changed the gaseous diffusion through the pulp of 'Brookfield' apple, mainly in the treatment AVG + ABS, which kept the highest gas diffusion rate. NAA spraying in the field, with or without another growth regulator, increased ripening metabolism by rising ethylene production and respiration rate, and reduced gas diffusion during shelf life. AVG spraying cannot avoid the ethephon effect during the ripening process, and reduces both the internal space and mealiness incidence, but it is not able to induce ethylene production or to increase respiration rates.

Vaccines safety; effect of supervision or SMS on reporting rates of adverse events following immunization (AEFI) with meningitis vaccine (MenAfriVac?): a randomized controlled trial.

BACKGROUND: To ensure vaccines safety, given the weaknesses of the national pharmacovigilance system in Cameroon, there is a need to identify effective interventions that can contribute to improving AEFI reporting. OBJECTIVE: To assess the effect of: (i) sending weekly SMS, or (ii) weekly supervisory visits on AEFI reporting rate during a meningitis immunization campaign conducted in Cameroon in 2012 using the meningitis A conjugate vaccine (MenAfriVac?). METHODS: Health facilities that met the inclusion criteria were randomly assigned to receive: (i) a weekly standardized SMS, (ii) a weekly standardized supervisory visits or (iii) no intervention. The primary outcome was the reported AEFI incidence rate from week 5 to 8 after the immunization campaign. Poisson regression model was used to estimate the effect of interventions after adjusting for health region, type of health facility, type and position of health workers as well as the cumulative number of AEFI reported from weeks 1 to 4. RESULTS: A total of 348 (77.2%) of 451 health facility were included, and 116 assigned to each of three groups. The incidence rate of reported AEFI per 100 health facility per week was 20.0 (15.9-24.1) in the SMS group, 40.2 (34.4-46.0) in supervision group and 13.6 (10.1-16.9) in the control group. Supervision led to a significant increase of AEFI reporting rate compared to SMS [adjusted RR=2.1 (1.6-2.7); p<0.001] and control [RR=2.8(2.1-3.7); p<0.001)] groups. The effect of SMS led to some increase in AEFI reporting rate compared to the control group, but the difference was not statistically significant [RR=1.4(0.8-1.6); p=0.07)]. CONCLUSION: Supervision was more effective than SMS or routine surveillance in improving AEFI reporting rate. It should be part of any AEFI surveillance system. SMS could be useful in improving AEFI reporting rates but strategies need to be found to improve its effectiveness, and thus maximize its benefits.

Safety of intramuscular influenza vaccine in patients receiving oral anticoagulation therapy: a single blinded multi-centre randomized controlled clinical trial

Influenza vaccines are recommended for administration by the intramuscular route. However, many physicians use the subcutaneous route for patients receiving an oral anticoagulant because this route is thought to induce fewer hemorrhagic side effects. Our aim is to assess the safety of intramuscular administration of influenza vaccine in patients on oral anticoagulation therapy. Methods: Design: Randomised, controlled, single blinded, multi-centre clinical trial. Setting: 4 primary care practices in Barcelona, Spain. Participants: 229 patients on oral anticoagulation therapy eligible for influenza vaccine during the 20032004 season. Interventions: intramuscular administration of influença vaccine in the experimental group (129 patients) compared to subcutaneous administration in the control group (100 patients). Primary outcome: change in the circumference of the arm at the site of injection at 24 hours. Secondary outcomes: appearance of local reactions and pain at 24 hours and at 10 days; change in INR (International Normalized Ratio) at 24 hours and at 10 days. Analysis was by intention to treat using the 95% confidence intervals of the proportions or mean differences. Results: Baseline variables in the two groups were similar. No major side effects or major haemorrhage during the follow-up period were reported. No significant differences were observed in the primary outcome between the two groups. The appearance of local adverse reactions was more frequent in the subcutaneous administration group (37,4% vs. 17,4%, 95% confidence interval of the difference 8,2% to 31,8%). Conclusion: This study shows that the intramuscular administration route of influenza vaccine in patients on anticoagulant therapy does not have more side effects than the subcutaneous administration route

Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial.

BACKGROUND: Enteral nutrition (EN) is recommended for patients in the intensive-care unit (ICU), but it does not consistently achieve nutritional goals. We assessed whether delivery of 100% of the energy target from days 4 to 8 in the ICU with EN plus supplemental parenteral nutrition (SPN) could optimise clinical outcome. METHODS: This randomised controlled trial was undertaken in two centres in Switzerland. We enrolled patients on day 3 of admission to the ICU who had received less than 60% of their energy target from EN, were expected to stay for longer than 5 days, and to survive for longer than 7 days. We calculated energy targets with indirect calorimetry on day 3, or if not possible, set targets as 25 and 30 kcal per kg of ideal bodyweight a day for women and men, respectively. Patients were randomly assigned (1:1) by a computer-generated randomisation sequence to receive EN or SPN. The primary outcome was occurrence of nosocomial infection after cessation of intervention (day 8), measured until end of follow-up (day 28), analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00802503. FINDINGS: We randomly assigned 153 patients to SPN and 152 to EN. 30 patients discontinued before the study end. Mean energy delivery between day 4 and 8 was 28 kcal/kg per day (SD 5) for the SPN group (103% [SD 18%] of energy target), compared with 20 kcal/kg per day (7) for the EN group (77% [27%]). Between days 9 and 28, 41 (27%) of 153 patients in the SPN group had a nosocomial infection compared with 58 (38%) of 152 patients in the EN group (hazard ratio 0·65, 95% CI 0·43-0·97; p=0·0338), and the SPN group had a lower mean number of nosocomial infections per patient (-0·42 [-0·79 to -0·05]; p=0·0248). INTERPRETATION: Individually optimised energy supplementation with SPN starting 4 days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom EN is insufficient. FUNDING: Foundation Nutrition 2000Plus, ICU Quality Funds, Baxter, and Fresenius Kabi.

Efficacy of a dilemma-focused intervention for unipolar depression: study protocol for a multicenter randomized controlled trial

Background Depression is one of the more severe and serious health problems because of its morbidity, disabling effects and for its societal and economic burden. Despite the variety of existing pharmacological and psychological treatments, most of the cases evolve with only partial remission, relapse and recurrence. Cognitive models have contributed significantly to the understanding of unipolar depression and its psychological treatment. However, success is only partial and many authors affirm the need to improve those models and also the treatment programs derived from them. One of the issues that requires further elaboration is the difficulty these patients experience in responding to treatment and in maintaining therapeutic gains across time without relapse or recurrence. Our research group has been working on the notion of cognitive conflict viewed as personal dilemmas according to personal construct theory. We use a novel method for identifying those conflicts using the repertory grid technique (RGT). Preliminary results with depressive patients show that about 90% of them have one or more of those conflicts. This fact might explain the blockage and the difficult progress of these patients, especially the more severe and/or chronic. These results justify the need for specific interventions focused on the resolution of these internal conflicts. This study aims to empirically test the hypothesis that an intervention focused on the dilemma(s) specifically detected for each patient will enhance the efficacy of cognitive behavioral therapy (CBT) for depression. Design A therapy manual for a dilemma-focused intervention will be tested using a randomized clinical trial by comparing the outcome of two treatment conditions: combined group CBT (eight, 2-hour weekly sessions) plus individual dilemma-focused therapy (eight, 1-hour weekly sessions) and CBT alone (eight, 2-hour group weekly sessions plus eight, 1-hour individual weekly sessions). Method Participants are patients aged over 18 years meeting diagnostic criteria for major depressive disorder or dysthymic disorder, with a score of 19 or above on the Beck depression inventory, second edition (BDI-II) and presenting at least one cognitive conflict (implicative dilemma or dilemmatic construct) as assessed using the RGT. The BDI-II is the primary outcome measure, collected at baseline, at the end of therapy, and at 3- and 12-month follow-up; other secondary measures are also used. Discussion We expect that adding a dilemma-focused intervention to CBT will increase the efficacy of one of the more prestigious therapies for depression, thus resulting in a significant contribution to the psychological treatment of depression. Trial registration ISRCTN92443999; ClinicalTrials.gov Identifier: NCT01542957.

Working alliance in communication skills training for oncology clinicians: A controlled trial.

OBJECTIVE: The aim of this study was to evaluate the impact of communication skills training (CST) on working alliance and to identify specific communicational elements related to working alliance. METHODS: Pre- and post-training simulated patient interviews (6-month interval) of oncology physicians and nurses (N=56) who benefited from CST were compared to two simulated patient interviews with a 6-month interval of oncology physicians and nurses (N=57) who did not benefit from CST. The patient-clinician interaction was analyzed by means of the Roter Interaction Analysis System (RIAS). Alliance was measured by the Working Alliance Inventory - Short Revised Form. RESULTS: While working alliance did not improve with CST, generalized linear mixed effect models demonstrated that the quality of verbal communication was related to alliance. Positive talk and psychosocial counseling fostered alliance whereas negative talk, biomedical information and patient's questions diminished alliance. CONCLUSION: Patient-clinician alliance is related to specific verbal communication behaviors. PRACTICE IMPLICATIONS: Working alliance is a key element of patient-physician communication which deserves further investigation as a new marker and efficacy criterion of CST outcome.

A prospective, randomized, and controlled study of fluid management in children with severe head injury: lactated Ringer's solution versus hypertonic saline.

OBJECTIVES: Resuscitation in severe head injury may be detrimental when given with hypotonic fluids. We evaluated the effects of lactated Ringer's solution (sodium 131 mmol/L, 277 mOsm/L) compared with hypertonic saline (sodium 268 mmol/L, 598 mOsm/L) in severely head-injured children over the first 3 days after injury. DESIGN: An open, randomized, and prospective study. SETTING: A 16-bed pediatric intensive care unit (ICU) (level III) at a university children's hospital. PATIENTS: A total of 35 consecutive children with head injury. INTERVENTIONS: Thirty-two children with Glasgow Coma Scores of <8 were randomly assigned to receive either lactated Ringer's solution (group 1) or hypertonic saline (group 2). Routine care was standardized, and included the following: head positioning at 30 degrees; normothermia (96.8 degrees to 98.6 degrees F [36 degrees to 37 degrees C]); analgesia and sedation with morphine (10 to 30 microg/kg/hr), midazolam (0.2 to 0.3 mg/kg/hr), and phenobarbital; volume-controlled ventilation (PaCO2 of 26.3 to 30 torr [3.5 to 4 kPa]); and optimal oxygenation (PaO2 of 90 to 105 torr [12 to 14 kPa], oxygen saturation of >92%, and hematocrit of >0.30). MEASUREMENTS AND MAIN RESULTS: Mean arterial pressure and intracranial pressure (ICP) were monitored continuously and documented hourly and at every intervention. The means of every 4-hr period were calculated and serum sodium concentrations were measured at the same time. An ICP of 15 mm Hg was treated with a predefined sequence of interventions, and complications were documented. There was no difference with respect to age, male/female ratio, or initial Glasgow Coma Score. In both groups, there was an inverse correlation between serum sodium concentration and ICP (group 1: r = -.13, r2 = .02, p < .03; group 2: r = -.29, r2 = .08, p < .001) that disappeared in group 1 and increased in group 2 (group 1: r = -.08, r2 = .01, NS; group 2: r = -.35, r2 =.12, p < .001). Correlation between serum sodium concentration and cerebral perfusion pressure (CPP) became significant in group 2 after 8 hrs of treatment (r = .2, r2 = .04, p = .002). Over time, ICP and CPP did not significantly differ between the groups. However, to keep ICP at <15 mm Hg, group 2 patients required significantly fewer interventions (p < .02). Group 1 patients received less sodium (8.0 +/- 4.5 vs. 11.5 +/- 5.0 mmol/kg/day, p = .05) and more fluid on day 1 (2850 +/- 1480 vs. 2180 +/- 770 mL/m2, p = .05). They also had a higher frequency of acute respiratory distress syndrome (four vs. 0 patients, p = .1) and more than two complications (six vs. 1 patient, p = .09). Group 2 patients had significantly shorter ICU stay times (11.6 +/- 6.1 vs. 8.0 +/- 2.4 days; p = .04) and shorter mechanical ventilation times (9.5 +/- 6.0 vs. 6.9 +/- 2.2 days; p = .1). The survival rate and duration of hospital stay were similar in both groups. CONCLUSIONS: Treatment of severe head injury with hypertonic saline is superior to that treatment with lactated Ringer's solution. An increase in serum sodium concentrations significantly correlates with lower ICP and higher CPP. Children treated with hypertonic saline require fewer interventions, have fewer complications, and stay a shorter time in the ICU.

Logistics Development in Finnish and Swedish Companies with Respect of Russia and Four Asian Countries: Traffic Flow and Warehousing Analysis from Current Situation and Likely Development Trends

On selvää, että tänä päivänä maailmankaupan painopiste on hiljalleen siirtymässä Aasiaan ja varsinkin Kiina on ollut huomion keskipisteessä. Erityisesti valmistavien yritysten perspektiivistä muutos on ollut merkittävä ja tämä tosiasia kasvattaa yrityksissä paineita luoda kustannustehokkaita toimitusketjuratkaisuja,joiden vasteaika on mahdollisimman lyhyt. Samaan aikaan kun tarkastellaan kuljetusvirtoja, huomattaan että maanosien välillä on suuri epätasapaino. Tämä on enimmäkseen seurausta suurten globaalisti toimivien yritysten toimitusketjustrategioista. Useimmat näistä toimijoista optimoivat verkostonsa turvautumalla 'paikalliseen hankintaan', jotta he voisivat paremmin hallita toimitusketjujaan ja saada näitä reagointiherkimmiksi. Valmistusyksiköillä onkin monesti Euroopassa pakko käyttää kalliita raaka-aineita ja puolivalmisteita. Kriittisiksi tekijöiksi osoittautuvat kuljetus- ja varastointikustannukset sekä näiden seurauksena hukka-aika, joka aiheutuu viivästyksistä. Voidakseen saavuttaa optimiratkaisun, on tehtävä päätös miten tuotteet varastoidaan: keskitetysti tai hajautetusti ja integroida tämä valinta sopivien kuljetusmuotojen kanssa. Aasiasta Pohjois-Eurooppaan on halpaa käyttää merikuljetusta, mutta operaatio kestää hyvin pitkään - joissain tapauksessa jopa kahdeksan viikkoa. Toisaalta lentokuljetus on sekä kallis että rajoittaa siirrettävien tuotteiden eräkokoa.On olemassa kolmaskin vaihtoehto, josta voisi olla ratkaisuksi: rautatiekuljetus on halvempi kuin lentokuljetus ja vasteajat ovat lyhyemmät kuin merikuljetuksissa. Tässä tutkimuksessa tilannetta selvitetään kyselyllä, joka suunnattiin Suomessa ja Ruotsissa toimiville yrityksille. Tuloksien perusteella teemme johtopäätökset siitä, mitkä kuljetusmuotojen markkinaosuudet tulevat olemaan tulevaisuudessa sekä luomme kuvan kuljetusvirroista Euroopan, Venäjän, Etelä-Korea, Intian, Kiinan ja Japanin välillä. Samalla on tarkoitus ennakoida sitä, miten tarkastelun kohteena olevat yritykset aikovat kehittää kuljetuksiaan ja varastointiaan tulevien vuosien aikana. Tulosten perusteella näyttää siltä, että seuraavan viiden vuoden kuluessa kuljetuskustannukset eivät merkittävissä määrin tule muuttuman ja meri- sekä kumipyöräkuljetukset pysyvät suosituimpina vaihtoehtoina.Kuitenkin lentokuljetusten osuus laskee hiukan, kun taas rautatiekuljetusten painotus kasvaa. Tulokset paljastavat, että Kiinassa ja Venäjällä kuljetettava konttimäärä kasvaa; Intiassa tulos on saman suuntainen, joskaan ei niin voimakas. Analyysimme mukaan kuljetusvirtoihin liittyvä epätasapaino säilyy Venäjän kuljetusten suhteen: yritykset jatkavat tulevaisuudessakin vientiperusteista strategiaansa. Varastoinnin puolella tunnistamme pienemmän muutoksen, jonka mukaan pienikokoisten varastojen määrät todennäköisesti vähenevät tulevaisuudessa ja kiinnostus isoja varastoja kohtaan lisääntyy. Tässä kohtaa on mainittava, että suomalaisilla yrityksillä on enemmän varastoja Keski- ja Itä-Euroopassa verrattuna ruotsalaisiin toimijoihin, jotka keskittyvät selkeämmin Länsi-Euroopan maihin. Varastoja yrityksillä on molemmissa tapaukissa paljolti kotimaassaan. Valitessaan varastojensa sijoituskohteita yritykset painottavat seuraavia kriteereitä: alhaiset jakelukustannukset, kokoamispaikan/valmistustehtaan läheisyys, saapuvan logistiikan integroitavuus ja saatavilla olevat logistiikkapalvelut. Tutkimuksemme lopussa päädymme siihen, että varastojen sijoituspaikat eivät muutu satamien rakenteen ja liikenneyhteyksien takia kovinkaan nopeasti.

Improving Dynamic Characteristics of Open-loop Controlled Log Crane

The improvement of the dynamics of flexible manipulators like log cranes often requires advanced control methods. This thesis discusses the vibration problems in the cranes used in commercial forestry machines. Two control methods, adaptive filtering and semi-active damping, are presented. The adaptive filter uses a part of the lowest natural frequency of the crane as a filtering frequency. The payload estimation algorithm, filtering of control signal and algorithm for calculation of the lowest natural frequency of the crane are presented. The semi-active damping method is basedon pressure feedback. The pressure vibration, scaled with suitable gain, is added to the control signal of the valve of the lift cylinder to suppress vibrations. The adaptive filter cuts off high frequency impulses coming from the operatorand semi-active damping suppresses the crane?s oscillation, which is often caused by some external disturbance. In field tests performed on the crane, a correctly tuned (25 % tuning) adaptive filter reduced pressure vibration by 14-17 % and semi-active damping correspondingly by 21-43%. Applying of these methods require auxiliary transducers, installed in specific points in the crane, and electronically controlled directional control valves.

Using the optical flow to implement a relative virtual mouse controlled by head movements

The following paper introduces the work conducted to create a relative virtual mouse based on the interpretation of head movements and face gesture through a low cost camera and the optical flow of the images. This virtual device is designed specifically as an alternative non-contact pointer for people with mobility impairments in the upper extremities and reduced head control. The proposed virtual device was compared with a conventional mouse, a touchpad and a digital joystick. Validation results show performances close to a digital joystick but far away from a conventional mouse.