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Higher inflammation has been linked to poor physical and mental health outcomes, and mortality, but few studies have rigorously examined whether changes in perceived stress and depressive symptoms are associated with increased inflammation within family caregivers and non-caregivers in a longitudinal design.
REasons for Geographic And Racial Differences in Stroke cohort study.
Participants included 239 individuals who were not caregivers at baseline but transitioned to providing substantial and sustained caregiving over time. They were initially matched to 241 non-caregiver comparisons on age, sex, race, education, marital status, self-rated health, and history of cardiovascular disease. Blood was drawn at baseline and approximately 9.3 years at follow-up for both groups.
Perceived Stress Scale, Center for Epidemiological Studies-Depression, inflammatory biomarkers, including high-sensitivity C-reactive protein, D dimer, tumor necrosis factor alpha receptor 1, interleukin (IL)-2, IL-6, and IL-10 taken at baseline and follow-up.
Although at follow-up, caregivers showed significantly greater worsening in perceived stress and depressive symptoms compared to non-caregivers, there were few significant associations between depressive symptoms or perceived stress on inflammation for either group. Inflammation, however, was associated with multiple demographic and health variables, including age, race, obesity, and use of medications for hypertension and diabetes for caregivers and non-caregivers.
These findings illustrate the complexity of studying the associations between stress, depressive symptoms, and inflammation in older adults, where these associations may depend on demographic, disease, and medication effects. Future studies should examine whether resilience factors may prevent increased inflammation in older caregivers.
Hip and knee arthroplasty infections are associated with considerable healthcare costs. The merits of reducing the postoperative surveillance period from 1 year to 90 days have been debated.
To report the first pan-Canadian hip and knee periprosthetic joint infection (PJI) rates and to describe the implications of a shorter (90-day) postoperative surveillance period.
Prospective surveillance for infection following hip and knee arthroplasty was conducted by hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) using standard surveillance definitions.
Overall hip and knee PJI rates were 1.64 and 1.52 per 100 procedures, respectively. Deep incisional and organ-space hip and knee PJI rates were 0.96 and 0.71, respectively. In total, 93% of hip PJIs and 92% of knee PJIs were identified within 90 days, with a median time to detection of 21 days. However, 11%–16% of deep incisional and organ-space infections were not detected within 90 days. This rate was reduced to 3%–4% at 180 days post procedure. Anaerobic and polymicrobial infections had the shortest median time from procedure to detection (17 and 18 days, respectively) compared with infections due to other microorganisms, including Staphylococcus aureus.
PJI rates were similar to those reported elsewhere, although differences in national surveillance systems limit direct comparisons. Our results suggest that a postoperative surveillance period of 90 days will detect the majority of PJIs; however, up to 16% of deep incisional and organ-space infections may be missed. Extending the surveillance period to 180 days could allow for a better estimate of disease burden.
To assess clinically relevant outcomes after complete cessation of control measures for vancomycin-resistant enterococci (VRE).
Quasi-experimental ecological study over 3.5 years.
All VRE screening and isolation practices at 4 large academic hospitals in Ontario, Canada, were stopped on July 1, 2012. In total, 618 anonymized abstracted charts of patients with VRE-positive clinical isolates identified between July 1, 2010, and December 31, 2013, were reviewed to determine whether the case was a true VRE infection, a VRE colonization or contaminant, or a true VRE bacteremia. All deaths within 30 days of the last VRE infection were also reviewed to determine whether the death was fully or partially attributable to VRE. All-cause mortality was evaluated over the study period. Generalized estimating equation methods were used to cluster outcome rates within hospitals, and negative binomial models were created for each outcome.
The incidence rate ratio (IRR) for VRE infections was 0.59 and the associated P value was .34. For VRE bacteremias, the IRR was 0.54 and P=.38; for all-cause mortality the IRR was 0.70 and P=.66; and for VRE attributable death, the IRR was 0.35 and P=.49. VRE control measures were not significantly associated with any of the outcomes. Rates of all outcomes appeared to increase during the 18-month period after cessation of VRE control measures, but none reached statistical significance.
Clinically significant VRE outcomes remain rare. Cessation of all control measures for VRE had no significant attributable adverse clinical impact.
The transfusion of blood and blood components is associated with a very low but ever-present risk of infection. It is estimated that 1 in every 2000 units of blood may carry an infectious agent and that about 4 in 10 000 recipients develop a chronic disease or die as a result of receiving contaminated blood. A wide variety of viral, bacterial, and parasitic agents have been associated with blood transfusion (Table 106.1). Concerns have also been raised about the potential for transmission of Creutzfeldt–Jakob disease (CJD) and its new variant (vCJD) through blood products. However, no human episodes of CJD or vCJD have been definitively linked to blood or blood component transfusion to date, and case–control studies have not found blood transfusion to be a risk factor for CJD. The risk of viral transmission has been markedly reduced with improved screening, particularly using nucleic acid testing (NAT). The risk is now estimated to be 1 in 2 million units for human immunodeficiency virus (HIV) or hepatitis C virus (HCV) and approximately 1 in 200 000 units for hepatitis B virus (HBV). Because the risk of viral or parasitic infection is very low and blood is screened for HCV, HBV, HIV, and human T-cell lymphoma/leukemia virus (HTLV) 1, the remainder of this chapter focuses on bacterial complications of blood transfusion, which can be diagnosed and treated.
To identify the behavioral determinants—both barriers and enablers—that may impact physician hand hygiene compliance.
A qualitative study involving semistructured key informant interviews with staff physicians and residents.
An urban, 1,100-bed multisite tertiary care Canadian hospital.
A total of 42 staff physicians and residents in internal medicine and surgery.
Semistructured interviews were conducted using an interview guide that was based on the theoretical domains framework (TDF), a behavior change framework comprised of 14 theoretical domains that explain health-related behavior change. Interview transcripts were analyzed using thematic content analysis involving a systematic 3-step approach: coding, generation of specific beliefs, and identification of relevant TDF domains.
Similar determinants were reported by staff physicians and residents and between medicine and surgery. A total of 53 specific beliefs from 9 theoretical domains were identified as relevant to physician hand hygiene compliance. The 9 relevant domains were knowledge; skills; beliefs about capabilities; beliefs about consequences; goals; memory, attention, and decision processes; environmental context and resources; social professional role and identity; and social influences.
We identified several key determinants that physicians believe influence whether and when they practice hand hygiene at work. These beliefs identify potential individual, team, and organization targets for behavior change interventions to improve physician hand hygiene compliance.
Infect Control Hosp Epidemiol 2014;35(12):1511–1520
The objective of this study was to determine whether skin and soft tissue infections (SSTIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) in patients presenting to The Ottawa Hospital emergency departments (TOHEDs) differed from SSTIs caused by methicillin-susceptible Staphylococcus aureus (MSSA) with regard to risk factors, management, and outcomes.
All patients seen at TOHEDs in 2006 and 2007 with SSTIs who yielded MRSA or MSSA in cultures from the site of infection were eligible for inclusion. We excluded patients with decubitus ulcers and infections related to diabetes or peripheral vascular disease. We used an unmatched case-control design. Cases were defined as patients with MRSA isolated from the infection site, and controls were defined as patients with MSSA isolated from the infection site. Data were collected retrospectively from health records and laboratory and hospital information systems.
A total of 153 patients were included in the study (81 cases and 72 controls). The mean age of cases was 37 years, compared to 47 years for the controls (p < 0.001). Cases were more likely to have transient residence (31% v. 3% [OR 15.6, 95% CI 3.9–61.8, p < 0.001]), present with abscesses (64% v. 15% [OR 9.9, 95% CI 4.3–23.7, p < .001]), have a documented history of hepatitis C infection (28% v. 3% [OR 13.9, 95% CI 3.9–55.0, p < 0.001]), and have a history of substance abuse (53% v. 10% [OR 10.5, 95% CI 4.4–25.1, p < 0.001]). Cases most commonly used crack cocaine and injection drugs.
SSTIs caused by MRSA at TOHEDs mainly occur in a population that is young and transient with comorbidities such as hepatitis C and substance abuse.
Several medical devices used during hemodynamic procedures, particularly angiographic diagnostic and therapeutic cardiac catheters, are manufactured for single use only. However, reprocessing and reuse of these devices has been reported, to determine the frequency of reuse and reprocessing of single-use medical devices used during hemodynamic procedures in Brazil and to evaluate how reprocessing is performed.
National survey, conducted from December 1999 to July 2001.
Most of the institutions affiliated with the Brazilian Society of Hemodynamic and Interventional Cardiology were surveyed by use of a questionnaire sent in the mail.
The questionnaire response rate was 50% (119 of 240 institutions). Of the 119 institutions that responded, 116 (97%) reported reuse of single-use devices used during hemodynamic procedures, and only 26 (22%) reported use of a standardized reprocessing protocol. Cleaning, flushing, rinsing, drying, sterilizing and packaging methods varied greatly and were mostly inadequate. Criteria for discarding reused devices varied widely. Of the 119 institutions that responded, 80 (67%) reported having a surveillance system for adverse events associated with the reuse of medical devices, although most of these institutions did not routinely review the data, and only 38 (32%) described a training program for the personnel who reprocessed single-use devices.
The reuse of single-use devices used during hemodynamic procedures was very frequent in hospitals in Brazil. Basic guidance on how to reuse and reprocess single-use medical devices is urgently needed, because, despite the lack of studies to support reusing and reprocessing single-use medical devices, such devices are necessary in limited-resource areas in which these practices are current.
The transfusion of blood and blood components is associated with a very low but ever-present risk of infection. It is estimated that 1 in every 2000 units of blood may carry an infectious agent and that about 4 in 10 000 recipients develop a chronic disease or die as a result of receiving contaminated blood. A wide variety of viral, bacterial, and parasitic agents have been associated with blood transfusion (Table 104.1). Concerns have also been raised about the potential for transmission of Creutzfeldt–Jakob disease (CJD) and its new variant (nv-CJD) through blood products. However, no human episodes of CJD or nv-CJD have been causally liked to blood transfusion, and case–control studies have not found blood transfusion to be a risk factor for CJD. The risk of viral transmission has been markedly reduced with improved screening, particularly using nucleic acid testing (NAT). The risk is now estimated to be 1 in 2 million units for human immunodeficiency virus (HIV) or hepatitis C virus (HCV) and approximately 1 in 200 000 units for hepatitis B virus (HBV). Because the risk of viral or parasitic infection is very low and blood is screened for HCV, HBV, HIV, and human T-cell lymphoma/leukemia virus (HTLV) 1, the remainder of this chapter focuses on bacterial complications of blood transfusion, which can be diagnosed and treated.
To review the severe acute respiratory syndrome (SARS) infection control practices, the types of exposure to patients with SARS, and the activities associated with treatment of such patients among healthcare workers (HCWs) who developed SARS in Toronto, Canada, after SARS-specific infection control precautions had been implemented.
A retrospective review of work logs and patient assignments, detailed review of medical records of patients with SARS, and comprehensive telephone-based interviews of HCWs who met the case definition for SARS after implementation of infection control precautions.
Seventeen HCWs from 6 hospitals developed disease that met the case definition for SARS after implementation of infection control precautions. These HCWs had a mean age ( ± SD) of 39 ± 2.3 years. Two HCWs were not interviewed because of illness. Of the remaining 15, only 9 (60%) reported that they had received formal infection control training. Thirteen HCWs (87%) were unsure of proper order in which personal protective equipment should be donned and doffed. Six HCWs (40%) reused items (eg, stethoscopes, goggles, and cleaning equipment) elsewhere on the ward after initial use in a room in which a patient with SARS was staying. Use of masks, gowns, gloves, and eyewear was inconsistent among HCWs. Eight (54%) reported that they were aware of a breach in infection control precautions. HCWs reported fatigue due to an increase number and length of shifts; participants worked a median of 10 shifts during the 10 days before onset of symptoms. Seven HCWs were involved in the intubation of a patient with SARS. One HCW died, and the remaining 16 recovered.
Multiple factors were likely responsible for SARS in these HCWs, including the performance of high-risk patient care procedures, inconsistent use of personal protective equipment, fatigue, and lack of adequate infection control training.
Routine use of mupirocin to prevent staphylococcal infections is controversial. We assessed attitudes and practices of healthcare professionals attending the Fourth Decennial International Conference on Nosocomial and Healthcare-Associated Infections regarding mupirocin prophylaxis. Eighty percent of participants did not use mupirocin routinely. At the end of the session, 58% indicated they would consider increased use of mupirocin.
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