Approaches to the rationalization of surgical instrument trays: scoping review and research agenda

BACKGROUND: Surgical Tray Rationalization (STR) consists of a systematic reduction in the number of surgical instruments to perform specific procedures without compromising patient safety while reducing losses in the sterilization and assembly of trays. STR is one example of initiatives to improve process performance that have been widely reported in industrial settings but only recently have gained popularity in healthcare organizations. METHODS: We conduct a scoping review of the literature to identify and map available evidence on surgical tray management. Five methodological stages are implemented and reported; they are: identifying research questions, identifying relevant studies, study selection, charting the data, and collating, summarizing and reporting the results. RESULTS: We reviewed forty-eight articles on STR, which were grouped according to their main proposed approaches: expert analysis, lean practices, and mathematical programming. We identify the most frequently used techniques within each approach and point to their potential contributions to operational and economic dimensions of STR. We also consolidate our findings, proposing a roadmap to STR with four generic steps (prepare, rationalize, implement, and consolidate) and recommended associated techniques. CONCLUSIONS: To the best of our knowledge, ours is the first study that reviews and systematizes the existing literature on the subject of STR. Our study closes with the proposition of future research directions, which are presented as nine research questions associated with the four generic steps proposed in the STR roadmap

Intervertebral Disc Extrusion between T8 and T9 in a Dachshund

Background: Intervertebral disc extrusion with consequent spinal compression or intervertebral disc disease (IVDD) is one of the most common causes of compressive myelopathy in dogs, and the thoracolumbar spine discs between T12 and L2 are most affected. Extrusions in cranial thoracic region are rare, and there is few cases in literature reporting this situations, this rarity is attributed to the presence of the intercapital ligament connecting the rib heads between T2 and T10, which strengthens this region both mechanically and anatomically. The aim of this article is report the clinical signs, diagnosis and treatment of a case of Type I Hansen IVDD between T8 and T9 in a Dachshund breed dog.Case: An 8-year-old Dachshund male dog was presented for investigation of pelvic limb incoordination and back pain, which started 10 days prior to the consultation. It had a history of a similar condition 3 months earlier that showed improvement after clinical treatment. On neurological examination was identified in both pelvic limbs proprioceptive ataxia, absence of proprioception, increased muscle tone, presence of interdigital reflex and increased patellar reflex. Cutaneous trunci reflex was absent below T11 on the left side, and pain was noted upon palpation of T7 through the T12 vertebrae. A grade II asymmetric thoracolumbar lesion with hyperesthesia was diagnosed. On suspicion of IVDD, cerebrospinal fluid (CSF) collection and CT scan analysis of the thoracolumbar region were performed. CT scan showed the presence of hyperattenuating and mineralized material, 1 cm long, on the floor of the spinal canal, mainly on the left side, occupying 80% of the diameter of the spinal canal between T8 and T9. The patient was then submitted to decompression surgery through hemilaminectomy and showed a good recovery. As the occurrence of disc extrusion in cranial thoracic region of chondrodystrophic breeds is rare, we report the clinical signs, diagnosis and treatment of a case of Type I Hansen intervertebral disc disease (IVDD) between T8 and T9 in a Dachshund breed dog.Discussion: All spinal discs can undergo a process of degeneration causing IVDD, in which the cervical and thoracolumbar regions are the most affected due to reasons not yet fully understood, however spinal cord compression between the T1 and T9 vertebrae is very rare, probably due to the strengthening provided by the intercapital ligament to the posterior annulus fibrosus. Disc extrusion in unusual locations in chondrodystrophic breeds is mainly reported as extrusion between vertebrae T1 and T2, and T9 and T10, with some cases was attributed to an anatomical abnormality of the intercapital ligament. The evaluation of intervertebral discs of the German shepherd breed dogs using MRI showed disc degeneration processes in thoracic vertebras. Disc extrusions often result in more severe clinical signs than protrusions, and occur acutely or subacutely, which was different from the case described here, maybe because the presence of the intercapital ligament permitted gradual extrusion allowing the spinal cord to adapt to the compression. Despite surgical access to this region being described as more complex due to the presence and proximity of the rib head to the vertebral body and the possibility of injuring the intercostal muscles causing pneumothorax, the hemilaminectomy and rib head excision at T9 could be performed without any complications. Thus, although unusual, the cranial thoracic region should not be overlooked as a possible site of occurrence of IVDD, since the diagnosis, treatment and prognosis are similar to those in patients with extrusions in the most common sites.Keywords: intervertebral disc degeneration, dogs, paresis, ataxia

What’s in a mass

This short essay pretends to make the reader reflect on the concept of biological mass and on the added value that the determination of this molecular property of a protein brings to the interpretation of evolutionary and translational snake venomics research. Starting from the premise that the amino acid sequence is the most distinctive primary molecular characteristics of any protein, the thesis underlying the first part of this essay is that the isotopic distribution of a protein's molecular mass serves to unambiguously differentiate it from any other of an organism's proteome. In the second part of the essay, we discuss examples of collaborative projects among our laboratories, where mass profiling of snake venom PLA2 across conspecific populations played a key role revealing dispersal routes that determined the current phylogeographic pattern of the species.Ministerio de Ciencia, Innovación y Universidades/[BFU2017-89103-P]/MICIU/EspañaUCR::Vicerrectoría de Investigación::Unidades de Investigación::Ciencias de la Salud::Instituto Clodomiro Picado (ICP

Use of Autogenous Fascia Lata Graft in the Treatment of Chronic Segmental Defect of the Common Calcaneus Tendon in Domestic Feline

Background: The common calcaneus tendon is formed by the common tendon of the femoral biceps muscle, tendon of the superficial digital flexor muscle and gastrocnemius muscle tendon, and its rupture is related to acute traumas in small animals. Among some applications described, surgical repair can be adopted in the correction of tendon ruptures and theuse of grafts may be indicated in some severe lesions, where it is not possible to perform tenorrhaphy. This study aims to report the case of a feline with rupture of the common calcaneus tendon in which the tenorrafia associated with the autogenous fascia lata graft was performed as adjuvant to the cicatrization of the same.Case: A 24-month-old, undefined male feline with approximately 3 kg was treated at the FCAV Veterinary Hospital, UNESP Jaboticabal, State of São Paulo, Brazil, with a history of falling, for approximately two weeks, and has since plantigrade posture. Upon physical examination, it was possible to identify a discontinuity of the common calcaneus tendon. The radiographs were performed, which did not show any bone changes. A hemogram and biochemical profile were performed, which were within normal limits. The patient underwent surgery, and a complete lesion of the common calcaneus tendon was identified, with a chronic aspect. Approximation of the stumps was impossible, so a flap of fascia lata, about two centimeters long and one centimeter wide, was removed, which was used as a bed and tendon support for tendon growth. After removal all of the present fibrosis, the tendon stumps were approximated by means of modified Kessler suture with mononylon thread, and fascia lata flap of the ipsilateral limb was sutured with separate single points in both tendon endsand in their lateral and medial portion. In the tibiotarsic joint, the external skeletal fixator type II was used for immobilization, during a period of 30 days. In the immediate postoperative period the patient was already able to support the member on the floor, with progressive improvement, and after 60 days of surgery the animal presented complete support of thelimb, without pain or any other alteration coming from the surgery. The animal presented a rapid recovery after surgical treatment with the autogenous fascia lata flap.Discussion: The rupture of the common calcaneus tendon is not commonly reported in felines and its occurrence is related to acute trauma, where the animals will present lameness and plantigrade posture. Depending on the degree of tendon involvement, there are different procedures that may be indicated, such as tenorrhaphy, reimplantation for avulsion cases, and transplantation with grafts when there is segment loss. In the present study, the use of tenorrhaphy associated with the implantation of autogenous lata-fascia graft was chosen, since the grafts generally provide the framework for healing due to its replacement by collagen tissue in the recipient, in addition to providing mechanical protection initially. Fascia lata, due to its antigenic character as being autogenous, has been shown to be a viable and easily obtained surgical option. The use of the fascia lata graft associated with external immobilization with external fixator type II in the tibiotarsal joint allowed an excellent result and is therefore a recommended treatment for cases of rupture of the common calcaneus tendon in felines.Keywords: cats, lameness, plantigrade stance

DISFUNÇÃO ERÉTIL EM INDIVÍDUOS COM DIABETES MELLITUS

A disfunção erétil é um tipo de disfunção sexual muito comum, sobretudo, nos brasileiros que perpassam os 40 anos, com média de 2 milhões de casos anuais. O objetivo deste estudo foi realizar uma análise detalhada e comparativa da relação entre disfunção erétil (DE) e Diabetes Mellitus (DM). Trata-se de um resumo expandido de 5 artigos encontrados nas bases de dados Scielo e Google Acadêmico, buscados através dos descritores: disfunção erétil, disfunção erétil e diabetes e impotência sexual, que relacionavam DE à DM em alguma parte do estudo, em um período de busca entre 2004 a 2016. Os artigos convergiam em relação ao real aumento de incidência de DE em indivíduos portadores de DM e divergiam na comprovação dessa relação a partir de dados estatísticos significativos provenientes de suas amostras. Além disso, descreveu-se o conceito, a fisiopatologia, e os tratamentos terapêuticos sobre disfunção erétil que foram somados as estatísticas presentes nos trabalhos estudados. Permitindo assim, concluir uma real relação entre o aumento de incidência de DE em portadores de DM

La investigación desde sus protagonistas : senderos y estrategias

Este libro es el resultado de un trabajo de equipo multidisciplinar de investigadores que, durante dos años, ha estado discutiendo sobre el tema de la INVESTIGACIÓN desde sus respectivas perspectivas individuales. La riqueza particular de la obra proviene de que cada uno aportó su criterio y su experiencia y cada uno defendió su postura y se enriqueció con la de los demás (..) Lo que sí resultó notorio fue que varios de los autores descubrieron nuevas perspectivas para enriquecer sus propios esquemas y fue por eso que durante su elaboración, los proyectos y esquemas originales fueron variando a medida que el grupo avanzaba en el conocimiento mutuo y en el trabajo de discusión y análisis. (...) René Gotthelf (Dir.

Non-invasive estimation of in vivo optical properties and hemodynamic parameters of domestic animals: a preliminary study on horses, dogs, and sheep

Biosensors applied in veterinary medicine serve as a noninvasive method to determine the health status of animals and, indirectly, their level of welfare. Near infrared spectroscopy (NIRS) has been suggested as a technology with this application. This study presents preliminary in vivo time domain NIRS measurements of optical properties (absorption coefficient, reduced scattering coefficient, and differential pathlength factor) and hemodynamic parameters (concentration of oxygenated hemoglobin, deoxygenated hemoglobin, total hemoglobin, and tissue oxygen saturation) of tissue domestic animals, specifically of skeletal muscle (4 dogs and 6 horses) and head (4 dogs and 19 sheep). The results suggest that TD NIRS in vivo measurements on domestic animals are feasible, and reveal significant variations in the optical and hemodynamic properties among tissue types and species. In horses the different optical and hemodynamic properties of the measured muscles can be attributed to the presence of a thicker adipose layer over the muscle in the Longissimus Dorsi and in the Gluteus Superficialis as compared to the Triceps Brachii. In dogs the absorption coefficient is higher in the head (temporalis musculature) than in skeletal muscles. The smaller absorption coefficient for the head of the sheep as compared to the head of dogs may suggest that in sheep we are indeed reaching the brain cortex while in dog light penetration can be hindered by the strongly absorbing muscle covering the cranium

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

A Cozinha Gaúcha: um resgate dos sabores e saberes da Gastronomia do Rio Grande do Sul

O contexto atual da alimentação encontra-se em meio a sistemas agroalimentares cada vez mais segmentados, o que põe em risco as tradições relacionadas à alimentação. Ao se conferir à comida e à culinária o status de bem cultural e identitário, elas passam a ser instrumentos de transmissão, de vivência e de valorização das tradições. Esse aparente estratégico papel de receitas e produtos típicos para o desenvolvimento regional impulsionou a instituição dodecreto nº 4868, Programa RS MAIS GASTRONOMIA/Casa Civil, do Governo do Estado do Rio Grande do Sul com a finalidade de resgatar, pesquisar, catalogar e divulgar os assuntos referentes à gastronomia gaúcha, que atuou de 2011 a 2015. Este artigo deriva de um projeto de pesquisa vinculado a este programa e teve como objetivo verificar o cenário das tradições gastronômicas dos principais grupos étnicos do estado, tendo como recorte para a pesquisa de campo, a região centro sul, composta pelas cidades: Charqueadas, Jaguarão, Pelotas, Piratini, Rio Grande, Santa Vitória do Palmar, Turuçu e Porto Alegre. Para tanto, utilizou-se uma abordagem qualitativa, com pesquisa documental e entrevistas semiestruturadas. Foram realizadas 50 entrevistas com donos de restaurantes, agricultores, representantes de grupos étnicos e agentes do poder público. Os dados foram analisados com auxílio do software NVIVO versão 10. A partir das entrevistas infere-se que, em meio ao processo de globalização e consumo cotidiano de produtos processados, muitas receitas, técnicas e pratos tradicionais foram se modificando ao longo do tempo pela busca de praticidade e pela dificuldade de adquirir os ingredientes típicos, principalmente no meio urbano, onde se nota uma desconexão na relação produtor-ingrediente-consumidor. No entanto, essas tradições mantêm-se vivas nos núcleos familiares e nas comunidades, preparadas principalmente aos domingos e dias de festa, manifestando, assim, as tradições que compõem a identidade dos grupos

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication