Sepsis patients with first and second-hit infections show different outcomes depending on the causative organism

Objective. With improving rates of initial survival in severe sepsis, second-hit infections that occur following resolution of the primary insult carry an increasing burden of morbidity. However, despite the clinical relevance of these infections, no data are available on differential outcomes in patients with first and second-hit infections depending on the nature of the causative organism. This study aims to explore any differences in these subgroups. Design. In a retrospective, observational cohort study, the United Kingdom Intensive Care National Audit and Research Centre (ICNARC) database was used to explore the outcomes of patient with first-hit infections leading to sepsis, and sepsis patients with second-hit infections grouped according to the Gram status of the causative organism. Setting. General critical care units in England, Wales, and Northern Ireland participating in the ICNARC programme between 1 January 2007 – 30 June 2012. Patients. Patient groups analysed included 2119 patients with and 1319 patients without sepsis who developed an intensive care unit acquired infection in blood. Subgroups included patients with trauma, emergency neurosurgical, elective surgical, and cardiogenic shock. Measurements and main results. Gram-negative organisms were associated with poorer outcomes in first-hit infections. The 90-day mortality of patients who developed a Gram-negative infection was 43.6% following elective surgery and 27.9% following trauma. This compared with a mortality of 25.6% and 20.6%, respectively, in Gram-positive infections. Unexpectedly, an inverse relationship between Gram status and mortality was observed in second-hit infections. Patients with an initial diagnosis of sepsis who developed secondary infections caused by Gram-negative organisms had a 90-day mortality of 40.4%, compared with 43.6% in Gram-positive infections. Conclusions. Our study identifies a fundamental difference in patient outcomes between first-hit and second-hit bacterial infections, which may be due to genetic, microbiological, immunological, and environmental factors. This finding has direct implications for risk stratification and defines future research priorities

Violent behaviour on construction sites: Structural equation modelling of its impact on unsafe behaviour using partial least squares

Purpose: Work on construction sites involves individuals with diverse character, temperament,age, physical strength, culture, religion and experience level. A good number of these individuals are also alleged to involve themselves in substance and alcohol abuse due to the physically demanding nature of their work. These could promote the prevalence of violence on construction sites which could in turn affect safety on construction sites. However, there is a lack of empirical insight into the effect of violent behaviour and unsafe behaviour on construction sites. This study therefore pioneers an empirical inquiry into the relationship between violent behaviour and unsafe behaviour on construction sites. Design/methodology/approach: Seventeen violent behaviours and 15 unsafe behaviours were measured on 12 construction sites among 305 respondents using a structured questionnaire. A total of 207 valid questionnaire responses were collected from site workers. Partial least square–structural equation modelling (PLS-SEM) technique was used to examine the relationship between violent behaviour and unsafe behaviour. Findings: The results indicate that there is a significant positive relationship between violent behaviour and unsafe behaviour on construction sites. Originality/value: The findings from this study provide valuable insight into a less investigated dimension of the problem of construction site safety management. A focus on attitudinal issues such as how workers relate toward others and toward self should be an important consideration in safety improvement interventions on construction sites

Infrastructure procurement capacity gaps in Nigeria public sector institutions

Purpose: The achievement of sustainable development goals is linked to the procurement of public infrastructure in a manner that meets key procurement objectives, such as sustainability, value-for-money, transparency and accountability. At the heart of achieving these procurement objectives and others is the capacity of public procurement institutions. Whereas previous reports have hinted that there are deficiencies in procurement capacity in Nigeria, insights regarding critical aspects of organisational capacity deficiencies among different tiers of government agencies is limited. This study investigates the critical gaps in the procurement capacity of state and local government agencies involved in the procurement of public infrastructure in Nigeria.Design/methodology/approach: The study employed a survey of public infrastructure procurement personnel which yielded 288 responses.Findings: Among 23 operationalised items that are related to organisational procurement capacity, none is perceived to be adequate by the procurement personnel. Additionally, among 14 procurement objectives only one is perceived as being attained to at least a high extent.Originality/value: The findings underscore the acuteness of organisational procurement capacity weaknesses among public procurement institutions within Nigeria’s governance structure. It is, thus, imperative for policy makers within state and local government to formulate, resource and implement procurement capacity building initiatives/programmes to address these deficiencies. Additionally, the organisational procurement capacity items operationalised in this study could serve as a useful blueprint for studying capacity deficiencies among public infrastructure procurement agencies in other developing countries, especially within sub-Saharan Africa where several countries have been implementing public procurement reforms

The burden of visual impairment and blindness from vitreoretinal diseases: A Nigerian tertiary hospital retina unit experience

Objective: The objective of this study is to determine the burden of visual impairment and blindness from vitreoretinal diseases in the retina unit of a Nigerian tertiary hospital. Methodology: A prospective, cross‑sectional study on all consecutive new patients presenting with vitreoretinal diseases (VRD) at the vitreoretinal (VR) clinic at Obafemi Awolowo University Teaching Hospitals Complex, Ile‑Ife from May 2011 to April 2014. Patient’s bio‑data, presenting complains, Snellen’s or tumbling E‑chart visual acuity unaided, slit‑lamp examination of the vitreous and fundus with +90/+78D, binocular indirect ophthalmoscopy as well as slit‑lamp examination of anterior segment, and applanation tonometry findings were recorded in predesigned pro forma. Visual acuity was categorized using WHO/ICD. The data were analyzed using the SPSS software version 16 for simple frequencies and presented. Results: Of 2025 eyes reviewed, 112 (49.8%) eyes were visually impaired and 67 (29.8%) were blind. Eight (5.2%) patients were bilaterally blind. Diabetic retinopathy was the most common cause of bilateral blindness (25%), and concurrently, the most common VRD (29.8%). All categories of visual loss were more prevalent among the aged ≥65 years. More males (62.2%) were blind from VRD. Cataract was the most common ocular comorbidity seen (43.6%). Conclusion: The burden of visual impairment and blindness from VRD is large; eye health education for early presentation for eye care as well as the development of VR care with infrastructure upscale to include optical coherence tomography, laser, and surgical care for prompt diagnosis and treatment will be of benefit in reducing the burden

Intraocular pressure variation after conventional extracapsular cataract extraction, manual small incision cataract surgery and phacoemulsification in an indigenous black population

Introduction: intraocular pressure changes have been reported following the various cataract surgical technique. This study aims to compare the intra-ocular pressure (IOP) variation following conventional extra-capsular cataract extraction (ECCE), manual small incision cataract surgery (MSICS) and phacoemulsification in an indigenous black population. Methods: a comparative cross-sectional study of adult patients aged 40 years and above who had pressure was measured with Goldman´s applanation tonometer pre-operatively and 1st day, 1st week, 1st month as well as 3rd month post-operative periods and recorded. Data was analyzed using SPSS version 21. Mean IOP changes between study groups were compared using ANOVA. P-value of < 0.05 was taken as statistically significant. Results: total of 82 patients consisting of 20(24.4%) ECCE, 32(39%) MSICS and 30(36.6%) phacoemulsification with mean preoperative 13.4mmHg, 13.5mmHg and 14.1 mmHg (p = 0.657) respectively was studied. Mean IOP increased from baseline at 1st day post-operative period in the ECCE and MSICS groups (13.4 ± 3.0mmHg to 13.7 ± 4.5mmHg (p = 0.84) and 13.5 ± 3.1mmHg to 15.3 ± 5.1mmHg (P = 0.48) respectively), and decrease in the phacoemulsification group (14.1 ± 2.6mmHg to 13.9 ± 3.5mmHg (p = 0.378). There was a decline in IOP in all the 3 study groups by one week post-operative period; the difference was significant only in the ECCE group (p = 0.032). By 3rd month postoperatively, there was a reduction in mean IOP when compared with pre-operative IOP the difference being greatest in the ECCE group. Conclusion: ECCE, MSICS, and Phacoemulsification cause a decline in IOP below preoperative levels at 3rd month postoperatively in the MSICS group

Qualitative assessment of the conservative management of nocturia with standardised written materials for Lower Urinary Tract Symptoms in men treated in primary care

Background: Many men prefer conservative treatment of lower urinary tract symptoms (LUTS) but education and self-help guidance are limited in primary care. Objective: To report qualitative interview findings for men reporting nocturia in a primary care setting for LUTS. Design, setting, and participants: TRIUMPH (Treating Urinary Symptoms in Men in Primary Healthcare) is a multicentre cluster randomised trial of standardised manualised care (a booklet delivered by a health care professional) versus usual care for LUTS. The participants (524 in the intervention arm and 553 in the usual care arm) were men presenting for primary care for LUTS at 30 general practice (GP) sites in the UK. Intervention: Delivery of a LUTS self-management booklet by health care staff in comparison to usual care for men with LUTS. Outcome measurements and statistical analysis: The qualitative component included 58 early-stage (0–3 mo after study enrolment) and 33 late-stage (3–9 mo later) interviews with participants to assess their experience of LUTS and conservative treatment in primary care. Purposive sampling was used to select participants for interview. Results and limitations: Nocturia is a common driver for seeking health care and is perceived by men as relatively acceptable to discuss. Information and self-help guidance were largely absent from descriptions of GP consultations, other than reducing evening caffeine and fluid intake. The TRIUMPH LUTS intervention booklet offers explanations and self-management guidance. Men with long-term disruptive symptoms, a perception that the booklet content was novel or worthwhile, and a belief that self-management might help, were more receptive to the intervention. In follow-up, improvements in nocturia were related to successful implementation of several aspects of the guidance. Most men were willing to complete a bladder diary, but some found it inconvenient, especially men in employment. The characteristics of the trial population mean that the findings may not apply to all men. Conclusions: Reassuring men that nocturia is part of ageing without offering them information and support risks reinforcing the tendency to discount problematic LUTS. The trial booklet and the training of health care professionals support guidance on nocturia self-management, which is most effective for men receptive to this approach. However, the nature of the trial population means that the findings may not apply to all men. Patient summary: Men are more comfortable in discussing waking at night to urinate than talking about other urinary symptoms with their GP. This problem should lead to a detailed discussion of all urinary symptoms rather than being thought of as a sign of ageing. An information booklet and nurse consultation helped many men to improve this symptom

Adaptation of the Wound Healing Questionnaire universal-reporter outcome measure for use in global surgery trials (TALON-1 study): mixed-methods study and Rasch analysis

BackgroundThe Bluebelle Wound Healing Questionnaire (WHQ) is a universal-reporter outcome measure developed in the UK for remote detection of surgical-site infection after abdominal surgery. This study aimed to explore cross-cultural equivalence, acceptability, and content validity of the WHQ for use across low- and middle-income countries, and to make recommendations for its adaptation.MethodsThis was a mixed-methods study within a trial (SWAT) embedded in an international randomized trial, conducted according to best practice guidelines, and co-produced with community and patient partners (TALON-1). Structured interviews and focus groups were used to gather data regarding cross-cultural, cross-contextual equivalence of the individual items and scale, and conduct a translatability assessment. Translation was completed into five languages in accordance with Mapi recommendations. Next, data from a prospective cohort (SWAT) were interpreted using Rasch analysis to explore scaling and measurement properties of the WHQ. Finally, qualitative and quantitative data were triangulated using a modified, exploratory, instrumental design model.ResultsIn the qualitative phase, 10 structured interviews and six focus groups took place with a total of 47 investigators across six countries. Themes related to comprehension, response mapping, retrieval, and judgement were identified with rich cross-cultural insights. In the quantitative phase, an exploratory Rasch model was fitted to data from 537 patients (369 excluding extremes). Owing to the number of extreme (floor) values, the overall level of power was low. The single WHQ scale satisfied tests of unidimensionality, indicating validity of the ordinal total WHQ score. There was significant overall model misfit of five items (5, 9, 14, 15, 16) and local dependency in 11 item pairs. The person separation index was estimated as 0.48 suggesting weak discrimination between classes, whereas Cronbach's α was high at 0.86. Triangulation of qualitative data with the Rasch analysis supported recommendations for cross-cultural adaptation of the WHQ items 1 (redness), 3 (clear fluid), 7 (deep wound opening), 10 (pain), 11 (fever), 15 (antibiotics), 16 (debridement), 18 (drainage), and 19 (reoperation). Changes to three item response categories (1, not at all; 2, a little; 3, a lot) were adopted for symptom items 1 to 10, and two categories (0, no; 1, yes) for item 11 (fever).ConclusionThis study made recommendations for cross-cultural adaptation of the WHQ for use in global surgical research and practice, using co-produced mixed-methods data from three continents. Translations are now available for implementation into remote wound assessment pathways