Chlorhexidine versus povidone–iodine skin antisepsis before upper limb surgery (CIPHUR) : an international multicentre prospective cohort study

Introduction Surgical site infection (SSI) is the most common and costly complication of surgery. International guidelines recommend topical alcoholic chlorhexidine (CHX) before surgery. However, upper limb surgeons continue to use other antiseptics, citing a lack of applicable evidence, and concerns related to open wounds and tourniquets. This study aimed to evaluate the safety and effectiveness of different topical antiseptics before upper limb surgery. Methods This international multicentre prospective cohort study recruited consecutive adults and children who underwent surgery distal to the shoulder joint. The intervention was use of CHX or povidone–iodine (PVI) antiseptics in either aqueous or alcoholic form. The primary outcome was SSI within 90 days. Mixed-effects time-to-event models were used to estimate the risk (hazard ratio (HR)) of SSI for patients undergoing elective and emergency upper limb surgery. Results A total of 2454 patients were included. The overall risk of SSI was 3.5 per cent. For elective upper limb surgery (1018 patients), alcoholic CHX appeared to be the most effective antiseptic, reducing the risk of SSI by 70 per cent (adjusted HR 0.30, 95 per cent c.i. 0.11 to 0.84), when compared with aqueous PVI. Concerning emergency upper limb surgery (1436 patients), aqueous PVI appeared to be the least effective antiseptic for preventing SSI; however, there was uncertainty in the estimates. No adverse events were reported. Conclusion The findings align with the global evidence base and international guidance, suggesting that alcoholic CHX should be used for skin antisepsis before clean (elective upper limb) surgery. For emergency (contaminated or dirty) upper limb surgery, the findings of this study were unclear and contradict the available evidence, concluding that further research is necessary

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

A place of considerable importance: Lord Cochrane and the siege of Roses 1808

Five months before the battle of Aix Roads (April 1809), his successful but frustrated attack on the French Brest fleet and his last action as a Royal Navy frigate commander, Captain Thomas, Lord Cochrane was engaged in an important operation at Roses on the coast of Catalonia. The Catalonia maritime theatre is considered by some historians to have been something of a backwater for the Royal Navy during the Peninsular War, but Napoleon Bonaparte’s overall strategic vision demanded unfettered access to the Mediterranean, and the Royal Navy’s constant patrols, many based on or near Rosas, kept the French navy contained at Toulon and the French army under duress on the right flank of Bonaparte’s southern Continental theatre. This article, from original research and analysis of primary source material, much of it unpublished, sheds new light on the events surrounding the Siege of Roses in November and December 1808, particularly the strategic context of the part played by Lord Cochrane, and the strategic importance of Rosas as a rendezvous for British fleets and a beachhead for allied forces

In search of Nelson’s spy: a research case study

In the summer of 1803 Admiral Lord Nelson arrived on the coast of Catalonia as Commander-in-Chief of the Royal Navy's Mediterranean Fleet. In addition to leading the blockade of Toulon and other operations of his fleet, for the first few months he managed himself the day-to-day business of keeping his ships in good order, including ordering in detail the supply of food, water and wine for the 10,000 men under his command. At this time he made the acquaintance of Edward Gayner, an English wine merchant living in the strategically important port of Rosas, who supplied the Royal Navy in the western Mediterranean with local produce. This article describes the author's research into Gayner's life and work at Rosas, and presents new evidence to support the claim that Gayner provided Nelson with important confidential information concerning French military and naval movements. The article offers an outline of Gayner's life and describes the primary and secondary research sources and methodology, including the use of previously unpublished manuscripts. The author is completing a monograph about Gayner which will present all the known facts and a calendar of all Gayner's identified correspondence, to be published in English and Catalan later in 2010

Evaluating dental aerosol and splatter in an open plan clinic environment: implications for the COVID-19 pandemic

Aim: To identify splatter and aerosol distribution resulting from dental aerosol generating procedures (AGPs) in the open plan clinic environment. A secondary aim is to explore the detailed time course of aerosol settling after an AGP. Methodology: Dental procedures were undertaken on a dental mannequin. Fluorescein dye was placed into the irrigation system of the high-speed air turbine handpiece for the first experimental design, and in the second, fluorescein dye was entered into the mannequin's mouth via artificial salivary ducts. Filter papers were placed at set distances around the open plan clinic environment to collect aerosol and splatter under various mitigating conditions including ventilation and aspiration flow rate. An 8-metre diameter rig was set up to investigate the effect of fallow time. Filter papers were analysed using imaging software and spectrofluorometric analysis. Results: The distribution of fluorescein contamination varied widely across the open plan clinic depending on the experimental conditions. Unmitigated (i.e. no suction) procedures have the potential to deposit contamination at large distances. Medium volume dental suction (159 L/min air) reduced contamination in the AGP bay by 53%, and in adjacent and distant bays/walkways by 81-83%. Low volume suction (40 L/min air) gave similar reductions. Cross-ventilation reduced contamination in adjacent and distant bays/walkways by 80-89%. In the most realistic model (dye in mouth with medium volume suction) the samples in distant bays (≥5 m head-to-head chair distance) either gave zero readings or very low readings (< 0.0016% of the fluorescein introduced into the system during the procedure). Almost all (99.99%) of the splatter detected was retained within the AGP bay/walkway. Time course experiments showed that after 10 minutes, very little additional contaminated aerosol settled. Conclusions: The cross-infection risk from conducting AGPs in an open plan clinic environment appears small, particularly when bays are ≥ 5 m apart. There is a major dilution effect from the instrument water spray and a substantial protective effect from using dental suction. The majority of aerosol settles in the first 10 minutes indicating that environmental cleaning may be appropriate after this time

Role Transition and the Interaction of Relational and Social Identity: New Nursing Roles in the English NHS

Our study provides an analysis of role transition, examining how macro-level influences and micro-level practice interact in framing role transition, with a focus upon professional identity. Empirically, we examine the case of nurses in the English NHS, for whom government ‘modernization’ policy has opened up a new occupational position in the delivery of genetics services within a professional bureaucracy. We track the experiences of the nurses through their recruitment to, enactment of, and progress on from, the new genetics role over two years. Our qualitative interview-based study encompasses six comparative cases. Analysis draws upon two linked literatures — role and identity, and sociology of professions — to examine the tension between the identity expected by the profession and the role expected by government policy-makers. While policy encourages reconfiguration of roles and relationships to support the new, less-bounded role, concerns aligned to professional identity mean that inter-professional competition between doctors and nurses, and intra-professional competition within nursing itself, constrain the enactment of the new role. Through our empirical study, we develop literature on role transition through its application to a professionalized context, and sociology of professions literature, within which issues of identity are relatively neglected. Our study demonstrates that the emphasis of identity within a professional bureaucracy lies at the collective level

Scientists' call to action: Microbes, planetary health, and the Sustainable Development Goals.

Microorganisms, including bacteria, archaea, viruses, fungi, and protists, are essential to life on Earth and the functioning of the biosphere. Here, we discuss the key roles of microorganisms in achieving the United Nations Sustainable Development Goals (SDGs), highlighting recent and emerging advances in microbial research and technology that can facilitate our transition toward a sustainable future. Given the central role of microorganisms in the biochemical processing of elements, synthesizing new materials, supporting human health, and facilitating life in managed and natural landscapes, microbial research and technologies are directly or indirectly relevant for achieving each of the SDGs. More importantly, the ubiquitous and global role of microbes means that they present new opportunities for synergistically accelerating progress toward multiple sustainability goals. By effectively managing microbial health, we can achieve solutions that address multiple sustainability targets ranging from climate and human health to food and energy production. Emerging international policy frameworks should reflect the vital importance of microorganisms in achieving a sustainable future

Scientists' warning to humanity: microorganisms and climate change.

In the Anthropocene, in which we now live, climate change is impacting most life on Earth. Microorganisms support the existence of all higher trophic life forms. To understand how humans and other life forms on Earth (including those we are yet to discover) can withstand anthropogenic climate change, it is vital to incorporate knowledge of the microbial 'unseen majority'. We must learn not just how microorganisms affect climate change (including production and consumption of greenhouse gases) but also how they will be affected by climate change and other human activities. This Consensus Statement documents the central role and global importance of microorganisms in climate change biology. It also puts humanity on notice that the impact of climate change will depend heavily on responses of microorganisms, which are essential for achieving an environmentally sustainable future