Four waste simulants, representative of Plutonium Contaminated Materials (PCMs) at the Sellafield site, were vitrified through additions of Ground Granulated Blast-furnace Slag (GGBS). Ce (as a Pu surrogate) was effectively partitioned into the slag product, enriched in an amorphous CaO-Fe2O3-Al2O3-SiO2 phase when other crystalline phases were also present. Ce L-3 edge XANES data demonstrated Ce to be present as trivalent species in the slag fraction, irrespective of the waste type. Estimated volume reductions of ca. 80-95% were demonstrated, against a baseline of uncompacted 200 L PCM waste drums. The dissolution behaviour of PCM slag wasteforms was investigated at 50 degrees C in saturated Ca(OH)(2) solution under N-2 atmosphere, to simulate the hyperalkaline anoxic environment of a cementitious UK Geological Disposal Facility for Intermediate Level Waste (ILW). These experiments demonstrated the performance of the slag wasteforms to be comparable to that of other vitrified ILW materials considered potentially suitable for geological disposal. (C) 2013 The Authors. Published by Elsevier B.V. All rights reserved.

A flock of New Zealand Wiltshire sheep was divided into two lines and selected for increased greasy fleece weight or decreased greasy fleece weight as yearlings. Wiltshires shed their fleece annually, and although these yearlings may have expressed shedding as lambs in the preceding summer, they were shorn in autumn at 5 months and again in spring at 12 months of age to determine fleece weight before the subsequent shedding. A rapid separation in fleece weight was observed within 8 years, with ewe (0.89 kg) and ram yearlings (0.92 kg) selected for increased fleece weight producing significantly more wool (P < 0.001) than ewe (0.43 kg) or ram yearlings (0.39 kg) from the line selected for decreased fleece weight. There was no significant difference between sexes, and the sex × line interaction was not significant. Clearly this was very low wool production, but fleece weight was heritable (h2 = 0.57 ± 0.04). Shedding was scored from 0 (not shed) to 5 (completely shed) for all animals (n = 2505 records) and was found to be heritable in December (h2 = 0.39 ± 0.04) and again in January (h2 = 0.52 ± 0.05), but less so in September at shearing (h2 = 0.24 ± 0.03). Fleece weight in spring was negatively correlated with shedding score in January, both phenotypically (–0.52 ± 0.02) and genetically (–0.81 ± 0.04). Selecting yearlings for low fleece weight developed a shedding sheep with negligible fleece, which may not require shearing. Selecting for shedding of lambs in January would likely achieve a similar outcome.

BACKGROUND Surgical site infections (SSIs) are complications of surgery that cause significant postoperative morbidity. SSI has been proposed as a potential indicator of the quality of care in the context of clinical governance and monitoring of the performance of NHS organisations against targets. OBJECTIVES We aimed to address a number of objectives. Firstly, identify risk factors for SSI, criteria for stratifying surgical procedures and evidence about the importance of postdischarge surveillance (PDS). Secondly, test the importance of risk factors for SSI in surveillance databases and investigate interactions between risk factors. Thirdly, investigate and validate different definitions of SSI. Lastly, develop models for making risk-adjusted comparisons between hospitals. DATA SOURCES A single hospital surveillance database was used to address objectives 2 and 3 and the UK Surgical Site Infection Surveillance Service database to address objective 4. STUDY DESIGN There were four elements to the research: (1) systematic reviews of risk factors for SSI (two reviewers assessed titles and abstracts of studies identified by the search strategy and the quality of studies was assessed using the Newcastle Ottawa Scale); (2) assessment of agreement between four SSI definitions; (3) validation of definitions of SSI, quantifying their ability to predict clinical outcomes; and (4) development of operation-specific risk models for SSI, with hospitals fitted as random effects. RESULTS Reviews of SSI risk factors other than established SSI risk indices identified other risk; some were operation specific, but others applied to multiple operations. The factor most commonly identified was duration of preoperative hospital stay. The review of PDS for SSI confirmed the need for PDS if SSIs are to be compared meaningfully over time within an institution. There was wide variation in SSI rate (SSI%) using different definitions. Over twice as many wounds were classified as infected by one definition only as were classified as infected by both. Different SSI definitions also classified different wounds as being infected. The two most established SSI definitions had broadly similar ability to predict the chosen clinical outcomes. This finding is paradoxical given the poor agreement between definitions. Elements of each definition not common to both may be important in predicting clinical outcomes or outcomes may depend on only a subset of elements which are common to both. Risk factors fitted in multivariable models and their effects, including age and gender, varied by surgical procedure. Operative duration was an important risk factor for all operations, except for hip replacement. Wound class was included least often because some wound classes were not applicable to all operations or were combined because of small numbers. The American Association of Anesthesiologists class was a consistent risk factor for most operations. CONCLUSIONS The research literature does not allow surgery-specific or generic risk factors to be defined. SSI definitions varied between surveillance programmes and potentially between hospitals. Different definitions do not have good agreement, but the definitions have similar ability to predict outcomes influenced by SSI. Associations between components of the National Nosocomial Infections Surveillance risk index and odds of SSI varied for different surgical procedures. There was no evidence for effect modification by hospital. Estimates of SSI% should be disseminated within institutions to inform infection control. Estimates of SSI% across institutions or countries should be interpreted cautiously and should not be assumed to reflect quality of medical care. Future research should focus on developing an SSI definition that has satisfactory psychometric properties, that can be applied in everyday clinical settings, includes PDS and is formulated to detect SSIs that are important to patients or health services. FUNDING The National Institute for Health Research Technology Assessment programme.

The national mandatory surveillance system for reporting meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia in England has captured data on the source of reported bacteraemias since 2006. This study analysed episodes of MRSA bacteraemia (N=4404) where a probable source of infection was reported between 2006 and 2009. In 2009, this information was available for one-third of reported episodes of MRSA bacteraemia. Of these, 20% were attributed to intravascular devices and 28% were attributed to skin and soft tissue infection. Sixty-four percent of the patients were male, and urinary tract infection was a significantly more common source of MRSA bacteraemia in males compared with females (12% vs 3%). Detection of bacteraemia within two days of hospital admission does not reliably discriminate between community- and hospital-associated MRSA bacteraemia as community cases are frequently associated with an invasive procedure/device. Between 2006 and 2009, there was a significant decline in the proportion of episodes of MRSA bacteraemia associated with central vascular catheters [incidence rate ratio (IRR) 0.42, 95% confidence interval (CI) 0.29–0.61; P<0.001], peripheral vascular catheters (IRR 0.69, 95% CI 0.48–0.99; P=0.042) and surgical site infection (IRR 0.42, 95% CI 0.25–0.72; P=0.001), and a significant increase in the proportion of episodes of MRSA bacteraemia associated with skin and soft tissue infection (IRR 1.33, 95% CI 1.05–1.69; P=0.017) and attributed to contamination of the specimen (IRR 1.96, 95% CI 1.25–3.06; P=0.003). Since data were not available for all cases, the generalizability of these trends depends on the assumption that records with source data reflect a reasonably random sample of cases in each year. These changes have occurred in the context of a general decline in the rate of MRSA bacteraemia in England since 2006.

We would like to congratulate Symth et al. for the publication of the prevalence survey of healthcare-associated infection (HCAI) in the UK. 1 Smyth E.T.M. McIlvenny G. Enstone J.E. et al. On behalf of the Hospital Infection Society Prevalence Survey Steering Group. Four country healthcare associated infection prevalence survey 2006: overview of results. J Hosp Infect. 2008; 69: 230-248 Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar Co-ordinating and implementing such a project is an enormous undertaking and the level of participation by hospitals in the four countries is impressive. However, though the data provide an important overview of the major causes of HCAI and variation between different specialties, there are several methodological issues which suggest that the large observed differences in prevalence of HCAI between countries are biased.

A surveillance study designed to provide a representative sample of the strains of Clostridium difficile causing infections in hospitals in England was in operation from April 2007 to the end of March 2008. Six hundred and seventy-seven isolates were obtained from 186 hospitals in the nine geographical regions of England as recognised by the Health Protection Agency's Regional Microbiology Network. Typing studies revealed that PCR ribotype 027 is now the most common strain isolated from symptomatic patients, accounting for over 41.3% of isolates in English hospitals. Type 106 was the second most common strain (20.2%) and Type 001, which was once the most common strain associated with hospital outbreaks, has now been reduced to only 7.8% of the total. A mixture of 44 other PCR ribotypes accounted for the remaining 28.9% of isolates. This represents a changing distribution of strains when compared to a previous study performed two years earlier which showed roughly equal proportions of types 106, 001 and 027. Antimicrobial susceptibility testing by the E test method revealed significantly lower susceptibility to metronidazole in the more common strains when compared to the less common ribotypes, although none were classified as clinically resistant. Similarly, no resistance to vancomycin was detected. However, common PCR ribotypes were more resistant to moxifloxacin and erythromycin than the less common strains, which may indicate a selective advantage for resistance to these agents, and combined resistance to these two agents was a good indicator of a common ribotype.

Antibiotic resistance surveys are published widely, citing percentage resistance rates, sometimes for vast transcontinental regions. Such data seem straightforward, but when one drills deeper, great complexity emerges. Rates for methicillin resistance among Staphylococcus aureus from bacteraemias vary from <1% to 50% among European countries, and vary greatly among both hospitals and hospital units. Methicillin-resistant S. aureus (MRSA) resistance rates are typically higher for tertiary-care hospitals and intensive care units than in general hospitals and wards, and lowest in single specialist centres. The likelihood of resistance also varies according to patient characteristics: those patients from nursing homes and with underlying disease, recent antibiotic treatment and hospitalisation are more likely to harbour resistant pathogens. Percentage rates themselves also may be misleading; they may be high only because the denominator is small or inaccurate; i.e., resistance may be common but the pathogen rare. Measures of disease burden—cases per 1000 bed-days or per 105 individuals—overcome this deficiency but are harder to collect, influenced by case mix, and associated with other problems: how to count part days or infections acquired elsewhere; most important, are all cases captured? National or international resistance statistics may illustrate trends and provide benchmarks, but for patient management, good local data are essential. Which units are most affected? Are the resistant infections locally acquired or imported with transferred patients? Are the resistant isolates clonal, indicating cross-infection, or diverse, indicating repeated selection or reflecting antibiotic policy? Unless these aspects of infection are considered, interventions to reduce resistance may be misdirected.

Recent outbreaks of Clostridium difficile-associated diarrhoea (CDAD) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America, Japan and Europe. Definitions have been proposed by the European Centre of Disease Prevention and Control (ECDC) to identify severe cases of CDAD and to differentiate community-acquired cases from nosocomial CDAD (http://www.ecdc.europa.eu/documents/pdf/Cl_dif_v2.pdf). CDAD is mainly known as a healthcare-associated disease, but it is also increasingly recognised as a community-associated disease. The emerging strain is referred to as North American pulsed-field type 1 (NAP1) and PCR ribotype 027. Since 2005, individual countries have developed surveillance studies to monitor the spread of this strain. C. difficile type 027 has caused outbreaks in England and Wales, Ireland, the Netherlands, Belgium, Luxembourg, and France, and has also been detected in Austria, Scotland, Switzerland, Poland and Denmark. Preliminary data indicated that type 027 was already present in historical isolates collected in Sweden between 1997 and 2001.

An outbreak of Clostridium difficile infection in Stoke Mandeville hospital in south-east England [1] in 2004/2005 was primarily due to a new and possibly more virulent strain known in the United Kingdom (UK) as PCR ribotype 027. Coinciding with this outbreak, a surveillance programme of C. difficile isolates from symptomatic patients in England with additional results of outbreak investigation requests to the Anaerobe Reference Laboratory (ARL) in Cardiff has established the true extent of its spread throughout British hospitals.

Los recientes brotes epidemicos de diarrea asociada a Clostridium difficile (DACD), de mayor intensidad y con una elevada tasa de recidivas y una mortalidad importante, han sido relacionados con la aparicion de una nueva cepa hipervirulenta de C. difficile en Norteamerica, Japon y Europa.

De recentes epidemies de diarrhees associees a Clostridium difficile (DACD), d’une severite accrue et dont les taux de rechute et de mortalite sont importants, ont ete mises en relation avec l’apparition d’une nouvelle souche de C. difficile tres virulente en Amerique du Nord, au Japon et en Europe.

Clostridium difficile is an anaerobic Gram-positive, spore-forming, toxin-producing bacillus transmitted among humans through the faecal–oral route. Despite increasing carriage rates and the presence of C. difficile toxin in stool, patients with CF rarely appear to develop typical manifestations of C. difficile infection (CDI). In this study, we examined the carriage, toxin production, ribotype distribution and antibiotic susceptibility of C. difficile in a cohort of 60 adult patients with CF who were pre-lung transplant. C. difficile was detected in 50% (30/60) of patients with CF by culturing for the bacteria. C. difficile toxin was detected in 63% (19/30) of C. difficile-positive stool samples. All toxin-positive stool samples contained toxigenic C. difficile strains harbouring toxin genes, tcdA and tcdB. Despite the presence of C. difficile and its toxin in patient stool, no acute gastrointestinal symptoms were reported. Ribotyping of C. difficile strains revealed 16 distinct ribotypes (RT), 11 of which are known to be disease-causing including the hyper-virulent RT078. Additionally, strains RT002, RT014, and RT015, which are common in non-CF nosocomial infection were described. All strains were susceptible to vancomycin, metronidazole, fusidic acid and rifampicin. No correlation was observed between carriage of C. difficile or any characteristics of isolated strains and any recorded clinical parameters or treatment received. We demonstrate a high prevalence of hypervirulent, toxigenic strains of C. difficile in asymptomatic patients with CF. This highlights the potential role of asymptomatic patients with CF in nosocomial transmission of C. difficile.

Between October 1997 and June 2001, 140 English hospitals participating in the surveillance of surgical site infection (SSI) with the Nosocomial Infection National Surveillance Service (NINSS) reported 2832 SSIs following 67 410 surgical procedures in nine defined categories of surgery. Limb amputation had the highest incidence of SSI with 14.3 SSIs per 100 operations. For all categories of surgery, except knee prosthesis (P=0.128), there was a linear increase in the incidence of SSI when the American National Nosocomial Infections Surveillance risk index increased. Superficial incisional SSI was more common than deep incisional and organ/space SSI, and accounted for more than half of all SSIs for all categories of surgery. The postoperative length of stay (LOS) was longer for patients with SSI, and when adjusted for other factors influencing LOS, the extra LOS due to SSI ranged from 3.3 days for abdominal hysterectomy to 21.0 days for limb amputation, and was at least nine days for the other categories. The additional cost attributable to SSI ranged from pound959 for abdominal hysterectomy to pound6103 for limb amputation. Deep incisional and organ/space SSI combined incurred a greater extra LOS and cost than superficial incisional SSI for all categories of surgery, except limb amputation. The crude mortality rate was higher for patients with SSI for all categories of surgery but, after controlling for confounding, only patients with SSI following hip prosthesis had a mortality rate that was significantly higher than those without SSI [odds ratio (OR)=1.8, P=0.002]. However, the adjusted mortality rate for patients with deep incisional and organ/space SSI compared with those without SSI was significantly higher for vascular surgery (OR=6.8, P<0.001), hip prosthesis (OR=2.5, P=0.005) and large bowel surgery (OR=1.8, P=0.04). This study shows that the adverse impact of SSI differs greatly for different categories of surgery, and highlights the importance of measuring the impact for defined categories rather than for all SSIs and all surgical procedures.

We wished to estimate the incidence of surgical-site infection (SSI) after total hip replacement (THR) and hemiarthroplasty and its strength of association with major risk factors. The SSI surveillance service prospectively gathered clinical, operative and infection data on inpatients from 102 hospitals in England during a four-year period. The overall incidence of SSI was 2.23% for 16 291 THRs, 4.97% for 5769 hemiarthroplasty procedures, 3.68% for 2550 revision THRs and 7.6% for 198 revision hemiarthroplasties. Staphylococcus aureus was identified in 50% of SSIs; 59% of these isolates were methicillin-resistant (MRSA). In the single variable analysis of THRs, age, female gender, American Society of Anesthesiologists (ASA) score, body mass index, trauma, duration of operation and pre-operative stay were significantly associated with the risk of SSI (p < 0.05). For hemiarthroplasty, the ASA score and age were significant factors. In revision THRs male gender, ASA score, trauma, wound class, duration of operation and pre-operative stay were significant risk factors. The median time to detection of SSI was eight days for superficial incisional, 11 days for deep incisional and 11 days for joint/bone infections. For each procedure the mean length of stay doubled for patients with SSI. The multivariate analysis identified age group, trauma, duration of operation and ASA score as significant, independent risk factors for SSI. There was significant interhospital variation in the rates of SSI. MRSA was the most common pathogen to cause SSI in hip arthroplasty, especially in patients undergoing hemiarthroplasty, but coagulase-negative Staph. aureus may be more important in deep infections involving the joint.

Objective To assess the level of agreement between common definitions of wound infection that might be used as performance indicators. Design Prospective observational study. Setting London teaching hospital group receiving emergency cases as well as tertiary referrals. Participants 4773 surgical patients staying in hospital at least two nights. Main outcome measures Numbers of wound infections based on purulent discharge alone, on the Centers for Disease Control (CDC) definition of wound infection, on the nosocomial infection national surveillance scheme (NINSS) version of the CDC definition, and on the ASEPSIS scoring method. Results 5804 surgical wounds were assessed during 5028 separate hospital admissions. The mean percentage of wounds classified as infected differed substantially with different definitions: 19.2% with the CDC definition (95% confidence interval 18.1% to 20.4%), 14.6% (13.6% to 15.6%) with the NINSS version, 12.3% (11.4% to 13.2%) with pus alone, and 6.8% (6.1% to 7.5%) with an ASEPSIS score > 20. The agreement between definitions with respect to individual wounds was poor. Wounds with pus were automatically defined as infected with the CDC, NINSS, and pus alone definitions, but only 39% (283/714) of these had ASEPSIS scores > 20. Conclusions Small changes made to the CDC definition or even in its interpretation, as with the NINSS version, caused major variation in estimated percentage of wound infection. Substantial numbers of wounds were differently classified across the grades of infection. A single definition used consistently can show changes in percentage wound infection over time at a single centre, but differences in interpretation prevent comparison between different centres.

Aims: Data collected on knee replacements from 93 hospitals in England were analysed to identify risk factors for surgical site infection. Methods: Prospective surveillance data collected from hospitals in England to calculate surgical site infection rates and potential risk factors Results: There were 242 (1.6%) infections in 15427 primary TKR, with a 0.11% joint infection rate, and 36 (3.6%) infections in 988 revisions, with a signiþcantly higher joint infection rate of 0.35%. There was considerable variation between hospitals. Multivariable logistic regression found signiþcant association between risk of SSI and type of procedure (p<0.01), the hospital where the procedure was performed, male sex (p<0.001), age (p<0.001) and wound class (p<0.05). The mean length of stay in primary TKROs increased from 9 days to 18 days with an infection; and in revision procedures from 12 to 24 days. The median time to diagnosis for SSI was 7.5 days. Staphylococcus aureus accounted for 33%, 66% of which were methicillin resistant (MRSA). Conclusions: There is signiþcant inter-hospital variation in the incidence of SSI following knee replacements in England. Signiþcant risk factors include revision procedures. Male sex, age and wound class. SSIOs doubled the length of post-operative stay and MRSA accounted for 21% of organisms.