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BACKGROUND: The addition of vancomycin to beta-lactam prophylaxis in arthroplasty may reduce surgical-site infections; however, the efficacy and safety are unclear. METHODS: In this multicenter, double-blind, superiority, placebo-controlled trial, we randomly assigned adult patients without known methicillin-resistant Staphylococcus aureus (MRSA) colonization who were undergoing arthroplasty to receive 1.5 g of vancomycin or normal saline placebo, in addition to cefazolin prophylaxis. The primary outcome was surgical-site infection within 90 days after surgery. RESULTS: A total of 4239 patients underwent randomization. Among 4113 patients in the modified intention-to-treat population (2233 undergoing knee arthroplasty, 1850 undergoing hip arthroplasty, and 30 undergoing shoulder arthroplasty), surgical-site infections occurred in 91 of 2044 patients (4.5%) in the vancomycin group and in 72 of 2069 patients (3.5%) in the placebo group (relative risk, 1.28; 95% confidence interval [CI], 0.94 to 1.73; P = 0.11). Among patients undergoing knee arthroplasty, surgical-site infections occurred in 63 of 1109 patients (5.7%) in the vancomyin group and in 42 of 1124 patients (3.7%) in the placebo group (relative risk, 1.52; 95% CI, 1.04 to 2.23). Among patients undergoing hip arthroplasty, surgical-site infections occurred in 28 of 920 patients (3.0%) in the vancomyin group and in 29 of 930 patients (3.1%) in the placebo group (relative risk, 0.98; 95% CI, 0.59 to 1.63). Adverse events occurred in 35 of 2010 patients (1.7%) in the vancomycin group and in 35 of 2030 patients (1.7%) in the placebo group, including hypersensitivity reactions in 24 of 2010 patients (1.2%) and 11 of 2030 patients (0.5%), respectively (relative risk, 2.20; 95% CI, 1.08 to 4.49), and acute kidney injury in 42 of 2010 patients (2.1%) and 74 of 2030 patients (3.6%), respectively (relative risk, 0.57; 95% CI, 0.39 to 0.83). CONCLUSIONS: The addition of vancomycin to cefazolin prophylaxis was not superi

The deposit comprises disseminated and net-textured ores within a parent intrusion and a high proportion of massive, semimassive, and breccia exocontact ores within the underlying country rocks. Desktop microbeam X-ray fluorescence mapping of ore textures has been carried out for drill core samples and saw-cut hand samples from underground exposures. There appear to be magmatic textures within the ores despite clear evidence for deformation, the association of sulphide veins with locally derived leucosomes, and the a large degree of small-scale infiltration of country-rock gneisses by molten sulphides. It is thought that the apparently unique combination of features arose from a combination of two conditions: emplacement of ores and intrusions at mid-crustal depths into already-hot granulite facies rocks, and simultaneous dilation of the country-rock sequence under conditions that permitted rapid transitions between brittle and ductile extension. These conditions gave rise to a sequence of events where sulphide infiltration and migration, driven by both gravity and tectonics, occurred over a much longer time span than that for the emplacement and crystallisation of the carrier silicate magma., The deposit comprises disseminated and net-textured ores within a parent intrusion and a high proportion of massive, semimassive, and breccia exocontact ores within the underlying country rocks. Desktop microbeam X-ray fluorescence mapping of ore textures has been carried out for drill core samples and saw-cut hand samples from underground exposures. There appear to be magmatic textures within the ores despite clear evidence for deformation, the association of sulphide veins with locally derived leucosomes, and the a large degree of small-scale infiltration of country-rock gneisses by molten sulphides. It is thought that the apparently unique combination of features arose from a combination of two conditions: emplacement of ores and intrusions at mid-crustal depths into already-hot granulite facies rocks, and simultaneous dilation of the country-rock sequence under conditions that permitted rapid transitions between brittle and ductile extension. These conditions gave rise to a sequence of events where sulphide infiltration and migration, driven by both gravity and tectonics, occurred over a much longer time span than that for the emplacement and crystallisation of the carrier silicate magma.

INTRODUCTION: Resistant Gram-positive organisms, such as methicillin-resistant staphylococci, account for a significant proportion of infections following joint replacement surgery. Current surgical antimicrobial prophylaxis guidelines recommend the use of first-generation or second-generation cephalosporin antibiotics, such as cefazolin. Cefazolin, however, does not prevent infections due to these resistant organisms; therefore, new prevention strategies need to be examined. One proposed strategy is to combine a glycopeptide antibiotic with cefazolin for prophylaxis. The clinical benefit and cost-effectiveness of this combination therapy compared with usual therapy, however, have not been established. METHODS AND ANALYSIS: This randomised, double-blind, parallel, superiority, placebo-controlled, phase 4 trial will compare the incidence of all surgical site infections (SSIs) including superficial, deep and organ/space (prosthetic joint) infections, safety and cost-effectiveness of surgical prophylaxis with cefazolin plus vancomycin to that with cefazolin plus placebo. The study will be performed in patients undergoing joint replacement surgery. In the microbiological sub-studies, we will examine the incidence of SSIs in participants with preoperative staphylococci colonisation (Sub-Study 1) and incidence of VRE acquisition (Sub-Study 2). The trial will recruit 4450 participants over a 4-year period across 13 orthopaedic centres in Australia. The primary outcome is the incidence of SSI at 90 days post index surgery. Secondary outcomes include the incidence of SSI according to joint and microorganism and other healthcare associated infections. Safety endpoints include the incidence of acute kidney injury, hypersensitivity reactions and all-cause mortality. The primary and secondary analysis will be a modified intention-to-treat analysis consisting of all randomised participants who undergo eligible surgery. We will also perform a per-protocol analysis. ETHICS AND DISS

A systemic training and education continuum for the NCO will produce a technically and procedurally proficient leader with the inherent ability to apply desired judgment in decision making, thus achieving the consistent capability of a "Strategic Corporal." The U.S. Marine Corps is obligated to develop and sustain a flexible force that can operate across the entire spectrum of conflict. This versatility relies significantly on the capacity of small units and their leaders. If the Marine Corps is to maximize the potential of its Strategic Corporals, a holistic training and education continuum must be designed and implemented to support their development. the critical capabilities of a Strategic Corporal are identified through an abbreviated Mission Essential Task List process. These critical capabilities provide the foundation on which to structure a precise and balanced training and education continuum. The recommended continuum for the Strategic Corporal needs to be of a systemic design along three avenues: training, education, and professional development. Training establishes the technique, procedure, and battle drill proficiency demanded in an infantry squad. Education develops the NCO's capability as an adaptive, creative problem solver who appreciates the operating environment and can be relied upon to apply sound judgment. Professional development is a classification for the remaining intangible skills required by a Strategic Corporal. Emphasis in this category is guided by relevance to the small unit leader and includes the study of ethics, leadership, and current events. The proposed continuum provides an evolutionary approach to develop leaders preparing for wars of fire and maneuver and wars of insurgency. A holistic NCO continuum integrating training, education, and professional development establishes the true capacity for a Strategic Corporal to succeed and make reliable decisions in complex and chaotic environments.

Inter-organisational activity, whether public and private sector collaborations, university and industry partnerships or joint ventures between businesses, has benefits that range from increased market efficiency to innovative product development. Yet too often such activity can founder under the weight of differing expectations and divergent interests. How Organisations Connect shows how to avoid the pitfalls and make partnerships work. The contributors, experts from a range of disciplines, demonstrate the importance of developing strategies and establishing infrastructures that enable organisations to connect, and communicate, effectively. Their insights are backed up by case studies that include an investigation of three government and community sector partnerships in Australia, Canada and New Zealand; analysis of what makes a university-industry collaboration successful; an exploration of the changing relations between central banks and governments in Australia and New Zealand throughout the twentieth century; and a study of recent innovative developments in the supply chain networks of some British consumer industries. Through economic and business theory, historical perspectives and contemporary evidence How Organisations Connect presents both fascinating research findings and practical advice

ARC LP0348816