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Objectives. To determine the percentage of US outpatient substance use treatment facilities that offer HIV preexposure prophylaxis (PrEP). Methods. We used a retrospective cross-sectional design with data from the National Substance Use and Mental Health Services Survey, which was administered to directors of US outpatient substance use treatment facilities in 2021. We evaluated the percentage of outpatient substance use treatment facilities offering PrEP and factors associated with the likelihood of offering PrEP. Results. We included 12 182 outpatient substance use treatment facilities. Of these, 637 (5.2%) offered PrEP. Offering HIV treatment (adjusted odds ratio [AOR] = 45.3; 95% confidence interval [CI] = 36.0, 56.9) and offering programs for LGBTQ (lesbian, gay, bisexual, transgender, and queer or questioning) people (AOR = 1.3; 95% CI = 1.0, 1.6) were associated with higher likelihoods of offering PrEP. Conclusions. PrEP is highly effective and recommended for patients at risk for HIV from injection drug use. Nearly 95% of US outpatient substance use treatment facilities did not offer PrEP-a missed opportunity for harm reduction through primary HIV prevention. Public Health Implications. Diversification of the array of available HIV PrEP options and the ongoing HIV and opioid use epidemics require outpatient substance use treatment facilities to expand PrEP availability. ( Am J Public Health . 2024;114(8):833-837. https://doi.org/10.2105/AJPH.2024.307699).

Enteroids are in vitro models to study gastrointestinal pathologies and test personalized therapeutics; however, the inherent complexity of enteroids often renders standard gene editing approaches ineffective. Here, we introduce a refined lentiviral transfection protocol, ensuring sufficient lentiviral engagement with enteroids while considering spatiotemporal growth variability throughout the extracellular matrix. Additionally, we highlight a selection process for transduced cells, introduce a protocol to accurately measure transduction efficiency, and explore methodologies to gauge effects of gene knockdown on biological processes., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: In the United States, a disproportionate number of persons with HIV (PWH) and opioid use disorder (OUD) are involved in the justice system. Medications for OUD (MOUD) can reduce convictions and incarceration time in persons with OUD. Extended-release naltrexone (XR-NTX) has been shown to reduce craving of opioids, recurrence of use, and overdose and help achieve or maintain HIV viral suppression in PWH with OUD involved with the justice system., Objectives: This retrospective study aimed to describe factors associated with reincarceration and to evaluate if XR-NTX was associated with reduced reincarceration among PWH and OUD who were released to the community from incarceration., Methods: Data from participants released to the community from incarceration from a completed randomized controlled trial was analyzed using a generalized linear model to estimate odds ratios associated with reincarceration and a Kaplan-Meier survival analysis to determine time to reincarceration and non-reincarcerated individuals were compared., Results: Of the 77 participants, 41 (53.2%) were reincarcerated during the 12-month study period. The mean time to reincarceration was 190 days (SD=108.3). Compared with participants who remained in the community, reincarcerated participants were more likely to have major depressive disorder at study baseline, increased opioid cravings, longer mean lifetime incarceration, and a higher physical quality of life score. XR-NTX was not significantly associated statistically with reincarceration in this analysis., Conclusion: Reducing reincarceration is a public health priority, given the high proportion of PWH and OUD in the U.S. justice system as well as high degrees of persons returning to the community and having care interrupted due to reincarceration. This analysis determined that potentially identifying depression in recently released individuals could improve HIV outcomes, decrease recurrence of opioid use, and reduce reincarceration., Competing Interests: Author Sandra Springer, MD has provided paid scientific consultation to Alkermes Inc. Sandra Springer, MD has received in-kind study drug donations from Alkermes Inc and Indivior Pharmaceutical Company for NIH-funded research. The authors alone are responsible for the content and writing of this paper.

Competing Interests: Declaration of Competing Interest The authors have no competing interest to declare.

How to cite this article: Arjun R, Niyas VKM, Thomas S, Muralidharan R, Thomas A, Wilson AP, et al . MIS-C/A/V: There is More to It than Meets the Eye! Indian J Crit Care Med 2022;26(4):532., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2022; Jaypee Brothers Medical Publishers (P) Ltd.)

Diarrhoea, defined as > 3 loose or liquid stools per day, affects 9.7-41% of intensive care unit patients, negatively impacting on patient dignity, intensifying nursing workload and increasing morbidity. Its pathogenesis is poorly understood, but infective agents, intensive care unit therapies (such as enteral feed) and critical illness changes in the gut microbiome are thought to play a role. We analysed a consecutive cohort of 3737 patients admitted to a mixed general intensive care unit. Diarrhoea prevalence was lower than previously reported (5.3%), rarely infective in origin (6.5%) and associated with increased length of stay (median (inter-quartile range) 2.3 (1.0-5.0) days vs. 10 days (5.0-22.0), p < 0.001, sub-distribution hazard ratio 0.55 (95% CI 0.48-0.63), p < 0.001) and mortality (9.5% vs. 18.1%, p = 0.005, sub-distribution hazard ratio 1.20 (95% CI 0.79-1.81), p = 0.40), compared to patients without diarrhoea. In addition, 17.1% of patients received laxatives <24 h prior to diarrhoea onset. Further research on diarrhoea's pathogenesis in critical care is required; robust treatment protocols, investigation rationalisation and improved laxative prescribing may reduce its incidence and improve related outcomes., (© The Intensive Care Society 2019.)

In many field applications where alpha-induced radioluminescence (or so-called UV fluorescence) could potentially be used for stand-off detection of alpha-emitting materials, it may not be possible to create a fully purged gas atmosphere. Hence, an alternative gas delivery method to utilise the radioluminescence enhancing properties of gases has been investigated, with the novel results from this presented herewithin. A solar blind ultraviolet C (UVC) sensor (UVTron R9533, Hamamatsu, Japan) has been used to detect changes in the signal in the UVC wavelength range (180⁻280 nm), where gases of Ar, Xe, Ne, N₂, Kr, and P-10 were flowed over a 6.95 MBq 210 Po source using a narrow diameter pipe close to the source. In comparison with an air atmosphere, there was an increase in signal in all instances, the greatest being the flow of Xe, which in one instance greater than doubled the average counts per second. This increase in signal could prove beneficial in the design of a stand-off alpha detector to detect the very small UVC radioluminescence signals from alpha-emitting materials found in nuclear decommissioning environments.

In this work, a robust stand-off alpha detection method using the secondary effects of alpha radiation has been sought. Alpha particles ionise the surrounding atmosphere as they travel. Fluorescence photons produced as a consequence of this can be used to detect the source of the alpha emissions. This paper details experiments carried out to detect this fluorescence, with the focus on photons in the ultraviolet C (UVC) wavelength range (180-280 nm). A detector, UVTron R9533 (Hamamatsu, 325-6, Sunayama-cho, Naka-ku, Hamamatsu City, Shizuoka Pref., 430-8587, Japan), designed to detect the UVC emissions from flames for fire alarm purposes, was tested in various gas atmospheres with a 210 Po alpha source to determine if this could provide an avenue for stand-off alpha detection. The results of the experiments show that this detector is capable of detecting alpha-induced air fluorescence in normal indoor lighting conditions, as the interference from daylight and artificial lighting is less influential on this detection system which operates below the UVA and UVB wavelength ranges (280-315 nm and 315-380 nm respectively). Assuming a standard 1 r 2 drop off in signal, the limit of detection in this configuration can be calculated to be approximately 240 mm, well beyond the range of alpha-particles in air, which indicates that this approach could have potential for stand-off alpha detection. The gas atmospheres tested produced an increase in the detector count, with xenon having the greatest effect with a measured 52% increase in the detector response in comparison to the detector response in an air atmosphere. This type of alpha detection system could be operated at a distance, where it would potentially provide a more cost effective, safer, and faster solution in comparison with traditional alpha detection methods to detect and characterise alpha contamination in nuclear decommissioning and security applications., Competing Interests: The authors declare no conflict of interest.

Background: The increasing prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in the healthcare setting and in the community despite established infection control guidelines indicates that these microorganisms may possess survival strategies that allow them to persist in the environment., Aims: To determine the extent and variation in endemic ESBL-carrying species in different ward environments, and to investigate the potential for cephalosporin resistance to be transferred from environmental isolates to human pathogens., Methods: Conventional microbiological methods were used to sample 1436 environmental surfaces for ESBL-producing bacteria. Transconjugation assays (broth mating experiments) were performed using environmental ESBL-producing isolates as donors and streptomycin-resistant Escherichia coli (NCTC 50237) as the recipient., Findings: The prevalence of ESBL-producing bacteria on surfaces in a non-outbreak setting was low (45/1436; 3.1%). The sites most likely to be contaminated were the drains of handwash basins (28/105; 26.7%) and floors (14/160; 8.8%). Fifty-nine ESBL-carrying organisms were isolated. Of these, Klebsiella spp. (33.9%), Enterobacter spp. (20.3%), Pantoea spp. (15.3%) and Citrobacter spp. (13.6%) were the most common isolates. ESBL determinants were transferred successfully from three representative environmental isolates (Pantoea calida, Klebsiella oxytoca, Raoultella ornithinolytica) to the human pathogen E. coli., Conclusion: ESBL-producing Gram-negative isolates were recovered from the hospital environment in the absence of any ESBL infection on the wards. The drains of handwash basins should be considered potential long-term reservoirs of multi-drug-resistant bacteria and drug resistance genes. These genes can reside in various genera of hardy environmental organisms and be a potential source of ESBL for more common human pathogens., (Copyright © 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Objectives: The UK 5 year antimicrobial resistance strategy recognizes the role of point-of-care diagnostics to identify where antimicrobials are required, as well as to assess the appropriateness of the diagnosis and treatment. A sore throat test-and-treat service was introduced in 35 community pharmacies across two localities in England during 2014-15., Methods: Trained pharmacy staff assessed patients presenting with a sore throat using the Centor scoring system and patients meeting three or all four of the criteria were offered a throat swab test for Streptococcus pyogenes, Lancefield group A streptococci. Patients with a positive throat swab test were offered antibiotic treatment., Results: Following screening by pharmacy staff, 149/367 (40.6%) patients were eligible for throat swab testing. Of these, only 36/149 (24.2%) were positive for group A streptococci. Antibiotics were supplied to 9.8% (n = 36/367) of all patients accessing the service. Just under half of patients that were not showing signs of a bacterial infection (60/123, 48.8%) would have gone to their general practitioner if the service had not been available., Conclusions: This study has shown that it is feasible to deliver a community-pharmacy-based screening and treatment service using point-of-care testing. This type of service has the potential to support the antimicrobial resistance agenda by reducing unnecessary antibiotic use and inappropriate antibiotic consumption., (© The Author 2016. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.)

Wilson's disease (WD) is a rare autosomal recessive disease due to mutations of the gene encoding the copper-transporter ATP7B. The diagnosis is hampered by the variability of symptoms induced by copper accumulation, the inconstancy of the pathognomonic signs and the absence of a reliable diagnostic test. We investigated the diagnostic potential of X-ray fluorescence (XRF) that allows quantitative analysis of multiple elements. Studies were performed on animal models using Wistar rats (n = 10) and Long Evans Cinnamon (LEC) rats (n = 11), and on human samples including normal livers (n = 10), alcohol cirrhosis (n = 8), haemochromatosis (n = 10), cholestasis (n = 6) and WD (n = 22). XRF experiments were first performed using synchrotron radiation to address the elemental composition at the cellular level. High-resolution mapping of tissue sections allowed measurement of the intensity and the distribution of copper, iron and zinc while preserving the morphology. Investigations were further conducted using a laboratory X-ray source for irradiating whole pieces of tissue. The sensitivity of XRF was highlighted by the discrimination of LEC rats from wild type even under a regimen using copper deficient food. XRF on whole formalin-fixed paraffin embedded needle biopsies allowed profiling of the elements in a few minutes. The intensity of copper related to iron and zinc significantly discriminated WD from other genetic or chronic liver diseases with 97.6% specificity and 100% sensitivity. This study established a definite diagnosis of Wilson's disease based on XRF. This rapid and versatile method can be easily implemented in a clinical setting.

Background: Hydrogen peroxide vapour (HPV) disinfection systems are being used to reduce patients' exposure to hospital pathogens in the environment. HPV whole-room aerial disinfection systems may vary in terms of operating concentration and mode of delivery., Aim: To assess the efficacy of two HPV systems (HPS1 and HPS2) for whole-room aerial disinfection of single isolation rooms (SIRs)., Methods: Ten SIRs were selected for manual terminal disinfection after patient discharge. Test coupons seeded with biological indicator (BI) organisms [∼10(6) colony-forming units (cfu) of meticillin-resistant Staphylococcus aureus (MRSA) or Klebsiella pneumoniae, or ∼10(5)cfu Clostridium difficile 027 spores] prepared in a soil challenge were placed at five locations per room. For each cycle, 22 high-frequency-touch surfaces in SIRs were sampled with contact plates (∼25cm(2)) before and after HPV decontamination, and BIs were assayed for the persistence of pathogens., Findings: Approximately 95% of 214 sites were contaminated with bacteria after manual terminal disinfection, with high numbers present on the SIR floor (238.0-352.5cfu), bed control panel (24.0-33.5cfu), and nurse call button (21.5-7.0cfu). Enhanced disinfection using HPV reduced surface contamination to low levels: HPS1 [0.25cfu, interquartile range (IQR) 0-1.13] and HPS2 (0.5cfu, IQR 0-2.0). Both systems demonstrated similar turnaround times (∼2-2.5h), and no differences were observed in the efficacy of the two systems against BIs (C. difficile ∼5.1log10 reduction; MRSA/K. pneumoniae ∼6.3log10 reduction). Despite different operating concentrations of hydrogen peroxide, MRSA persisted on 27% of coupons after HPV decontamination., Conclusion: Enhanced disinfection with HPV reduces surface contamination left by manual terminal cleaning, minimizing the risks of cross-contamination. The starting concentration and mode of delivery of hydrogen peroxide may not improve the efficacy of decontamination in practice, and therefore the choice of HPV system may be based upon other considerations such as cost, convenience and logistics., (Copyright © 2016. Published by Elsevier Ltd.)

Diarrhoea is common in Intensive Care Unit (ICU) patients, with a reported prevalence of 15-38%. Many factors may cause diarrhoea, including Clostridium difficile, drugs (e.g. laxatives, antibiotics) and enteral feeds. Diarrhoea impacts on patient dignity, increases nursing workload and healthcare costs, and exacerbates morbidity through dermal injury, impaired enteral uptake and subsequent fluid imbalance. We analysed a cohort of 9331 consecutive patients admitted to a mixed general intensive care unit to establish the prevalence of diarrhoea in intensive care unit patients, and its relationship with infective aetiology and clinical outcomes. We provide evidence that diarrhoea is common (12.9% (1207/9331) prevalence) in critically ill patients, independently associated with increased intensive care unit length of stay (mean (standard error) 14.8 (0.26) vs 3.2 (0.09) days, p < 0.001) and mortality (22.0% (265/1207) vs 8.7% (705/8124), p < 0.001; adjusted hazard ratio 1.99 (95% CI 1.70-2.32), p < 0.001) compared to patients without diarrhoea even after adjusting for potential confounding factors, and infrequently caused by infective aetiology (112/1207 (9.2%)) such as Clostridium difficile (97/1048 (9.3%) tested) or virological causes (9/172 (5.7%) tested). Our findings suggest non-infective causes of diarrhoea in ICU predominate and pathophysiology of diarrhoea in critically ill patients warrants further investigation.

Background: Monitoring of hand hygiene compliance (HHC) by observation has been used in healthcare for more than a decade to provide assurance of infection control practice. The validity of this information is rarely tested., Aim: To examine the process and validity of collecting and reporting HHC data based on direct observation of compliance., Methods: Five years of HHC data routinely collected in one large National Health Service hospital trust were examined. The data collection process was reviewed by survey and interview of the auditors. HHC data collected for other research purposes undertaken during this period were compared with the organizational data set., Findings: After an initial increase, the reported HHC remained unchanged close to its intended target throughout this period. Examination of the data collection process revealed changes, including local interpretations of the data collection system, which invalidated the results. A minority of auditors had received formal training in observation and feedback of results., Conclusion: Whereas observation of HHC is the current gold standard, unless data collection definitions and methods are unambiguous, published, carefully supervised, and regularly monitored, variations may occur which affect the validity of the data. If the purpose of HHC monitoring is to improve practice and minimize transmission of infection, then a focus on progressively improving performance rather than on achieving a target may offer greater opportunities to achieve this., (Copyright © 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: In order to study the micro-epidemiology of meticillin-resistant Staphylococcus aureus (MRSA) effectively, the molecular typing method used must be able to distinguish between different MRSA strains. Pulsed-field gel electrophoresis (PFGE) can detect small genetic differences but is limited in its potential to distinguish isolates within a major lineage. Whole-genome sequencing (WGS) provides sufficient resolution to support or exclude links between otherwise indistinguishable isolates, but lacks the practical utility of conventional typing methods., Aim: To explore the utility of WGS in a hierarchical approach with PFGE to help establish possible sources of MRSA cross-transmission in the intensive care setting., Methods: Possible transmission routes from donor to recipient via the hands of staff, the air or environmental surfaces were identified. Focused molecular typing used PFGE to explore these transmission hypotheses. WGS was applied when an acquisition event involved a common PFGE pulsotype., Findings: Thirty-eight of the 78 acquisition events could not be explored as clinical isolates were not available. PFGE excluded all potential donors from 26 of the remaining 40 acquisition events, but did identify a probable source in 14 new colonizations. Within the hypotheses tested, PFGE supported links between patients occupying the same bay, the same bed space, adjacent isolation rooms and different wards. When a patient source was not identified, PFGE implicated the ward environment and the hands of staff. However, WGS disproved three of these transmission pathways., Conclusion: WGS can complement conventional typing methods by confirming or refuting possible MRSA transmission hypotheses. Epidemiological data are crucial in this process., (Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.)

Objectives: The optimal duration of antibiotic treatment in patients with bloodstream infections remains contentious, with concerns regarding both undertreatment and the encouragement of antibiotic resistance. In our ICU we traditionally use short-course antibiotic monotherapy as the mainstay of treatment. We sought to document the impact of this strategy on pathogen type, resistance patterns and patient outcomes. A comparison was made against data collected during a similar exercise in 2000., Methods: We retrospectively reviewed data on all patients with community-, hospital- and ICU-acquired bacteraemia over a 6 month period (1 December 2012 to 31 May 2013) in a general medical-surgical ICU in a London university hospital. Causative pathogens, resistance patterns, use and duration of monotherapy or combination therapy, breakthrough and relapse rates, and patient outcomes were assessed., Results: The 2013 cohort comprised 113 episodes in 87 patients. Short-course monotherapy (median course 4-5 days) was used in 65.7% of episodes (73.5% in 2000). As with the 2000 cohort, the incidence of antimicrobial resistance, fungaemia, bacteraemia breakthrough and relapse remained low. Of note, there was a decreasing incidence of ICU-acquired MRSA, MDR Gram-negative bacteraemia and fluconazole-resistant candidaemia. Hospital mortality was 32% (45% in 2000)., Conclusions: Our strategy predominantly utilizing short-course antibiotic monotherapy remains effective in achieving good clinical outcomes among patients with bloodstream infections, with low rates of antibiotic resistance and clinical relapse. Prospective trials of short-course monotherapy are warranted to assess clinical efficacy and antimicrobial resistance., (© The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Background: Research in tobacco control demonstrating best practices is widely disseminated; however, application at the local level is often difficult. Translating research into practice requires a concerted effort to develop an understanding of the evidence and how it can be applied within diverse contexts., Purpose: A strategic planning infrastructure was developed to support the translation of evidence-based interventions into community practice. This paper highlights the strategic process of turning "know-what" into "know-how" to facilitate the strategic planning and implementation of tobacco control best practices at the local level., Design: The purpose, people, process, and product strategies of knowledge management and translation provided a framework for the strategic planning infrastructure. The knowledge translation concepts of audience, motivations, and mechanisms were synergized in the neo-strategic planning component design., Setting/participants: The participants were 20 community coalitions funded to implement local tobacco control programs., Intervention: From 2004 to 2011, the strategic planners facilitated a cyclical process to translate research into practice using a trio of integrated tools, skill-building workshops on strategic planning, and grantee-driven technical assistance and consultation., Main Outcome Measures: In the short term, the usefulness of the strategic planning components to the programs was measured. The intermediate outcome was the successful movement of the community programs from the planning stage to the implementation stage. The achievement of community-level changes in planned tobacco control efforts was the overall outcome measure for the success of the local coalitions., Results: Seventeen of 20 communities that began the planning process implemented strategic plans. All 17 of the programs implemented evidence-based practices, resulting in numerous tobacco-free policies, increased cessation, and increased support from the media and community., Conclusions: Bridging the gap between research and practice can enhance the practicality, efficiency, and effectiveness of tobacco control programs at the local level, maximizing the potential positive health impact., (Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Hand hygiene compliance is traditionally monitored by visual methods that are open to bias and strictly limited in time and place. Automatic monitoring may be more effective for infection control as well as performance management., Aim: To establish accuracy and acceptability of an automatic contact monitoring system for hand hygiene., Methods: Monitoring equipment was installed across 55 beds in three wards, and included modified identity badges, bedside furniture, sinks and alcohol gel dispensers. Badges were in near-skin contact (through uniform) and could detect alcohol vapour. All devices were linked by wi-fi. A traffic light system on the badge provided immediate feedback to staff and patients on the hand hygiene status of a member of staff on approach to a patient. Compliance was logged automatically. Following a period of immediate feedback, no visual feedback was given for two weeks. Subsequently, feedback was given using red/green lights for 10 days, followed by retrospective feedback to the ward. Hand hygiene was verified independently by an observer., Findings: Hand hygiene compliance increased from 21% of 97 opportunities to 66% of 197 opportunities during active immediate feedback. Compliance decreased when feedback was provided to wards retrospectively. Six staff (26%) avoided wearing a badge, saying that it was too heavy or they were not on the ward all day. Only three of 30 patients stated that they would challenge staff who had not performed hand hygiene., Conclusions: Automatic contact monitoring with immediate feedback was effective in increasing hand hygiene compliance, but feedback given retrospectively did not prevent a decrease in compliance., (Copyright © 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Family screening is a main step for the diagnosis in Wilson disease. This study was undertaken to evaluate the value of relative exchangeable copper for family screening., Methods: Data from family screening were collected from the French National Center of Reference for Wilson disease. Subjects who were first- or second-degree relatives of the index case underwent clinical examination and biological parameters., Results: Of 127 subjects examined, copper abnormalities or low ceruloplasminemia were detected in 21 subjects, corresponding to 5 patients with Wilson disease, 14 heterozygous ATP7B carriers and 2 subjects with no ATP7B mutations. Relative exchangeable copper determination significantly discriminates heterozygous ATP7B carriers and subjects with no ATP7B mutations from WD patients with a cutoff of 15%., Conclusions: Exchangeable copper appears to be a promising tool for family screening in Wilson disease., (© 2013 International Parkinson and Movement Disorder Society.)

Objectives: Staphylococcus aureus bacteraemia is a common, often fatal infection. Our aim was to describe how its clinical presentation varies between populations and to identify common determinants of outcome., Methods: We conducted a pooled analysis on 3395 consecutive adult patients with S. aureus bacteraemia. Patients were enrolled between 2006 and 2011 in five prospective studies in 20 tertiary care centres in Germany, Spain, United Kingdom, and United States., Results: The median age of participants was 64 years (interquartile range 50-75 years) and 63.8% were male. 25.4% of infections were associated with diabetes mellitus, 40.7% were nosocomial, 20.6% were caused by methicillin-resistant S. aureus (MRSA), although these proportions varied significantly across studies. Intravenous catheters were the commonest identified infective focus (27.7%); 8.3% had endocarditis. Crude 14 and 90-day mortality was 14.6% and 29.2%, respectively. Age, MRSA bacteraemia, nosocomial acquisition, endocarditis, and pneumonia were independently associated with death, but a strong association was with an unidentified infective focus (adjusted hazard ratio for 90-day mortality 2.92; 95% confidence interval 2.33 to 3.67, p < 0.0001)., Conclusion: The baseline demographic and clinical features of S. aureus bacteraemia vary significantly between populations. Mortality could be reduced by assiduous MRSA control and early identification of the infective focus., (Copyright © 2013 The British Infection Association. Published by Elsevier Ltd. All rights reserved.)

Background: Healthcare workers generally underestimate the role of environmental surfaces in the transmission of infection, and compliance with hand hygiene following contact with the environment is generally lower than following direct patient contact. To reduce the risk of onward transmission, healthcare workers must identify the need to wash hands with specific tasks or events., Aim: To observe the movement of staff in critical care and general wards and determine the routes most commonly travelled and the surfaces most frequently touched with and without appropriate hand hygiene., Methods: Fifty-eight 90 min sessions of unobtrusive observation were made in open bays and isolation rooms. Link analysis was used to record staff movement from one location to another as well as the frequency of motion. Hand-hygiene audits were conducted using the World Health Organization 'five moments for hand hygiene' observational tool., Findings: In critical care, the majority of movement occurred within the bed space. The bedside computer and equipment trolley were the surfaces most commonly touched, often immediately after patient contact. In the general ward, movement between bed spaces was more common and observed hand hygiene ranged from 25% to 33%. Regardless of ward type, observed hand-hygiene compliance when touching the patient immediately on entering an isolation room was less than 30%., Conclusions: Healthcare workers must be made aware that bacterial spread can occur even during activities of perceived low risk. Education and intervention programmes should focus on the potential contamination of ward computers, case notes and door handles., (Copyright © 2013 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

OBJECTIVE. To investigate the distribution of hospital pathogens within general and critical care ward environments and to determine the most significant bacterial reservoirs within each ward type. DESIGN. Prospective 4-month microbiological survey. SETTING. The intensive care unit (ICU) and gastrointestinal (GI) surgical ward of a London teaching hospital. PATIENTS. Sampling was conducted in and around the bed space of 166 different patients (99 in the ICU and 67 in the GI ward). METHODS. Conventional agar contact methodology was used to sample 123 predetermined sites twice a week for 17 weeks. Sixty-one surfaces were located within the ICU, and 62 were located within the GI ward. Each surface was located within a theoretical zone of increasing distance from the patient. Aerobic colony counts were determined, and confirmatory testing was conducted on all presumptive pathogens. RESULTS. Regardless of ward type, surfaces located closest to the patient, specifically those associated with the bed (side rails, bed control, and call button), were the most heavily contaminated. Elsewhere, the type of surfaces contaminated differed with ward type. In the ICU, bacteria were most likely to be on surfaces that were regularly touched by healthcare workers (e.g., telephones and computer keyboards). In the GI ward, where the patients were mobile, the highest numbers of bacteria (including potential nosocomial pathogens) were on surfaces that were mainly touched by patients, particularly their toilet and shower facilities. CONCLUSIONS. In terms of cleaning, a hospital should not be considered a single entity. Different ward types should be treated as separate environments, and cleaning protocols should be adjusted accordingly.

Background: Colonized or infected patients pose a significant risk to noncolonized patients occupying the same room. The aim of this study was to investigate how far Enterococcus spp can spread from isolated and nonisolated patients., Methods: Conventional microbiological methods were used to recover enterococci from the air and from 62 high-contact sites located within the near-patient and wider ward environment. Samples were collected twice weekly for 17 weeks. The similarity between isolates was determined via pulsed-field gel electrophoresis., Results: Vancomycin-susceptible enterococci (VSE) were recovered from 352 of 2,046 environmental surfaces (17.2%) and from 27 of 66 air samples (40.9%). During study week 14, VSE was recovered from 75 of the 124 surfaces sampled, representing 21.3% of all VSE-positive sites. A gentamicin-resistant VS Enterococcus faecium clone was recovered in high numbers from the air (>100 cfu/m(3)) and from surfaces throughout a 4-bed bay. The same clone was recovered from an adjacent isolation room as well. A total of 55 surfaces were contaminated with vancomycin-resistant enterococci (VRE). The environment of 2 isolated patients accounted for 85% of contaminated sites. Neither patient was known to be VRE-positive., Conclusions: Unrecognized colonization and/or the aerosolization of enterococci together with inadequate cleaning can lead to heavy, widespread, and persistent environmental contamination. All pose a significant risk for acquisition of antibiotic-resistant enterococci., (Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Although disposable gloves can protect the hands of a health care worker from acquiring bacteria, during patient care the glove surface itself can become heavily contaminated making cross transmission via contaminated gloved hands likely. The aim of this study was to determine whether the type of glove worn by health care workers could influence the spread of methicillin-resistant Staphylococcus aureus (MRSA)., Methods: Laboratory studies were conducted to assess the ease with which MRSA was transferred between different types of glove and surfaces likely to be found within the ward environment., Results: In the absence of simulated body fluid, mean bacterial transfer to and from the different gloves ranged from 0.1% to 16% and from 0.01% to 19.5%, respectively. Glove material and glove hydrophobicity were identified as the 2 most important factors influencing bacterial transfer. Nitrile gloves were associated with the lowest transfer rates. The highest numbers of bacteria were transferred to and from the most hydrophilic and most hydrophobic glove, respectively. The adsorption of simulated body fluids altered the physiochemical properties of the gloves. Bacterial transfer significantly increased and was similar to and from all glove types., Conclusion: Disposable glove type can affect cross-contamination rates among patient, health care worker, and environment. Nonetheless, choice of glove should be considered less important than the correct use of gloves and proper hand hygiene., (Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: The near-patient environment is often heavily contaminated, yet the decontamination of near-patient surfaces and equipment is often poor. The Nanoclave Cabinet produces large amounts of ultraviolet-C (UV-C) radiation (53 W/m2) and is designed to rapidly disinfect individual items of clinical equipment. Controlled laboratory studies were conducted to assess its ability to eradicate a range of potential pathogens including Clostridium difficile spores and Adenovirus from different types of surface., Methods: Each test surface was inoculated with known levels of vegetative bacteria (10(6) cfu/cm(2)), C. difficile spores (10(2)-10(6) cfu/cm(2)) or Adenovirus (10(9) viral genomes), placed in the Nanoclave Cabinet and exposed for up to 6 minutes to the UV-C light source. Survival of bacterial contaminants was determined via conventional cultivation techniques. Degradation of viral DNA was determined via PCR. Results were compared to the number of colonies or level of DNA recovered from non-exposed control surfaces. Experiments were repeated to incorporate organic soils and to compare the efficacy of the Nanoclave Cabinet to that of antimicrobial wipes., Results: After exposing 8 common non-critical patient care items to two 30-second UV-C irradiation cycles, bacterial numbers on 40 of 51 target sites were consistently reduced to below detectable levels (≥ 4.7 log10 reduction). Bacterial load was reduced but still persisted on other sites. Objects that proved difficult to disinfect using the Nanoclave Cabinet (e.g. blood pressure cuff) were also difficult to disinfect using antimicrobial wipes. The efficacy of the Nanoclave Cabinet was not affected by the presence of organic soils. Clostridium difficile spores were more resistant to UV-C irradiation than vegetative bacteria. However, two 60-second irradiation cycles were sufficient to reduce the number of surface-associated spores from 10(3) cfu/cm(2) to below detectable levels. A 3 log10 reduction in detectable Adenovirus DNA was achieved within 3 minutes; after 6 minutes, viral DNA was undetectable., Conclusion: The results of this study suggest that the Nanoclave Cabinet can provide rapid and effective disinfection of some patient-related equipment. However, laboratory studies do not necessarily replicate 'in-use' conditions and further tests are required to assess the usability, acceptability and relative performance of the Nanoclave Cabinet when used in situ.

Surveillance and feedback of results to clinical teams is central to performance improvement in managing healthcare-acquired infections. A major role of the Advisory Committee on Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) is to advise on surveillance priorities. A sub-committee was set up to systematically review existing UK surveillance schemes. The following three systems were examined in detail: mandatory reporting of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and Clostridium difficile infection to the HPA; surveillance of surgical site infection undertaken by the HPA; and surgical site infection surveillance undertaken at University College London Hospital. Recommendations included the extension of mandatory reporting to include bacteraemia due to Escherichia coli and methicillin-susceptible S. aureus (MSSA), post-discharge surveillance of surgical site infection, the need for validation of surveillance systems and mandatory reporting of Caesarean section wound infections. Mandatory reporting of bacteraemia due to E. coli and MSSA were introduced during 2011 and further extension of surveillance is likely.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Are antibiotic implants like gentamicin-collagen implants useful in preventing sternal wound infections (SWIs)? Altogether, more than 484 papers were found using the reported search; of these, 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that most randomized controlled trials (RCTs) have been performed with gentamicin-collagen sponges for sternal closure. Two out of four RCTs showed a significant benefit of the implant in a reduction in superficial and deep SWIs in routine and emergency cardiac surgery. One RCT showed a significant reduction in superficial infections in 2005, a follow-up trial by the same group in 2009 showed a reduction in deep infections as well. Another group has shown a reduction in deep and superficial SWI with gentamicin implant, in an RCT on 800 patients, however have not published details of the complete trial. The third trial on 542 patients showed no benefit of the implant, but was not adequately powered. However, the most recent multicentre RCT conducted on 1052 patients showed no benefit of gentamicin-collagen sponges in elective surgery (coronary artery bypass grafting and/or valve surgery) in high-risk patients with diabetes, obesity or both. Concerns were raised that gentamicin sponges dipped in saline 1-2 s prior to application may have lost the gentamicin into the saline, thereby reducing their efficacy and that some surgeons may have been unfamiliar with wound closure with sponges. However, these were robustly refuted by the authors. One RCT showed that gentamicin sponges may cause increased sternal rebleeding if used in double layers. Coagulase-negative staphylococci were predominantly isolated from infected wounds in all the trials except the one from USA, where infections were polymicrobial. Gentamicin resistance among common pathogens causing SWIs can vary from 15 to 80%. Gentamicin-collagen is unlikely to reduce SWIs in high-risk patients and polymicrobial infections.

Background: Bacterial reservoirs in the near-patient environment are likely vectors of healthcare-acquired infection., Aim: To conduct a laboratory-based study to confirm a previous clinical finding of higher numbers of bacteria on plastic than on painted steel bed rails., Methods: Six different surfaces were inoculated with Staphylococcus aureus suspended in a range of synthetic soils. Aerobic colony counts and ATP bioluminescence were used to assess the efficacy of cleaning with microfibre cloths and antibacterial wipes. The ease with which S. aureus was transferred between fingertips and each bed rail was also investigated., Findings: Antibacterial wipes reduced bacterial numbers to below detectable levels on all rails but were less effective than microfibre cloths in removing organic debris. Surfaces that were comparatively easy to clean were more likely to transfer S. aureus on contact. If inadequately disinfected these rails could pose the greatest risk in terms of cross-transmission. In the absence of contaminating soil, bacterial transfer from fingertips to rail ranged from 38% to 64%. Transfer from rail to fingertip ranged from 22% to 38%. Surface material and rugosity were important factors in determining cleanability and transfer rate. However, the presence of organic soils affected bacterial transfer from all bed rails regardless of material or finish., Conclusion: Bed rails can become heavily contaminated. Regular wiping with antibacterial wipes could be a cost-effective means of maintaining low numbers of bacteria near to the patient. To minimize the risk of cross-transmission, cleaning protocols should be validated to ensure effective removal of microbial and non-microbial surface contamination., (Copyright © 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Empyema is an increasingly frequent clinical problem worldwide, and has substantial morbidity and mortality. Our objectives were to identify the clinical, surgical and microbiological features, and management outcomes, of empyema., Methods: A retrospective observational study over 12 years (1999-2010) was carried out at The Heart Hospital, London, United Kingdom. Patients with empyema were identified by screening the hospital electronic 'Clinical Data Repository'. Demographics, clinical and microbiological characteristics, underlying risk factors, peri-operative blood tests, treatment and outcomes were identified. Univariable and multivariable statistical analyses were performed., Results: Patients (n = 406) were predominantly male (74.1%); median age = 53 years (IQR = 37-69). Most empyema were community-acquired (87.4%) and right-sided (57.4%). Microbiological diagnosis was obtained in 229 (56.4%) patients, and included streptococci (16.3%), staphylococci (15.5%), gram-negative organisms (8.9%), anaerobes (5.7%), pseudomonads (4.4%) and mycobacteria (9.1%); 8.4% were polymicrobial. Most (68%) cases were managed by open thoracotomy and decortication. Video-assisted thoracoscopic surgery (VATS) reduced hospitalisation from 10 to seven days (P = 0.0005). All-cause complication rate was 25.1%, and 28 day mortality 5.7%. Predictors of early mortality included: older age (P = 0.006), major co-morbidity (P = 0.01), malnutrition (P = 0.001), elevated red cell distribution width (RDW, P<0.001) and serum alkaline phosphatase (P = 0.004), and reduced serum albumin (P = 0.01) and haemoglobin (P = 0.04)., Conclusions: Empyema remains an important cause of morbidity and hospital admissions. Microbiological diagnosis was only achieved in just over 50% of cases, and tuberculosis is a notable causative organism. Treatment of empyema with VATS may reduce duration of hospital stay. Raised RDW appears to associate with early mortality.

We describe a software tool specifically developed to support the monitoring and reporting of the occurrence of surgical site infections (SSI) in hospitals. The tool uses data collected routinely by a London teaching hospital as part of its infection surveillance system, which includes post-discharge follow-up. Based on these data, the tool is used to generate graphs showing cumulative infections over time and variable life-adjusted display (VLAD) charts that account for the expected specialty average infection risk. The user can select, along with other options, the definition of infection used in the preparation of the graphs. Using an illustrative example of SSI monitoring in orthopaedic surgery, we demonstrate the tool and its intended use to trigger further scrutiny rather than draw firm conclusions. We show that the tool has the ability to generate departmental debate, which should ultimately lead to the increased safety of surgical patients. We recommend adopting the tool and VLAD charts wherever surgical site surveillance is continuous., (Copyright © 2011 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Objective: To determine perioperative risk factors for complications that occur before hospital discharge after gastrointestinal (GI) surgery in cats with alimentary lymphosarcoma (LSA)., Study Design: Case series., Animals: Cats (n=70) with a histopathologically confirmed diagnosis of alimentary LSA that had full-thickness GI surgery., Methods: Medical record data (February 1996-March 2009) from 3 academic referral centers were reviewed. Retrieved data included signalment, preoperative clinical signs and laboratory findings, perioperative medications administered, type and location of GI surgery performed and outcome until hospital discharge., Results: In 38 surgeries, intestinal resection and anastomosis was performed. Gastrotomy and/or enterotomy was performed in 53 surgeries. A preoperative serum albumin concentration <2.5 g/dL was recorded for 11 cases. There was no clinical evidence of postoperative leakage from any biopsy or anastomosis site. Postoperative complications that occurred before hospital discharge included: anorexia or decreased appetite (n=8), hyperthermia (3), pancreatitis (1) and constipation (1)., Conclusions: Cats with alimentary LSA do not appear to be at high risk of postoperative dehiscence after full-thickness GI surgery., (© Copyright 2011 by The American College of Veterinary Surgeons.)

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.

Objectives: To determine the effect of enhanced cleaning of the near-patient environment on the isolation of hospital pathogens from the bed area and staff hands., Design: Prospective randomized crossover study over the course of 1 yr., Setting: Intensive care units at two teaching hospitals., Patients: There were 1252 patients staying during enhanced cleaning and 1331 staying during standard cleaning., Interventions: In each of six 2-month periods, one unit was randomly selected for additional twice-daily enhanced cleaning of hand contact surfaces., Measurements and Main Results: Agar contact samples were taken at five sites around randomly selected bed areas, from staff hands, and from communal sites three times daily for 12 bed days per week. Patients admitted in the year commencing April 2007 were analyzed for hospital-acquired colonization and infection. Over the course of 1152 bed days, 20,736 samples were collected. Detection of environmental methicillin-resistant Staphylococcus aureus per bed-area day was reduced during enhanced cleaning phases from 82 of 561 (14.6%) to 51 of 559 (9.1%) (adjusted odds ratio, 0.59; 95% confidence interval, 0.40-0.86; p = .006). Other targeted pathogens (Acinetobacter baumannii, extended-spectrum β-lactamase-producing Gram-negative bacteria, vancomycin-resistant enterococci, and Clostridium difficile) were rarely detected. Subgroup analyses showed reduced methicillin-resistant Staphylococcus aureus contamination on doctors' hands during enhanced cleaning (3 of 425; 0.7% vs. 11 of 423; 2.6%; adjusted odds ratio, 0.26; 95% confidence interval, 0.07-0.95; p = .025) and a trend to reduction on nurses' hands (16 of 1647; 1.0% vs. 28 of 1694; 1.7%; adjusted odds ratio 0.56; 95% confidence interval, 0.29-1.08; p = .077). All 1252 critical care patients staying during enhanced and 1,331 during standard cleaning were included, but no significant effect on patient methicillin-resistant Staphylococcus aureus acquisition was observed (adjusted odds ratio, 0.98; 95% confidence interval, 0.58-1.65; p = .93)., Conclusions: Enhanced cleaning reduced environmental contamination and hand carriage, but no significant effect was observed on patient acquisition of methicillin-resistant Staphylococcus aureus., Trial Registry: ISRCTN. Identifier: 06298448. http://www.controlled-trials.com/isrctn/.

Background: Calcitonin gene related peptide (CGRP) is a neuropeptide that is abundant in the sensory neurons which innervate bone. The effects of CGRP on isolated bone cells have been widely studied, and CGRP is currently considered to be an osteoanabolic peptide that has effects on both osteoclasts and osteoblasts. However, relatively little is known about the physiological role of CGRP in-vivo in the skeletal responses to bone loading, particularly fatigue loading., Methodology/principal Findings: We used the rat ulna end-loading model to induce fatigue damage in the ulna unilaterally during cyclic loading. We postulated that CGRP would influence skeletal responses to cyclic fatigue loading. Rats were fatigue loaded and groups of rats were infused systemically with 0.9% saline, CGRP, or the receptor antagonist, CGRP(8-37), for a 10 day study period. Ten days after fatigue loading, bone and serum CGRP concentrations, serum tartrate-resistant acid phosphatase 5b (TRAP5b) concentrations, and fatigue-induced skeletal responses were quantified. We found that cyclic fatigue loading led to increased CGRP concentrations in both loaded and contralateral ulnae. Administration of CGRP(8-37) was associated with increased targeted remodeling in the fatigue-loaded ulna. Administration of CGRP or CGRP(8-37) both increased reparative bone formation over the study period. Plasma concentration of TRAP5b was not significantly influenced by either CGRP or CGRP(8-37) administration., Conclusions: CGRP signaling modulates targeted remodeling of microdamage and reparative new bone formation after bone fatigue, and may be part of a neuronal signaling pathway which has regulatory effects on load-induced repair responses within the skeleton.

Most UK hospitals lack enough single rooms to provide source isolation for all infected patients. The aim of this study was to test prototype isolation systems on general wards together with specifically designed portable sink units and toilets. Questionnaires were offered to staff, patients and visitors covering ease of use and acceptability. A total of 53 patients were isolated, with concurrent collection of environmental samples and staff hand hygiene audit. Blocking of beds next to infected patients was avoided but patients and staff were concerned about limited space and communication. Hand hygiene compliance on entry or exit to/from an isolated bed space significantly improved [43/76 (56.6%) to 107/147 (72.8%), P<0.05]. Although popular, the toilets were mechanically unreliable. Low levels of microbial contamination (<1-3.4cfu/cm(2)) were present within all isolated bed spaces. The highest colony counts were obtained from high contact sites (e.g. remote controls). Meticillin-resistant Staphylococcus aureus (MRSA) was present at similar levels inside all systems. Although one system was designed to provide airborne as well as contact isolation, MRSA was isolated from air inside and outside the system suggesting poor efficiency of the air door. The finding was confirmed by aerobiology tests at the Health Protection Agency Laboratory, Porton Down, UK. A trial of redesigned units is required to establish efficacy (Trial Identifier: ISRCTN02681602)., (Copyright 2010 The Hospital Infection Society. All rights reserved.)

Functional skeletal adaptation is thought to be a local phenomenon controlled by osteoctyes. However, the nervous system also may have regulatory effects on adaptation. The aim of this study was to determine the effects of loading of a single bone on adaptation of other appendicular long bones and whether these responses were neuronally regulated. Young male Sprague-Dawley rats were used. The right ulna was loaded to induce a modeling response. In other rats, a second regimen was used to induce bone fatigue with a mixed modeling/remodeling response; a proportion of rats from each group received brachial plexus anesthesia to induce temporary neuronal blocking during bone loading. Sham groups were included. Left and right long bones (ulna, humerus, tibia, and femur) from each rat were examined histologically 10 days after loading. In fatigue- and sham-loaded animals, blood plasma concentrations of TNF-α, RANKL, OPG, and TRAP5b were determined. We found that loading the right ulna induced an increase in bone formation in distant long bones that were not loaded and that this effect was neuronally regulated. Distant effects were most evident in the rats that received loading without bone fatigue. In the fatigue-loaded animals, neuronal blocking induced a significant decrease in plasma TRAP5b at 10 days. Histologically, bone resorption was increased in both loaded and contralateral ulnas in fatigue-loaded rats and was not significantly blocked by brachial plexus anesthesia. In young, growing male rats we conclude that ulna loading induced increased bone formation in multiple bones. Systemic adaptation effects were, at least in part, neuronally regulated., (© 2010 American Society for Bone and Mineral Research.)

As of April 2010 all NHS institutions in the United Kingdom are required to publish data on surgical site infection, but the method for collecting this has not been decided. We examined 7448 trauma and orthopaedic surgical wounds made in patients staying for at least two nights between 2000 and 2008 at our institution and calculated the rate of surgical site infection using three definitions: the US Centers for Disease Control, the United Kingdom Nosocomial Infection National Surveillance Scheme and the ASEPSIS system. On the same series of wounds, the infection rate with outpatient follow-up according to Centre for Disease Control was 15.45%, according to the UK Nosocomial infection surveillance was 11.32%, and according to ASEPSIS was 8.79%. These figures highlight the necessity for all institutions to use the same method for diagnosing surgical site infection. If different methods are used, direct comparisons will be invalid and published rates of infection will be misleading.

Background: The lack of prospective, randomized, controlled trial data to guide optimal antibiotic use in bacteraemic critically ill patients has led to a wide variety of strategies and major issues with drug resistance. We therefore prospectively investigated the epidemiology of bacteraemia and fungaemia in intensive care units (ICUs); and the impact of timing, type and appropriateness of antibiotic intervention., Methods: We conducted a multinational, multicentre, prospective observational study in 132 ICUs from 26 countries with no interventions., Results: 1702 patients [European (69.6%), Australasian (12.2%), South American (8.3%) and Asian (9.9%)] developed 1942 bacteraemic episodes over the study period. Mortality rates were similar for those receiving empirical (40.5%), semi-targeted (37.6%) or fully targeted (33.3%) antibiotic therapy (P=0.40), and in those initially receiving broad- (39.3%) or restricted-spectrum (39.1%) therapy (P=0.94). First-line therapy was effective in terms of the antibiogram (where available) in 70.4% of cases. This in vitro susceptibility ranged from 76.3% for broad-spectrum antibiotics to 46.3% for restricted-spectrum antibiotics (P<0.0001). However, no antibiotic policy-associated variable, including in vitro susceptibility (odds ratio 0.89, 95% confidence interval 0.61-1.30), was a statistically significant predictor of mortality., Conclusions: We could not show an impact of antibiotics on mortality in critically ill patients, despite in vitro activity and early commencement. Randomized, multicentre trials are urgently needed to establish the appropriate duration, timing and combinations of antibiotics that will both optimally treat infection and minimize development of resistance and other complications.

Involvement of the pancreas by metastatic sarcoma is rare, and can prove challenging to differentiate from sarcomatoid carcinomas which occur more commonly. The endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) technique has been successfully used for the diagnosis of pancreatic carcinomas whether primary or metastatic, and is now considered the most effective noninvasive method for the identification of pancreatic metastases. However, to date very few reports detail the diagnosis of mesenchymal neoplasms by EUS-FNA. Herein, we report a series of four patients who underwent EUS-FNA of the pancreas, where the diagnosis of metastatic sarcoma was made based on morphology and ancillary studies. The cases include metastases of leiomyosarcoma, liposarcoma, alveolar rhabdomyosarcoma, and solitary fibrous tumor. The history of a primary sarcoma of the chest wall, mediastinum, and respectively lower extremity was known for the first three of these patients while in the case of the solitary fibrous tumor a remote history of a paraspinal "hemangiopericytoma" was only elicited after the EUS-FNA diagnosis was made. We conclude that EUS-FNA is efficient and accurate in providing a diagnosis of sarcoma, even in patients without a known primary sarcoma, thus allowing institution of therapy without additional biopsies.

Background: An ideal computer keyboard for clinical use would be easily cleanable and cleaned by staff, meet acceptable levels of usability, and not attract hospital bacteria., Methods: In vitro studies were performed to demonstrate bacterial transfer between keyboard surfaces and gloves. This was followed by a usability study and a controlled trial of keyboard contamination in an intensive care unit both with and without an alarm to indicate the need for cleaning. Eight cleanable keyboards were placed at random beds and compared with standard keyboards., Results: Bacteria were most easily removed from a flat silicone-coated surface. The total viable count on flat keyboards with an alarm was lower than that on standard or other cleanable keyboards (median, 19 colony-forming units [cfu] (interquartile range, 7 to 40 cfu), n = 34; 65 cfu (33 to 140 cfu), n = 50; and 40 cfu (21 to 57 cfu), n = 80). Compliance with hand hygiene before touching the standard keyboard was 27%, but the alarmed keyboard was cleaned on 87% of occasions on which the alarm was triggered. The usability study found the flat profile of the cleanable keyboard did not interfere with routine use, except for touch-typing., Conclusion: The flat keyboard with an alarm is easy to clean, and it use is associated with better cleaning compliance.

Aims: We sought to explain the unexpected failure of the inorganic copper-based biocide CuWB50 to effectively decontaminate microfibre cleaning cloths that became contaminated with Acinetobacter lwoffii., Methods and Results: CuWB50 was diluted using distilled water or tap water obtained from two different ICUs. Microtitre plate assays were used to determine the minimum inhibitory concentration (MIC) for the implicated A. lwoffii. pH and oxidation-reduction potential (ORP) tests were performed and representative water samples were chemically analysed. When diluted in distilled water, the CuWB50 MIC for A. lwoffii was 9 mg l(-1) but in tap water from each ICU it was 37 and 75 mg l(-1) at hardness levels of 246 and 296 mg CaCO(3) l(-1) respectively. CuWB50-distilled water solutions consistently had a lower pH and higher ORP than CuWB50-tap water solutions., Conclusions: Hard water adversely affects the biocidal efficacy of CuWB50., Significance and Impact of the Study: Unintentional environmental contamination is a risk when using wet microfibre cloths. This occurred when cloths were stored in CuWB50 overnight combined with the unintentional but erroneous use of tap water. This study emphasizes the need for clearly documented cleaning protocols embedded within a culture of adequate training and constant supervision of cleaning staff.

Background: This study aimed to establish the feasibility and cost-effectiveness of rapid molecular screening for hospital-acquired meticillin-resistant Staphylococcus aureus (MRSA) in surgical patients within a teaching hospital., Methods: In 2006, nasal swabs were obtained before surgery from all patients undergoing elective and emergency procedures, and screened for MRSA using a rapid molecular technique. MRSA-positive patients were started on suppression therapy of mupirocin nasal ointment (2 per cent) and undiluted chlorhexidine gluconate bodywash., Results: A total of 18,810 samples were processed, of which 850 (4.5 per cent) were MRSA positive. In comparison to the annual mean for the preceding 6 years, MRSA bacteraemia fell by 38.5 per cent (P < 0.001), and MRSA wound isolates fell by 12.7 per cent (P = 0.031). The reduction in MRSA bacteraemia and wound infection was equivalent to a saving of 3.78 beds per year (276,220 pounds sterling), compared with the annual mean for the preceding 6 years. The cost of screening was 302,500 pounds sterling, making a net loss of 26,280 pounds sterling. Compared with 2005, however, there was a net saving of 545,486 pounds sterling., Conclusion: Rapid MRSA screening of all surgical admissions resulted in a significant reduction in staphylococcal bacteraemia during the screening period, although a causal link cannot be established., (2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Objective: To assess the degree of environmental contamination with methicillin-resistant Staphylococcus aureus (MRSA) in critical care and the likelihood of subsequent new patient acquisition if carriers were or were not moved to single rooms., Design: Randomized sequential sampling of bed areas., Setting: Intensive care units of two teaching hospitals., Patients: Medical and surgical patients requiring critical care., Interventions: Six environmental sites around randomly selected patients plus two communal sites were sampled using contact plates during periods when patients with MRSA were physically isolated or not. Admission, weekly, and discharge screening patient swabs were taken to identify patients admitted with, or newly acquiring, MRSA., Measurements and Main Results: A total of 2,436 samples were taken from environments around 114 patients, plus a further 349 samples from doctors' hands and telephones. Of the 47 bed areas where MRSA strains were identified that were not found initially on patients, only one patient subsequently acquired the same strain. Five other patients became colonized with new MRSA strains, but these were not found in their environment beforehand. Of 52 patients colonized with MRSA, 34 had a similar strain found subsequently in their environment., Conclusions: Whereas the MRSA-colonized patient frequently contaminates his or her local environment, transmission of MRSA from the environment to the patient was not commonly identified. Studies elucidating possible routes of MRSA transmission are urgently needed to inform infection control policies., ((C) 2007 Lippincott Williams & Wilkins, Inc)

Wound infection in cardiac surgery is a continuing problem despite improvements in surgical technique. The risk factors for, and appearance of, the infected wound differ from operations in other specialties. A robust definition is required for successful surveillance but many are open to different interpretations. At UCLH, comparison between UK and US definitions shows marked differences in patients defined as infected. Surveillance with feedback is effective if conducted over several years, but a high proportion of infected wounds are only identified during post-discharge follow-up. Deteriorating performance of an individual surgeon can be detected and interventions focused on improving faults identified during data collection. Often highlighting the problem is sufficient to reverse the trend, but the process of audit and control is becoming more important as accountability and performance is demanded by primary care providers and patients.