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•Tumor-infiltrating lymphocytes (TILs) exhibit higher cytokine production compared to peripheral TILs (pTILs) in patients with RCC.•CD8+ T cells predominantly utilize Fas Ligand, while CD4+ T cells rely on CD107a for cytotoxicity in RCC.•The migration capacity of tumor-infiltrating lymphocytes (TILs) is inversely correlated with the proportion of cancer-associated fibroblasts (CAFs).•Tumor and peritumoral T cells exhibit limited responsiveness to additional activation signals, while peripheral T cells in circulation retain their capacity to respond to stimulatory signals.

Our results support the recent changes in the European Association of Urology non–muscle-invasive bladder cancer guidelines for a more refined risk stratification of Ta grade 3 tumors because many of these patients have better prognosis than previously thought.

Objective.Interventions for reducing methicillin-resistant Staphylococcus aureus(MRSA) healthcare-associated disease require outcome assessment; this is typically done by manual chart review to determine infection, which can be labor intensive. The purpose of this study was to validate electronic tools for MRSA healthcare-associated infection (HAI) trending that can replace manual medical record review.Design and Setting.This was an observational study comparing manual medical record review with 3 electronic methods: raw culture data from the laboratory information system (LIS) in use by our healthcare organization, LIS data combined with admission-discharge-transfer (ADT) data to determine which cultures were healthcare associated (LIS + ADT), and the CareFusion MedMined Nosocomial Infection Marker (NIM). Each method was used for the same 7-year period from August 2003 through July 2010.Patients.The data set was from a 3-hospital organization covering 342,492 admissions.Results.Correlation coefficients for raw LIS, LIS + ADT, and NIM were 0.976, 0.957, and 0.953, respectively, when assessed on an annual basis. Quarterly performance for disease trending was also good, with R2values exceeding 0.7 for all methods.Conclusions.The electronic tools accurately identified trends in MRSA HAI incidence density when all infections were combined as quarterly or annual data; the performance is excellent when annual assessment is done. These electronic surveillance systems can significantly reduce (93% [in-house-developed program] to more than 99.9999% [commercially available systems]) the personnel resources needed to monitor the impact of a disease control program.

ABSTRACTOur three-hospital system began active surveillance for methicillin-resistant Staphylococcus aureus(MRSA) nasal colonization, with decolonization of positive patients, on all admissions starting 1 August 2005. A question not previously addressed is whether reduction of the incidence of MRSA disease would lower the total number of S. aureusclinical isolates recovered by the microbiology laboratory that are reported to health care providers. The decreases in the numbers of MRSA and total S. aureusclinical isolates for each year after August 2005 were highly statistically significant compared to the numbers in each of the prior 3 years (P< 0.0001).

ABSTRACTNasal and perianal swab specimens were tested for detection of Staphylococcus aureusand vancomycin-resistant Enterococcusspecies (VRE) using a laboratory-developed real-time PCR test and microbiological cultures. The real-time PCR and culture results for S. aureuswere similar. PCR had adequate sensitivity, but culture was more specific for the detection of VRE.

ABSTRACTWe evaluated the use of the BD GeneOhm MRSA real-time PCR assay (BD Diagnostics, San Diego, CA) for the detection of nasal colonization with methicillin-resistant Staphylococcus aureus(MRSA). The initial evaluation consisted of 403 paired nasal swabs and was done using the specimen preparation provided with the kit and an in-house lysis method that was specifically developed to accommodate large-volume testing using a minimal amount of personnel time. One swab was placed in an achromopeptidase (ACP) lysis solution, and the other was first used for culture and then prepared according to the kit protocol. PCR was performed on both lysates, and results were compared to those for culture. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the PCR assay were 98%, 96%, 77%, and 99.7% with the kit lysate and 98%, 95%, 75%, and 99.7% with the ACP lysate (P, not significant), respectively. The second evaluation was done after implementation of all-admission surveillance using PCR with ACP lysis and a sampling of 1,107 PCR-negative samples and 215 PCR-positive samples that were confirmed by culture. The results of this sampling showed an NPV of 99.9% and a PPV of 73.5% (prevalence, 6%), consistent with our initial findings. The BD GeneOhm MRSA assay is an accurate and rapid way to detect MRSA nasal colonization. When one is dealing with large specimen numbers, the ACP lysis method offers easier processing without negatively affecting the sensitivity or specificity of the PCR assay.

Faced with expectations to improve patient safety and contain costs, the US health care system is under increasing pressure to comprehensively and objectively account for nosocomial infections. Widely accepted nosocomial infection surveillance methods, however, are limited in scope, not sensitive, and applied inconsistently. In 907 inpatient admissions to Evanston Northwestern Healthcare hospitals (Evanston, IL), nosocomial infection identification by the Nosocomial Infection Marker (MedMined, Birmingham, AL), an electronic, laboratory-based marker, was compared with hospital-wide nosocomial infection detection by medical records review and established nosocomial infection detection methods. The sensitivity and specificity of marker analysis were 0.86 (95% confidence interval [CI 95], 0.76-0.96) and 0.984 (CI 95, 0.976, 0.992). Marker analysis also identified 11 intensive care unit-associated nosocomial infections (sensitivity, 1.0; specificity, 0.986). Nosocomial Infection Marker analysis had a comparable sensitivity (P > .3) to and lower specificity (P < .001) than medical records review. It is important to note that marker analysis statistically outperformed widely accepted surveillance methods, including hospital-wide detection by Study on the Efficacy of Nosocomial Infection Control chart review and intensive care unit detection by National Nosocomial Infections Surveillance techniques.

The conflict between civil servants and politicians has often been described as the basic problem of modern authorities, for this reason, one must understand and thus research the relationship between these two groups of very influential actors in order to understand the governing process, In modern democracies, civil servants have outgrown their classic role of mere implementers of orders given by politicians. Both civil servants and politicians serve the same democratic state, and both are hews to the same democratic evolution. S argue that based mainly on the historically developed division of labour between bureaucracy and politics civil servants have never been tasked with creating the conditions for more democracy m the state, but instead with creating the conditions for a more effective and successful slate. Given that political bodies in which politicians operate have been established as the institutionalised personification of democracy, the task of politicians is above alt to promote democracy, its values and norms.

AbstractObjective:To evaluate the cost-effectiveness and detection sensitivity associated with three active surveillance strategies for the identification of patients harboring vancomycin-resistant enterococci (VRE) to determine which is the most medically and economically useful.Design:Culture for VRE from 200 consecutive stool specimens submitted for Clostridium difficileculture. Following this, risk factors were assessed for patients whose culture yielded VRE, and a cost-effectiveness evaluation was performed using a decision analytic model with a probabilistic analysis.Setting:A 688-bed, tertiary-care facility in Chicago, Illinois, with approximately 39,000 annual admissions, 7,000 newborn deliveries, 56,000 emergency department visits, and 115,000 home care and 265,000 outpatient visits.Subjects:All stool specimens submitted to the clinical microbiology laboratory for C. difficileculture from hospital inpatients.Results:From 200 stool samples submitted for C. difficiletesting, we identified 5 patients with VRE in non-high-risk areas not screened as part of our routine patient surveillance. Medical record review revealed that all 5 had been hospitalized within the prior 2 years. Three of 5 had a history of renal impairment. The strategy that would involve screening the greatest number of patients (all those with a history of hospital admission in the prior 2 years) resulted in highest screening cost per patient admitted ($2.48), lower per patient admission costs ($480), and the best survival rates.Conclusion:An expanded VRE surveillance program that encompassed all patients hospitalized within the prior 2 years was a cost-effective screening strategy compared with a more traditional one focused on high-risk units.

Nasal carriage of Staphylococcus aureusis considered a source of subsequent infection in health care settings. Utilization of real-time polymerase chain reaction (PCR) for detection of S. aureushas the potential to dramatically affect infection control practice by rapidly identifying S. aureus-colonized patients. We developed and validated the use of real-time PCR for detection of S. aureuscolonization in two patient populations. Paired nasal swabs were collected from 299 neonates and from 151 adult patients at Evanston Hospital. One swab was used for culture and the other placed into a bacterial lysis solution containing achromopeptidase. The DNA liberated was used as the template for real-time PCR with primers for the femAgene. SYBR Green was used for amplicon detection. In the neonatal population the sensitivity, specificity, predictive value positive and predictive value negative for culture and PCR was 92%versus96%, 100%versus100%, 100%versus100%, and 98%versus99%, respectively. In the adults the results were 90%versus100%, 100%versus98%, 100%versus96%, and 95%versus100%, respectively. Real-time PCR was able to detect S. aureusin 2 hours compared to 1 to 4 days for culture and provided sensitivity equal to or greater than culture.

ABSTRACTWhole-house surveillance for healthcare-associated infection is no longer the recommended practice because of the large personnel time investment required. We developed a computer-based tracking system using microbiologic data as an aid in detecting potential outbreaks of healthcare-associated infections on a hospital-wide basis. Monthly total isolates of 25 clinically significant hospital pathogens were tallied from 1991 to 1998 to form a database for future comparison. Two different algorithm tools (based on increases of organism numbers over baseline) were applied to determine alert thresholds for suspected outbreaks using this information. The first algorithm (2SD) defined an alert as two standard deviations above the mean monthly number of isolates. The second (MI) defined an alert as either a 100% increase from the baseline organism number over 2 months or a =50% increase (compared to baseline) during a three-consecutive-month period. These two methods were compared to standard infection control professional surveillance (ICP) for the detection of clonal outbreaks over 12 months. Overall, a total of seven clonal outbreaks were detected during the 1-year study. Using standard methods, ICP investigated nine suspected outbreaks, four of which were associated with clonal microbes. The 2SD method signaled a suspected outbreak 15 times, of which three were clonal and ICP had detected one. The MI method signaled a suspected outbreak 30 times; four of these were clonal, and ICP had detected one. The sensitivity and specificity values for ICP, 2SD, and MI for detecting clonal outbreaks were 57, 43, and 57% and 17, 83, and 67%, respectively. Statistical methods applied to clinical microbiology laboratory information system data efficiently supplement infection control efforts for outbreak detection.

Objectives:Investigate and control an increase in bloodstream infections (BSIs) in an outpatient hemodialysis center.Patients and Design:A retrospective cohort study was conducted for patients receiving dialysis at the center from February 2000 to April 2001. A case–control study compared microbiological data for all BSIs that occurred during the study period with those for BSIs that occurred during a baseline period Qanuary 1999 to January 2000). BSI rates before and after a 1-month intervention (May 2001) were assessed. A case was defined as a new BSI during the study period.Results:The outbreak was polymicrobial, with approximately 30 species. The baseline BSI rate was 0.7 per 100 patient-months. From February 2000 to April 2001, the BSI rate increased to 4.2 per 100 patient-months. Overall, 75% of the BSIs were associated with central venous catheters (CVCs), but CVC use did not fully explain the increase in BSIs. In January 2000, when the center changed ownership, prepackaged CVC dressing kits and biweekly infection control monitoring were discontinued. Beginning in May 2001, staff were educated on CVC care, chlorhexidine replaced povidone-iodine for cutaneous antisepsis, gauze replaced transparent dressings, antimicrobial ointments containing polyethylene glycol at CVC exit sites were discontinued, and patients with CVCs were educated on cutaneous hygiene. After the intervention period, by October 2001, rates decreased to less than 1 BSI per 100 patient-months.Conclusions:Proper cutaneous antisepsis and access site care is crucial in preventing BSIs in patients receiving hemodialysis. Infection control programs, staff and patient education, and use of optimal antisepsis agents or prepackaged kits are useful toward this end.

ABSTRACTBactericidal testing historically has exhibited variable reproducibility, even when prior standardized methods were employed. Several modifications to the National Committee for Clinical Laboratory Standards (NCCLS) broth macrodilution method are proposed to improve reproducibility. Recommended changes from the approved NCCLS guidelines (M21-A and M26-A) include omitting serum supplementation of Mueller-Hinton broth, incubating tubes at 35°C for 24 h with no agitation until they are sampled, running all tests in duplicate with six dilutions instead of nine, reincubating the test for an additional 24 h to resolve discrepant bactericidal activity test results, using a single 0.1-ml sample from each clear tube for subculture, and adopting an alternate method for calculating endpoint determination. In order to test these recommendations in a clinical laboratory setting, we used the modified methodology on 224 separate tests for bactericidal activity. There were 102 serum bactericidal titer (SBT) and 122 minimum bactericidal concentration (MBC) assays performed. By defining reproducibility as agreement between duplicate tests ± 1 dilution, we found 207 of 224 tests (92%) were reproducible at the 24-h subculture point (94% for the SBT assay and 91% for the MBC assay). When the 17 assays with discrepant results were incubated an additional 24 h for a second subculture, only 1 of 224 tests (0.4%) remained discrepant. The method used is practical for a clinical laboratory that chooses to perform bactericidal activity testing and assures a high level of reproducibility between duplicate assays. The total cost of a test was approximately $25.00.

ABSTRACTThe emergence of resistance in gram-positive bacteria has necessitated a search for new antimicrobial agents. Linezolid is an oxazolidinone, a new class of antibacterial agents with enhanced activity against pathogens. We compared the activity of linezolid to those of other antimicrobial agents against 3,945 clinical isolates. Linezolid demonstrated potent activity against all isolates tested. For all vancomycin-susceptible enterococci, staphylococci, and streptococci, the activity of linezolid was comparable to that of vancomycin. Against oxacillin-resistant staphylococci and vancomycin-resistant enterococci, linezolid was the most active agent tested. In summary, linezolid appears to be a promising new antimicrobial agent for the treatment of gram-positive infections.

Antifungal susceptibility testing methods currently lack a standardized procedure. Many factors, such as inoculum preparation, inoculum density, medium selection, pH, incubation time and temperature, and endpoint determination, affect results. We developed a workable procedure for fungal susceptibility testing, with a microtiter method based upon modifications of the proposed guidelines from the National Committee for Clinical Laboratory Standards, using two different growth media. For this procedure, the microtiter tray is prepared as a panel of 6 drugs (amphotericin B, flucytosine, fluconazole, ketoconazole, miconazole, and itraconazole) alone and in combination with amphotericin B. Eagle's minimal essential medium and RPMI 1640 are the two growth media. Two separate susceptibility trays are inoculated for each sensitivity test, with one tray incubated at 30 degrees C and the other incubated at 35 degrees C. After 48 h of growth, results for both temperatures and both media are recorded and interpreted. The four test environments (two media each at two temperatures) provided growth for 100 of the first 104 organisms that were submitted for testing. This approach provides a workable methodology for routine antifungal susceptibility testing in a clinical microbiology laboratory setting.

Nine selected isolates of Candida albicans were tested for their susceptibilities to amphotericin B and fluconazole by using three methods to assess the effect of incubation time and buffer concentration. By using a microdilution method with 0.0165 M 3-(N-morpholino)propanesulfonic acid (MOPS) and a 24-h incubation time, all of the isolates were found to be susceptible to amphotericin B and fluconazole. After 48 h of incubation, all isolates were still susceptible to amphotericin B. Seven of the nine isolates were resistant to fluconazole, and for the remaining two isolates, MICs increased by fourfold or more but the isolates remained susceptible (MIC, < or = 10 microg/ml). The nine isolates, along with three control strains, were further tested against amphotericin B and fluconazole by a standard broth macrodilution method with both 0.165 and 0.0165 M MOPS. The susceptibility results for fluconazole by the broth macrodilution method with the lower MOPS concentration correlated with the results of the 24-h broth microdilution method for determination of susceptibility or resistance in eight of nine tests and with the results of the 48 h broth microdilution method in three of nine tests. The results of the broth macrodilution method with the standard MOPS concentration did not correlate with any of the results obtained by the 24-h broth microdilution but correlated with results of seven of nine tests by the 48-h broth microdilution method. All nine test strains appeared to be susceptible when they were examined by a flow cytometric method. For clinical yeast susceptibility testing in microdilution panels, the 0.0165 M MOPS concentration combined with 24 h of incubation appeared to be the method of choice. The lower MOPS concentration may also be a useful modification to the tentative broth macrodilution method of the National Committee for Clinical Laboratory Standards. Use of the higher buffer concentration or longer incubation time may lead to false in vitro resistance for agents like fluconazole.

Reducing the rate of avoidable errors is crucial to patient safety. Telephone calls with misunderstood critical results constitute one area in which opportunities for improvement exist. The aviation industry has dealt with this issue by requiring pilots to repeat instructions received from the air traffic controller. At 3 health care organizations, we tested a program to decrease telephone reporting errors by requiring the recipients of critical results to repeat the message. Of 822 outgoing telephone calls from the laboratory, 29 errors were detected (error rate 3.5%). Calls to physicians had the highest rate of errors (6/95 [5%]). The time required to ask for the information and for the message to be repeated averaged 12.8 seconds per call, which corrected 29 errors. A simple system of repeating telephoned laboratory results has the potential to reduce the risk of medical errors and improve patient safety.

ABSTRACTWe surveyed environmental surfaces in our clinical microbiology laboratory to determine the prevalence of vancomycin-resistant enterococci (VRE) and multidrug-resistantEnterobacteriaceae(MDRE) during a routine working day. From a total of 193 surfaces, VRE were present on 20 (10%) and MDRE were present on 4 (2%) of the surfaces tested. In a subsequent survey after routine cleaning, all of the 24 prior positive surfaces were found to be negative. Thus, those in the laboratory should recognize that many surfaces may be contaminated by resistant organisms during routine processing of patient specimens.

ABSTRACTCommunity-acquired MRSA (CA-MRSA) is potentially a new emerging pathogen with most strains susceptible to many antimicrobials except for ß-lactam antibiotics. We retrospectively reviewed MRSA isolates during a 20-month study period (January 1998 through August 1999) and investigated those that were clindamycin susceptible. Patients were not considered to harbor CA-MRSA if they had been admitted to a hospital within the preceding 2 years or if their isolate had been obtained more than 72 h after admission. There were 2,817 S. aureusisolates, with 1,071 (38%) being MRSA. Of these 1,071 isolates, 161 were clindamycin susceptible; these were recovered from 81 patients. Of these 81 patients, 20 appeared to have community-acquired strains, but only 2 could be confirmed as having CA-MRSA.

ABSTRACTIt has been suggested that a method of performing surveillance for vancomycin-resistant enterococci (VRE) is to screen specimens submitted for Clostridium difficiletesting. We compared this approach to our focused surveillance program of high-risk units during October 1997 to compare the yield of VRE and multidrug-resistantEnterobacteriaceae(MDRE) with both methods. Of the stools submitted for C. difficiletesting, 14% were positive for VRE or MDRE, whereas rectal swabs from routine surveillance yielded 11% VRE- or MDRE-positive results. Although stools submitted forC. difficiletesting resulted in a higher percentage of positive cultures, 14 VRE- and 2 MDRE-positive patients from our high-risk population were missed because many patients had no stool submitted for C. difficiletesting. Therefore, while screening stools submitted for C. difficiletesting cannot replace our focused surveillance program, it appears advantageous to assess these stools at various intervals to detect new patient reservoirs of drug-resistant organisms that may benefit from routine surveillance cultures.

ABSTRACTWe compared the Rodac imprint technique to selective enrichment broth for detecting vancomycin-resistant enterococci (VRE) and multidrug-resistant Enterobacteriaceae(MDRE) on surfaces. Rodac plates contained tryptic soy agar with 5% sheep blood, vancomycin (6 µg/ml), ceftazidime (2 µg/ml), amphotericin B (2 µg/ml), and clindamycin (1 µg/ml). Two types of broth were used: brain heart infusion (BHI) and BHI plus vancomycin (6 µg/ml) and ceftazidime (2 µg/ml) (BHIVC). Of the 46 surfaces cultured for VRE, 12 (26%) were positive. Of the 12 VRE-positive surfaces, 11 (92%) grew from Rodac, 8 (67%) grew from BHIVC, and 7 (58%) grew from BHI. A larger study is needed for MDRE, as only 4 of 43 surfaces were MDRE positive. The Rodac imprint technique successfully recovered VRE from environmental surfaces.

ABSTRACTA real-time PCR assay was developed targeting the blaKPCresponsible for Klebsiella pneumoniaecarbapenemase (KPC)-mediated carbapenem resistance and was validated for testing colonies or enrichment broth cultures. The assay accurately detects KPC-containing strains with high analytical specificity and sensitivity.

Interleukin-35 (IL-35) is a newly described hetero-dimeric cytokine of the IL-12 family. Studies of immunopathogenesis in idiopathic inflammatory myopathies (IIM) are of interest for future biological therapies.

Reducing the rate of avoidable errors is crucial to patient safety. Telephone calls with misunderstood critical results constitute one area in which opportunities for improvement exist. The aviation industry has dealt with this issue by requiring pilots to repeat instructions received from the air traffic controller. At 3 health care organizations, we tested a program to decrease telephone reporting errors by requiring the recipients of critical results to repeat the message. Of 822 outgoing telephone calls from the laboratory, 29 errors were detected (error rate 3.5%). Calls to physicians had the highest rate of errors (6/95 [5%]). The time required to ask for the information and for the message to be repeated averaged 12.8 seconds per call, which corrected 29 errors. A simple system of repeating telephoned laboratory results has the potential to reduce the risk of medical errors and improve patient safety.