Drug repurposing: Misconceptions, challenges, and opportunities for academic researchers

[Figure: see text].

pH - Responsive colloidal carriers assembled from β-lactoglobulin and Epsilon poly-L-lysine for oral drug delivery

Site specific oral delivery of many biopharmaceutical classification system (BCS) class II and IV drugs is challenging due to their poor solubility, low permeability and degradation in the gastrointestinal tract. Whilst colloidal carriers have been used to improve the bioavailability of such drugs, most nanocarriers based drug delivery systems suffer from multiple disadvantages, including low encapsulation efficiency (liposomes, polymeric nanoparticles), complex synthesis methods (silica, silicon-based materials) and poorly understood biodegradability (inorganic nanoparticles). Herein, a novel pH responsive nanocolloids were self-assembled using natural compounds such as bovine β-lactoglobulin (BLG) and succinylated β-lactoglobulin (succ. BLG) cross-linked with epsilon poly l-lysine (BCEP and BCP), and found to possess high loading capacity, high aqueous solubility and site-specific oral delivery of a poorly soluble nutraceutical (curcumin), improving its physicochemical properties and biological activity in-vitro and ex-vivo. Our optimized synthesis formed colloids of around 200 nm which were capable of encapsulating curcumin with ~100% encapsulation efficiency and ~10% w/w drug loading. By forming nanocomplexes of curcumin with BLG and succ. BLG, the aqueous solubility of curcumin was markedly increased by ~160-fold and ~86-fold, respectively. Encapsulation with BLG increased the solubility, whereas succ. BLG prevent release of encapsulated curcumin when subjected to gastric fluids as it is resistant to breakdown on exposure to pepsin at acidic pH. In conditions mimicking the small intestine, Succ. BLG was more soluble resulting in sustained release of the encapsulated drug at pH 7.4. Additionally, crosslinking succ. BLG with E-PLL significantly enhanced curcumin's permeability in an in-vitro Caco-2 cell monolayer model compared to curcumin solution (dissolved in 1% DMSO), or non-crosslinked BLG/succ. and BLG. In a mouse-derived intestinal epithelial 3D organoid culture stimulated with IL-1β, BLG-CUR and crosslinked BCEP nanoparticles reduced the production of inflammatory cytokines and chemokines such as Tnfα and Cxcl10 more than curcumin solution or suspension while these nanoparticles were non-toxic to organoids. Overall this work demonstrates the promise of nutraceutical-based hybrid self-assembled colloidal system to protect hydrophobic drugs from harsh gastrointestinal conditions and improve their solubility, dissolution, permeability and biological activity.

Oral Delivery of β-Lactoglobulin-Nanosphere-Encapsulated Resveratrol Alleviates Inflammation in Winnie Mice with Spontaneous Ulcerative Colitis

Resveratrol (RES) is a nutraceutical with promising anti-inflammatory properties for the treatment of inflammatory bowel diseases (IBD). However, the clinical effectiveness of resveratrol as an oral anti-inflammatory agent is hindered by its extremely poor solubility and poor stability. In this study, we encapsulated resveratrol in β-lactoglobulin (BLG) nanospheres and systematically analyzed their formulation parameters in vitro followed by a thorough in vivo anti-inflammatory testing in a highly specialized spontaneous murine UC model (Winnie mice model). Complexation of resveratrol with BLG increased the aqueous solubility of resveratrol by ≈1.7 times with 10% w/w loading. Additionally, the in vitro dissolution of resveratrol from the particles was found to be higher compared to resveratrol alone, resulting in >90% resveratrol dissolution in ∼8 h. The anti-inflammatory activity of resveratrol was examined for the first time in Winnie mice, a mouse model that closely represents the clinical signs of IBD. At a 50 mg/kg oral dose for 2 weeks, BLG-RES significantly improved both % body weight and disease activity index (DAI), compared to free resveratrol in Winnie mice. Importantly, histological evaluations revealed a similar trend with striking improvement in the pathology of the colon via an increase in goblet cell numbers and recovery of colonic epithelium. BLG-RES significantly increased the expression level of cytokine interleukin-10 (Il10), which confirms the reduction in inflammation potentially because of the increased dissolution and stability of resveratrol by complexation with BLG. This comprehensive study demonstrates the effectiveness of biocompatible nanomaterials such as BLG in oral delivery of poorly soluble anti-inflammatory molecules such as resveratrol in the treatment of IBD.

Effect of Different Volumes of Interval Training and Continuous Exercise on Interleukin-22 in Adults with Metabolic Syndrome: A Randomized Trial

INTRODUCTION

IL-22 may have a role in the alleviation of the metabolic syndrome (MetS) via protection of pancreatic beta and endothelial cells from oxidative and lipid-induced damage. We aimed to investigate the effects of moderate-intensity continuous training (MICT) and different volumes of high-intensity interval training (HIIT) on changes in circulating IL-22.

METHODS

This was a sub-study of the "Exercise in the prevention of Metabolic Syndrome" (EX-MET) a multi-center, randomized trial. This study used data collected at the Brisbane site. Thirty-nine individuals with MetS were randomized to one of three 16-wk interventions: 1) MICT (n=10, 30min at 60-70% HR peak, 5x/wk); 2) 4HIIT (n=13, 4x4min at 85-95% HR peak, interspersed with 3min of active recovery at 50-70% HR peak, 3x/wk); or 3) 1HIIT (n=16, 1x4min at 85-95% HR peak, 3x/wk). Serum IL-22 concentration was measured following a 12-hr fast via an enzyme linked immunosorbent assay, before and after the intervention. MetS severity, insulin resistance (IR), visceral adipose tissue (VAT), and cardiorespiratory fitness (CRF) were also measured via MetS z-score, HOMA-IR, dual-energy X-ray absorptiometry, and indirect calorimetry (maximal exercise test), respectively.

RESULTS

The median (IQR) IL-22% changes from pre- to post-intervention in the MICT, 4HIIT, and 1HIIT groups were -17% (-43.0% to 31.3%), +16.5% (-18.9% to 154.9%), and +15.9% (-28.7% to 46.1%), respectively. Although there were no significant between-group differences in IL-22 concentration change, there was a medium-to-large group × time interaction effect [F(2,35)=2.08, p=0.14, η²=0.14].

CONCLUSION

Although there was no statistically significant between-group difference in IL-22 change, the study suggests that different exercise intensities may have opposing effects on IL-22 concentration in individuals with MetS.

P647An audit of possible familial hypercholesterolaemia in general practice

Background

Familial hypercholesterolaemia (FH) is an autosomal dominant condition associated with elevated total cholesterol and low-density lipoprotein (LDL). It confers an increased risk of premature cardiovascular disease and associated mortality. It is estimated that the majority of patients with FH in Ireland are undiagnosed and structured care programmes are not available.

Purpose

To undertake an audit of those patients in a general practice with possible FH

Methods

A retrospective audit was carried out on the patients attending a GP practice. Inclusion criteria for the study were as follows:

LDL level >4.9mmol/L

Triglyceride level (<2mmol/L)

Data was collected from the patients' clinical notes and patients were interviewed to acquire additional details not available in the clinical notes where possible. A Dutch Lipid Clinic Network Score (DLCNS) was calculated for each patient.

Results

Of 5,438 patients with a LDL recorded 284 patients fulfilled the inclusion criteria. 52.4% were female. Mean age 60 years old (range: 19–95 years). The highest LDL level recorded for these patients ranged from 5.0 - 8.6 mmol/L, with a mean value of 5.4 mmol/L. The mean most recent LDL level was 3.6mmol/L (range: 1.0–6.3 mmol/L). 42 patients (14.8%) had a family history of premature coronary and/or vascular disease in line with DLCNS criteria. 9 patients (3.2%) had a personal history of premature cardiovascular disease. The DLCNS was calculated for each patient based on the information available. 225 patients (79.2%) had a score of 3, 36 patients (12.7%) had a score of 4, 12 patients (4.2%) had a score of 5 and 6 patients (2.1%) had a score of 6. This equates to 273 patients (96.1%) with a possible diagnosis of FH, and 6 patients (2.1%) with a probable diagnosis of FH. The mean most recent systolic blood pressure reading for these patients was 128mmHg, and diastolic 76mmHg. 51 patients (18%) were current smokers, 83 (29.2%) were ex-smokers, and 111 (39%) had never smoked. Smoking status was unknown for 38 patients (13.4). 128 patients (45%) were on lipid-lowering treatment at the time of this audit. 60 (21.1%) were on high intensity treatment, 68 (23.9%) were on medium intensity treatment and none were on low intensity treatment. 24.3% of patients were at target LDL. There were 5 patients (1.8%) currently receiving ezetimibe and 1 (0.4%) on fenofibrate.

Conclusion

A significant number of patients had a LDL >5mmol/l in this audit. Only 45% were on lipid lowering treatment and 24.3% were at a target LDL. This highlights the needs for structured programmes for screening and management of FH in primary care.

Acknowledgement/Funding

Funded by an unrestricted grant from Amgen

Is There a Link Between H. Pylori and the Epidemiology of Crohn's Disease?

INTRODUCTION

Case control studies suggest an inverse association between Helicobacter pylori (H. pylori) and Crohn's disease (CD). It is possible this could be accounted for by confounders such as antibiotic therapy. Analyzing the geographic distribution of H. pylori and the links with the incidence and prevalence of CD would be an alternative approach to circumvent these confounders.

METHODS

The literature was searched for studies published between 1990 and 2016 that reported incidence or prevalence data for CD in random population samples in developed countries (GDP per capita >20,000 USD/year). Corresponding prevalence studies for H. pylori in these same regions were then sought matched to the same time period (±6 years). The association between the incidence and prevalence of CD and H. pylori prevalence rates were assessed before and after adjusting for GDP and life expectancy.

RESULTS

A total of 19 CD prevalence and 22 CD incidence studies from 10 European countries, Japan, USA, and Australia with date-matched H. pylori prevalence data were identified. The mean H. pylori prevalence rate was 43.4% (range 15.5-85%), and the mean rates for incidence and prevalence for CD were 6.9 and 91.0/100,000 respectively. The incidence (r = -0.469, p < 0.03) and prevalence (r = -0.527, p = 0.02) of CD was inversely and significantly associated with prevalence of H. pylori infection.

CONCLUSIONS

Our data demonstrate a significant inverse association between geographic distribution of H. pylori and CD. Thus, it is highly unlikely that the findings of previous case control studies were simply due to confounding factors such as concomitant antibiotic use in CD patients.

Enhanced colloidal stability, solubility and rapid dissolution of resveratrol by nanocomplexation with soy protein isolate

The polyphenolic compound resveratrol has received significant attention due to its many pharmacological actions such as anti-cancer, anti-inflammatory, antioxidant and antimicrobial activities. However, poor solubility and stability are major impediments for resveratrol's clinical effectiveness. In this work we have encapsulated resveratrol into soy protein isolate nanoparticles using a simple rotary evaporation technique. Resveratrol-loaded nanoparticles were around 100nm in diameter and negatively charged. Nano-encapsulated resveratrol was found to be in amorphous form and showed more than two times higher solubility with significantly increased dissolution when compared to free resveratrol. Finally, an in-vitro NF-κB inhibition assay revealed that encapsulated resveratrol was stable and retained bioactivity. This new formulation of resveratrol has the potential to boost the clinical effectiveness of this drug and could be utilised for other poorly soluble hydrophobic drugs.

Increased Helicobacter felis colonization in male 129/Sv mice fails to suppress gastritis

Development of the pathologies associated with Helicobacter pylori infection, most seriously gastric adenocarcinoma, are a consequence of chronic inflammation, which both host and pathogen go to some lengths to minimize. Recently, we presented evidence that H. pylori can suppress the development of inflammation in its immediate microenvironment in the gastric mucosa of 129/Sv mice. We have now extended this study by showing that H. felis, a gastric colonizing Helicobacter closely related to H. pylori, does not possess the same ability to suppress Helicobacter-induced gastritis in mice. Differences between these bacterial species may provide clues as to the mechanism behind the inflammation-regulating ability of H. pylori. Moreover, our demonstration that H. pylori but not H. felis can locally suppress inflammation in vivo may explain why H. felis infection induces superior levels of gastritis as compared with H. pylori infection of mice.

Ghrelin in gastrointestinal disease

Enteroendocrine cells of the gastric fundus are the predominant source of ghrelin production, although ghrelin gene transcripts and ghrelin-producing cells have been identified throughout the gastrointestinal tract. Various infectious, inflammatory and malignant disorders of the gastrointestinal system have been shown to alter ghrelin production and secretion and consequently to affect endocrine ghrelin levels and activity. Animal studies have demonstrated that ghrelin and synthetic ghrelin mimetics can reduce the severity of gastric and colonic inflammation and human clinical trials are underway to determine the efficacy of ghrelin in improving motility disorders. This review summarises the impact of gastrointestinal disease on ghrelin synthesis and secretion and the potential use of ghrelin and its mimetics for the treatment of these diseases.

No evidence of the unfolded protein response in patients with chronic hepatitis C virus infection

BACKGROUND AND AIM

Hepatitis C virus (HCV) proteins activate the unfolded protein response (UPR) in experimental models. The role of the UPR in the pathogenesis of HCV-induced liver injury has not been determined. Our aim was to investigate the role of the UPR in the pathogenesis of chronic HCV.

METHODS

Liver biopsy samples from 124 patients with chronic HCV and 24 HCV/HBV-negative subjects with histologically normal liver (NDL) were assessed. The hepatic mRNA expression of components of the UPR was measured by semi-quantitative real-time polymerase chain reaction. Glucose regulated protein (GRP) 78 protein expression was assessed by immunohistochemistry.

RESULTS

The expression of GRP78 mRNA and growth arrest and damage inducible protein 34 (GADD34) mRNA was significantly lower in subjects with HCV than NDL (P = 0.007 and P < 0.001, respectively). There was no significant difference in the expression of GRP94 mRNA, spliced X box binding protein 1 (sXBP1) mRNA, C/EBP homologous protein mRNA (CHOP) and ER degradation enhancing α-mannosidase-like protein (EDEM) mRNA and GRP78 protein between patients with HCV and NDL. There were no relationships between elements of the UPR and inflammation or fibrosis in patients with HCV.

CONCLUSION

Downstream components of UPR were not activated in patients with chronic HCV. Therefore, the UPR may not play a prominent role in liver injury in patients with chronic HCV infection.

Abstract 32: Lynch syndrome-associated breast cancers: Clinicopathological characteristics of a case series from the Colon CFR

Background: Lynch Syndrome is an autosomal dominant condition which predisposes to early-onset cancer of the colorectum, endometrium, and to a lesser extent, stomach, ureter and renal pelvis, ovary, brain and small bowel. It is thought, however, that there is no significant increase in risk of developing breast cancer. The aim of this study was to determine the prevalence and clinicopathological features of breast cancers arising in families with a history of both colorectal and breast malignancy.

Design: 107 cases of breast carcinoma (BC) from 90 families were identified from the Australasian Colorectal Cancer Family Registry. Comprehensive cancer histories were available for all families: 53 (59%) families met the modified Amsterdam criteria, and the remainder had multiple cancers including at least one early onset (&lt;50 years) colorectal cancer per family. A full histology review of the breast cancers was performed by a single pathologist (MC). DNA was extracted from paraffin-embedded tumors. Tumor sections were stained for the four DNA mismatch repair (MMR) proteins MLH1, PMS2, MSH2 and MSH6. A subset of MLH1 negative tumors was assessed for MLH1 promoter methylation using a MethyLight assay. Microsatellite instability (MSI) testing was performed using a panel of 10 markers and PCR was also performed to detect the somatic V600E BRAF mutation. Results were analysed using 2×2 contingency tables and exact probabilities.

Results: Loss of one or more MMR proteins was seen in 18/107 tumors (17%): five cancers showed loss of MLH1 and PMS2, twelve tumors MSH2 and MSH6, and one tumor MSH6 alone. IHC and MSI results were concordant in 85/89 (96%) tumors tested. Invasive MMR-deficient BCs were more likely to be poorly differentiated (p=0.005), steroid hormone receptor negative (p&lt;0.05), have confluent necrosis (p=0.002), have growth in solid sheets (p&lt;0.001) and high mitotic index (p=0.002). Additionally, MMR deficient breast cancers were less likely to have contiguous in situ carcinoma present (p=0.004). No association was seen between MMR status and tumor size, lymphovascular invasion, node status, prominent eosinophilic nucleoli, or tumoral calcification. No somatic BRAF V600E mutation was found.

Conclusion: DNA mismatch repair protein deficiency was identified in 18/107 cases (17%) of breast cancer arising in a familial setting of colorectal and breast carcinoma. The MMR-deficient BCs were more likely to be high grade, steroid hormone receptor negative, have areas of solid growth, confluent necrosis and high mitotic index than MMR-proficient tumors. The study suggests that breast cancer arising in a setting of Lynch syndrome commonly demonstrates evidence of MMR deficiency and that breast cancers may represent a valid tissue option for the detection of MMR deficiency where colorectal or other spectrum tumors are difficult to obtain.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 32.

Improving handwashing in hospitals: a patient education and empowerment program

Each year, about 5% of people admitted to U.S. hospitals (about 2 million people) acquire an infection there. These infections cause nearly 20,000 deaths each year, and cost an estimated $4.5 billion to treat. Handwashing is the single most effective measure for preventing hospital-acquired infections. Despite widespread knowledge of the importance of handwashing, health care workers wash their hands far less often than is indicated. This Issue Brief describes a novel strategy to improve handwashing among hospital personnel, by involving the people with the most to gain--the patients themselves.

Evaluation of a patient-empowering hand hygiene programme in the UK

Partners in Your Care, a patient education behavioral model for increasing handwashing compliance and empowering the patient with responsibility for their care was evaluated in an acute care hospital in Oxford, UK. A controlled prospective intervention study comparing medical and surgical patients was performed. Ninety-eight patients were eligible for the study. Thirty-nine patients (40%) agreed to participate in the programme Partners in Your Care by asking all healthcare workers who were going to have direct contact with them "Did you wash your hands?" Compliance with the programme was measured through soap/alcohol usage and handwashings per bed day before and after its introduction. Partners in Your Care increased handwashing on average 50%. Healthcare workers washed hands more often with surgical patients than with medical (P< 0.05). Alcohol gel was used on less than 1% of occasions. Sixty-two percent of patients in study felt at ease when asking healthcare workers "Did you wash your hands?" Seventy-eight percent received a positive response (washed hands). All patients asked nurses, but only 35% asked physicians. Partners in Your Care increased handwashing compliance in the UK. This programme empowers patients with responsibility for their care, provides infection control staff with a continuing means for providing handwashing education without additional staff and can save costs for a hospital.

Guidelines in practice: the effect on healing of venous ulcers

OBJECTIVE

To determine the effect of guidelines on vascular assessment, compression usage, dressing selection, and healing rates of patients with a venous ulcer.

DESIGN

Prospective descriptive intervention evaluation.

SETTING

Oxfordshire Community National Health Service (NHS) Trust, United Kingdom.

PATIENTS

40 consecutive prospective patients seen by Oxfordshire district nurses, either at home or at a wound clinic coordinated by district nurses located in a surgery office.

INTERVENTION

The Guideline for Diagnosis and Treatment of Venous Leg Ulcers (University of Pennsylvania) and the Oxfordshire Leg Ulcer Guideline.

MAIN OUTCOME MEASURES

Time to healing, compliance with vascular assessment, compression usage, and nursing costs.

MAIN RESULTS

91% of patients had a vascular assessment; all patients were treated with compression. Mean time to healing was 8 weeks and was not related to dressing selection or type of compression (short- versus long-stretch bandage). Nursing costs were slightly higher for wounds that healed after 12 weeks and were treated with a long-stretch bandage (Pound Sterling 170.00 [$250.00] vs Pound Sterling 272.00 [$395.00]).

CONCLUSION

Use of compression was influenced by guidelines that emphasize a vascular assessment. Choice of dressing or type of compression was not a significant factor in healing rates.

Venous leg ulcers: the role of the GP and district nurse

AIM

To identify the healing rates for patients with venous leg ulcers (VLUs) who are nursed by district nurses.

METHOD

The researchers performed a retrospective chart review of patients treated for VLU disease by district nurses to determine the healing rate, time to heal and variables associated with diagnosis. Forty random charts were abstracted from seven surgeries in Oxfordshire.

RESULTS

Forty per cent of patients healed in less than 12 weeks and a further 42.5 per cent healed in 6.5 months. Some trusts and GPs lack understanding of what the district nursing service can offer patients with VLUs.

CONCLUSION

If district nurses work collaboratively with GPs, either in the home or in a weekly clinic, they can provide good care to patients with VLUs.

Infection and antimicrobial use in laparoscopic cholecystectomy

Retrospective chart review of 1,702 patients undergoing laparoscopic cholecystectomy (LC) revealed an overall infection rate of 2.3% and a surgical-site infection rate of 0.4%. Preoperative antimicrobial prophylaxis was received by 79% of patients, but only 33% of these received the agent within 1 hour or less prior to surgery. These facts suggest that antimicrobial prophylaxis may not be necessary for low-risk LC patients.

Patient education model for increasing handwashing compliance

BACKGROUND

A review of the literature on handwashing has documented the absence of research on the education of the patient as an intervention model for changing staff behavior regarding handwashing compliance. The primary objective of this project was to conduct a prospective control study of the effect of patient handwashing education on staff compliance with handwashing.

METHOD

A prospective, controlled, 6-week intervention/control study was performed in 4 community hospitals in South Jersey. Each hospital served as its own control. Patients were educated within 24 hours of admission about the importance of asking their health care workers to wash their hands. Soap usage and handwashing was calculated by bed-days. Patient follow-up was conducted through telephone interviews 2 weeks after discharge.

RESULTS

The patient handwashing education model increased soap usage by health care workers an average of 34% (P =.021); this increase was consistent across hospitals regardless of the initial soap usage rates. Of the patients interviewed, 81% read the materials provided, 57% asked health care workers whether they had washed their hands, and 81% of this 57% said they received positive responses.

CONCLUSIONS

For the first time, our findings document that education of patients regarding their role in monitoring handwashing compliance among health care workers can increase soap usage and handwashing and provide sustainable reinforcement of handwashing principles for health care workers.

Combined Inhibin and CA125 Assays in the Detection of Ovarian Cancer

Background: The reproductive hormone inhibin has been used as a diagnostic marker of ovarian mucinous and granulosa cell cancers. The aims of this study were to develop a new inhibin immunofluorometric assay (αC IFMA) to replace an inhibin RIA as a diagnostic marker of these ovarian cancers and to assess whether the αC IFMA in combination with CA125, which detects serous cancers, leads to an improved biochemical diagnosis of all ovarian cancers.

Methods: Serum inhibin concentrations were determined in healthy postmenopausal women (n = 165) and women with ovarian cancers (n = 154), using an inhibin RIA and an αC IFMA, which detects inhibin forms containing the αC subunit as well as the free αC subunit.

Results: The αC IFMA gave a similar or better discrimination of mucinous (90% vs 71%) and granulosa cell (100% vs 100%) cancers compared with the inhibin RIA. Combination of CA125 and αC IFMA values by canonical variate analysis or by multiROC analysis showed that the percentage of all ovarian cancers detected was significantly increased compared with either CA125 or αC IFMA alone.

Conclusions: The αC IFMA shows a similar or better specificity compared with the RIA, but with increased sensitivity. In combination with CA125, the αC IFMA provides an effective dual test for the detection of the majority (90%) of ovarian cancers.

Combined inhibin and CA125 assays in the detection of ovarian cancer

BACKGROUND

The reproductive hormone inhibin has been used as a diagnostic marker of ovarian mucinous and granulosa cell cancers. The aims of this study were to develop a new inhibin immunofluorometric assay (alphaC IFMA) to replace an inhibin RIA as a diagnostic marker of these ovarian cancers and to assess whether the alphaC IFMA in combination with CA125, which detects serous cancers, leads to an improved biochemical diagnosis of all ovarian cancers.

METHODS

Serum inhibin concentrations were determined in healthy postmenopausal women (n = 165) and women with ovarian cancers (n = 154), using an inhibin RIA and an alphaC IFMA, which detects inhibin forms containing the alphaC subunit as well as the free alphaC subunit.

RESULTS

The alphaC IFMA gave a similar or better discrimination of mucinous (90% vs 71%) and granulosa cell (100% vs 100%) cancers compared with the inhibin RIA. Combination of CA125 and alphaC IFMA values by canonical variate analysis or by multiROC analysis showed that the percentage of all ovarian cancers detected was significantly increased compared with either CA125 or alphaC IFMA alone.

CONCLUSIONS

The alphaC IFMA shows a similar or better specificity compared with the RIA, but with increased sensitivity. In combination with CA125, the alphaC IFMA provides an effective dual test for the detection of the majority (90%) of ovarian cancers.

Handwashing education practices: a descriptive survey

Hand washing is the single most important function in preventing the spread of infection. However, compliance by healthcare workers still remains under 50%. Intensive observational and interventional programs have been shown to increase compliance, but the increase in compliance is short-term. Therefore, in April 1998, we conducted a random survey of 500 members of the Association for Practitioners in Infection Control and the Society for Healthcare Epidemiology of America to determine the didactic educational practices (in-service lectures) of practitioners with regard to hand washing. Response rate was 18% (n = 90). Eighty-eight percent (73) conducted new employee orientation, 64% (73) conducted yearly in-service, whereas monthly, quarterly, and semiannual in-service were 11% (9), 11% (9), and 14% (12), respectively. Thirty-nine percent (35) of our respondents rated their compliance to hand washing as > 50%; 31% (19), < 50%; and, 39% (33) did not know. Only 5% (4) of our respondents determined the outcome measures and cost-effectiveness of their present handwashing program. Our survey had identified the lack of ongoing education for the healthcare worker about handwashing compliance. Continuous reinforcement through monthly in-service is labor-intensive and costly. An alternative model using the patient as ongoing reinforcement may be a solution for increasing compliance.

Venous leg ulcers and the family physician

Family physicians often are the first contact for patients with venous leg ulcerations (VLUs). A random survey of 2,000 family physicians was conducted to determine patterns for diagnosis and treatment of VLUs, including type of leg ulcer (arterial, venous, diabetic), whether compression therapy was ordered, whether a Doppler system was available to aide in diagnosis, and which health care professional ultimately cared for the patient. Of the 325 family physicians who participated, 96% (311/325) see patients with VLUs, averaging 1.5 VLUs per week. Compression therapy is prescribed by 96% of family physicians, and 83% (259/325) refer these patients to other health care professionals. Only 27% (89/325) have a Doppler system in the office to measure the ankle-brachial index (ABI). These findings document for the first time in the United States the large number of patients with VLUs seen by family physicians.

Indications for and outcomes of cholecystectomy: a comparison of the pre and postlaparoscopic eras

PURPOSE

Examine changing patient characteristics and surgical outcomes for patients undergoing cholecystectomy at five community hospitals in 1989 and 1993.

PROCEDURES

In a retrospective chart review, data were gathered regarding gallstone disease severity, type of admission, patient age, number of comorbidities, American Society of Anesthesiologists (ASA) Physical Status Classification, length of stay, and multiple outcomes of surgery.

MAIN FINDINGS

The volume of nonincidental cholecystectomies increased 26%, from 1611 in 1989 to 2031 in 1993. Nearly all of the increase occurred among patients with uncomplicated cholelithiasis and with elective admissions. In 1993, lengths of stay were significantly shorter and percentages of complications were significantly lower for infectious, cardiac, pulmonary, and gastrointestinal complications when controlling for patient case-mix characteristics. There were more major intraoperative complications (unintended wounds or injuries to the common bile duct, bowel, blood vessel(s), or other organs) in 1993.

CONCLUSIONS

Different types of patients underwent cholecystectomy in 1993 compared with patients in 1989, which supports the hypothesis of changing thresholds. Statements supporting the safety of cholecystectomy in the laparoscopic era were borne out when controlling for differences in patient characteristics.

The road to developing standards for the diagnosis and treatment of venous leg ulcers

In early 1996 the Venous Leg Ulcer Guideline was developed for the diagnosis and treatment of venous leg ulcers. In order to discuss the development of standards in general, and the Venous Leg Ulcer Guideline in particular, we first need to understand the difference between the following terms: Critical pathway, consensus statement, guideline, and standard. There are advantages and disadvantages to the use of guidelines. In the development of a guideline, endorsement by a respected colleague is important. Development of the Venous Leg Ulcer Guideline began with a consensus statement and then underwent review by a national advisory panel and national peer review through publication. A revised guideline has now been developed which will be tested in a pilot study for clinical efficacy, effect on cost, and impact on quality of life. Validation will require implementation in a prospective clinical trial. Diagnostic and Treatment Algorithm forms for the diagnosis and treatment of venous leg ulcers were developed as part of the preliminary testing of the guideline. Although guidelines do not substitute for good clinical judgement, they can encourage clinical judgement and help reduce fragmented care and the costs associated with inappropriate treatments.

Occlusive dressings: a microbiologic and clinical review

This review discusses the microbiology of normal skin and wounds and examines the rates of infection reported under both conventional (nonocclusive) dressings and all occlusive dressings, together with cost factors. The overall infection rate under conventional dressings was 7.1% in 1085 wounds, whereas under occlusive dressings on 3047 wounds the rate was 2.6%. In studies in which the two dressing types were directly compared, the respective rates were 7.6% and 3.2%. The reasons for this difference may include both dressing-specific and host-specific factors, and these factors are discussed.

Elements of an effective infection control program

In summary, the future direction of infection control in nursing homes was best stated by Eickhoff in 1978 when he said that failure to accept responsibility in hospital epidemiology will result in the loss of the opportunity to make the discipline "more scientific and to differentiate more clearly between sense and nonsense in hospital infection control." Today, ten years later, the various members of the health care team need to assume the same responsibilities in the nursing home setting, working together to advance the scientific basis of infection control and, in turn, to safeguard and improve the health of residents in long-term care institutions.

Increasing handwashing compliance with more accessible sinks

The frequency of handwashing in two intensive care units (ICUs) was observed. Handwashing after direct contact with patients or their support equipment was recorded. The ratio of beds to sinks was 1:1 in the medical ICU and 4:1 in the surgical ICU. Surveillance of physicians, nurses, and other personnel demonstrated a greater frequency of handwashing by nurses (63%) compared with physicians (19%) and other personnel (25%). The nurses in the unit with one sink per bed had a significantly greater number of handwashes (76%) than those in the unit with fewer sinks (51%).

Duration of handwashing in intensive care units: A descriptive study

The duration of handwashing was studied in two community hospitals (teaching and nonteaching). The duration in seconds of 180 handwashes by health care personnel and 52 handwashes by non-health care personnel were recorded. The mean duration for health care personnel was 8.62 +/- 0.29 SEM; the degree of patient contact did not influence the duration of handwashing. The duration of handwashing was two times longer in health care personnel vs. non-health care personnel (8.62 +/- 0.29 vs. 4.14 +/- 0.42; t = 7.7; p less than 0.001). Comparisons revealed no statistically significant difference in duration between personnel at teaching and nonteaching hospitals or among those in different occupations. The data indicate that the duration of handwashing among health care personnel is below the standard recommended by authorities in hospital infection control. This may be an important factor in the transmission and persistence of nosocomial infection in critical care units. The antimicrobial efficacy of handwashing agents should be reevaluated considering the actual duration of handwashing by health care personnel within the hospital environment or efforts should be made to increase the duration of handwashing.

Airborne contamination of fine-particle nebulizers

To determine whether bacteria present in ambient air play a role in the contamination of fine-particle reservoir nebulizers, nebulizers were placed in operation in separate hospital locations having qualitatively and quantitatively different bacterial flora in background air. Nebulizers placed in a surgical intensive care unit that had higher numbers of bacteria and a predominance of Gram-negative organisms in background air had a significantly higher incidence of nebulizer contamination (33.0%) than did nebulizers placed in a non-patient-care area that had lower bacterial counts and a predominance of Gram-positive organisms (0%) (P less than .05). The present study indicates that airborne contamination of fine-particle reservoir nebulizers occurs when bacteria present in ambient air enter the nebulizer during its operation.