Finding a benchmark for monitoring hospital cleanliness

This study evaluated three methods for monitoring hospital cleanliness. The aim was to find a benchmark that could indicate risk to patients from a contaminated environment. We performed visual monitoring, ATP bioluminescence and microbiological screening of five clinical surfaces before and after detergent-based cleaning on two wards over a four-week period. Five additional sites that were not featured in the routine domestic specification were also sampled. Measurements from all three methods were integrated and compared in order to choose appropriate levels for routine monitoring. We found that visual assessment did not reflect ATP values nor environmental contamination with microbial flora including Staphylococcus aureus and meticillin-resistant S. aureus (MRSA). There was a relationship between microbial growth categories and the proportion of ATP values exceeding a chosen benchmark but neither reliably predicted the presence of S. aureus or MRSA. ATP values were occasionally diverse. Detergent-based cleaning reduced levels of organic soil by 32% (95% confidence interval: 16-44%; P<0.001) but did not necessarily eliminate indicator staphylococci, some of which survived the cleaning process. An ATP benchmark value of 100 relative light units offered the closest correlation with microbial growth levels <2.5 cfu/cm(2) (receiver operating characteristic ROC curve sensitivity: 57%; specificity: 57%). In conclusion, microbiological and ATP monitoring confirmed environmental contamination, persistence of hospital pathogens and measured the effect on the environment from current cleaning practices. This study has provided provisional benchmarks to assist with future assessment of hospital cleanliness. Further work is required to refine practical sampling strategy and choice of benchmarks.

Intra-operative contrast-enhanced ultrasound improves image enhancement in the evaluation of liver tumors

BACKGROUND

Intra-operative hepatic tumor ultrasound assessment can be difficult in patients with abnormal hepatic parenchyma because of the inability to enhance echogenic differences.

METHODS

Prospective pilot study of intra-operative ultrasound contrast enhancement in the evaluation of liver tumors to establish safety, dosing, and increased image enhancement with ultrasound contrast evaluation. A single bolus of perfluten lipid microspheres was then injected and ultrasound images were then re-recorded and saved.

RESULTS

Twenty consecutive patients underwent contrast-enhanced ultrasound evaluation during the operative procedure. All patients received at least one bolus dose of microspheres (median 2 dose, range 1-3), without change in heart rate, blood pressure, end tidal CO(2), oxygen saturation, and sedation monitoring at the time of dosing and until 4 hr post-bolus doses. Two blinded independent readers found the contrasted images to have a statistically greater degree of enhancement (median improvement of 4, P = 0.01) and greater degree of size/border characteristics in the contrasted images (median improvement of 5, P = 0.01) for all histologies. In five patients, the extent of hepatic resection was altered from partial to complete lobectomy in order to obtain acceptable oncologic margin.

CONCLUSIONS

Contrast-enhanced ultrasound is safe and effective in pre-resection and pre-ablation treatment planning.

The impact of obesity on outcomes following pancreatectomy for malignancy

BACKGROUND

Obesity has previously been shown to correlate with higher stage and decreased survival in pancreatic cancer. The aim of this study was to determine the impact of obesity on operative outcomes, recurrence, and overall survival.

METHODS

A review of our 1345 patient prospective hepatopancreaticobiliary database was performed to identify patients undergoing pancreatic resection from January 1991 to August 2008 for adenocarcinoma. Obesity was defined as a body mass index (BMI) > 30 kg/m(2). Data was analyzed using Wilcoxon, t test, and chi-square methods. Survival was analyzed using log-rank analysis. Postoperative complications were assessed using a 5-point scale. P < .05 was considered significant.

RESULTS

Of 306 patients undergoing pancreatic resection for pancreatic adenocarcinoma examined, 68 were defined as obese. There was no significant difference seen in length of stay, operative time, tumor size, or node status. Obese patients had a higher operative blood loss (median 650 vs. 400 mL, P = .0008). Obese patients were more likely to suffer postoperative complications (67.6% vs. 50.4%, P = .01). There was no significant difference seen in disease-free survival or overall survival (22.1 months for obese vs. 25.6 months for nonobese, P = .5; 19.8 months for obese vs. 23.5 months for nonobese, P = .46).

CONCLUSION

Obese patients had a higher rate and greater severity of postoperative complications, with increased operative blood loss. However, obese patients did not demonstrate any significant difference in specific oncologic factors or survival. These data suggest an equivalent biologic effect of obesity on pancreatic cancer survival.

The use of self-expanding silicone stents in esophagectomy strictures: less cost and more efficiency

BACKGROUND

Benign and postoperative anastomotic esophageal strictures remain a common problem in the management of esophageal diseases and cancer. Repeated dilation remains the most common treatment algorithm. Esophageal stenting with a removable plastic stent is another option. This study evaluated the dysphagia effects and cost of removable silicone stents in the management of benign and postoperative anastomotic strictures compared with standard repeat dilation.

METHODS

A matched case-control study was done of benign esophageal stricture treatments from July 2004 to August 2006 in all patients treated for benign esophageal strictures identified in a prospectively maintained esophageal database. Eighteen patients had a retrievable silicone-covered stent placed, and 24 were treated with standard repeated dilations without stents. Early esophageal stenting vs repeated dilation in esophagectomy strictures and other benign strictures was compared.

RESULTS

The median number of dilatations was two (range, 1 to 3) for the 18 stent patients, with all stents placed for 3 months' duration, and four dilations (range, 2 to 12) in 24 patients treated solely with dilatation. An evaluation of median, high, and low total charges, net revenue, and direct margin demonstrated that the use of a removable stent after one failed dilation was more cost-efficient than repeated dilations.

CONCLUSIONS

In patients who do not respond to initial dilation, placement of removable esophageal stent at the second dilation leads to improved quality of life and dysphagia relief. Early use of a removable esophageal stent is significantly more cost-efficient when two or more esophageal dilations are avoided.

Analysis of 900 appendiceal carcinoid tumors for a proposed predictive staging system

BACKGROUND

Appendiceal carcinoid tumors (ACTs) are rare, and little is known about the long-term prognosis for these tumors because no staging system exists. Therefore, we sought to investigate prognostic factors associated with ACTs and to create a predictive staging system to accurately estimate prognosis.

HYPOTHESIS

In patients with ACTs, TNM staging will accurately predict prognosis.

DESIGN

Retrospective review of 15 983 patients with carcinoid tumors in the Surveillance Epidemiology and End Results (SEER) database from January 1, 1977, to December 31, 2004.

SETTING

SEER database study.

PARTICIPANTS

Nine hundred patients with ACTs (552 females and 348 males; mean age, 47.1 years [age range, 9-89 years]; mean size of the primary tumor, 2.4 cm [range, 0.1-11.5 cm]). Main Outcome Measure Clinicopathologic features in patients with ACTs that affect prognosis using a newly created TNM staging system incorporating these parameters.

RESULTS

Lymph node metastasis was found in 137 patients (24%), and distant metastatic disease in 89 patients (10%). Stage-specific survival was statistically significant between stages (P < .001) but not within stages. At multivariate analysis, patient age, primary tumor size, histologic features, lymph node involvement, and distant metastasis were significant factors predicting survival.

CONCLUSIONS

Our newly developed TNM staging system accurately predicts prognosis in patients with ACTs. A TNM staging system for ACTs will be helpful not only for physician education about factors that affect the outcome with this disease but also to observe trends in prognosis.

The use of dynamic positron emission tomography imaging for evaluating the carcinogenic progression of intestinal metaplasia to esophageal adenocarcinoma

BACKGROUND

In this study, we investigate the use of PET scanning in the carcinogenic progression of reflux esophagitis to Barrett's esophagus to high grade dysplasia to esophageal adenocarcinoma, and correlate the uptake levels of 18F-FDG related to histological changes, and the rates of proliferation and apoptosis.

METHODS

An established esophagoduodenal anastomsis rat model in conjunction with micro-PET scanning at 1 week, 1 month, 3 month, and 6 month after procedure was performed.

RESULTS

Increased uptake levels of 18F-FDG were observed in the esophagi after EDA procedure. The higher level of 18F-FDG uptake within esophageal epithelium was identified in intestinal metaplastic transformation and esophagoduodenal adenocarcinoma by histological examination.

CONCLUSIONS

Dynamic PET scanning represents a powerful tool in analyzing morphological carcinogenic transformation non-invasively in the esophagus. 18F- FDG accumulation was a sensitive marker in reflux esophageal injury carcinogenic progression from intestinal metaplasia to EAC.

Administration of glutamine after hemorrhagic shock restores cellular energy, reduces cell apoptosis and damage, and increases survival

BACKGROUND

Hemorrhagic shock causes a rapid depletion of adenosine triphosphate (ATP) and an increase of the terminal metabolite xanthine. Free radicals generated from xanthine oxidase play a major role in cell injury. Programmed cell death, apoptosis, is a major pathway causing reperfusion injury. During apoptosis, cytosolic cytochrome-c is released from damaged mitochondria, and it further initiates activation of apoptosis as evidenced by the appearance of caspase-3. The bcl-2 protein serves as an antiapoptosis found on the mitochondrial membrane. Glutamine has been known as a conditionally essential nutrient and seems to have beneficial effects in critically ill patients. The hypothesis of the present study is that glutamine administered during resuscitation following hemorrhagic shock would restore the depletion of hepatic ATP, reduce cellular apoptosis, and increase survival.

METHODS

Male Sprague-Dawley rats were randomly assigned to 3 groups for resuscitation after the same pattern of hemorrhagic shock: Ringer's lactate (LR 21 ml/kg); Alanine-glycine (LR with alanine 0.15 gm/kg and glycine 0.18 gm/kg); and glutamine (LR with glutamine 0.3 gm/kg). Hepatic ATP and xanthine was measured at different time periods. Hepatic apoptosis was measured and the levels of cytosolic cytochrome-c, caspase-3 and bcl-2 were analyzed. Another group of rats were used for survival study.

RESULTS

Glutamine administered during resuscitation following hemorrhagic shock partially restored the depletion of hepatic ATP, reduced cellular apoptosis, and increased survival.

CONCLUSIONS

Glutamine administration during resuscitation significantly protected the liver from tissue damage caused by hemorrhagic shock. Glutamine supplementation may offer opportunities for therapeutic intervention during and after shock.

Effect of DHEA on the Hemodynamic Response to Resuscitation in a Porcine Model of Hemorrhagic Shock

BACKGROUND

Hemorrhagic shock is a major cause of death from trauma. Pharmacologic treatment has not been satisfactory. The objective of this study was to use a porcine model of hemorrhagic shock and resuscitation to access the hemodynamic effects of dehydroepiandrosterone (DHEA), an adrenal steroid hormone reported to improve cardiac function in patients.

METHODS

Hemorrhagic shock was produced in 20- to 30-kg male Yorkshire pigs anesthetized with 2% isoflurane by withdrawing blood through a carotid cannula to a mean arterial pressure (MAP) of 40 to 45 mm Hg and maintaining that level for 60 minutes by further removals of blood. Resuscitation was with 21 mL/kg Ringer's lactate (LR), with (n = 6) or without (n = 6) DHEA (4 mg/kg) dissolved in propylene glycol. The animals were killed after 7 days. Continuous cardiac output (CCO) was recorded using a modified Swan-Ganz catheter system. MAP, heart rate (HR), central venous pressure (CVP), and pulmonary arterial pressure (PAP) were measured every 5 minutes until 60 minutes postresuscitation. From MAP, CCO, HR, and CVP, we calculated total peripheral resistance (TPR), stroke volume (SV), and left ventricular stroke work (SW).

RESULTS

The MAP, CCO, SV, and SW decreased significantly during hemorrhagic shock, and then gradually increased to baseline levels during and 1 hour after resuscitation. The TPR was increased during hemorrhagic shock, and then gradually decreased to baseline levels during and after resuscitation. DHEA administration was associated with no significant improvement.

CONCLUSION

DHEA when added to standard fluid resuscitation showed no added benefit as resumed by the hemodynamic response.

Response of Xenopus laevis to cadmium administration

1. Levels of copper, zinc and cadmium have been determined in the plasma, liver and kidneys of Xenopus laevis. 2. Administration of cadmium by subcutaneous injection induces metallothionein synthesis in the liver of Xenopus laevis. Cadmium is found to accumulate in both liver and kidneys following injection. 3. Cadmium uptake, following injection, is biphasic, suggesting a saturable first-phase uptake mechanism, followed by a linear second phase. 4. Zinc is displaced from the liver by administration of cadmium in a dose-dependent manner.

Enteroviral RNA sequences detected by polymerase chain reaction in muscle of patients with postviral fatigue syndrome

OBJECTIVE

To determine the presence of enteroviral sequences in muscle of patients with the postviral fatigue syndrome.

DESIGN

Detection of sequences with the polymerase chain reaction in a well defined group of patients with the syndrome and controls over the same period.

SETTING

Institute of Neurological Sciences, Glasgow.

SUBJECTS

60 consecutive patients admitted to the institute with the postviral fatigue syndrome who had undergone extensive investigation to exclude other conditions. 41 controls from the same catchment area without evidence of fatigue, all undergoing routine surgery.

MAIN OUTCOME MEASURES

Routine investigations, serological screen for antibodies to a range of viruses, and presence of enteroviral RNA sequences in muscle biopsy specimens.

RESULTS

15 (25%) patients and 10 (24.4%) controls had important serological findings. 12 patients had neutralising antibody titres of greater than or equal to 256 to coxsackieviruses B1-5 (six positive for enteroviral RNA sequences, six negative); three were positive for Epstein-Barr virus specific IgM (two positive, one negative). Six controls had similar neutralising antibody titres to coxsackieviruses (all negative); one was positive for Epstein-Barr virus specific IgM (negative); and three had titres of complement fixing antibody greater than or equal to 256 to cytomegalovirus (all negative). Overall, significantly more patients than controls had enteroviral RNA sequences in muscle (32/60, 53% v 6/41, 15%; odds ratio 6.7, 95% confidence interval 2.4 to 18.2). This was not correlated with duration of disease, patient and age, or to raised titres of antibodies to coxsackieviruses B1-5.

CONCLUSIONS

Persistent enteroviral infection of muscle may occur in some patients with postviral fatigue syndrome and may have an aetiological role.

Responses of trout fry (Salmo gairdneri) and Xenopus laevis tadpoles to cadmium and zinc

1. Toxicity of cadmium chloride and zinc sulphate in solution has been determined for Xenopus tadpoles and rainbow trout fry in recirculated water systems. 2. Both animals show approximately equal tolerance of zinc but Xenopus tadpoles tolerate cadmium at approximately 10 times the lethal concentration for trout fry. 3. In the case of Xenopus tadpoles, pre-treatment with sub-lethal concentrations of cadmium or zinc protects against subsequent exposure to either metal. For trout fry, cadmium gives little protection against later exposure to either cadmium or zinc, while zinc gives moderate protection against either metal. 4. Protection is attributed to metallothionein [MT] synthesis.

Injection of the mouse MT-1 gene into rainbow trout eggs and assay of trout fry for resistance to cadmium and zinc toxicity

The mouse MT-1 gene, cloned into the plasmid pBR 322, has been injected into fertilised eggs of the rainbow trout, Salmo gairdneri. About 10(6) copies of the construct, either circular or linearized, have been injected into 1 cell stage eggs within 4 hours of fertilisation, and fry hatched from such eggs are being assayed for evidence of integration of the injected sequence. In addition, with a view to the development of an assay which can be used to monitor for expression of the injected gene, uninjected fry have been exposed to various concentrations of cadmium chloride or zinc sulphate, with or without prior exposure to inducing doses of these compounds. Whereas a distinct protection is evident following induction with zinc, no such protection has been detected with cadmium induction.