Perioperative Infection Transmission: the Role of the Anesthesia Provider in Infection Control and Healthcare-Associated Infections.

PURPOSE OF REVIEW: This review aims to highlight key factors in the perioperative environment that contribute to transmission of infectious pathogens, leading to healthcare-associated infection. This knowledge will provide anesthesia providers the tools to optimize preventive measures, with the goal of improved patient and provider safety. RECENT FINDINGS: Over the past decade, much has been learned about the epidemiology of perioperative pathogen transmission. Patients, providers, and the environment serve as reservoirs of origin that contribute to infection development. Ongoing surveillance of pathogen transmission among these reservoirs is essential to ensure effective perioperative infection prevention. SUMMARY: Recent work has proven the efficacy of a strategic approach for perioperative optimization of hand hygiene, environmental cleaning, patient decolonization, and intravascular catheter design and handling improvement protocols. This work, proven to generate substantial reductions in surgical site infections, can also be applied to aide prevention of SARS-CoV-2 spread in the COVID-19 era.

3D localization of electrophysiology catheters from a single x-ray cone-beam projection.

PURPOSE: X-ray images allow the visualization of percutaneous devices such as catheters in real time but inherently lack depth information. The provision of 3D localization of these devices from cone beam x-ray projections would be advantageous for interventions such as electrophysiology (EP), whereby the operator needs to return a device to the same anatomical locations during the procedure. A method to achieve real-time 3D single view localization (SVL) of an object of known geometry from a single x-ray image is presented. svl exploits the change in the magnification of an object as its distance from the x-ray source is varied. The x-ray projection of an object of interest is compared to a synthetic x-ray projection of a model of said object as its pose is varied. METHODS: svl was tested with a 3 mm spherical marker and an electrophysiology catheter. The effect of x-ray acquisition parameters on svl was investigated. An independent reference localization method was developed to compare results when imaging a catheter translated via a computer controlled three-axes stage. svl was also performed on clinical fluoroscopy image sequences. A commercial navigation system was used in some clinical image sequences for comparison. RESULTS: svl estimates exhibited little change as x-ray acquisition parameters were varied. The reproducibility of catheter position estimates in phantoms denoted by the standard deviations, (σ(x), σ(y), σ(z)) = (0.099 mm, 0.093 mm, 2.2 mm), where x and y are parallel to the detector plane and z is the distance from the x-ray source. Position estimates (x, y, z) exhibited a 4% systematic error (underestimation) when compared to the reference method. The authors demonstrated that EP catheters can be tracked in clinical fluoroscopic images. CONCLUSIONS: It has been shown that EP catheters can be localized in real time in phantoms and clinical images at fluoroscopic exposure rates. Further work is required to characterize performance in clinical images as well as the sensitivity to clinical image quality.

Clinical apparatus for the reduction of dose area product for patients undergoing x-ray catheterization.

PURPOSE: The authors describe a design for prepatient region of interest attenuators (ROIAs) to reduce dose area product (DAP) for clinical use. The authors describe a model to predict DAP values from x-ray technique parameters recorded during a clinical procedure for image sequences obtained in the presence or absence of ROIAs. The model was developed primarily to determine what the DAP to a patient undergoing cardiac catheterization with a ROIA would have been if no ROIA had been used allowing a determination of DAP reduction. METHODS: Copper ROIAs with thicknesses that vary gradually so as not to cause significant image artifacts were constructed. X-ray image sequences were acquired on a clinical catheterization system with and without ROIAs with varying x-ray technique parameters. DAP values were measured for all said exposures using an ionization chamber and compared to a model the authors developed. RESULTS: The model can predict DAP values within 3.5% on average with or without ROIAs when compared to ionization chamber measurements. CONCLUSIONS: The proposed experimental design is adequate for measuring DAP reductions on the order of 1.5-3.5 that are expected when introducing a ROIA during patient catheterization imaging.

Video observation to map hand contact and bacterial transmission in operating rooms.

BACKGROUND: Hand hygiene (HH) is considered a primary intervention to avoid transmission of bacteria in health care settings and to prevent health care-associated infections. Despite efforts to decrease the incidence of health care-associated infections by improving HH, HH compliance rates vary widely depending on the hospital environment. METHODS: We used intraoperative video observation to map temporal patterns of anesthesia provider hand contact with anesthesia work environment (AWE) surfaces and to assess HH compliance. Serial bacterial cultures of high contact objects were subsequently used to characterize bacterial transmission over time. RESULTS: Using World Health Organization criteria, we found a large number of HH opportunities and a low rate of HH compliance by anesthesia providers (mean, 2.9%). We observed an inverse correlation between provider hand hygiene compliance during induction and emergence from anesthesia (3.2% and 4.1%, respectively) and the magnitude of AWE surface contamination (103 and 147 CFU, respectively) at these time points. We found no correlation between frequency of hand contact with the AWE and bacterial contamination. CONCLUSIONS: Compliance with current HH recommendations by anesthesia providers is not feasible. However, there does appear to be a correlation between HH compliance rates and bacterial contamination of the AWE, an observation that should stimulate further work to design new methods for control of bacterial transmission in operating rooms.

Electroded avalanche amorphous selenium (a-Se) photosensor.

Although avalanche amorphous selenium (a-Se) is a very promising photoconductor for a variety of imaging applications, it is currently restricted to applications with electron beam readout in vacuum pick-up tube called a High-gain Avalanche Rushing Photoconductor (HARP). The electron beam readout is compatible with high definition television (HDTV) applications, but for use in solid-state medical imaging devices it should be replaced by an electronic readout with a two-dimensional array of metal pixel electrodes. However, due to the high electric field required for avalanche multiplication, it is a technological challenge to avoid possible dielectric breakdown at the edges, where electric field experiences local enhancement. It has been shown recently that this problem can be overcome by the use of a Resistive Interface Layer (RIL) deposited between a-Se and the metal electrode, however, at that time, at a sacrifice in transport properties.Here we show that optimization of RIL deposition technique allows for electroded avalanche a-Se with transport properties and time performance previously not achievable with any other a-Se structures. We have demonstrated this by detailed analysis of transport properties performed by Time-of-Flight (TOF) technique. Our results showed that a stable gain of 200 is reached at 104 V/µm for a 15-µm thick a-Se layer, which is the maximum theoretical gain for this thickness. We conclude that RIL is an enabling technology for practical implementation of solid-state avalanche a-Se image sensors.

Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling.

BACKGROUND: Device-related bloodstream infections are associated with a significant increase in patient morbidity and mortality in multiple health care settings. Recently, intraoperative bacterial contamination of conventional open-lumen 3-way stopcock sets has been shown to be associated with increased patient mortality. Intraoperative use of disinfectable, needleless closed catheter devices (DNCCs) may reduce the risk of bacterial injection as compared to conventional open-lumen devices due to an intrinsic barrier to bacterial entry associated with valve design and/or the capacity for surface disinfection. However, the relative benefit of DNCC valve design (intrinsic barrier capacity) as compared to surface disinfection in attenuation of bacterial injection in the clinical environment is untested and entirely unknown. The primary aim of the current study was to investigate the relative efficacy of a novel disinfectable stopcock, the Ultraport zero, with and without disinfection in attenuating intraoperative injection of potential bacterial pathogens as compared to a conventional open-lumen stopcock intravascular device. The secondary aims were to identify risk factors for bacterial injection and to estimate the quantity of bacterial organisms injected during catheter handling. METHODS: Four hundred sixty-eight operating room environments were randomized by a computer generated list to 1 of 3 device-injection schemes: (1) injection of the Ultraport zero stopcock with hub disinfection before injection, (2) injection of the Ultraport zero stopcock without prior hub disinfection, and (3) injection of the conventional open-lumen stopcock closed with sterile caps according to usual practice. After induction of general anesthesia, the primary anesthesia provider caring for patients in each operating room environment was asked to perform a series of 5 injections of sterile saline through the assigned device into an ex vivo catheter system. The primary outcome was the incidence of bacterial contamination of the injected fluid column (effluent). Risk factors for effluent contamination were identified in univariate analysis, and a controlled laboratory experiment was used to generate an estimate of the bacterial load injected for contaminated effluent samples. RESULTS: The incidence of effluent bacterial contamination was 0% (0/152) for the Ultraport zero stopcock with hub disinfection before injection, 4% (7/162) for the Ultraport zero stopcock without hub disinfection before injection, and 3.2% (5/154) for the conventional open-lumen stopcock. The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of bacterial injection as compared to the conventional open-lumen stopcock (RR = 8.15 × 10(-8), 95% CI, 3.39 × 10(-8) to 1.96 × 10(-7), P = <0.001), with an absolute risk reduction of 3.2% (95% CI, 0.5% to 7.4%). Provider glove use was a risk factor for effluent contamination (RR = 10.48, 95% CI, 3.16 to 34.80, P < 0.001). The estimated quantity of bacteria injected reached a clinically significant threshold of 50,000 colony-forming units per each injection series. CONCLUSIONS: The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of inadvertent bacterial injection as compared to the conventional open-lumen stopcock. Future studies should examine strategies designed to facilitate health care provider DNCC hub disinfection and proper device handling.

Amorphous and polycrystalline photoconductors for direct conversion flat panel x-ray image sensors.

In the last ten to fifteen years there has been much research in using amorphous and polycrystalline semiconductors as x-ray photoconductors in various x-ray image sensor applications, most notably in flat panel x-ray imagers (FPXIs). We first outline the essential requirements for an ideal large area photoconductor for use in a FPXI, and discuss how some of the current amorphous and polycrystalline semiconductors fulfill these requirements. At present, only stabilized amorphous selenium (doped and alloyed a-Se) has been commercialized, and FPXIs based on a-Se are particularly suitable for mammography, operating at the ideal limit of high detective quantum efficiency (DQE). Further, these FPXIs can also be used in real-time, and have already been used in such applications as tomosynthesis. We discuss some of the important attributes of amorphous and polycrystalline x-ray photoconductors such as their large area deposition ability, charge collection efficiency, x-ray sensitivity, DQE, modulation transfer function (MTF) and the importance of the dark current. We show the importance of charge trapping in limiting not only the sensitivity but also the resolution of these detectors. Limitations on the maximum acceptable dark current and the corresponding charge collection efficiency jointly impose a practical constraint that many photoconductors fail to satisfy. We discuss the case of a-Se in which the dark current was brought down by three orders of magnitude by the use of special blocking layers to satisfy the dark current constraint. There are also a number of polycrystalline photoconductors, HgI(2) and PbO being good examples, that show potential for commercialization in the same way that multilayer stabilized a-Se x-ray photoconductors were developed for commercial applications. We highlight the unique nature of avalanche multiplication in a-Se and how it has led to the development of the commercial HARP video-tube. An all solid state version of the HARP has been recently demonstrated with excellent avalanche gains; the latter is expected to lead to a number of novel imaging device applications that would be quantum noise limited. While passive pixel sensors use one TFT (thin film transistor) as a switch at the pixel, active pixel sensors (APSs) have two or more transistors and provide gain at the pixel level. The advantages of APS based x-ray imagers are also discussed with examples.

Nonlinear multicontrast microscopy of hematoxylin-and-eosin-stained histological sections.

Imaging hematoxylin-and-eosin-stained cancerous histological sections with multicontrast nonlinear excitation fluorescence, second- and third-harmonic generation (THG) microscopy reveals cellular structures with extremely high image contrast. Absorption and fluorescence spectroscopy together with second hyperpolarizability measurements of the dyes shows that strong THG appears due to neutral hemalum aggregation and is subsequently enhanced by interaction with eosin. Additionally, fluorescence lifetime imaging microscopy reveals eosin fluorescence quenching by hemalums, showing better suitability of only eosin staining for fluorescence microscopy. Multicontrast nonlinear microscopy has the potential to differentiate between cancerous and healthy tissue at a single cell level.

Digital radiography using amorphous selenium: photoconductively activated switch (PAS) readout system.

A new amorphous selenium (a-Se) digital radiography detector is introduced. The proposed detector generates a charge image in the a-Se layer in a conventional manner, which is stored on electrode pixels at the surface of the a-Se layer. A novel method, called photoconductively activated switch (PAS), is used to read out the latent x-ray charge image. The PAS readout method uses lateral photoconduction at the a-Se surface which is a revolutionary modification of the bulk photoinduced discharge (PID) methods. The PAS method addresses and eliminates the fundamental weaknesses of the PID methods--long readout times and high readout noise--while maintaining the structural simplicity and high resolution for which PID optical readout systems are noted. The photoconduction properties of the a-Se surface were investigated and the geometrical design for the electrode pixels for a PAS radiography system was determined. This design was implemented in a single pixel PAS evaluation system. The results show that the PAS x-ray induced output charge signal was reproducible and depended linearly on the x-ray exposure in the diagnostic exposure range. Furthermore, the readout was reasonably rapid (10 ms for pixel discharge). The proposed detector allows readout of half a pixel row at a time (odd pixels followed by even pixels), thus permitting the readout of a complete image in 30 s for a 40 cm x 40 cm detector with the potential of reducing that time by using greater readout light intensity. This demonstrates that a-Se based x-ray detectors using photoconductively activated switches could form a basis for a practical integrated digital radiography system.

Joint modelling of repeated measurements and event time: application to performance traits and survival of lambs bred in sub-humid tropics.

We considered the analysis of a study for Dorper, Red Maasai and crossbred lambs born over a period of 6 years at the Diani Estate, Kenya. The study was designed to compare survival and performance traits of genotypes with differing susceptibilities to helminthiasis. The available data include information on time to death and repeated measurements of body weight, packed cell volume (PCV) and faecal egg count (FEC) of the animals. In the paper, we consider joint modelling of the survival time and the repeated measurements. Such an approach allows to account for the possible association between the survival and repeated measurement processes. The advantages and limitations of the joint modelling are discussed and illustrated using the Diani Estate study data.

Subunit vaccine based on the p67 major surface protein of Theileria parva sporozoites reduces severity of infection derived from field tick challenge.

Two recombinant vaccines against Theileriaparva, based on a near full-length version of the sporozoite surface antigen p67 (p67(635)), or an 80 amino acid C-terminal section (p67C), were evaluated by exposure of immunized cattle to natural tick challenge in two sites at the Kenya Coast and one in Central Kenya. Vaccination reduced severe ECF by 47% at the coast and by 52% in central Kenya from an average incidence of 0.53+/-0.07 (S.E.) in 50 non-immunised controls to an average of 0.27+/-0.05 in 83 immunised animals. The reduction in severe East Coast fever was similar to that observed in laboratory experiments with p67(635) and p67C. The p67 coding sequence from thirteen T. parva field isolates including seven from vaccinated cattle that were not protected, was 100% identical to the gene on which the recombinant vaccine is based, suggesting a predominantly homologous p67 antigenic challenge. The same parasite isolates were however genetically heterogeneous at several loci other than p67.

Novel baculovirus-derived p67 subunit vaccines efficacious against East Coast fever in cattle.

Two novel baculovirus-derived recombinant Theileria parva p67 constructs were tested for their vaccine potential against East Coast fever. Boran calves were immunized with a his-GFP-p67 fusion protein (GFP:p67deltaSS) or with GP64:p67C, a protein fusion between a C-terminal domain of p67 and the baculovirus envelope protein GP64. Both GFP:p67deltaSS and GP64:p67C induced antibodies with high ELISA titers that neutralized T. parva sporozoites with high efficiency. Upon challenge, a correlation was observed between the in vitro neutralizing capacity and the reduction in severe ECF for individual animals. A protection level upto 85% was obtained. This level of protection was achieved with only two inoculations of 100 microg per dose, which is a major improvement over previous recombinant p67 products.

Immunity to East Coast fever in cattle induced by a polypeptide fragment of the major surface coat protein of Theileria parva sporozoites.

Full-length recombinant versions of p67, the 709 amino acid major surface protein of Theileria parva sporozoites, induce immunity to East Coast fever (ECF) in cattle. We show that a soluble Escherichia coli recombinant version of p67 (p67(635)), in which a prokaryotic signal peptide replaces the eukaryotic one, confers protection comparable to that induced by the full-length molecule, but is unstable. Peptides encoding 80 (p67C) and 205 (p67N) amino acid fragments of p67, containing epitopes recognised by sporozoite neutralising monoclonal antibodies, exhibit improved stability in E. coli. Antibodies raised against the central region of p67 (p67M) neutralise sporozoite infectivity in vitro. The p67C peptide induced immunity against ECF in cattle, at a level equivalent to p67(635), suggesting that a synthetic peptide vaccine might be achievable.