Disinfection of vascular catheter connectors that are protected by antiseptic caps is unnecessary.

OBJECTIVE: Determination of whether vascular catheter disinfecting antiseptic-containing caps alone are effective at decreasing microbial colonization of connectors compared to antiseptic-containing caps plus a 5-second alcohol manual disinfection. SETTING: The study was conducted in a 718-bed, tertiary-care, academic hospital. PATIENTS: A convenience sample of adult patients across intensive care units and acute care wards with peripheral and central venous catheters covered with antiseptic-containing caps. METHODS: Quality improvement study completed over 5 days. The standard-of-care group consisted of catheter connectors with antiseptic-containing caps cleaned with a 5-second alcohol wipe scrub prior to culture. The comparison group consisted of catheter connectors with antiseptic-containing caps without a 5-second alcohol wipe scrub prior to culture. The connectors were pressed directly onto blood agar plates and incubated. Plates were assessed for growth after 48-72 hours. RESULTS: In total, 356 catheter connectors were cultured: 165 in the standard-of-care group, 165 in the comparison group, and 26 catheters connectors without an antiseptic-containing cap, which were designated as controls. Overall, 18 catheter connectors (5.06%) yielded microbial growth. Of the 18 connectors with microbial growth, 2 (1.21%) were from the comparison group, 1 (0.61%) was from the standard-of-care group, and 15 were controls without an antiseptic-containing cap. CONCLUSIONS: Bacterial colonization rates were similar between the catheter connectors cultured with antiseptic-containing caps alone and catheter connectors with antiseptic-containing caps cultured after a 5-second scrub with alcohol. This finding suggests that the use of antiseptic-containing caps precludes the need for additional disinfection.

Microbial colonization of intravascular catheter connectors in hospitalized patients.

BACKGROUND: Central line-associated bloodstream infections may be due to catheter connector colonization and intraluminal migration of pathogens. We assessed the colonization of the split septum catheter connector system, and subsequently the luer lock catheter connector system. METHODS: This was a prospective, 2 phase, quality improvement study at a tertiary referral center. Each phase of the study was performed over 3 consecutive days in hospitalized patients receiving an active infusion; first with a split septum lever lock connector and second with a luer lock connector and alcohol port protector. The connectors were inoculated onto blood agar plates and incubated. Plates were assessed for microbial growth after 48-72 hours. RESULTS: In phase I, 98 (41.9%) of 234 split septum connectors yielded microbial growth. In phase II, 56 (23.1%) of 243 luer lock connectors yielded microbial growth. In phase II only, there was a significant increased rate of contamination in peripheral catheters compared with all other catheters, and the rate of contamination on the acute care wards was significantly higher when compared with the intensive care units. CONCLUSIONS: Bacterial colonization of the lever lock system was unacceptably high among all catheter types and hospital locations. Transition to luer lock catheter connectors and alcohol port protectors decreased the colonization; however, colonization still remained substantial. Causation of colonization cannot be determined with these results.

Reduction in Blood Culture Contamination Through Use of Initial Specimen Diversion Device.

BACKGROUND: Blood culture contamination is a clinically significant problem that results in patient harm and excess cost. METHODS: In a prospective, controlled trial at an academic center Emergency Department, a device that diverts and sequesters the initial 1.5-2 mL portion of blood (which presumably carries contaminating skin cells and microbes) was tested against standard phlebotomy procedures in patients requiring blood cultures due to clinical suspicion of serious infection. RESULTS: In sum, 971 subjects granted informed consent and were enrolled resulting in 904 nonduplicative subjects with 1808 blood cultures. Blood culture contamination was significantly reduced through use of the initial specimen diversion device™ (ISDD) compared to standard procedure: (2/904 [0.22%] ISDD vs 16/904 [1.78%] standard practice, P = .001). Sensitivity was not compromised: true bacteremia was noted in 65/904 (7.2%) ISDD vs 69/904 (7.6%) standard procedure, P = .41. No needlestick injuries or potential bloodborne pathogen exposures were reported. The monthly rate of blood culture contamination for all nurse-drawn and phlebotomist-drawn blood cultures was modeled using Poisson regression to compare the 12-month intervention period to the 6 month before and after periods. Phlebotomists (used the ISDD) experienced a significant decrease in blood culture contamination while the nurses (did not use the ISDD) did not. In sum, 73% of phlebotomists completed a post-study anonymous survey and widespread user satisfaction was noted. CONCLUSIONS: Use of the ISDD was associated with a significant decrease in blood culture contamination in patients undergoing blood cultures in an Emergency Department setting. CLINICAL TRIALS REGISTRATION: NCT02102087.

Optimum outlier model for potential improvement of environmental cleaning and disinfection.

The effectiveness and efficiency of 17 housekeepers in terminal cleaning 292 hospital rooms was evaluated through adenosine triphosphate detection. A subgroup of housekeepers was identified who were significantly more effective and efficient than their coworkers. These optimum outliers may be used in performance improvement to optimize environmental cleaning.

Impact of adenosine triphosphate detection and feedback on hospital room cleaning.

OBJECTIVE: To assess the effect of adenosine triphosphate (ATP) device measurement of hospital room cleaning and feedback of pooled results to environmental service workers (EVS) to improve cleaning efficacy. DESIGN: Nonrandomized controlled trial conducted over 20 months. SETTING: Three hospitals of varying size. PARTICIPANTS: EVS workers, randomly selected on the basis of convenience sample of rooms. INTERVENTIONS: Environmental cleanliness composite scores were combined with layered educational interventions and used to provide feedback to EVS workers on specific hospital units. Trends in cleaning efficacy were observed after the interventions. RESULTS: Cleaning efficacy improved significantly with each intervention (P < .01) and decreased during the washout period. CONCLUSIONS: The ATP detection device combined with educational feedback for EVS workers resulted in significant improvement in cleaning efficacy of the hospital room environment.

Effect of hospital-wide chlorhexidine patient bathing on healthcare-associated infections.

BACKGROUND: Chlorhexidine gluconate (CHG) bathing has been used primarily in critical care to prevent central line-associated bloodstream infections and infections due to multidrug-resistant organisms. The objective was to determine the effect of hospital-wide CHG patient bathing on healthcare-associated infections (HAIs). DESIGN: Quasi-experimental, staged, dose-escalation study for 19 months followed by a 4-month washout period, in 3 cohorts. SETTING: Academic medical center. PATIENTS: All patients except neonates and infants. INTERVENTION AND MEASUREMENTS: CHG bathing in the form of bed basin baths or showers administered 3 days per week or daily. CHG bathing compliance was monitored, and the rate of HAIs was measured. RESULTS: Over 188,859 patient-days, 68,302 CHG baths were administered. Adherence to CHG bathing in the adult critical care units (90%) was better than that observed in other units (57.7%, [Formula: see text]). A significant decrease in infections due to Clostridium difficile was observed in all cohorts of patients during the intervention period, followed by a significant rise during the washout period. For all cohorts, the relative risk of C. difficile infection compared to baseline was 0.71 (95% confidence interval [CI], 0.57-0.89; [Formula: see text]) for 3-days-per-week CHG bathing and 0.41 (95% CI, 0.29-0.59; [Formula: see text]) for daily CHG bathing. During the washout period, the relative risk of infection was 1.85 (95% CI, 1.38-2.53; [Formula: see text]), compared to that with daily CHG bathing. A consistent effect of CHG bathing on other HAIs was not observed. No adverse events related to CHG bathing were reported. CONCLUSIONS: CHG bathing was well tolerated and was associated with a significant decrease in C. difficile infections in hospitalized patients.

Adequate disinfection of a split-septum needleless intravascular connector with a 5-second alcohol scrub.

OBJECTIVE: Define optimum vascular catheter connector valve disinfection practices under laboratory and clinical conditions. DESIGN: Prospective observational clinical survey and laboratory assessment of disinfection procedures. SETTING: All adult inpatients at an academic healthcare center. METHODS: In the clinical setting, contamination of needleless connectors was assessed in 6 weekly prevalence surveys in which the connector valves from central venous catheters (CVCs) in situ were cultured by pressing the connector diaphragm to an agar plate. Before culture, valves were disinfected by scrubbing the diaphragm with a 70% isopropyl alcohol pledget for 0, 5, 10, 15, or 30 seconds. In the laboratory, the diaphragms on 150 unused sterile connector valves were inoculated with 10(3), 10(5), or 10(8) colony-forming units of Staphylococcus epidermidis and allowed to dry. After disinfection of the diaphragms by scrubbing with a 70% isopropyl alcohol pledget for 0, 5, 10, 15, or 30 seconds, the valves were sampled by pressing the diaphragm to an agar plate. RESULTS: In the clinical setting, 363 connector valves from patients with CVCs were sampled, and 66.7% of nondisinfected valves revealed bacterial contamination. After 5-second disinfection with an alcohol pledget, only 1 (1.4%) of 71 yielded microbial growth (P < .005). In the laboratory, at the 10(3) and 10(5) inoculum, all connector valves yielded sterile cultures when scrubbed for 5 or more seconds (P < .001). At the 10(8) inoculum, 2 (20%) of 10 connector valves yielded minimal growth of S. epidermidis. CONCLUSIONS: A 5-second scrub with a 70% isopropyl alcohol pledget yields adequate disinfection of a split-septum intravascular catheter connector valve under clinical and laboratory conditions.

A state observer for the Virgo inverted pendulum.

We report an application of Kalman filtering to the inverted pendulum (IP) of the Virgo gravitational wave interferometer. Using subspace method system identification techniques, we calculated a linear mechanical model of Virgo IP from experimental transfer functions. We then developed a Kalman filter, based on the obtained state space representation, that estimates from open loop time domain data, the state variables of the system. This allows the observation (and eventually control) of every resonance mode of the IP mechanical structure independently.

Fetal demise secondary to massive rhabdomyoma in the early second trimester of pregnancy.

Rhabdomyoma is the most common cardiac tumor in fetuses, often associated with tuberous sclerosis complex and usually diagnosed in the third trimester of pregnancy, with a benign course in the majority of cases. The hemodynamic impact of cardiac tumor depends on the location and size of the mass and the presence of dysrhythmia (4). Fetal cardiac rhabdomyoma accounts for less than 10% of fetal demise cases (1). This report presents a case of massive cardiac rhabdomyoma filling the entire right heart with pericardial extension, leading to hydrops and subsequent fetal death in the early second trimester of pregnancy.

In-vacuum Faraday isolation remote tuning.

In-vacuum Faraday isolators (FIs) are used in gravitational wave interferometers to prevent the disturbance caused by light reflected back to the input port from the interferometer itself. The efficiency of the optical isolation is becoming more critical with the increase of laser input power. An in-vacuum FI, used in a gravitational wave experiment (Virgo), has a 20 mm clear aperture and is illuminated by an almost 20 W incoming beam, having a diameter of about 5 mm. When going in vacuum at 10(-6) mbar, a degradation of the isolation exceeding 10 dB was observed. A remotely controlled system using a motorized lambda=2 waveplate inserted between the first polarizer and the Faraday rotator has proven its capability to restore the optical isolation to a value close to the one set up in air.

In-vacuum optical isolation changes by heating in a Faraday isolator.

We describe a model evaluating changes in the optical isolation of a Faraday isolator when passing from air to vacuum in terms of different thermal effects in the crystal. The changes are particularly significant in the crystal thermal lensing (refraction index and thermal expansion) and in its Verdet constant and can be ascribed to the less efficient convection cooling of the magneto-optic crystal of the Faraday isolator. An isolation decrease by a factor of 10 is experimentally observed in a Faraday isolator that is used in a gravitational wave experiment (Virgo) with a 10 W input laser when going from air to vacuum. A finite element model simulation reproduces with a great accuracy the experimental data measured on Virgo and on a test bench. A first set of measurements of the thermal lensing has been used to characterize the losses of the crystal, which depend on the sample. The isolation factor measured on Virgo confirms the simulation model and the absorption losses of 0.0016 +/- 0.0002/cm for the TGG magneto-optic crystal used in the Faraday isolator.

Primary cutaneous CD30+ T-cell lymphoma responsive to topical imiquimod (Aldara).

CD30+ anaplastic large cell lymphoma is a primary cutaneous lymphoproliferative disorder with a high rate of spontaneous regression (almost 25%). The suggested therapies are radiation, surgery and methotrexate. We describe two patients with nonregressing primary cutaneous CD30+ T-cell lymphoma that was successfully treated with topical imiquimod 5% cream (Aldara, 3M) three times weekly for 6 weeks. In both cases we obtained complete clinical remission, confirmed by histology. No recurrences were observed during the following 8 months. We consider that topical application of an immune response modifier, such as imiquimod, could be a good alternative to other potentially more dangerous or aggressive treatments.

Association between residual thyroid carcinoma and diffuse hepatic uptake of 131I following radioiodine ablation in postoperative total thyroidectomy patients.

In patients with differentiated thyroid cancer (DTC) total or near-total thyroidectomy, postoperative 131I ablation, and thyroid suppression therapy are reported to be associated with fewer recurrences than other treatments. Many patients with DTC after total thyroidectomy and radioablation therapy have diffuse hepatic uptake of radioiodine, and its clinical importance is debated. Some investigators report that diffuse liver uptake correlates with uptake in the thyroid bed or the presence of metastatic thyroid cancer somewhere in the body, whereas others note no such correlation. The purpose of this research was to determine the clinical importance of diffuse hepatic uptake of radioiodine after 131I ablative therapy in patients with DTC. We retrospectively reviewed 141 posttherapy scans done in 118 patients with DTC. Patients had had total thyroidectomy and were hypothyroid when serum thyroglobulin (Tg) levels were obtained, and they were treated with 30 to 200 mCi of 131I. Scans were performed 3 to 21 days after radioablation therapy. Information was collected regarding the patients' age and gender, the interval between the ablation therapy and scan, uptake of radioiodine, serum thyroglobulin level, thyroid-stimulating hormone (TSH) level, thyroglobulin antibodies, TNM classification, mortality, and recurrence. Diffuse liver uptake was classified from 0 to 4 depending on hepatic brightness. Radioiodine scans were done to determine whether there was uptake in the thyroid bed or elsewhere. Statistical analyses included analysis of variance and Kaplan-Meier survival analysis. Diffuse hepatic uptake was observed (grades 1-4) in 96.4% of the patients; thus 3.6% had no hepatic uptake. There was no significant association between liver uptake and the uptake in the thyroid bed, the dose of 131I administered for ablation therapy, thyroglobulin levels, age, stage of the disease, presence of local or distant metastases, recurrence, or survival. Diffuse hepatic uptake was therefore not associated with residual normal thyroid or metastases as suggested by some but not all previous investigators.

Association of piebaldism and neurofibromatosis type 1 in a girl.

We report an 11-year-old girl with both piebaldism and neurofibromatosis type 1 (NF1). The patient had large depigmented patches on her lower limbs and a white forelock since birth. In addition, some café au lait spots were present on her trunk at birth and had increased in number and size during childhood in concomitance with the appearance of axillary and inguinal freckling. Neither neurofibromas nor Lisch nodules were detected and the patient was otherwise healthy. Pedigree analysis revealed inheritance for piebaldism on the paternal side. To our knowledge, the association of piebaldism and NF1 has been described previously in only three patients. Awareness of this rare association is relevant to ensure early diagnosis and adequate follow-up for NF1.

UV mutation signature in tumor suppressor genes involved in skin carcinogenesis in xeroderma pigmentosum patients.

Molecular analysis of p53 and patched (PTCH), two candidate tumor suppressor genes for non-melanocytic skin cancer, was performed in skin tumors from six patients affected by the cancer-prone disease xeroderma pigmentosum (XP). UV-specific p53 mutations were detected at a frequency of 38-50% in all the tumor types analysed, including melanomas. Additional analysis of PTCH mutations in the subset of eight basal call carcinomas (BCC) revealed a very high mutation frequency of this gene (90%) which exceeded that detected in the p53 gene in the same tumors (38%). PTCH mutations were predominantly UV-specific C>T transitions. This mutation pattern is different from that reported in BCC from normal donors where PTCH mutation frequency is 27% and mutations are frequently deletions and insertions. These findings suggest that PTCH mutations represent an earlier event in BCC development than p53 alterations and that the inability of XP patients to repair UV-induced PTCH mutations might significantly contribute to the early and frequent appearance of BCC observed in these patients.

A comparison of recombinant human thyrotropin and thyroid hormone withdrawal for the detection of thyroid remnant or cancer.

Recombinant human TSH has been developed to facilitate monitoring for thyroid carcinoma recurrence or persistence without the attendant morbidity of hypothyroidism seen after thyroid hormone withdrawal. The objectives of this study were to compare the effect of administered recombinant human TSH with thyroid hormone withdrawal on the results of radioiodine whole body scanning (WBS) and serum thyroglobulin (Tg) levels. Two hundred and twenty-nine adult patients with differentiated thyroid cancer requiring radioiodine WBS were studied. Radioiodine WBS and serum Tg measurements were performed after administration of recombinant human TSH and again after thyroid hormone withdrawal in each patient. Radioiodine whole body scans were concordant between the recombinant TSH-stimulated and thyroid hormone withdrawal phases in 195 of 220 (89%) patients. Of the discordant scans, 8 (4%) had superior scans after recombinant human TSH administration, and 17 (8%) had superior scans after thyroid hormone withdrawal (P = 0.108). Based on a serum Tg level of 2 ng/mL or more, thyroid tissue or cancer was detected during thyroid hormone therapy in 22%, after recombinant human TSH stimulation in 52%, and after thyroid hormone withdrawal in 56% of patients with disease or tissue limited to the thyroid bed and in 80%, 100%, and 100% of patients, respectively, with metastatic disease. A combination of radioiodine WBS and serum Tg after recombinant human TSH stimulation detected thyroid tissue or cancer in 93% of patients with disease or tissue limited to the thyroid bed and 100% of patients with metastatic disease. In conclusion, recombinant human TSH administration is a safe and effective means of stimulating radioiodine uptake and serum Tg levels in patients undergoing evaluation for thyroid cancer persistence and recurrence.

Thyroid hormone export in rat FRTL-5 thyroid cells and mouse NIH-3T3 cells is carrier-mediated, verapamil-sensitive, and stereospecific.

Export of L-T3 out of the cell is one factor governing the cellular T3 content and response. We previously observed in liver-derived cells that T3 export was inhibited by verapamil, suggesting that it is due to either ATP-binding cassette/multidrug resistance (MDR1/mdr1b) or multidrug resistance-related (MRP1/mrp1) proteins. To test this hypothesis we measured T3 export in FRTL-5, NIH-3T3, and rat hepatoma (HTC) cells that varied in expression of these proteins. FRTL-5 and NIH-3T3 cells were found to contain a T3 efflux mechanism that is verapamil inhibitable, saturable, and stereospecific. By contrast, T3 efflux in HTC cells was slow and unaffected by verapamil. Neither FRTL-5 nor NIH-3T3 cells express mdrlb, but all three cell types express mrpl, as assessed by immunoblotting. Overexpression of MDR1 in NIH-3T3 cells did not enhance verapamil-inhibitable T3 efflux. Photoaffinity labeling of FRTL-5 and NIH-3T3 cells with [125I]L-T3 revealed a labeled 90- to 100-kDa protein that was not present in HTC cells. Verapamil and excess nonradioactive L-T3, but not D-T3, inhibited labeling of this protein. The lack of correlation between T3 efflux and MDR1 and mrpl expression and the finding of a photoaffinity-labeled putative transport protein smaller than MDR1 or mrp1 protein (approximately 170 kDa) suggest that a novel protein is involved in the transport of T3 out of cells.