Evaluation of daily environmental cleaning and disinfection practices in veterans affairs acute and long-term care facilities: A mixed methods study.

OBJECTIVES: To describe daily environmental cleaning and disinfection practices and their associations with cleaning rates while exploring contextual factors experienced by healthcare workers involved in the cleaning process. METHODS: A convergent mixed methods approach using quantitative observations (ie, direct observation of environmental service staff performing environmental cleaning using a standardized observation form) and qualitative interviews (ie, semistructured interviews of key healthcare workers) across 3 Veterans Affairs acute and long-term care facilities. RESULTS: Between December 2018 and May 2019 a total of sixty-two room observations (N = 3602 surfaces) were conducted. The average observed surface cleaning rate during daily cleaning in patient rooms was 33.6% for all environmental surfaces and 60.0% for high-touch surfaces (HTS). Higher cleaning rates were observed with bathroom surfaces (Odds Ratio OR = 3.23), HTSs (OR = 1.57), and reusable medical equipment (RME) (OR = 1.40). Lower cleaning rates were observed when cleaning semiprivate rooms (OR = 0.71) and rooms in AC (OR = 0.56). In analysis stratified by patient presence (ie, present, or absent) in the room during cleaning, patient absence was associated with higher cleaning rates for HTSs (OR = 1.71). In addition, the odds that bathroom surfaces being cleaned more frequently than bedroom surfaces decreased (OR = 1.97) as well as the odds that private rooms being cleaned more frequently than semi-private rooms also decreased (OR = 0.26; 0.07-0.93). Between January and June 2019 eighteen qualitative interviews were conducted and found key themes (ie, patient presence and semiprivate rooms) as potential barriers to cleaning; this supports findings from the quantitative analysis. CONCLUSION: Overall observed rates of daily cleaning of environmental surfaces in both acute and long-term care was low. Standardized environmental cleaning practices to address known barriers, specifically cleaning practices when patients are present in rooms and semi-private rooms are needed to achieve improvements in cleaning rates.

A study of bone marrow and subcutaneous fatty acid composition in subjects of varying bone mineral density.

Osteoporosis is associated with an increase in marrow fat. Fats, particularly polyunsaturated fats, either in co-cultures or diet, have been shown to significantly influence bone remodeling. Whether the increase in marrow fat seen in osteoporosis is also associated with a change in fatty acid composition is not known. This study was undertaken to investigate the fatty acid composition in subjects of varying bone mineral density (BMD). Samples of marrow fat and subcutaneous fat from 126 subjects (98 females, 34 males, mean age 69.7+/-10.5 years) undergoing orthopedic surgery were analyzed for fatty acid composition by gas chromatography. These results were correlated with BMD assessed by DXA. A total of 22 fatty acids were identified in marrow and subcutaneous fat. Significant differences in fatty acid composition existed between marrow and subcutaneous fat as well as between marrow fat samples obtained from the proximal femur and proximal tibia. Other than cis-7-hexadecenoic acid [C16:1 (n=9)] and docosanoic acid [C22:0], no difference in marrow fatty acid composition was evident between subject groups of varying BMD (normal, low bone mass, and osteoporosis). In conclusion, there exists a wide range of individual fatty acids in marrow fat. Marrow fatty acid composition differs from that of subcutaneous fat and varies between predominantly erythropoetic and fatty marrow sites. Other than cis-7-hexadecenoic acid [C16:1 (n=9)] and docosanoic acid [C22:0], no difference in marrow fatty acid composition was evident between subjects of varying BMD.

In vivo 1H MR spectroscopy of thyroid carcinoma.

To determine if proton magnetic resonance spectroscopy (1H MRS) of thyroid carcinoma is feasible and to determine if 1H MRS spectra of malignant tumors differ from that of normal thyroid tissue. We performed 1H MRS at 1.5 T at echo-times (TE) 136 and 272 ms to examine eight patients with thyroid cancer (primary tumour or nodal metastasis) larger than 1 cm3 in size and five volunteers with normal thyroids. Spectra acquired from six primary tumors (three anaplastic carcinomas, two papillary carcinomas and one follicular carcinoma) and two nodes (two papillary carcinoma metastases) were analyzed in the time-domain using a non-linear least squares fitting algorithm with incorporation of prior knowledge. Choline (3.2 ppm) was identified in all solid carcinomas with a mean choline/creatine of 4.3 at TE 136 ms and 5.4 at TE 272 ms. Ratios for malignant tumors at TE 136 ms ranged from 1.6 in well differentiated follicular carcinoma to 9.4 in anaplastic carcinoma. No choline was detected in normal thyroid tissues. Our results showed that 1H MRS is a feasible technique for the evaluation of malignant thyroid tumors larger than 1 cm3 and that proton spectra of malignant tumors differ from that of normal thyroid tissue.

Primary biliary cirrhosis, primary sclerosing cholangitis, and autoimmune cholangitis.

Primary biliary cirrhosis (PBC), and autoimmune cholangitis are presumed to be autoimmune cholestatic diseases, but the relevant antigens are unknown. Primary biliary cirrhosis is diagnosed by a positive serum mitochondrial antibody test. It usually affects women and has a very long course, culminating in liver transplantation or death. Ursodeoxycholic acid is probably the appropriate treatment. Primary sclerosing cholangitis (PSC) is marked by progressive destruction of extrahepatic and intrahepatic bile ducts. There is no specific diagnostic test or treatment. Cholangiocarcinoma is the dreaded complication and precludes liver transplantation, the only chance of a cure. Autoimmune cholangitis overlaps PBC and autoimmune chronic hepatitis. It is a rare condition, resembling PBC but with a negative serum mitochondrial antibody test; however, serum antinuclear antibodies and smooth muscle antibodies are present in high titers.

Biotechnologies and liver diseases.

Viral hepatitis is surveyed as a European problem. The economic implications of including vaccines against hepatitis A and B in infant and adolescent immunisation programmes are discussed. The urgent need for vaccine against hepatitis C is stressed. Antiviral therapy for hepatitis B and C infections remains unsatisfactory. Costs of widespread implementation, particularly for hepatitis C, would be enormous and the selection of candidates for therapy is still under discussion. Increasing use of liver transplantation is prevented by donor shortage. Methods of artificial liver support must attract more research support.

The hepatic flaviviridae: summary.

Hepatitis C envelope proteins (E1, E2) induce protective neutralizing antibodies. The extent of sequence diversity reflects the host's ability to control viral populations and the response to antiviral therapy. Attempts to prepare effective vaccines against HCV are foiled by lack of prolonged protective immunity. Plasmid vaccines and the use of uninfectious virus-like particles are being developed. HCV induces a cellular humoral immune response, but this is inadequate to clear the virus and the disease becomes chronic. In any patient, the natural history of HCV infection depends on the age when infected, and the presence of other diseases. The transfusion-related disease has a worse prognosis than that transmitted by syringes and needles. The outlook in 'healthy blood donors' is uncertain. Interferon therapy for 3 or preferably 6 months results in a sustained response in about 30% of patients. Negative serum HCV RNA and normal AST values after 3 months of therapy indicates that there may be a sustained response. Whether or not to stop treatment at that time if HCV is still positive remains a matter of debate. The role of interferon treatment in preventing progression to cirrhosis and hepatocellular cancer is still uncertain. Ribavirin therapy alone reduces transaminases and hepatic histology improves. Improved results follow the combination of ribavirin with interferon. Ribavirin may have immuno-modularity and anti-inflammatory actions. Hepatitis G virus (HGV) is unlikely to play a significant role in liver disease in man.

Ludwig Symposium on biliary disorders. Autoimmune cholangitis: a unique entity?

Overlap syndromes between cholestatic autoimmune chronic hepatitis and primary biliary cirrhosis are being increasingly discussed. The diagnosis depends particularly on the pattern of serum autoantibodies, whether suggestive of one condition or the other. The autoantibodies have an important diagnostic role, but their contribution in mediating bile duct and hepatocellular injury is uncertain. In this report, five patients (three women and two men) are described with hepatic histologic features resembling primary biliary cirrhosis but with negative results for serum antimitochondrial antibody (M2) tests. Serum antinuclear antibody of diffuse type is strongly positive. The serum transaminase levels are 4 to 6 times the upper limit of normal, and serum gamma-glutamyl transpeptidase values are substantially increased. The response to prednisolone therapy is partial: inflammation is reduced, but the serum gamma-glutamyl transpeptidase level remains high and bile duct lesions persist. This condition, which is an overlap between primary biliary cirrhosis and autoimmune hepatitis, has been termed "autoimmune cholangitis." Treatment with ursodeoxycholic acid is recommended, and prednisolone therapy may be considered even though beneficial results have not been impressive.

Carbon dioxide embolism following diagnostic hysteroscopy.

A 50-year-old woman ASA 2 underwent carbon dioxide hysteroscopy under general anaesthesia. Monitoring showed a sudden and rapid fall in end-tidal carbon dioxide followed by oxygen desaturation. She became pulseless and cyanosed. Resuscitation with oxygen, intravenous adrenaline and head-down tilt restored her to haemodynamic stability. Hyperbaric therapy was also administered as air embolism could not be excluded.

Focal nodular hyperplasia in a young female.

A 41-year-old woman, who was taking oral contraceptive drugs, presented with a symptomless hepatic mass lesion shown by abdominal ultrasound. Doppler ultrasound, computed tomography (unenhanced and enhanced with contrast) and magnetic resonance imaging after intravenous gadolinium suggested this was focal nodular hyperplasia. Ultrasound-guided liver biopsy had been performed elsewhere and was also diagnostic. The differential diagnosis of hepatic mass lesion is illustrated and particularly the distinction of focal nodular hyperplasia from adenoma. The importance of radiological imaging techniques is stressed. Clinical management is discussed.

Overview of chronic cholestatic conditions in adults: terminology and definitions.

The cholangiopathies represent diseases and syndromes affecting the biliary system at any site between the canals of Hering and the ampulla of Vater. Hepato-canalicular cholestasis reflects biliary secretory failure of the hepatocyte caused by disturbances of intracellular organelles or damage to the bile canalicular excretory functions. Drug reactions are related especially to antibiotics, phenothiazine derivates and carbamazepine. Immune-mediated cholangiopathies cause destruction and reduction of interlobular bile ducts, and are sometimes called vanishing bile duct diseases. They include primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune cholangitis, chronic hepatic allograft rejection, graft-versus-host disease and chronic cholestatic sarcoidosis. Ischemic (vascular) cholangiopathies include traumatic, hepatic arteritis and mechanical causes. Infectious cholangiopathies usually are associated with the immunosuppressed patient.

Hepatitis C virus: a historical perspective.

Identification and diagnosis of the infecting agent responsible for hepatitis C have only recently occurred. Recognition of an infecting agent distinct from that resulting in hepatitis A or B was made approximately 50 years ago. However, the ability to screen and detect this agent was possible only after molecular biology studies which led to the cloning of parts of the hepatitis C virus (HCV) and the development of a diagnostic antibody test reported by Michael Houghton and colleagues in 1989. The discovery and cloning of HCV has led to a greater understanding of its relationship to acute and chronic hepatitis, cirrhosis, primary liver cancer, and extrahepatic conditions including essential cryoglobulinemia, glomerulonephritis, and serum autoantibody positivity. New antibody tests and quantitation of HCV-RNA have allowed better diagnosis of infectivity and monitoring of treatment effects. HCV genotypes are being related to the natural history of the disease and the effects of treatment. Research continues on HCV hepatitis and other newly identified viral hepatitis agents.

VI International Symposium on Viral Hepatitis: summary.

The VI International Symposium on Viral Hepatitis was held in Madrid, Spain, 3-5 February 1994, under the chairmanship of Dr Vicente Carreño. Over 800 attended from more than 30 countries. Considerable advances have been made since the fifth conference, which was held in 1992. These relate particularly to the role of hepatitis B virus (HBV) mutants and hepatitis C virus (HCV) genotypes and the prolonged assessment of interferon and its side-effects. The role of newer antiviral drugs alone or in combination was stressed. Emphasis was on assessment by serum markers of the actual virus, HBV-DNA and HCV-RNA, rather than by nonspecific serum transaminase estimations.

Antiviral therapy for chronic hepatitis C viral infection.

Hepatitis C affects at least 200 million people worldwide. It can be followed by chronic hepatitis, cirrhosis, and primary liver cancer. Outcome assessments in controlled trials of antiviral therapy are based on serum transaminase values, serum HCV-RNA determinations, and liver biopsy scores. Patients most likely to respond to antiviral treatment are relatively young, have low serum HCV-RNA and transaminase levels, and do not have cirrhosis. Patients whose disease is caused by genotype 1b HCV isolates are unlikely to respond. Interferon alfa (3 million units [MU] three times a week for 6 months) is associated with a 50% response rate and a 50% relapse rate--an overall response rate of 25%. Increasing the duration of therapy may increase the sustained response rate. Ribavirin, given orally, may be used for patients who fail to respond to or relapse after interferon therapy. Its side effects are few. Treatment results in a fall in transaminase levels and some decrease in hepatic inflammation, but serum HCV RNA (viral titer) is unaltered. Combinations of interferon with ribavirin are giving promising results with increased sustained, complete responses.