Assessment of mould remediation in a healthcare setting following extensive flooding.

BACKGROUND: A new hospital building was close to completion when a large pipe carrying clean water broke, causing extensive flooding. AIM: To determine the flood-associated fungal risk to susceptible patients who would use that building. METHODS: Though standard flood remediation by the builders was relatively straightforward, there was no model for specialist assessment of patient risk due to the flood-associated mould growth. As levels of background airborne fungal spores can be expected to vary significantly over time, we could not use absolute levels to indicate either an excess of airborne fungal spores or successful remediation. Therefore it was decided to use weekly settle plates, exposed at the same time in flooded (test) and equivalent non-flooded (control) areas to compensate for variations in background levels. Flood-related risk was estimated by the ratio between fungal colonies on the test and control sets of settle plates, rather than absolute number. FINDINGS: Whereas the physical flood remediation, including the use of 'anti-fungal' treatments, was completed in three weeks post flooding, fungal contamination in flooded areas took 38 weeks to return to control levels and remained so for a further six weeks of observation. CONCLUSION: By the use of this method, we were able to assure the absence of flood-associated fungal risk to susceptible patients who would use that building. We recommend that infection prevention and control teams consider using this approach should they be faced with similar situations.

Determinants of exposure to endocrine disruptors following hurricane Harvey.

Hurricane Harvey was a category four storm that induced catastrophic flooding in the Houston metropolitan area. Following the hurricane there was increased concern regarding chemical exposures due to damage caused by flood waters and emergency excess emissions from industrial facilities. This study utilized personal passive samplers in the form of silicone wristbands in Houston, TX to both assess chemical exposure to endocrine disrupting chemicals (EDCs) immediately after the hurricane and determine participant characteristics associated with higher concentrations of exposure. Participants from the Houston-3H cohort (n = 172) wore a wristband for seven days and completed a questionnaire to determine various flood-related and demographic variables. Bivariate and multivariate analysis indicated that living in an area with a high Area Deprivation Index (ADI) (indicative of low socioeconomic status), identifying as Black/African American or Latino, and living in the Houston neighborhoods of Baytown and East Houston were associated with increased exposure to EDCs. These results provide evidence of racial/ethnic and socioeconomic injustices in exposure to EDCs in the Houston Metropolitan Area. Since the multiple regression models conducted did not fully explain exposure (0.047 < R2 < 0.34), more research is needed on the direct sources of EDCs within this area to create effective exposure mitigation strategies.

Cardiothoracic ratio may be misleading in the assessment of right- and left-ventricular size in patients with repaired tetralogy of Fallot.

AIM: To assess the relationship between cardiothoracic ratio (CTR) and ventricular and atrial volumes in patients with repaired tetralogy of Fallot (TOF). MATERIALS AND METHODS: Patients with repaired TOF undergoing cardiac magnetic resonance (CMR) and chest radiography within 1 day were included (n = 82; median age: 24.7 years, interquartile range: 21.5-35.9). The CTR was obtained from upright posteroanterior chest roentgenograms. Analyses of CMR images and radiographs were performed in a blinded fashion. RESULTS: There were 35.1% (13/37) of patients with normal CTR (<0.5) who had severe right ventricular (RV) dilatation. There were six patients (13.3%, 6/45) with high CTR with both normal RV and left-ventricular (LV) volumes. CTR did not correlate with either RV or LV volumes but showed a weak correlation with right- and left-atrial volumes (r = 0.43, p = 0.0001; r = 0.27, p = 0.01, respectively). CTR ≥0.5 showed poor ability in the identification of severe RV dilatation (sensitivity: 61.8%, specificity: 50%). The combination of CTR and signs of RV enlargement on lateral radiographs did not improve the diagnostic accuracy of any of those parameters alone. CONCLUSION: CTR in patients with repaired TOF reflected atrial rather than ventricular dilatation. The use of CTR or lateral radiographs in patients with repaired TOF may lead to false conclusions concerning ventricular size.

Assessment of heifer grazing experience on short-term adaptation to pasture and performance as lactating cows.

A 3-yr study evaluated the carryover effects of dairy heifer grazing experience on behavior and first-lactation performance as dairy cows. Forty-one Holstein and 23 Holstein-Jersey crossbred calves born between January and April 2008 were randomly assigned to 1 of 4 treatments (n=8 per group, 2 groups per treatment) in a completely randomized design. Treatments were combinations of managing dairy heifers in confinement (CNF) or on pasture (PST): grazed yr 1 and 2 (PSTPST); grazed yr 1, but confined yr 2 (PSTCNF); confined yr 1 and grazed yr 2 (CNFPST); or confined yr 1 and 2 (CNFCNF). After calving, all heifers on all treatments were grazed as cows in yr 3. In yr 1, PSTPST and PSTCNF heifers were grazed for 41 d on Italian ryegrass pastures, whereas CNFPST and CNFCNF were housed in bedded-pack pens and fed a TMR. In yr 2, PSTPST and CNFPST heifers grazed Italian ryegrass pasture for 65 d, whereas PSTCNF and CNFCNF remained in confinement. In yr 2, a mid-trial assessment of heifer grazing behavior was made on PSTPST versus CNFPST heifers. Grazing activities were assessed by visual observation and heifer movement measured by portable global positioning system units. Heifers from all treatment groups subsequently calved between January and April in yr 3. All primiparous cows were then allocated to pastures by treatment group, grazed for 61 d, (May through July) in yr 3, with grazing behavior and milk production evaluated while grazing. In yr 2, heifers on the PSTPST treatment spent more time grazing than heifers on the CNFPST treatment (78 vs. 35% of the time) when first exposed to pasture (d 1). On d 1 to 3, PSTPST heifers walked a greater distance than CNFPST heifers; however, PSTPST and CNFPST heifers had similar daily grazing times and walking patterns after 3 d of pasture exposure in yr 2. As lactating cows (yr 3), cows with no (CNFCNF) grazing experience grazed less on d 1 compared with cows with (PSTPST, PSTCNF, or CNFPST) grazing experience. Day-1 grazing times in yr 3 were 62, 59, 76, and 13% of the times for cows with PSTPST, PSTCNF, CNFPST, and CNFCNF grazing experience, respectively. In yr 3, on d 1 to 3, cows with previous grazing experience as heifers (PSTPST, CNFPST, and PSTCNF) walked a greater distance than cows without previous grazing experience (CNFCNF). Milk production was lowest on d 1 to 3 for cows with no previous grazing experience (CNFCNF), but average daily milk production was not different overall over the 61 d of study in yr 3. Results indicate that grazing experiences as a heifer can affect behavior and milk production during a cow's first days on pasture. After a short acclimation period, dairy cows without grazing experience as heifers developed similar grazing behaviors and performance as cows with grazing experience as heifers.

Potential gains in lifetime net merit from genomic testing of cows, heifers, and calves on commercial dairy farms.

The objective of this study was to quantify the gains in genetic potential of replacement females that could be achieved by using genomic testing to facilitate selection and culling decisions on commercial dairy farms. Data were simulated for 100 commercial dairy herds, each with 1,850 cows, heifers, and calves. Parameters of the simulation were based on the US Holstein population, and assumed reliabilities of traditional and genomic predictions matched reliabilities of animals that have been genotyped to date. Selection of the top 10, 20, 30, …, 90% of animals within each age group was based on parent averages and predicted transmitting abilities with or without genomic testing of all animals or subsets of animals that had been presorted by traditional predictions. Average gains in lifetime net merit breeding value of selected females due to genomic testing, minus prorated costs of genotyping the animals and their unselected contemporaries, ranged from $28 (top 90% selected) to $259 (top 20% selected) for heifer calves with no pedigrees, $14 (top 90% selected) to $121 (top 10% selected) for heifer calves with known sires, and $7 (top 90% selected) to $87 (top 20% selected) for heifer calves with full pedigrees. In most cases, gains in genetic merit of selected heifer calves far exceeded prorated genotyping costs, and gains were greater for animals with missing or incomplete pedigree information. Gains in genetic merit due to genomic testing were smaller for lactating cows that had phenotypic records, and in many cases, these gains barely exceeded or failed to exceed genotyping costs. Strategies based on selective genotyping of the top, middle, or bottom 50% of animals after presorting by traditional parent averages or predicted transmitting abilities were cost effective, particularly when pedigrees or phenotypes were available and a relatively small proportion of animals were to be selected or culled. Based on these results, it appears that routine genotyping of heifer calves or yearling heifers can be a cost-effective strategy for enhancing the genetic level of replacement females on commercial dairy farms. Increasing the accuracy of predicted breeding values for young females with genomic testing might lead to synergies with other management tools and strategies, such as propagating genetically superior females using advanced reproductive technologies or selling excess females that were generated by the use of sex-enhanced semen.

Developing & using management reports under PPS.

Financial stability through appropriate revenue recognition, steady cash flow, and a well-defined picture of the makeup of an agency's Medicare population comes through the knowledge gained from properly designed management reports.

Clinical and echocardiographic assessment of a right-to-left shunt across an atrial septal defect secondary to tricuspid regurgitation.

OBJECTIVE: Cyanosis in conjunction with atrial septal defect does not necessarily indicate the Eisenmenger syndrome. Exceptionally, the right-to-left shunt may result from tricuspid regurgitant flow and its unusual direction. METHODS: We describe thirteen patients with atrial septal defect and accompanying tricuspid regurgitation. In all of them, the tricuspid regurgitant jet was oriented towards the interatrial septum. This was found on the basis of echocardiographic examination and subsequent frame-by-frame analysis of videotape. RESULTS: Of thirteen patients, cyanosis was observed in 7 (53%). Among those seven, three had moderate pulmonary hypertension (pulmonary artery systolic pressure (PASP) between 40 and 60 mm Hg). The remaining four patients with marked pulmonary hypertension (PASP > 60 mm Hg) underwent cardiac catheterization, which demonstrated low values of pulmonary artery resistance. Except for the one patient with a history of the cerebral embolic event, all were qualified for cardiac surgery. In the postoperative observation they were uneventful and showed clinical recovery and echocardiographic improvement. CONCLUSIONS: Appreciable arterial desaturation and cyanosis in patients with ASD, regarded as uncomplicated, should be followed by careful investigation for the direction of tricuspid regurgitant flow.

[Assessment of myocardial function at infarct zone after PTCA infarct-related artery--a study with tissue Doppler echocardiography]. / Ocena wplywu PTCA tetnicy odpowiedzialnej za zawal na funkcje miesnia sercowego w strefie zawalu metoda tkankowej echokardiografii dopplerowskiej (TDE).

UNLABELLED: Angioplasty of an infarct-related artery (IRA) performed several weeks or months after myocardial infarction (MI) may improve myocardial function. It is still unclear though, how soon wall function is restored following the procedure. This study was designed to assess quantitatively changes of regional left ventricular function after PTCA of IRA by means of tissue Doppler echocardiography (TDE). Thirty nine patients (30 male, mean age 53.4 +/- 8.4 yrs) who had MI 13 +/- 6 weeks earlier were qualified for IRA angioplasty on the basis of dobutamine stress echocardiography (DSE) if a viable myocardium was demonstrated. Regional wall function at infarct zone was assessed by TDE one day before PTCA (exam 1), 1-3 days (exam 2) and 28-30 days (exam 3) after successful angioplasty. Myocardial velocities and time--derived TDE intervals were calculated both in systole (systolic peak velocity--S, pre-ejection period--PEP, contraction time--CT), and diastole (E and A velocity waves, E/A ratio, isovolumic relaxation time--IVRT, rapid filling time--RFT, atrial filling time--AFT). All parameters were measured in longitudinal direction (annulus, basal and medial segments) of posterior (20 pts), anterior (17 pts) and lateral (2 pts) walls. S wave velocity increased between exam 1 and 2 (4.9 +/- 1.2 cm/s vs 5.6 +/- 1.3 cm/s, p < 0.02), whereas E wave decreased between examinations. Pre-PTCA E/A ratio was significantly lower than in exam 2 and 3. PEP decreased between exam 1 and 2 (96 +/- 23 ms vs 84 +/- 16 ms, p < 0.01). Significant correlation was found in IVRT and RFT prior and immediately after PTCA (103 +/- 21 ms vs 87 +/- 20 ms, p < 0.001, 151 +/- 39 ms, vs 170 +/- 30 ms p < 0.01 respectively). CONCLUSIONS: Patients after infarction with persisted viable myocardium may benefit from late angioplasty of IRA. In regional wall function assessment TDE seems to be more sensitive technique than visual wall motion analysis alone. TDE parameters demonstrated a rapid initial improvement. Changes of myocardial velocities (S, E) and time--derived TDE intervals (IVRT, PEP, RFT) are sensitive markers of restored myocardial function.

Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: a consensus panel report. Association for Professionals in Infection Control and Epidemiology and Society for Healthcare Epidemiology of America.

In 1997 the Association for Professionals in Infection Control and Epidemiology and the Society for Healthcare Epidemiology of America established a consensus panel to develop recommendations for optimal infrastructure and essential activities of infection control and epidemiology programs in out-of-hospital settings. The following report represents the Consensus Panel's best assessment of requirements for a healthy and effective out-of-hospital-based infection control and epidemiology program. The recommendations fall into 5 categories: managing critical data and information; developing and recommending policies and procedures; intervening directly to prevent infections; educating and training of health care workers, patients, and nonmedical caregivers; and resources. The Consensus Panel used an evidence-based approach and categorized recommendations according to modifications of the scheme developed by the Clinical Affairs Committee of the Infectious Diseases Society of America and the Centers for Disease Control and Prevention's Healthcare Infection Control Practices Advisory Committee.

Immunological assessment of the distribution of type VII adenylyl cyclase in brain.

The localization of the nine identified isoforms of adenylyl cyclase in brain has been largely based on determination of patterns of mRNA expression. A polyclonal antibody has now been developed that specifically recognizes Type VII adenylyl cyclase. This antibody was used for immunocytochemical analysis of the distribution of Type VII adenylyl cyclase in rat brain. Labeling of Type VII adenylyl cyclase was observed in several areas, including cerebellum, caudate-putamen, nucleus accumbens, hippocampus and cerebral cortex. In some of these areas, the staining of the adenylyl cyclase protein suggested the possibility of presynaptic localization. For example, in situ hybridization showed Type VII adenylyl cyclase mRNA concentrated in cerebellar granule neurons. The cerebellar granule cell layer, however, showed little immunostaining, while punctate immunostaining was observed in the molecular layer. These results suggested that protein synthesized in the granule neurons may be targeted to the neuron terminals. Punctate staining in the caudate-putamen, globus pallidus and nucleus accumbens also suggested the possibility of axonal and/or dendritic localization of Type VII adenylyl cyclase in these regions. Labeling of the soma of cerebellar Purkinje cells, cortical pyramidal and non-pyramidal cells and interneurons in the cerebellum and hippocampus was also observed. Type VII adenylyl cyclase, like the other adenylyl cyclase isoforms, has distinct regulatory characteristics, including sensitivity to stimulation by Gsalpha and G protein betagamma subunits, modulation by protein kinase C, and high sensitivity to stimulation by ethanol. These characteristics, and the discrete localization of this enzyme, may contribute to its ability to provide signal integration and/or control of neurotransmitter release in particular neurons or brain areas.

Pursuing clinical and operational improvement in an academic medical center.

BACKGROUND: An academic medical center in an increasingly competitive market, the University of California-Davis Medical Center in Sacramento started working with a consulting firm in 1995 to reduce overall operational costs and costs for the clinical processes involved in treating patients with specific conditions. ESTABLISHING THE TEAMS: Twelve operational efficiency (OE) teams and five clinical teams were commissioned, with a combined total of nearly one-half of the target cost reduction. The second wave of six clinical teams was simultaneously initiated in late spring 1996. THE IMPROVEMENT METHOD: The quality improvement process for clinical improvement teams included the review and inquiry method, which enables many pilot experiments to be conducted in parallel by work groups and coordinated by the main task team. RESULTS AND CASE STUDIES: Within six weeks of launching, the 12 OE teams achieved their goals and identified savings opportunities of more than $27 million. One OE team, medical records, had set a goal of $514,000 in cost reduction for a three-year period and achieved the first-year goal of $190,000. For a clinical team on interventional cardiology, the clinical benchmark data revealed that the cost per case of providing cardiac catheterization was greater than for all three benchmark groups. These patients, including 270 patients per year, showed a possible savings through process improvement of nearly $1.4 million. From January 1996 through March 1997, the rate of occurrence of complications decreased from 5.5% to 3%. EPILOGUE: Physicians gradually accepted more responsibility and accountability for controlling and reducing costs, while maintaining their traditional role as advocates for improved patient care.

Prospering under PPS. A guide for financial managers.

The survivors of PPS will be those organizations that gain knowledge and control of their true costs, learning how to manage them within the constraints imposed by the new payment system. It is difficult to predict the exact details of PPS legislation; however, several principles of PPS appear to be emerging that will probably be a part of the finished legislative product. Together they provide a framework sufficient to begin the process of analyzing how to prepare for PPS.

Nutrition assessment in long-term care facilities.

Elderly LTCF residents pose a challenging problem in terms of nutrition assessment at all three levels: intake, macronutrient, and micronutrient. In terms of macronutrient status, the focus of this work, newer techniques such as BIA and indirect calorimetry offer the promise of more accurate and widespread assessment in LTCFs. Future work will need to focus on the cost-effectiveness of this approach and on demonstrating that improved nutrition assessment can lead to better nutrition therapy and improved outcome.

Health care network communications infrastructure: an engineering design for the Military Health Service System.

The Military Health Service System (MHSS) provides health care for the Department of Defense (DOD). This system operates on an annual budget of $15 Billion, supports 127 medical treatment facilities (MTFs) and 500 clinics, and provides support to 8.7 million beneficiaries worldwide. To support these facilities and their patients, the MHSS uses more than 125 different networked automated medical systems. These systems rely on a heterogeneous telecommunications infrastructure for data communications. With the support of the Defense Medical Information Management (DMIM) Program Office, our goal was to identify the network requirements for DMIM migration and target systems and design a communications infrastructure to support all systems with an integrated network. This work used tools from Business Process Reengineering (BPR) and applied it to communications infrastructure design for the first time. The methodology and results are applicable to any health care enterprise, military or civilian.

Assessment of microwave-based clinical waste decontamination unit.

A clinical waste decontamination unit that used microwave-generated heat was assessed for operator safety and efficacy. Tests with loads artificially contaminated with aerosol-forming particles showed that no particles were detected outside the machine provided the seals and covers were correctly seated. Thermometric measurement of a self-generated steam decontamination cycle was used to determine the parameters needed to ensure heat disinfection of the waste reception hopper, prior to entry for maintenance or repair. Bacterial and thermometric test pieces were passed through the machine within a full load of clinical waste. These test pieces, designed to represent a worst case situation, were enclosed in aluminium foil to shield them from direct microwave energy. None of the 100 bacterial test pieces yielded growth on culture and all 100 thermal test pieces achieved temperatures in excess of 99 degrees C during their passage through the decontamination unit. It was concluded that this method may be used to render safe the bulk of of ward-generated clinical waste.

Additional value of biplane transoesophageal imaging in assessment of mitral valve prostheses.

OBJECTIVES: To determine whether biplane transoesophageal imaging offers advantages in the evaluation of mitral prostheses when compared with standard single transverse plane imaging or the precordial approach in suspected prosthetic dysfunction. DESIGN: Prospective mitral valve prosthesis in situ using precordial and biplane transoesophageal ultrasonography. SETTING: Tertiary cardiac referral centre. SUBJECTS: 67 consecutive patients with suspected dysfunction of a mitral valve prosthesis (16 had bioprostheses and 51 mechanical prostheses) who underwent precordial, transverse plane, and biplane transoesophageal echocardiography. Correlative invasive confirmation from surgery or angiography, or both, was available in 44 patients. MAIN OUTCOME MEASURES: Number, type, and site of leak according to the three means of scanning. RESULTS: Transverse plane transoesophageal imaging alone identified all 31 medial/lateral paravalvar leaks but only 24/30 of the anterior/posterior leaks. Combining the information from both imaging planes confirmed that biplane scanning identified all paravalvar leaks. Five of the six patients with prosthetic valve endocarditis, all three with valvar thrombus or obstruction, and all three with mitral annulus rupture were diagnosed from transverse plane imaging alone. Longitudinal plane imaging alone enabled diagnosis of the remaining case of prosthetic endocarditis and a further case of subvalvar pannus formation. CONCLUSIONS: Transverse plane transoesophageal imaging was superior to the longitudinal imaging in identifying medial and lateral lesions around the sewing ring of a mitral valve prosthesis. Longitudinal plane imaging was superior in identifying anterior and posterior lesions. Biplane imaging is therefore an important development in the study of mitral prosthesis function.

Transgastric imaging: a valuable addition to the assessment of congenital heart disease by transverse plane transesophageal echocardiography.

Multiview transgastric imaging was performed with standard single transverse plane transesophageal probes in 16 patients to assess its potential additional value in defining the complexities of congenital heart disease. The age of patients studied ranged from 1.1 to 32 years (mean of 10.4 years). Their body weight ranged from 8.3 kg to 69 kg (mean of 29 kg). In all studies, a complete range of transesophageal and transgastric views could be obtained. The information thus obtained was correlated with the findings of prior precordial echocardiography and subsequent cardiac catheterization or surgical inspection. The pathologic conditions studied included tetralogy of Fallot, (4), isolated ventricular septal defect (4), valvular aortic stenosis (1), subvalvular and valvular aortic stenosis (1), supraaortic stenosis (1), total atrioventricular septal defect (1), secundum atrial septal defect (1), double-outlet right ventricle (1), double-chambered right ventricle (1), and pulmonary atresia, ventricular septal defect, and superoinferior ventricles (1). The single-plane data provided by transgastric scanning were compared and contrasted with that obtained from transesophageal scanning. Transgastric views were shown to be superior to transesophageal imaging in demonstrating the anatomy of the right ventricular outflow tract, the left ventricular outflow tract, and the apical and anterior aspects of the ventricular septum. In addition, these views offered a favorable angle of incidence for spectral wave Doppler studies of flow in both outflow tracts. We conclude that transverse plane transgastric imaging is an important addition to the transesophageal assessment of congenital cardiac disease. Its main additional benefit is in the study of lesions that involve either the right or left ventricular outflow tract or the anteroapical ventricular septum. Its main clinical value is likely to be in the evaluation of the perioperative patient in whom diagnostic precordial imaging is frequently impossible.

Bronchoscope damage and repair costs: results of a regional postal survey.

Flexible fiberoptic bronchoscopy is a commonly performed procedure for which the indications, technical aspects, and potential patient complications have been well described. However, limited information is available regarding damage to the instrument itself. In order to better describe the types and causes of bronchoscope damage, repair costs, and time out of service, we performed a postal survey of hospital bronchoscopy laboratories in Alabama, Mississippi, and Louisiana. We received 43 completed surveys from laboratories that perform an average of 233 bronchoscopies per year. The respondents reported 103 episodes of bronchoscope damage, the majority of which consisted of damage to the bronchoscope cover, broken fiber bundles, malfunction of the bending apparatus, and suction channel damage. The respondents attributed 62% of all the damage to one of the three following categories: unknown, improper handling, and damage caused by biopsy forceps, brushes, or needles. Of the 103 episodes of bronchoscope damage, 66 (64%) were judged to be preventable, 13.6% not preventable, and 17.5% to be indeterminant. The average time out of service (mean, SD) for each damaged bronchoscope was 3.5 (3.9) weeks, and the average repair cost per episode of bronchoscope damage was $2,726.13 ($1,391.21). At least 19 episodes of bronchoscope damage occurred during cleaning and disinfecting procedures. We conclude that the majority of bronchoscope damage and repair costs should be potentially preventable and suggest that a program to familiarize all personnel handling bronchoscopes with proper maintenance and handling procedures should decrease the risk of bronchoscope damage.