Emerging evidence in infection control: effecting change regarding use of disposable laryngoscope blades.

The purpose of this evidence-based project was to determine the perceptions of anesthesia providers regarding the use of disposable laryngoscope blades. Frequency of use, ease of use, and complications encountered when using the disposable blade were evaluated before and after an in-service program designed to increase the use of disposable blades. Participants completed an anonymous questionnaire about their knowledge and practice regarding disposable laryngoscope blades. Then they received an investigator-developed article to read about the best and most recent practices regarding disposable laryngoscope blades. The same anonymous questionnaire was completed 3 months later. Inventory of the disposable laryngoscope blades was collected before the project and 1 and 3 months later. After the intervention, 25% of anesthesia providers described performance as their reason for not using the disposable laryngoscope blade, which was down from 60% at the project's start. Inventory showed a 23% increase in use of disposable laryngoscope blades after the intervention, which a single-proportion Z test showed was statistically significant (Z = 2.046, P = .041). This evidence-based project shows that a change in practice was evident after dissemination of the best and most recent clinical evidence regarding laryngoscope blades, which should translate to improved patient outcomes.

Radiation safety for anesthesia providers.

Many modern diagnostic and surgical procedures rely heavily on the use of ionizing radiation. These procedures include computed tomography, nuclear medicine procedures, interventional radiology, and cardiac catheterization and electrophysiology procedures. Recent trends toward increased patient visits and patients with multiple challenging comorbidities have meant that anesthesia providers are increasingly required to provide services in the ancillary areas using ionizing radiation. As a result, anesthesia providers are at a greater-than-ever risk for excessive radiation doses. An overview of some of the basic principles of radiation biology, radiation physics, and radiation protection and specific guidelines related to radiation exposure and pregnancy are described. The effects of radiation exposure are cumulative and permanent, and an understanding of these principles and practices will help anesthesia providers keep their occupational exposure to a minimum.

Articular chondrocyte passage number: influence on adhesion, migration, cytoskeletal organisation and phenotype in response to nano- and micro-metric topography.

The isolation and culture of articular chondrocytes is a prerequisite of their use in tissue engineering, but prolonged culture and passaging is associated with de-differentiation. In this paper we studied the influence of nanometric and micrometric grooves (85 nm to 8 microm in depth and 2 microm to 20 microm in width) on 1st and 2nd passage ovine chondrocytes since our earlier findings indicate that primary cells are not affected by such features. 1st and 2nd passage chondrocytes cultured on grooved substrata showed a polarisation of cell shape parallel to the groove long axis and F-actin condensations were evident at groove ridge boundaries. An increase in cell migration with increasing groove depth was observed. Both passages of chondrocytes maintained type II collagen expression, but to a lesser degree in 2nd. This study demonstrates that passage number alters the response of chondrocytes to micrometric and nanometric topography, and could be important in ex vivo cartilage engineering.

The response of primary articular chondrocytes to micrometric surface topography and sulphated hyaluronic acid-based matrices.

Understanding the response of chondrocytes to topographical cues and chemical patterns could provide invaluable information to advance the repair of chondral lesions. We studied the response of primary chondrocytes to nano- and micro-grooved surfaces, and sulphated hyaluronic acid (HyalS). Cells were grown on grooves ranging from 80 nm to 9 microm in depth, and from 2 microm to 20 microm in width. Observations showed that the cells did not spread appreciably on any groove size, or alter morphology or F-actin organization, although cells showed accelerated movement on 750 nm deep grooves in comparison to flat surfaces. On chemical patterns, the cells migrated onto, and preferentially attached to, HyalS and showed a greater degree of spreading and F-actin re-arrangement. This study shows that 750 nm deep grooves and sulphated hyaluronic acid elicit responses from primary chondrocytes, and this could have implications for the future direction of cartilage reconstruction and orthopaedic treatments in general.

An in vivo microfabricated scaffold for tendon repair.

A new type of in vivo tissue engineering system for tendon repair in situ after cut or crush of a flexor tendon is described. The system is based on the topographical reaction, alignment, migration and perhaps proliferation of tendon cells on micrometrically grooved substrates made in a biodegradable polymer. Macrophage trapping in the structure may also help to prevent inflammation. Tendon damage including crush and section injury is a fairly frequent occurrence. The conventional treatment is surgical repair, however frequently this leads, especially in hand wounds, to attachment of the tendon surface to the surrounding synovium, which is very undesirable. We present an approach based on using a biodegradable device to ensure that the healing of severed or crushed flexor tendons is aided, synovial adhesion prevented and the final result anatomically correct. The biodegradable sheath carries microgrooves fabricated into the polymer by embossing that orient and guide the cells towards each other from either side of the region of damage. After six weeks an apparently normal functional tendon is reformed.

The prevalence of visible and/or occult blood on anesthesia and monitoring equipment.

The Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control and Prevention (CDC) have attempted to stop the spread of blood-borne pathogens by issuing several recommendations and regulations. However, unless healthcare workers comply with these standards, they are not effective. In the anesthesia care environment, the anesthetist is responsible for ensuring that the equipment is clean, and disinfected, before use. We studied the prevalence of visible and occult blood on 6 types of anesthesia and monitoring equipment identified as ready for use in 28 operating suites, in 2 facilities. The sample consisted of 336 observations of the 6 types of equipment. The equipment was inspected for visible blood and then tested for occult blood using a 3-stage phenolphthalein test. Of the 336 observations, 110 (32.7%), were positive for occult blood with only 6 showing visible blood. The presence of blood on this equipment may be in direct violation of the OSHA Blood-borne Pathogen Standard and the infection control guidelines of the American Association of Nurse Anesthetists. Furthermore, the presence of blood on this equipment may increase the risk for nosocomial and occupational exposure to viral and bacterial pathogens. Recommendations were made to decrease the risks from this contamination by redesigning equipment, increasing the use of disposable equipment, and ensuring compliance with effective infection control practices.

Attachment of fibroblasts on smooth and microgrooved polystyrene.

In this study rat dermal fibroblasts (RDFs) were cultured on smooth or microgrooved (1-20 microm wide, 0.5-5.4 microm deep) substrates. Polystyrene microgrooved substrates were produced by solvent casting on molds that had been produced by photolithographic techniques. We investigated the attachment of RDFs with various analytical techniques. Light microscopy and image analysis showed that RDFs were oriented on most microgrooves. The rate of orientation effectively was increased by an increase of groove depth. An analysis of confluent layers of RDF showed that at confluency microgrooves were able to support greater numbers of cells. However, the largest numbers of cells were not found on the narrowest and deepest microgrooves even though such microgrooves have the largest total surface and induce the strongest alignment. Interference reflection microscopy (IRM) showed that the RDFs form focal adhesions where the cell membrane is only 10 nm from the substrate. IRM also showed that RDFs follow the contours of shallow and wide microgrooves but bridge the grooves on deeper and narrower ones. This could explain why such grooves are not able to increase the numerical cell adhesion to a greater degree. The absence of contact between cells and the bottom of the grooves is a very important factor in establishing contact guidance.

The first four years of the Uniformed Services University of the Health Sciences Graduate School of Nursing.

The Graduate School of Nursing (GSN) was established at the Uniformed Services University of the Health Sciences in 1993 to prepare advanced practice nurses, namely family nurse practitioners (FNPs) and nurse anesthetists (CRNAs), for the uniformed services. A study of needs for nurses in the uniformed services in these specialties indicated that by the year 2000 there would be a need requiring a total enrollment in educational programs of 268 CRNAs and 100 FNPs over a 5-year period. Offering the master of science in nursing degree, the GSN has enrolled 61 students in its two programs, and by the end of the 1997 academic year, it will have graduated 19 FNPs and 19 CRNAs. The GSN was authorized by the Department of Defense, Office of Health Affairs, in February 1996. Federal nursing chiefs serve as advisors to the GSN. The GSN received full accreditation from the Council on Accreditation of Nurse Anesthesia Educational Programs in 1994 and from the National League for Nursing in December 1996. All students who have graduated have successfully passed their certification examinations. Supplementing other educational resources, the GSN is helping to meet the educational needs of the uniformed nursing services by introducing pilot programs specifically designed to meet these needs.

Incidence of visible and occult blood on laryngoscope blades and handles.

Anesthesia providers must take appropriate precautions to reduce the potential for transmission of infectious agents to the patients under their care. The devastating spread of human immunodeficiency virus (HIV) and hepatitis B virus (HBV) over the past decade has resulted in the development of specific guidelines for the cleaning, disinfection, sterilization, and handling of medical equipment and instruments. Contamination of laryngoscope blades and handles with visible and occult blood frequently occurs during routine airway management. Several studies suggest procedures for cleaning, disinfection, sterilization, or handling of laryngoscope blades and handles are ineffective, or there may be poor compliance with the established protocols. The purpose of this study was to determine the incidence of visible and occult blood on laryngoscope blades and handles that were identified as ready for patient use. Sixty-five laryngoscope blades and handles identified as ready for patient use were observed for visible blood and tested for occult blood. A modified version of the three-stage phenolphthalein blood indicator test was employed to determine the presence of occult blood. None of the blades or handles observed had visible blood. Of the 65 blades tested for occult blood, 13 (20%) tested positive. Of the 65 handles tested for occult blood, 26 (40%) tested positive. More afternoon blades and handles tested positive for occult blood than morning blades and handles (P < 0.01). The extent to which contaminated anesthesia equipment plays in nosocomial infection is difficult to determine. The presence of blood is an indicator of potential cross-infection, since biological fluids, such as blood and saliva, are known to transmit infectious diseases. This study confirms that more rigorous decontamination protocols must be instituted to ensure complete removal of blood prior to sterilization, since laryngoscope blades and handles have irregular surfaces with repositories for infectious material.

Guidance and activation of murine macrophages by nanometric scale topography.

We studied the guidance and activation of macrophages from the P388D1 cell line and rat peritoneum by topographic features on a nanometric scale. Cells were plated on plain fused silica substrata or substrata with microfabricated grooves and steps, 30-282 nm deep. The contact of cells with the patterned surface activated cell spreading and adhesion and increased the number of protrusions of the cell membrane. These changes were accompanied by an increase in the amount of F-actin in cells. The accumulation of F-actin and vinculin in cells was observed along the edges of single steps or grooves. Formation of focal contacts along discontinuities in the substratum was accompanied by the phosphorylation of tyrosine colocalized with F-actin and vinculin. A similar pattern of staining was seen in cells stained for vitronectin receptor, alphaV integrin, but not for integrins alpha5beta1 or alpha3beta1. Cells cultured on nanogrooves showed a higher phagocytotic activity than cells cultured on plain substrata. We show that macrophages can react to ultrafine features of topography of a size comparable to that of a single collagen fiber and become activated by the contact with topographic features.

Role of the cytoskeleton in the reaction of fibroblasts to multiple grooved substrata.

The role of the cytoskeleton and cell attachments in the alignment of baby hamster kidney fibroblasts to ridge and groove substratum topography was investigated using confocal scanning microscopy. This was carried out with normal cells and cells treated with the cytoskeleton modifiers cytochalasin D, colcemid, and taxol. Actin was localised with fluorescent phalloidin. Tubulin, vinculin, and intracellular adhesion molecule-1 were visualised by indirect immunofluorescence. The spreading, elongation, and orientation of the cells after 24 h of culture in these conditions were measured on grooves of 5, 10, and 25 microns width and 0.5, 1, 2, and 5 microns depth. We have also observed events over the first 30 min of cell attachment. Five minutes after cell attachment, F-actin condensations were seen close to the intersection of groove wall and ridge top, that is, at a topographic discontinuity. The condensations were often at right angles to the groove edge and showed a periodicity of 0.6 microns. Vinculin arrangement at the early stages of cell spreading was similar to that of actin. Organisation of the microtubule system followed later, becoming obvious at about 30 min after cell plating. The Curtis and Clark theory (that cells react to topography primarily at lines of discontinuity in the substratum by actin nucleation) is supported by these results. The use of cytoskeletal poisons did not entirely abolish cell reaction to grooves. Colcemid increased cell spreading and reduced cell orientation and elongation. Cytochalasin D reduced cell spreading, orientation, and elongation. Taxol reduced cell elongation but did not affect cell spreading and orientation. We conclude that the aggregation of actin along groove/ridge boundaries is a primary driving event in determining fibroblast orientation on microgrooved substrata.

The use of frozen intravenous crystalloid solutions as the refrigerant for shipping blood.

The authors studied whether cooled sterile intravenous crystalloid solutions could be used to refrigerate red cells during shipment. Six 1000-ml bags of 0.9 percent normal saline and lactated Ringers (RL) solutions were supercooled and tested separately at temperatures ranging from 1 to -78 degrees C, with either 5 or 30 units of packed red cells (PRBCs). The PRBCs were shipped in a standard military container that permitted separation of the supercooled solutions from the PRBCs. Cooling RL solutions to 6 degrees C and to -22 degrees C maintained acceptable storage temperatures of the PRBC for 36 and 50 hours, respectively, and did not cause visible damage to the units. No significant changes were observed in various biochemical measurements of the cells and plasma. Cooling the RL solution to -78 degrees C caused a significant (p less than 0.05) increase in plasma potassium concentration. The effectiveness of the crystalloid solutions in refrigerating blood varied with the ratio of the number of PRBCs to the volume of cooled solutions and with the ambient temperature surrounding the container. The results of this study suggest that cooled intravenous crystalloid solutions can be used as refrigerants for PRBCs during shipment.

Plasma and amniotic fluid concentrations of fibronectin during normal pregnancy.

To ascertain the influence of pregnancy on plasma concentrations of fibronectin, we quantified plasma concentrations of fibronectin in 22 normal, pregnant women during the first, second, and third trimesters; at the time of delivery; and at six weeks and eight months postpartum, using a rapid, immunoturbidimetric procedure. Mean plasma concentrations of fibronectin rose significantly throughout pregnancy, and were significantly greater than umbilical cord plasma concentrations. Maternal plasma concentrations of fibronectin at six weeks postpartum were similar to those observed at the time of delivery, but returned to concentrations observed in nonpregnant women by eight months postpartum. No significant differences between concentrations of fibronectin in amniotic fluid obtained during the second and third trimesters of pregnancy were observed. Six-week postpartum values appeared to depend upon the type of infant feeding as values rose in bottle feeding but fell in breast-feeding mothers.