The application of STEP-technology® for particle and protein dispersion detection studies in biopharmaceutical research.

Particle detection and analysis techniques are essential in biopharmaceutical industries to evaluate the quality of various parenteral formulations regarding product safety, product quality and to meet the regulations set by the authority agencies. Several particle analysis systems are available on the market, but for the operator, it is quite challenging to identify the suitable method to analyze the sample. At the same time these techniques are the basis to gain a better understanding in biophysical processes, e.g. protein interaction and aggregation processes. The STEP-Technology® (Space and Time resolved Extinction Profiles), as used in the analytical photocentrifuge LUMiSizer®, has been shown to be an effective and promising technique to investigate particle suspensions and emulsions in various fields. In this study, we evaluated the potentials and limitations of this technique for biopharmaceutical model samples. For a first experimental approach, we measured silica and polystyrene (PS) particle standard suspensions with given particle density and refractive index (RI). The concluding evaluation was performed using a variety of relevant data sets to demonstrate the significant influences of the particle density for the final particle size distribution (PSD). The most challenging property required for successful detection, turbidity, was stated and limits have been set based on the depicted absorbance value at 320 nm (A320 values). Furthermore, we produced chemically cross-linked protein particle suspensions to model physically "stable" protein aggregates. These results of LUMiSizer® analysis have been compared to the orthogonal methods of nanoparticle tracking analysis (NTA), dynamic light scattering (DLS) and micro-flow imaging (MFI). Sedimentation velocity distributions showed similar tendencies, but the PSDs and absolute size values could not be obtained. In conclusion, we could demonstrate some applications as well as limitations of this technique for biopharmaceutical samples. In comparison to orthogonal methods this technique is a great complementary approach if particle data e.g. density or refractive index can be determined.

[Assessment of hygiene practices in anaesthesia between 1998 and 2007 in Lorraine]. / Evaluation des pratiques d'hygiène en anesthésie entre 1998 et 2007 en Lorraine.

OBJECTIVES: To study the assessment of hygiene practices in anaesthesia in Lorraine between 1998 and 2007, after recommendations from the French Society of Anaesthesia and Reanimation (SFAR) in December 1997, and different local actions. STUDY DESIGN: Two surveys performed at a nine-year interval in Lorraine hospitals. POPULATION AND METHOD: Questionnaires about risk infection management and hygiene practices were sent by post to all anaesthetists, nurse anaesthetists and recovery room nurses in 1998 (n=279) and in 2007 (n=259). RESULTS: Between the two surveys multidrug-resistant bacteria signalling, movements of the staff in operating rooms, septic isolation protocol and management of single-use disposable anaesthesia material have been improved (p<0.05). Central venous catheters are less performed in recovery rooms and rings wearing decreased by 16% (p<0.05). Wearing of nonsterile gloves for peripheral venous catheter and intubation is not generalized (p<0.05). About half of the hospitals have cleanup procedures of anaesthesia furniture. Washing of hands by anaesthesia staff is not sometimes respected but it's more frequent for medicine preparation and between two operations. A good skin disinfection (cleaning - rinsing - drying - antiseptic) is more recurrent in 2007 (61.4%) than in 1998 (41.9%) for arterial catheter. Wearing of glasses for intubation is each times rare, about 15%. CONCLUSION: Hygiene practices in anaesthesia in Lorraine have been improved between the two surveys by recommendations from the Sfar and the work of the Antenne Régional de Lorraine (audits, manuals, formations). Promising progress has been made but some points must still be worked on.

Trends of methicillin-resistant Staphylococcus aureus (MRSA) and Enterobacteriaceae-producing extended-spectrum beta-lactamase (ESBLE) in eastern France: a three-year multi-centre incidence study.

The objective of this study was to describe trends for the years 2004 to 2006 in the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Enterobacteriaceae-producing extended-spectrum beta-lactamase (ESBLE) in a large hospital network (70 hospitals in eastern France). The incidence of MRSA per 1,000 patient-days decreased significantly from 0.55 in 2004 to 0.45 in 2006. This trend was observed in medicine and surgery units, whereas MRSA incidence was stable in intensive care, paediatric and obstetric units. The incidence of blood cultures positive for MRSA remained stable at 0.04 per 1,000 patient-days. Conversely, the incidence of ESBLE increased significantly from 0.04 in 2004 to 0.08 in 2006. This increase was caused by the spread of ESBLE-producing Escherichia coli. The mean consumption of alcohol-based gel and solution (ABS), expressed in litres per 1,000 patient-days, was 3.3 in 2002, 4.5 in 2003, 5.4 in 2004 and 6.4 in 2005. There was no association between the consumption of ABS and MRSA incidence. These findings suggest that the French recommendations for the control of multi-drug-resistant bacteria (MDRB) have been effective in reducing, or at least stabilising, the incidence of MRSA in an international context of general increase. However, the diffusion of ESBLE-producing E. coli is a matter of concern and should be carefully monitored.

An outbreak of Mycobacterium jacuzzii infection following insertion of breast implants.

BACKGROUND: Surgical wound infections caused by rapidly growing mycobacteria developed in 15 women after insertion of breast implants from August to November 2003 at a single medical center. METHODS: A case-control study was conducted that included the identified patients, as well as women who underwent breast operations at the same center who did not develop infections. The study was accompanied by an extensive environmental investigation. Isolates were identified by standard bacteriological methods and by comparison of their 16S rRNA, HSP65, RPOB, SODA, and RECA gene sequences. Isolates were compared by random amplified polymorphic DNA analysis and by pulsed-field gel electrophoresis. RESULTS: The risk factors for infection included surgery performed by 1 specific surgeon (odds ratio, 21.3; 95% confidence interval, 3.64-125.6). Identical strains of mycobacteria were isolated from the infected wounds of the patients; from the eyebrows, hair, face, nose, ears, and groin of this particular surgeon; and from this surgeon's outdoor whirlpool. The isolates exhibited a biochemical profile overlapping that of Mycobacterium wolinskyi, but their sequences of 16S rRNA and HSP65, RPOB, SODA, and RECA genes differed. We propose the name "Mycobacterium jacuzzii" for this new species. DNA fingerprints of cultured isolates from the surgical wounds, areas of the surgeon's body that grow hair, and the surgeon's whirlpool were identical. When the surgeon discontinued his use of the whirlpool and began cleaning the hairy areas of his body with a shampoo containing triclosan, the outbreak ended. CONCLUSIONS: This outbreak brings to light the possibility of the colonization of human skin and human-to-human transmission of environmental mycobacteria during surgery that involves implant insertion.

[Intra-amoebal development of Legionella pneumophila and the potential role of amoebae in the transmission of Legionnaires' disease]. / Multiplication intra-amibienne de Legionella pneumophila et rôle potentiel des amibes dans la transmission de la légionellose.

Legionnaires' disease is one of the major infectious risks related to hospital water systems. It is commonly accepted, that the disease is transmitted to man mostly by inhalation of water aerosols contaminated by Legionella pneumophila. The ability of L. pneumophila to multiply intracellularly within some amoebae better explains the ecology, the pathogenicity, and the virulence of this bacterium against human alveolar macrophages. The presence of these amoebae in water systems located where cases of Legionnaire's disease broke out, partly explains the difficulty in eradicating Legionella. Some studies also show that amoebae can play a major role in the transmission of the disease to man. Some other studies point out that inhaled amoebae could be involved in the pathogenesis of Legionnaire's disease. Future strategies to prevent the transmission of Legionella will probably have to include efficient treatments against amoebae.

[Surveillance of multi-resistant bacteria in Lorraine: a three-year multicentre incidence study]. / Surveillance des bactéries multirésistantes en Lorraine: étude d'incidence multicentrique de trois ans.

OBJECTIVE: Controlling outbreaks of nosocomial infections is a priority for public healthcare in France. This study concerned the incidence of multidrug-resistant bacteria (MDRB) in Lorraine and the impact of the national guidelines for the prevention of MDRB. METHODS: A multicenter incidence study was conducted for 5 months, in volunteer hospitals. Samples collected for the clinical diagnostic were included. The bacteria studied were: methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella sp., Enterobacter sp., and other Enterobacteriaceae producing extended-spectrum beta-lactamase (ESBL), and vancomycin resistant Enterococci sp. RESULTS: A total of 30 hospitals were included in the surveillance of MDRB. During the study period (2001-2003), 17874 strains were identified. MRSA reached 29.3% of the 4038 strains of S. aureus, 20.9%, 1.23% and 1.21% of ESBL, respectively, for Enterobacter sp., Klebsiella sp., and other Enterobacteriaceae (for 895, 1061 and 9419 strains). Overall, the incidence of MRSA reached 0.55 per 1000 hospital-days and 0.087 for Enterobacter sp. The incidence increased during the 3 years, from 3.36 to 4.84 per 1000 new patients for MRSA, and from 0.43 to 0.90 for Enterobacter sp. CONCLUSION: Despite guidelines on isolation, MRSA remains poorly controlled and requires more efficient measures. Surveillance of ESBL should be improved.

Microbiologic contamination study of nebulizers after aerosol therapy in patients with cystic fibrosis.

BACKGROUND: To evaluate the contamination of delivery systems after an aerosol therapy session in patients with cystic fibrosis who have chronic Pseudomonas aeruginosa infection. METHODS: Fifty-three patients with cystic fibrosis were enrolled in the study from March 1996 to June 1997. All patients were age 7 years or older and had P aeruginosa infection. They also had been treated with recombinant deoxyribonuclease and were capable of producing sputum for culture. RESULTS: Nine devices were excluded for the study. A total of 44 nebulizers were included: 37 from patients with P aeruginosa colonization with a count of 10(6) colony-forming units/mL or more and 7 with a count of between 10(5) colony-forming units/mL and 10(6) colony-forming units/mL. CONCLUSION: This study demonstrates that in the absence of cleaning, nebulizers of patients with cystic fibrosis who are infected with P aeruginosa are likely to be contaminated by a pathogenic flora.

Occupational exposure to blood: search for a relation between personality and behavior.

OBJECTIVE: To describe the behavior of French nurses after occupational exposure to blood (OEB); to study the reasons for not reporting an OEB to the occupational medicine service or the hospital authorities, and to explore the links between personality traits and both the risk of having an OEB and the likelihood of reporting it. DESIGN: A descriptive and correlational study using a cross-sectional survey for data collection. SETTING: Six nursing schools (four initial training institutes and two specialty training schools, one for surgical nurses and one for nurse anesthetists) and six hospitals in Lorraine. PARTICIPANTS: 942 nurses and 459 nursing students were approached, and 964 (69%) replied to the questionnaire. METHODS: The participants received an anonymous two-part questionnaire. The first part explored the knowledge of the risk and Standard Precautions and collected details of the history of OEB. Reporting of OEB to the occupational medicine service or the hospital authorities and the nature of serological monitoring after OEB also were explored. The second part was composed of the Zuckerman sensation-seeking scale, exploring four areas: disinhibition, danger- and adventure-seeking, seeking new experiences, and susceptibility to boredom. RESULTS: 947 nurses were vaccinated against hepatitis B, but only 528 (56%) had checked that they were effectively immunized. Only 166 respondents (17%) stated they routinely used gloves during all procedures in which they were exposed to blood. There were 505 recorded OEB during the study period (0.24 per person per year). The most frequently reported OEB were those involving hollow needles (57%). Approximately one half (48.5%) of all OEB were reported. "Good local antisepsis immediately after the accident" was the reason most often given to justify nonreporting. Only 57% of OEB victims sought to determine the serological status of the source patient for human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus immediately after accident. Only 40% and 31% of OEB victims checked their own HIV and HCV serostatus 3 and 6 months after OEB, respectively. Few staff adopted safer-sex measures after OEB, and some continued to donate blood in subsequent months. Logistic regression identified two variables significantly and independently linked to the risk of having at least one OEB in the 27 months preceding the date on which the questionnaire was completed: having a permanent position and having a higher degree of disinhibition. Taking into account the number of OEB during this period (Poisson regression), four variables were significantly and independently linked to the risk of having a larger number of OEB: having a permanent position; having a higher degree of disinhibition; being more susceptible to boredom; and having less nursing experience. In logistic regression, three variables emerged as being significantly and independently linked to reporting all OEB: younger age; having had at least one percutaneous injury (excluding splashes); and having lower susceptibility to boredom. CONCLUSION: Nursing personnel continue to ignore or be unaware of many factors surrounding OEB, meaning that information and counseling must continue unabated. Knowledge of the risk, of the benefit of respecting Standard Precautions, and of the importance of notification and serological follow-up is still inadequate. Finally, certain personality traits, such as a high level of disinhibition and susceptibility to boredom, appear to be linked to the risk of OEB. Subjects strongly susceptible to boredom are less likely to report such accidents.

Electrolyte equilibration of human kidneys during perfusion with HTK-solution according to Bretschneider.

Twelve surgically removed human kidneys (mainly tumor kidneys) were investigated. The investigations comprised perfusion criteria (perfusion flow, perfusion pressure, perfusion resistance, electrolyte equilibration). During perfusion of the kidneys with HTK solution, the perfusion resistance was nearly three times as high in human kidneys as in canine kidneys perfused under the same conditions in previous studies. Beside possible species differences the raised perfusion resistance may be explained by the greater trauma to the human kidneys due to the surgery, the primary ischemic stress which cannot be avoided clinically and the often nonoptimal initial diuresis. Nevertheless definitive perfusion is possible under clinical conditions although pronounced increases of perfusion resistance may occur. As indicated by the raised perfusion resistance of human kidneys under clinical conditions as compared with canine kidneys in an experimental model, electrolyte equilibration of human kidneys was protracted. For this reason, a duration of perfusion of at least 10 min is necessary in clinical application of HTK solution, i.e., longer than in animal experiments.

The social HMOs. Meeting the challenge of integrated team care coordination.

Four social health maintenance organizations (social HMOs) implemented care coordination programs in 1985 to integrate acute and long-term care for aged Medicare beneficiaries. The team approach to care coordination has been the key concept of the model at all four sites. Team members include the primary care physician, the care coordinator, inpatient and medical office staff, geriatric nurse practitioners, home care nurses and social workers, contracted community-based care staff, and, at three of the sites, volunteers. This article describes how care coordinators work with the health care teams in the social HMOs.

[Impact of antibiotic prophylaxis on microbial ecology]. / Impact de l'antibioprophylaxie sur l'écologie microbienne.

This review of the literature analysed the impact of prophylactic antibiotics on patients, nurses, the ecosystem of the wards, the hospital and the general environment. After prophylactic antibiotics a qualitative and quantitative modification of the cutaneous and digestive flora of the patient can occur, as well as modification of susceptibility to antibiotics. Several factors may modulate their action on the bacterial flora: the breadth of the spectrum, the administered dose, the duration of treatment, the form of development of resistance and the type of antibiotics. Numerous studies have demonstrated the role of the nursing staff as a reservoir of multi-resistant micro-organisms. Staff of intensive care units is apparently the most affected. Prophylactic antibiotics can also induce changes in the quantitative and qualitative features both in the ward and hospital flora. An increase in the bacterial resistance to antibiotics in the general environment can occur; a long duration of oral prophylactic antibiotic administration is undoubtedly associated with this phenomenon. Thus, the benefit associated with prophylactic antibiotic in the prevention of postoperative infections, unquestionable in some indications, must be balanced with the possible selection of resistant micro-organisms and their consequences on the environment.

Heterogeneity of tumour necrosis factor production in renal cell carcinoma.

Endogenous tumour necrosis factor (TNF) production was investigated by in situ hybridisation and immunohistochemistry in 8 renal cell carcinoma (RCC) patients at different stages of disease. Analysis of frozen sections of tumour biopsy specimens revealed variable degrees of macrophage infiltration and great heterogeneity in TNF gene expression. Two metastatic tumours investigated showed abundant TNF protein production and marked macrophage infiltration. Based on morphological criteria, these TNF-positive cells most likely belong to the macrophage lineage. Two years after nephrectomy the individual survival time was recorded; however, the small numbers did not yet allow any correlation of TNF production to the clinical course of disease. Further studies will be required to eventually reveal the role of TNF in renal cell carcinoma development.

[Do water mycobacteria present any infectious risk in immunocompromised patients?]. / Les mycobactéries de l'eau représentent-elles un risque infectieux pour les sujets immuno-déprimés?

Atypical Mycobacteria were demonstrated in tap water. Mycobacteria are generally more resistant to chemical disinfection than other bacteria and grow and survive in water. In an effort to clarify the role of water in the transmission of Mycobacteria, water from various sites in the hospital was analysed. Atypical Mycobacteria were isolated from 58 of 60 samples of cold water distributor. Species more frequent are M.Kansasii, M.Gordonae, M.Fortuitum. 3 of 10 samples of hot water were positives M.Xenopi was isolated once. 1 of 10 samples of mineral waters was contaminated with M.Gordonae. The atypical Mycobacteria in normal patient are relatively less virulent, in a host with an impaired cellular immunity they caused active diseases. The number of published cases is low. The incidence in transplant patients ranges from 0.5 to 1%. Infections with atypical Mycobacteria differ in several clinical features. Person to person does not occur. Water is a source of infection induce direct inoculation inhalation and ingestion.

[Preparation of a polymer named Porimid, and its sterilization]. / Préparation d'un polymère, le Porimid, et sa stérilisation.

From a concrete example, the authors remind the interest to envisage the possibilities of sterilization as early as the initial period of a research about biomaterials. Indeed certain kinds of sterilization may be too much aggressive for biomaterials, especially the polymers, whom the structure is so impaired. These biomaterials may become ineffective even dangerous and blight a long time of research. The authors also expose the necessity to respect the good manufacturing practices of laboratory and the rules of hospital hygienics which is indispensable for all the members of the teams which participate to biomedical or clinical researches. A condition for the respect of these rules is the utilization of a common and well understood language between the medical and no medical teams.

[Risk of infection related to the use of cryopreserved bone grafts from domestic banks]. / Risques infectieux liés à l'emploi de greffons osseux cryoconservés provenant d'une banque domestique.

The authors report their experience of a home bone bank of cryopreserved femoral heads on a period of 3 years. They remind the rules to observe for the harvesting, the storage and the utilization of these allografts, and also the indispensable biological tests (at the moment when the article was written). About their series, the authors remind the risks of infection in relation with the utilization of femoral head from bone bank, which justify a great rigour in the organization and the managing of these home bone bank.

[Urinary tract infections during the 1st month after kidney transplantation]. / Infections urinaires du premier mois post-transplantation rénale.

The incidence and the predisposal factors of urinary tract infections (UTI) in the first month post-transplant were studied in 255 kidney transplantations (252 patients). UTI episodes were demonstrated in 73.7% of the grafts. The most common organisms were: Escherichia coli (35.8%), Staphylococcus (33.6%), Streptococcus D (11.2%), Klebsiella (5.3%). The infectious episodes were recurrent in 39% of the cases. The majority of the UTIs were asymptomatic but 7% of the infections led to septicaemia. Etiology of end-stage renal disease, pre-graft binephrectomy, asymptomatic vesicoureteral reflux into the patient's own kidneys, type of immunosuppressive treatment, acute tubular necrosis, rejection episodes, urological complications, coexistent other infections were not predisposal factors. Bacteriuria was more frequent in female than in male patients. The incidence of UTI was found to be statistically increased with history of UTI preoperatively (p = 0.039) and the use of ureteral catheter (p = 0.018). Occurrence of UTI was less common when the donor was treated by antibiotics before brain death (p-0.025). These results provide additional support for regular monitoring of urine cultures in the first month post-transplant. They should help to identify means of reduction of this infectious risk.

[Preliminary study of the antimicrobial activity of traditional plants against E. coli]. / Etude préliminaire du pouvoir antimicrobien de plantes traditionnelles sur E. coli.

The microbiological quality of drinking water is a major public health priority in developing countries. As an alternative proposal to chemical treatment of water, we have studied the antibacterial effectiveness against E. coli of plants traditionally used for antisepsis. Traditional plants were freshly sampled from Burkina Faso and Vietnam. Two of them, Tamarinier and Derris elliptica respectively, were selected for the study. Various part of the plants, i.e. seeds, cloves and fruits were prepared in both decoction and maceration. Their antibacterial activity was assessed using standardized preparations of E. coli (Pasteur 792) in water (10(5), 10(6) and 10(7) germs/ml). Some preparations of Tamarinier showed encouraging results, whereas Derris elliptica was uneffective. Solutions of Tamarinier seeds produced a 4.5 log decrease of the germ concentration in standardized 10(7) germs/ml preparation. Decoction and maceration are still effective 24 h after a 10(4) bacteria/ml overloading. On the other hand, acid pH of clove and fruit solutions explains the slight effectiveness (1 log UFC/g of dry extract/48 h) of these solutions. Though the results are not meeting with the AFNOR requirements for disinfection, this preliminary study demonstrates a bacteriostatic effect of traditional plants against E. coli in water. Further study is needed to valid this property in the field.

[Localization and extent of tissue damage caused by extracorporeal lithotripsy (ESWL)]. / Lokalisation und Ausmass einer Gewebeschädigung durch die extrakorporale Lithotrypsie (ESWL).

Extracorporeal shock wave lithotripsy (ESWL) causes proteinuria. In our study we investigated the protein fractions and the electrolyte composition of the urine in patients who had been treated with ESWL. The aim was to obtain information on the degree and the localisation of the glomerular, tubular or vascular destruction caused by ESWL in humans. A total of 34 patients with stones had been treated with ESWL. As parameters we used: urine output, creatinine clearance, total protein, albumin, immunoglobulin G, N-acetyl-beta-D-glucosaminidase (beta-NAG), alpha-1-microglobulin, the fractional excretion of Na+ and apolipoprotein-A-1. After ESWL treatment proteinuria and albuminuria are found. Our parameters show no deterioration of the glomerula or the tubulus. The increase in apolipoprotein-A-1, a postglomerular parameter, however, is interpreted as a manifestation of vascular destruction after ESWL; this is normally temporary, leaving no permanent damage.

[Contribution of a 3% solution of boric acid in the treatment of deep wounds with loss of substance]. / Apport d'une solution d'acide borique à 3% pour le traitement des plaies profondes avec perte de substance.

The correct application of antiseptics to major surgical wounds must comply with appropriate protocols. Compliance with the protocol established by the CHRU of Nancy was evaluated by means of a questionnaire assessing the understanding of the protocol by the nursing staff and by a survey in the wards in which it was applied. The defects observed cannot be explained by a lack of efficacy for superficial wounds and deep wounds, as a randomised study of 42 wounds demonstrated the superiority of the protocol in relation to the use of another product which is widely used in the wards. In contrast, for deep wounds with loss of substance, the proposed protocol does not always achieve therapeutic success. This finding has led the authors to propose the use of a 3% boric acid solution based on a case-control study which demonstrated a significantly superior efficacy. All of the epidemiological and clinical elements are summarised in order to demonstrate the solid basis for compliance with antiseptic protocols of surgical wounds which can only be beneficial in terms of therapeutic success, length of hospital stay and cost savings.