Evaluation of ozonated water using ASTM E1174 for standardized testing of handwash formulations for healthcare personnel.

Removal of bacteria by handwashing with ozonated water was evaluated using the ASTM E1174 standard test method. Thirty healthy volunteers were assigned randomly to three groups: ozonated water, antimicrobial soap and water, and non-antimicrobial soap and water. A 3 log10 cfu reduction was achieved by washing hands with ozonated water or antimicrobial soap and water. However, ozonated water was not significantly superior to non-antimicrobial soap and water. Ozonated water may remove bacteria from the hands to at least a similar extent as that by non-antimicrobial soap and water in the absence of visible dirt or body fluid contamination.

Pertussis outbreak among patients and healthcare workers in a provincial dialysis facility in Japan.

BACKGROUND: Sixteen pertussis cases in haemodialysis patients and healthcare workers were detected in a 25-bed outpatient haemodialysis facility in Japan between October 2013 and April 2014. AIM: To describe an outbreak of pertussis among patients and healthcare workers, and to identify risk factors for pertussis infection. METHODS: Sputum cultures, loop-mediated isothermal amplification assays performed on nasopharyngeal swabs to detect respiratory pathogens including Bordetella pertussis, and serum anti-pertussis toxin immunoglobulin G measurements were performed for all haemodialysis patients and healthcare workers. A retrospective case-control study was performed to identify the risk factors for pertussis infection in the clinic. FINDINGS: Only six of the 16 pertussis patients (37.5%) had respiratory symptoms. Recent exposure to an unmasked individual with a cough was associated with pertussis infection (odds ratio 6.25, P<0.05). The outbreak was terminated successfully after enforcing the use of surgical masks among both patients and healthcare workers. CONCLUSION: This report demonstrates the risk of pertussis transmission in a haemodialysis facility, and underscores the importance of wearing surgical masks to control a pertussis outbreak.

Outbreak of extended-spectrum ß-lactamase-producing Escherichia coli transmitted through breast milk sharing in a neonatal intensive care unit.

BACKGROUND: Routine surveillance in a neonatal intensive care unit (NICU) showed an increased detection of extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli (ESBL-E. coli) in August 2012, following nearly a year without detection. AIM: To describe the investigation and interventions by a hospital infection control team of an outbreak of ESBL-E. coli in a NICU. METHODS: Six neonates with positive cultures of ESBL-E. coli (five with respiratory colonization, one with a urinary tract infection), control infants who were negative for ESBL-E. coli during the study period, and mothers who donated their breast milk were included. A case-control study was performed to identify possible risk factors for positive ESBL-E. coli cultures and molecular typing of isolated strains by pulsed-field gel electrophoresis. FINDINGS: The odds ratio for ESBL-E. coli infection after receiving shared unpasteurized breast milk during the study period was 49.17 (95% confidence interval: 6.02-354.68; P < 0.05). The pulsed-field gel electrophoresis pattern showed that all strains were identical, and the same pathogen was detected in freshly expressed milk of a particular donor. After ceasing the breast milk sharing, the outbreak was successfully terminated. CONCLUSION: This outbreak indicates that contamination of milk packs can result in transmission of a drug-resistant pathogen to newborn infants. Providers of human breast milk need to be aware of the necessity for low-temperature pasteurization and bacterial cultures, which should be conducted before and after freezing, before prescribing to infants.

Safety of polypropylene mesh for incarcerated groin and obturator hernias: a retrospective study of 110 patients.

PURPOSE: The purpose of this study was to evaluate the mesh repair for an incarcerated groin hernia. METHODS: A total of 110 patients who underwent emergency surgery for incarcerated hernias were retrospectively analyzed using a multivariate analysis. RESULTS: The postoperative complications were associated with bowel resection, odds ratio (OR) 2.984, and 95 % confidence interval (CI) 1.273 to 6.994. The risk factors for bowel resection were femoral hernia, (OR 5.621, 95 % CI 2.243 to 14.082), and late hospitalization (24 h<), (OR 2.935, 95 % CI 1.163-7.406). The hernias were repaired with mesh in ten of the 39 (25.6 %) patients with bowel resection and sixty-four of the 71 (90.1 %) patients without bowel resection. The complication rate of the patients with bowel resection was 53.8 % and was 26.8 % in those without. The ratios of wound infection were 23.1 and 0.0 %, respectively. Wound infections were detected in two (20 %) of the ten patients who underwent bowel resection with mesh repair; however, there were no patients in whom the mesh was withdrawn due to infection. CONCLUSIONS: No wound infections in patients without bowel resection were detected, and mesh repair could be safely performed. Mesh repair for the patients with bowel resection is not contraindicated, as long as the clean-contamination of the wound was maintained during surgery.

Measurement of short-chain fatty acids in human faeces using high-performance liquid chromatography: specimen stability.

BACKGROUND: Short-chain fatty acids such as lactic acid produced by the intestinal bacterial flora have various physiological actions involved in health, and it is important to determine the concentrations of faecal short-chain fatty acids and evaluate their relationship with large intestinal diseases. In this study, we evaluated the highly selective and sensitive simultaneous measurement of both volatile and non-volatile short-chain fatty acid hydrazides using high-performance liquid chromatography (HPLC). MATERIALS AND METHODS: Faeces treated with ethanol were used as analytic samples. Short-chain fatty acids were measured as fatty acid hydrazides by HPLC. RESULTS: For 12 types of short-chain fatty acid, the results regarding linearity, recovery tests and reproducibility were favourable. Faeces treated with ethanol could be stored at room temperature. DISCUSSION: The stability of short-chain fatty acids in faeces at room temperature was statistically analysed. Faeces stored without treatment with ethanol showed increases/decreases in the concentrations of short-chain fatty acids, which may be due to assimilation by intestinal bacteria. However, specimen in 70% ethanol and stored in room temperature exhibited no substantial changes in concentrations of short-chain fatty acids up to seven days.

A randomised phase III trial comparing gemcitabine with surgery-only in patients with resected pancreatic cancer: Japanese Study Group of Adjuvant Therapy for Pancreatic Cancer.

BACKGROUND: This multicentre randomised phase III trial was designed to determine whether adjuvant chemotherapy with gemcitabine improves the outcomes of patients with resected pancreatic cancer. METHODS: Eligibility criteria included macroscopically curative resection of invasive ductal carcinoma of the pancreas and no earlier radiation or chemotherapy. Patients were randomly assigned at a 1 : 1 ratio to either the gemcitabine group or the surgery-only group. Patients assigned to the gemcitabine group received gemcitabine at a dose of 1000 mg m(-2) over 30 min on days 1, 8 and 15, every 4 weeks for 3 cycles. RESULTS: Between April 2002 and March 2005, 119 patients were enrolled in this study. Among them, 118 were eligible and analysable (58 in the gemcitabine group and 60 in the surgery-only group). Both groups were well balanced in terms of baseline characteristics. Although heamatological toxicity was frequently observed in the gemcitabine group, most toxicities were transient, and grade 3 or 4 non-heamatological toxicity was rare. Patients in the gemcitabine group showed significantly longer disease-free survival (DFS) than those in the surgery-only group (median DFS, 11.4 versus 5.0 months; hazard ratio=0.60 (95% confidence interval (CI): 0.40-0.89); P=0.01), although overall survival did not differ significantly between the gemcitabine and surgery-only groups (median overall survival, 22.3 versus 18.4 months; hazard ratio=0.77 (95% CI: 0.51-1.14); P=0.19). CONCLUSION: The current results suggest that adjuvant gemcitabine contributes to prolonged DFS in patients undergoing macroscopically curative resection of pancreatic cancer.

Risk of facial splashes in four major surgical specialties in a multicentre study.

This study analyses the results of face-shield blood spatter contamination at six medical facilities to determine exposure risk when facial protection is not used. Blood spatter exposure was evaluated on the basis of overall incidence, location of spatter on face shields, surgical specialty, risk for operating room staff, length of surgery and volume of blood loss. Six hundred face shields were evaluated for blood spatter contamination by visual inspection as well as by staining with leucomalachite green. The face shield was divided into three regions: Orbital (O-region), Paraorbital (P-region) and Mask (M-region). Visual examination detected blood spatter contamination in 50.5% (303/600) of the face shields, whereas leucomalachite green staining detected blood contamination in 66.0% (396/600). Blood contamination was 36.6% (220/600) in the O-region, 37.8% (227/600) in the P-region and 57.0% (342/600) in the M-region. Among operating room staff, the incidence of blood spatter was greatest among lead surgeons at 83.5% (167/200), followed by the first assistant at 68.5% (137/200) and the scrub nurse at 46.0% (92/200). By specialty, cardiovascular surgery was at highest risk with an incidence of 75.3% (113/150) followed by neurosurgery at 69.3% (104/150), gastrointestinal at 60.0% (90/150) and orthopaedic surgery at 60.0% (90/150).

An increased incidence of Enterobacter cloacae in a cardiovascular ward.

Routine surveillance in a cardiovascular ward showed that the incidence of Enterobacter cloacae isolated from sputum and oropharyngeal cultures in June 2004 increased to 27.6% (8/29) compared to 5.5% (12/219) from the rest of the hospital during the same period (OR=13.2; 95% CI 2.97-58.7; P<0.05). While an increase in E. cloacae pneumonia was not verified, an investigation was undertaken by the infection control team to prevent an outbreak. The estimate of relative risk for E. cloacae infection was based on a case-control study which measured exposure to intubation, history of a stay in the intensive care unit (ICU) and oral care between patients with E. cloacae and those negative for E. cloacae. An odds ratio of 13.2 suggested cross-contamination via the transoesophageal echocardiography (TOE) probe in the ICU prior to transfer to the cardiovascular ward. Pulsed-field gel electrophoresis and antibiogram patterns were also consistent with this hypothesis. Intervention was undertaken in the form of enforcing the disinfection of TOE probes using a 0.55% phtharal solution and the use of a single-use sheath to protect the probe from recontamination. Following intervention, the incidence rate returned to previous levels. This report illustrates the limitations in the effectiveness of current nosocomial surveillance strategies due to the retrospective nature of analysis. Improved surveillance methods such as data-mining tools specifically applicable to the institution, patient population, region and country are needed to increase the sensitivity of detecting unrecognized outbreaks, including cross-contamination.

Evaluation of the mechanical strength and patency of functional end-to-end anastomoses.

BACKGROUND: Although many mechanical devices are being developed for functional end-to-end anastomosis (FETEA), the best choice remains to be determined. The mechanical strength of each device is an important factor associated with anastomotic leakage. In turn, anastomotic patency is related to postoperative stenosis. This study examined the bursting pressure and circumference of several FETEAs. METHODS: Young domestic pigs were used in this study. In experiment 1, a 10-cm segment of intestine was transected using an EndoGIA 60 blue, EndoGIA 60 green, or GIA 60 blue stapler, and the bursting pressure of each instrument's mechanical staple line was examined. In experiment 2, after FETEA had been created with EndoGIA 60 blue, the bursting sites were examined, and the bursting pressures of buttressed and nonbuttressed FETEA were measured and compared. In experiment 3, the circumference of FETEA was compared between the closed technique and reinforcement. RESULTS: The bursting pressure of EndoGIA 60 blue was significantly higher than that of the other devices. When an anastomotic crotch was buttressed, the bursting pressure (44 +/- 13 mmHg) was significantly increased over that of the nonbuttressed FETEA (27.5 +/- 5.8 mmHg; p < 0.05). The circumference of FETEA using the wide technique (92.7 +/- 2.3 mm) was larger than that using the offset technique (55.7 +/- 5.8 mm). CONCLUSIONS: The bursting pressure of the mechanical staple line using the EndoGIA 60 stapler was the strongest. Functional end-to-end anastomosis was stronger when created with buttress of an anastomotic crotch, and larger circumferences were created with the wide technique.

Evaluation of the efficacy of combined continuous arterial infusion and systemic chemotherapy for the treatment of advanced pancreatic carcinoma.

PURPOSE: To evaluate the effects of combined continuous transcatheter arterial infusion (CTAI) and systemic chemotherapy in patients with advanced pancreatic carcinoma. METHODS: CTAI was performed in 17 patients with stage IV pancreatic cancer with (n = 11) or without (n = 6) liver metastasis. The reservoir was transcutaneously implanted with the help of angiography. The inferior pancreatic artery (IPA) was embolized to achieve delivery of the pancreatic blood supply through only the celiac artery. The systemic administration of gemcitabine was combined with the infusion of 5-fluorouracil via the reservoir. Treatment effects were evaluated based on the primary tumor size, liver metastasis, and survival time and factors such as tumor size, tumor location, and stage of pancreatic carcinoma; the embolized arteries were analyzed with respect to treatment effects and prognosis. RESULTS: A catheter was fixed in the gastroduodenal artery and splenic artery in 10 and 7 patients, respectively. Complete peripancreatic arterial occlusion was successful in 10 patients. CT showed a decrease in tumor size in 6 of 17 (35%) patients and a decrease in liver metastases in 6 of 11 (55%) patients. The survival time ranged from 4 to 18 months (mean +/- SD, 8.8 +/- 1.5 months). Complete embolization of arteries surrounding the pancreas was achieved in 10 patients; they manifested superior treatment effects and prognoses (p < 0.05). CONCLUSION: In patients with advanced pancreatic cancer, long-term CTAI with systemic chemotherapy appeared to be effective not only against the primary tumor but also against liver metastases. Patients with successfully occluded peripancreatic arteries tended to survive longer.

Evaluation of a fully automated system (RAISUS) for rapid identification and antimicrobial susceptibility testing of Staphylococci.

RAISUS is a system for rapid bacterial identification and antimicrobial susceptibility testing. RAISUS and VITEK showed 97.8% and 75.9% agreement in identification of 45 Staphylococcus aureus strains and 58 coagulase-negative staphylococci (CoNS), respectively, and RAISUS and CLSI (formerly NCCLS) methods showed 87.2% and 87.9% agreement in the MICs for S. aureus and CoNS, respectively. RAISUS provided these data within 3.75 h, suggesting its utility for clinical bacteriological laboratories.

Does incineration turn infectious waste aseptic?

Incineration of infectious waste is considered to be biologically safe. We performed basic experiments to confirm that bacillus spores are killed by incineration in a muffle furnace. Biological samples containing 10(6) spores of Bacillus stearothermophilus were placed in stainless steel Petri dishes and then into hot furnaces. The furnace temperature and duration of incineration were 300 degrees C for 15 min, 300 degrees C for 30 min, 500 degrees C for 15 min, 500 degrees C for 30 min and 1100 degrees C for 3 min. We confirmed that all spores of B. stearothermophilus were killed at each of these settings. The effect of incineration seems to be equivalent to that of sterilization, based on the satisfactory sterilization assurance level of 10(-6).

Pigment epithelium-derived factor induces pro-survival genes through cyclic AMP-responsive element binding protein and nuclear factor kappa B activation in rat cultured cerebellar granule cells: Implication for its neuroprotective effect.

Pigment epithelium-derived factor (PEDF) protects immature cerebellar granule cell neurons (CGCs) against apoptosis induced by K+ and serum deprivation. However, the precise mechanism of this protection remains unknown. We recently reported that the transcription factor nuclear factor kappa B (NF-kappaB) is activated in PEDF-treated CGCs. Although it is well known that NF-kappaB blocks apoptotic cell death through the induction of pro-survival factors, the effects of PEDF on the expression of these factors are not fully understood. In this study, we employed the use of reverse transcriptase-polymerase chain reaction to analyze the gene expression of certain pro-survival genes and found that genes such as c-IAP1, c-IAP2, FLIPs, A1/Bfl-1 and Mn-SOD were induced in PEDF-treated neurons. On the other hand, no induction was observed of the pro-apoptotic Bcl-2 family members Bax and Bid at any time from 3 to 24 h following PEDF addition. Furthermore, phosphorylation of cyclic AMP-responsive element binding protein (CREB) and increment of nuclear cyclic AMP-response element (CRE)-like DNA binding were observed in PEDF-treated CGCs. The anti-apoptotic effect of PEDF was blocked by overexpression of dominant negative CREB or a mutated form of IkappaBalpha. These results suggested that induction of both CRE- and NF-kappaB-dependent genes is required for the observed neuroprotective effects of PEDF on CGCs.

Residual formaldehyde on plastic materials and medical equipment following low-temperature steam and formaldehyde sterilization.

We measured the amount of residual formaldehyde on 16 plastic materials and five medical devices following low-temperature steam and formaldehyde (LTSF) sterilization, based on the European Standard EN14180. The amounts of formaldehyde residue on the plastic materials were compared with that on a filter paper of similar dimensions. The amount of residual formaldehyde on polyamide 6, polyurethane, natural rubber and polyacetal was higher (21.9, 15.2, 3.0 and 2.1 times, respectively) than that on the filter paper. The amount of formaldehyde recovered from a breathing circuit, anaesthesia circuit, oxygen tubing, airway tube and tweezers was 260, 240, 594, 56 and 0 microg, respectively, following LTSF sterilization. Our results emphasize the need to verify the main material composing the medical equipment before LTSF sterilization, as the amount of formaldehyde retrieved following sterilization varies according to the material used for construction.

A new method to establish the rational extent of hepatic resection for advanced gallbladder cancer using dye injection through the cystic artery.

BACKGROUND: Hepatic resection has been indicated to eliminate cancer at the surgical margin in cases of advanced gallbladder carcinoma, but there is considerable controversy about the reasonable extent of liver resection. A new on-table dye injection technique has been introduced to determine the venous drainage of the gallbladder and ascertain the amount of liver to remove. METHODS: In four hepatic resections for pT2 gallbladder cancer, indocyanine green solution (25 mg/20 ml) was injected over a period of 30 seconds through the cystic artery. The stained area of the liver surface was completely resected, maintaining a margin of at least 2 cm from the gallbladder. RESULTS: The entire serosal surface of the gallbladder takes on a light green stain immediately after dye injection, and then the liver surface around the gallbladder gradually becomes stained with a clear demarcation line. The distance between the demarcation line and the gallbladder ranged from 1.0 to 5.0 cm. The extent of the stained area differed from one individual to another. Histopathological examination of resected liver specimens revealed that one of the four resected livers had micrometastasis in the portal area 27 mm from the gallbladder wall and there were no cancer cells at the surgical margins. No recurrence has been seen in any of our 4 patients at 16-26 months after operation. DISCUSSION: The dye injection method is useful in determining the appropriate extent of hepatic resection for advanced gallbladder cancer, as it is possible to determine the necessary and sufficient amount of liver parenchyma that should be removed according to the perfusion area of the cystic veins in each individual patient.

Evaluation of a low-temperature steam and formaldehyde sterilizer.

We evaluated a low-temperature steam and formaldehyde (LTSF) sterilizer based on the draft European Standard prEN 14180. Microbiological tests were conducted on small and full loads using process challenge devices in five programs (P1-P5). With small loads all tests showed no growth of Bacillus stearothermophilus (ATCC7953) spores. However, positive cultures were observed with full-load tests using P5 (sterilization temperature, 50 degrees C). Our data indicated that the load influenced the efficacy of the LTSF sterilizer. Desorption tests were conducted to determine residual formaldehyde in indicator strips. The mean concentrations of formaldehyde in P1-P5 were 31.9, 56.3, 54.9, 82.2 and 180.6 microg, respectively, which are below the limits allowed by the draft Standard. Our results indicate that the LTSF sterilizer is useful for sterilization because of its excellent efficacy, short handling time, and safety.

Quantitative determination of gelatinase activity among enterococci.

Gelatinase, hemolysin and aggregation substance have all been reported to be virulence factors of enterococci. In this study, gelatinase production was investigated in isolates of Enterococcus faecalis (n=93), E. faecium (n=49) and E. avium (n=36) recovered from hospitalized patients. Gelatinase was detected in 45% of E. faecalis isolates, but could not be detected in E. faecium and E. avium. Gelatinase activity was then measured by radial diffusion for the 42 gelatinase-positive E. faecalis isolates. To convert gelatinase activity into proteinase K activity, a standard curve was produced by placing different concentrations of proteinase K into wells in the gelatine plate. Gelatinase activity per E. faecalis colony ranged from 2.6 x 10(-7) to 2.2 x 10(-5) microg/ml, proportionate to the activity of proteinase K. An approximately 84-fold difference in gelatinase concentration was observed between the colony producing the highest amount and that producing the lowest amount. This method may be useful for determining the virulence of given isolates in relation to gelatinase production as it is quick, easy and inexpensive to perform.

Characterization of MRSA transmission in an emergency medical center by sequence analysis of the 3'-end region of the coagulase gene.

The distribution of methicillin-resistant Staphylococcus aureus (MRSA) isolates at the St. Marianna University affiliated emergency medical center (EMC) was studied by sequence analysis of the 3'-end region of the coagulase gene. We collected a total of 42 MRSA isolates, consisting of 20 strains from the hospital environment, 13 strains from the nostrils or fingers of medical staff, and 9 strains from inpatients in the EMC. We compared our results with those from 27 stock strains of known coagulase serotype and 2 strains reported in the literature. All 69 strains tested have four to six tandem repeats in the 3'-end region of the coagulase gene. Among the 42 MRSA isolates collected, the base sequence of the 3'-end region of the coagulase gene was identical in 28 of them (67%). The number of isolates originating from the hospital environment, medical staff, and patients, respectively, that were identical to this representative strain were 18 (90%), 6 (46%), and 4 (44%). Phylogenetic analysis using the DNA sequences of the tandem repeat region demonstrated that almost all strains from the patients formed a concordant cluster with the representative strain from the hospital ward. We also assessed the value of sequence analysis of the 3'-end region of the coagulase gene as an epidemiological marker. Our results indicate that sequence analysis of the 3'-end region of the coagulase gene of MRSA may be a potent epidemiologic typing system.

Vascular encasement by pancreatic cancer: correlation of CT findings with surgical and pathologic results.

PURPOSE: The purpose of this study was to correlate thin-slice high-resolution helical CT findings of arterial and venous involvement in pancreatic cancers with surgical and histopathologic results. METHOD: Forty-eight patients with pancreatic cancer underwent preoperative thin-slice high-resolution helical CT, followed by surgical dissection of the pancreatic vessels during curative or palliative surgery. Major vessels running within 1 cm from the tumor margin were evaluated. CT appearance was graded on a 0-4 scale (0: none, 1: <24%, 2: 25-49%, 3: 50-74%, 4: 75-100%) by circumferential contiguity of tumor to vessels. Resected specimens were available from 26 patients. RESULTS: Surgical correlation of CT findings was available in 89 veins and 83 arteries, and both surgical and histologic correlation was available for 42 veins and 29 arteries. At surgical observation, 29 of 35 veins (82.9%) evaluated as CT grade 3 or 4 were found to be involved, whereas only 18 of 30 arteries (60%) evaluated as CT grade 3 or 4 were proved to be involved. On microscopic observation, tumor invasion to the portal venous systems was confirmed in 15 of 42 (35.7%) vessels, and this invasion was depicted as from CT grades 1 to 4. In arteries, tumor invasion was seen in 3 of 29 vessels (10.3%), all of which were graded as 3 or 4 by CT. CONCLUSION: The grading system of vascular invasion should differ between arteries and veins. Involvement of the venous system exceeding one-half circumference of the vessels (grade 3 or 4) was suggestive of vascular invasion; however, this criterion was not always satisfactory for the evaluation of tumor invasion in the arterial system.

Lymphatic spreading pattern of intrahepatic cholangiocarcinoma.

BACKGROUND: There have been very few reports on the pattern of lymphatic spread of intrahepatic cholangiocarcinoma. This pattern was elucidated to help define the rational extent of radical lymph node dissection. METHODS: Thirty-nine consecutive patients who underwent hepatectomy with radical lymph node dissection were reviewed retrospectively. RESULTS: Lymph node metastases were detected in 24 of the 39 patients (62%). The metastatic nodes were found in the hepatoduodenal ligament, along the common hepatic artery, around the abdominal aorta, on the posterior surface of the pancreas head, along the left gastric artery, along the superior mesenteric artery, around the celiac artery, along the lesser curvature of the stomach, and around the cardia. The nodal involvements along the left gastric artery, along the lesser curvature, or around the cardia were recognized only in the left peripheral and hilar types of cholangiocarcinoma, while all other sites included both the left or right peripheral type and the hilar type cholangiocarcinoma. CONCLUSIONS: Intrahepatic cholangiocarcinomas, irrespective of their intrahepatic location, mainly spread to the nodes in the hepatoduodenal ligament, then to the para-aortic nodes, retropancreatic nodes, or common hepatic artery nodes. In addition to these spreading routes, the left peripheral type or hilar type of cholangiocarcinoma tends to spread along the left gastric nodes through the lesser curvature.