Shortage of paediatric radiologists acting as an expert witness: position statement from the British Society of Paediatric Radiology (BSPR) National Working Group on Imaging in Suspected Physical Abuse (SPA).

One of the most challenging areas of radiological imaging in children is the diagnosis of physical abuse. There is a dearth of paediatric radiologists willing to act as expert witnesses, particularly in the family courts. There are a number of reasons why radiologists may not be interested or willing to put themselves forward to work as expert witnesses in this field. A group of imaging experts recently formed the "British Society of Paediatric Radiology (BSPR) Working Group on Imaging in Suspected Physical Abuse (SPA)". The group comprises radiologists and neuroradiologists with current or previous experience of providing expert witness reports to the court in cases of SPA. The group met in January 2019 to explore pragmatic solutions to the chronic inefficiencies in both medical and legal practices and the challenges that arise from working in a legal arena with different structures, goals, and assessment criteria. Key issues concerned organisational inefficiencies, variable support from National Health Service Trusts and the Royal College of Radiologists to conduct this work, and the risk/benefit of involvement. This work is important for the patient, parents, and society in general, and highly rewarding for clinical practitioners who are involved, but there are several issues with current practices that discourage active participation. With several members of the group either retired or close to retirement, the shortage of experts is becoming a pressing issue within the UK, which requires an engaged multidisciplinary group to come up with creative solutions. Here, the group provide a consensus opinion highlighting the current barriers and potential facilitators to increasing the number of radiologists willing to provide opinions to the court.

Hand hygiene compliance monitoring in anaesthetics: Feasibility and validity.

BACKGROUND: Hand hygiene compliance scores in the anaesthetic department of an acute NHS hospital were persistently low. AIMS: To determine the feasibility and validity of regular accurate measurement of HHC in anaesthetics and understand the context of care delivery, barriers and opportunities to improve compliance. METHODS: The hand hygiene compliance of one anaesthetist was observed and noted by a senior infection control practitioner (ICP). This was compared to the World Health Organization five moments of hand hygiene and the organisation hand hygiene tool. FINDINGS: In one sequence of 55 min, there were approximately 58 hand hygiene opportunities. The hand hygiene compliance rate was 16%. The frequency and speed of actions in certain periods of care delivery made compliance measurement difficult and potentially unreliable. During several activities, taking time to apply alcohol gel or wash hands would have put the patients at significant risk. DISCUSSION: We concluded that hand hygiene compliance monitoring by direct observation was invalid and unreliable in this specialty. It is important that hand hygiene compliance is optimal in anaesthetics particularly before patient contact. Interventions which reduce environmental and patient contamination, such as cleaning the patient and environment, could ensure anaesthetists encounter fewer micro-organisms in this specialty.

Impact of observing hand hygiene in practice and research: a methodological reconsideration.

The purpose of hand hygiene is to break the chain of healthcare-associated infection. In many countries hand hygiene is regularly audited as part of quality assurance based on recommendations from the World Health Organization. Direct observation is the recommended audit method but is associated with disadvantages, including potential for being observed to alter usual behaviour. The Hawthorne effect in relation to hand hygiene is analogous with productivity improvement by increasing the frequency with which hand hygiene is undertaken. Unobtrusive and/or frequent observation to accustom staff to the presence of observers is considered an acceptable way of reducing the Hawthorne effect, but few publications have discussed how to implement these techniques or examine their effectiveness. There is evidence that awareness of being watched can disrupt the usual behaviour of individuals in complex and unpredictable ways other than simple productivity effect. In the presence of auditors, health workers might defer or avoid activities that require hand hygiene, but these issues are not addressed in guidelines for practice or research studies. This oversight has implications for the validity of hand hygiene audit findings. Measuring hand hygiene product use overcomes avoidance tactics. It is cheaper and generates data continuously to assess the compliance of all clinicians without disrupting patient care. Disadvantages are the risk of overestimating uptake through spillage, wastage, or use by visitors and non-clinical staff entering patient care areas. Electronic devices may overcome the Hawthorne and avoidance effects but are costly and are not widely used outside research studies.

Efficacy of two hydrogen peroxide vapour aerial decontamination systems for enhanced disinfection of meticillin-resistant Staphylococcus aureus, Klebsiella pneumoniae and Clostridium difficile in single isolation rooms.

BACKGROUND: Hydrogen peroxide vapour (HPV) disinfection systems are being used to reduce patients' exposure to hospital pathogens in the environment. HPV whole-room aerial disinfection systems may vary in terms of operating concentration and mode of delivery. AIM: To assess the efficacy of two HPV systems (HPS1 and HPS2) for whole-room aerial disinfection of single isolation rooms (SIRs). METHODS: Ten SIRs were selected for manual terminal disinfection after patient discharge. Test coupons seeded with biological indicator (BI) organisms [∼10(6) colony-forming units (cfu) of meticillin-resistant Staphylococcus aureus (MRSA) or Klebsiella pneumoniae, or ∼10(5)cfu Clostridium difficile 027 spores] prepared in a soil challenge were placed at five locations per room. For each cycle, 22 high-frequency-touch surfaces in SIRs were sampled with contact plates (∼25cm(2)) before and after HPV decontamination, and BIs were assayed for the persistence of pathogens. FINDINGS: Approximately 95% of 214 sites were contaminated with bacteria after manual terminal disinfection, with high numbers present on the SIR floor (238.0-352.5cfu), bed control panel (24.0-33.5cfu), and nurse call button (21.5-7.0cfu). Enhanced disinfection using HPV reduced surface contamination to low levels: HPS1 [0.25cfu, interquartile range (IQR) 0-1.13] and HPS2 (0.5cfu, IQR 0-2.0). Both systems demonstrated similar turnaround times (∼2-2.5h), and no differences were observed in the efficacy of the two systems against BIs (C. difficile ∼5.1log10 reduction; MRSA/K. pneumoniae ∼6.3log10 reduction). Despite different operating concentrations of hydrogen peroxide, MRSA persisted on 27% of coupons after HPV decontamination. CONCLUSION: Enhanced disinfection with HPV reduces surface contamination left by manual terminal cleaning, minimizing the risks of cross-contamination. The starting concentration and mode of delivery of hydrogen peroxide may not improve the efficacy of decontamination in practice, and therefore the choice of HPV system may be based upon other considerations such as cost, convenience and logistics.

Collecting the data but missing the point: validity of hand hygiene audit data.

BACKGROUND: Monitoring of hand hygiene compliance (HHC) by observation has been used in healthcare for more than a decade to provide assurance of infection control practice. The validity of this information is rarely tested. AIM: To examine the process and validity of collecting and reporting HHC data based on direct observation of compliance. METHODS: Five years of HHC data routinely collected in one large National Health Service hospital trust were examined. The data collection process was reviewed by survey and interview of the auditors. HHC data collected for other research purposes undertaken during this period were compared with the organizational data set. FINDINGS: After an initial increase, the reported HHC remained unchanged close to its intended target throughout this period. Examination of the data collection process revealed changes, including local interpretations of the data collection system, which invalidated the results. A minority of auditors had received formal training in observation and feedback of results. CONCLUSION: Whereas observation of HHC is the current gold standard, unless data collection definitions and methods are unambiguous, published, carefully supervised, and regularly monitored, variations may occur which affect the validity of the data. If the purpose of HHC monitoring is to improve practice and minimize transmission of infection, then a focus on progressively improving performance rather than on achieving a target may offer greater opportunities to achieve this.

Performance of ultramicrofibre cleaning technology with or without addition of a novel copper-based biocide.

This study compared the bacterial removal performance of ultramicrofibre cloths and mops (UMF) moistened with water (UMF+water), with those moistened with a novel copper-based biocide (UMF+CuWB50, 300ppm) in several working hospital environments, specifically accident and emergency (A&E) and three other wards. A total of 13 defined sampling sites (10 sites per ward) were sampled in order to retrieve, culture, and enumerate total viable (bacterial) counts (TVC) for each site. We sampled 1h before, and 1 and 4h after, cleaning three times per week. The trial ran for 7 weeks. Two wards were cleaned with UMF+water for 3 weeks, and UMF+CuWB50 for 4 weeks. The reverse applied to the other two wards in a cross-over design fashion, to eliminate ward- and time-specific bias. Multivariate statistical analyses were used to establish extent and significance of any perceived differences, and to eliminate the effects of potential confounders. Cleaning with UMF+water reduced TVC on the test surfaces by 30%, whereas cleaning with TVC+CuWB50 reduced TVC by 56%. CuWB50 had two separate effects; a direct antibacterial effect (evident shortly after cleaning), and a residual antibacterial effect that lasted approximately 2 weeks. The residual effect requires regular application of CuWB50 if it is to persist. This 'real life' hospital implementation study demonstrates encouraging microbiological cleaning performance for UMF, which is further enhanced with CuWB50.

Severe invasive Panton-Valentine Leucocidin positive Staphylococcus aureus infections in children in London, UK.

OBJECTIVE: To describe the features of invasive Panton-Valentine Leucocidin positive Staphylococcus aureus (PVL-SA) in children at a London teaching hospital, from 2004 to 2008. METHODS: Retrospective case note review. RESULTS: Eleven previously healthy children, 7 male, median age 9 years (range 7 months-13 years), had invasive infections due to unrelated community-acquired meticillin-sensitive PVL-SA. Possible risk factors were identified in 10 cases. Eight patients had complicated musculoskeletal infections, 2 had pneumonia, and 1 had a massive retropharyngeal abscess. At admission neutropenia was present in 2 patients, deep vein thrombosis in 3, and initial blood cultures were positive in 8. Patients with musculoskeletal involvement had a median of 3 (range 1-6) sites of infection, and required median 5 (range 1-11) operative procedures. Eight patients were admitted to PICU, 7 had septic shock. Median duration of hospital stay was 51 (range 14-255) days. One child died and 5 have long-term morbidity. CONCLUSIONS: The clinical features of invasive PVL-SA in this series were similar to those reported from USA and Europe. Musculoskeletal infection was the most common manifestation, frequently progressing to multiple sites and severe sepsis. Most cases had risk factors and clinical features which might have allowed earlier diagnosis, and possibly improved outcome.

Effectiveness of short-term, enhanced, infection control support in improving compliance with infection control guidelines and practice in nursing homes: a cluster randomized trial.

In this prospective cluster randomized controlled trial we evaluated the impact of short-term provision of enhanced infection control support on infection control practice in nursing homes in South London. Twelve nursing homes were recruited, six each in intervention (300 residents) and control (265 residents) groups. Baseline observations of hand hygiene facilities, environmental cleanliness and safe disposal of clinical waste showed poor compliance in both groups. Post-intervention observations showed improvement in both groups. There was no statistical difference between the two groups in the compliance for hand hygiene facilities (P=0.69); environmental cleanliness (P=0.43) and safe disposal of clinical waste (P=0.96). In both groups, greatest improvement was in compliance with safe disposal of clinical waste and the least improvement was in hand hygiene facilities. Since infection control practice improved in intervention and control groups, we could not demonstrate that provision of short-term, enhanced, infection control support in nursing homes had a significant impact in infection control practice.

Cadherins and cancer: how does cadherin dysfunction promote tumor progression?

It has long been recognized that the cell-cell adhesion receptor, E-cadherin, is an important determinant of tumor progression, serving as a suppressor of invasion and metastasis in many contexts. Yet how the loss of E-cadherin function promotes tumor progression is poorly understood. In this review, we focus on three potential underlying mechanisms: the capacity of E-cadherin to regulate beta-catenin signaling in the canonical Wnt pathway; its potential to inhibit mitogenic signaling through growth factor receptors and the possible links between cadherins and the molecular determinants of epithelial polarity. Each of these potential mechanisms provides insights into the complexity that is likely responsible for the tumor-suppressive action of E-cadherin.

Removing bacteria from hospital surfaces: a laboratory comparison of ultramicrofibre and standard cloths.

We compared the ability of ultramicrofibre-woven cloths with conventional cloths moistened with water only, for their ability to remove several types of organisms relevant to hospital-acquired infections from a variety of surfaces in hospitals. We showed that ultramicrofibre cloths consistently outperformed conventional cloths in their decontamination ability, across all surfaces, and irrespective of whether the bacteria were coated on to the surfaces with phosphate-buffered saline (PBS) or PBS containing horse serum to simulate real-life soiling. The ability of the cloths to remove bacteria from surfaces was assessed by contact plating and colony formation, and by swabbing and measurement of ATP bioluminescence. The results suggest potential for use of ultramicrofibre in healthcare environments. Further studies are required, however, to define accurately how these cloths, which are designed to be used without detergent or biocides, might be capable of safe and effective deployment and recycling in the healthcare environment.

Gab2 and Src co-operate in human mammary epithelial cells to promote growth factor independence and disruption of acinar morphogenesis.

The Gab2 docking protein is a target of several oncogenic protein tyrosine kinases and potentiates activation of the Ras/extracellular signal regulated kinase and phosphatidylinositol 3-kinase (PI3-kinase) pathways. Since Gab2 is phosphorylated by c-Src, and both proteins are overexpressed in breast cancers, we have determined the biological consequences of their co-expression in the immortalized human mammary epithelial cell line MCF-10A. While overexpression of c-Src did not affect acinar morphogenesis or growth factor dependence in three-dimensional culture, c-Src co-operated with Gab2 to promote epidermal growth factor (EGF)-independent acinar growth. In contrast, expression of v-Src or the activated mutant c-SrcY527F led to a spectrum of aberrant phenotypes ranging from spheroids with incomplete luminal clearance to highly disrupted, dispersed structures. Gab2 co-expression shifted the phenotypic distribution towards the dispersed phenotype, an effect not observed with a Gab2 mutant unable to bind the p85 subunit of PI3-kinase (Gab2Deltap85). In v-Src-expressing cells, Gab2, but not Gab2Deltap85, significantly decreased E-cadherin adhesive strength without altering its surface expression. Gab2 associated with E-cadherin in the presence and absence of v-Src, indicating that the ability of Gab2 to weaken the strength of cell-cell contacts may reflect enhanced activation of PI3-kinase at adherens junctions. Gab2 also increased migration and invasion of these cells in transwell assays, but these effects were p85-independent. Overall, these findings demonstrate a novel mechanism whereby Gab2 may promote metastatic spread and indicate that Gab2 may play several roles during breast cancer progression.

Impact of rapid molecular screening for meticillin-resistant Staphylococcus aureus in surgical wards.

BACKGROUND: This study aimed to establish the feasibility and cost-effectiveness of rapid molecular screening for hospital-acquired meticillin-resistant Staphylococcus aureus (MRSA) in surgical patients within a teaching hospital. METHODS: In 2006, nasal swabs were obtained before surgery from all patients undergoing elective and emergency procedures, and screened for MRSA using a rapid molecular technique. MRSA-positive patients were started on suppression therapy of mupirocin nasal ointment (2 per cent) and undiluted chlorhexidine gluconate bodywash. RESULTS: A total of 18,810 samples were processed, of which 850 (4.5 per cent) were MRSA positive. In comparison to the annual mean for the preceding 6 years, MRSA bacteraemia fell by 38.5 per cent (P < 0.001), and MRSA wound isolates fell by 12.7 per cent (P = 0.031). The reduction in MRSA bacteraemia and wound infection was equivalent to a saving of 3.78 beds per year (276,220 pounds sterling), compared with the annual mean for the preceding 6 years. The cost of screening was 302,500 pounds sterling, making a net loss of 26,280 pounds sterling. Compared with 2005, however, there was a net saving of 545,486 pounds sterling. CONCLUSION: Rapid MRSA screening of all surgical admissions resulted in a significant reduction in staphylococcal bacteraemia during the screening period, although a causal link cannot be established.

Marketing hand hygiene in hospitals--a case study.

Hand hygiene of healthcare workers is frequently poor despite the efforts of infection control teams to promote hand decontamination as the most important method to prevent transmission of hospital-acquired infections. In this case study, we describe how principles of societal marketing were applied to improve hand hygiene. Pre-marketing analysis of strengths, weaknesses, opportunities and threats to implementation; attention to product, price, promotion and placement; and post-marketing 'customer' surveys were the essential components of the marketing strategy and its implementation. Placement of an alcohol-based gel decontaminant (Spirigel) at the bedside of every patient was widely welcomed in the hospital, and has played a major role in improving hand hygiene of healthcare workers. In the twelve months following the implementation, the decontaminant was used at least 440,000 times. The cost of purchasing the decontaminant was approximately 5000 pounds sterling. Following the introduction of Spirigel, there was a consistent reduction in the proportion of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) in each of the quarters of 2000-2001 compared with 1999-2000. In the period 1999-2000, nearly 50% of the MRSA were hospital acquired compared with 39% in 2000-2001. Similarly, the average incidence of Clostridium difficile associated diarrhoea (CDAD) decreased in each of the quarters in 2000-2001 following the introduction of Spirigel. During this period, there was an average incidence of 9.5 cases of CDAD/1000 admissions compared with 11.5 cases of CDAD/1000 admissions in 1999-2000. This represents a 17.4% reduction in the incidence of CDAD. However, this reduction was not statistically significant (P=0.2). Our case study demonstrates that principles of societal marketing methods can be used effectively to promote and sustain hand hygiene in hospitals. Improvement in hand hygiene will lead to considerable reduction in hospital-acquired infections.