Recall and patient perceptions of hip precautions 6 weeks after total hip arthroplasty.

Background and purpose - There is a lack of evidence to support the role of hip precautions in preventing dislocation following total hip arthroplasty (THA). We report an exploratory study which assesses recall, adherence, and the impact of precautions on activities of daily living in the first 6 weeks postoperatively. Patients and methods - We designed a new questionnaire based on the education patients receive and refined by professionals within our multidisciplinary team. 129 patients underwent primary elective THA during the study period and received the questionnaire at 6 weeks postoperatively. Results - 97 (75%) patients responded before the 8th week postoperatively. Most of these (83 patients) could remember all the precautions. Of the 97 who responded only 22 claimed to adhere to all of the precautions. 48 admitted to putting their own underwear on without the use of aids or assistance, and 38 had started walking without an aid. Due to the precautions 67 avoided leaving the house at some point and 63 were unable to perform desired activities. 84 stated that their sleep was affected. There were no dislocations among the 97 patients who responded; however, there was 1 dislocation among the 32 non-responders. Interpretation - We found that most patients did not adhere to hip precaution advice. Precautions have a detrimental effect on patient activity and sleep. In view of the limited efficacy in reducing dislocation rate, we question the use of precautions in the primary arthroplasty setting.

Experience of vancomycin-resistant enterococci in a children's hospital.

Vancomycin resistant enterococci (VRE) are increasingly important nosocomial pathogens. This paper describes our experience of the epidemiology and clinical impact of VRE in the two years since the occurrence of our first case of VRE infection. Following introduction of surveillance, gastrointestinal colonization with VRE was detected in 38.3% of Haematology/Oncology and 11.1% of Hepatology/Gastroenterology patients, but in only 2.3% of children in the Paediatric Intensive Care and 1.5% of children in the Renal Unit. Only five patients with gastrointestinal colonization subsequently developed clinical infection with VRE, giving an annual incidence of 7.5%. A further six children were colonized at extra-intestinal sites. Twelve children had clinical infections with VRE, of whom three (25%) died. Contamination of bedspaces was found in association with 2/3 (66.7%) children with extraintestinal colonization and 5/7 (71.4%) children with clinical infections, compared with 6/28 (21.4%) cases of gastrointestinal colonization. In the latter group, bedspace contamination was usually associated with widespread contamination of the ward with VRE and may have been the cause rather than the result of patients acquiring VRE. Originally we employed control measures based closely on the North American HICPAC guidelines, but our control strategy has since evolved in response to epidemiological and clinical observations.

An outbreak of Bacillus cereus respiratory tract infections on a neonatal unit due to contaminated ventilator circuits.

An outbreak of Bacillus cereus respiratory tract infections affecting six ventilated preterm neonates over a two-week period is described. Reusable ventilator circuits were identified as the cause of the outbreak. Ordinarily these were reprocessed on the Neonatal Unit (NNU), first through a washing machine and then through a low-temperature steam (LTS) disinfector. The onset of the outbreak coincided with a breakdown of the LTS facility, which necessitated sending the washed circuits off site for LTS disinfection. The washing machine was shown to be contaminated with the same serovars of B. cereus as those isolated from patients. Two critical steps in the off site LTS disinfection process allowed exsporulation and multiplication of B. cereus: the circuits were inadequately dried after processing, whilst return of the moist circuits to the NNU was often delayed. The outbreak was terminated by withdrawal of the heat-disinfected ventilator circuits. This outbreak emphasizes the need for high standards where medical equipment is reprocessed, especially for use in vulnerable patients.

Thermal independence of muscle tissue metabolism in the leatherback turtle, Dermochelys coriacea.

Metabolic rates of animal tissues typically increase with increasing temperature and thermoregulatory control in an animal is a regional or whole body process. Here we report that metabolic rates of isolated leatherback turtle (Dermochelys coriacea) pectoralis muscle are independent of temperature from 5-38 degrees C (Q10 = 1). Conversely, metabolic rates of green turtle (Chelonia mydas) pectoralis muscle exhibit a typical vertebrate response and increase with increasing temperature (Q10 = 1.3-3.0). Leatherbacks traverse oceanic waters with dramatic temperature differences during their migrations from sub-polar to equatorial regions. The metabolic stability of leatherback muscle effectively uncouples resting muscle metabolism from thermal constraints typical of other vertebrate tissues. Unique muscle physiology of leatherbacks has important implications for understanding vertebrate muscle function, and is another strong argument for preservation of this endangered species.

Reducing bacterial contamination of enteral feeds.

OBJECTIVE: It has previously been shown that microbial contamination of enteral feeds given to children in hospital and at home is common. This study therefore examined the effects of improvements in the enteral feeding protocol, coupled with an intensive staff training programme, on bacterial contamination. METHODS: The enteral feeding protocol was modified by: priming the feeding set on an alcohol treated metal tray, spraying the bottle opener and top with 70% alcohol, wearing non-sterile disposable gloves, and filling the feeding reservoir with feed for up to 24 hours' use rather than only four hours. Daily feeds samples were collected from 16 inpatients and home patients on enteral nutrition at the start and end of feeding. Seventy seven samples were cultured. Results were compared with previously published control data. RESULTS: Enteral feed contamination rates were reduced significantly from 62% to 6% of feeds given at home (p < 0.001), and from 45% to 4% of feeds given in hospital (p < 0.001). CONCLUSIONS: This study highlights the importance of using an appropriate enteral feeding protocol, and of regular staff training in reducing contamination rates of enteral feeds to an acceptable level.

Central venous catheter-related septicaemia in paediatric cancer patients.

A prospective study of septicaemia, with special reference to central venous catheter (CVC)-related septicaemia, was performed over a nine-month period in paediatric cancer patients undergoing anti-neoplastic therapy. A total of 142 patients with 153 CVCs were included in the study. Seventy-two episodes of septicaemia were detected in 66 patients; overall, 46% of patients developed one or more episodes of septicaemia. Thirty-nine (54%) of these episodes occurring in 34 patients were CVC-related. Twenty-one (29%) of the episodes occurring in twenty patients were probably unrelated to CVCs and 12 (17%) episodes in 12 patients were of uncertain source. A total of 22932 CVC days were studied. The rate of CVC-related septicaemia was 1.7 episodes/1000 catheter days. Gram-positive organisms were commonest, causing 34 (87%) episodes of CVC-related septicaemia. Twenty-five (71%) of 35 evaluable episodes were successfully treated with antibiotics without CVC removal. Two patients died, CVC related sepsis probably contributing to death, and one patient suffered prolonged morbidity associated with CVC sepsis. Gram-negative organisms were the commonest cause of CVC-unrelated septicaemia, being implicated in 13 (62%) episodes.

Bacterial contamination of enteral feeds.

Enteral nutrition is increasingly used to provide nutritional support for children in hospital and at home. No suitable formula is available for preschool children, however, and until recently a modular feed has been prepared. The hypotheses were examined that the use of a modular feed is associated with increased bacterial contamination, and that contamination is more common in the home than in hospital. Thirty five children receiving enteral nutrition initially in hospital and subsequently at home were allocated randomly to receive either a modular feed or a newly available sterile ready to use paediatric feed. Samples of feed were taken from the nutrient container immediately after filling and at the end of feeding. The results show that feed contamination is common in hospital and at home, but significantly more so at home. The data indicate the importance of hygiene training for parents and the desirability of a ready to use formula.

Staff training: a key factor in reducing intravascular catheter sepsis.

A children's hospital nutritional care team prospectively monitored the frequency of sepsis in central venous catheters used for administering parenteral nutrition. During an initial study period of 12 months, 26/58 (45%) of catheters were removed because of proved sepsis. The possible causes of this alarmingly high rate were examined, with catheter care techniques on the wards coming under particular scrutiny. As a result protocols were modified and an intensive staff training programme implemented throughout the hospital, led by the nutritional care sister. Subsequently, the catheter sepsis rate was significantly reduced with only 9/107 (8%) of consecutive catheters becoming infected. These findings emphasise the key role that education of staff plays in controlling central venous catheter sepsis and the importance and cost effectiveness of special nursing staff in implementing such measures.

Dietary management of D-lactic acidosis in short bowel syndrome.

Manipulation of carbohydrate intake was used to treat severe, recurrent D-lactic acidosis in a patient with short bowel syndrome. Dietary carbohydrate composition was determined after assessment of D-lactic acid production from various carbohydrate substrates by faecal flora in vitro. This approach may be preferable to repeated courses of antibiotics.

Evaluation of use of Signal system of blood culture in paediatrics.

A new method of blood culture, the Signal system (Oxoid), was assessed in paediatric practice. Isolation rates of pathogens, frequency of contamination (false positive results), and time taken to detect positive cultures were analysed. Four hundred and seventy nine organisms were isolated from 457 of 3000 cultures collected, of which 283 organisms were considered to be clinically important. The overall rate of positive cultures was 15.2%, and clinically important organisms were isolated from 9.1%, giving an overall contamination rate of 6.1%. The rate of contamination with Gram positive bacilli was 1.1% and coagulase negative staphylococci 4.2%. Over 51.6% of all isolates were detected within 24 hours, 81% within 48 hours, and 86% within three days: 91.1% of clinically important organisms were isolated within three days. Unimportant organisms tended to give a delayed signal, although this sometimes occurred with Candida spp, Klebsiella spp, Pseudomonas spp and a small number of other such organisms. Four hundred and forty nine of the 457 positive cultures gave a visible signal. Six of seven isolates of Haemophilus influenzae failed to give a signal, as did two coagulase negative staphylococci. The Signal system is a convenient and cost effective method of blood culture.

The prevention and control of mycobacterial infections in hospitals.

Infections resulting from contamination of medical equipment and medications with opportunistic mycobacteria are reviewed and the mode of spread discussed. The prevention of Mycobacterium tuberculosis in patients and staff, by the implementation of occupational health schemes, infection control policies and disinfection policies is also reviewed. The problems relating to immunocompromised patients are also discussed.