A Review of the Evidence on the Role of Floors and Shoes in the Dissemination of Pathogens in a Healthcare Setting.

Background: It is generally accepted that shoes and floors are contaminated with pathogens including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile, yet correlation to clinical infection is not well established. Because floors and shoes are low-touch surfaces, these are considered non-critical surfaces for cleaning and disinfection. The purpose of this review is to assess peer-reviewed literature inclusive of floors and shoe soles as contributors to the dissemination of infectious pathogens within healthcare settings. Methods: Using the Preferred Reporting Items for Systematic Reviews (PRISMA) methodology, PubMed and Medline were searched for articles assessing the presence of pathogens on or the transmission of pathogens between or from floors or shoe soles/shoe covers. Inclusion criteria are the human population within healthcare or controlled experimental settings after 1999 and available in English. Results: Four hundred eighteen articles were screened, and 18 articles documented recovery of bacterial and viral pathogens from both floors and shoes. Seventy-two percent (13/18) of these were published after 2015, showing increased consideration of the transfer of pathogens to high-touch surfaces from shoe soles or floors during patient care. Conclusions: There is evidence that floors and shoes in healthcare settings are contaminated with several different species of health-care-associated pathogens including MRSA, VRE, and Clostridium difficile.

Effectiveness versus Uptake: The Challenges of Implementing Evidence-Based Strategies to Reduce Surgical Site Infection in Patients with Colon Surgeries.

Background: National and international recommendations for the prevention of surgical site infection (SSI) were published six years ago, but little is known about implementation in colon surgeries. Methods: We conducted an observational study to evaluate the implementation of seven SSI-prevention elements in colon surgeries. Study coordinators recorded the implementation using an electronic case report. Surgeons completed a survey that identified key drivers of implementation. Three peer-to-peer calls and a study coordinator survey provided insights on the obstacles and drivers to implementation. Results: The elements ranged in compliance from 100% to below 1%. Absence of documentation in the electronic medical record (EMR), conflicting local policies, and a lack of standardization of processes and products were significant obstacles in implementation. Discussion: Standardizing peri-operative procedures may be accomplished by implementing guidelines. Using implementation science to reduce variability and stocking leads to product standardization with items that support evidence-based practices. Administration, material management, and surgical leadership all have a duty to the patient to reduce obstacles to implement evidence-based practices. Conclusions: Our study reveals variability in in the integration of published guidelines into clinical practice. Every surgical patient deserves the best possible care by using evidence-based guidelines and practices centered on reducing SSIs.

Effects of medical scribes on physician productivity in a Canadian emergency department: a pilot study.

BACKGROUND: Emergency department efficiency is a priority across Canada. In the United States, scribes may increase the number of patients seen per hour per physician; however, Canadian data are lacking. We sought to implement scribes in a Canadian emergency department with the hypothesis that scribes would increase the number of patients seen per hour per physician. METHODS: We conducted a 4-month quality improvement pilot study in a community emergency department in Ottawa, Ontario. Data collection began January 2015 after scribe training. Physicians received shifts with and without a scribe for a period of 4 months. Across the study, the mean number of patients seen per hour was determined for each physician during shifts with and without a scribe. We compared mean (± standard deviation [SD]) number of patients seen per hour based on presence or absence of a scribe by 2-tailed paired-samples t test. RESULTS: Eleven scribes participated and ranged in age from 18 to 23 years. Twenty-two full- or part-time emergency physicians were followed. We documented 463 physician-hours without use of a scribe and 693.75 physician-hours with use of a scribe. Across all 22 physicians, 18 (81.8%) saw more patients per hour with use of a scribe. Overall, the number of patients seen per hour per physician was significantly greater (+12.9%) during shifts with a scribe (mean [± SD] 2.81 [± 0.78]) than during shifts without a scribe (mean [± SD] 2.49 [± 0.60]; p = 0.006). INTERPRETATION: In this pilot study, the use of scribes resulted in an increased number of patients seen per hour per physician. Because this was a small study at a single centre, further research on the effects of scribes in Canada is warranted.

Xanthochromia is not pathognomonic for subarachnoid hemorrhage.

OBJECTIVE: To test the hypothesis that xanthochromia may be observed in traumatic lumbar puncture (LP). Xanthochromia, the yellow discoloration of cerebrospinal fluid (CSF) caused by hemoglobin catabolism, is classically thought to arise within several hours after subarachnoid hemorrhage (SAH). The presence of xanthochromic supernatant is often used to distinguish the elevated red blood cell (RBC) count observed in the CSF of SAH from the elevated RBC count observed after traumatic LP. METHODS: The authors developed a model of traumatic LP by adding whole blood to pigment-free CSF to obtain RBC concentrations of 0, 5000, 10000, 20000, 30000, and 40000 RBC/ microL. Supernatant from centrifuged samples was assessed for xanthochromia by spectrophotometry. Xanthochromia was considered present if the absorption followed a characteristic oxyhemoglobin curve with a maximal absorption greater than 0.023 at 415 nm. RESULTS: Samples with at least 30000 RBC/ microL demonstrated xanthochromia immediately. Samples with 20000 RBC/ microL demonstrated xanthochromia within one hour, and samples with 10000 RBC/ microL or less, within two hours. CONCLUSIONS: Cerebrospinal fluid xanthochromia may be observed within two hours after traumatic LP and sooner in samples with greater than 10000 RBC/ microL. Conversely, xanthochromia in traumatic LP with less than 5000 RBC warrants further investigation for SAH. When the CSF RBC count is elevated above 10000 RBC/ microL, or the time between sample acquisition and analysis is prolonged, the clinician should not rely on xanthochromia to confirm SAH.

Induction of thyroid-stimulating hormone receptor autoimmunity in hamsters.

Female Chinese hamsters (n = 10) were immunized with Chinese hamster ovary (CHO) cells that expressed the human TSH receptor (TSHR) to generate a model of Graves' disease. TSHR-autoantibodies (TSHR-Ab) were determined by CHO-TSHR. Two hamsters with stimulating TSHR-Ab showed thyrocyte hypertrophy associated with a focal lymphocytic infiltration. CHO-TSHR were then stimulated with interferon gamma to enhance major histocompatibility complex class II expression. However, after immunization no stimulating TSHR-Ab were detected, but blocking TSHR-Ab were found in three of five animals. The thyroid glands from these hamsters showed marked thinning of thyroid epithelial cells, indicative of early thyroid atrophy consistent with a TSHR blocking antibody, but no lymphocytic infiltration. Lastly, female Armenian hamsters were immunized with an adenovirus construct incorporating wild-type TSHR. High titers of TSHR-Ab were induced effectively, but the thyroid hypertrophy observed was not associated with a lymphocyte infiltration. In summary, we demonstrated that the hamster could serve as a model of TSHR autoimmunity and that an adenoviral vector produced higher levels of TSHR-Ab than more conventional immunization with cells. The data also indicated that the intrathyroidal cellular immunity in this model was not related to TSHR-Ab formation and was an independent reflection of the T-cell immune response to TSHR antigen.

Ligand-dependent inhibition of oligomerization at the human thyrotropin receptor.

Recently, several studies have reported oligomerization of G protein-coupled receptors, although the functional implications of this phenomenon are still unclear. Using fluorescence resonance energy transfer (FRET) and coimmunoprecipitation (COIP), we previously reported that the human thyrotropin (TSH) receptor tagged with green fluorescent protein (TSHR(GFP)) and expressed in a heterologous system was present as oligomeric complexes on the cell surface. Here, we have extended this biophysical and biochemical approach to study the regulation of such oligomeric complexes. Co-expression of TSHR(GFP) and TSHR(Myc) constructs in Chinese hamster ovary cells resulted in FRET-positive cells. The specificity of the FRET signal was verified by the absence of energy transfer in individually transfected TSHR(GFP) and TSHR(Myc):Cy3 cells cultured together and also by acceptor photobleaching. Occupation of the receptor molecule by the ligand (TSH) resulted in a dose-dependent decrease in the FRET index from 20% in the absence of TSH to <1% with 10(3) microunits/ml of TSH. Such reduction in oligomeric forms was also confirmed by coimmunoprecipitation. Exposure of TSHR(GFP/Myc) cells to forskolin or cytochalasin D caused no change in the FRET index, confirming that the decrease in the oligomeric complexes was a receptor-dependent phenomenon and free of energy or microtuble requirements. The TSH-induced decrease in TSHR oligomers was found to be secondary to dissociation of the TSHR complexes as evidenced by an increase in fluorescent intensity of photobleached spots of GFP fluorescence with 10(3) microunits/ml of TSH. These data indicated that the less active conformation of the TSHR was comprised of receptor complexes and that such complexes were dissociated on the binding of ligand. Such observations support the concept of a constitutively active TSHR dimer or monomer that is naturally inhibited by the formation of higher order complexes. Inhibition of these oligomeric forms by ligand binding returns the TSHR to an activated state.

The changing face of hand protection.

Perioperative nurses are empowered to act as patient advocates. As such, it is their responsibility to critically evaluate all products used in the surgical environment, including gloves. A basic understanding of the history of surgical gloves, health issues associated with their use, glove materials, and the essential properties of hand scrubs can help perioperative nurses choose appropriate products. This article explores these issues so that nurses and other health care workers can develop a framework for making informed decisions based on clinical reasoning.

CTLA-4 and autoimmune thyroid disease: lack of influence of the A49G signal peptide polymorphism on functional recombinant human CTLA-4.

A single nucleotide A49G polymorphism (SNP) of CTLA-4 has been linked and associated with the autoimmune thyroid diseases (AITD) and thyroid autoantibody secretion. We have explored the functional mechanisms of CTLA-4 by means of recombinant human CTLA-4 expressed on transfected Jurkat T cells. Analysis of CTLA-4 transcripts with quantitative real-time PCR demonstrated similar baseline and PHA-stimulated levels for both the A49 and G49 alleles, which were markedly enhanced by anti-CTLA-4 engagement. Both alleles also coded for proteins which were expressed on the cell membrane, as measured by FACS analysis using anti-CTLA-4 (G: 34.4+/-11.9% cells, A: 27.6+/-8.6% cells) (p=ns). Baseline and PHA-stimulated IL-2 production were also similar among control and CTLA-4 clones expressing both alleles. After anti-CTLA-4 engagement, IL-2 production was markedly inhibited in a dose- and time-dependent manner but this also appeared to be similar in the A and G allele expressing cells (95.7+/-1.2% inhibition and 94.9+/-1.1% inhibition, respectively). In conclusion, both the extrinsic and intrinsic actions of human CTLA-4 were not affected by the signal peptide A49G polymorphism. Therefore, the linkage of the CTLA-4 A49G SNP to AITD is most likely secondary to linkage disequilibrium.

Intrathyroidal fetal microchimerism in Graves' disease.

During pregnancy, fetal cells are known to reach the maternal circulation and infiltrate a variety of tissues (fetal microchimerism). Although the presence of such cells has the potential to modulate the maternal immune response to both self antigens and fetal alloantigens, the degree of their influence remains unclear. The hyperthyroidism of Graves' disease frequently abates during pregnancy and exacerbates after childbearing. Thus, we have hypothesized that fetal cells in the maternal circulation and tissues may influence this decrescendo to crescendo pattern of autoimmune thyroid disease. Part of this hypothesis was tested using an ELISA-PCR for the detection of DNA for a male-specific gene, sex-determining region Y. The sensitivity of this assay was the equivalent of approximately 1 male cell among 10(5) female cells. We initially examined paraffin-embedded thyroid tissues and detected male cells in 4 of 20 female Graves' thyroid specimens, but not in 6 of 6 female adenoma specimens. Using frozen thyroid tissue specimens, an additional 6 of 7 Graves' disease samples demonstrated intrathyroidal fetal microchimerism, whereas 1 of 4 female samples with thyroid nodules showed male cells. The greater detection of the sex-determining region Y gene in frozen female thyroid tissues was probably due to DNA fragmentation in the paraffin-derived samples. In summary, we demonstrated that intrathyroidal fetal microchimerism was common and profound in female patients with Graves' disease. Thus, fetal male cells are valid candidates for modulating autoimmune thyroid disease in pregnancy and postpartum.