Diagnostic stewardship for Clostridioides difficile testing in an acute care hospital: A quality improvement intervention.

Objective: To evaluate the impact of a diagnostic stewardship intervention on Clostridioides difficile healthcare-associated infections (HAI). Design: Quality improvement study. Setting: Two urban acute care hospitals. Interventions: All inpatient stool testing for C. difficile required review and approval prior to specimen processing in the laboratory. An infection preventionist reviewed all orders daily through chart review and conversations with nursing; orders meeting clinical criteria for testing were approved, orders not meeting clinical criteria were discussed with the ordering provider. The proportion of completed tests meeting clinical criteria for testing and the primary outcome of C. difficile HAI were compared before and after the intervention. Results: The frequency of completed C. difficile orders not meeting criteria was lower [146 (7.5%) of 1,958] in the intervention period (January 10, 2022-October 14, 2022) than in the sampled 3-month preintervention period [26 (21.0%) of 124; P < .001]. C. difficile HAI rates were 8.80 per 10,000 patient days prior to the intervention (March 1, 2021-January 9, 2022) and 7.69 per 10,000 patient days during the intervention period (incidence rate ratio, 0.87; 95% confidence interval, 0.73-1.05; P = .13). Conclusions: A stringent order-approval process reduced clinically nonindicated testing for C. difficile but did not significantly decrease HAIs.

Evaluation of Viral Loads in Patients With SARS-CoV-2 Delta Variant Infection: Higher Loads Do Not Translate Into Different Testing Scenarios.

The Delta SARS-CoV-2 variant is very infectious, and it is spreading quickly during this pandemic. In the study, we compared viral loads estimated by means of the Ct values emerging from RT-PCR swab tests in surging cases infected with the SARS-CoV-2 Delta variant in the fourth wave of COVID-19 with the three prior waves. The data comprised viral loads from positive cases detected within the UPMC health care system in Allegheny County, Pennsylvania. A total of 2059 upper airway samples were collected and tested for SARS-CoV-2 positive by RT-PCR during March 2020 to September 2021. We did not observe significant difference in viral load difference between the third (December 2020 to January 2021) and fourth (June 2021 to September 2021) waves; however, they had the higher viral load than the first (March 2020 to June 2020) and second waves (June 2020 to August 2020). We did find an age-related effect with the elderly presenting with lower viral loads, which was also seen in the earlier waves. However, the level of the viral loads in the fourth wave in the respect of the previous ones was not sufficiently increased to change our testing strategies by means of increased use of rapid antigen tests (RAT).

Evaluation of the Cepheid Xpert Xpress SARS-CoV-2 test for bronchoalveolar lavage.

Accurate and rapid laboratory tests are essential for the prompt diagnosis of COVID-19, which is important to patients and infection control. The Xpert Xpress SARS-CoV-2 test is a real-time RT-PCR intended for the qualitative detection of nucleic acid from SARS-CoV-2 in upper respiratory specimens. In this study, we assessed the analytical performance characteristics of this rapid test for SARS-CoV-2 in 60 bronchoalveolar lavage (BAL) specimens. BAL is a specimen type that is not authorized under EUA for the Xpert Xpress SARS-CoV-2 test. The limit of detection of the Xpert Xpress SARS-CoV-2 test was 500 copies/ml. The overall agreement of the Xpert Xpress SARS-CoV-2 test was 100%. The Xpert Xpress SARS-CoV-2 test is sensitive and specific to aid in diagnosis of COVID-19 using bronchoalveolar lavage.

Development of a Global Design Education Experience in Bioengineering Through International Partnerships.

The field of engineering is increasingly appreciating the value of diversity for innovative design solutions. Successful engineering depends on our ability to explore constrained parameter spaces for finding the best solutions, and more diverse minds and experiences enable us to explore the entire potential solution space more thoroughly, more quickly, and more creatively. With a goal to expand the diversity of experiences and mindsets in our undergraduate bioengineering curricula, Arusha Technical College (ATC) in Arusha, Tanzania and Clemson University (CU) in Clemson, South Carolina, U.S., have partnered together over the past 5 years to provide intercontinental educational opportunities for undergraduate students, graduate assistants, and faculty. In 2018, CU and ATC collaborated on an international design course targeting undergraduate students in biomedical engineering focused on global health solutions for resource poor communities. Undergraduate students from ATC and CU collaborated on design projects through formal videoconferenced group meetings, e-mail, and various social media platforms. The year ended with a joint design symposium in Arusha where the students presented on their work in a public poster forum. This successful ATC-CU Global Health Design Collaboration pilot year provides a solid model upon which to build. Students reported overall positive experiences and plans to continue in their curriculum to graduation, as well as some ATC and CU students changing their career direction to include global health initiatives.

Herpes Simplex Virus-1 qPCR in the Diagnosis of Lower Respiratory Tract Infections in Organ Transplant Recipients and Critically Ill Patients.

OBJECTIVES: To determine a quantitative herpes simplex virus (HSV) DNA threshold in lower respiratory tract specimens that correlates with positive viral culture and clinical outcomes. METHODS: Bronchoalveolar lavage and bronchial wash samples from 53 HSV culture-positive and 61 culture-negative matched controls were tested using HSV-1 and HSV-2 quantitative polymerase chain reaction (qPCR). RESULTS: Median viral culture turnaround time was 21.8 days and 9.9 days for culture-negative and culture-positive specimens, respectively. Using an HSV-1 viral load threshold of 1.62 × 103 copies/mL, there was 93% agreement with viral culture. An HSV-1 viral load ≥1.3 × 104 copies/mL was associated with worse clinical outcome compared to a viral load <1.3 × 104 copies/mL (hazard ratio [HR] = 4.27, P = .017), and there was a trend of worse outcome compared to patients with undetectable HSV-1 DNA (HR = 1.60, P = .056). CONCLUSIONS: qPCR has clinical utility for rapid accurate identification of HSV-1 in lower respiratory tract specimens.

Ethical reasoning through simulation: a phenomenological analysis of student experience.

BACKGROUND: Medical students transitioning into professional practice feel underprepared to deal with the emotional complexities of real-life ethical situations. Simulation-based learning (SBL) may provide a safe environment for students to probe the boundaries of ethical encounters. Published studies of ethics simulation have not generated sufficiently deep accounts of student experience to inform pedagogy. The aim of this study was to understand students' lived experiences as they engaged with the emotional challenges of managing clinical ethical dilemmas within a SBL environment. METHODS: This qualitative study was underpinned by an interpretivist epistemology. Eight senior medical students participated in an interprofessional ward-based SBL activity incorporating a series of ethically challenging encounters. Each student wore digital video glasses to capture point-of-view (PoV) film footage. Students were interviewed immediately after the simulation and the PoV footage played back to them. Interviews were transcribed verbatim. An interpretative phenomenological approach, using an established template analysis approach, was used to iteratively analyse the data. RESULTS: Four main themes emerged from the analysis: (1) 'Authentic on all levels?', (2)'Letting the emotions flow', (3) 'Ethical alarm bells' and (4) 'Voices of children and ghosts'. Students recognised many explicit ethical dilemmas during the SBL activity but had difficulty navigating more subtle ethical and professional boundaries. In emotionally complex situations, instances of moral compromise were observed (such as telling an untruth). Some participants felt unable to raise concerns or challenge unethical behaviour within the scenarios due to prior negative undergraduate experiences. CONCLUSIONS: This study provided deep insights into medical students' immersive and embodied experiences of ethical reasoning during an authentic SBL activity. By layering on the human dimensions of ethical decision-making, students can understand their personal responses to emotion, complexity and interprofessional working. This could assist them in framing and observing appropriate ethical and professional boundaries and help smooth the transition into clinical practice.

The view from over there: reframing the OSCE through the experience of standardised patient raters.

CONTEXT: Ratings awarded by standardised patients (SPs) in UK objective structured clinical examinations (OSCEs) are typically based on humanistic (non-technical) skills and are complementary to clinician-examiner ratings. In psychometric terms, SP ratings appear to differ from examiner ratings and improve reliability. For the first time, we used qualitative methods from a constructivist perspective to explore SP experiences of rating, and consider how these impact our understanding of assessment. METHODS: We used constructivist grounded theory to analyse data from focus groups and individual semi-structured interviews with 38 SPs and four examiners. Inductive coding, theoretical sampling and constant comparison continued until theoretical saturation was achieved. RESULTS: Standardised patients assessed students on the core process of relationship building. Three theoretical categories informed this process. The SP identity was strongly vocational and was both enacted and reinforced through rating as SPs exerted their agency to protect future patients by promoting student learning. Expectations of performance drew on individual life experiences in formulating expectations of doctors against which students were measured, and the patient experience was a lens through which all interactions were refracted. Standardised patients experienced the examination as real rather than simulated. They rated holistically, prioritised individuality and person-centredness, and included technical skill because the perception of clinical competence was an inextricable part of the patient experience. CONCLUSIONS: The results can be used to reframe understanding of the SP role and of the psychometric discourse of assessment. Ratings awarded by SPs are socially constructed and reveal the complexity of the OSCE process and the unfeasibility of absolute objectivity or standardisation. Standardised patients valued individuality, subjective experience and assessment for learning. The potential of SPs is under-used their greater involvement should be used to promote real partnership as educators move into a post-psychometric era. New-generation assessments should strive to value subjective experience as well as psychometric data in order to utilise the significant potential for learning within assessment.

Morphological aspects of interactions between microparticles and mammalian cells: intestinal uptake and onward movement.

Uptake of ingested microparticles into small intestinal tissues and on to secondary organs has moved from being an anecdotal phenomenon to a recognised and quantifiable process, which is relevant to risk assessment of accidental exposure, treatment of multi-organ dysfunction syndrome and therapeutic uses of encapsulated drug or vaccine delivery. This review puts in context with the literature the findings of a morphological study of microparticle uptake, using two approaches. The first is a rat in vivo in situ model, appropriate to a study rooted in the exposure of human populations to microparticles. Latex microspheres 2 µm in diameter are the principal particle type used, although others are also investigated. Most data are based on microscopy, but analysis of macerated bulk tissue is also useful. Uptake occurs at early time points after a single dose and is shown to take place almost entirely at villous rather than Peyer's patch sites: however, multiple feeding and therefore a longer time-span produces a higher proportion of particles associated with Peyer's patches, albeit for very small total uptake at those later time points. Uptake is less affected by species, fasting and immunological competence than by age and reproductive status. The second approach uses in vitro methods to confirm the role of intercellular junctions in particle uptake. Particle-associated tight junction opening, in a Caco-2 monolayer, is reflected in changes in transepithelial resistance and particle uptake across the epithelial monolayer: Tight junction opening and particle uptake are both increased further by external irradiation, ethanol and sub-epithelial macrophages, but reduced by exposure to ice. An M cell model has looser tight junctions than Caco-2 cells, but a similar level of particle uptake. These results, along with the changes seen in junctional proteins after particle addition, confirm the role of tight junctions in uptake but suggest that adhering junctions are also important.

An ethicist's journey as a patient: are we sliding down the slippery slope to sloppy healthcare?

People who are sick are often the most vulnerable in society. They frequently rely on caring and competent healthcare professionals and should and do have expectations of a safe and caring environment. In a recent unexpected adventure through the healthcare system, the organisation, professionalism, caring and compassion associated with healthcare provision were in very short supply. A lack of basic dignity and humanity were among the most concerning deficits. Any form of dehumanisation of the national health service that leads to unsafe, undignified and degrading treatment not only infringes patients' and clients' human rights but should not be acceptable or excused as a by-product of economic pressures.

Effect of reproductive status on uptake of latex microparticles in rat small intestine.

This study investigates whether pregnancy or lactation affects microparticle uptake across the small intestinal mucosal barrier, since aspects of gastrointestinal physiology such as motility may be altered in these conditions. It also reports on validation of the model by several methods and discusses the findings in relation to possible mechanisms. Anaesthetised, pregnant, lactating, virgin female or male adult rats were gavaged with fluorescent latex microparticles. The small intestine was removed and fixed either 5 or 30 min later and successive segments of equal length were examined with fluorescence microscopy. Minor adjustments were made to experimental methods to explore details of the uptake mechanism. Control sections contained no particles. All experimental samples showed luminal and surface particles and also contained particles within the tissue, most associated with villous absorptive enterocytes. Particle uptake was greatest at the 30-min time-point, when maximum uptake was usually in the proximal jejunum; although in the early lactating group, this was shifted distally. Total tissue uptake was increased in pregnant and early lactating groups, mainly at villous absorptive and mucus-secreting cells. Accumulation and progression of particles was reflected in increased numbers in the lamina propria. These data were validated by several methods, including particle detection in the blood and mesenteric lymph nodes in some groups. At both time-points, uptake profiles for pregnancy and early lactation differed from those of other groups, implying possible links between particle uptake and hormone levels, surface mucus and tight junction patency.