Removal, Kill, and Transfer of Bacteria from Hands by Antibacterial or Nonantibacterial Soaps After Handling Raw Poultry.

Hand hygiene is broadly recognized as a critical intervention in reducing the spread of disease-causing pathogens in both professional and personal uses. In this study, the impact of antibacterial (AB) or nonantibacterial soaps on the removal and postwash transfer of E. coli following the handling of raw poultry was assessed. Baseline bacterial contamination ranged between 107 and 109 CFU per hand. Hands were washed for 30 s in 40°C ± 2°C tap water using 2 mL of AB soap (0.5% and 1.0% Chloroxylenol, 0.5% Benzalkonium Chloride, or 4.0% Chlorhexidine Gluconate), non-AB soap (cosmetic/plain soap), or water. Postwash, water, and non-AB soap had a mean 3.63 and 3.65 Log10 reduction of E. coli on hands. AB treatments had a mean 4.19-4.35 Log10 reduction. Rinse water had mean bacterial counts of 8.62 and 8.88 Log10 CFU/mL for non-AB soap and water and 5.37-6.90 Log10 CFU/mL for AB treatments. Bacterial transfer was assessed by following the test subject's handling of a sterile polymer knife handle for 30 s postwash. E. coli transfer ranged from 263 to 903 CFU/handle for AB soaps and 1572 or 1709 CFU/handle for water and non-AB soap. Differences between AB and non-AB treatments were statistically significant (p < 0.0001) for hands and rinse water. Differences in transfer from hands to knife handle were not statistically significant (p = 0.139). Combined, these data highlight significant differences in the performance of AB soaps relative to non-AB soaps in a food handling environment-specific usage example and provide an unexplored assessment of the bactericidal vs. removal effects of AB vs. non-AB soaps on bacteria removed from the hands. These data reinforce the importance of hand hygiene, provide new details on the differences between AB vs. non-AB soaps, and highlight potential differences to inform food handling environment operators and public health personnel on how these products may impact food safety.

Transmission of Viruses from Restroom Use: A Quantitative Microbial Risk Assessment.

Restroom use has been implicated in a number of viral outbreaks. In this study, we apply quantitative microbial risk assessment to quantify the risk of viral transmission by contaminated restroom fomites. We estimate risk from high-touch fomite surfaces (entrance/exit door, toilet seat) for three viruses of interest (SARS-CoV-2, adenovirus, norovirus) through eight exposure scenarios involving differing user behaviors, and the use of hand sanitizer following each scenario. We assessed the impacts of several sequences of fomite contacts in the restroom, reflecting the variability of human behavior, on infection risks for these viruses. Touching of the toilet seat was assumed to model adjustment of the seat (open vs. closed), a common touch point in single-user restrooms (home, small business, hospital). A Monte Carlo simulation was conducted for each exposure scenario (10,000 simulations each). Norovirus resulted in the highest probability of infection for all exposure scenarios with fomite surfaces. Post-restroom automatic-dispensing hand sanitizer use reduced the probability of infection for each virus by up to 99.75%. Handwashing within the restroom, an important risk-reduction intervention, was not found to be as effective as use of a non-touch hand sanitizer dispenser for reducing risk to near or below 1/1,000,000, a commonly used risk threshold for comparison.

The Need for Responsive Workforce Development During the Pandemic and Beyond: A Case Study of the Regional Public Health Training Centers.

CONTEXT: The COVID-19 pandemic underscored the importance of a strong public health infrastructure for protecting and supporting the health of communities. This includes ensuring an adaptive workforce capable of leading through rapidly changing circumstances, communicating effectively, and applying systems thinking to leverage cross-sector partnerships that help promote health equity. The 10 Regional Public Health Training Centers (PHTCs) advance the capacity of the current and future public health workforce through skill development and technical assistance in these and other strategic areas. PROGRAM: This study examines activities through which the Regional PHTCs and their partners supported the public health workforce during the pandemic. Representatives of the 10 Regional PHTCs completed a survey in the spring of 2022. The survey included (1) pulling trends in training usage from 2018-2021 annual performance reports and (2) questions assessing the type, content, and reach of training needs assessments, training and technical assistance, student placements, and PHTC Network collaborative activities that occurred from January 1, 2020, to December 31, 2021. Respondents also reflected on trends in use, challenges, lessons learned, stories of impact, and future PHTC practice. EVALUATION: During the pandemic, the Regional PHTCs engaged in numerous efforts to assess needs, provide training and technical assistance to the practice community, facilitate projects that built student competency to support public health agency efforts, and collaborate as the PHTC Network on national-level initiatives. Across these activities, the Regional PHTCs adjusted their approaches and learned from each other in order to meet regional needs. DISCUSSION: The Regional PHTCs provided student and professional development in foundational public health knowledge and skills within their regions and nationally while being flexible and responsive to the changing needs of the field during the pandemic. Our study highlights opportunities for collaboration and adaptive approaches to public health workforce development in a postpandemic environment.

Evaluating infection risks and importance of hand hygiene during the household laundry process using a quantitative microbial risk assessment approach.

BACKGROUND: Contaminated laundry contributes to infectious disease spread in residential and home health care settings. The objectives were to (1) evaluate pathogen transmission risks for individuals doing laundry, and (2) compare hand hygiene timing to reduce risks. METHODS: A quantitative microbial risk assessment using experimental data from a laundry washing effectiveness study was applied to estimate infection risks from SARS-CoV-2, rotavirus, norovirus, nontyphoidal Salmonella, and Escherichia coli in 4 laundry scenarios: 1 baseline scenario (no hand hygiene event) and 3 hand hygiene scenarios (scenario 1: after moving dirty clothes to the washing machine, scenario 2: after moving washed clothes to the dryer, and scenario 3: hand hygiene events following scenario 1 and 2). RESULTS: The average infection risks for the baseline scenario were all greater than 2 common risk thresholds (1.0×10-6and 1.0×10-4). For all organisms, scenario 1 yielded greater risk reductions (39.95%-99.86%) than scenario 2 (1.35%-55.25%). Scenario 3 further reduced risk, achieving 1.0×10-6(SARS-CoV-2) and 1.0×10-4risk thresholds (norovirus and E. coli). CONCLUSIONS: The modeled results suggest individuals should reduce hand-to-facial orifice (eyes, nose, and mouth) contacts and conduct proper hand hygiene when handling contaminated garments. More empirical data are needed to confirm the estimated risks. DATA AVAILABILITY STATEMENT: The data and code that support the findings of this study can be retrieved via a Creative Commons Zero v1.0 Universal license in GitHub at https://github.com/yhjung1231/Laundry-QMRAproject-2022.git DOI: http://doi.org/10.5281/zenodo.7122065.

Personality disorders in dermatology: A review of patient characteristics, associated dermatologic conditions, and pearls for management.

Personality disorders are characterized by "ego-syntonic" maladaptive behaviors that impair functioning. This contribution outlines the relevant characteristics and approach to patients with personality disorders pertaining to the dermatology setting. For patients with Cluster A personality disorders (paranoid, schizoid, and schizotypal), it is crucial to avoid being overly contradictory of eccentric beliefs and to take a straightforward, unemotional approach. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Promoting safety and boundaries is paramount when interacting with patients with an antisocial personality disorder. Patients with borderline personality disorder have higher rates of various psychodermatologic conditions and benefit from an empathetic approach and frequent followup. Patients with borderline, histrionic, and narcissistic personality disorders all have higher rates of body dysmorphia, and the cosmetic dermatologist needs to avoid unnecessary cosmetic procedures. Patients with Cluster C personality disorders (avoidant, dependent, and obsessive-compulsive) often have significant anxiety associated with their illness and may benefit from extensive and clear explanations of their condition and management plan. Due to the challenges posed by these patients' personality disorders, they are often undertreated or receive poorer quality care. Although it is essential to acknowledge and address challenging behaviors, their dermatologic concerns should not be dismissed.

Treatment of traumatic hypertrophic scars and keloids: a systematic review of randomized control trials.

Exaggerated healing and remodeling after skin injury may cause hypertrophic and keloidal scars, which are associated with functional and quality of life impairment. There is limited guidance available regarding the relative effectiveness of therapies for hypertrophic scars and keloids. In this review, we aim to compare the effectiveness of treatments for hypertrophic scars and keloids. MEDLINE, Embase, Scopus, and the Cochrane Collaboration database were searched from inception to March 2019 for randomized control trials of treatments for hypertrophic and keloid scars that included 20 or more patients. Outcomes evaluated included the standardized mean reduction in scarring and adverse events. The type of scar and the demographic features were analyzed for their effect on clinical outcome. Based on 25 included clinical trials, intralesional injection (64.1% [95% CI 60.8-67.5%]) may be more effective than physical (29.9% [95% CI 28.9-30.9%]) or topical treatments (34% [95% CI 31.8-36.8%]). Combination of 5-fluorouracil and triamcinolone (9:1 dilution) appeared superior among intralesional treatments for keloids. Ablative laser and pulsed-dye laser were the most useful laser treatments. Regression modeling showed laser treatment response was linked to Fitzpatrick skin type (p = 0.002). Adverse events were uncommon for all treatments and mostly transient. Intralesional treatments for keloid and hypertrophic scars may be the most reliable treatment option to improve pathologic scars, while laser treatment may have specific benefits for Fitzpatrick skin types I-III over types IV-VI. Management of pathological scars is an area of critical need, where appropriate treatment can have a significant impact on quality of life.

Rapid, sensitive detection of PFOA with smartphone-based flow rate analysis utilizing competitive molecular interactions during capillary action.

Perfluorinated-alkyl substances (PFAS) pose an unmet threat to the public because they are not strictly monitored and regulated. Perfluorinated-carbon alkyl chains (PFOA), a type of PFAS, at 70 fg/µL is the current health and safety recommendation. Current testing methods for PFOA and PFAS chemicals include HPLC-MS/MS and molecularly imprinted polymers, which are expensive, time-consuming, and require training. In this work, PFOA and PFOS detection was performed on a paper microfluidic chip using competitive interactions between PFOA/PFOS, cellulose fibers, and various reagents (L-lysine, casein, and albumin). Such interactions altered the surface tension at the wetting front and, subsequently, the capillary flow rate. A smartphone captured the videos of this capillary action. The samples flowed through the channel in less than 2 min. Albumin worked the best in detecting PFOA, followed by casein. The detection limit was 10 ag/µL in DI water and 1 fg/µL in effluent (processed) wastewater. Specificity to other non-fluorocarbon surfactants was also tested, using anionic sodium dodecyl sulfate (SDS), non-ionic Tween 20, and cationic cetrimonium bromide (CTAB). A combination of the reagents successfully distinguished PFOA from all three surfactants at 100% accuracy. This low-cost, handheld assay can be an accessible alternative for rapid in situ estimation of PFOA concentration.

Generalized Pustular Psoriasis: A Review of the Pathophysiology, Clinical Manifestations, Diagnosis, and Treatment.

Generalized pustular psoriasis (GPP) is a rare severe variant of psoriasis that is characterized by the abrupt widespread onset of small pustules accompanied by systemic manifestations of inflammation. It can arise in patients with a history of psoriasis as well as in those without, sometimes due to medication initiation or withdrawal, pregnancy, or infection. Generalized pustular psoriasis is thought to be driven primarily by innate immunity and unrestrained IL-36 cytokine activity. Recent genetic analyses have identified 3 genetic mutations that are associated with GPP-IL36RN, CARD14, and AP1S3-though these mutations only account for a minority of cases. There are many cutaneous pustular diseases that must be ruled out in the evaluation of a patient with suspected GPP, especially acute generalized exanthematous pustulosis (AGEP), and histologic analysis is the cornerstone of diagnosis. Although the quality of evidence to generate treatment recommendations for GPP is limited, management often includes utilization of systemic agents and/or biologics, usually with adjunctive topical treatment. Accumulating evidence suggests that biologic agents, especially infliximab, may be considered as first-line treatment of GPP, especially in severe acute cases, due to their abrupt onset of action and favorable side-effect profiles compared with oral systemic agents.

Utility of high-resolution ultrasound in measuring subcutaneous fat thickness.

OBJECTIVE: Previous studies conclude that high-resolution ultrasound (HRUS) enables noninvasive and accurate measurements of subcutaneous fat thickness. The primary objective of this cross-sectional study was to better characterize subcutaneous fat thickness measurements in a diverse patient population using HRUS. Secondarily, we sought to correlate these measurements with patients' body image. METHODS: A cross-sectional study to measure subcutaneous fat measurements at seven distinct anatomic sites, including upper and lower extremities, submental, and torso regions, in 40 men and women of different ages and races using HRUS. Independent t-tests and analysis of variance were performed to analyze findings. RESULTS: In our patient population, on average, women had thicker subcutaneous fat than men at all anatomic sites. Asian patients had significantly reduced fat thickness at peripheral anatomic sites, such as arms when compared to patients who identified as Black and Other (p = 0.05 and p = 0.008, respectively). Lastly, women reported decreased total body satisfaction at all anatomic sites when compared to men. CONCLUSION: The information obtained and methods developed in this study may be utilized clinically during patient selection for fat reduction procedures, including for estimating the degree of likely benefit; for managing pathologies involving subcutaneous fat thickness alteration; and to monitor the progression of lipodystrophy secondary to disease or drugs.

Risk perceptions of drinking bottled vs. tap water in a low-income community on the US-Mexico Border.

BACKGROUND: Previous studies have shown that low-income Latinos generally drink bottled water over tap water and might be at increased risks for cavities from unfluoridated bottled water. In order to better design interventions, it is important to understand the risk perceptions of this unique high-risk yet historically marginalized group. METHODS: We interviewed low-income Latino households (n = 90) from Nogales, Arizona who primarily drink bottled water and asked them to evaluate potential health risks of drinking tap water compared to 16 other voluntary activities. Unpaired t-tests were used to determine if statistically significant (α = 0.05) differences occurred in perceived risk by drinking-water source and differences among demographic groups in their level of (dis)agreement with statements regarding tap or bottled water safety. To assess significant differences (α = 0.05) in perceived risks and voluntariness to engage in a number of activities, including drinking local tap water and drinking water in different geographic regions, a one-way analysis of variance (ANOVA) followed by Scheffe's post-hoc test (a conservative post-hoc test) with adjustment for the number of pairwise comparisons was used. RESULTS: Participants viewed bottled water to be significantly safer to consume than tap water (p < 0.001). On a Likert scale from 1 (low risk) to 5 (high risk), "drinking tap water in Nogales, Arizona" received an average score of 4.7, which was significantly higher than the average perceived risk of drinking San Francisco, California tap water (µ = 3.4, p < 0.001), and as risky as drinking and driving (µ = 4.8, p = 1.00) and drinking Nogales, Sonora, Mexico tap water (µ = 4.8, p = 1.00). Ninety-eight percent of participants feared that drinking local tap water could result in illness, 79% did not drink their water because of fear of microbial and chemical contamination and 73% would drink their water if they knew it was safe regardless of taste. CONCLUSIONS: These results suggest that fear of illness from tap-water consumption is an important contributing factor to increased bottled water use. Future efforts should focus on the development of educational and outreach efforts to assess the safety and risks associated with tap-water consumption.

Minding the matrix: The importance of inoculum suspensions on finger transfer efficiency of virus.

AIMS: The aim of this study was to determine how the transfer efficiency of MS-2 coliphage from the toilet seat to hands and fingertip to lip differs according to the suspension of the inoculum. METHODS AND RESULTS: Hands were sampled after lifting a toilet seat which was inoculated with MS-2 on the underneath side. MS-2 was suspended in a spectrum of proteinaceous and non-proteinaceous solutions. Transfer efficiencies were greatest with the ASTM tripartite soil load (3.02% ± 4.03) and lowest with phosphate-buffered saline (PBS) (1.10% ± 0.81) for hand-to-toilet seat contacts. Finger-to-lip transfer rates were significantly different (p < 0.05) depending on suspension matrix, with PBS yielding the highest transfer (52.53% ± 4.48%) and tryptose soy broth (TSB) the lowest (23.15% ± 24.27%). Quantitative microbial risk assessment was used to estimate the probability of infection from adenovirus and norovirus from finger contact with a toilet seat. CONCLUSIONS: The greatest transfer as well as the largest variation of transfer were measured for finger-to-lip contacts as opposed to toilet seat-to-finger contacts. These factors influence the estimation of the probability of infection from micro-activity, that is, toilet seat adjustment. SIGNIFICANCE AND IMPACT: Viruses may be transferred from various human excreta with differing transfer efficiencies, depending on the protein content.

An application for relating Legionella shower water monitoring results to estimated health outcomes.

Exposure models are useful tools for relating environmental monitoring data to expected health outcomes. The objective of this study was to (1) compare two Legionella shower exposure models, and (2) develop a risk calculator tool for relating environmental monitoring data to estimated Legionella infection risks and Legionnaires' Disease (LD) illness risks. Legionella infection risks for a single shower event were compared using two shower Legionella exposure models. These models varied in their description of partitioning of Legionella in aerosols and aerosol deposition in the lung, where Model 1 had larger and fewer aerosol ranges than Model 2. Model 2 described conventional vs. water efficient showers separately, while Model 1 described exposure for an unspecified shower type (did not describe it as conventional or water efficient). A Monte Carlo approach was used to account for variability and uncertainty in these aerosolization and deposition parameters, Legionella concentrations, and the dose-response parameter. Methods for relating infection risks to illness risks accounting for demographic differences were used to inform the risk calculator web application ("app"). Model 2 consistently estimated higher infection risks than Model 1 for the same Legionella concentration in water and estimated deposited doses with less variability. For a 7.8-min shower with a Legionella concentration of 0.1 CFU/mL, the average infection risks estimated using Model 2 were 4.8 × 10-6 (SD=3.0 × 10-6) (conventional shower) and 2.3 × 10-6 (SD=1.7 × 10-6) (water efficient). Average infection risk estimated by Model 1 was 1.1 × 10-6 (SD=9.7 × 10-7). Model 2 was used for app development due to more conservative risk estimates and less variability in estimated dose. While multiple Legionella shower models are available for quantitative microbial risk assessments (QMRAs), they may yield notably different infection risks for the same environmental microbial concentration. Model comparisons will inform decisions regarding their integration with risk assessment tools. The development of risk calculator tools for relating environmental microbiology data to infection risks will increase the impact of exposure models for informing water treatment decisions and achieving risk targets.

Voting behavior during FDA Medical Device Advisory Committee panel meetings.

OBJECTIVES: During premarket review, the US Food and Drug Administration may ask its Medical Device Advisory Committee (MDAC) Panels to assess the safety and effectiveness of medical devices being considered for approval. The objective of this study is to assess the relationship, if any, between individual votes and Panel recommendations and: (1) the composition of Panels, specifically the expertise and demographic features of individual members; or (2) Panel members' propensity to speak during Panel deliberations. METHODS: This was a retrospective cohort study of routinely collected data from voting members of MDAC panels convened between January 2011 to June 2016 to consider premarket approval. Data sources were verbatim transcripts available publicly from the FDA. Number of words spoken, directionality of votes on device approval, profession, and demographics were collected. RESULTS: 658,954 words spoken by 536 members during 49 meetings of 11 Panels were analyzed. Based on multivariate analysis, biostatisticians spoke more (+373 words; P = 0.0002), and women (-187 words; P = 0.0184) and other non-physician voting members less (-213 words; P = 0.0306), than physicians. Speaking more was associated with abstaining (P = 0.0179), and with voting against the majority (P = 0.0153). Non-physician, non-biostatistician members (P = 0.0109), and those having attended more meetings as a voting member (P = 0.0249) were more likely to vote against approval. In bivariable analysis, unanimous Panels had a greater proportion of biostatisticians (mean 0.1580; 95% CI 0.1237-0.1923) than non-unanimous Panels (0.1107; 95% CI 0.0912-0.1301; p = 0.0201). CONCLUSIONS: Panelists likely to vote against the majority include non-physician, non-biostatisticians; experienced Panelists; and more talkative members. The increased presence of biostatisticians on Panels leads to greater voting consensus. Having a diversity of opinions on Panels, including in sufficient numbers those members likely to dissent from majority views, may help ensure that a diversity of opinions are aired before decision-making.

While ethical considerations predominate, scientific merit can impact Institutional Review Board (IRB) determinations: a cross-sectional study.

BACKGROUND AND OBJECTIVES: To determine the most common reasons for Institutional Review Boards deferral of biomedical research proposals. METHODS: Cross-sectional study administered to chairs, vice-chairs, and co-chairs of IRBs at NIH-funded institutions. RESULTS: Data forms were distributed to IRB chairs at 21 of 25 NIH-funded institutions (four declined to participate), with an institutional response rate of 86% (18/21). Overall, ethical considerations were more likely than scientific merit to be a reason for protocol deferral. Common ethical considerations for deferral were inadequate informed consent, inadequate detail for risk assessment, insufficient protection of participant safety, and inadequate minimization of risks. Important elements of scientific merit were appropriate research design, adequate adverse event reporting, and the importance of knowledge to be gained. Nonsponsored, investigator-initiated proposals (including those receiving internal funding) were more likely to be deferred (66%), usually due to inadequate protocol development (43%), less external vetting and oversight (20%), and submissions from inexperienced faculty (16%). CONCLUSION: Deferrals may be avoided by careful compliance with ethical considerations, and by ensuring sufficient scientific merit of the proposal, with research design optimized for participant safety. Those submitting investigator-initiated proposals may consider obtaining at least partial funding to decrease the risk of deferral.

The evidence base for US joint commission hospital accreditation standards: cross sectional study.

OBJECTIVE: To evaluate the evidence upon which standards for hospital accreditation by The Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission) are based. DESIGN: Cross sectional study. SETTING: United States. PARTICIPANTS: Four Joint Commission R3 (requirement, rationale, and reference) reports released by July 2018 and intended to become effective between 1 July 2018 and 1 July 2019. INTERVENTIONS: From each R3 report the associated standard and its specific elements of performance (or actionable standards) were extracted. If an actionable standard enumerated multiple requirements, these were separated into distinct components. Two investigators reviewed full text references, and each actionable standard was classified as either completely supported, partly supported, or not supported; Oxford evidence quality ratings were assigned; and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the strength of recommendations. MAIN OUTCOME MEASURE: Strengths of recommendation for actionable standards. RESULTS: 20 actionable standards with 76 distinct components were accompanied by 48 references. Of the 20 actionable standards, six (30%) were completely supported by cited references, six were partly supported (30%), and eight (40%) were not supported. Of the six directly supported actionable standards, one (17%) cited at least one reference of level 1 or 2 evidence, none cited at least one reference of level 3 evidence, and five (83%) cited references of level 4 or 5 evidence. Of the completely supported actionable standards, strength of recommendation in five was deemed GRADE D and in one was GRADE B. CONCLUSIONS: In general, recent actionable standards issued by The Joint Commission are seldom supported by high quality data referenced within the issuing documents. The Joint Commission might consider being more transparent about the quality of evidence and underlying rationale supporting each of its recommendations, including clarifying when and why in certain instances it determines that lower level evidence is sufficient.

Development of a core outcome set for basal cell carcinoma.

BACKGROUND: There is variation in the outcomes reported in clinical studies of basal cell carcinoma. This can prevent effective meta-analyses from answering important clinical questions. OBJECTIVE: To identify a recommended minimum set of core outcomes for basal cell carcinoma clinical trials. METHODS: Patient and professional Delphi process to cull a long list, culminating in a consensus meeting. To be provisionally accepted, outcomes needed to be deemed important (score, 7-9, with 9 being the maximum) by 70% of each stakeholder group. RESULTS: Two hundred thirty-five candidate outcomes identified via a systematic literature review and survey of key stakeholders were reduced to 74 that were rated by 100 health care professionals and patients in 2 Delphi rounds. Twenty-seven outcomes were provisionally accepted. The final core set of 5 agreed-upon outcomes after the consensus meeting included complete response; persistent or serious adverse events; recurrence-free survival; quality of life; and patient satisfaction, including cosmetic outcome. LIMITATIONS: English-speaking patients and professionals rated outcomes extracted from English language studies. CONCLUSION: A core outcome set for basal cell carcinoma has been developed. The use of relevant measures may improve the utility of clinical research and the quality of therapeutic guidance available to clinicians.