Anti-Inflammatory, Antioxidant, Chemical Characterization, and Safety Assessment of Argania spinosa Fruit Shell Extract from South-Western Morocco.

Argania spinosa (L.) plays an important role in the Moroccan agroeconomy, providing both employment and export revenue. Argan oil production generates different by-products with functionalities that are not yet investigated, in particular, the shell fruit. The present study aims, for the first time, at evaluating the acute and subacute toxicity, anti-inflammatory, and antioxidant effects of argan fruit shell ethanol extract (AFSEE). The LD50 of AFSEE was determined to be greater than the 5000 mg/kg body weight of mice. No significant variation in the body and organ weights was observed after 28 days of AFSEE treatment compared to that of the control group. Biochemical parameters and histopathological examination revealed no toxic effects of AFSEE. The AFSEE produced a significant inhibition of xylene-induced ear edema in mice. AFSEE reduced significantly the paw edema in mice after carrageenan injection. The chemical characterization showed that AFSEE contains a high level of total phenol content, flavonoids, condensed tannins, and flavanols. The obtained IC50 of DPPH, ABTS, reducing power, and ß-carotene demonstrates that AFSEE has a potential antioxidant effect. The results indicate that AFSEE was safe and nontoxic to mice even at higher doses. Furthermore, the present findings demonstrate that AFSEE has potential anti-inflammatory and antioxidant activities.

Dietary Alcohol and Fat Differentially Affect Plasma Cholesteryl Ester Transfer Activity and Triglycerides in Normo- and Hypertriglyceridemic Subjects.

Moderate alcohol consumption is associated with increased plasma high-density lipoprotein (HDL)-cholesterol concentrations and reduced risk for cardiovascular disease. Plasma cholesteryl ester transfer activity (CETA) mediates the exchange of HDL-cholesteryl ester (CE) for the triacylglycerol (TAG) of very-low-density lipoproteins. We compared the effects of oral challenges of Alcohol, saturated fat (SAT), and (Alcohol + SAT) on plasma CETA, cholesterol, nonesterified fatty acids (NEFA), and TAG among normo-triglyceridemic (NTG) and mildly hypertriglyceridemic (HTG) volunteers having a range of plasma TAG concentrations. The major changes were (1) CETA increased more after ingestion of SAT and (Alcohol + SAT) in the HTG group versus the NTG group; (2) after all three challenges, elevation of plasma TAG concentration persisted longer in the HTG versus NTG group. Plasma cholesterol was not affected by the three dietary challenges, while Alcohol increased NEFA more in the HTG group than the NTG group. Plasma TAG best predicted plasma CETA, suggesting that intestinally derived lipoproteins are acceptors of HDL-CE. Unexpectedly, ingestion of (Alcohol + SAT) reduced the strength of the correlation between plasma TAG and CETA, that is the effects of (SAT and Alcohol) on plasma CETA are not synergistic nor additive but rather mutually suppressive. The alcohol-mediated inhibition of CE-transfer to chylomicrons maintains a higher plasma HDL-cholesterol concentration, which is athero-protective, although the suppressive metabolite underlying this correlation could be acetate, the terminal alcohol metabolite, other factors, including CETA inhibitors, are also likely important.

The use of 3.15% chlorhexidine gluconate/70% alcohol hub disinfection to prevent central line-associated bloodstream infections in dialysis patients.

PURPOSE: Preventing CLABSI events in the dialysis inpatient population represents significant challenges. Bacteremia associated with lines or grafts are common health-associated infections that lead to adverse patient outcomes. Dialysis patients represent a much higher infection risk due to health frequency needs, more frequent hospitalizations, multiple comorbidity issues, fistula functionality, and multiple attempts for line access leading to additional complications, costs, morbidity, and mortality. METHODS: An observational study was conducted including central line device days, CLABSI events, and possible confounding variables in admitted dialysis patients. All CLABSI data were identified according to the Centers for Disease Control and Prevention's National Healthcare Safety Network's definitions for CLABSIs. The intervention involved the removal of 70% alcohol swabs and alcohol hub disinfecting caps, then replacing with swabs containing 3.15% chlorhexidine gluconate/70% alcohol for central line hub disinfection and vascular graft access skin disinfection. RESULTS: The 5-year preintervention period (2008-2012) involved 7568 central line days, 11 CLABSI events, and a 1.45 per 1000 device day rate. The 6-month trial period involved 1559 central line days and no CLABSI events. The 5-year postimplementation period (2013-2017) involved 9787 central line days, 5 CLABSI events, and a 0.51 per 1000 device day rate. The postimplementation period represented a statistically significant (P value=0.0493) reduction with 65% fewer CLABSI events compared with the preimplementation period. LIMITATIONS: A limitation was variations in scrub time and dry time during central venous catheter hub access. While we were comparing 2 products, behavioral practices using these 2 products were possible influencers and represent a possible confounding variable. CONCLUSIONS: This study found that using alcohol with chlorhexidine gluconate prior to accessing central line hubs and vascular grafts allows for reduction in CLABSI events and sustains statistically significant lower CLABSI rates in the inpatient dialysis population. HIGHLIGHTS Using alcohol with chlorhexidine gluconate (CHG) before accessing central line hubs helps reduce central line-associated bloodstream infection (CLABSI) events Using alcohol with CHG before accessing vascular grafts helps reduce CLABSI events A statistically significant reduction (65%) in CLABSI events occurred after use. Statistically significant lower CLABSI rates are sustainable with use of alcohol with CHG.

Sequential use of povidone-iodine and chlorhexidine for cutaneous antisepsis: A systematic review.

Cutaneous antisepsis with chlorhexidine or povidone-iodine, usually with alcohol, has been extensively studied. This review of published studies reveals that sequential use of povidone-iodine and chlorhexidine leads to a greater reduction in the bioburden of aerobic and anaerobic bacteria on the skin, lower risk of intravascular catheter colonization, and lower risk of surgical site infection compared to use of either agent alone. As such, sequential use of cutaneous antiseptic agents may further reduce risk of surgical site infections, as well as infections associated with insertion of transdermal devices such as nephrostomy tubes, left-ventricular assistance devices, and intravascular catheters.

Early dialysis in a rare case of combined toxic alcohols ingestion.

Ingestion of toxic alcohols (TA) typically presents with a high anion gap (AG) metabolic acidosis, and elevated osmolar gap (OG). Hemodialysis (HD) has not been recommended in early phases of intoxication with high OG and normal AG metabolic acidosis. We describe the case of a 40-year-old male who was brought to our emergency department for reported paint thinner ingestion. He was unable to protect his airway and required intubation. Blood gas showed respiratory acidosis, an initial AG, corrected by albumin of 12.75, lactic acid 5.26 mmol/L, and an OG of 170. Patient was treated with bicarbonate drip, fomepizole and emergent HD, which improved his neurologic status. Days after his admission, alcohol levels came positive for a co-ingestion of ethylene glycol, diethylene glycol, and methanol. Most of the TA are metabolized into their toxic byproducts by the enzyme alcohol dehydrogenase (ADH). The kinetics of these alcohols will be altered when there is co-ingestion of multiple substances. Moreover, early ingestions will translate in a high OG without a high AG. False elevation of lactate can occur with the ingestion of ethylene glycol due to a cross-reaction with L-lactate oxidase in the analyzer. In our case, the administration of fomepizole followed by an early HD given the poor clinical improvement, was followed by a fast recovery of the neurological status and potentially prevented renal failure. A high index of suspicion for TA ingestion should be raised when encountering an individual with lactic acidosis, high OG, and normal AG.

Persistence of Burkholderia thailandensis E264 in lung tissue after a single binge alcohol episode.

BACKGROUND: Binge drinking, an increasingly common form of alcohol use disorder, is associated with substantial morbidity and mortality; yet, its effects on the immune system's ability to defend against infectious agents are poorly understood. Burkholderia pseudomallei, the causative agent of melioidosis can occur in healthy humans, yet binge alcohol intoxication is increasingly being recognized as a major risk factor. Although our previous studies demonstrated that binge alcohol exposure increased B. pseudomallei near-neighbor virulence in vivo and increased paracellular diffusion and intracellular invasion, no experimental studies have examined the extent to which bacterial and alcohol dosage play a role in disease progression. In addition, the temporal effects of a single binge alcohol dose prior to infection has not been examined in vivo. PRINCIPAL FINDINGS: In this study, we used B. thailandensis E264 a close genetic relative of B. pseudomallei, as useful BSL-2 model system. Eight-week-old female C57BL/6 mice were utilized in three distinct animal models to address the effects of 1) bacterial dosage, 2) alcohol dosage, and 3) the temporal effects, of a single binge alcohol episode. Alcohol was administered comparable to human binge drinking (≤ 4.4 g/kg) or PBS intraperitoneally before a non-lethal intranasal infection. Bacterial colonization of lung and spleen was increased in mice administered alcohol even after bacterial dose was decreased 10-fold. Lung and not spleen tissue were colonized even after alcohol dosage was decreased 20 times below the U.S legal limit. Temporally, a single binge alcohol episode affected lung bacterial colonization for more than 24 h after alcohol was no longer detected in the blood. Pulmonary and splenic cytokine expression (TNF-α, GM-CSF) remained suppressed, while IL-12/p40 increased in mice administered alcohol 6 or 24 h prior to infection. Increased lung and not intestinal bacterial invasion was observed in human and murine non-phagocytic epithelial cells exposed to 0.2% v/v alcohol in vitro. CONCLUSIONS: Our results indicate that the effects of a single binge alcohol episode are tissue specific. A single binge alcohol intoxication event increases bacterial colonization in mouse lung tissue even after very low BACs and decreases the dose required to colonize the lungs with less virulent B. thailandensis. Additionally, the temporal effects of binge alcohol alters lung and spleen cytokine expression for at least 24 h after alcohol is detected in the blood. Delayed recovery in lung and not spleen tissue may provide a means for B. pseudomallei and near-neighbors to successfully colonize lung tissue through increased intracellular invasion of non-phagocytic cells in patients with hazardous alcohol intake.

Chlorhexidine-alcohol versus iodine-alcohol for surgical site skin preparation in an elective arthroplasty (ACAISA) study: a cluster randomized controlled trial.

OBJECTIVES: Surgical site skin preparation is an effective method to prevent wound complications. The optimal agent has not been established, and guidelines contain conflicting recommendations. METHODS: The aim of alcoholic chlorhexidine or alcoholic iodine skin antisepsis (ACAISA) was to assess the efficacy of surgical site skin preparation with 0.5% chlorhexidine gluconate (w/v) in 70% ethanol (v/v) to 1% iodine (w/v) in 70% ethanol (v/v). This was a cluster randomized, controlled, single-centre, assessor-blinded, superiority trial in patients undergoing elective hip or knee arthroplasty. Each surgeon had a set operating day and the unit of randomization was the day of surgery. The primary outcome was superficial wound complication, defined as a composite endpoint of superficial incisional surgical site infection and/or clinically significant wound ooze in the 30 days following arthroplasty. The secondary outcome was any surgical site infection, including prosthetic joint infection. Outcome ascertainment was undertaken by an independent verification panel. The primary analysis was intention-to-treat, performed at the individual level. Taking into account the clustering effect, analysis of primary and secondary outcomes was undertaken at the level of the surgeon. RESULTS: A total of 780 participants were included; 390 participants were allocated chlorhexidine-alcohol and 390 participants were allocated iodine-alcohol. There was no difference in superficial wound complications: 19 (4.9%) versus 15 (3.8%) respectively (OR 1.28; 95%CI 0.62, 2.63; p 0.50). There was an increased odds of surgical site infection in the chlorhexidine-alcohol group compared to iodine-alcohol: 12 (3.1%) versus four (1.0%) respectively (OR 3.06; 95%CI 1.26, 7.46; p 0.014). The odds of prosthetic joint infection were also increased in the chlorhexidine-alcohol arm compared with iodine-alcohol: seven (1.8%) versus two (0.5%) respectively (OR 3.55; 95%CI 1.20, 10.44; p 0.022). CONCLUSIONS: No difference was observed in the primary outcome of superficial wound complications when chlorhexidine-alcohol and iodine-alcohol were compared. However, on a secondary analysis, iodine-alcohol had greater efficacy than chlorhexidine-alcohol for preventing surgical site infection. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614000177651.

Current issues in hand hygiene.

Although substantial improvements in hand hygiene practices have occurred in recent years, many health care facilities continue to encounter challenges in achieving and maintaining high levels of hand hygiene compliance. Issues of current interest include the optimum dose of alcohol-based handrub (ABHR) that should be applied, the impact of hand size and alcohol-based handrub dry times have on efficacy, and ideal hand hygiene technique. There is a need to determine which additional promotional activities can augment improvements in hand hygiene that are achieved by implementing the multimodal improvement strategy recommended by the World Health Organization. Monitoring hand hygiene performance and providing personnel with feedback on their performance are essential elements of successful improvement programs. Further research is needed to establish the most effective methods of providing feedback. Additional studies are needed to optimize strategies for performing direct observation of hand hygiene compliance, and to determine the role of supplementing direct observations using automated monitoring systems.

Antibacterial efficacy of handrubbing for 15 versus 30 seconds: EN 1500-based randomized experimental study with different loads of Staphylococcus aureus and Escherichia coli.

OBJECTIVES: Compliance with the World Health Organization 'how to handrub' action is suboptimal. Simplifying the hand-hygiene action may improve practice. However, it is crucial to preserve antibacterial efficacy. We tested the non-inferiority of 15 versus 30 seconds handrubbing for Staphylococcus aureus and Escherichia coli contamination at different loads, using hand-size customized alcohol-based handrub (ABHR) volumes. METHODS: In an EN1500-based study, 18 health-care workers (HCWs) with extensive experience in hand hygiene rubbed hands with a hand-size customized volume of isopropanol 60% v/v. They repeated the following sequence: hand contamination (E. coli or S. aureus; broth containing 108 or 106 CFU/mL); baseline fingertips sampling; handrubbing (15 or 30 seconds); re-sampling. The main outcome was log10 CFU corrected reduction factor (cRF) on HCWs' hands, applying a generalized linear mixed model with a random intercept for subject. RESULTS: The median cRF was 2.1 log10 (interquartile range 1.50-3.10). After fitting the model, cRF was significantly higher for S. aureus compared with E. coli but there was no significant effect for duration of handrubbing or contamination fluid concentration. Fifteen seconds of handrubbing was non-inferior to 30 (-0.06 log10, 95% CI -0.34 to 0.22; EN1500 0.60 log10 non-inferiority margin). This was confirmed in all pre-specified subgroups. CONCLUSION: Among experienced HCWs using a hand-size customized volume of ABHR, handrubbing for 15 seconds was non-inferior to 30 seconds in reducing bacterial load, irrespective of type of bacteria or contamination fluid concentration. This provides further support for a shorter, 15-seconds, hand-hygiene action.

Service evaluation of alcohol-release door plates: an addition to hand hygiene.

A service evaluation was designed to examine the effect of installation of alcohol-releasing Surfaceskins doorplates on routine alcohol hand gel hygiene use by healthcare workers. There was an approximate doubling increase in healthcare worker use of alcohol hand gel dispensers following the installation of Surfaceskins doorplates in two operating theatre suites. No evidence was found that Surfaceskins doorplates replaced routine hand hygiene. It is concluded that these devices represent a useful adjunct to routine hand hygiene practice in healthcare environments, and potentially in other settings (e.g. washrooms, restaurants) where frequent contact with doors could undermine infection prevention practice.

Ozonized water as an alternative to alcohol-based hand disinfection.

BACKGROUND: Hand hygiene plays a vital role in the prevention of transmission of micro-organisms. Ozone (O3) is a highly reactive gas with a broad spectrum of antimicrobial effects on bacteria, viruses, and protozoa. It can easily be produced locally in small generators, and dissolved in tap water, and quickly transmits into ordinary O2 in the surrounding air. AIM: To compare ozonized tap water and alcohol rub in decontamination of bacterially contaminated hands. METHODS: A cross-over study among 30 nursing students. Hands were artificially contaminated with Escherichia coli (ATCC 25922), then sanitized with ozonized tap water (0.8 or 4 ppm) or 3 mL standard alcohol-based rub (Antibac 85%). The transient microbes from fingers were cultivated and colony-forming units (cfu)/mL were counted. The test procedure was modified from European Standard EN 1500:2013. FINDINGS: All contaminated hands before disinfection showed cfu >30,000/mL. The mean (SD) bacterial counts in (cfu/mL) on both hands combined were 1017 (1391) after using ozonized water, and 2337 (4664) after alcohol hand disinfection. The median (range) values were 500 (0-6700) and 250 (0-16,000) respectively (non-significant difference). Twenty per cent of participants reported adverse skin effects (burning/dryness) from alcohol disinfection compared with no adverse sensations with ozone. CONCLUSION: Ozonized tap water is an effective decontaminant of E. coli, and it could be an alternative to traditional alcohol-fluid hand disinfectants both in healthcare institutions and public places. Ozonized water may be especially valuable for individuals with skin problems.

Operating Room Hand Preparation: To Scrub or to Rub?

BACKGROUND: The alcohol rub has been proposed as an alternative to the traditional surgical scrub in preparing the hands for surgical procedures. Few reviews have examined critically the evidence that favors or discredits the use of the alcohol rub instead of the traditional scrub. METHODS: A review of available published literature was undertaken to define the evidence for the best methods for hand preparation before surgical procedures. The focus of this literature review was to compare the bacteriologic and clinical outcomes of conventional surgical scrubbing of the hands compared with alcohol rubs. RESULTS: The bacteriologic studies of the hands after the conventional scrub versus the alcohol rub demonstrated consistently comparable or superior reductions in bacterial presence on the hand with the alcohol rub. Only four clinical studies were identified that compared the scrub versus the rub in the frequency of surgical site infections. No difference in surgical site infections were identified. CONCLUSIONS: The alcohol rub appears to have comparable results to the surgical scrub and is a reasonable alternative in preparation of the hands for surgical procedures.

Large variations in the practice patterns of surgical antiseptic preparation solutions in patients with open and closed extremity fractures: a cross-sectional survey.

Background: Surgically-managed fractures, particularly open fractures, are associated with high rates of surgical site infections (SSIs). To reduce the risk of an SSI, orthopaedic surgeons routinely clean open fracture wounds in the emergency department (ED) and then apply a bandage to the open wound. Prior to the surgical incision, it is standard practice to prepare the fracture region with an antiseptic skin solution as an additional SSI prevention strategy. Multiple antiseptic solutions are available. Objectives: To explore the variation in practice patterns among orthopaedic surgeons regarding antiseptic solution use in the ED and antiseptic preparatory techniques for fracture surgery. Methods: We developed a 27-item survey and surveyed members of several orthopaedic associations. Results: Two hundred and-ten surveys were completed. 71.0% of respondents irrigate the open wound and skin in the ED, primarily with saline alone (59.7%) or iodine-based solutions (32.9%). 90.5% of responders indicated that they dress the open wound in the ED, with 41.0% applying a saline-soaked bandage and 33.7% applying an iodine-soaked dressing (33.7%). In their surgical preparation of open fractures, 41.0% of respondents used an iodine-based solution, 26.7% used a chlorhexidine gluconate (CHG)-based solution, and 31.4% used a combination of the two. In closed fractures, 43.8% of respondents used a CHG-based solution, 28.1% used an iodine-based solution, and 27.1% used a combination. Despite theoretical concerns about the use of alcohol in open wounds, 51.4% used alcohol-based solutions or alcohol alone during skin preparation of open fractures. Conclusions: A lack of consensus exists regarding use of antiseptic surgical preparation solutions for fractures. High-quality clinical research is needed to assess the effectiveness of different surgical antiseptic preparation solutions on patient outcomes in fracture populations.

Adhesive arachnoiditis following inadvertent epidural injection of 2% chlorhexidine in 70% alcohol-partial recovery over the ensuing eight years.

We report a case of serious neurologic injury due to inadvertent epidural injection of 8 ml of the antiseptic 2% chlorhexidine in 70% alcohol during a procedure aimed to relieve the pain of labour. This resulted in immediate severe back pain, progressive tetraparesis and sphincter dysfunction caused by damage to the spinal cord and nerve roots. Subacute hydrocephalus necessitated drainage, but cranial nerve and cognitive function were spared. Magnetic resonance imaging documented marked abnormality of the spinal cord and surrounding leptomeninges. In the ensuing eight years, there has been clinical and electrophysiological evidence of partial recovery, but neurologic deficit remains severe.

Supraclavicular Brachial Plexus Neurolysis for a Malignant Peripheral Nerve Sheath Tumor: A Case Report.

The perineural administration of alcohol or phenol results in protein denaturation and, consequently, neurolysis. This can produce long-lasting analgesia, with a duration of 3-6 months. Although neurolytic blocks for the brachial plexus have been described in multiple review articles and textbooks, they are rarely performed. As such, little is known about the efficacy and adverse effect profile of this commonly described treatment. In this article, we report the outcomes of a patient who underwent a left brachial plexus neurolytic block for the management of upper limb pain arising from a malignant peripheral nerve sheath tumor.

Nutrients, Nutraceuticals, and Xenobiotics Affecting Renal Health.

Chronic kidney disease (CKD) affects 8⁻16% of the population worldwide. In developed countries, the most important risk factors for CKD are diabetes, hypertension, and obesity, calling into question the importance of educating and acting on lifestyles and nutrition. A balanced diet and supplementation can indeed support the maintenance of a general health status, including preservation of renal function, and can help to manage and curb the main risk factors for renal damage. While the concept of protein and salt restriction in nephrology is historically acknowledged, the role of some nutrients in renal health and the importance of nutrition as a preventative measure for renal care are less known. In this narrative review, we provide an overview of the demonstrated and potential actions of some selected nutrients, nutraceuticals, and xenobiotics on renal health and function. The direct and indirect effects of fiber, protein, fatty acids, curcumin, steviol glycosides, green tea, coffee, nitrates, nitrites, and alcohol on kidney health are reviewed here. In view of functional and personalized nutrition, understanding the renal and systemic effects of dietary components is essential since many chronic conditions, including CKD, are related to systemic dysfunctions such as chronic low-grade inflammation.

Use patterns and frequency of hand hygiene in healthcare facilities: Analysis of electronic surveillance data.

BACKGROUND: Healthcare workers perform hand hygiene much more frequently than workers in other fields. As a result, healthcare workers have a higher exposure to topical antiseptic products. METHODS: Five tertiary care facilities were equipped with an electronic hand hygiene compliance monitoring system. Alcohol-based handrub (ABHR) and handwash use was recorded on a worker-specific basis for 6 months. Total hand hygiene product use and total hours worked were calculated for each worker to determine use frequency. RESULTS: A detailed, descriptive analysis of hand hygiene practices was performed. All facilities demonstrated high hand hygiene compliance rates (>85%). ABHR use was more frequent (9.1 uses/hour, 95th percentile) than handwashing (2.1 uses/hour, 95th percentile). This study identified a relationship between hand hygiene frequency and job function. Nursing and nonclinical support staff demonstrated higher usage rates than other healthcare workers. For these workers with high hand hygiene frequency, 95th percentile usage rates for ABHR use and handwashing were 9.6 and 2.2 uses/hour, respectively. CONCLUSIONS: This extensive dataset, monitoring nearly 4000 healthcare workers and more than 6 million data points, provides a detailed description of current hand hygiene practices of hospital staff. ABHR was used more frequently than handwashing. Job function was found to affect hand hygiene frequency, with nonclinical staff and nursing staff demonstrating elevated rates of hand hygiene.

Moderate acute alcohol intoxication increases visual motion repulsion.

Among the serious consequences of alcohol abuse is the reduced ability to process visual information. Diminished vision from excessive consumption of alcohol has been implicated in industrial, home, and automobile accidents. Alcohol is also generally recognized as an inhibitor in the brain by potentiating GABA-ergic transmission. In this study, we focused on visual motion processing and explored whether moderate alcohol intoxication induced changes in inhibitory mediated motion repulsion in a center-surround configuration. We conducted a double-blind, placebo-controlled, within-subjects study on the effect of alcohol on visual motion repulsion. Each subject underwent three experimental conditions (no alcohol, placebo and moderate alcohol) on separate days. The order of the placebo and moderate alcohol conditions was counterbalanced. The results showed that the effects of the surround context on the perception of the center motion direction were similar in both the sober (no alcohol) and placebo conditions. However, contextual modulations were significantly stronger during intoxication compared to both the sober and placebo conditions. These results demonstrate that moderate alcohol consumption is associated with altered neural function in visual cortical areas and that motion repulsion deficits might reflect the inhibitory effects of alcohol on the central nervous system.

Validation of a national hand hygiene proxy measure in NHS Scotland.

The Scottish national hand hygiene proxy measure uses the volume of alcohol-based hand rub (ABHR) purchased by NHS Scotland boards as an indicator of the number of hand hygiene moments being performed per patient-bed-day. The proxy measure calculation is based on the assumption that 3 mL of ABHR is used per hand hygiene moment. This study aimed to validate the volume of ABHR being used per hand hygiene moment. It found that the median volume of ABHR being used in practice is approximately 1 mL per hand hygiene moment, and that using this validated volume in the calculation substantially increases the proxy measure of hand hygiene compliance.