How to carry out microbiological sampling of healthcare environment surfaces? A review of current evidence

There is increasing evidence that the hospital surface environment contributes to the spread of pathogens. However, evidence on how best to sample these surfaces is inconsistent and there is no guidance or legislation in place on how to do this. The aim of this review was to assess current literature on surface sampling methodologies, including the devices used, processing methods, and the environmental and biological factors that might influence results. Studies published prior to March 2019 were selected using relevant keywords from ScienceDirect, Web of Science, and PubMed. Abstracts were reviewed and all data-based studies in peer-reviewed journals in the English language were included. Microbiological air and water sampling in the hospital environment were not included. Although the numbers of cells or virions recovered from hospital surface environments were generally low, the majority of surfaces sampled were microbiologically contaminated. Of the organisms detected, multidrug-resistant organisms and clinically significant pathogens were frequently isolated and could, therefore, present a risk to vulnerable patients. Great variation was found between methods and the available data were incomplete and incomparable. Available literature on sampling methods demonstrated deficits with potential improvements for future research. Many of the studies included in the review were laboratory-based and not undertaken in the real hospital environment where sampling recoveries could be affected by the many variables present in a clinical environment. It was therefore difficult to draw overall conclusions; however, some recommendations for the design of routine protocols for surface sampling of healthcare environments can be made.

Spinal projection of spindle afferents of the longissimus lumborum muscles of the cat

The connections and monosynaptic projections of muscle spindle afferents of individual heads of the longissimus lumborum have been studied in cats by natural stimulation, by electrical stimulation and by spike-triggered averaging from single identified afferents. The spindle afferents were classified by sensitivity to vibration and by the effect of succinylcholine on their response to ramp-and-hold muscle stretches. Axonal conduction and synaptic effects were recorded as field potentials and focal synaptic potentials during systematic exploration of the spinal cord in segments L1 to L4 with extracellular metal microelectrodes, singly and in linear arrays. Ascending branches of afferent axons within the cord had a significantly higher mean conduction velocity (CV: 56.5 m s(-1)) than descending branches (40.8 m s(-1)). The CV of ascending branches was significantly positively correlated with a measure of the strength of intrafusal bag(2) muscle fibre contacts, but not to a measure of bag(1) contacts. Two sites of monosynaptic excitatory projection in the cord were identified, namely to the intermediate region (laminae V, VI and VII) and to ventral horn region (laminae VIII and IX). In tests of 154 single afferents, signs of central projection were detected for 60, providing 122 regions of maximum negative focal synaptic potentials (FSPs) of mean amplitude 7.51 microV. Their longitudinal spacing indicated that axons gave off descending collaterals at intervals of 1.5-3.5 mm. Based on the amplitude of FSPs, the projection of secondary afferents is stronger than that of primaries in the intermediate region and possibly also in the ventral horn region. Evidence is also presented that spindle afferent input from different heads of the longissimus converges into any given spinal segment and that input in one spinal root projects to adjacent segments. It is concluded that the organization of the longissimus monosynaptic spindle input favours relatively tonic and diffuse stretch reflexes.

Classification of longissimus lumborum muscle spindle afferents in the anaesthetized cat

Recordings have been made from 127 single muscle spindle afferents from the longissimus lumborum muscles of anaesthetized cats. They have been characterized by their responses to passive muscle stretch and the effects of succinylcholine (SCh) and by their sensitivity to vibration. The use of SCh permitted the assessment for each afferent of the influence of bag1 (b1) and bag2 (b2) intrafusal muscle fibres. From this, on the assumption that all afferents were affected by chain (c) fibres, they were classified in four groups: b1b2c (41.9%), b2c (51.4%), b1c (1.3%) and c (5.4%). All the afferents with b1 influence were able to respond one to one to vibration at frequencies above 100 Hz and were considered to belong to primary endings. On the basis of the vibration test, 64% of the b2c type afferents appeared to be primaries and 36% secondaries. Of the units classified as primaries, 41% were designated as b2c and would not therefore be able to respond to dynamic fusimotor activity. The significance of this relatively high proportion of b2c-type spindle primary afferents is discussed in relation to the specialized postural function of the back muscles.

Static and dynamic gamma-motor output to ankle flexor muscles during locomotion in the decerebrate cat

In locomotion, the flexor muscles of the leg are mainly concerned with the relatively constant task of raising the foot, whereas the extensors have the more variable task of support and propulsion at different speeds. This suggests that the way in which the fusimotor system works may differ between the two muscle groups. Observations previously made of the static and dynamic gamma-motor firing patterns in the ankle extensor medial gastrocnemius (MG) have therefore been repeated in the flexor tibialis anterior (TA). One or more single gamma-motor axons, dissected from a small filament of TA nerve, were recorded simultaneously with a number of single spindle afferents in dorsal rootlets. Cats were decerebrated and locomoted spontaneously on a treadmill. Identification of each gamma-motor axon depended on relating the changes in firing caused by midbrain stimulation to the changes in static and dynamic behaviour of the spindle afferents in response to repetitive ramp and hold stretches. Static gamma axons all showed a smooth modulation in frequency, increasing in phase with muscle shortening, superimposed on a minimum frequency of about 20-30 impulses s(-1). Dynamic gamma axons showed interrupted firing with the frequency rising abruptly from zero at the onset of shortening, and falling again to zero shortly after the onset of lengthening. The frequency during the active periods was relatively constant, even when movement amplitudes varied. The basic similarity in the static and dynamic gamma discharge patterns for the two muscles suggests that the strategy of gamma-motor control is common to both flexors and extensors. The static gamma pattern is thought to be a 'temporal template' of the expected movement, effectively expanding the dynamic response range of the spindles in active movements. The dynamic gamma pattern sensitizes the primary afferents to detect the onset of muscle lengthening and to detect departures from the intended movement trajectory.

The influence of bag2 and chain intrafusal muscle fibers on secondary spindle afferents in the cat

Static gamma-motor activity is strongly modulated by a particular phase relationship to the cyclic movements of locomotion, and this has a profound effect on the firing patterns of muscle spindle afferents. Whilst primary afferents are affected by both static and dynamic gamma-motor output,secondary afferents are affected significantly only by the static system acting via the intrafusal bag2 and chain fibres. It is therefore important to know how fluctuating patterns of static gamma-motor activity affect secondary afferents and to relate this to the actions of bagt and chain fibres. We have studied the action of single static gamma axons on secondary afferents in cat hindlimb muscles. Various physiological methods were explored to identify which of the intrafusal muscle fibres were being activated in each case, including the use of random stimulation and ramp frequency stimulation. The effects were also recorded of I Hz sinusoidally frequency-modulated gamma-axon stimuli and the amplitude and phase of the resulting afferent modulation related to the involvement of the bag2 and chain fibres. It was found that bag2 fibres are effective in biasing the secondary discharge, but their modulating action is relatively weak and involves a marked phase lag. Chain fibres acting alone cause strong modulation with very little phase lag. Mixed bag2 and chain-fibre action is most effective in modulating afferent discharge and causes intermediate values of phase lag. The results are discussed in relation to the control of natural movements and it is concluded that an important function of the static gamma motor system is to provide a signal to sum algebraically with the length-related signal. The results do not suggest that it could also usefully control stretch sensitivity.

Role of the fusimotor system in locomotion

The contribution of muscle spindles to the control of locomotion depends on the patterns of discharge that occur in static and dynamic gamma motoneurones (gammaS and gammaD). Discharges of gamma-axons to the MG muscle were studied during treadmill locomotion in pre-mammillary, decerebrated cats. All gammaS-efferents increased their rate of discharge at onset of locomotion and were modulated with movement. Type-1 increased their rate with muscle shortening whereas type-2 gammaS efferents increased their discharge rate during muscle lengthening. The type-1 gammaS pattern appears to be a temporal template of the intended movement. The type-2 gammaS pattern may be appropriate for afferent biasing through bag2 intrafusal fibres. The gammaD axons showed an interrupted discharge pattern with sudden onset of firing at the start of muscle shortening and falling quiet shortly after the beginning of lengthening. The gammaD discharge would prepare primary endings to respond with high sensitivity at the start of muscle lengthening.

Quality improvement report: Effect of a formal education programme on safety of transfusions

PROBLEM

Failure of correct identification and insufficient monitoring of patients receiving transfusions continue to be appreciable and avoidable causes of morbidity and mortality.

DESIGN

A study by a regional transfusion service and a transfusion nurse specialist of the effects of an education programme based on the current national guidelines on identification and monitoring of patients receiving transfusions.

SETTING

A large United Kingdom teaching hospital which houses the headquarters of the regional transfusion service.

KEY MEASURES FOR IMPROVEMENT

Improvement in compliance with published national guidelines on the prescription and administration of blood transfusions.

STRATEGY FOR CHANGE

An audit of current compliance followed by dissemination by a transfusion nurse specialist of a clinical skills package (based on the best practice for transfusion) to all staff involved in giving transfusions. This was supported by trained instructors and the display of standard operating procedures for transfusion in all clinical areas. EFFECT OF CHANGE: An improvement in compliance with the national guidelines to over 95% in six out of seven of the recommendations on best practice was seen 18 months after the initial intervention.

LESSONS LEARNT

The study shows that education of those who prescribe and administer transfusions, as recommended by bodies concerned with the hazards of transfusion, can improve the safety of transfusions.

Modulation of primary afferent discharge by dynamic and static gamma motor axons in cat muscle spindles in relation to the intrafusal fibre types activated

1. Recordings were made from muscle spindle primary afferents from medial gastrocnemius and soleus muscles of the cat to study the modulating effects of varying gamma-motor stimulation frequency at constant muscle length. Stimulus trains had a mean frequency of 50 Hz and were sinusoidally frequency modulated at 1 Hz, with an amplitude of modulation of +/- 5 to +/- 30 Hz. 2. When dynamic gamma-axons (gamma(d)) were selected for their pure effect on bag(1) fibres, they were found to have very little modulating effect on afferent firing. 3. Static gamma-axons (gamma(s)) were tested with a random stimulus and correlation method to determine whether they acted purely on bag(2) fibres, purely on chain fibres or on both together. Pure bag(2) gamma(s)-axons had weak modulating effects with large values of phase lag. Pure chain connections were effective in modulating with very little phase lag, but their mean gain was low. Mixed bag(2) and chain axons were most effective and showed phase shifts proportional to gain. 4. The effects of muscle length changes recorded previously from locomotor movements were also tested, with and without accompanying stimulation of mixed gamma(s)-axons with pulse trains recorded from gamma(s)-axons. This gamma(s) stimulation had a powerful effect in increasing afferent discharge during muscle shortening. The difference in afferent firing between the stimulated and non-stimulated conditions accurately predicted the profile of the gamma(s) stimulation. 5. The results are discussed in relation to the ways in which the gamma-motor system may be used in natural movements.

Distinctive patterns of static and dynamic gamma motor activity during locomotion in the decerebrate cat

Simultaneous recordings were made from gamma (gamma) motor axons and from muscle spindle afferents of the medial gastrocnemius (MG) muscle during locomotion in decerebrate cats. The gamma-neurons were identified as static or dynamic (gammas or gammad) by correlating their behaviour during midbrain stimulation with changes in muscle spindle afferent responses to muscle stretch. On the basis of their behaviour during locomotion, gammas neurons could be divided into two groups. One group (type-1) showed strongly and smoothly modulated discharge increasing in parallel with the active muscle shortening in ankle extension, but with phase advance. The other group (type-2) also showed a modulated pattern, but with increased firing centred on the flexion phase. The proportions of the two were 13 type-1 and 7 type-2. The type-1 firing pattern accurately predicted the difference in firing frequency for secondary afferents obtained by subtracting from the recordings made during active movements the response of the same units to the movements repeated passively in the absence of fusimotor activity. The type-2 pattern also became consistent with the difference signal, when operated on by a phase lag appropriate to the effects of bag2 intrafusal fibres. These results suggest that there may be some degree of separate control of chain and bag2 intrafusal fibres. The discharge of gammad axons was also found to fluctuate with the locomotor cycle, with a pattern very distinct from that of the gammas records. The gammad firing frequency rose very suddenly from zero to a maximum at the onset of muscle shortening and continued into the beginning of lengthening. The term 'interrupted' discharge is suggested as a useful description. The timing of this discharge was shown to be appropriate for sensitising the primary afferents to detect the onset of stretch.

Transfusion-associated graft vs. host disease in a patient with high-grade B-cell lymphoma. Should cellular products for patients with non-Hodgkin's lymphoma be irradiated?

We present the case of a 64-year-old man who died from transfusion-associated graft vs. host disease (TA-GVHD) having been treated 2 years earlier for a high-grade, non-Hodgkin's lymphoma (NHL). We suggest that he was at increased risk of developing TA-GVHD as a result of the NHL and its subsequent treatment, and propose that patients with NHL should be added to those 'at risk' groups who receive irradiated cellular blood components.

Patterns of fusimotor activity during locomotion in the decerebrate cat deduced from recordings from hindlimb muscle spindles

1. Recordings have been made from multiple single muscle spindle afferents from medial gastrocnemius (MG) and tibialis anterior (TA) muscles of one hindlimb in decerebrate cats, together with ankle rotation and EMG signals, during treadmill locomotion. Whilst the other three limbs walked freely, the experimental limb was denervated except for the nerves to MG and TA and secured so that it could rotate only at the ankle joint, without any external load. Each afferent was characterised by succinylcholine testing with regard to its intrafusal fibre contacts. Active movements were recorded and then replayed through a servo mechanism to reproduce the muscle length changes passively after using a barbiturate to suppress gamma-motor firing. 2. The difference in secondary afferent firing obtained by subtracting the discharge during passive movements from that during active movements was taken to represent the profile of static fusimotor activity. This indicated an increase before the onset of movement followed by a strongly modulated discharge in parallel with muscle shortening during locomotion. The pattern of static firing matched the pattern of unloaded muscle shortening very closely in the case of TA and with some phase advance in the case of MG. The same effects were observed in primary afferents. 3. Primary afferents with bag1 (b1) contacts in addition showed higher firing frequencies during muscle lengthening in active than in passive movements. This indicated increased dynamic fusimotor firing during active locomotion. There was no evidence as to whether this fluctuated during the movement cycles. 4. When the mean active minus passive difference profile of firing in bag2-chain (b2c) type primary afferents was subtracted from that for b1b2c afferents, the difference was dominated by a peak centred on the moment of maximum lengthening velocity (v). 5. The component of the active minus passive difference firing due to b1 fibre contacts could be modelled by f(t) = av (where a is a constant) during lengthening and by f(t) = 0.2 av during shortening. The remainder of the difference signal matched the predictions of the static fusimotor signal derived from secondary afferents. 6. The findings are discussed in relation to the concept that the modulated static fusimotor pattern may represent a 'temporal template' of the expected movement, though the relationship of the results to locomotion in the intact animal will require further investigation. The analysis of the data indicates that the combined action of muscle length changes and static and dynamic fusimotor activity to determine primary afferent firing can be understood in terms of the interaction between the b1 and b2c impulse initiation sites.