Assessing the stability and sporicidal efficacy of oxidizing disinfectants

BACKGROUND

The role of the healthcare environment in the transmission of clinical pathogens is well established. EN 17126:2018 was developed to address the need for regulated sporicidal product testing and includes a realistic medical soil to enable validation of products that claim combined cleaning and disinfection efficacy.

AIM

To investigate the chemical stability and sporicidal efficacy of oxidizing disinfectant products in the presence of simulated clean and medical dirty conditions.

METHODS

Disinfectant stability and sporicidal efficacy were evaluated in like-for-like ratios of soil:product. Disinfectants were exposed to simulated test soils and free chlorine, chlorine dioxide or peracetic acid concentrations were measured using standard colorimetric methods. Efficacy of disinfectants against C. difficile R027 endospores was assessed as per EN 17126:2018. Comparisons of performance between clean and medical dirty conditions were performed using one-way analysis of variance. Correlation analysis was performed using Pearson product-moment correlation.

FINDINGS

Performance of chlorine-releasing agents (sodium dichloroisocyanurate, chlorine dioxide and hypochlorous acid) was concentration dependent, with 1000 ppm chlorine showing reduced stability and efficacy in dirty conditions. By contrast, peracetic acid product demonstrated stability and consistently achieved efficacy in dirty conditions.

CONCLUSION

These results have implications for clinical practice, as ineffective environmental decontamination may increase the risk of transmission of pathogens that can cause healthcare-associated infections.

Impact of precursor-derived peracetic acid on post-weaning diarrhea, intestinal microbiota, and predicted microbial functional genes in weaned pigs

Post-weaning diarrhea affects piglets in the nursery phase of production, leading to a substantial impact both at the farm and financial levels. The multifactorial etiology of this disease includes housing conditions, pig genetics, microbial composition, and metagenomic assets. Among the common therapeutic approaches, the widely used zinc oxide underwent a European Union ban in 2022 due to its negative environmental impact and correlation to increased antimicrobial resistance. During this study, we have tested two levels of inclusion of the potential antimicrobial alternative peracetic acid, delivered in water via the hydrolysis of the precursors sodium percarbonate and tetraacetylethylenediamine, in comparison to zinc oxide and an untreated control during a 2-week animal study. We assessed the microbial composition and predicted the metagenome, together with performance and physiological parameters, in order to describe the microbial functional role in etiopathology. Both zinc oxide and peracetic acid resulted in amelioration of the diarrheal status by the end of the trial period, with noticeable zinc oxide effects visible from the first week. This was accompanied by improved performance when compared to the first-week figures and a decreased stomach pH in both peracetic acid levels. A significant reduction in both stomach and caecal Proteobacteria was recorded in the zinc oxide group, and a significant reduction of Campylobacter in the stomach was reported for both zinc oxide and one of the peracetic acid concentrations. Among other functional differences, we found that the predicted ortholog for the zonula occludens toxin, a virulence factor present in pathogens like Escherichia coli and Campylobacter jejuni, was less abundant in the stomach of treated pigs compared to the control group. In water, peracetic acid delivered via precursor hydrolysis has the potential to be a valid intervention, an alternative to antimicrobial, to assist the weaning of piglets. Our findings support the view that post-weaning diarrhea is a complex multifactorial disease with an important metagenomic component characterized by the differential abundance of specific predicted orthologs and microbial genera in the stomach and caecum of pigs.

Prospective Evaluation of Implementation of a Tattoo-less Workflow for Non-Spine Bone SBRT

PURPOSE/OBJECTIVE(S)

Oligometastatic disease has expanded the clinical indications for non-spine bone (NSB) SBRT. Optical surface monitoring systems (OSMS) may reduce treatment time if it represents an effective surrogate for bone intrafraction motion monitoring. We aimed to identify whether OSMS could substitute for 2D-3D mid-imaging and enable a tattoo-less set up in NSB SBRT.

MATERIALS/METHODS

Beginning 11/2019, OSMS was incorporated in parallel with an existing workflow using CBCT and mid 2D-3D kV/kV imaging for pre- and mid-imaging for NSB SBRT. The ability of OSMS to detect both observed out-of-tolerance (>2mm/>2deg) shifts and manual couch shifts was analyzed. A workflow incorporating OSMS reference captures, CBCT for pre-treatment verification and OSMS/triggered imaging (TI) for intrafraction monitoring was developed and deployed for rib/sternum SBRT beginning 11/2021 and all NSB SBRT beginning 2/2022. All NSB SBRT treatment appointments were analyzed through statistical process control (SPC) with use of an XmR chart of average set up and total treatment time per quarter from 2/2019 to 2/2023. Special cause rules were based on IHI rules and conduced with spreadsheet software.

RESULTS

From 2/2019 to 2/2023, 1962 NSB SBRT fractions were delivered, including 337 rib, 150 sternum, 197 femur, 266 ilium, 222 multi-site. Over 104 femur and 87 ilium images, there were no over tolerance intra-fraction events detected with 2D-3D or OSMS. Over 20 manual shifts, OSMS could detect 2mm shifts to within 0.4mm 67% of the time and 0.8mm 95% of time. There was no difference in treatment set up time following adoption of an OSMS/TI workflow as a replacement for 2D-3D mid-imaging. A reduction in rib SBRT delivery and multi-site treatment set-up times was significantly associated with the adoption of OSMS/TI and OSMS, respectively, as assessed based on special cause variation with 8 consecutive points below the mean.

CONCLUSION

Integration of OSMS and triggered imaging has enabled the transition to a completely tattoo-less workflow, thus sparing patients the need for permanent tattoos whilst also allowing more continuous motion monitoring and reduced radiation exposure related to unnecessary 2D-3D or CBCT mid-imaging. Treatment times were significantly reduced for patients receiving rib SBRT or multi-site NSB SBRT with this workflow.

What the COVID pandemic taught us about the management of pediatric minor trauma

The COVID-19 pandemic necessitated a change in our practice in the management of pediatric soft-tissue injuries. Patients were managed conservatively whenever possible. Our aim in this study was to see whether this more conservative approach adversely affected clinical, and patient-reported outcomes, including scarring. A prospective record of children presenting to the plastic surgery "Early Bird" clinic for pediatric trauma between 01.04.2020 and 30.06.2020 was kept. Electronic patient records were reviewed. An outpatient telephone clinic was scheduled for all patients. Parents were asked about complications and what they thought about the scar and to rate it as either: "poor," "satisfactory," "good," or "excellent." There were 240 patients, including 136 (57%) males and 104 (43%) females. The most frequent type of injury was a facial laceration in 123 patients (51.3%), followed by hand lacerations in 43 (17.9%), fingertip injuries in 31 (12.9%), and others. Ninety out of 240 (37.5%) were offered surgery. Follow-up times ranged from 17 to 20 months. Most parents (86.2%) were happy with the scarring and reported it as "good" or "excellent." The proportion rating the scar "excellent" or "good" was similar in the non-operated cohort (i.e., 85.5%) versus the operated cohort (88.5%) (p-value 0.16). The overall complication rate of patients seen during this time was 5.9%; 7.4% in the conservatively managed and 4.9% of those who went to the theater. Despite managing more wounds, including some dog bites, conservatively, patients and parents reported low complication rates and high levels of satisfaction with the final scarring.

Encapsulated peracetic acid as a valid broad-spectrum antimicrobial alternative, leading to beneficial microbiota compositional changes and enhanced performance in broiler chickens

BACKGROUND

Antimicrobial alternatives are urgently needed, including for poultry production systems. In this study, we tested the potential broad-range antimicrobial alternative peracetic acid, delivered in feed via the hydrolysis of encapsulated precursors through a 28-day study using 375 Ross 308 broiler chickens. We tested two peracetic acid concentrations, 30 and 80 mg/kg on birds housed on re-used litter, and we evaluated the impact of both levels on gut microbial communities, bacterial concentration, antimicrobial resistance genes relative abundance and growth performance when compared to control birds housed on either clean or re-used litter.

RESULTS

Body weight gain and feed conversion ratio improved in peracetic acid fed birds. At d 28, birds given 30 mg/kg of peracetic acid had a decreased Firmicutes and an increased Proteobacteria abundance in the jejunum, accompanied by an increase in Bacillus, Flavonifractor and Rombustia in the caeca, and a decreased abundance of tetracycline resistance genes. Chicken given 80 mg/kg of peracetic acid had greater caecal abundance of macrolides lincosamides and streptogramins resistance genes. Growth performance on clean litter was reduced compared to re-used litter, which concurred with increased caecal abundance of Blautia, decreased caecal abundance of Escherichia/Shigella, Anaerostipes and Jeotgalicoccus, and greater gene abundance of vancomycin, tetracycline, and macrolides resistance genes.

CONCLUSIONS

Peracetic acid could be used as a safe broad-spectrum antimicrobial alternative in broilers. Encapsulated precursors were able to reduce the bacterial concentration in the jejunum whilst promoting the proliferation of probiotic genera in the caeca, especially at the low peracetic acid concentrations tested, and improve growth performance. Moreover, our findings offer further insights on potential benefits of rearing birds on re-used litter, suggesting that the latter could be associated with better performance and reduced antimicrobial resistance risk compared to clean litter rearing.

Precursor-derived in-water peracetic acid impacts on broiler performance, gut microbiota, and antimicrobial resistance genes

Past antimicrobial misuse has led to the spread of antimicrobial resistance amongst pathogens, reportedly a major public health threat. Attempts to reduce the spread of antimicrobial resistant (AMR) bacteria are in place worldwide, among which finding alternatives to antimicrobials have a pivotal role. Such molecules could be used as "green alternatives" to reduce the bacterial load either by targeting specific bacterial groups or more generically, functioning as biocides when delivered in vivo. In this study, the effect of in-water peracetic acid as a broad-spectrum antibiotic alternative for broilers was assessed via hydrolysis of precursors sodium percarbonate and tetraacetylethylenediamine. Six equidistant peracetic acid levels were tested from 0 to 50 ppm using four pens per treatment and 4 birds per pen (i.e., 16 birds per treatment and 96 in total). Peracetic acid was administered daily from d 7 to 14 of age whilst measuring performance parameters and end-point bacterial concentration (qPCR) in crop, jejunum, and ceca, as well as crop 16S sequencing. PAA treatment, especially at 20, 30, and 40 ppm, increased body weight at d 14, and feed intake during PAA exposure compared to control (P < 0.05). PAA decreased bacterial concentration in the crop only (P < 0.05), which was correlated to better performance (P < 0.05). Although no differences in alpha- and beta-diversity were found, it was observed a reduction of Lactobacillus (P < 0.05) and Flectobacillus (P < 0.05) in most treatments compared to control, together with an increased abundance of predicted 4-aminobutanoate degradation (V) pathway. The analysis of the AMR genes did not point towards any systematic differences in gene abundance due to treatment administration. This, together with the rest of our observations could indicate that proximal gut microbiota modulation could result in performance amelioration. Thus, peracetic acid may be a valid antimicrobial alternative that could also positively affect performance.

Increased recurrence in Scarf osteotomy for mild & moderate hallux valgus with Meary's line disruption

BACKGROUND

Scarf osteotomy for hallux valgus is a successful procedure. Neverthless recurrence of deformity is reported as 5-8%. First ray instability is a recognised risk factor for recurrence. We investigate whether a radiographic marker such as Meary's line can be used to predict recurrence. This paper aims to test the null hypothesis that there is no difference in recurrence for mild and moderate hallux valgus treated with Scarf osteotomy in the presence of a disrupted Meary's line compared to an intact line.

METHODS

At a minimum of 3 months follow up we retrospectively analysed radiographs, theatre and clinic notes of 74 (n=74) consecutive patients treated with Scarf osteotomy for mild and moderate hallux valgus at a single centre. The patients were divided into Group A (n=30) - patients who on pre-operative weight bearing radiographs had a disrupted Meary's line, and Group B (n=44) - those with a normal Meary's line on pre-operative weight bearing radiographs.

RESULTS

Our results demonstrate statistically significant five times higher odds of recurrence in Group A compared to Group B with an odds ratio of 5.2 p=0.006 [95% CI 1.6-17]. On this basis we reject the Null hypothesis.

CONCLUSION

In this paper, we link a disrupted Meary's line with risk of recurrence of deformity. We demonstrate that, when Scarf osteotomy is used to correct mild and moderate hallux valgus in the presence of a broken Meary's line, the odds of recurrence as compared to the same procedure being performed with an intact line are 5.2 times higher. Alternative corrective techniques such as the Lapidus procedure warrant further investigation for the treatment of mild and moderate hallux valgus in the presence of Meary's line disruption.

Control of carbapenemase-producing Enterobacteriaceae outbreaks in acute settings: an evidence review

BACKGROUND

In recent years, infections with carbapenemase-producing Enterobacteriaceae (CPE) have been increasing globally and present a major public health challenge.

AIM

To review the international literature: (i) to describe CPE outbreaks in acute hospital settings globally; and (ii) to identify the control measures used during these outbreaks and report on their effectiveness.

METHODS

A systematic search of MEDLINE and EMBASE databases, abstract lists for key conferences and reference lists of key reviews was undertaken, and information on unpublished outbreaks was sought for 2000-2015. Where relevant, risk of bias was assessed using the Newcastle-Ottawa scale. A narrative synthesis of the evidence was conducted.

FINDINGS

Ninety-eight outbreaks were eligible. These occurred worldwide, with 53 reports from Europe. The number of cases (CPE infection or colonization) involved in outbreaks varied widely, from two to 803. In the vast majority of outbreaks, multi-component infection control measures were used, commonly including: patient screening; contact precautions (e.g. gowns, gloves); handwashing interventions; staff education or monitoring; enhanced environmental cleaning/decontamination; cohorting of patients and/or staff; and patient isolation. Seven studies were identified as providing the best-available evidence on the effectiveness of control measures. These demonstrated that CPE outbreaks can be controlled successfully using a range of appropriate, commonly used, infection control measures. However, risk of bias was considered relatively high for these studies.

CONCLUSION

The findings indicate that CPE outbreaks can be controlled using combinations of existing measures. However, the quality of the evidence base is weak and further high-quality research is needed, particularly on the effectiveness of individual infection control measures.

Profiles of language development in pre-school children: a longitudinal latent class analysis of data from the Early Language in Victoria Study

BACKGROUND

Pre-school language impairment is common and greatly reduces educational performance. Population attempts to identify children who would benefit from appropriately timed intervention might be improved by greater knowledge about the typical profiles of language development. Specifically, this could be used to help with the early identification of children who will be impaired on school entry.

METHODS

  This study applied longitudinal latent class analysis to assessments at 8, 12, 24, 36 and 48 months on 1113 children from a population-based study, in order to identify classes exhibiting distinct communicative developmental profiles.

RESULTS

Five substantive classes were identified: Typical, i.e. development in the typical range at each age; Precocious (late), i.e. typical development in infancy followed by high probabilities of precocity from 24 months onwards; Impaired (early), i.e. high probabilities of impairment up to 12 months followed by typical language development thereafter; Impaired (late), i.e. typical development in infancy but impairment from 24 months onwards; Precocious (early), i.e. high probabilities of precocity in early life followed by typical language by 48 months. The entropy statistic (0.84) suggested classes were fairly well defined, although there was a non-trivial degree of uncertainty in classification of children. That half of the Impaired (late) class was expected to have typical language at 4 years and 6% of the numerically large Typical class was expected to be impaired at 4 years illustrates this. Characteristics indicative of social advantage were more commonly found in the classes with improving profiles.

CONCLUSIONS

Developmental profiles show that some pre-schoolers' language is characterized by periods of accelerated development, slow development and catch-up growth. Given the uncertainty in classifying children into these profiles, use of this knowledge for identifying children who will be impaired on school entry is not straightforward. The findings do, however, indicate greater need for language enrichment programmes among disadvantaged children.

Transport policy and health inequalities: a health impact assessment of Edinburgh's transport policy

Health impact assessment (HIA) can be used to examine the relationships between inequalities and health. This HIA of Edinburgh's transport policy demonstrates how HIA can examine how different transport policies can affect different population groupings to varying degrees. In this case, Edinburgh's economy is based on tourism, financial services and Government bodies. These need a good transport infrastructure, which maintains a vibrant city centre. A transport policy that promotes walking, cycling and public transport supports this and is also good for health. The HIA suggested that greater spend on public transport and supporting sustainable modes of transport was beneficial to health, and offered scope to reduce inequalities. This message was understood by the City Council and influenced the development of the city's transport and land-use strategies. The paper discusses how HIA can influence public policy.

Achieving better health through health impact assessment

OBJECTIVE

Health Impact Assessment (HIA) provides a method of predicting the health impacts of policies and activities, in order to recommend changes that would improve health. We piloted approaches to health impact assessment and made recommendations for its use as part of the planning and policy making processes in Scotland.

DESIGN

Two Health Impact Assessments were done as case studies. One assessed the City of Edinburgh Council's Local Transport Strategy. The other assessed North Edinburgh Area Renewal Housing Strategy. Both were done in partnership with the professionals responsible for developing the strategies.

RESULTS

The main health impacts of transport strategy were in the areas of: accidents, pollution, access to amenities, jobs and social contacts, opportunities for physical activity in walking and cycling and impacts on community networks. Overall, housing strategy impacted most on mental health, especially stress and depression. The recommendations of both HIAs are being used in developing the strategies further.

CONCLUSIONS

Health impact assessment can make explicit the health consequences of decisions in different sectors, including impacts on health inequalities. Health Impact Assessment should be done as part of community planning and other partnership activities. Consideration of health impacts should become part of routine decision making.

Developing principles for health impact assessment

BACKGROUND

Policies and practice in many sectors affect health. Health impact assessment (HIA) is a way to predict these health impacts, in order to recommend improvements in policies to improve health. There has been debate about appropriate methods for this work. The Scottish Executive funded the Scottish Needs Assessment Programme to conduct two pilot HIAs and from these to develop guidance on HIA.

METHODS

Case study 1 compared three possible future scenarios for developing transport in Edinburgh, based on funding levels. It used a literature review, analysis of local data and the knowledge and opinions of key informants. Impacts borne by different population groups.were compared using grids. Case study 2 assessed the health impacts of housing investment in a disadvantaged part of Edinburgh, using published literature, focus groups with community groups and interviews with professionals.

RESULTS

Disadvantaged communities bore more detrimental effects from the low transport investment scenario, in the areas of: accidents; pollution; access to amenities, jobs and social contacts; physical activity; and impacts on community networks. The housing investment had greatest impact on residents' mental health, by reducing overcrowding, noise pollution, stigma and fear of crime.

CONCLUSION

Although there is no single 'blueprint' for HIA that will be appropriate for all circumstances, key principles to inform future HIA were defined. HIA should be systematic; involve decision-makers and affected communities; take into account local factors; use evidence and methods appropriate to the impacts identified and the importance and scope of the policy; and make practical recommendations.

Energy metabolism during CAPD: a controlled study

Abnormalities of energy metabolism may exacerbate the high prevalence of protein-calorie malnutrition and inadequate calorie intake in continuous ambulatory peritoneal dialysis (CAPD) patients, leading to further nutritional depletion. In a controlled study, using indirect calorimetry, we evaluated oxygen consumption (VO2), CO2 production, resting energy expenditure, and respiratory exchange ratio (RER) in 12 CAPD patients at rest and during a standard CAPD exchange and in 11 healthy nonuremic control patients. In addition, we investigated the influence of nutritional status and dialysis adequacy on energy metabolism in the CAPD group. There was no significant difference in resting energy parameters between the two groups. Unlike the control group, blood glucose and RER were maintained during prolonged fasting in the CAPD patients. This observation indicates that all the absorbed glucose was used as a metabolic fuel preventing fat oxidation. There was no significant relationship between energy expenditure and dialysis adequacy. There was no significant relationship between nutritional state (including energy intake) and energy expenditure despite evidence of malnutrition in 41% of the patients. If maintenance of "normal levels" of energy expenditure occurs in dialysis patients with suboptimal calorie intake (especially with evidence of protein-calorie malnutrition), this inability to conserve energy may act as an additional risk factor for ongoing malnutrition.

Diagnosis of polyhydramnios in early gestation: indication for prenatal diagnosis?

Previously published reports have indicated that idiopathic polyhydramnios may be associated with trisomies 18 and 21 and that chromosomal analysis is indicated. Furthermore, the natural history and fetal outcome of polyhydramnios diagnosed in early gestation have not been well delineated. We identified 138 pregnancies with polyhydramnios prior to 26 weeks' gestation. Of 131 complete cases, 21 were diagnosed as severe, 18 as moderate, and 92 as mild polyhydramnios. Congenital abnormalities were noted in 18 of 21 severe cases (86 per cent). Two of the remaining three cases were twin-to-twin transfusion. Thirteen of 18 cases with moderate polyhydramnios (72 per cent) were associated with anomalies; six of the remaining cases were twin-to-twin transfusion. Sixteen of 92 cases of mild polyhydramnios (17 per cent) were associated with congenital abnormalities. In 69 of 76 cases of mild hydramnios not associated with anomalies (91 per cent), the hydramnios resolved prior to delivery. Only 2 of 16 (13 per cent) associated with anomalies resolved. In 4 of 5 cases (80 per cent) with moderate hydramnios and no anomalies, the amniotic fluid volume was normal on subsequent ultrasound. No case of moderate polyhydramnios associated with anomalies or maternal conditions nor any case of severe polyhydramnios resolved. There were seven cases of chromosomal abnormalities in this series; all were associated with sonographic findings in addition to the presence of polyhydramnios. On the basis of these data, we doubt the benefit of amniocentesis following the early diagnosis of idiopathic polyhydramnios in the absence of other ultrasound findings.

Analysis of mRNA 3′ end formation by modification interference: the only modifications which prevent processing lie in AAUAAA and the poly(A) site

A modification interference method is described in which chemically modified transcripts are used to identify bases required for any reaction for which synthetic RNA is a substrate. This technique provides information analogous to that obtained from the analysis of a complete set of point mutants. Using SV40 late pre-mRNAs, we determine that modification of any base in the AAUAAA sequence prevents cleavage, polyadenylation and formation of pre-cleavage complexes in vitro. Modification of the A to which poly(A) is added prevents polyadenylation, but does not interfere with formation of the pre-cleavage complex. No single modification downstream of the poly(A) site significantly affects cleavage efficiency. Since the region downstream of the poly(A) site is required for cleavage and complex formation (Conway and Wickens, 1985; Zarkower and Wickens, 1987b), we infer that the critical features of this downstream region are either diffuse or redundant.