Frequency and component analysis of contaminants generated in preparation of anticancer agents using closed system drug transfer devices (CSTDs)

Occupational exposure of anticancer agents during their preparation has been recognized as a serious hazard. Closed system drug transfer devices (CSTDs) enable “safe” preparation of agents for medical personnel and ensure a safe hospital environment. However, artificial particles of infusion materials have been reported during CSTD use. Here, the incidence of insoluble fine particles during preparation of anticancer agents using CSTDs was examined. Visible insoluble fine particles were found in 465 (9.4%) of 4948 treatment cases at Ehime University Hospital with CSTD use. Contaminants occurred more frequently during preparation of monoclonal antibodies than cytotoxic anticancer agents (19.4% vs. 4.1%, respectively, P < 0.01). A similar survey was conducted at nine hospitals to investigate the incidence of insoluble fine particles with or without CSTDs. Insoluble fine particles were detected in 113 (15.4%) of 732 treatment cases during preparation of monoclonal antibodies with CSTD use. In contrast, the occurrence of insoluble fine particles without CSTDs was found in only 3 (0.073%) of 4113 treatment cases. Contamination with CSTDs might cause harmful effects on patients during cancer therapy. We strongly recommend the use of in-line filters combined with infusion routes after CSTD use to avoid contamination-associated adverse events.

Extensive outbreak of colistin resistant, carbapenemase (blaOXA-48, blaNDM) producing Klebsiella pneumoniae in a large tertiary care hospital, India

Background Extensive drug resistance in Klebsiella pneumoniae (K. pneumoniae) causing major outbreaks in large hospitals is an emerging challenge. We describe a near fatal outbreak of colistin resistant, carbapenem resistant K. pneumoniae (CRKp) producing metallo beta-lactamases (blaNDM) and blaOXA-48 in the neonatal intensive care unit (NICU) at the background of a larger outbreak involving multiple parts of the hospital and the challenges in its containment. Methods Following identification of an outbreak due to colistin resistant CRKp between April to June 2017 in the NICU, a thorough surveillance of similar cases and the hospital environment was performed to trace the source. All the isolated K. pneumoniae were tested for susceptibility to standard antibiotics by disc diffusion and microbroth dilution methods. Molecular detection of extended spectrum beta lactamases (ESBLs) and carbapenemases (classes A, B, D) genes was done. Enterobacterial repetitive intergenic consensus (ERIC) PCR and multi-locus sequence typing (MLST) was done to determine the genetic relatedness of the isolates. Characteristics of different sequence types were statistically compared (Student’s t-test). Results A total of 45 K. pneumoniae isolates were studied from NICU (14 cases of neonatal sepsis), ICU (18 cases), other wards (7 cases) along with 6 isolates from hospital environment and human colonizers. The primary case was identified in the ICU. All the K. pneumoniae from NICU and 94.4% from the ICU were colistin resistant CRKp. Majority (59.37% and 56.25%) harbored blaSHV/blaCTXM and blaOXA-48 genes, respectively. Two distinct sequence types ST5235 and ST5313 were noted with colistin resistance, distribution within the NICU and mortality as significant attributes of ST5235 (p < 0.05). The outbreak was contained with strengthening of the infection control practices and unintended short duration closure of the hospital. Conclusion Large hospital outbreaks with considerable mortality can be caused by non-dominant clones of colistin resistant CRKp harboring blaOXA-48 and blaNDM carbapenemases in endemic regions. The exact global impact of these sequence types should be further studied to prevent future fatal outbreaks.

O cão como coterapeuta e os cuidados para a sua atuação em ambiente hospitalar

Este estudo teve por objetivo abordar a cinoterapia como modalidade terapêutica capaz de promover uma maior humanização do atendimento ao doente, atuando como ferramenta efetiva no tratamento do assistido, dando ênfase aos cuidados necessários para o emprego do cão no ambiente hospitalar. A humanização da saúde, hoje já bem discutida, apoia iniciativas que visem à transformação do ambiente hospitalar. Acredita-se que, através de pequenas ações, podemos amenizar a dor de muitos, contribuir para o sucesso dos tratamentos e para a diminuição do tempo de hospitalização. A Cinoterapia, apoiada por uma equipe multidisciplinar, tem assistido crianças e adultos hospitalizados por diferentes patologias, pacientes cardíacos, psiquiátricos, portadores de Alzheimer, Parkinson, AIDS, paralisia cerebral, acidente vascular cerebral, câncer entre outras. Mesmo diante da tendência mundial e do reconhecimento da importância da terapia, a implantação de projetos ainda tem sido dificultada pela carência de estudos que demonstrem o impacto do cão no ambiente hospitalar. O desconhecimento dos riscos inerentes à terapia, principalmente no que diz respeito à transmissão de doenças, assim como a falta de protocolos com normas específicas para a sua implantação, são alguns dos entraves para uma maior disseminação da técnica. The aim of this study was to approach Pet therapy as a therapeutic modality capable of promoting a greater humanization of patient care, acting as an effective tool in the treatment of the assisted, emphasizing the necessary care for the use of the dog in the hospital environment. The humanization of health, now well discussed, supports initiatives aimed at transforming the hospital environment. It is believed that, through small actions, we can ease the pain of many, contribute to the success of the treatments and decrease the length of hospitalization. Pet therapy, supported by a multidisciplinary team, has assisted children and adults hospitalized for different pathologies, cardiac patients, psychiatric patients with Alzheimer's, Parkinson's, AIDS, cerebral palsy, stroke, cancer, among others. Even in the face of the worldwide trend and recognition of the importance of therapy, the implementation of projects has still been hampered by the lack of studies that demonstrate the impact of the dog in the hospital environment. The lack of knowledge about the risks inherent to the therapy, especially regarding the transmission of diseases, as well as the lack of protocols with specific norms for its implantation, are some of the obstacles for a greater dissemination of the technique.

Predominance of Acinetobacter spp., Harboring the blaIMP Gene, Contaminating the Hospital Environment in a Tertiary Hospital in Mwanza, Tanzania: A Cross-Sectional Laboratory-Based Study

Data on colonization and hospital contamination of carbapenem-resistant Gram-negative bacteria (CR-GNB) are limited in low- and middle-income countries. We designed this study to determine the prevalence and co-existence of carbapenemase genes among CR-GNB isolated from clinical, colonization, and hospital environmental samples at a tertiary hospital in Mwanza, Tanzania. The modified Hodge test (MHT), the combined disk test (CDT), and the double-disk synergy test (DDST) were used for the phenotypic detection of carbapenemases. A multiplex PCR assay was used to detect blaIMP and blaKPC, and a singleplex PCR assay was used to detect blaOXA-48. Data were analyzed by STATA version 13.0. Overall, 68.8% (44/64) of the CR-GNB had at least one phenotype by phenotypic methods, whereby 60.9% (39/64) were both CDT and DDST positive and 31.3% (20/64) were MHT positive. A total of 23/64 (35.9%) had at least one of the genes tested with the predominance of blaIMP (91.3%; 21/23). In addition, 47.7% (21/44) of the CR-GNB phenotypes had at least one gene. Around 47.8% (11/23) of the CR-GNB carried multiple genes encoding for carbapenem resistance, with the maximum co-existence of blaIMP/blaKPC/blaOXA-48 (45.5%; 5/11). The majority of carbapenem-resistant genes were detected in Acinetobacter spp. (82.6%; 19/23) and isolated from bed swabs (69.6%; 16/23). Acinetobacter spp. carrying the blaIMP gene predominantly contaminated the hospital environment. Therefore, we recommend routine decontamination of inanimate hospital surfaces, including patient beds.

Recognising, assessing and managing chest pain

Chest pain is a common medical symptom that paramedics attend to in the out-of-hospital environment. The causes of chest pain and the signs and symptoms are explained in this article, alongside tools that could be useful in diagnosis, such as clinical risk scores and troponin testing. Finally, pain management strategies that use a balanced approach for optimal patient care are referred to, with some specificity for cardiac chest pain explained.

Hand hygiene determinants of informal caregivers in hospitals under Pender's perspective

ABSTRACT Objectives: to analyze hand hygiene determinants of informal caregivers in a hospital environment. Methods: qualitative study conducted with 55 caregivers at a university hospital in the Northeast of Brazil. A semi-structured instrument was used, adapted from Nola Pender's Health Promotion Model, from which the deductive categories were derived. Results: the general behavior included hand hygiene before meals and after using the bathroom. Sensitivity to the requirements for hand hygiene was observed, but the barriers and self-efficacy consisted of the availability of soap or alcohol-based hand sanitizers, the lack of knowledge on the importance of and forgetfulness of the practice. The reinforcement on the importance of the practice and being in a contaminated environment were influencers, and commitment, warnings, and training were indispensable. Conclusions: benefits related to protection from infections were seen as positive determinants for hand hygiene adherence. For non-adherence, factors such as lack of sanitizing supplies, ignorance towards the importance of the activity, and forgetfulness stood out.

Experience of Late Miscarriage and Practical Implications for Post-Natal Health Care: Qualitative Study

Miscarriage is the most common reason for pregnancy loss, affecting around one in four pregnancies. It is classified as a traumatic event, associated with an increased risk for depression, anxiety, post-traumatic stress, alcohol dependence, somatic symptoms, sexual dysfunction, suicide, and complicated grief. This study aimed to analyse experiences of late miscarriage and to describe practical implications for post-natal health care based on characteristics of pregnancy loss revealed in a qualitative study. Seven women who had late miscarriages participated in in-depth biographical interviews. A phenomenological thematic analysis was applied. Experiential characteristics of late miscarriage were described by four themes and 13 subthemes: the initial splitting state (Dissociation, An Opened Void, An impaired Symbiosis, and The Body is Still Pregnant while the Psyche is Mourning); Betrayal of the body (Symbolic Experience of Internalised Death, Shocking Materiality of the Ongoing Miscarriage, Lost control of the Body, and Confusing Body Signals); Disconnecting (Depersonalising Medical Environment, Guilt Falsifies perception, and Retreat as a means of Self-Preservation); and Reconnecting (Collecting Shatters and Reinterpretation of Maternal Identity). Based on the results of the experiential analysis, another four themes represent practical recommendations for post-natal health care: Informing, Opportunity for Goodbye, Attention to Emotional Wellbeing, and Respectful Hospital Environment.