Unintended consequences of long-sleeved gowns in a critical care setting during the COVID-19 pandemic.

At the peak of the coronavirus disease 2019 (COVID-19) pandemic, hand hygiene audits indicated decreased compliance in a 12-bed critical care (CC) area with ventilated COVID-19 patients, where staff used personal protective equipment (PPE), including sessional use of long-sleeved gowns in accordance with the recommendations of Public Health England. There was also a cluster of three central venous catheter (CVC) infections along with increases in the number of patients from whom enteric Gram-negative bacteria (GNB) were isolated from sterile sites. Environmental sampling of near-patient surfaces and frequently touched sites demonstrated that 11.5% of areas were contaminated with enteric GNB in the COVID-19 CC area, compared with 2.6% and 2.7% in COVID-19 and non-COVID-19 general wards, respectively. Following a risk assessment, hospital policy was changed to replace long-sleeved gowns with short-sleeved gowns. The CC unit underwent enhanced cleaning with hypochlorite-based disinfectant and was resampled 8 days later. On resampling, no GNB were isolated from the CC unit. Following this change in PPE, hand hygiene compliance returned to baseline standards and no further CVC infections were identified. Staff reported a preference for short-sleeved gowns. No evidence currently exists that PPE beyond that recommended for pandemic influenza (respiratory protection plus standard PPE) adds to the protection of healthcare workers (HCWs) from severe acute respiratory syndrome coronavirus-2. Long-sleeved gowns prevent HCWs performing hand hygiene effectively. While it is imperative that HCWs are adequately protected, protection of patients from infection hazards is equally important. Further studies are necessary to establish risks from PPE to inform a review of current guidance.

Personal protective equipment solution for UK military medical personnel working in an Ebola virus disease treatment unit in Sierra Leone.

The combination of personal protective equipment (PPE) together with donning and doffing protocols was designed to protect British and Canadian military medical personnel in the Kerry Town Ebola Treatment Unit (ETU) in Sierra Leone. The PPE solution was selected to protect medical staff from infectious risks, notably Ebola virus, and chemical (hypochlorite) exposure. PPE maximized dexterity, enabled personnel to work in hot temperatures for periods of up to 2h, protected mucosal membranes when doffing outer layers, and minimized potential contamination of the doffing area with infectious material by reducing the requirement to spray PPE with hypochlorite. The ETU was equipped to allow medical personnel to provide a higher level of care than witnessed in many existing ETUs. This assured personnel working as part of the international response that they would receive as close to Western treatment standards as possible if they were to contract Ebola virus disease (EVD). PPE also enabled clinical interventions that are not seen routinely in West African EVD treatment regimens, whilst providing a robust protective barrier. Competency in using PPE was developed during a nine-day pre-deployment training programme. This allowed over 60 clinical personnel per deployment to practice skills in PPE in a simulated ETU and in classrooms. Overall, the training provided: (i) an evidence base underpinning the PPE solution chosen; (ii) skills in donning and doffing of PPE; (iii) personnel confidence in the selected PPE; and (iv) quantifiable testing of each individual's capability to don PPE, perform tasks and doff PPE safely.

Soy-dairy protein blend and whey protein ingestion after resistance exercise increases amino acid transport and transporter expression in human skeletal muscle.

Increasing amino acid availability (via infusion or ingestion) at rest or postexercise enhances amino acid transport into human skeletal muscle. It is unknown whether alterations in amino acid availability, from ingesting different dietary proteins, can enhance amino acid transport rates and amino acid transporter (AAT) mRNA expression. We hypothesized that the prolonged hyperaminoacidemia from ingesting a blend of proteins with different digestion rates postexercise would enhance amino acid transport into muscle and AAT expression compared with the ingestion of a rapidly digested protein. In a double-blind, randomized clinical trial, we studied 16 young adults at rest and after acute resistance exercise coupled with postexercise (1 h) ingestion of either a (soy-dairy) protein blend or whey protein. Phenylalanine net balance and transport rate into skeletal muscle were measured using stable isotopic methods in combination with femoral arteriovenous blood sampling and muscle biopsies obtained at rest and 3 and 5 h postexercise. Phenylalanine transport into muscle and mRNA expression of select AATs [system L amino acid transporter 1/solute-linked carrier (SLC) 7A5, CD98/SLC3A2, system A amino acid transporter 2/SLC38A2, proton-assisted amino acid transporter 1/SLC36A1, cationic amino acid transporter 1/SLC7A1] increased to a similar extent in both groups (P < 0.05). However, the ingestion of the protein blend resulted in a prolonged and positive net phenylalanine balance during postexercise recovery compared with whey protein (P < 0.05). Postexercise myofibrillar protein synthesis increased similarly between groups. We conclude that, while both protein sources enhanced postexercise AAT expression, transport into muscle, and myofibrillar protein synthesis, postexercise ingestion of a protein blend results in a slightly prolonged net amino acid balance across the leg compared with whey protein.

Protein composition of endurance trained human skeletal muscle.

Evidence suggests that myofibers from endurance trained skeletal muscle display unique contractile parameters. However, the underlying mechanisms remain unclear. To further elucidate the influence of endurance training on myofiber contractile function, we examined factors that may impact myofilament interactions (i. e., water content, concentration of specific protein fractions, actin and myosin content) or directly modulate myosin heavy chain (MHC) function (i. e., myosin light chain (MLC) composition) in muscle biopsy samples from highly-trained competitive (RUN) and recreational (REC) runners. Muscle water content was lower (P<0.05) in RUN (73±1%) compared to REC (75±1%) and total muscle and myofibrillar protein concentration was higher (P<0.05) in RUN, which may indicate differences in myofilament spacing. Content of the primary contractile proteins, myosin (0.99±0.08 and 1.01±0.07 AU) and actin (1.33±0.09 and 1.27±0.09 AU) in addition to the myosin to actin ratio (0.75±0.04 and 0.80±0.06 AU) was not different between REC and RUN, respectively, when expressed relative to the amount of myofibrillar protein. At the single-fiber level, slow-twitch MHC I myofibers from RUN contained less (P<0.05) MLC 1 and greater (P<0.05) amounts of MLC 3 than REC, while MLC composition was similar in fast-twitch MHC IIa myofibers between REC and RUN. These data suggest that the distinctive myofiber contractile profile in highly-trained runners may be partially explained by differences in the content of the primary contractile proteins and provides unique insight into the modulation of contractile function with extreme loading -patterns.

Effect of maximal and slow versus recreational muscle contractions on energy expenditure in trained and untrained men.

AIM: The primary purpose of this study was to compare energy expenditure among resistance exercise protocols using maximally explosive or slow contractions versus recreational in trained and untrained men. METHODS: Seven trained (21.9±2.1 yrs) and seven untrained men (20.1±2.2 yrs) performed three nearly identical exercise protocols, and a no-exercise (CONTROL) session in a randomly assigned, counterbalanced order. Subjects performed three sets of squats, dumbbell-row, deadlift, bench press, lat-pulldown, shoulder press, arm curls and dips using either recreational (REC), 2s (SLOW) or maximally explosive contractions (MAX). Expired air was collected continuously for 15 min before, ~37-43 min during, and 2 hr postexercise. Finger prick samples (25 µL) were collected and analyzed for blood lactate (BL) (mmol.L-1) before, immediately after, and during 120 min of recovery. RESULTS: Rates of energy expenditure were significantly (P≤0.05) greater for MAX than SLOW and REC during all exercises and +5 min after exercise in trained men, and MAX was greater than REC during all exercises except deadlift in untrained men. In trained men, total kcal were significantly greater (P≤0.05) with MAX (507±48) compared to REC (431±47), but not in untrained. Conversely, BL was significantly greater (P≤0.05) after SLOW compared to REC in trained and untrained men, while BL was only greater after MAX versus REC in trained men. CONCLUSION: For whole-body resistance exercise programs, maximally explosive contractions optimize energy expenditure in trained men, but slow contractions are recommended for untrained exercisers. Therefore, contraction intensity should be considered a program design variable for exercise prescriptions aimed to improve general health and fitness.

The use of clinical practice guidelines (CPGs) to evaluate practice and control costs in ventriculoperitoneal shunt management.

BACKGROUND: As a step toward maximizing the quality and cost-effectiveness of neurosurgical care, we designed clinical practice guidelines (CPGs) for the management of VP shunt malfunctions and infections at a tertiary care pediatric teaching institution. The detailed CPGs determine the use of radiographic studies, laboratory tests, and invasive procedures in the management of this problem. One purpose of the CPGs is to provide clear clinical guidelines for the medical trainee, thereby reducing variability in care and unnecessary utilization of resources. METHODS: The CPGs were developed in stages over a 2-year period. The practice patterns in our institution for the management of shunt malfunctions and infections were articulated. They were compared with those published in the neurosurgical literature, and areas of clinical decision-making variability were identified. Preliminary guidelines were formulated, and data regarding patient care were prospectively collected. Based on this data, final CPGs were formulated and implemented. Total and itemized hospital charges for patients managed according to the CPGs were compared with those for patients in the 3 years before CPG implementation. RESULTS: CPG-managed patients had generally lower total and itemized charges as compared with control patients. Decreased charges per hospital day and charges for shunt films in the CPG group were statistically significant. CONCLUSIONS: The process by which the CPGs were developed and implemented, as well as the CPGs themselves, are described. We also present the clinical, demographic, and financial data that were prospectively collected for all patients managed within the CPGs over an initial 1-year period and compare it with data obtained for control groups of shunt malfunction patients admitted during the 3 years before implementation of the CPGs. We find a trend toward reduction of charges after implementation of the CPG.

Heart rate and estimated energy expenditure during ballroom dancing.

Ten competitive ballroom dance couples performed simulated competitive sequences of Modern and Latin American dance. Heart rate was telemetered during the dance sequences and related to direct measures of oxygen uptake and heart rate obtained while walking on a treadmill. Linear regression was employed to estimate gross and net energy expenditures of the dance sequences. A multivariate analysis of variance with repeated measures on the dance factor was applied to the data to test for interaction and main effects on the sex and dance factors. Overall mean heart rate values for the Modern dance sequence were 170 beats.min-1 and 173 beats.min-1 for males and females respectively. During the Latin American sequence mean overall heart rate for males was 168 beats.min-1 and 177 beats.min-1 for females. Predicted mean gross values of oxygen consumption for the males were 42.8 +/- 5.7 ml.kg-1 min-1 and 42.8 +/- 6.9 ml.kg-1 min-1 for the Modern and Latin American sequences respectively. Corresponding gross estimates of oxygen consumption for the females were 34.7 +/- 3.8 ml.kg-1 min-1 and 36.1 +/- 4.1 ml.kg-1 min-1. Males were estimated to expand 54.1 +/- 8.1 kJ.min-1 of energy during the Modern sequence and 54.0 +/- 9.6 kJ.min-1 during the Latin American sequence, while predicted energy expenditure for females was 34.7 +/- 3.8 kJ.min-1 and 36.1 +/- 4.1 kJ.min-1 for Modern and Latin American dance respectively. The results suggested that both males and females were dancing at greater than 80% of their maximum oxygen consumption. A significant difference between males and females was observed for predicted gross and net values of oxygen consumption (in L.min-1 and ml.kg-1 min-1).