Interventions designed to control postpasteurization contamination in high-temperature, short-time-pasteurized fluid milk processing facilities: A case study on the effect of employee training, clean-in-place chemical modification, and preventive maintenance programs.

Postpasteurization contamination (PPC) with gram-negative bacteria adversely affects the quality and shelf-life of milk through the development of flavor, odor, texture, and visual defects. Through evaluation of milk quality at 4 large fluid milk processing facilities in the northeast United States, we examined the efficacy of 3 strategies designed to reduce the occurrence of PPC in fluid milk: (1) employee training (focusing on good manufacturing practices) alone and (2) with concurrent implementation of modified clean-in-place chemistry and (3) preventive maintenance (PM) focused on replacement of wearable rubber components. Despite increases in employee knowledge and self-reported behavior change, microbiological evaluation of fluid milk before and after interventions indicated that neither training alone nor training combined with modified clean-in-place interventions significantly decreased PPC. Furthermore, characterization of gram-negative bacterial isolates from milk suggested that specific bacterial taxonomic groups (notably, Pseudomonas sequence types) continued to contribute to PPC even after interventions and that no major changes in the composition of the spoilage-associated microbial populations occurred as a consequence of the interventions. More specifically, in 3 of 4 facilities, gram-negative bacteria with identical 16S rDNA sequence types were isolated on multiple occasions. Evaluation of a PM intervention showed that used rubber goods harbored PPC-associated bacteria and that PPC may have been less frequent following a PM intervention in which wearable rubber goods were replaced (reduction from 3/3 samples with PPC before to 1/3 samples after). Overall, our findings suggest that commonly used "broad stroke interventions" may have a limited effect on reducing PPC. Our case study also demonstrates the inherent complexities of identifying and successfully addressing sanitation problems in large and complex fluid milk processing facilities. For example, broad changes to sanitation practices without improvements in PM and sanitary equipment design may not always lead to reduced PPC. Our data also indicate that although short-term evaluations, such as pre- and post-tests for employee training, may suggest improvements after corrective and preventive actions, extensive microbial testing, ideally in combination with isolate characterization, may be necessary to evaluate return on investment of different interventions.

Transfusion service knowledge and immunohaematological practices related to sickle cell disease and thalassemia.

OBJECTIVES: To assess current knowledge of National Heart, Lung and Blood Institutes (NHLBI) and Thalassemia International Federation (TIF) recommendations, blood banking practices and perceived challenges among transfusion services in the management of patients with haemoglobinopathies. BACKGROUND: Previous reports have demonstrated variations in transfusion practices for sickle cell disease (SCD) and thalassemia patients. Recently, NHLBI/TIF have provided transfusion recommendations for patients with haemoglobinopathies. METHODS: A cross-sectional survey was conducted of transfusion services from the state of Georgia previously identified as having SCD/thalassemia populations. The survey assessed transfusion service practices in pre-transfusion testing and blood product selection; awareness/implementation of NHLBI/TIF transfusion-based recommendations and perceived challenges in transfusing haemoglobinopathy patients. RESULTS: Responses were received from 35 of 49 (71%) institutions. Only institutions indicating transfusing SCD or thalassemia patients (32) were included in analysis. Seventy-one percent of non-sickle cell treatment centres (SCTCs) and 20% of non-thalassemia treatment centres follow NHLBI and TIF recommendations to perform a red blood cell phenotype beyond ABO/Rh(D) and provide Rh and Kell prophylactically matched units for SCD and thalassemia patients, respectively. Forty percent of institutions (33% of non-SCTCs) employ RBC genotyping to evaluate the red cell phenotype for SCD patients. Over 77% of institutions do not utilise a reliable method to identify SCD patients prior to transfusion, such as a required question/answer field on type/screen or crossmatch orders. CONCLUSION: Many healthcare systems' transfusion practices for haemoglobinopathy patients are discordant with NHLBI/TIF recommendations. Efforts are needed to increase awareness and implementation of current recommendations among all transfusion services seeing these patients.

Thoracotomy versus video-assisted thoracoscopic pleurectomy for spontaneous pneumothorax.

We reviewed our experience with thoracotomy (TH) and video-assisted thoracoscopic pleurectomy (VAT) for the treatment of recurrent spontaneous pneumothorax. Nine patients underwent 10 VATs. One patient had bilateral procedures 1 week apart. Nine patients underwent 10 THs. One patient had bilateral TH at the same session. The mean duration of postoperative hospital stay for VAT and TH was 5.7 days and 6.4, respectively. VAT operative time was longer (128 vs 93.6 min in the TH group); however, the estimated blood loss was larger in the TH group (136 vs 108.3 ml in the VAT group). There were no deaths in either group. In the VAT group, one patient had recurrence of pneumothorax 1 month after surgery. In the TH group, there was no recurrence of pneumothorax, but one patient had chronic pain at the site of the thoracotomy incision. One patient was lost to follow-up in each group. We conclude that VAT is a safe and reasonably effective treatment of spontaneous pneumothorax. However, large series with long-term follow-up are needed to place this procedure in its proper perspective.

Treatment strategies in shock: use of oxygen transport measurements.

Shock has traditionally been categorized according to its cause. Shock can result from hemorrhage, primary cardiac failure, central nervous system failure, trauma, or sepsis. Therapeutic principles have been developed for each etiologic type. End points for such therapy have included optimization of pulmonary capillary wedge pressure, cardiac output, blood pressure, and urine output. Recent investigators agree that the common denominator in each of the shock syndromes is a reduction in the amount of oxygen consumed by the cell. The logical therapeutic approach would be to increase oxygen delivery to support the increased metabolic demand of the cells. The end point of resuscitation should be optimization of oxygen delivery and oxygen consumption. These variables are easily calculated by using data obtained from pulmonary artery catheter and laboratory measurements. The physician or nurse caring for critical ill patients should have a thorough understanding of the rationale for the use of oxygen transport calculations and the methods of manipulating oxygen delivery. A simple explanation of these principles including the importance of hemoglobin, cardiac index, and percent saturation of hemoglobin and suggested treatment strategies are presented.

A simple method of repositioning the wayward central venous catheter.

Malposition of a central venous catheter occurs despite improvements in catheter design and regardless of the skill of the physician. A simple method of repositioning a central venous catheter has been successful in 25 of 25 attempts. Documentation of the rationale for the use of this technique is provided using x-rays.