The CleanYourHandsCampaign: critiquing policy and evidence base.

Handwashing is considered to be the most effective way of reducing cross-infection. Rates of healthcare-associated infection and the incidence of meticillin-resistant Staphylococcus aureus are higher in the UK than in many other European countries. The government has responded by introducing the 'CleanYourHandsCampaign' throughout England and Wales, based on the success of the approach employed in Geneva. Alcohol hand rub is placed at every bedside in acute hospitals, ward housekeepers should replenish supplies and feedback on compliance is provided to health workers. Posters and other promotional materials are used to remind health workers and visitors to use the hand rub. Patients are encouraged to ask health workers if they have cleaned their hands before contact. In this paper we argue that the evidence base underpinning the CleanYourHandsCampaign is incomplete. Alcohol hand rub is acknowledged as a useful adjunct to hand hygiene but it is not effective in all circumstances. There is some evidence to support the use of feedback on performance to encourage compliance but no evidence that promotional materials such as posters or patient reminders are effective. The ethics of encouraging hospital patients to take responsibility for their own safety is questioned. Much of the success in Geneva must be attributed to the attention given to contextual factors within the organization that encouraged hand rub use, especially hospital-wide 'ownership' of the initiative by managers and senior health professionals. A customized intervention from another country that fails to consider local organizational factors likely to influence the implementation of the campaign is unlikely to be effective. It is concluded that although hand hygiene is of undoubted importance, undue emphasis should not be placed on it as a 'quick fix' to solve the unacceptably high rates of healthcare-associated infection in National Health Service hospitals.

NMDAR1 and primary afferent terminals in the superficial spinal cord.

We previously demonstrated a predominance of contacts by one type of glomerular ending (presumably from unmyelinated fibers) upon postsynaptic sites expressing the GluR1 subunit of the AMPA receptor, and of contacts by another type of glomerular ending (presumably from small myelinated fibers) upon postsynaptic sites expressing GLuR2. We here investigate whether any one of three types of primary afferent terminals, two glomerular and one non-glomerular, have direct contacts with postsynaptic sites containing the NMDAR1 subunit. Counts of gold particles revealed that contacts by primary afferents with NMDAR1-positive sites were less frequent than in material processed for AMPA receptor subunits, but that all three types of terminals contact NMDAR1-immunopositive postsynaptic sites in about equal proportions.

Experimental field studies with Mya arenaria (Bivalvia) on the induction and effect of hematopoietic neoplasia.

A field experiment was conducted from 1991 to 1992 to examine induction and impact of hematopoietic neoplasia on the marine bivalve Mya arenaria in southeastern Massachusetts. Clams were collected from Little Buttermilk Bay and separated into three size classes (20-29, 30-39, and 40-49 mm shell length) in the laboratory. These sizes span the range of adults found in the population. A random subsample of these clams was taken to estimate disease prevalence at the start of the experiment, and this was found to be

Rhinocerebral mucormycosis diabetes mellitus and adrenogenital syndrome.

A case of rhinocerebral mucormycosis in a diabetic is described. The case is unusual as the mucormycosis developed in the absence of ketoacidosis and because that patient had concomitant adrenogenital syndrome.

Lipopolysaccharide, tumor necrosis factor, and interleukin-1 interact to cause hypotension.

Lipopolysaccharide (LPS) causes the syndrome of septic shock by initiating the release of endogenous mediators such as tumor necrosis factor (TNF) and interleukin-1 (IL-1) from macrophages. Hypotension is one of the important clinical features of septic shock; however, TNF is only hypotensive in high doses. Therefore we have investigated the interactions of low, nonhypotensive doses of LPS, IL-1, and TNF in the restrained unanesthetized rabbit. Combinations of nonhypotensive doses of TNF, IL-1, and LPS produced significant (p less than 0.05) decreases in blood pressure as compared with doses of each of the substances alone. TNF bioactivity in animals that were made hypotensive with combinations of TNF, IL-1, and LPS was lower than in animals that were made hypotensive with TNF alone. This suggests that TNF release that is stimulated by LPS is not the sole cause of the hypotension that is seen in this model of endotoxic shock. In this model, interactions of LPS, IL-1, and TNF occur and may explain hypotension during some episodes of sepsis.

Fever, cytokines and shock.

Septic shock is a complex event with activation of many inflammatory pathways. Recent advances have begun to make some sense of the pathophysiological events. This review describes the historical background to the contemporary concepts and outlines the important role that cytokines probably have in the pathophysiology of septic shock. A consequence of the changing understanding of septic shock is that new therapeutic interventions are becoming available.

Hypothermia and infection in elderly patients admitted to hospital.

Twenty-five consecutive elderly patients with hypothermia were studied. Data were gathered regarding their home conditions, the circumstances in which they had been found, and their recent medical history. Clinical and laboratory examinations were performed to establish accurate diagnoses of underlying illnesses present at the time of arrival in hospital. Patients were followed up until the completion of the study. Evidence of an underlying cause was found in all cases. Twenty-two patients had evidence of definite or probable infection at the time of admission. Drugs may have contributed in seven cases. There were multiple significant causes for hypothermia in nine cases. Only 12 patients survived the index admission, and six of these had previous or subsequent admissions with hypothermia.

The increase in body temperature of elderly patients in the first twenty-four hours following admission to hospital.

In 76 unselected patients aged 70 years or over, the mean increase in rectal temperature in the 24 hours following admission to hospital was 0.4 degrees C. In those who did not receive antibiotics on admission, the mean increase in rectal temperature was 0.6 degrees C, with increases of up to 2.3 degrees C recorded. There were no significant changes in C-reactive protein, white cell count or erythrocyte sedimentation rate over that period, suggesting that the changes were due to passive warming rather than to progression of the underlying disease. Infected patients may have low or normal body temperatures on admission. Within 24 hours, nearly all infected patients (excluding a few with low or normal temperatures on admission, who receive antibiotics) have a raised body temperature. The most sensitive test for a raised body temperature is the rectal temperature measured at least 24 hours after admission. A patient who has a low or normal body temperature on admission has a 61% chance of having a raised body temperature the next day. At least 55% of patients admitted with a febrile illness have low or normal body temperatures on admission.

Normal rectal, auditory canal, sublingual and axillary temperatures in elderly afebrile patients in a warm environment.

Fifty hospital inpatients were selected, who, on the basis of their history and on clinical and laboratory findings, were believed not to have a febrile illness. Body temperature was measured simultaneously at four sites, in order to compile a normal range of temperature at each site for patients under these conditions. The observed range of rectal temperature was 36.7-37.5 degrees C, auditory canal temperature 36.4-37.2 degrees C, sublingual temperature 36.2-37.0 degrees C, and axillary temperature 35.5-37.0 degrees C.

Capillary blood cell velocity is reduced in fever without hypotension.

Capillary blood cell velocity was measured in a group of normotensive febrile patients as a basis for further study into the microvascular physiology of febrile hypotensive patients with sepsis. Television videomicroscopy was used to record the capillary blood cell movement in the finger nailfold. Analysis of all moving gaps in the red cell column seen during a minimum of 2 minutes was done by the frame-by-frame technique and mean blood cell velocity derived. Core (external auditory meatus) and skin (finger) temperature were also measured. Subjects (n = 6) were sex and skin temperature matched to controls. Although the mean skin temperature of subjects [28.73 degrees C, SD = 0.28] was not significantly different to controls [30.63 degrees C, SD = 3.11; p less than 0.05] the mean velocity was significantly reduced in the febrile subject group [0.28 mm/sec, SD = 0.17] as compared with controls [0.56 mm/sec, SD = 0.22; p less than 0.05]. It is likely therefore that these skin vessels vasoconstrict as part of the integrated response to reduce heat loss.

Studies on the circulation in normotensive febrile patients.

Normotensive febrile patients were studied in a constant-temperature room during stable fever, They were restudied later while afebrile and after heating the trunk. Finger and forearm blood flow were measured by venous occlusion plethysmography. The ability of cutaneous vessels to constrict on dependence of the limb was measured by laser Doppler flowmetry. The volume, velocity and acceleration of the blood in the ascending aorta were determined using pulsed Doppler ultrasound with a probe in the supra-sternal notch; measurements of systolic time intervals were made. While febrile, patients had a tachycardia and shortened systolic ejection times; cardiac output and total peripheral resistance were unchanged on average as compared to when afebrile. There was no evidence of any change in left ventricular contractility during fever from measurements of the peak velocity, maximum acceleration of blood or from the systolic time intervals. As compared to when heated, febrile patients had a skin blood flow that was relatively reduced for their skin temperature and had preservation of postural vasoconstriction.

Tropical pyomyositis associated with Trypanosoma brucei rhodesiense infection in a Europid.

A 29-year-old European woman became infected with Trypanosoma brucei rhodesiense in the Luangwa valley, Zambia. Six days after the initial presentation of this infection she developed evidence of tropical pyomyositis (TP). These diseases, both of which are rare in Europids, were satisfactorily treated. The pathogenesis of TP, which is nearly always caused by Staphylococcus aureus, is undetermined. It seems possible that in this case either (i) both infections were introduced simultaneously by a tsetse-fly bite, or (ii) T. b. rhodesiense produced multiple focal necroses in skeletal muscles which acted as niduses for the staphylococcal infections; immunodepression caused by this parasite might also have been important.

Interleukin-1 and tumour necrosis factor cause hypotension in the conscious rabbit.

1. The cardiovascular effects of intravenous injections of interleukin-1 (IL-1) and tumour necrosis factor (TNF) have been investigated in the conscious rabbit. They have been compared with the effects of bacterial lipopolysaccharide (LPS) because both IL-1 and TNF are released from macrophages by LPS. 2. IL-1, TNF and Escherichia coli J5-LPS all caused hypotension when given intravenously in a dose with low mortality. The time course of the hypotension caused by IL-1 and LPS was similar, although the maximal fall in mean blood pressure occurred earlier after IL-1. TNF produced a more sustained fall in blood pressure. Hypotension was not accompanied by a compensatory tachycardia after any of the test substances. Hypotension was associated with a fever after TNF, hypothermia after LPS and no significant change in temperature after IL-1. 3. The packed cell volume did not change during hypotension in any of the study groups, implying that the hypotension was not due to fluid loss resulting from increased capillary permeability. 4. IL-1 and TNF are candidates for the role of effectors of LPS-induced hypotension.

Pubic osteomyelitis presenting as irritable hip.

Two cases of pubic osteomyelitis presenting as a painful hip are reported. In both cases the diagnosis was delayed by the unusual presentation and by the limited radiological investigation. Pubic osteomyelitis is rare in childhood but should be considered in the differential diagnosis of the 'irritable hip'.

Positive bromide partition test in the absence of tuberculous meningitis.

Five cases of lymphocytic meningitis are described where a Bromide Partition Test was performed and proved positive at levels usually considered consistent with tuberculous meningitis. Three of these cases were ultimately shown to have herpes simplex viral encephalitis, one had Listeria monocytogenes in the CSF and the fifth patient recovered without treatment and was thought to have had a viral encephalitis. The Bromide Partition Test may not be as good a discriminant as has previously been suggested in differentiating between tuberculous and viral meningitis, especially when performed in a population at low risk of getting tuberculous meningitis.

Toward classifying psychoactive chemical use.

A classification scheme is proposed based on description of consequences of psychoactive chemical use. It is an alternative to current labels (e.g., alcoholic, drug abuser, chemically dependent) which are often controversial or pejorative, as well as being imprecise and limited to pathology. The categories are: Helpful, Low Risk Potential Harm, High Risk Potential Harm, and Harmful. These are briefly defined and illustrative examples are cited. The appropriate treatment responses for the four categories are, respectively: Encouragement, Accurate Information, Persuasive Education, and Active Intervention. The basic rationale and procedure for each is discussed. The system incorporates prevention as well as remediation.

Assessing drinking problems by history.

Patients with alcohol problems can be categorized as either medical alcoholics, who have medical problems caused by high levels of alcohol consumption, or behavioral alcoholics, whose drinking results in adverse changes in their behavior. Behavioral alcoholics pose a diagnostic problem to the physician because of their highly developed denial systems. A detailed, accurate drinking history is necessary for diagnostic assessment, and the physician must employ several key strategies in order to circumvent the denial system and elicit relevant information. Additional information can be obtained from a member of the problem drinker's family. Family members should also be involved in the treatment process.