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Background:Candida auris is an emerging multidrug-resistant yeast that is transmitted in healthcare facilities and is associated with substantial morbidity and mortality. Environmental contamination is suspected to play an important role in transmission but additional information is needed to inform environmental cleaning recommendations to prevent spread. Methods: We conducted a multiregional (Chicago, IL; Irvine, CA) prospective study of environmental contamination associated with C. auris colonization of patients and residents of 4 long-term care facilities and 1 acute-care hospital. Participants were identified by screening or clinical cultures. Samples were collected from participants’ body sites (eg, nares, axillae, inguinal creases, palms and fingertips, and perianal skin) and their environment before room cleaning. Daily room cleaning and disinfection by facility environmental service workers was followed by targeted cleaning of high-touch surfaces by research staff using hydrogen peroxide wipes (see EPA-approved product for C. auris, List P). Samples were collected immediately after cleaning from high-touch surfaces and repeated at 4-hour intervals up to 12 hours. A pilot phase (n = 12 patients) was conducted to identify the value of testing specific high-touch surfaces to assess environmental contamination. High-yield surfaces were included in the full evaluation phase (n = 20 patients) (Fig. 1). Samples were submitted for semiquantitative culture of C. auris and other multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase–producing Enterobacterales (ESBLs), and carbapenem-resistant Enterobacterales (CRE). Times to room surface contamination with C. auris and other MDROs after effective cleaning were analyzed. Results:Candida auris colonization was most frequently detected in the nares (72%) and palms and fingertips (72%). Cocolonization of body sites with other MDROs was common (Fig. 2). Surfaces located close to the patient were commonly recontaminated with C. auris by 4 hours after cleaning, including the overbed table (24%), bed handrail (24%), and TV remote or call button (19%). Environmental cocontamination was more common with resistant gram-positive organisms (MRSA and, VRE) than resistant gram-negative organisms (Fig. 3). C. auris was rarely detected on surfaces located outside a patient’s room (1 of 120 swabs; <1%). Conclusions: Environmental surfaces near C. auris–colonized patients were rapidly recontaminated after cleaning and disinfection. Cocolonization of skin and environment with other MDROs was common, with resistant gram-positive organisms predominating over gram-negative organisms on environmental surfaces. Limitations include lack of organism sequencing or typing to confirm environmental contamination was from the room resident. Rapid recontamination of environmental surfaces after manual cleaning and disinfection suggests that alternate mitigation strategies should be evaluated.
Ventilator-capable skilled nursing facilities (vSNFs) are critical to the epidemiology and control of antibiotic-resistant organisms. During an infection prevention intervention to control carbapenem-resistant Enterobacterales (CRE), we conducted a qualitative study to characterize vSNF healthcare personnel beliefs and experiences regarding infection control measures.
A qualitative study involving semistructured interviews.
One vSNF in the Chicago, Illinois, metropolitan region.
The study included 17 healthcare personnel representing management, nursing, and nursing assistants.
We used face-to-face, semistructured interviews to measure healthcare personnel experiences with infection control measures at the midpoint of a 2-year quality improvement project.
Healthcare personnel characterized their facility as a home-like environment, yet they recognized that it is a setting where germs were ‘invisible’ and potentially ‘threatening.’ Healthcare personnel described elaborate self-protection measures to avoid acquisition or transfer of germs to their own household. Healthcare personnel were motivated to implement infection control measures to protect residents, but many identified structural barriers such as understaffing and time constraints, and some reported persistent preference for soap and water.
Healthcare personnel in vSNFs, from management to frontline staff, understood germ theory and the significance of multidrug-resistant organism transmission. However, their ability to implement infection control measures was hampered by resource limitations and mixed beliefs regarding the effectiveness of infection control measures. Self-protection from acquiring multidrug-resistant organisms was a strong motivator for healthcare personnel both outside and inside the workplace, and it could explain variation in adherence to infection control measures such as a higher hand hygiene adherence after resident care than before resident care.
Background: During a 2017–2019 intervention in Chicago-area vSNFs to control carbapenem-resistant Enterobacteriaceae, healthcare worker adherence to hand hygiene and personal protective equipment was stubbornly inadequate (hand hygiene adherence, ~16% and 56% on entry and exit), despite educational and monitoring efforts. Little is known about vSNF staff understanding of multidrug-resistant organism (MDRO) transmission. We conducted a qualitative analysis of staff members at a vSNF that included assessment of staff perceptions of personal MDRO acquisition risk and associated personal hygiene routines transitioning from work to home. Methods: Between September 2018 and November 2018, a PhD-candidate medical anthropologist conducted semistructured interviews with management (N = 5), nursing staff (N = 6), and certified nursing assistants (N = 6) at a vSNF in the Chicago region (Illinois) who had already received 1 year of MDRO staff education and hand hygiene adherence monitoring. More than 11 hours of semistructured interviews were collected and transcribed. Data collection and analysis included identifying how staff members related to their own risk of MDRO acquisition/infection and what personal hygiene routines they followed. Transcriptions of the data were analyzed using thematic coding aided by MAXQDA qualitative analysis software. Results: Staff members at all levels were able to describe their perceptions related to the risk of acquiring an MDRO and personal hygiene in great detail. The risk of acquiring an MDRO was perceived as a constant threat by staff members, who described germs as bad and everywhere (Table 1). The perceived threat of MDRO acquisition was connected to individual personal hygiene routines (eg, changing shoes before leaving work), which were considered important by staff members (Table 2). Nursing staff and certified nursing assistants noted that personal hygiene was a critical factor keeping their residents, themselves, and their families free from MDROs. Conclusions: In the context of a quality improvement campaign, vSNF healthcare workers are aware of the transmissibility of microscopic MDROs and are highly motivated in preventing transmission of MDROs to themselves. Such perceptions may explain actions such as why workers may be differentially adherent with infection control interventions (eg, more likely to perform hand hygiene leaving a room rather than going into a room, or less likely to change gowns in between residents in multibed rooms if they believe they are already personally protected with a gown). Our findings suggest that interventions to improve staff adherence to infection control measures may need to address other factors related to adherence besides knowledge deficit (eg, understaffing) and may need to acknowledge self-protection as a driving motivator for staff adherence.
Background: Carbapenem-resistant Enterobacteriaceae (CRE) are endemic in the Chicago region. We assessed the regional impact of a CRE control intervention targeting high-prevalence facilities; that is, long-term acute-care hospitals (LTACHs) and ventilator-capable skilled nursing facilities (vSNFs). Methods: In July 2017, an academic–public health partnership launched a regional CRE prevention bundle: (1) identifying patient CRE status by querying Illinois’ XDRO registry and periodic point-prevalence surveys reported to public health, (2) cohorting or private rooms with contact precautions for CRE patients, (3) combining hand hygiene adherence, monitoring with general infection control education, and guidance by project coordinators and public health, and (4) daily chlorhexidine gluconate (CHG) bathing. Informed by epidemiology and modeling, we targeted LTACHs and vSNFs in a 13-mile radius from the coordinating center. Illinois mandates CRE reporting to the XDRO registry, which can also be manually queried or generate automated alerts to facilitate interfacility communication. The regional intervention promoted increased automation of alerts to hospitals. The prespecified primary outcome was incident clinical CRE culture reported to the XDRO registry in Cook County by month, analyzed by segmented regression modeling. A secondary outcome was colonization prevalence measured by serial point-prevalence surveys for carbapenemase-producing organism colonization in LTACHs and vSNFs. Results: All eligible LTACHs (n = 6) and vSNFs (n = 9) participated in the intervention. One vSNF declined CHG bathing. vSNFs that implemented CHG bathing typically bathed residents 2–3 times per week instead of daily. Overall, there were significant gaps in infection control practices, especially in vSNFs. Also, 75 Illinois hospitals adopted automated alerts (56 during the intervention period). Mean CRE incidence in Cook County decreased from 59.0 cases per month during baseline to 40.6 cases per month during intervention (P < .001). In a segmented regression model, there was an average reduction of 10.56 cases per month during the 24-month intervention period (P = .02) (Fig. 1), and an estimated 253 incident CRE cases were averted. Mean CRE incidence also decreased among the stratum of vSNF/LTACH intervention facilities (P = .03). However, evidence of ongoing CRE transmission, particularly in vSNFs, persisted, and CRE colonization prevalence remained high at intervention facilities (Table 1). Conclusions: A resource-intensive public health regional CRE intervention was implemented that included enhanced interfacility communication and targeted infection prevention. There was a significant decline in incident CRE clinical cases in Cook County, despite high persistent CRE colonization prevalence in intervention facilities. vSNFs, where understaffing or underresourcing were common and lengths of stay range from months to years, had a major prevalence challenge, underscoring the need for aggressive infection control improvements in these facilities.
Funding: The Centers for Disease Control and Prevention (SHEPheRD Contract No. 200-2011-42037)
Disclosures: M.Y.L. has received research support in the form of contributed product from OpGen and Sage Products (now part of Stryker Corporation), and has received an investigator-initiated grant from CareFusion Foundation (now part of BD).
Background: During 2017–2019 in the Chicago region, several ventilator-capable skilled nursing facilities (vSNFs) participated in a quality improvement project to control the spread of highly prevalent carbapenem-resistant Enterobacteriaceae (CRE). With guidance from regional project coordinators and public health departments that involved education, assistance with implementation, and adherence monitoring, the facilities implemented a CRE prevention bundle that included a hand hygiene campaign that promoted alcohol-based hand rub, contact precautions (personal protective equipment with glove/gown) for care of CRE-colonized residents, and 2% chlorhexidine gluconate (CHG) wipes for routine resident bathing. We conducted a qualitative study to better understand the ways that vSNF employees engage with the implementation of such infection control measures. Methods: A PhD-candidate medical anthropologist conducted semistructured interviews with management (N = 5), nursing staff (N = 6), and certified nursing assistants (N = 6) at a vSNF in the Chicago region (Illinois) between September 2018 and November 2018. More than 11 hours of semistructured interviews were collected and transcribed. Data collection and analysis focused on identifying healthcare worker experiences during an infection control intervention. Transcriptions of the data were analyzed using thematic coding aided by MAXQDA qualitative analysis software. Results: Healthcare workers described the facility using language associated with a family environment (Table 1). Furthermore, healthcare workers demonstrated motivation to implement infection control policies (Table 2). However, healthcare workers expressed cultural and structural challenges encountered during implementation, such as their belief that some infection control measures discouraged maintenance of a home-like environment, lack of time, and understaffing. Some healthcare workers perceived that alcohol-based hand rub was ineffective over time and left unpleasant textures on the skin. Additionally, some workers did not trust the available gown and gloves used to prevent transmission. Lastly, healthcare workers typically did not prefer 2% CHG wipes over soap and water, citing residual resident postbathing smell as one indicator of CHG ineffectiveness. Conclusions: In a vSNF we found both considerable support and challenges implementing a CRE prevention bundle from the healthcare worker perspective. Healthcare workers were dedicated to recreating a home-like environment for their residents, which sometimes felt at odds with infection control interventions. Residual misconceptions (eg, alcohol-based hand rub is not effective) and negative worker perceptions (eg, permeability of contact precaution gowns and/or residue from alcohol-based hand rub) suggest that ongoing education and participation by healthcare workers in evaluating infection control products for interventions is critical.
We undertake a critical literature review to facilitate academic dialogs regarding decisions under uncertainty in international business settings and highlight the growing focus on international investments as conveyers of real options. Our literature review (1) provides a systematic overview of uncertainty types considered in this literature, real options identified as particular to international investments, and valuation approaches used and (2) highlights key methodological approaches used for testing real options models applied to international investments, and the controversies in this regard. This study draws on the above to shed light on important avenues for future research including (a) the need for more fine-grained and diverse measures of uncertainty in the international context, (b) an emphasis on clarifying the value effects of combinations of real options, and (c) the necessity of further consideration of the costs of options along with the value.
Carcinoma of the uterine cervix is the second most common gynecologic malignancy worldwide and the third most common cause of cancer deaths in women all over the world. In 2010, an estimated 12,200 women in the USA were diagnosed with cervical cancer, and 4,210 women died from the disease.
Attempts to treat cervical cancer in the early nineteenth century were deemed largely unsuccessful due to the frequent occurrence of recurrent disease in the vaginal cuff. Surgeons such as Wertheim and Clark postulated that this was likely due to inadequate margin of excision. At the turn of the nineteenth century, these surgeons developed an operation that involved removal of the uterus, along with a wide resection of tissues around the involved cervical tumor.
The primary goal of radical hysterectomy is removal of
the cervical tumor with a sufficient surgical margin. This entails
removal of the uterus, cervix, superior vaginal margin, and
parametrial tissue. Removal of the latter involves extensive dissection
of the bladder, ureters, rectum, and lateral pelvic sidewalls.
Cervical cancer is staged clinically. All stages may be
treated with a combination of radiotherapy and chemotherapy;
however, early-stage cervical cancer may be treated with
a radical hysterectomy. While microinvasive disease or
stage IA1 can be adequately treated with a vaginal or simple
abdominal hysterectomy, radical hysterectomy along with
pelvic lymphadenectomy is utilized to treat stages IA2 through
IIA. The overall survival of early-stage cervical cancer is similar
between radical hysterectomy and radiotherapy. Therefore,
patients who are poor surgical candidates due to severe
medical illness or morbid obesity are probably best treated
with primary radiotherapy.
In continuation of our ongoing revisionary studies on the lichen family Graphidaceae from India, a treatment of 25 species of the lichen genera Fissurina and Hemithecium from India is presented. In our earlier work on the lichen genus Fissurina, 16 species were reported from India. In the present study, 17 additional species of Fissurina from India are recognized. Nine species, viz. Fissurina andamanensis, F. disposita, F. immersa, F. indica, F. microcarpa, F. nicobarensis, F. simplex, F. sporolata, and F. submonospora, are described as new to science. Seven species, viz. Fissurina canlaonensis, F. cingalina, F. comparimuralis, F. monospora, F. nitidescens, F. rubiginosa, and F. subnitidula, are recorded for the first time from India. One species, Fissurina sp. 1, is recorded but not formally described as new due to scanty material. Eight species in the lichen genus Hemithecium, including three new species, viz. H. kodayarense, H. longilirellatum, H. verrucosum, and five new combinations, viz. Hemithecium andamanicum, H. flabillatum, H. flavoalbum, H. flexile, and H. norlabiatum, are also recognized in the present work. A revised key for the identification of all 33 species of Fissurina and 26 species of Hemithecium so far known from India is provided.
In the present paper four etomentose species of Leptogium are recorded from Maharashtra, western India. Three species, viz. Leptogium patwardhanii Dube & Makhija sp. nov., Leptogium subazureum Dube & Makhija sp. nov., and Leptogium verrucosum Dube & Makhija sp. nov., are described as new to science and one species, Leptogium propaguliferum Vain., is recorded for the first time from India. A revised key to the non-hairy species of Leptogium from India is provided.
Recent revisions of the graphidaceous lichens of India have brought to light several new taxa in the family Graphidaceae. In the present study seven species of Acanthothecis are recognized from India. Three new species, viz. Acanthothecis archeri, A. celata, and A. coccinea, are described and A. nivalis, a species described earlier from the Andaman Islands, has now been recorded from the mainland. A revised key to the seven Acanthothecis species so far known from India is also presented.
Two species of the lichen genus Carbacanthographis, namely C. marcescens and a new species, C. sorediata, are reported from India. The new species is characterized by a sorediate thallus, laterally carbonized exciple, submuriform ascospores, and salazinic and consalazinic acids in the thallus. A worldwide key to the species of Carbacanthographis is provided.
Anomomorpha elegans, a new species characterized by lirelline ascocarps, dark reddish brown, pruinose disc, bowl shaped exciple composed of elongate hyphae, hymenium inspersed with crystals, muriform ascospores and salazinic acid in the thallus, is described from India.
The new species Parmeliella subfuscata A. Dube & Makhija, belonging in the P. mariana group, is described. It is recognized by its squamulose, loosely attached, spreading, brownish thallus with cylindrical, branched isidia, indistinct, black prothallus of slightly projecting rhizohyphae, and its apothecia with an unusual, fresh green coloured epithecium and proper exciple. It is so far known only from the type locality in Maharashtra, India.
Legal rights of investors are recognized as an essential component of corporate governance. We assess the efficacy of these rights by examining board changes surrounding the filings of shareholder derivative lawsuits. We find that the incidence of derivative lawsuits is higher for firms with a greater likelihood of agency conflicts. We also find that derivative lawsuits are associated with significant improvements in the boards of directors. In particular, the proportion of outside representation on the board of directors increases. There is also some evidence that other board characteristics change favorably. These findings suggest that shareholder derivative lawsuits are not frivolous as is often claimed, but rather that they can serve as an effective corporate governance mechanism.
Eighteen species in the lichen genera Acanthothecis Clem. and Fissurina Fée (Graphidaceae) with colourless, trans-septate ascospores are recorded from India. Eight new species, namely Acanthothecis collateralis, Fissurina capsulata, F. coarctata, F. karnatakensis, F. khasiana, F. longiramea, F. taeniocarpoides and F. verrucosa, and a new variety, F. dumastioides var. salazinica, are described. Fissurina saxicola ad int., clearly distinguished from the other species is recorded, but is not formally described as new to science as the material is scanty. Acanthothecis consocians, F. globulifica, F. insidiosa and F. rugosa are reported for the first time from India. A key for the trans-septate species of Acanthothecis and Fissurina in India is provided.
The first lichen records from the Lakshadweep (Laccadive) Islands are presented.Lithothelium insulare (Pyrenulaceae) is described as new and nine other taxa are reported. The poor lichen flora, dominated by pantropical species, is probably a result of the lack of natural habitats in this area.