Draught beer hygiene: cleaning of dispense tap nozzles

Draught beer quality can be compromised by the growth of spoilage microorganisms. Whilst best practice for assuring dispense hygiene is broadly recognized, it is not always fully or regularly implemented. In some markets, tap nozzles are removed and stored overnight at room temperature in carbonated (soda) water. The next morning they are returned (sometimes after rinsing) to the dispense tap. The effectiveness of this approach is compared with soaking in diluted line-cleaning solution (UK best practice)or a solution containing hypochlorous acid (commercial sanitizing tablets). Two novel approaches – ozonated water and use of ultrasonics – were also evaluated. Bioluminescence analysis of microbial attachment to the inner surfaces of nozzles showed that soaking in carbonated water resulted in gross contamination. Sanitizing tablets achieved ‘commercial sterility’ and a 4-log reduction in bioluminescence compared with carbonated water. The efficacy of hypochlorous acid was confirmed by incubating cleaned nozzles in fresh beer without any increase in turbidity. Diluted line-cleaning solution was less effective and achieved a 2-log reduction. Ultrasonics reduced microbial attachment but effectiveness was aligned to increasing process time. Soaking in ozonated water was without antimicrobial impact. This work has shown carbonated water to be ineffective in cleaning microbiologically contaminated nozzles. This is a concern as these microorganisms derive from the dispense line, the environment and likely human interaction. To minimize the risks of transfer to dispensed product or back-contaminating the dispense line, soaking draught beer nozzles in an effective sanitizing solution is strongly recommended

Gotta Escape EM all! Emergency Medicine Resident Education with Gamification

Learning Objectives: Priapism drainage; Common causes of hyperkalemia; Pacemaker EKGs and errors; Common toxic botanicals and their treatments; Beta-blocker toxicity management; Psychiatric medical emergencies; Resuscitation of adult and pediatric burn victims; Wilderness resuscitation skills.Introduction/Background: Traditional conferences provide a uniform, didactic review. Modern residents can benefit from a structure that engages them in active learning with immersive and collaborative experiences. Activities like flipped classrooms, simulation, and virtual learning have improved upon the ennui of prior conferences. We seek to appropriate the escape room to review key, uncommon topics in emergency medicine (EM) as a conference activity to address areas of improvement in residents’ knowledge prior to their in-training exam (ITE).Educational Objectives: At the completion of the escape room activity, residents and medical students will be tested upon and be able to perform the following: Priapism drainage Common causes of hyperkalemia Pacemaker EKGs and errors Common toxic botanicals and their treatments Beta-blocker toxicity management Psychiatric medical emergencies Resuscitation of adult and pediatric burn victims Wilderness resuscitation skills.Curricular Design: A survey-based needs assessment was done by EM residents about the topics which needed more review before their ITE. Topics were assessed to determine an optimal method for review: lecture, group session, or gamification. Those selected for gamification were designed to fit a predetermined theme to complement a ninety minute conference lecture alternative escape room. Residents were split into four groups and raced to complete the activity. Afterward, residents were provided a review over each topic and the escape room was surveyed for its effectiveness and satisfaction with respect to the review of the objectives.Impact/Effectiveness: An anonymous Likert scale survey provided to residents showed 90% rating the activity successful in achieving its academic goal and 95% as an activity that residents wanted to implement again in the future. 93% of residents who provided feedback regarding topic selection agreed that the activity addressed their prior curricular deficits

Pulmonary Artery Pseudoaneurysm due to Mucormycosis: Case Report and Literature Review.

Pulmonary artery pseudoaneurysm (PAP) is a rare vascular phenomenon with a high mortality rate, as these entities can enlarge, rupture, and lead to asphyxiation. Pulmonary mucormycosis (PM), an underdiagnosed but an increasingly seen entity in the era of chemotherapy and immunosuppression, is a known cause of PAP, and should be suspected in immunosuppressed patients with hemoptysis. We present a case of PAP due to PM in a patient with recently diagnosed diffuse large B-cell lymphoma of the liver who underwent chemotherapy and developed acute cavitary lung disease and hemoptysis. His diagnosis was delayed due to the withholding of iodinated contrast with computer tomography (CT) imaging in the setting of renal failure. He then underwent embolization of his PAP with resolution of his hemoptysis. PAP is an uncommon cause of hemoptysis that can be diagnosed with CT pulmonary angiography, and mucormycosis is a known but rare cause of PAP in patients with malignancy receiving immunosuppression

Immunopathology in human lymphoedema

Empirical thesis.Bibliography: pages 49-55.Introduction -- Materials and methods -- Results -- Discussion.Lymphoedema is a condition of abnormal tissue swelling resulting from failure of lymph drainage. The condition is often chronic and it frequently results in the accumulation of adipose tissue (AT) within the affected region. The mechanisms underlying AT formation in lymphoedema have not been determined. This research therefore aims to characterize the AT of patients with lymphoedema. Liposuction tissue samples were obtained from lymphoedema patients’ limbs (4 arms, 4 legs) and from limbs of healthy individuals undergoing cosmetic liposuction surgery (3 arms, 4 legs). AT tissue samples were fixed in neutral buffered formalin and processed for histological analysis, including hematoxylin and eosin, Milligan’s trichrome, or picrosirius red staining. Image analysis was performed to determine the mean adipocyte cell number, size, tissue fibrosity, and the degree of collagen deposition. Immunohistochemical analyses was also performed, using antibodies specific to lymphatic endothelial cells (podoplanin), blood vascular endothelial cells (CD31), and macrophages (HAM56), to determine the relative location of perivascular collagen and the identity of macrophage-like cells. Histological analysis of lymphoedema AT revealed abundant collagen, especially type III collagen, and perivascular fibrosis. Overall, adipocyte cell number, size, and the extent of collagen content were found to be similar in lymphoedema and normal AT. Using immunohistochemistry, we detected CD31 expression in lymphoedema and normal AT, and this occurred in areas of collagen deposition. Unfortunately, no positive staining for podoplanin and HAM56 were detected in either lymphoedema or normal AT. Taken together, this research provides important information into the etiopathology of this chronic and debilitating condition.Mode of access: World wide web1 online resource (vii, 62 pages) colour illustration

Characterisation of the host immune response to biofilm-related infections

Thesis by publication.Bibliography: pages 333-382.Chapter I. Literature review -- Chapter II. Materials and methods -- Chapter III. The functional influence of breast implant outer shell morphology on bacterial attachment and growth -- Chapter IV. The influence of implant surface on biofilm formation in an in vivo porcine model -- Chapter V. Analysis of bacterial biofilm and host response in new cases of breast Implant-associated anaplastic large-cell lymphoma -- Chapter VI. Differential mitogenic response of breast implant-associated anaplastic large-cell lymphoma to gram-negative lipopolysaccharide -- Chapter VII. Differential mitogenic response of breast implant-associated anaplastic large-cell lymphoma to staphylococcal superantigens -- Chapter VIII. The development of a co-culture system of mammalian cells and biofilm composed of different bacterial species -- Chapter IX. Effect of TLR4 on LPS stimulation of BIA-ALCL tumour cells --Chapter X. General discussion -- Appendices -- References.Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a recently diagnosed, rare non-Hodgkin T-cell lymphoma in tissue around a breast implant. Since 2000, its detection and incidence has risen worldwide due to the increase use of breast implants in breast surgery. Although the aetiopathogenesis is unclear, it is postulated that the cancer results from chronic bacterial antigen stimulation and sustained T-cell proliferation that potentially leads to malignant transformation. This is in conjunction with implant properties, implant exposure time and host predisposition or genetic factors. The experiments described in this thesis explore the influence of implant surface texture, bacterial load and host response in patient specimens, and initiating and potentiating factors to malignancy.The majority of BIA-ALCL cases have occurred in patients with textured implants, which have been shown to support a higher bacterial load. The work described in Chapter III of this thesis describes the development of an in vitro bacterial attachment assay to further characterise the surface texture of implants and their capacity to support bacterial growth in vitro. We describe a significant relationship between the measurement of available surface area, surface roughness and potentiation of bacterial growth for both Gram-positive and Gram-negative bacteria. In Chapter IV, we examine the influence of implant texture in vivo using a well-established porcine model. We describe the association between textured implant surfaces with bacterial attachment, biofilm formation, development of capsular contracture and host response following artificial bacterial contamination of breast implants in pigs.The role of bacteria in BIA-ALCL has recently been supported by the discovery of high levels of bacterial contamination within BIA-ALCL specimens. In Chapter V, we compare the bacterial load and host response in fresh implants and capsules from new cases of BIA-ALCL to non-tumour specimens.In Chapter VI, we utilise previous findings of a significantly higher proportion of Gram-negative pathogens present in the microbiome of BIA-ALCL specimens when compared to the microbiome surrounding non-tumour implant capsules. We interrogate BIA-ALCL cell lines derived from fresh tumour with antigens including lipopolysaccharide from Gram-negative bacterial cell wall. We demonstrate a unique response to lipopolysaccharide in BIA-ALCL cells compared to other tumour and non-tumour cell lines. In Chapter VII, we also interrogate these cell lines with staphylococcal superantigens since their potential to restrict T-cell receptor expression has recently been reported. We describe a differential response to Gram-positive bacterially derived antigens, providing support to the hypothesis of a Gram-negative antigenic trigger to malignancy.We further investigated the potentiation of BIA-ALCL tumour cell growth this time to bacterial biofilm infection composed of different pathogen species. In Chapter VIII, we develop a co-culture system of biofilm and mammalian cells and describe the differential responses of BIA-ALCL cells when challenged with biofilm consisting of Gram-negative or Gram-positive bacteria.The work described in Chapter IX, examines whether the stimulation by lipopolysaccharide is through Toll-like receptor 4 (TLR4), which positively impacts T-cell priming. We demonstrate a dampening of responses to lipopolysaccharide in BIA-ALCL cells following inhibition of TLR4 signalling.The data from this thesis provides important new insights into the aetiopathogensis of this newly characterised neoplasm.Mode of access: World wide web1 online resource (xl, 383 pages) colour illustration