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pudendal nerves

The pudendal nerve is the main nerve of the perineum.[1]:274 It carries sensation from the external genitalia of both sexes and the skin around the anus and perineum, as well the motor supply to various pelvic muscles, including the male or female external urethral sphincter and the external anal sphincter. If damaged, most commonly by childbirth, lesions may cause sensory loss or fecal incontinence. The nerve may be temporarily blocked as part of an anaesthetic procedure.image

https://en.m.wikipedia.org/wiki/Pudendal_nerve#

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Kidney functions

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Joubert syndrome

imageimageimage is disorder of brain development that may affect many parts of the body. It is characterized by the absence or underdevelopment of the cerebellar vermis (a part of the brain that controls balance and coordination) and a malformed brain stem (connection between the brain and spinal cord). Together, these cause the characteristic appearance of a molar tooth sign on MRI. Signs and symptoms can vary but commonly include weak muscle tone (hypotonia); abnormal breathing patterns; abnormal eye movements; ataxia; distinctive facial features; and intellectual disability.Various other abnormalities may also be present. Joubert syndrome may be caused by mutations in any of many genes. Inheritance is usually autosomal recessive, but rarely it may be X-linked recessive. Treatment is supportive and depends on the symptoms in each person.”

https://rarediseases.info.nih.gov/diseases/6802/joubert-syndrome

 

Sarcopenic obesity

Sarcopenic obesity is a medical condition which is defined as the presence of both sarcopenia (loss of muscle) and obesity.

Sarcopenia refers to the presence of low muscle mass and either low muscular strength or low physical performance.

When this is accompanied by a high fat mass the condition is known as sarcopenic obesity.[1]

Case 7: Paediatric Issues in Infection Control (practice/redo)

You were informed by one of the patient service managers that one of her staff (a 26 year-old female) has just been diagnosed by her family practitioner as having chicken pox. She works on the general paediatric ward and her last day of work was three days ago, the same day the rash developed. The nurse had worked with three patients in adjacent rooms for five days prior to her last day of work, although she had been giving break relief to other nurses throughout that period. The unit has twelve patients on the one wing. The children range from age 2 to 13.

Case Seven Questions:

1.What precautions should be taken, if any, to protect patients on the ward? Would you recommend prophylactic therapy for any of the patients? Justify your response.

Precautions for patients:

  • Varicella zoster can be transmitted through air or contact from persons (Lautenbach, p. 301) Therefore all patients with symptoms should be placed on airborne and contact precautions.
  • Patients who have contracted varicella zoster should remain on precautions until lesions have dried and crusted to prevent hospital exposures (Lautenbach, p. 301).
  • Non-immune exposed patients should be placed on airborne precautions for the period from day 10 through day 21 after their exposure or through day 28 if the patient is immunocompromised or has received Varicella zoster immunoglobulin
  • Varicella zoster is rarely spread through air from individuals with localized herpes zoster so patients, visitors and healthcare workers with this disease entity do not need to be restricted so long as their lesions are covered (Lautenbach, p. 301)

Prophylactic therapy:

  • Patients and staff who are non-immune should receive the varicella zoster vaccine as it results in milder outbreak and is cost effective for the hospital given costs associated with secondary cases (Lautenbach, p301)
  • All patients on the unit are a high risk for complications therefore if they can safely receive varicella vaccine, and it is within 3 to 5 days after exposure, give the vaccine (BCCDC, 2004)
  •  For immunocompormized patients give Varicella zoster immune globulin (VZIG) given within 96 hours of exposure (BCCDC, 2004)

2. What, if any, infection control measures should be considered for the hospital workers.

  • non-immune workers could be incubating the infection and could spread it to others
  • all healthcare workers who might have been exposed should not work in patient care capacity during the incubation period (Lautenbach, p. 301)
  • staff members who develop varicella zoster must not work until all lesions have crusted over(Lautenbach, p. 301)
  • non-immunized exposed staff should be considered potentially infectious 8 to 21 days following exposure (28 days if VZIG was given (BCCDC, 2004)

  • Staff who are pregnant or have immunocompromizing conditions such as corticosteroid treatments should receive VZIG  (BCCDC, 2004).
  • immunization status of current staff should be known or sought (BCCDC, 2004)

  • Lab results for Serology for VZV IgG should be determined for non-immune staff before immunization (i.e.unknown or no history of chickenpox) (BCCDC, 2004).

  • staff who are immunized are considered to be immune (4 weeks after the second dose) and no special precautions need to be taken if they are exposure

  • If susceptible staff is not eligible for immunization, or if serology results can not be promptly obtained, refer to a physician for clinical management, which may include prophylaxis with antiviral and VZIG if the HCW is at high risk for complications of varicella disease.

  • susceptible non-immunized HCW/students from work from days 8 through days 21 post-exposure. Extend the exclusion to 28 days, if VZIG is given.

3. What are the tests available to confirm a diagnosis of chicken pox? Is laboratory confirmation always necessary – why or why not?

Laboratory confirmation from Isolation of varicella virus from an appropriate clinical specimen or significant rise in serum varicella IgG antibody level by any standard serologic assay (BCCDC, 2004).

Laboratory confirmation not always necessary in cases where clinical illness arises in an epidemiologically linked person where the link individual has lab confirmed chicken pox.

4. How effective is Varicella zoster vaccination in children? In adults? What are the potential complications?

  • In immunocompetent children 12 months to 12 years of age, a single univalent varicella vaccine dose results in a seroconversion rate of 98% at 4 to 6 weeks after vaccination, with antibodies persisting in 98% at 5 years and 96% at 7 years after vaccination.
  • A second dose of a univalent varicella vaccine in children produces an improved immunologic response that is correlated with improved protection (Government of Canada, 2016).
  • In immunocompetent adults and adolescents 13 years of age and older, 2 vaccine doses administered 4 to 8 weeks apart result in seroconversion rates of 99% at 4 to 6 weeks after the second dose, with persistence of antibodies 5 years later in 97% of vaccine recipients(Government of Canada, 2016).

Potential Complications:

  • injection site pain
  • swelling and redness in 10% to 20% of recipients
  • A low-grade fever has been documented in 10% to 15% of vaccine recipients.
  • A varicella-like rash occurs at the injection site or is generalized in 3% to 5% of vaccine recipients after the first dose.
  • The rash usually appears within 5 to 26 days after immunization.
  • As varicella-like rashes that occur within the first 2 weeks after immunization may be caused by wild-type virus (varicella virus circulating in the community), health care providers should obtain specimens from the vaccine recipient to determine whether or not the rash is due to a natural varicella infection or to the vaccine-derived strain (Government of Canada, 2016).

5. This nurse, as the case turns out, is pregnant and delivers the day following her visit to her family practitioner. The baby is admitted to the neonatal intensive care unit. What measures should be taken?

References:

  1. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.
  2.  BCCDC. 2004. Communicable disease control Varicella zoster.  http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%201%20-%20CDC/Epid_GF_VaricellaZoster_July04.pdf
  3. Government of Canada. 2016. Canadian Immunization guide. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-24-varicella-chickenpox-vaccine.html#p4c23a4

Case 6: Infection control in institutional contruction and design (practice/redo)

You have identified a burn patient (60% burns) in the ICU with serial blood and tissue cultures positive for Aspergillus fumigatus. Upon reviewing the patient in ICU and inspecting the area, you notice a bulging ceiling tile in the corridor adjacent to his room. You are told that the tile has been like this for one week now. Maintenance is called and the ceiling tile is removed, at which point you notice greenish discoloration of the inner surface of the tile and evidence of water leakage from the pipe above. The air intake into the patient’s room runs above the discoloured ceiling tile.
Case Six Questions:
1. What special precautions should have been taken for this burn patient upon his admission to the unit?

The patient has burns to 60% of his body and is therefore at very high risk of infections.

Precautions for the patient upon admission to the unit:

  • physical isolation in a private room
  • gloves and gowns during patient contact
  • full body wound assessment
  • appropriate empirical antimicrobial therapy
  • laboratory surveillance cultures
  • routine microbial burn wound cultures (Coban, 2012)
  • patient should have been moved or air intake sealed off when discoloured ceiling tile noted near the air intake to his room

“During, maintenance, renovation and contruction, bacterial or fungal microorganisms in the dust and dirt can contaminate air handling or water systems wich can transmit these organisms to susceptible persons” (Lautenbach, p. 394).
2. If you had been asked to perform an infection control risk assessment prior to tile removal and plumbing remediation, what risk would you assign and why?

Type construction activity: Type C (working on ducts, removing ceiling tiles) (LAUTENBACH, P. 446).

Patient risk group: high risk, immunocompromized, burn patient (Lautenbach, p. 447).

Class of precautions: III/IV due to highest risk and type C (Lautnbach, p. 447).
3. What precautions should the maintenance workers take when they remove and dispose of the affected materials? Is this considered biohazardous material?

Precautions to be taken:

Seeing as we designated the risk class III/IV above, class 4 precations should be used for the most encomapssing precations for all involved.

Class IV precautions to be taken during the contruction project according to Lautenback, p. 448 are as follows:

  • Isolate HVAC systems in the work area to prevent air duct contamination
  • Implement barrier cube method or barrier sealing off of work area out of sheetrock, plywood, or plastic (Lautenback, p. 448)
  • maintain negative air pressure within work site
  • use HEPA equipped air filitration units (lautenback, p. 448)
  • seal off holes, pipes, conduits, punctures
  • construct anteroom: 1. all personel to be HEPA vaccummed before leaving the work site or 2. workers change out of paper coveralls each time they exit the work site (Lautenback, p. 448)
  • all personel to wear shoe covers  that are changed prior to exiting the work site
  • contain contruction waste: transport in tightly covered containers with added cover over transport receptacle or cart (Lautenbach, p. 448).

Disposal of material: Aspergillus is not a biohazard because it is readily found in the hospital environment (dust, dirt, construction debris). Aspergillus is not harmful to healthy people therefore can be disposed of without biohazard precautions(Lautenbach, 441).

4. How should air flow be designed in intensive care areas such as burn units and ICUs?

  • patient rooms should have 6 air changes per hour (Lautenbach, p. 451).
  • 2/6 of the air exchanges per hour must be outdoor exchanges
  • rooms where high risk procedures are performed such as bronchoscopies, should have negative pressure with respect to adjacent areas (Lautenbach, p.451)
  • these high risk ventiliation procedure rooms should have flexible ventilation where pressure can be changed from neutral to negative (Lautenbach, p. 451).
  • If a room with special ventiliation is renovated, air exchanges and air pressure should be measured following the renovation
  • exterior air intakes should be place minimum 8m upwind of exhaust outlets
  • the bottom of such air intakes should be minimum 2m above ground or 1m above roof level
  • air intakes should be located away from cooling towers, trash compactors, loading docks, heliports, biological safety exhaust hoods, sterilizers, aerators, and incinerators (Lautenbach, p. 451).

5. Guidelines exist for new construction and renovations in hospitals. Give examples of these and explain how they differ from construction regulations.

References:

1. Coban, Y. K. (2012). Infection control in severely burned patients. World Journal of Critical Care Medicine, 1(4), 94–101. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3953869/

2. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.