EMPOWERING NURSING PROFESSIONALS IN ICU CARE
INFECTION MATTERS MOST
Dr.T.V.Rao MD Intensive care units are just not another area to care patients, but certainly everybody admitted are certainly suffering with an ailment of organ involvement and much of the seriously injured are put in intensive care units, the great and continuous visitor to these patients are microbes around the bed, environment the patient lodged, and on hands of those who care for them, however the nursing staff continue to be great care taker, the western world and developed countries have recognized nurses are champions of infection control and certainly recognized the nursing staff as most important persons to care the best to save many lives, however the role of Nursing is not well recognized in many regions of the developing countries and suffers higher number of patients die and morbid for longer times, The infection control field now has its own three-word maxim: vigilance, vigilance, vigilance it just means how much we are vigilant to implement, watch and take better decisions and follow basic principles of HAND WASHING
HOW THE PATIENTS DIFFER FROM OTHER PATIENTS IN HOSPITALS
And ICU patients, more than the general population of patients , may already be compromised by several elements:
Disease processes
Trauma
Interruption of normal defense mechanisms (by mechanical ventilation, etc.)
Malnutrition due to the inability to eat and needs the help to be fed.
The inability to ambulate and lesser mobility liable for bed sores which unpredictable outcomes
PATENTS IN ICU ARE PREDISPOSED FOR INFECTIONS - the difference between infection control in ICUs vs. the wards is one of degree. "Patients in the ICU are severely ill and often bed-ridden," "They also tend to have many invasive devices such as Foley catheters to measure output, central lines for fluids and monitoring, arterial lines to measure pressures, endotracheal tubes for assisted ventilation, etc., that patients in other parts of the hospital don't have. The presence of an invasive device automatically increases the risk of infection because it provides a ready means of entry by bacteria into a normally clean space CARING MOST CRITICALLY ILL WITH IMMUNE SUPPRESSION
The segment of potentially immune compromised patients. "Oncology is much the same as the ICU setting, except that the patients tend to have fewer invasive devices (they rarely have Foley's; they are rarely intubated unless critically ill; all have central lines of some sort. "However, many oncology patients have altered neutrophil counts, which directly impacts the body's ability to fight off infection. Oncology patients are particularly prone to infection with opportunistic organisms, or organisms that are ubiquitous in the environment but cause problems in severely immuno compromised patients, like Aspergillus, other molds and fungi and certain viruses like cytomegalovirus, herpes virus, etc. This is one reason stem cell/bone marrow transplant units have special ventilation systems (all the rooms are at positive pressure, so the air flows from the room into the hall). This is specifically designed to keep airborne pathogens out of the patient rooms."
Hand washing - ICU patients' severe illnesses and injuries necessitate much more hands-on care than in normal wards, although these patients can be particularly susceptible to infections, hand hygiene guidelines remain the same everywhere there are more situations requiring good hand hygiene on the part of HCWs with either soap/water or alcohol based product. I believe some researchers have found that the busier staff are, the more likely they are to not wash their hands when they should, which again increases the potential for person-to-person transmission." "The use of alcohol-based waterless products can improve adherence with hand hygiene practices due to ease of use and less time required for effective disinfection."
." Next who manages these devices and major matters in control of infections IT IS JUST NON- OTHER THAN OUR NURSING STAFF, THE QUESTIONS REAMIN ARE WE TRAINING THEM TO BE THE REAL EXPERTS IN DEALING THE MATTERS
Ref Infection Control in the ICU: The Final Frontier By Kathy Dix
The CDC has numerous recommendations for preventing hospital-acquired infections. A complete list is available at www.cdc.gov.
Dr.T.V.Rao MD
Can be reached at doctortvrao@hotmail.com
WhatsApp +91828169524

MISSED DIAGNOSIS OF CRYPTOCOCCUS NEOFORMANS – It was a uncommon infection in the past From its humble beginnings as a single case report in 1895 to its worldwide explosion of disease with a million cases per year as the HIV epidemic peaked (Park et al., 2009), Cryptococcus has achieved a major place in clinical mycology. We are all much trained that if on has HIV/AIDS are linked with cryptococcal meningitis, I always wished that all specimens of CSF should along with Gram stain and culturing should never forget to an India ink preparation. The diagnosis of cryptococcosis, after 100 years of experience, is relatively facile with multiple methods and improved diagnostic strategies however it certainly need a qualified microbiologists patience and competence we can do better, as happened a 24 years young person’s CSF ( HIV negative by Rapid dot method ) a CSF specimen was sent to the Microbiology Laboratory with a persistent head ache qualified in post-graduation too do not care much and matters are left to technicians a sterile culture report sent after, for bacteriological work up, as the case of treated as Viral meningitis with antiviral drugs and lower doses of steroid patient becomes top moribund and a MRI was done and Radio logical opinion suggests possible cryptococcal Meningitis ? need Microbiology reviews and I happened to see the slide at emergency hour and happen to observe the CSF flooded with many capsulated with India ink preparation as it is one and only we can do in the critical hour, and patient dies after 3 days after aggressive anti fungal therapy with Ketoconazole , has some legal and litigation into this case, and we are helpless on many matters, and as many specimens are totally not evaluated as it is a dedicated workup and expensive, It is unfortunate still we may be missing many cases of Cryptococcus with lack of laboratory facilities . certainly need better methods as the techniques include direct examination of the fungus in body fluids with India ink examination, histopathology of infected tissue with specific stains to identify capsule (mucicarmine and alcian blue) or presence of melanin (Fontana-Masson), serology from body fluids and culture of fluids and/or tissues, Certainly we miss with India ink preparation the sensitivity is poorer than many other emerging tests as Polysaccharide antigen testing has two other important principles. First, a baseline high titer of polysaccharide antigen in serum or CSF carries prognostic significance, in that a high titer (>1:1024) is associated with a large burden of yeasts and a high viable quantitative yeast count in CSF is a predictor of death during systemic anti fungal therapy (Jarvis et al., 2014)
Not forgetting cryptococcosis is in a state of evolution, from the organism, to the host, to the guidelines for diagnosis and treatment. We know a lot but still not enough! The sugar-coated yeast still sickens and we need better technologies and dedicated diagnostic microbiology to manage it better. As many patients treated assuming as bacterial infection and many die and Cryptococcus are missed as we too primitive in approaches to diagnosis
Not to forget any patient After organ transplantation heavy doses of corticosteroid therapy are potential medications to treat rheumatoid arthritis, or other medications that weaken the immune system. and there are many surprises that without any established predisposing conditions can infected with Cryptococcal infections in any organ of the body
Photo courtesy CDC 1 and 2
Ref Cryptococcosis diagnosis and treatment: What do we know now Author John R. Perfecta Fungal Genetics and Biology Science Direct
Formulated by Dr.T.V.Rao MD

HAZARDOUS CHEMICALS IN THE NURSING CARE – REASONS TO STOP FUMIGATION IN HEALTH CARE ?
Question to Post graduate education in Nursing European union There was much communications and knowledge spread on the Universal precautions to prevent infections from HIV / HBV/ HCV in the past 2 decades after the onset of AIDS pandemic, it paid the good results, There is growing concern on the excessive use of chemical disinfectants in the health care areas can be of risk to human life and Nurses are at greater risk than anyone who continuously present in the health care environments The bad news is that if you work in healthcare, you are exposed to hazardous chemicals, Among the hazardous chemicals still used widely in hospitals are cleaning products, disinfectants, sterilant, and floor care products that contain toxic active ingredients, such as ammonia, chlorine, phosphates, alkylphenol ethoxylates, volatile organic compounds, formaldehyde, phenolic compounds, propellants, and petroleum solvents. In specific areas of the hospital, workers can be exposed to glutaraldehyde, ethylene oxide, formaldehyde, para formaldehyde, methyl methacrylate, Freon, peracetic acid, or waste anesthetic gases. Pesticides, rodenticides, and fungicides are also used in hospitals. Unfortunately, many chemicals which are banned in developed countries are dumped with commercial interests, in developing countries, today much of our hospitals use chemical disinfectants not caring much of cleanliness and hygiene
FORMALDEHYDE - Formaldehyde inactivates microorganisms by alkylating the amino acid and sulfhydryl groups of proteins and ring nitrogen atoms of purine bases.
Occupational Safety and Health Administration OSHA indicated Formaldehyde as potential carcinogen and limits an 8-hour time- weighted average exposure concentration of 0.75ppm. Still many hospitals use the fumigation as a habit without much scientific discussion of hazards It is surprising that many people are unaware of the longstanding scientific evidence on the carcinogenicity of formaldehyde. However, this had been detailed in five National Toxicology Program Reports on Carcinogens from 1981 to 2004. These classified formaldehyde as “reasonably anticipated to be a human carcinogen,” based on limited evidence of carcinogenicity in humans, and sufficient evidence in experimental animals. This evidence was confirmed in a series of reports by the prestigious International Agency for Research on Cancer (IARC). Its 2006 and 2010 reports explicitly warn that formaldehyde is “a known cause of leukemia in experimental animals — and nasal cancer” in humans.“Strong” evidence of the nasal cancer risk was also cited in the May 2010 President’s Cancer Panel report, “Environmental Cancer Risk: What Can We Do Now?” Nevertheless, and despite this explicit evidence, a September 2010 Government Accountability Office report attempted to trivialize the cancer risks of formaldehyde on the alleged grounds that exposure levels are low or “non-detectable.”
Fumigation is obsolete in many developed nations in view of toxic nature of Formalin. Too frequent use and inhalation is hazardous. Several new safe chemicals are emerging but constrains of economy limit the use and several hours of closure of operation theaters can be curtailed as with Fumigation. Aldehydes are potentially carcinogenic and it is therefore recommended that other agents such as hydrogen peroxide, hydrogen peroxide with silver nitrate, peracitic acid and other chemical compounds of formaldehyde should be used in place of the currently prevalent practice of using formaldehyde,
Many developing counties to regulate the hazardous chemicals with mandatory laws and needs more research and documentation of health hazards on the health caring staff. Reference- Unrecognized Dangers of Formaldehyde Samuel S. Epstein Cancer prevention expert, Prof. emeritus at U. of IL School of Public Health, Chicago
Answered by Dr.T V.Rao MD for online resources

TEACHING PROFESSIONALISM AND ETHICS TO MEDICAL STUDENTS- WHAT THE MEDICAL STUDENTS THINK? I happens to be Student of ANDHRA Loyola College Vijayawada in1964 to 1965 for my course in PUC before my Medical Under graduation – and it was Fridays the first lecture was a Moral class, mainly based on Christian teachings, truly the lectures were good but many times we never followed as we are too young to follow the good advises, The great spirit for many was Father Gordon a American his actions and discipline was a great spirit to progress in life, not to forget that Andhra Loyal college has produced most trusted medical profession in society and certainly USA, in the last 5 decades India has grown boundless with the conflicts in morality, ethics and economic matters, Every Medical Teacher carries the mission to make every Medical student a productive individual to make the human suffering reduced and curing the ailment and above all as Doctors hold a position of power and responsibility that demands trust when carrying out professional duties. While doctors are often rated by the public as the ‘most trusted profession’ in the past, no longer today as there is a mismatch between the expectations to live better and cured of the ailments and current advances in Medicine and the faster eroding of human ethics and need for more money, India hugely grown in Medical profession with hundreds of Medical colleges and research Institutes, as medical students they are placed in a somewhat unique position. Unlike many other disciplines of study, they are scrutinized even before entry to university through extensive entrance tests, as NEET Many academic ethical surveys prove many students feel many teachers advise more on discipline than they follow, and they are compelled to follow whatever they think as a dictum, we as students know what our teachers are up in life, we see many teachers hardly do anything both in teaching and publishing fake papers attaining fake PhD degrees or even MD or MS occupying higher chairs to improve their own careers,
WE LIVE IN CHANGING TIMES - As many students say teachers too are confused with conflicts and selfish interests individual most untrusty control us, However, many MERITORIOUS say we learned professionalism from very good of our teacher’s BEHAVIOR TO US AND ENCOURAGING TO THE LEAST PERFORMING STUDENTS, it just means honesty and integrity are core values of professionalism that we must all embody Many students expressed because of demand and supply many teachers and doctors, living with immorality than by professionalism so much rot in the system and express Teachers too need moral classes as happening in Developed countries MANY STUDENTS OPPOSE THE MORAL AND ETHICAL CLASSES AND THEY WISH TO HAVE COMPETENT AND MORAL BEHAVIOR IN TEACHERS?
Dr.T.V.Rao MD @ What students think on Moral classes in medical education

MICROBIOLOGICAL DIAGNOSIS OF URINARY CATHETER ASSOCIATED INFECTIONS- A topic of growing importance to both treating physicians and microbiologists, as we all know a catheter is a foreign substance can lead to changing dynamics of urinary bladder and urethra, A specimen for urine culture should be obtained before initiation of antibiotic therapy, because of the wide spectrum of potential infecting organisms and the increased likelihood of antimicrobial resistance is priority that the treating physician should write in requests that the reasons for cauterization and how long the catheter in place, and blind processing of the urine and reporting is counterproductive, as we teach our students as the signs and symptoms are different from a non-catheterized patients, Symptoms of catheter-related urinary tract infection (UTI) generally are nonspecific; most patients present with fever and leukocytes. Significant pyuria is generally represented by more than 50 white blood cells (WBCs) per high-power field (HPF). Colony counts on a urine culture range from 100-10,000/mL. If we read the culture plate from these patients much to our surprise the growth is poly microbial flora certainly we will miss many individual bacteria if we compromise inoculating many specimens on a single plate as many have resource crunch not to forget a full plate is an optimal area to identify the isolates with clarity, The 2009 Infectious Diseases Society of America (IDSA) guidelines define catheter-related UTI in patients whose urinary (urethral, supra pubic, or condom) catheter has been removed within the previous 48 hours by the presence of symptoms or signs compatible with UTI with no other identified source of infection along with 1000 or more colony-forming units (CFU)/mL of 1 or more bacterial species. Repeated poly microbial isolation should warrant for aseptic collection of the urine by trained paramedical staff this is true problem many do not care to send a specimen worth processing leading to prescription of antibiotic which are not warranted, and we will be treating all contamination as true infection
NEED FOR REPEATED CULTURING - If cauterization can be discontinued, the culture can be obtained in a voided midstream urine specimen A better understanding needed. If an indwelling catheter has been in place for longer than 2 weeks at the onset of the UTI and is still indicated, as happening with paralytic patients who have no control and many surgical interventions it should be replaced, and the urine culture should be obtained from the freshly placed catheter.
CAUTIs are one of the most common hospital-related infections. Therefore, many healthcare organizations place great emphasis on prevention. Catheter care in prevention of Hospital associated catheter infections
Healthcare providers clean their hands by washing them with soap and water or using an alcohol-based hand rub before and after touching catheter.
If you do not see your providers clean their hands, please ask them to do so.
NOT TO FORGET DIAGNOSING AND TREATING CATHETER ASSOCIATED INFECTIONS A GREAT CHALLENGE IN SPITE MANY ADVANCES IN PATIENT CARE
Ref Catheter-Related Urinary Tract Infection (UTI) Updated: Sep 08, 2017 Author: John L Brusch, MD, FACP;1 Chief Editor: Michael Stuart Bronze, MD
2 FAQs (frequently asked questions) “Catheter-Associated Urinary Tract Infection” IDSA AND CDC
Formulated by Dr.T.V.Rao MD for Infectious disease resource on worldwide web

TUBERCULIN SKIN TESTING IN HEALTH CARE WORKERS
Dr.T.V.Rao MD It was interesting to listen to Dr Chug MD one of the living legend in Microbiology on tuberculosis at Care Hospital Hyderabad, his work proves that the Health care workers at least a few of them succumb to tuberculosis and even the incidence rate of tuberculosis is higher in family members, Yet we have not mandatory recommendation how we care our Health care professionals, with progress of time many Doctors practicing in clinical care too get infected, however much under reported to health records fearing losing the confidence of the public and patients
UTILITY OF TUBERCILIN SKIN TESTING - We have certainly underutilized to Skin testing for tuberculosis at our Hospitals. Skin testing in Tuberculosis is one of the oldest testing method to evaluated for the infection with tuberculosis A tuberculin skin test (also called a Mantoux tuberculin test) is done to see if one is being exposed to tuberculosis (TB). The TB antigens used in a tuberculin skin test are called purified protein derivative (PPD). A measured amount of PPD (5 units to 10 units) and is injected with tuberculin syringe under the epidermal layer of skin on your forearm. Periodic testing of health care workers is recommended as part of a TB Infection Control Plan, and may be required by state regulations. and hospital policies This is a good test for finding a TB infection. It is often used when symptoms, screening, or testing, such as a chest X-ray, show that a person may have TB. a strong tuberculin test certainly supports the presence of tuberculous bacilli and its reactivity with immune repose
TESTING TO NEEDED AS FOLLOWING PROTOCLS
There are two types of testing for TB in health care workers.
Initial baseline testing upon hire: Two-step testing with a TB skin test
Annual or serial screening: determined by state regulations or risk assessment outcomes.
Baseline Testing: Two-Step Test
Two-step testing with the Mantoux tuberculin skin test (TST) should be used for baseline or initial testing. Some people with latent TB infection have a negative reaction when tested years after being infected. The first TST may stimulate or boost a reaction. Positive reactions to subsequent TSTs could be misinterpreted as a recent infection. And people to be watched for active infection with tuberculosis in future
Step 1
Administer first TST following proper protocol
Review result
Positive — consider TB infected, no second TST needed; evaluate for TB disease.
Negative — a second TST is needed. Retest in 1–3 weeks after first TST result is read.
Document result
Step 2
Administer second TST 1-3 weeks after first test
Review results
Positive — consider TB infected and evaluate for TB disease.
Negative — consider person not infected.
Document result
Improper Tuberculin skin testing -Administer the TB skin test following proper protocol In many hospitals the matter of testing Tuberculin is left to student nurses and untrained staff, never to forget the best results will be possible only with injecting the material as intradermal injection going deeper will lose the validity of test as the material is deposited in the fatty layer, and certainly the test will be negative in actively infected people, Injecting tuberculin is a skill the professionals should practice to perfection
TURNING FROM NEGATIVE TO POSITVE HAS A SUPPORTING VALUE IN DIAGNOSIS IN CASES PULONARY AND ETRA PULMONARY TUBERCULOIS
Review result — a change from a prior negative test result to a positive test result is evidence of recent TB infection
Document the Results in proper fashion
TODAY MANY HOSPITALS ARE ASKING FOR STATUS OF HBV AND HIV WHEN TAKING UP EMPLOYMENT WITH OR WITHOUT REASON
EVALUATION ON TUBERCULOSIS CARRIES MUCH IMPORTANCE AS TB IS TOTALLY CURABLE DISEASE Ref - Testing Health Care Workers Tuberculosis CDC
Formulated by Dr.T.V.Rao. MD for Medical and paramedical professionals in Euro vision to Health

LEARNING IS A GREAT INVESTMENT? When we talk about investing the common man’s idea is investing in wealth, and fortune, however with time you will realize only sustainable investment without much fluctuation is investing in knowledge and learning better things in life, At every stage of our lives as said – by Dan Gilbert, we make decisions that will profoundly influence the lives of the people we’re going to become, then when we become those people, we’re not always thrilled with the decisions we made.” –, never forget our desire to learn to better of the matters and skills never go waste, If I remained as a Graduate I would not have made as I have become a postgraduate, one effective way to trick yourself into stronger learning habits, and better exercise habits, is to think of you now and your future self as the same person. Everyone has problem non-free from the circumstances, we live with people the aim is only the money and power to survive and many find this the cause of much organizational failures, the world is changing fast with much growing intelligence and artificial intelligence and a simple machine or robot can take over our job, Today the world is too small with internet making us to be heard by many, or even when we have something to tell, or even a good story of our lives, Grow personal and professional networks. Learning provides a comfortable space to meet new people and makes for a great icebreaker, giving you a common topic to talk about. Depending on what learning opportunity you choose to invest in, the potential to establish both friendship and professional connections are abundant, You don’t have to attend a lectures, there are great podcasts teaching you best of what you are supposed to teach, or strive for an excellence, to be a better survivor you have to be top on many matters, Are you a Doctor? never mind nurses are best watching how good you are in practical skills are you a teacher the students know well of us, never mind accept the truth of yourself learning is only short cut await you and everyone , people around laugh if you are talking same things what you are doing yesterday The practice of teaching and learning has experienced tremendous growth in terms of methodology and engagement. There are countless ways to acquire the knowledge you seek, it’s simply a matter of which method is the most fun for you.
ONE IS NEVER OLD TO LEARN NEW ?

Dr.T.V.Rao MD

HOW NEET HAS BECOME A REALITY – FACTS BEHIND NEET Times of India ran an article that the market for black money on medical colleges is to the tune of Rs. 12,000 cr. The article further states that ‘Of the 422 medical colleges in India, 224 are private, accounting for 53% of MBBS seats. Many of these colleges are running with little or no facilities, no patients and fake faculty. The going price for an MBBS seat could range from Rs. 1 crore in colleges in Bangalore to Rs 25-35 lakh in some in UP. Seats in MD in radiology and dermatology cost up to Rs 3 crore.’ The article points that the PG seat are been offered at Rs. 3.0 cr., for radiology, ortho and dermatology streams. In fact, of the total value of ‘Seat Sale’ is about Rs. 9000 cr., just from the MBBS stream. Add to those statistics, most of the private colleges with management quota and NRI quota have a seat sale to the extent of 60% of total seats. This is quite alarming and incomprehensible.” “The medical education sector is sickening and everyone is hurt” or “The noble profession and its education is tarnished “The important point that has come is that NEET is applicable to private educational institutes”. This is the biggest Game Changers. This has such far reaching ramifications, that it will change the way Medical Institutions operate in this country; as explained in the ensuing section. The blame must be shared by the medical fraternity as well, which is mainly behind promoting the practice of paid seats in private colleges. After all they need to secure the investments made by them in their clinics and nursing homes by pushing their kids into medicine even if they are not competent, NEET will curb the malpractices and corruption in medical seat allocation. Medical institution which should be quality based has become business market with huge capitation fees and rampant corruption. It is generally owned and managed by politicians and businessmen without any medical background. Government should also try to make this course low cost as much possible. However many senior professionals with stature think it will make many colleges suffer the impact with financial crisis, and certainly affect the newly started colleges as many old one made their own buck and established, Some colleges will go bankrupt WE FIND MANY SELLERS AND FEW TO BUY AS NO BODY WILL BUY A SICK HORSE AND will certainly have great impact on students’ parents, and society, It was suggested medical colleges should take some senior professionals skilled clinicians who are retired with academic mind to help the Institutes facing financial crunch, However there is great support for NEET as many middle class families with intention of making their children doctors it is possible now with NEET
Far reaching problem lies with shortage of senior dedicated teachers and the on going problem of Ghost teachers, and teachers fit only for MCI inspections spoiling the work culture in the Medical colleges
A great suggestion was rich parents can donate for development of the Institute ?
The matter of Medical education under the control of Judiciary and Supreme court and all judgments from lower courts are subject of overruling by higher courts
Resource TOI
tvraomd

LABORATORY ERRORS - IMPLICATIONS ON CLINICAL CARE
Dr.T.V.Rao MD
Post graduate topic for discussion in Laboratory Medicine and Critical Care Medicine in Afro Asian web resources
DEFINING LABORATORY ERROR – as Dictionary by FARLEX
Any error made by the personnel in a clinical laboratory in performing a test, interpreting data, or reporting or recording the results. Laboratory error must always be considered a possible explanation for findings that are at variance with the composite clinical condition of the patient or are widely divergent from previous laboratory tests. The general procedure is to repeat the test when an abnormal result is found.
Although tens of thousands of people around the world suffer harm, many times disabling, and even die because of unsafe acts in health care, in the past the Clinicians were taking much responsibility and matters of omission and commission was lying with treating physicians we as laboratory personal had little infrastructure and resources to do many investigations, with progress of clinical care, the treating physicians must dependent on laboratory investigations taking critical decisions. Since many decades western medicine identified that laboratories are source of scientific information and made a great impact on the developed countries, Laboratory medicine is a substantial part of health care systems. It is essential for many decision-making tasks by doctors, nurses and other health professionals, and is related to prevention, diagnosis, treatment, management of illnesses and patients' rehabilitation. WHAT IS A LABORATORY ERROR IN CLINICAL CARE - Error is the difference between the true result (or accepted true result) and the measured result? If the error in an analysis is large, serious consequences may result. A patient may undergo expensive and even dangerous medical treatment based on an incorrect laboratory result may implement costly and incorrect modifications to process because of an analytical error. To initiate the Mattress, the science is a progressing a true reality, it just means the matters are never perfect and so also the laboratory which are based on scientific fundamentals, however we do so many investigations in the laboratories some are good, many imprecise and few certainly wrong to the circumstances we work,
Matter need a better understanding in every laboratory
wrong sample collected
sample mislabeled or unlabeled
sample stored inappropriately before testing
sample transported inappropriately
reagents or test kits damaged by improper storage-examination errors What matters to many in the health care, As Laboratory data are extensively used in medical practice; consequently, laboratory errors have a tremendous impact on patient safety. Therefore, programs designed to identify and reduce laboratory errors, as well as, setting specific strategies are required to minimize these errors and improve patient safety,
WHAT BEST WE CAN DO - The laboratory should:
employ an active process for occurrence management and take a positive approach.
try to detect problems early, and take immediate remedial and corrective action.
seek opportunities to identify potential error, thus preventing its occurrence.
keep good records of all problems, investigations, and actions taken.
I we do not focus on errors many litigation and career repercussions happens
Laboratory error is an occurrence or an event that has a negative impact on Laboratory, which includes personnel, product, equipment, or the environment. And interpersonal litigation in the Hospitals we work
UNSUPERVISED LABORATORIES ARE TRUE THREAT IN PATIENT CARE
References – 1Changing trends in laboratory medicine and human care training manual in health care
2 Errors in clinical laboratories or errors in laboratory medicine? Plebani M Clin Chem Lab Med. 2006; Pub Med
Dr.T.V.Rao. MD

Gonorrhea has affected humans for centuries and remains common sexually transmitted Infection Worldwide, an estimated 106.1 million cases occur annually, Gonorrhea disproportionately affects racial, ethnic, and sexual minorities. Untreated gonococcal infection can lead to pelvic inflammatory disease, ectopic pregnancy, and infertility in women and can facilitate transmission of human immunodeficiency virus. Childhood blindness still affects infants born to mothers infected with gonorrhea, particularly in resource-limited countries. In India like many in underdeveloped countries infected with sexually transmitted infection, primary consult the less qualified and many illiterate people approach to quacks, who experiment with least effective and sub optimal doses of the best options and making the bacteria venerable to drug resistance. We have few laboratories which try culturing for Gonorrheal infections, to any one’s surprise few patients attend a teaching hospital before exhausting the available new generation of antibiotics, many who chosen the topic of Gonorrhea find very difficult to isolate on the available media leave the topic as the growth of the organism is certainly difficult and a matter of happening Gonorrhea has progressively developed resistance to the antibiotic drugs prescribed to treat it. The emergence of cephalosporin-resistant gonorrhea would significantly complicate our ability to treat gonorrhea successfully, since we have few antibiotic options left that are simple, well-studied, and highly effective. It is critical to continuously monitor antibiotic resistance in Neisseria gonorrhea and encourage research and development of new treatment regimens. Cephalosporins continue to be newer options in treating emerging drug resistant strain in Gonorrhea. Trends in Declining Effectiveness cephalosporins, considering the proportion of samples with elevated “minimum inhibitory concentrations” (MICs) of Cefixime and ceftriaxone, recent analyses indicate that higher concentrations of cephalosporins are increasingly needed to stop the bacteria’s growth in laboratory tests. An MIC is the lowest concentration of antibiotics needed to stop the bacteria’s growth in the laboratory. The most significant change in the new guidelines is that CDC no longer recommends Cefixime as an effective oral treatment for gonorrhea, leaving only inject able ceftriaxone to be used in combination with one of two oral antibiotics, either azithromycin or doxycycline. Ceftriaxone is more potent against gonorrhea than Cefixime, and when paired with the additional oral antibiotic, might slow the emergence of drug resistance by ensuring that gonococcal infections are quickly cured and not allowed to spread. The newer research proves that that we are in need of regimes if the trends raise with resistance to ceftriaxone. Two new antibiotic regimens using existing drugs – inject able gentamicin in combination with oral azithromycin and oral Gemifloxacin in combination with oral azithromycin – successfully treated gonorrhea infections in a clinical trial. The trial was conducted by the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH). The study was conducted to identify new treatment options in the face of growing antibiotic resistance. CDC still recommends only one first-line treatment regimen: inject able ceftriaxone, in combination with one of two other oral antibiotics, either azithromycin or doxycycline. This regimen remains highly effective in treating gonorrhea and causes limited side effects. However, providers may consider using the regimens studied in this trial as alternative options when ceftriaxone cannot be used, such as in the case of a severe allergy. CDC is taking the findings of this trial into consideration for inclusion in future treatment guidelines. In the developing countries many are venerable to Gonorrhoea in view of lack of sex education and social support related to STD, it remains critical for people to take steps to protect themselves from gonorrhea infection. The surest way to prevent infection is not having sex. For those who are sexually active, consistent and correct condom use and limiting the number of sex partners can help reduce the risk of infection. (As per CDC guidelines)
MOLECULAR METHODS IN DIAGNOSIS - NAH, nucleic acid amplification test (NAAT) and multiplex PCR. Results are available in <24 above="" addition="" also="" and="" be="" br="" can="" endocervical="" even="" females.="" for="" h.="" having="" heterosexual="" in="" include="" males="" may="" men="" msm="" naat.="" or="" oropharyngeal="" rectal="" sex="" specimens="" swab="" swabs="" the="" to="" urethral="" urine="" used.="" used="" vaginal="" with="">The sensitivity of NAAT (95%), is superior to culture, especially for rectal and pharyngeal swabs, but specificity is less. Only NAAT for urethral swab is presently Food and Drug Administration (FDA), USA approved. And culture is the only method for antimicrobial susceptibility with many challenges in the resource poor laboratories.
WHAT WHO RECOMMENDS - Development of new drugs
The R&D pipeline for gonorrhoea is relatively empty, with only 3 new candidate drugs in various stages of clinical development: solithromycin, for which a phase III trial has recently been completed; zoliflodacin, which has completed a phase II trial; and gepotidacin, which has also completed a phase II trial.
The development of new antibiotics is not very attractive for commercial pharmaceutical companies. Treatments are taken only for short periods of time (unlike medicines for chronic diseases) and they become less effective as resistance develops, meaning that the supply of new drugs constantly needs to be replenished.
References -! Antibiotic-resistant gonorrhoea on the rise, new drugs needed 7 JULY 2017 | GENEVA
2- Molecular methods in the laboratory diagnosis of sexually transmitted infections Sumathi Muralidhar Indian J Sex Transm Dis. 2015 Jan-Jun; 36(1):
3 Current resources from CDC on Sexually transmitted infections
Updated Article by Dr.T.V.Rao MD

MICROBIOLOGICAL DIAGNOSIS OF CATHETER ASSOCIATED INFECTIONS-
A question to postgraduates in Pathology /Laboratory medicine in European union We receive few intravascular catheters for evaluation of infections from many critical care patients, every catheter we insert has some risk of systemic infection with involvement of blood stream with all percutaneous catheters are associated with risk of (skin) exit site infection and subsequent migration of that infection along the extraluminal catheter surface to the bloodstream. . Bacterial or fungal contamination of a catheter hub can also lead to intraluminal infection of the catheter and extension of that infection to the bloodstream.
MICROBIOLOGY MATTERS - The leading causes of CRBSI in descending order of frequency are staphylococci (both Staphylococcus aureus and the coagulase-negative staphylococci), enterococci, aerobic Gram-negative bacilli and yeast. When aerobic Gram-negative bacilli are assessed as a group, their frequency follows that of the staphylococci
Quantitative culture of the distal (5 cm) tip of central venous and arterial catheters should be performed when they are removed for suspected infection. The tip of the introducer should be sent for culture when a pulmonary artery line is removed. For patients with short-term central venous catheters without severe sepsis or shock, in whom the index of suspicion for catheter-related infection is moderate or less, the catheter may be exchanged over a guide wire for a new catheter allowing culture of the tip of the removed catheter without immediately sacrificing the site of insertion (The clinicians or phlebotomist s would do the matters with asepsis )
ESATBLISHED AND REVIWED STANDARS - positive culture with the same microorganism of either:
quantitative CVC culture ≥ 103 CFU/ml or semi-quantitative CVC culture > 15 CFU; quantitative blood culture ratio CVC blood sample/peripheral blood sample > ;differential delay of positivity of blood cultures: CVC blood sample culture positive two hours or more before peripheral blood culture (blood samples drawn at the same time);positive culture with the same microorganism from pus from insertion site. NEED FOR BLOOD CULTRUING At least 2 blood cultures should be obtained when catheter infection is suspected. When the tip of a catheter is sent for culture, the 2 blood cultures may be obtained by peripheral venipuncture. Alternatively, or when culture of the tip of the catheter is not performed, blood culture should be obtained by peripheral venipuncture and at least blood culture should be obtained from a lumen of the catheter. A recent study has found that for multilumen catheters, drawing multiple catheter blood cultures, one from each lumen of the catheter suspected of infection, in addition to blood culture obtained by peripheral venipuncture will enhance detection of catheter infection.
Currently, most hospital microbiology laboratories use automated systems for detecting growth in incubating blood cultures
A diagnosis of CRBSI is achieved by any of the following 3 criteria:
same organism recovered from percutaneous blood culture and from quantitative (>15 colony-forming units) culture of the catheter tip; same organism recovered from a percutaneous and a catheter lumen blood culture, with growth detected 2 hours sooner (ie, 2 hours less incubation) in the latter; same organism recovered from a quantitative percutaneous and a catheter lumen blood culture, with 3-fold greater colony count in the latter
Some hospitals report multiple cases of Catheter associated infection when the matters on aseptic precautions are neglect or under performed, the correction needs the understanding of pathophysiology and need proper caring technical and clinical staff WITH DEDICATED HAND WASH AND PROPER GLOVING WITH USE OF EFFECTIVE ANTISEPTIC AGENTS
All the critical care units should develop their own Standard operating procedures on the matters with effective training for all the staff and reviewed CME’s on matters
ARTICLE FOR REOSURCE AND BETTER UNDERSTANING LEARN FROM FULL TEXT
1 Intravascular Catheter-Related Bloodstream Infection Harshal Shah, Neurohospitalist. 2013 Jul; 3(3): 144–151. NCBI
2 Catheter-Related Infection ARTICLES - WIKI
Formulated for European on-line education on infectious diseases
Dr.T.V.Rao MD

MPLEMENTATION OF NEET - EMERGING CHALLENGES - Our Medical education is one of the most complicated system, In the past Government thought they cannot invest much in medical education and allowed many medical dental and nursing colleges, In the last two decades there is abrupt rise of Medical institutions, The government thought all is well as everyone has their own share, the Medical Council of India as a regulatory authority made rules, mended the rules made many rich through MCI inspectors I have seen many act as custodians of law and impossible regulations and made their buck to share with high ups with accepting all the lacunae in the system, The strict regulations made the corruption bigger, many preferred to initiate colleges in rural areas, where there are few people living lead to shortage of beds and turned to be a failed clinical learning, Many colleges have few patients for the University examination, However many private colleges improved and doing fine when the greediness was little and invested much in development of infrastructure and facilities to attract the poor people admitted, who alone allowed the students to examine and learn better of clinical medicine
Many Medical colleges heading to crisis
1 With growing costs it is certainly not possible to pay even the agreed salaries, leave developing infrastructure, the parents demanding least fees even in private medical colleges, it will certainly to lead to closure of some medical colleges recently initiated for profit purpose 
2 Difficult to bring in accountability of the senior teachers, and retired teachers many enjoyed unlimited leave, higher salaries, just coming 2 or 3 day, long weekends and only interested to be the Principals, vice principals and HOD’s it makes them to rule the system as they liked, It is certainly difficult to implement the Biometry many threaten the system, and then how to run the system a great question to many upcoming medical colleges, 
3 With ranking of NEET as criteria for admission a common students attained much rights, to question the system and many administrations and represent the matters to the higher authorities to fight for their rights 
4 Certainly there will much unrest from Nursing, technical, paramedical staff, for higher salaries comparing with few teachers and clinicians enjoying the boot without contributing anything, as we see many senior professors hardly interested to do anything as they are wanted by the Medical council of India as a mandatory requirements,
5 Laboratory medicine is in poor shape, least money is invested as laboratories are no more cheap to run, and buying the machines is too expensive to invest unless it can produce the returns, above all many Microbiology Pathology and Biochemistry professors run the laboratories with many remote controls and power and not even contribute a little, to improve the system most of the time happy to glued to chairs, leaving to technicians, and even the juniors try to imitate the bosses, as everyone has a reason to avoid work as management's never bothered to correct the system except the financial concerns, If you want to run the system with responsibility soon you are opposed by many it is unfortunate many professors think their presence is divine , rest to known to all who work in the system.
6 Power Brokers - Many colleges have a middle men even our teachers act high with the support of the management's loot / break the system and harass the innocent and sincere as the managements cannot handle the administration, With implementation NEET we moved from one extreme to another with lack of much money hitting the system
TIME to WATCH NEET WHAT NEXT ?
TRULY MONEY IS NEED OF THE HOUR WHO PAYS TO RUN THE PRIVATE MEDICAL COLLEGES ?
Dr.T.V.Rao MD

THINK BEFORE CHOOSING A THESIS TOPIC IN POST GRADUATION (MD / MS / MDS /MSc Nursing) - It is mandatory to write a thesis / dissertation to fulfill the Health University regulations, The MD /MS MDS MSc Nursing , thesis is a test more of scientific rather than clinical ability, as many times it is difficult to alter the standard regimen of treatments and surgical procedures as much of the matters are under scrutiny of Scientific and Ethical committee regulations and the candidate should normally provide some contribution to medical knowledge. The most important quality needed for undertaking it is enthusiasm for original work and for studying a subject in depth. Today it is much easier to get many articles and of the past and present with the proliferation of internet , Not to forget many students repeat the similar topics which were already done in the past, certainly choosing a topic becomes more difficult if the university is established for many decades, and many times the synopsis submitted with rejection or much quarries however newer universities have lesser control on the matters, as there few topics in the university,
WHAT IS THE PURPOSE OF A THESIS - However most post graduation residency programmes world over do require a thesis as a part of their curriculum.Aim of the thesis at this stage is to familiarize the resident on research methodology . At this stage, topic of thesis really does not matter.What matters is how it is done - That's, if all the process of a scientific research had been followed rigorously, Try not choosing a topic with high risks and many times the newly established institutes do not take responsibility if the litigations arise from your work University regulations
Each university has its own regulations such as order of headings and style of chapter. It is important that anyone undertaking a thesis reads the regulations of the own university and follows all details as well as visiting the library to look at theses which have been accepted. This article simplifies the thesis writing, which can be adapted to different Universities.( Try contacting members of the scientific and ethical committee )
Having formulated an idea it is essential that the candidate should meet the Statistician or else it will be cumbersome to complete the thesis, as any theses nowadays require the use of statistics, and expert help should be sought from the start. Nowadays many of the Medical colleges have competent statistician and try contacting a person from community medicine solve many matters, if you do not care the matters and truly face many obstacles to complete the thesis, never forget , Many new and upcoming Medical colleges find few patients to do a work with many number of patients as inflow out patients are few and few in hospital wards , and I always say some seniors may be working on a particular topic in the department try associate with them you can do a better work you will get the support of seniors who are interested on working a particular topic The topic must contain sufficient material for a thesis and originality is important, though, an excellent piece of work confirming what is known would sometimes be acceptable. There must be a consistent theme.
FIRST STEP OF THESIS PRESENTATION - Synopsis (summary)-This should describe the contents of the thesis in 200 to 500 words. Most careful attention should be given to it, for the assessor first turns to this to find out what has been done and why. Ethical consideration and informed consent: When planning / reporting experiments on human subjects, it should be indicated whether the procedures followed were in accord with the ethical standards on human experimentation (as per the guidelines laid down by the Central Ethical Committee of the ICMR). When reporting experiments on animals, procedures adopted for the care and use of laboratory animals need to be mentioned . The subject of the thesis may have to be approved beforehand by the scientific and Ethical committee and forwarded to the university by the Dean/ Principal , a period of at least two to eighteen months must elapse before the candidate can submit the thesis after certified by the concerned guide/Head of the department with final approval of the Institutional Ethical committee
NEVER FORGET THE THESIS CAN MAKE YOU A SCHOLAR The thesis is a scholarly effort that describes the scientific question that your thesis research addressed, the approaches that you used to answer this question, the results that you obtained from your studies, and the conclusions that you drew from your work.
References Adopted from 1 ICMR / guidelines on human research
2 Writing Thesis Protocol Medical Education Unit, University College of Medical Sciences,Delhi
3 Thesis Preparation Guidelines JOHNS HOPKINS May 19, 2016
Formulated by tvrao MD Chair person Institutional Ethical committee Azeezia Medical Institutions Kollam Kerala
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HOW THE INTERNET INFLUENCING LEARNING MEDICINE –Electronic-learning describes the use of information technology or the internet for learning activities. Integrating e-learning into medical education is supported by adult learning theory; learners control content, sequence, pace, time and media, fitting different learning styles. Courses are standardized in terms of content and delivery and can include assessment and feedback. Many developed countries trying to perfect the matters and developing countries are adopting where short of skilled teachers to deliver the matters, With proliferation of broad band and access to internet where we live it is certainly becomes a necessity rather than compulsion to search the matters, any new terminology we use in the class room and clinics, , Surveys show that around 70% of US Internet users consult the Internet when they require medical information. People seek this information using both traditional search engines and via social media. The information created using the search process offers an unprecedented opportunity for applications to monitor and improve the quality of life of people with a variety of medical conditions. Today it is just not learning little of medicine, and how the patients react to the illness, the true story of illness starts once a diagnosis is made, For example, the mental state of cancer patients in the first few days following diagnosis has been analyzed using web searches and changes in mood prior to the appearance of abnormal mental states detected
e-LEARNING Implications- Technology is a tool for deeper learning, and learning experiences beyond lecture-based learning. With the emergence of students who have grown up with technology, e-learning may increase. In an era of value for money, e-learning offers an opportunity to disseminate the experience of clinicians to a wide audience. Areas for research include assessing contexts for effective use of e-learning in medical education, the differential use of e-learning in preclinical versus clinical years, the adaptation of e-learning to a wide variety of medical specialties and clinical settings, and the incorporation of e-learning as part of a blended-learning strategy
WE CAN LEARN MANY MATTERS FASTER WITH the recent emergence of e-readers such as the iPad, and smart phones with their “apps”, e-learning is likely to continue to play a large role in education. The free downloadable Student British Medical Journal iPhone app provides news, research, education, blogs and podcasts
Close to 100 000 health related apps for smartphones are now available on the two-major mobile device software platforms, Apple’s iOS and Google’s Android. Medical apps have generated more than three million US downloads on iOS alone.
ALREADY INTERENT AND e-RESOURCES ARE REPLACING OUTDATED TEACHERS
Resources -Regulating medical apps: which ones and how much? BMJ 2013
t v rao

HOW TO REPORT BETTER AND FASTER IN DIAGNOSTIC BACTERIOLOGY ? The question has many limitations than answers, The great problem remain with humans have ten times more commensals bacteria occupying our body than our own cells, it just means we have occasion of useful and commensal bacteria, however sometimes few pathogens enter the humans and try to win the system, it we call as infection . however our own system of immunity saves from succumbing to the harmful effects and invasions, My teacher who has dedication to bench Dr Joga Lakshmi MD and emeritus professor from Andhra Medical colleges used to teach me the difficulty is understanding Medical Microbiology is what is harmful and which is not , it continues to be the challenge when we are reporting, not to forget much of our work is in in bacteriology which revolves around few bacteria and many others are discarded as insignificant, commensals to the clinical situation,.However we find many discussion and unnecessary conflicts and egoistic clashes in the departments continue to hamper the good relations in the departments, however much corrections can be brought with healthy understanding reading to basic books in diagnostic microbiology, If we look into the Matters with wisdom Microbiology including all the divisions it is truly difficult we can never become perfect with even many decades working in the laboratory However what is important for clinicians is a little communication at the end of our exhaustive work we do in laboratory, after culturing it really takes a minimum of 3 days to deliver a minimal report on Antibiograms let us be realistic let us not waste the time

Acute Pharyngitis - And specimen of throat swab routinely sent rarely in a suspected case of Diphtheria which we get rarely and higher clinical application needed to treat the patients with antitoxin even overruling the laboratory reports
At least in few cases every week we get isolates of Streptococcus group A and beta hemolytic Performing susceptibilities on beta-haemolytic streptococci: Beta-haemolytic streptococci are invariably susceptible to penicillin s, everywhere, and you can send the reports on the 2nd day and effective penicillin can be started ,If the patient has anaphylaxis to penicillin documented on the request form then fair enough. To test with better alternatives as Erythromycin Otherwise, it is all a bit academic and testing many drugs with Gram positives is unfair and causes confusion loss of times, DEALING WITH MIXED FLORA ON CULTURE PLATES Working up individual organisms where the culture plates clearly show”enteric flora”: For superficial swabs, this is a no-brainer. But even in sterile sites, the work up of each individual organism when they clearly represent enteric flora is of little clinical value. We get specimens from perforated intestines or Appendix certainly we isolate Enteric flora and dominance of E.coli truly it will not be useful to process for antibiograms, and much of the care will be taken by clinicians with combination of higher grade antibiotics with their own experience, proving only E.coli is difficult Anaerobic culturing - We have few facilities to culture anaerobes in our laboratories and very few have a practical experience Culturing for anaerobes in areas of the body where anaerobes live peri-anal area, vagina, oral, gastrointestinal This is not very wise because if you manage to grow anaerobes from such sites then it may well represent normal colonising flora. If we look at the anaerobes in the gut and oral cavity dominated by anaerobes and certainly routine microbiology laboratories do not point the true nature of infection, certain it needs the most advanced microbiology facilities whatever many times we report will not serve the matters, and truly it is better to explain to the clinicians limitations of our laboratory system
Sputum to be cultured and not Saliva - Never proceed to take up culturing of sputum unless it is truly sputum and not salivary secretions collected by inexperienced staff where there are lots of epithelial cells on microscopy: Because if you do so, you will simply be culturing a sample originating from the mouth or prophylaxis which will bear little relation to what is happening down in the lungs. However the laboratory reports misguide the clinicians with commensals isolated and tried with every new generation of antibiotics leading to reporting of MDR strains. Be hold to reject the specimens or else we will be delivering reports which are more harmful than useful
Culturing for bacteria in vaginal swabs: Vaginal flora contains lots of different colonizing bacteria, most of which very rarely causes problems. It is probably only worthwhile looking for staphylococci and streptococci when there has been instrumentation or trauma (e.g. post-natal). The vast majority of vaginal swabs do not need cultured for bacteria. Unless we suspect a infections with Gonorrhea bacterial vaginosis or matters related to pelvic inflammatory diseases
Let’s not waste time and be truly scientific
Try learn more at “Time Wasters ”Michael Microbiology matters concepts of clinical Microbiology
Dr.T.V.Rao MD free lance reporter on Infectious diseases