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Background: Personal syringe reuse (i.e., reuse of one's own syringes) can place people who inject drugs at increased risk for infectious disease but has received relatively little attention in published literature. The purpose of this study is to identify factors associated with syringe reuse among people who inject drugs in rural Kentucky., Methods: Participants (n = 238) completed interviewer-administered questionnaires on syringe reuse and demographic, behavioral, and service access characteristics. Unadjusted negative binomial regression with cluster-robust standard errors was used to model the associations with a logged offset for number of injections in the past 30 days., Results: The average age of the sample was 35 and 59.7 % were male. Most participants (77.7 %) reused syringes at least once in the past 30 days, using each syringe a median of three times. Reuse was higher among those who were older and reported a higher street price for syringes. Syringe reuse was lower among people who were within walking distance to a syringe service program (SSP) and who obtained most of their syringes from SSPs or pharmacies., Conclusion: Syringe reuse among people who inject drugs in rural Kentucky is common. However, these data suggest that increased access to syringes from SSPs and pharmacies, as well as policy-level interventions that reduce street syringe price, might reduce syringe reuse and related harms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Duodenoscopy-associated infections occur worldwide despite strict adherence to reprocessing standards. The exact scope of the problem remains unknown because a standardized sampling protocol and uniform sampling techniques are lacking. The currently available multi-society protocol for microbial culturing by the Centers for Disease Control and Prevention, the United States Food and Drug Administration (FDA) and the American Society for Microbiology, published in 2018 is too laborious for broad clinical implementation. A more practical sampling protocol would result in increased accessibility and widespread implementation. This will aid to reduce the prevalence of duodenoscope contamination. To reduce the risk of duodenoscopy-associated pathogen transmission the FDA advised four supplemental reprocessing measures. These measures include double high-level disinfection, microbiological culturing and quarantine, ethylene oxide gas sterilization and liquid chemical sterilization. When the supplemental measures were advised in 2015 data evaluating their efficacy were sparse. Over the past five years data regarding the supplemental measures have become available that place the efficacy of the supplemental measures into context. As expected the advised supplemental measures have resulted in increased costs and reprocessing time. Unfortunately, it has also become clear that the efficacy of the supplemental measures falls short and that duodenoscope contamination remains a problem. There is a lot of research into new reprocessing methods and technical applications trying to solve the problem of duodenoscope contamination. Several promising developments such as single-use duodenoscopes, electrolyzed acidic water, and vaporized hydrogen peroxide plasma are already applied in a clinical setting., (© 2021. The Author(s).)

Global shortages of N95 respirators have led to an urgent need of N95 decontamination and reuse methods that are scientifically validated and available world-wide. Although several large scale decontamination methods have been proposed (hydrogen peroxide vapor, UV-C); many of them are not applicable in remote and low-resource settings. Heat with humidity has been demonstrated as a promising decontamination approach, but care must be taken when implementing this method at a grassroots level. Here we present a simple, scalable method to provide controlled humidity and temperature for individual N95 respirators which is easily applicable in low-resource settings. N95 respirators were subjected to moist heat (>50% relative humidity, 65-80°C temperature) for over 30 minutes by placing them in a sealed container immersed in water that had been brought to a rolling boil and removed from heat, and then allowing the containers to sit for over 45 minutes. Filtration efficiency of 0.3-4.99 μm incense particles remained above 97% after 5 treatment cycles across all particle size sub-ranges. This method was then repeated at a higher ambient temperature and humidity in Mumbai, using standard utensils commonly found in South Asia. Similar temperature and humidity profiles were achieved with no degradation in filtration efficiencies after 6 cycles. Higher temperatures (>70°C) and longer treatment times (>40 minutes) were obtained by insulating the outer vessel. We also showed that the same method can be applied for the decontamination of surgical masks. This simple yet reliable method can be performed even without electricity access using any heat source to boil water, from open-flame stoves to solar heating, and provides a low-cost route for N95 decontamination globally applicable in resource-constrained settings., Competing Interests: The authors have declared that no competing interests exist.

Objectives: To synthesise evidence concerning the range of filtering respirators suitable for patient care and guide the selection and use of different respirator types., Design: Comparative analysis of international standards for respirators and rapid review of their performance and impact in healthcare., Data Sources: Websites of international standards organisations, Medline and Embase, hand-searching of references and citations., Study Selection: Studies of healthcare workers (including students) using disposable or reusable respirators with a range of designs. We examined respirator performance, clinician adherence and performance, comfort and impact, and perceptions of use., Results: We included standards from eight authorities across Europe, North and South America, Asia and Australasia and 39 research studies. There were four main findings. First, international standards for respirators apply across workplace settings and are broadly comparable across jurisdictions. Second, effective and safe respirator use depends on proper fitting and fit testing. Third, all respirator types carry a burden to the user of discomfort and interference with communication which may limit their safe use over long periods; studies suggest that they have little impact on specific clinical skills in the short term but there is limited evidence on the impact of prolonged wearing. Finally, some clinical activities, particularly chest compressions, reduce the performance of filtering facepiece respirators., Conclusion: A wide range of respirator types and models is available for use in patient care during respiratory pandemics. Careful consideration of performance and impact of respirators is needed to maximise protection of healthcare workers and minimise disruption to care., Competing Interests: Competing interests: SS recently retired from a scientific research position at a major manufacturer of respiratory protective equipment., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

The COVID-19 pandemic has led to widespread shortages of personal protective equipment (PPE) for healthcare workers, including of N95 masks (filtering facepiece respirators; FFRs). These masks are intended for single use but their sterilization and subsequent reuse has the potential to substantially mitigate shortages. Here we investigate PPE sterilization using ionized hydrogen peroxide (iHP), generated by SteraMist equipment (TOMI; Frederick, MD), in a sealed environment chamber. The efficacy of sterilization by iHP was assessed using bacterial spores in biological indicator assemblies. After one or more iHP treatments, five models of N95 masks from three manufacturers were assessed for retention of function based on their ability to form an airtight seal (measured using a quantitative fit test) and filter aerosolized particles. Filtration testing was performed at a university lab and at a National Institute for Occupational Safety and Health (NIOSH) pre-certification laboratory. The data demonstrate that N95 masks sterilized using SteraMist iHP technology retain filtration efficiency up to ten cycles, the maximum number tested to date. A typical iHP environment chamber with a volume of ~ 80 m 3 can treat ~ 7000 masks and other items (e.g. other PPE, iPADs), making this an effective approach for a busy medical center.

With COVID-19 N95 shortages, frontline medical personnel are forced to reuse this disposable-but sophisticated-multilayer respirator. Widely used to decontaminate nonporous surfaces, UV-C light has demonstrated germicidal efficacy on porous, non-planar N95 respirators when all surfaces receive ≥1.0 J/cm2 dose. Of utmost importance across disciplines, translation of empirical evidence to implementation relies upon UV-C measurements frequently confounded by radiometer complexities. To enable rigorous on-respirator measurements, we introduce a photochromic indicator dose quantification technique for: (1) UV-C treatment design and (2) in-process UV-C dose validation. While addressing outstanding indicator limitations of qualitative readout and insufficient dynamic range, our methodology establishes that color-changing dosimetry can achieve the necessary accuracy (>90%), uncertainty (<10%), and UV-C specificity (>95%) required for UV-C dose measurements. In a measurement infeasible with radiometers, we observe a striking ~20× dose variation over N95s within one decontamination system. Furthermore, we adapt consumer electronics for accessible quantitative readout and use optical attenuators to extend indicator dynamic range >10× to quantify doses relevant for N95 decontamination. By transforming photochromic indicators into quantitative dosimeters, we illuminate critical considerations for both photochromic indicators themselves and UV-C decontamination processes., Competing Interests: The authors have declared that no competing interests exist.

The COVID-19 pandemic has laid bare the inadequacy of the U.S. healthcare system to deliver timely and resilient care. According to the American Hospital Association, the pandemic has created a $202 billion loss across the healthcare industry, forcing health care systems to lay off workers and making hospitals scramble to minimize supply chain costs. However, as the demand for personal protective equipment (PPE) grows, hospitals have sacrificed sustainable solutions for disposable options that, although convenient, will exacerbate supply strains, financial burden, and waste. We advocate for reusable gowns as a means to lower health care costs, address climate change, and improve resilience while preserving the safety of health care workers. Reusable gowns' polyester material provides comparable capacity to reduce microbial cross-transmission and liquid penetration. In addition, previous hospitals have reported a 50% cost reduction in gown expenditures after adopting reusable gowns; given the current 2000% price increase in isolation gowns during COVID-19, reusable gown use will build both healthcare resilience and security from price fluctuations. Finally, with the United States' medical waste stream worsening, reusable isolation gowns show promising reductions in energy and water use, solid waste, and carbon footprint. The gowns are shown to withstand laundering 75-100 times in contrast to the single-use disposable gown. The circumstances of the pandemic forewarn the need to shift our single-use PPE practices to standardized reusable applications. Ultimately, sustainable forms of protective equipment can help us prepare for future crises that challenge the resilience of the healthcare system., (Copyright © 2020 Baker, Bromley-Dulfano, Chan, Gupta, Herman, Jain, Taylor, Lu, Pannu, Patel and Prunicki.)

Most respirators employed in health care settings, and often in first responder and industrial settings, are intended for single-use: the user dons the respirator, performs a work activity, and then doffs and discards the respirator. However, in the current COVID-19 pandemic, in the presence of persistent shortages of personal protective equipment, extended use and reuse of filtering facepiece respirators are routinely contemplated by many health care organizations. Further, there is considerable current effort to understand the effect of sterilization on the possibility of reuse, and some investigations of performance have been conducted. While the ability of such a respirator to continue to provide effective protection after repeated sanitization cycles is a critical component of implementing its reuse, of equal importance is an understanding of the impact that reusing the respirator multiple times in a day while performing work tasks, and even extending its wear over multiple days, has on the workplace protective performance. In this study, we subjected a stockpiled quantitatively fitted surgical style N95 filtering facepiece respirator device to extreme reuse and extended wear conditions (up to 19 uses over a duration of 5 days) and measured its protective performance at regular intervals, including simulated workplace protection factor measurements using total inward leakage. With this respirator, it was shown to be possible to maintain protection corresponding to an assigned protection factor greater than 10 under extreme usage conditions provided an individual is properly trained in the use of, and expertly fitted in, the respirator. Other factors such as hygiene and strap breakage are likely to place limits on reuse.

Background: The high demand for personal protective equipment during the novel coronavirus outbreak has prompted the need to develop strategies to conserve supply. Little is known regarding decontamination interventions to allow for surgical mask reuse., Aim: To identify and synthesize data from original research evaluating interventions to decontaminate surgical masks for the purpose of reuse., Methods: MEDLINE, Embase, CENTRAL, Global Health, the WHO COVID-19 database, Google Scholar, DisasterLit, preprint servers, and prominent journals from inception to April 8 th , 2020, were searched for prospective original research on decontamination interventions for surgical masks. Citation screening was conducted independently in duplicate. Study characteristics, interventions, and outcomes were extracted from included studies by two independent reviewers. Outcomes of interest included impact of decontamination interventions on surgical mask performance and germicidal effects., Findings: Seven studies met eligibility criteria: one evaluated the effects of heat and chemical interventions applied after mask use on mask performance, and six evaluated interventions applied prior to mask use to enhance antimicrobial properties and/or mask performance. Mask performance and germicidal effects were evaluated with heterogeneous test conditions. Safety outcomes were infrequently evaluated. Mask performance was best preserved with dry heat decontamination. Good germicidal effects were observed in salt-, N-halamine-, and nanoparticle-coated masks., Conclusion: There is limited evidence on the safety or efficacy of surgical mask decontamination. Given the heterogeneous methods used in studies to date, we are unable to draw conclusions on the most efficacious and safe intervention for decontaminating surgical masks., (Copyright © 2020 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: The shortage of single-use N95 respirator masks (NRMs) during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has prompted consideration of NRM recycling to extend limited stocks by healthcare providers and facilities., Aim: To assess potential reuse via autoclaving of NRMs worn daily in a major urban Canadian hospital., Methods: NRM reusability was assessed following collection from volunteer staff after 2-8 h use, sterilization by autoclaving and PortaCount fit testing. A workflow was developed for reprocessing hundreds of NRMs daily., Findings: Used NRMs passed fit testing after autoclaving once, with 86% passing a second reuse/autoclave cycle. A separate cohort of used masks pre-warmed before autoclaving passed fit testing. To recycle 200-1000 NRMs daily, procedures for collection, sterilization and re-distribution were developed to minimize particle aerosolization risk during NRM handling, to reject NRM showing obvious wear, and to promote adoption by staff. NRM recovery ranged from 49% to 80% across 12 collection cycles., Conclusion: Reuse of NRMs is feasible in major hospitals and other healthcare facilities. In sharp contrast to studies of unused NRMs passing fit testing after 10 autoclave cycles, we show that daily wear substantially reduces NRM fit, limiting reuse to a single cycle, but still increasing NRM stocks by ∼66%. Such reuse requires development of a comprehensive plan that includes communication across staffing levels, from front-line workers to hospital administration, to increase the collection, acceptance of and adherence to sterilization processes for NRM recovery., (Copyright © 2020 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: To review the effect of ultraviolet germicidal irradiation (UVGI) as a disinfection method for filtering facepiece respirators (FFRs) to facilitate reuse during COVID-19 pandemic., Methods: Systematic review of the research concerning UVGI for FFRs disinfection to facilitate reuse (also termed limited reuse) during respiratory infectious diseases where aerosol transmission is considered possible., Results: UVGI is one possible method for respiratory disinfection to facilitate the reuse of dwindling supplies. Appropriate dose UVGI exposition could provide enough energy to effectively decontaminate respiratory viral agents and maintain respirator's integrity for reuse. There was not currently sufficient research evidence on the effect of UVGI to inactivate coronaviruses SARS-CoV-2, and the practical application of UVGI is still unclear. ., Conclusion: Appropriate dose UVGI exposition could provide enough energy to effectively decontaminate respiratory viral agents and maintain respirator's integrity for reuse. Further evidence concerning UVGI as a decontamination technique specifically for SARS-CoV-2 isneeded., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Frequent reuse of syringes during medical injections is fuelling epidemics of human immunodeficiency virus and hepatitis C virus infections in many low- and middle-income countries including Pakistan., Aims: To explore specific factors related to syringe reuse during therapeutic injections., Methods: We randomly surveyed 319 healthcare providers from 2 socioeconomically diverse districts in Pakistan, along with 625 of their patients., Results: Providers see 12-25 patients per day, and provide 7-14 therapeutic injections or intravenous drips. Comparing daily stocks with injections provided, we estimated that 38% of providers (Rawalpindi: 14%, Tando Allah Yar: 44%) likely reuse syringes 2 or 3 times. Rural location and longer duration of practice predict a higher likelihood of reuse. Physicians and non-physicians were equally likely to reuse. Most patients were unaware when a syringe had been reused., Conclusions: High rate of syringe reuse is driven by high injection demand by patients, to which providers comply. Patients are generally unaware of the harm of injections with syringe reuse or that reuse happens. Our findings suggest that patient focused approaches may help reduce syringe reuse., (Copyright © World Health Organization (WHO) 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

Surgical gowns help protect patients from exposure to microorganisms and serve as personal protective equipment for perioperative staff members. Medical textiles, including surgical gowns, are available as reusable and disposable products. Health care facility administrators and leaders who endeavor to use environmentally sustainable practices require current data for decision making. This study analyzed all activities from the extraction of fossil materials from the earth to the end-of-life disposal of reusable and disposable surgical gowns. The researchers included calculations for laundry and wastewater treatment operations and compared the environmental effects of the two surgical gown systems. The study results showed that selection of reusable gowns rather than disposable gowns reduced natural resource energy consumption (64%), greenhouse gas emissions (66%), blue water consumption (83%), and solid waste generation (84%). Perioperative nurses can use this information to assist facility leaders as they make informed decisions related to gown system selection., (© AORN, Inc, 2020.)

Objectives: To summarize patient notifications resulting from unsafe injection practices by health care personnel in the United States and describe recommended actions for prevention and response., Patients and Methods: We examined records of events involving communications to groups of patients, conducted from January 1, 2012, through December 31, 2018, in which bloodborne pathogen testing was recommended or offered because of potential exposure to unsafe injection practices by health care personnel in the United States. Information compiled included: health care setting(s), type of unsafe injection practice(s), number of patients notified, number of outbreak-associated infections, and whether evidence suggesting bloodborne pathogen transmission prompted the notification. We compared these numbers with a similar review conducted from January 1, 2001, through December 31, 2011., Results: From 2012 through 2018, more than 66,748 patients were notified as part of 38 patient notification events. Twenty-one involved exposures in non-hospital settings. Twenty-five involved syringe and/or needle reuse in the context of routine patient care; 11 involved drug tampering by a health care provider. The majority of events (n=25) were prompted by identification of unsafe injection practices alone, absent any documented infections at the time of notification. Outbreak-associated hepatitis B virus and/or hepatitis C virus infections were documented for 11 of the events; 8 involved patient-to-patient transmission, and 3 involved provider-to-patient transmission., Conclusions: Since 2001, nearly 200,000 patients in the United States were notified about potential exposure to blood-contaminated medications or injection equipment. Facility leadership has an obligation to ensure adherence to safe injection practices and to respond properly if unsafe injection practices are identified., (Published by Elsevier Inc.)

One-fourth of all operating room (OR) waste is attributed to anesthesia-related material. The goal of this project was to reduce the waste and increase cost savings of opened and unused endotracheal (ET) tubes and disposable laryngoscope handles and blades in 2 separate OR environments. The production of these unused anesthesia supplies was assessed weekly in each of 2 OR environments for 8 weeks before an educational intervention, and for 8 weeks following the intervention. The average weekly waste production was summarized for each study period, compared between periods (preintervention vs postintervention), and analyzed per 100 surgeries using the 2-sample t test. The overall average weekly waste for ET tubes was significantly reduced from 26.7 ± 10.7 to 10.0 ± 6.1 from pre to post intervention (P = < .001), representing a 62.6% reduction. A similar significant reduction in waste was observed for laryngoscope handles (15.9 ± 8.1 vs 7.2 ± 3.1; P = .004; a 54.7% reduction) and laryngoscope blades (21.5 ± 11.0 vs 9.9 ± 4.4; P = .004; a 54.0% reduction). These results highlight the significance and feasibility of an educational intervention in reducing the environmental and economic waste produced by anesthetic practices in the OR., Competing Interests: This project was in part supported by the Department of Surgical Services, Mayo Clinic, and by the Mayo Clinic School of Health Sciences, Rochester, Minnesota. The authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did not discuss off-label use within the article. Disclosure statements are available for viewing upon request., (Copyright© by the American Association of Nurse Anesthetists.)

Background: Flexible ureteroscopy is an established treatment modality for evaluating and treating abnormalities in the upper urinary tract. Reusable ureteroscope (USC) durability is a significant concern., Objective: To evaluate the durability of the latest generation of digital and fiber optic reusable flexible USCs and the factors affecting it., Design, Setting, Participants: Six new flexible USCs from Olympus and Karl Storz were included. The primary endpoint for each USC was its first repair. Data on patient and treatment characteristics, accessory device use, ureteroscopy time, image quality, USC handling, disinfection cycles, type of damage, and deflection loss were collected prospectively., Intervention: Ureteroscopy., Outcome Measurements and Statistical Analysis: USC durability was measured as the total number of uses and ureteroscopy time before repair. USC handling and image quality were scored. After every procedure, maximal ventral and dorsal USC deflection were documented on digital images., Results and Limitations: A total of 198 procedures were performed. The median number of procedures was 27 (IQR 16-48; 14h) for the six USCs overall, 27 (IQR 20-56; 14h) for the digital USCs, and 24 (range 10-37; 14h) for the fiber optic USCs. Image quality remained high throughout the study for all six USCs. USC handling and the range of deflection remained good under incremental use. Damage to the distal part of the shaft and shaft coating was the most frequent reason for repair, and was related to intraoperative manual forcing. A limitation of this study is its single-center design., Conclusions: The durability of the latest reusable flexible USCs in the current study was limited to 27 uses (14h). Damage to the flexible shaft was the most important limitation to the durability of the USCs evaluated. Prevention of intraoperative manual forcing of flexible USCs maximizes their overall durability., Patient Summary: Current flexible ureteroscopes proved to be durable. Shaft vulnerability was the most important limiting factor affecting durability., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context/Objective: Inadequate bladder management in spinal cord injury (SCI) patients results in significant morbidity and even mortality. Clean intermittent catheterization (CIC) is the recommended option for SCI patients. The objective of the study was to document the bladder management practices of SCI patients in a developing country. Design: Questionnaire based cross sectional survey Setting: Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan Participants: All patients with SCI (irrespective of duration, level and etiology) Interventions: Data documentation included demographics, level, severity and time since injury, bladder management techniques used, details of CIC, results of Urodynamic studies (if available), complications resulting from bladder management technique and patient awareness of the yearly follow up. SPSS V 20 was used for analysis. Outcome Measures: Not applicable Results: Thirty four consenting patients were enrolled. All were males. Mean age was 31.24 ± 10.9. Most (17) of the patients were thoracic level paraplegics, while 12 patients had sustained a cervical SCI. Majority (23) had complete injury (ASIA A). Fifteen patients used CIC for bladder management followed by in dwelling Foley catheters in thirteen patients. Those using CIC performed the procedure every four hours and used disposable catheters. The same 'disposable' catheter was used for 5-7 days by half of these patients. Only Six patients independently performed CIC. Three patients on CIC reported urinary tract infection. Conclusions: In the largest spinal rehabilitation unit of a developing country; Pakistan CIC was the preferred method of bladder management followed by indwelling catheter. Re-use of disposable catheters is a common practice due to cost issues. The rate of UTI was significantly lower in patients on CIC.

Background: N95 filtering facepiece respirators (FFRs) are widely used in healthcare to reduce transmission of airborne infectious diseases. These respirators are generally described as single use or limited reuse devices, but cost and operational issues mean that they may be donned and doffed multiple times. There is scant research on the effect of this practice on adequacy of fit., Objective: The purpose of this study was to measure the effect on respirator fit of multiple donning and doffing of N95 FFRs., Methods: This was an experiment in which 16 women and 9 men employed by the National Institute for Occupational Health (NIOH), Johannesburg, donned their same N95 FFR six times. All 25 were trained in the correct wearing of the devices before the experiment. Four models of respirators were used: the six who did not use respirators at work (novice subjects) were issued a 3M 1860 FFR and the others used their currently supplied one. During the experiment subjects donned their respirators under the supervision of the tester. Quantitative fit testing was done in the NIOH Occupational Hygiene laboratory after each donning according to the OSHA-Accepted Fit Test Protocol using the TSI PortaCount Pro+ Model 8038 Respirator Fit Tester. During the test, fit was measured after each of seven exercises and then an overall fit factor was computed. Only individuals who achieved an initial overall fit factor of ≥100 were allowed to continue participation in the study. Median overall fit factors were calculated for the 25 subjects for each donning and changes across them was examined using Wilcoxon rank sum tests. Men and women and frequent and infrequent users were compared across the six tests. Infrequent use was defined as subjects who wore respirators ≤ once per week, and novice subjects., Results: Two subjects (8%) had an overall fit factor <100 at fit Test 2, 6 (24%) at Test 3, and 8 (32%) at Tests 4, 5, and 6. Thirteen respirator users (52%) achieved ≥100 throughout the fit testing, so 12 had at least one failure at either Tests 2-6. Five of the 12 subjects with at least one failure showed persistent failures on all subsequent donnings. Six subjects out of 12 (50%) who failed a fit test achieved an overall fit factor >100 at a subsequent test. There was a significant difference between the median first and sixth overall fit factors (195 versus 150; P = 0.0271), but not between the second and sixth (161 versus 150; P = 0.3584). Men and women had similar overall fit factors, but infrequent users had larger average overall fit factors than frequent users after all six donnings., Conclusion: Forty-eight percent of study subjects failed at least one fit test after re-donning an N95 FFR. The fit test data suggest that donning practices probably accounted for the fit test failures. The 50% of subjects who produced overall fit factors ≥100 after a test of <100 supports this contention., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Occupational Hygiene Society.)

Purpose: The aim of the study was to investigate if ultrasound probes are reusable medical devices that risk becoming contaminated after a patient examination in Japan., Methods: The level of bacterial contamination on transvaginal ultrasound (TVU) probes following current routine probe cleaning at a university hospital (site A) and a clinic (site B) in Japan was investigated., Results: A total of 98.1% of probes were found to be contaminated at site A (median CFU 40, IQR 10, 132.5) and 94.1% were found to be contaminated at site B (median CFU 50, IQR 20, 85). Of the contaminated probes, 52.9% at site A and 64.6% at site B harbored potentially pathogenic bacteria including methicillin-resistant Staphylococcus aureus (MRSA)., Conclusion: These findings suggest that there is a high rate of ultrasound probe residual bacterial contamination in Japan.

Background: Reuse of injection devices to give healthcare injections decreased from 39.8 to 5.5% between 2000 and 2010, but trends since 2011 have not been described. We reviewed results of Demographic and Health Surveys (DHS) to describe injection practices worldwide from 2011 to 2015., Methods: We searched the DHS Internet site for data published on injection practices conducted in countries from 2011 to 2015, extracted information on frequency (number of healthcare injections per person in the last 12 months) and safety (proportion of syringes and needles taken from a new, unopened package). We compared gender groups and WHO regions in terms of frequency and safety. For countries with data available, we compared injection practices 2004-2010 and 2011-2015., Results: Since 2011, 40 of 92 countries (43%) that conducted DHS surveys reported on injection practices. On average, the frequency of injection was 1.64 per person per year (from 3.84 in WHO Eastern Mediterranean region to 1.18 in WHO African region). Among those, 96.1% of injections reportedly used new injection devices (from 90.2% in the WHO Eastern Mediterranean region to 98.8% in the WHO Western Pacific region). On average, women received more injections per year (1.85) than men (1.41). Among 16 (40%) countries with data in 2004-2010 and 2011-2015, 69% improved in terms of safety. The annual number of unsafe injections reduced in 81% of countries. In Pakistan, the number of unsafe injections was the highest and did not decrease between 2006 and 2012., Conclusions: Injection practices have continued to improve in most countries worldwide, although the Eastern Mediterranean region in particular still faces unsafe practices that are not improving. Further efforts are needed to eliminate unsafe injection practices in health care settings, including through the use of reuse-prevention devices. Despite some limitations, DHS is an easily available method to measure progress over time.

Purpose: To critically review all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes., Materials and Methods: A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. All factors potentially affecting surgical costs or clinical outcomes were considered. Prospective assessments, case control and case series studies were included., Results: 741 studies were found. Of those, 18 were duplicated and 77 were not related to urology procedures. Of the remaining 646 studies, 59 were considered of relevance and selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. Operative time was in average 20% shorter with digital scopes, single-use or not. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Longer scope longevity is achieved with Cidex and if a dedicated nurse takes care of the sterilization process. The main surgical factors that negatively impact device longevity are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. We have built a comprehensive fi nancial costeffective decision model to fl exible ureteroscope acquisition., Conclusions: The cost-effectiveness of a fl exible ureteroscopy program is dependent of several aspects. We have developed a equation to allow a literature-based and adaptable decision model to every interested stakeholder. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Background: Medical supplies and equipment are unevenly distributed throughout the world., Objective: Our aim was to describe, quantify, and monetize unused supplies suitable for recovery produced from two urban emergency departments (EDs)., Methods: We trained ED staff to place opened, unused, uncontaminated medical supplies in strategically located bins located in two urban EDs for 30 days. We sorted and quantified collected supplies, then used hospital-specific supply catalogs to determine the total cost of recovered medical supplies during the 30-day study period. We extrapolated the amount of collected medical supplies and associated costs to yearly estimates., Results: We recovered 39.9 kg ($6,096) from the trauma center and 3.4 kg ($539) from the academic center during the 30-day study period. The most commonly collected supplies included open but unused procedure kits ($1,776), catheter needles ($1,009), and sutures ($698). We estimated that the trauma center produces $73,158 of unused medical supplies per year and the academic center produces $6,467 of unused medical supplies per year., Conclusions: We present a novel approach to decreasing waste and recovering usable medical supplies, in which we found that substantial, valuable medical supplies can be recovered in two urban EDs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: We assessed the frequency of preoperative and persistent microbial contamination of flexible ureteroscopes after reprocessing and the relation of contamination to cumulative ureteroscope use., Materials and Methods: We evaluated the effectiveness of high level disinfection with peracetic acid as well as data on ureteroscope use for 20 new flexible ureteroscopes from December 2015 to December 2017 at a single center. In the operating room pre-use and postuse microbial samples of the ureteroscope shaft and working channel were collected to evaluate microbial contamination after reprocessing. Positive cultures were defined as 30 cfu/ml or greater of skin flora, or 10 cfu/ml or greater of uropathogenic microorganisms. A generalized estimating equation model was used to analyze whether cumulative ureteroscope use was associated with positive pre-use cultures., Results: Microbial samples were collected during 389 procedures. Pre-use ureteroscope cultures were positive in 47 of 389 procedures (12.1%), of which uropathogens were found in 9 of 389 (2.3%) and skin flora in 38 of 389 (9.8%). Urinary tract infection symptoms did not develop in any of the patients who underwent surgery with a uropathogen contaminated ureteroscope. In 1 case the pre-use culture contained the same bacteria type as the prior postuse culture. Cumulative ureteroscope use was not associated with a higher probability of positive cultures., Conclusions: Microbial contamination of reprocessed ureteroscopes was found in an eighth of all procedures. Notably uropathogenic microorganisms were discovered in a small proportion of all procedures. Persistent ureteroscope contamination with uropathogens was only rarely encountered. Cumulative ureteroscope use was not associated with a higher probability of microbial contamination.

Background: In China, reprocessing and reuse of single-use medical devices (SUDs) are banned. However, the actual situation has not been reported so far. The study aims to clarify the perceptions and concerns of various sectors of the community on the reuse of SUDs, and whether such practice exists. In addition, we are also wondering how acceptable the respondents are on this matter., Methods: A cross-sectional study based on a national survey which was conducted on the professional online questionnaire survey platform ( www.wjx.cn ) from July 26 to August 4, 2015. We analyzed the data according to the work fields, sex, age, education level, professional background and participants' answers to 49 other questions., Results: Five hundred forty-four nationwide respondents belong to nine different work fields. In general, participants had positive attitudes towards the reprocessing and reuse of SUDs. However, many respondents doubted the hygienic and functional safety of the reprocessed SUDs. They also tended to think that the reuse of SUDs should have lower prices and more technical training as well as patient advocacy. Further analysis demonstrated the work fields, education level and professional background of respondents were statistically associated with their responses to certain questions., Conclusions: The research indicated that although the reuse of SUDs is prohibited legally in China, there were extensive reprocessing and reuse in hospitals. Most responses tended to accept reprocessed SUDs if safety and low prices were guaranteed. These existing contradictions and the lack of relevant research led to policy makers in China will confront numerous challenges in building and improving this use system of medical devices to meet escalating demands of social sectors.

Reprocessing single-use surgical supplies and devices is an option for hospitals and ambulatory surgery centers (ASCs). The US Federal Government has recognized the practice since 2000, and regulatory oversight has increased dramatically since that time. Reprocessing single-use devices is safe when personnel use approved methods, and health care facilities can experience significant cost savings by participating in this type of initiative. This article explores reprocessing and its benefits in ASCs, including a review of the oversight that the US Food and Drug Administration currently has for reprocessing and a discussion of the results of studies pertaining to this practice. The article also describes some issues that ASC leaders need to be aware of when considering the implementation of a reprocessing program. Single-use device reprocessing can be an effective tool for ASC leaders to conserve and manage resources., (© AORN, Inc, 2019.)

Background: Global estimates suggest there are 15.6 million people who inject drugs (PWID) of whom 17.8% are living with HIV.Few studies have characterized newly-onset injectors with long-term injectors and its association with injecting risk behaviors., Objectives: We examined the relationship between length of injection and risk behaviors among people who inject drugs (PWID) in Tehran, Iran., Methods: A cross-sectional study was conducted among PWID, from March to August 2016 in Tehran, Iran. PWID were recruited by convenience and snowball sampling from five Drop-in Centers (DIC) located in the south of Tehran. Our primary independent variable was length of injecting career, defined as the number of months since injecting initiation. Those defined as new injectors (were injecting for less than 18 months), and long-term injectors (as injecting drugs for more than 18 months). We reported the adjusted odds ratio (aOR) point estimate and 95% confidence interval (CI95%) as the effect measure. The level of significance used in multiple logistic regression model was 0.05. We used STATA v. 11 for all analyzes., Results: The analytical sample comprised of 500 participants (100% male). Mean (±SD) age of PWID with a length of injection history was 31.2 ± 7.2 years. Overall, 270 (54%) (CI95%: 49.6%, 58.4%) of participants were long-term injectors. The average age of drug use initiation among long-term injectors group was lower as compared to new injectors group (31.2 vs. 29.4, p < 0.001). The odds of distributive syringe sharing among new injectors were two times higher than long-term injectors (AOR = 2.1, 95% CI 1.4-4.7). The odds of receptive syringe sharing were lower among new injectors group (AOR = 0.7, CI95% 0.2-0.87), compared to long-term injectors. New injectors had higher odds of reusing their own syringes (OR = 2.8, 95% CI: 1.4-5.7; p = 0.01)., Conclusions: Improvements in harm reduction service provision can occur through taregted risk reduction education for new injectors focusing on reducing distributive syringe sharing among them.

Objective: To compare the reports of occupational events recorded by nursing professionals during the periods of reuse and single use of the dialyzer., Method: Retrospective longitudinal study with electronic medical records from nursing technicians of a hemodialysis service. Data were analyzed descriptively and Rate ratio., Results: During the reuse of the dialyzer, there were seven events from five professionals reporting musculoskeletal disorders, ocular allergies and dermatosis. During single use, two professionals reported low back pain. The rate ratio of medication use was 6.7 days for every 1000 professionals during the reuse period and 1.52 days in the single use period (RR=4.4; 95% CI 2.182-9.805). Anti-inflammatory drugs were the most prescribed, and sick leaves were similar in both periods., Conclusion: Dialyzer reuse was associated with musculoskeletal disorders, ocular irritation, dermatosis and increased use of medications by professionals. Sick leaves were similar on the periods of dialyzer reuse and single use.

Tourniquets are widely used to make the vein more visible prior to blood collection. Venepuncture tourniquets are however a non-sterile and potentially reusable equipment. Several studies have shown that they are colonised by a variety of pathogenic bacteria and consecutively use of the same tourniquet on multiple patients will increase the risk of a nosocomial infection. This matter is however only scarcely studied. The objective of this study was to investigate the nationwide use of disposable and non-disposable venepuncture tourniquets and the standardised procedures for cleaning the tourniquets. A questionnaire concerning use and cleaning of tourniquets was therefore sent to all major Danish clinical biochemistry laboratories (n = 12). All but one laboratory had a local procedure for usage and handling of tourniquets, including structured procedures for cleaning. Despite this, only 75% of laboratories had a guideline for cleaning the tourniquets and only 50% had a specified cleaning program. At the hospitals using non-disposable tourniquets the handling differed considerably and at two hospitals the tourniquets were only cleaned once a week, while one laboratory did not clean the tourniquet before it was visibly stained. Of note, five of the eight hospitals using disposable tourniquets only disposed the tourniquets on a daily basis. In conclusion, there is a lack of guidelines for handling tourniquets in 25-33% of the hospitals and a number of hospitals used both types (disposable and non-disposable), which could confuse the handling of the tourniquets. A national guideline for usage and cleaning of venepuncture tourniquets is therefore strongly recommended.

Background: The Asia Pacific Society of Infection Control launched its revised Guidelines for Disinfection and Sterilization of Instruments in Health Care Facilities in February 2017. This document describes the guidelines and recommendations for the reprocessing of instruments in healthcare setting. It aims to highlight practical recommendations in a concise format designed to assist healthcare facilities at Asia Pacific region in achieving high standards in sterilization and disinfection., Method: The guidelines were revised by an appointed workgroup comprising experts in the Asia Pacific region, following reviews of previously published guidelines and recommendations relevant to each section., Results: It recommends the centralization of reprocessing, training of all staff with annual competency assessment, verification of cleaning, continual monitoring of reprocessing procedures to ensure their quality and a corporate strategy for dealing with single-use and single-patient use medical equipment/devices. Detailed recommendations are also given with respect to reprocessing of endoscopes. Close working with the Infection Prevention & Control department is also recommended where decisions related to reprocessing medical equipment/devices are to be made., Conclusions: Sterilization facilities should aim for excellence in practices as this is part of patient safety. The guidelines that come with a checklist help service providers identify gaps for improvement to reach this goal., Competing Interests: Not applicable.APSIC gives consent for this manuscript to be published.The authors declare that they have no competing interests.

Background: The quality of instruments plays a pivotal role in governing safe operating room culture. The reprocessing system followed in the institution determines their durability thereby ensuring patient safety as well as minimizing health spending. Rigorous reprocessing in a centralized instrument reprocessing department by well trained staff following formulated guidelines helps to achieve the target of "safe surgery saves lives" as formulated by the World Health Organization. Methods: We sought to determine the patterns of wear and tear sustained among sets of surgical equipment from two surgical units that had been sent to the repair department within a year of their purchase. Analysis of similar changes in the joints of the instrument, as well as pattern of fractures sustained was performed. Results: All patterns of wear and tear were common in both the general surgical arm and neurosurgical counterpart, with the exception of fractures and mal-alignments. Similar study was performed examining changes in the joints. Stains were the most commonly observed change pattern in both sets of instruments. Fractures were most frequent in the working ends in both sets of instruments. Conclusion: There is an alarming incidence of wear and tear patterns in the instruments used in the surgical units, even within the first year of their use. This supports the strict implementation of reprocessing guidelines by well trained workers and their quality assessments via audit checks. The quality of the purchased instruments also plays a pivotal role., Competing Interests: No competing interests were disclosed.

Background: To inform development, targeting, and penetration of materials from a national injection safety campaign, an evaluation was conducted to assess provider knowledge, attitudes, and practices related to unsafe injection practices., Methods: A panel of physicians (n = 370) and nurses (n = 320) were recruited from 8 states to complete an online survey. Questions, using 5-point Likert and Spector scales, addressed acceptability and frequency of unsafe practices (eg, reuse of a syringe on >1 patient). Results were stratified to identify differences among physician specialties and nurse practice locations., Results: Unsafe injection practices were reported by both physicians and nurses across all surveyed physician specialties and nurse practice locations. Twelve percent (12.4%) of physicians and 3% of nurses indicated reuse of syringes for >1 patient occurs in their workplace; nearly 5% of physicians indicated this practice usually or always occurs. A higher proportion of oncologists reported unsafe practices occurring in their workplace., Conclusions: There is a dangerous minority of providers violating basic standards of care; practice patterns may vary by provider group and specialty. More research is needed to understand how best to identify providers placing patients at risk of infection and modify their behaviors., (Published by Elsevier Inc.)

Introduction: Nosocomial pneumonia accounts for the vast majority of healthcare-associated infections (HAI). Although numerous medical devices have been discussed as potential vehicles for microorganisms, very little is known about the role played by oxygen humidifiers as potential sources of nosocomial pathogens. The purpose of this research was to evaluate the safety of the reuse of humidifiers by analysing the rate of microbial contamination in reusable and disposable oxygen humidifiers used during therapy, and then discuss their potential role in the transmission of respiratory pathogens., Methods: Water samples from reusable and disposable oxygen humidifiers were collected from different wards of the University Hospital of Messina, Italy, where nosocomial pneumonia has a higher incidence rate due to the "critical" clinical conditions of inpatients. In particular, we monitored the Internal Medicine and Pulmonology wards for the medical area; the General Surgery and Thoracic and Cardiovascular Surgery wards for the surgical area and the Intensive Care Unit and Neonatal Intensive Care Unit for the emergency area. The samples were always collected after a period of 5 days from initial use for both types of humidifiers. Samples were processed using standard bacteriological techniques and microbial colonies were identified using manual and automated methods., Results: High rates of microbial contamination were observed in samples from reusable oxygen humidifiers employed in medical (83%), surgical (77%) and emergency (50%) areas. The most relevant pathogens were Pseudomonas aeruginosa, amongst the Gram-negative bacteria, and Staphylococcus aureus, amongst the Gram-positive bacteria. Other pathogens were detected in lower percentage. The disposable oxygen humidifier samples showed no contamination., Conclusions: This research presents evidence of the high rate and type of microbial contamination of reusable humidifiers employed for oxygen therapy. These devices may thus be involved in the transmission of potential pathogens. It could be important, for the prevention of nosocomial pneumonia, to replace them with singleuse humidifiers for which the absence of microbial contamination has been confirmed., Competing Interests: the authors declare that there are no conflicts of interest.

International corporations in an increasingly globalized economy exert a major influence on the planet's land use and resources through their product design and material sourcing decisions. Many companies use life cycle assessment (LCA) to evaluate their sustainability, yet commonly-used LCA methodologies lack the spatial resolution and predictive ecological information to reveal key impacts on climate, water and biodiversity. We present advances for LCA that integrate spatially explicit modelling of land change and ecosystem services in a Land-Use Change Improved (LUCI)-LCA. Comparing increased demand for bioplastics derived from two alternative feedstock-location scenarios for maize and sugarcane, we find that the LUCI-LCA approach yields results opposite to those of standard LCA for greenhouse gas emissions and water consumption, and of different magnitudes for soil erosion and biodiversity. This approach highlights the importance of including information about where and how land-use change and related impacts will occur in supply chain and innovation decisions.

Background: The feasibility and safety of postmortem cardiovascular implantable electronic device (CIED; pacemaker or defibrillator) retrieval for reuse has been shown. To date, studies indicate a low yield of reusable postmortem CIEDs (17%-30%)., Objective: The purpose of this study was to test the hypothesis that a higher rate of reusable CIEDs would be identified upon postmortem retrieval when an institutional protocol for systematic and routine acquisition, interrogation, reprogramming, and manufacturer analysis was used., Methods: Over a 6-year period, all subjects referred for autopsy underwent concomitant CIED pulse generator retrieval and enrollment in the Johns Hopkins Post-Mortem CIED Registry. CIEDs were interrogated, reprogrammed, and submitted for manufacturer analysis., Results: In total, 84 autopsies had CIEDs (37 pacemakers, 47 implantable cardioverter-defibrillators). CIEDs were implanted 2.84 ± 2.32 years before death, with 30% implanted <1 year before death. Overall, CIED postmortem longevity was 4.79 ± 3.41 years, with 56% demonstrating longevity ≥4 years (this group had an estimated mean longevity of 7.37 ± 2.44 years). Manufacturer analyses uncovered 2 falsely triggered elective replacement indication alerts, confirmed 5 correctly triggered elective replacement indication alerts, identified a recalled pacemaker, and verified that a defibrillator had undergone nonprogrammable hard reset., Conclusion: When a protocol for systematic and routine postmortem CIED retrieval, interrogation, reprogramming, and analysis was used, we noted that >60% of pacemakers and >50% of defibrillators demonstrated normal functional status with projected longevities >7 years on average. Formation of a national hospital-based "CIED donor network" would facilitate larger scale charitable efforts in underserved countries., (Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Objective: Undergloves are a way to reduce moisture-related skin damage. The aim of this feasibility study was to gain experience with logistics, applicability, acceptability and cost of the routine use of reusable textile undergloves in a hospital setting., Methods: Undergloves were tested with 18 health-care workers on an intensive care unit over three months. Data on usage as well as logistics were recorded. At baseline, personal data and knowledge and use of cotton undergloves, existing skin problems and the nursing behaviour of the hands by the subjects were determined by means of an input questionnaire. After each wearing, data on usage were collected by a questionnaire. Participants were interviewed by means of a questionnaire with respect to their experience with the use of the undergloves., Results: Acceptance and compliance with the use of undergloves was remarkably good. This was partly due to the properties of the gloves, and partly to the reduction of sweating and very positive effect on the skin of the hands. In the study period 2165 underglove uses were documented, resulting in an average daily consumption of four pairs per person per day. The average wearing time was 28.6 min. The undergloves were suitable for application as well as reprocessing. Reprocessment-related fatigue was relatively low and did not lead to the loss of the properties, only few gloves had to be sorted out. Even if one assumes a complete write-off of the gloves with end of the study, costs for reprocessing were about 0.46 € or 64 % less than the single use., Conclusion: The routine use of textile, reprocessable undergloves is feasible. Major challenges for broad usage are within logistics and acceptance by the user., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To investigate the rate of premature instrument exchange during robot-assisted laparoscopic radical prostatectomy (RALRP) and robot-assisted partial nephrectomy (RAPN). The majority of robotic instruments have a predetermined lifespan of 10 uses; however, it is unknown if instruments are routinely exchanged before 10 uses in clinical practice., Methods: We retrospectively reviewed instrument use in consecutive RALRP and RAPN cases performed by high-volume robotic surgeons at 1 tertiary care center between January 2011 and October 2014. The number of instruments used per case was evaluated and instances of additional instrument utilization were noted. Exchange number was compared between the first and second half of cases performed. Operative times were compared between cases with and without exchange. Student's t-test and Pearson's χ(2)-test were used to determine statistical significance., Results: Three surgeons performed 1579 RALRP procedures and 2 surgeons performed 313 RAPN procedures. During RALRP, monopolar curved scissors required exchange in 12.4% cases. Other instruments were exchanged in less than 2% of cases. Exchange rates were similar to those for RAPN. Only exchange of Prograsp forceps decreased with increasing surgeon experience (P = .02) and instrument exchange did not lengthen operative times (P >.05 for all instruments)., Conclusion: During RALRP and RAPN, monopolar curved scissors required exchange in approximately 10% of cases whereas other instruments were rarely exchanged. Robotic instrument lifetime may not uniformly be 10 uses. The preset lifetime of robotic instruments and/or pricing should be reevaluated., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To evaluate predictors of flexible ureterorenoscopes breakage and damage of their optical beam., Materials and Methods: Retrospective survey, single center on 393 interventions with 4 flexible ureterorenoscopes between January 2009 and March 2013. We analyzed factors linked to patient, pathology and surgical technique., Results: We identified 21 major accidents, a breakage rate of 5.34% and 76 pixels losses in the maintenance of endoscopes and 10 during the procedure. The only statistically significant predictor of loss was the cumulative duration of operating time since the last repair (P=0.04, OR=1.001 [1-1001]). For lesions of the optical beam between the procedures, parameters appearing as significant were the ureterorenoscope model (P=0.01, OR=2.558, 95% CI [1229-5326]), the use of instruments by the working channel: the laser (P=0.02, OR=2.06, 95% CI [1109-3827]), or the use of endoluminal graspers (P=0.007, OR=0.467, 95% CI [0269-0809]). Intraoperatively, the number of open or laparoscopic surgery (P=0.007, OR=3.105, 95% CI [1364-7068]), duration of intervention (P=0.01, OR=1.023, 95% CI [1.006-1041]) and the cumulative duration of intervention (P=0.003, OR=1.001, 95% CI [1-1002]) appeared to be statistically significant., Conclusion: The only predictor of loss of equipment under repair was the cumulative duration of operation time. It has not been demonstrated any difference between ureterorenoscopes. It was during the endoscopes disinfection that the majority of optical beam lesions take place., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objectives: To (1) evaluate the potential for recycling uncontaminated preoperative waste and (2) identify recycling differences within otolaryngology-head and neck surgery subspecialties., Study Design: Prospective study., Setting: Three university-affiliated tertiary level hospitals., Subjects: Otolaryngology-head and neck surgery operative procedures., Methods: A total of 97 operative procedures were evaluated. Preoperative waste products were sorted into recyclable and nonrecyclable materials; intraoperative waste was weighed for volume but not sorted. The preoperative period was defined as the opening of the surgical supply cart for operating room preparation until procedure initiation. Mass and volume of each type of waste were recorded upon the conclusion of the case., Results: Approximately 23.1% of total operative waste mass (36.7% by volume) was derived from the preoperative set-up, of which 89.7% was recyclable. Pediatric procedures produced the least recyclable material per operation as a proportion of total waste, which was statistically different than the 2 highest recyclable subspecialties, general and rhinology (P = .006); the remaining subspecialties did not statistically differ in proportion of recyclable material produced., Conclusion: This study identified a source of clean recyclable materials that could eliminate 21% of operating room waste mass., (© American Academy of Otolaryngology-Head and Neck Surgery Foundation 2014.)

Purpose: Replacing soft contact lenses (CLs) on a daily basis brings a number of advantages, most notably, reduced exposure to deposits, disinfectants, allergens, and other contaminants. This retrospective study estimated the prevalence of problems in current wearers of reusable soft CLs and tested the effect of refitting "problem" patients with daily disposable (DD) hydrogel lenses., Methods: Prevalence was estimated from 398 current reusable CL wearers for: frequent/constant discomfort or dryness, ≥2 h of uncomfortable wear, ≥grade 2 conjunctival hyperaemia (0-4), or ≥grade 3 corneal staining (0-15). In the second part of the study, 217 reusable CL wearers classified as problem patients were randomly refitted with DD lenses manufactured from one of two materials: etafilcon A (n=96) or nelfilcon A (n=121) and reassessed 1 week later., Results: Thirty-nine percent (154/398) had some qualifying criterion: reduced comfortable wearing time (CWT), 20%; dryness, 20%; irritation, 5%; corneal staining, 8%; and hyperaemia, 7%. After refitting with DDs, the prevalence of reduced CWT was decreased from 65% to 51% (P=0.0039), dryness from 60% to 41% (P < 0.0001) and corneal staining from 28% to 21% (P=0.04). There was no significant change in the prevalence of irritation, or hyperaemia. Some differences were noted between the two lens materials., Conclusions: A high proportion of reusable soft lens wearers encounter clinically relevant signs or symptoms with their current CLs. This study provides evidence that refitting with DD lenses is a useful strategy for alleviating some of the common problems of CL wear., (Copyright © 2014 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Field experiments on descriptive norms as a means to increase hotel guests' towel reuse [1] were replicated and extended. In two hotels in Germany (Study 1: N = 724; Study 2: N = 204), descriptive norm messages suggesting that 75% of guests had reused their towels, or a standard message appealing to environmental concerns, were placed in guests' bathrooms. Descriptive norm messages varied in terms of proximity of the reference group ("hotel guests" vs. "guests in this room") and temporal proximity (currently vs. two years previous). Reuse of towels was unobtrusively recorded. Results showed that reuse rates were high overall and that both standard and descriptive norm messages increased reuse rates compared to a no-message baseline. However, descriptive norm messages were not more effective than the standard message, and effects of proximity were inconsistent across studies. Discussion addresses cultural and conceptual issues in comparing the present findings with previous ones.

Objective: To retrospectively analyze a significant number of flexible ureterorenoscopic procedures performed with the Storz Flex-Xc model to evaluate its durability., Materials and Methods: Between May 2012 and May 2013, all the flexible ureteroscopic procedures performed with 3 Storz Flex-Xc flexible ureteroscopes were analyzed. Relocation of the lower pole stones was performed in all cases when possible. In the second and third series, the access sheath was retracted together with the flexible ureteroscope, thus preventing the damages, which its distal part may inflict on the flexed endoscope., Results: A total of 406 procedures were performed on 372 patients: first endoscope used on 96 procedures (90 patients), second one on 151 procedures (139 patients), and third one on 159 procedures (143 patients). Ureteral access sheath was used in 71.4% of the cases. The first endoscope was used for 67.1 hours, the second for 107.7 hours, and the third one for 107.2 hours. Major repairs were needed after significant damages of the outer coating (first endoscope) and severe deterioration of the deflecting mechanism (second and third endoscopes)., Conclusion: The digital Storz Flex-Xc seems to be a durable model of flexible ureteroscope. The use of ureteral access sheath and avoidance of overstressing the deflection mechanism by relocating lower pole stones seem to offer substantial advantages in prolonging the lifespan of these expensive instruments., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To evaluate the durability and cost of maintenance for outsourced, refurbished flexible ureteroscopes., Materials and Methods: Ureteroscope usage and repair were prospectively recorded over a 365-day period at a large 836-bed public hospital. Cases were performed by 14 different urologists using either refurbished DUR-8 or DUR-8 Elite model ureteroscopes. Retrograde cases involving calculi, urothelial carcinoma, stricture, and diagnostic evaluations were included. Ureteroscope repairs were performed by a single outsourced repair vendor, not the original manufacturer., Results: A total of 501 ureteroscopic cases involving 550 ureteroscope usages were performed over a 365-day period. Semirigid ureteroscopes were used for 281 (56.1%) cases and refurbished flexible ureteroscopes for 220 (43.9%). The reason for the ureteroscopy was calculi in 386 (77.0%) cases, urothelial carcinoma in 32 (6.4%), stricture in 36 (7.2%), and diagnostic in 47 (9.4%). No repairs were needed during this period for semirigid scopes. Ureteral access sheaths were used in 82 (37.7%) of the cases. A total of 32 instances of catastrophic breakage occurred. Each newly refurbished ureteroscope was used for an average of 6.9 times before incurring further damage requiring repair., Conclusion: Refurbished flexible ureteroscopes that have undergone comprehensive repair are extremely fragile in the setting of multiple surgeon users in a large public hospital that uses central processing for sterilization and storage. This poor durability results in significant maintenance, repair, and administrative inconvenience that should be considered along with the purchase price., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The international growth of cancer and lack of available treatment is en route to become a global crisis. With >60% of cancer patients needing radiation therapy at some point during their treatment course, the lack of available facilities and treatment programs worldwide is extremely problematic. The number of deaths from treatable cancers is projected to increase to 11.5 million deaths in 2030 because the international population is aging and growing. In this review, we present how best to answer the need for radiation therapy facilities from a technical standpoint. Specifically, we examine whether cobalt teletherapy machines or megavoltage linear accelerator machines are best equipped to handle the multitudes in need of radiation therapy treatment in the developing world., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: Prior studies have suggested that pacemaker reuse may be a reasonable alternative to provide device therapy in the low- and middle-income countries. We studied explant indications and remaining battery life of cardiac implantable electronic devices (CIEDs) at a tertiary medical center., Methods and Results: We conducted a retrospective review of all CIEDs extracted at the University of Michigan between 2007 and 2011. Devices were considered reusable if battery longevity was ≥48 months or >75% battery life was remaining; there was no evidence of electrical malfunction, and they were not under advisory or recall. Eight hundred and one CIEDs were explanted: Medtronic (MDT [Medtronic Inc., Minneapolis, MN, USA]; 454), Boston Scientific (BS [Boston Scientific Corp., Natick, MA, USA])/Guidant (GDT; 255 [Guidant Corp., St. Paul, MN, USA]), St. Jude Medical (SJM; 73 [St. Paul, MN, USA]), and Biotronik (BTK; 15 [Biotronik GmBH, Berlin, Germany]). After eliminating devices explanted for elective replacement indicator (ERI, 541), 51.9% of pacemakers (41/79), 54.2% of implantable cardioverter-defibrillators (ICDs) (64/118), and 47.6% of cardiac resynchronization therapy and defibrillation (CRT-D) devices (30/63) had sufficient battery life and no evidence of electrical malfunction to be considered for reuse. A logistic regression analysis found that the indications for device removal independently predicted reusability: upgrade to an ICD (odds ratio [OR] 162.8, P < 0.001) or CRT-D (OR 63.8, P < 0.001), infection (OR 110.7, P < 0.001), heart transplantation or left ventricular assist device placement (OR 56.6, P < 0.001), and device removal at patient's request (OR 115.4, P < 0.001)., Conclusion: The majority of explanted CIEDs for reasons other than ERI have an adequate battery life and, if proven safe, may conceivably be reutilized for basic pacing in underserved nations where access to this life-saving therapy is limited., (©2013 Wiley Periodicals, Inc.)

Purpose: This study evaluated and compared bone heating, drill deformation, and drill roughness after several implant osteotomies in the guided surgery technique and the classic drilling procedure., Materials and Methods: The tibias of 20 rabbits were used. The animals were divided into a guided surgery group (GG) and a control group (CG); subgroups were then designated (G0, G1, G2, G3, and G4, corresponding to drills used 0, 10, 20, 30 and 40 times, respectively). Each animal received 10 sequential osteotomies (5 in each tibia) with each technique. Thermal changes were quantified, drill roughness was measured, and the drills were subjected to scanning electron microscopy., Results: Bone temperature generated by drilling was significantly higher in the GG than in the CG. Drill deformation in the GG and CG increased with drill use, and in the CG a significant difference between G0 and groups G3 and G4 was observed. In the GG, a significant difference between G0 and all other groups was found. For GG versus CG, a significant difference was found in the 40th osteotomy. Drill roughness in both groups was progressive in accordance with increased use, but there was no statistically significant difference between subgroups or between GG and CG overall., Conclusion: During preparation of implant osteotomies, the guided surgery technique generated a higher bone temperature and deformed drills more than the classic drilling procedure. The increase in tissue temperature was directly proportional to the number of times drills were used, but neither technique generated critical necrosis-inducing temperatures. Drill deformation was directly proportional to the number of times the drills were used. The roughness of the drills was directly proportional to the number of reuses in both groups but tended to be higher in the GG group.