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De A, Datchanamurthy B, Y V, Bhosale N, Dakshinamurthy S. Effectiveness of Ultraviolet Radiation and Disinfectant Wipes in Reducing the Microbial Contamination of Mobile Phones in a Tertiary Care Hospital. Cureus 2024; 16:e64782. [PMID: 39156419 PMCID: PMC11329858 DOI: 10.7759/cureus.64782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2024] [Indexed: 08/20/2024] Open
Abstract
Background As mobile phones act as a potential source of microbial contamination, particularly in a hospital environment, the effectiveness of two most debated interventions namely ultraviolet radiation and disinfectant wipes in reducing the microbial contamination of mobile phones is compared. Objective To screen the mobile phones of healthcare personnel for the presence of microorganisms and to compare the effectiveness of ultraviolet radiation and disinfectant wipes in reducing microbial contamination. Methods and materials Pre-intervention and post-intervention swabs were collected before and after the use of each intervention respectively using 56 samples and cultured for growth in nutrient agar. Agar plates are subjected to quantitative analysis using bacterial colony count to reflect the efficacy of the specific intervention used. The data collected was entered in Microsoft Excel (Microsoft® Corp., Redmond, WA, USA) and analysis was done using standard statistical packages. Results While comparing the pre-intervention bacterial load with the post-intervention load, post-intervention bacterial contamination in terms of colony-forming units/CFU has drastically reduced after both interventions, which is validated by statistical significance. However, it was observed participants using disinfectant wipes as intervention had 2.07 times higher chance of having a low bacterial load which wasn't statistically significant. Conclusion Our study shows that with the use of any intervention from the above-mentioned interventions, bacterial load or bacterial contamination can be reduced significantly, thus pointing out that both ultraviolet radiation and disinfectant wipes are effective in reducing contamination of mobile phones. It was also found that male doctors have more bacterial load than females, which can be minimized by effectively changing behavioral habits.
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Affiliation(s)
- Arnabjyoti De
- Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, IND
| | | | - Valentina Y
- Microbiology, Mahatma Gandhi Medical College and Research Institute, Puducherry, IND
| | - Namrata Bhosale
- Microbiology, Mahatma Gandhi Medical College and Research Institute, Puducherry, IND
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Zenbaba D, Sahiledengle B, Beressa G, Desta F, Teferu Z, Nugusu F, Atlaw D, Shiferaw Z, Gezahegn B, Mamo A, Desalegn T, Negash W, Negash G, Mama M, Nigussie E, Chattu VK. Bacterial contamination of healthcare workers' mobile phones in Africa: a systematic review and meta-analysis. Trop Med Health 2023; 51:55. [PMID: 37798670 PMCID: PMC10552405 DOI: 10.1186/s41182-023-00547-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Mobile phones are potential reservoirs for pathogens and sources of healthcare-associated infections. More microbes can be found on a mobile phone than on a man's lavatory seat, the sole of a shoe, or a door handle. When examining patients, frequent handling of mobile phones can spread bacteria. Nevertheless, evidence of bacterial contamination of mobile phones used by healthcare workers in Africa was inconclusive. Thus, this meta-analysis and systematic review was conducted to estimate the pooled prevalence of bacterial contamination of mobile phones used by healthcare workers and the most frequent bacterial isolates in Africa. METHODS We systematically retrieved relevant studies using PubMed/MEDLINE, POPLINE, HINARI, Science Direct, Cochrane Library databases, and Google Scholar from July 1, 2023 to August 08, 2023. We included observational studies that reported the prevalence of bacterial contamination of mobile phones among healthcare workers. The DerSimonian-random Laird's effect model was used to calculate effect estimates for the pooled prevalence of bacterial contamination in mobile phones and a 95% confidence interval (CI). RESULTS Among 4544 retrieved studies, 26 eligible articles with a total sample size of 2,887 study participants were included in the meta-analysis. The pooled prevalence of mobile phone bacterial contamination among healthcare workers was 84.5% (95% CI 81.7, 87.4%; I2 = 97.9%, p value < 0.001). The most dominant type of bacteria isolated in this review was coagulase-negative staphylococci (CONS) which accounted for 44.0% of the pooled contamination rate of mobile phones used by healthcare workers, followed by Staphylococcus aureus (31.3%), and Escherichia coli (10.7%). CONCLUSIONS In this review, the contamination of mobile phones used by HCWs with various bacterial isolates was shown to be considerable. The most prevalent bacteria isolates were coagulase-negative staphylococci, Staphylococcus aurous, and Escherichia coli. The prevalence of bacterial contamination in mobile phones varies by country and sub-region. Hence, healthcare planners and policymakers should establish norms to manage healthcare workers' hand hygiene and disinfection after using mobile phones.
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Affiliation(s)
- Demisu Zenbaba
- Department of Public Health, School of Health Sciences, Madda Walabu University, P.O. Box 76, Goba, Ethiopia.
| | - Biniyam Sahiledengle
- Department of Public Health, School of Health Sciences, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Girma Beressa
- Department of Public Health, School of Health Sciences, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Fikreab Desta
- Department of Public Health, School of Health Sciences, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Zinash Teferu
- Department of Public Health, School of Health Sciences, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Fikadu Nugusu
- Department of Public Health, School of Health Sciences, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Daniel Atlaw
- Anatomy Unit, School of Medicine, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Zerihun Shiferaw
- Anatomy Unit, School of Medicine, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Bereket Gezahegn
- Anatomy Unit, School of Medicine, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Ayele Mamo
- Departments of Pharmacy, School of Medicine, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Tesfaye Desalegn
- Departments of Pharmacy, School of Medicine, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Wogene Negash
- Department of Nursing, School of Health Sciences, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Getahun Negash
- Department of Medical Laboratory, School of Health Sciences, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Mohammedaman Mama
- Department of Medical Laboratory, School of Health Sciences, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Eshetu Nigussie
- Department of Medical Laboratory, School of Health Sciences, Madda Walabu University, P.O. Box 76, Goba, Ethiopia
| | - Vijay Kumar Chattu
- Center for Transdisciplinary Research, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, 600077, India
- Department of Community Medicine, Faculty of Medicine, Datta Meghe Institute of Medical Sciences, Wardha, 442107, India
- Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Maurici M, Pica F, D'Alò GL, Cicciarella Modica D, Distefano A, Gorjao M, Simonelli MS, Serafinelli L, De Filippis P. Bacterial Contamination of Healthcare Students' Mobile Phones: Impact of Specific Absorption Rate (SAR), Users' Demographics and Device Characteristics on Bacterial Load. Life (Basel) 2023; 13:1349. [PMID: 37374131 DOI: 10.3390/life13061349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
We quantitatively and qualitatively evaluated the bacterial contamination of mobile phones (MPs) in relation to users' demographics, habits, and device characteristics by administering questionnaires to 83 healthcare university students and sampling their MPs by following a cross-sectional design. The heterotrophic plate count (HPC) at 22 °C (HPC 22 °C) and 37 °C (HPC 37 °C), Enterococci, Gram-negative bacteria, and Staphylococci were evaluated. Higher bacterial loads were detected for HPC 37 °C and Staphylococci (416 and 442 CFU/dm2, respectively), followed by HPC 22 °C, Enterococci, and Gram-negative bacteria; the vast majority of samples were positive for HPC 37 °C, HPC 22 °C, and Staphylococci (98%), while Enterococci (66%) and Gram-negative bacteria (17%) were detected less frequently. A statistically significant positive correlation (r = 0.262, p < 0.02) was found between the European head specific absorption rate (SAR) and both HPC 37 °C and Staphylococci; Enterococci showed a strong, significant correlation with HPC 37 °C, HPC 22 °C, and Gram-negative bacteria (r = 0.633, 0.684, 0.884) and a moderate significant correlation with Staphylococci (r = 0.390). Significant differences were found between HPC 22 °C and the type of internship attendance, with higher loads for Medicine. Students with a daily internship attendance had higher HPC 22 °C levels than those attending <6 days/week. Our study showed that bacteria can survive on surfaces for long periods, depending on the user's habits and the device's characteristics.
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Affiliation(s)
- Massimo Maurici
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Francesca Pica
- Department of Experimental Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Gian Loreto D'Alò
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy
- District 6, Local Health Authority Roma 2, 00100 Rome, Italy
| | | | - Alessandra Distefano
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Margarida Gorjao
- School of Hygiene and Preventive Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Maria Sofia Simonelli
- School of Hygiene and Preventive Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Livio Serafinelli
- School of Hygiene and Preventive Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Patrizia De Filippis
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy
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Suolaniemi J, Autio T, Heikkinen J, Räsänen K. Knowledge, Attitudes, and Practices of Finnish Dairy Farmers on Cryptosporidiosis. J Agromedicine 2023; 28:288-299. [PMID: 35993159 DOI: 10.1080/1059924x.2022.2112417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Calf-mediated zoonotic cryptosporidiosis is an emerging occupational health risk among Finnish dairy farmers. We studied farmers' knowledge, attitudes, and practices (KAP) regarding cryptosporidiosis to reveal possible weaknesses, which might increase the risk of zoonotic infection. KAP study was carried out as a cross-sectional questionnaire survey (n = 243). A total of 400 cryptosporidiosis-negative and 138 cryptosporidiosis-positive dairy farms, with more than 50 cows, were invited to participate in the study. The response rate was 45%. Half (49%) of the respondents had adequate knowledge concerning zoonotic cryptosporidiosis. Knowledge score was associated with age (p < 0.01), level of education (p < 0.01), and cryptosporidiosis status of the farm (p < 0.01). Though most respondents had favorable attitudes, one-third (32.5%) had poor zoonotic transmission prevention practices. Use of a personal mobile device was the most common risky practice (90%) performed daily in the cowhouse. Most respondents (93%) reported gaining information about infectious diseases in animals from more than two information sources. Veterinarians were the most mentioned source (n = 228), whereas primary care physicians were among the least common sources (n = 16). Having favorable attitudes towards the prevention of zoonotic cryptosporidiosis was common. However, shortages in knowledge and several risky practices were identified in both cryptosporidiosis positive and negative farms. The role of the occupational health sector should be strengthened in work-related zoonotic disease prevention and may require further education of the personnel. A one-health approach to control zoonotic diseases is recommended.
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Affiliation(s)
- J Suolaniemi
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - T Autio
- Veterinary Bacteriology and Pathology, Research and Laboratory Department, Finnish Food Authority, Kuopio, Finland
| | - J Heikkinen
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - K Räsänen
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Potentially Virulent Multi-Drug Resistant Escherichia fergusonii Isolated from Inanimate Surface in a Medical University: Omphisa fuscidentalis as an Alternative for Bacterial Virulence Determination. Diagnostics (Basel) 2023; 13:diagnostics13020279. [PMID: 36673089 PMCID: PMC9858318 DOI: 10.3390/diagnostics13020279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/29/2022] [Accepted: 01/01/2023] [Indexed: 01/14/2023] Open
Abstract
Multi-drug resistant (MDR) bacteria are becoming a worldwide problem due to limited options for treatment. Moreover, patients infected by MDR with highly virulent accessories are worsening the symptoms, even to the point of causing death. In this study, we isolated bacteria from 14 inanimate surfaces that could potentially be reservoirs for the spread of bacterial infections in the medical university. Blood agar media was used for bacterial isolation. The bacterial colony that showed hemolytic activities on each surface was tested for antimicrobial susceptibility against eight different antibiotics. We found that MDR bacterium, namely TB1, which was isolated from a toilet bowl, was non-susceptible to ampicillin, imipenem, chloramphenicol, amoxicillin-clavulanic acid, gentamicin, and tetracycline. Another MDR bacterium isolated from the mobile phone screen of security officers, namely HSO, was resistant to chloramphenicol, gentamicin, tetracycline, and cefixime. An in vivo virulence test of bacterial isolates used Omphisa fuscidentalis larvae as an alternative to Galleria mellonella larvae for the infection model. A virulence test of TB1 in O. fuscidentalis larvae revealed 20% survival in the bacterial density of 104 and 105 CFU/larvae; and 0% survival in the bacterial density of 106 CFU/larvae at 24 h after injection. Bacterial identification was performed for TB1 as a potential virulent isolate. Bacterial identification using partial 16s rRNA gene showed that TB1 exhibited 99.84% identity to Escherichia fergusonii 2611. This study concludes that TB1 is a potentially virulent MDR E. fergusonii isolated from toilet bowls at a medical university.
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Yao N, Yang XF, Zhu B, Liao CY, He YM, Du J, Liu N, Zhou CB. Bacterial Colonization on Healthcare Workers' Mobile Phones and Hands in Municipal Hospitals of Chongqing, China: Cross-contamination and Associated Factors. J Epidemiol Glob Health 2022; 12:390-399. [PMID: 36070175 PMCID: PMC9449931 DOI: 10.1007/s44197-022-00057-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/28/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Mobile phones are widely used in clinical settings and could be colonized by potential pathogenic bacteria which may lead to hospital-acquired infections (HAIs) transmission. This study aimed to determine the prevalence of bacterial contamination of healthcare workers' (HCWs) mobile phones, identify bacterial isolates, and assess the factors associated with mobile phone contamination. METHODS Self-administered questionnaire was used to collect the information on the demographic characteristics and the use of mobile phones. A total of 111 HCWs' hands and their mobile phones were swabbed, then bacterial culture, isolation, and identification were performed. Univariate and multivariable logistic regression were applied to identify factors associated with mobile phone bacterial contamination. RESULTS Totally 106 (95.5%) of the 111 mobile phones investigated were contaminated with bacteria. Staphylococcus epidermidis (13/111), Acinetobacter baumannii (4/111) and Staphylococcus aureus (3/111) were the predominant bacterial isolates from HCWs' mobile phones. Univariate analyses showed that age, gender, profession and the frequency of mobile phone utilization were significantly associated with the number of bacterial colonization. Frequency of phone utilization (OR 8.366; 95% CI 1.496-46.797) was found to be the most significant factors associated with the qualified rate of mobile phones bacterial load. In addition, phone cover using was associated with the increased risk of mobile phone bacterial contamination. CONCLUSION There was cross-contamination between hands and phones. It is necessary to develop guidelines for mobile phone cleaning. Special attention needs to be paid to the disinfection of mobile phone covers to reduce contamination and transmission of pathogens.
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Affiliation(s)
- Ning Yao
- Division of Expanded Program On Immunization (EPI), Chongqing Center for Disease Control and Prevention, Chongqing, China
| | - Xue-Fan Yang
- Department of Disinfection and Vector Control, Chongqing Center for Disease Control and Prevention, Chongqing, China
| | - Bing Zhu
- Department of Disinfection and Vector Control, Chongqing Center for Disease Control and Prevention, Chongqing, China
| | - Chun-Yan Liao
- Department of Microbiology, Chongqing Center for Disease Control and Prevention, Chongqing, China
| | - Ya-Ming He
- Department of Disinfection and Vector Control, Chongqing Center for Disease Control and Prevention, Chongqing, China
| | - Jiang Du
- Department of Disinfection and Vector Control, Chongqing Center for Disease Control and Prevention, Chongqing, China
| | - Nan Liu
- Department of Disinfection and Vector Control, Chongqing Center for Disease Control and Prevention, Chongqing, China
| | - Chun-Bei Zhou
- Department of Disinfection and Vector Control, Chongqing Center for Disease Control and Prevention, Chongqing, China.
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Hessling M, Haag R, Sicks B. Review of microbial touchscreen contamination for the determination of reasonable ultraviolet disinfection doses. GMS HYGIENE AND INFECTION CONTROL 2021; 16:Doc30. [PMID: 34956822 PMCID: PMC8662742 DOI: 10.3205/dgkh000401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: Touchscreens are usually microbially contaminated and can therefore act as fomites inside and outside healthcare environments. Due to the increasing use of such touchscreens and the growing awareness of infection risks, approaches that allow safe and automatic disinfection are desired. Ultraviolet (UV) irradiation, with its known antimicrobial efficacy, could achieve this goal, but should be executed with limited touchscreen degradation, disinfection duration, and energy consumption. It should also pose as little harm as possible to humans even in case of failure. Materials and methods: A literature search was performed first to identify the microorganisms most commonly found on touchscreens. Then, the 90% reduction doses (D90 doses) for the different relevant microorganisms and UV spectral ranges were determined from the literature, and irradiation doses are suggested that should reduce most of these important microorganisms by 5 log-levels. Results: The most frequent microorganisms are staphylococci, bacilli, micrococci, enterococci, pseudomonads and E. coli with small differences between hospital and community environments, if antibiotic resistance properties are ignored. The determined irradiation doses for a 5 log-reduction of the most frequent microorganisms are about 40 mJ/cm2, 80 J/cm2, 500 J/cm2 and 50 mJ/cm2 for the UV spectral ranges UVC, UVB, UVA and far-UVC, respectively. These doses are also sufficient to inactivate all nosocomial ESKAPE pathogens on touchscreens by at least 99.999%. Conclusion: Disinfection is achievable in all UV spectral ranges, with UVC being the most effective, enabling automatic disinfection within a minute or less. The much higher doses required in the UVB and UVA spectral range result in much longer disinfection durations, with the advantage of a reduced risk to humans. For all kinds of UV irradiation, the doses should be limited to reasonable values to avoid irradiating an already more or less sterile surface and to prevent degradation of touchscreen devices.
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Affiliation(s)
- Martin Hessling
- Ulm University of Applied Sciences, Institute of Medical Engineering and Mechatronics, Ulm, Germany
| | - Robin Haag
- Ulm University of Applied Sciences, Institute of Medical Engineering and Mechatronics, Ulm, Germany
| | - Ben Sicks
- Ulm University of Applied Sciences, Institute of Medical Engineering and Mechatronics, Ulm, Germany
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Araya S, Desta K, Woldeamanuel Y. Extended-Spectrum Beta-Lactamase-Producing Gram-Negative Bacteria on Healthcare Workers' Mobile Phones: Evidence from Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. Risk Manag Healthc Policy 2021; 14:283-291. [PMID: 33531847 PMCID: PMC7847411 DOI: 10.2147/rmhp.s291876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background Mobile phones are widely used in hospital settings for different purposes. Mobile phones of healthcare workers (HCWs) could be colonized or harbor extended-spectrum beta-lactamase (ESBL) producing gram-negative bacteria and may act as source of infectious agents. The aim of this study was to determine the rate of extended-spectrum beta-lactamase-producing Gram-negative bacteria on mobile phones of healthcare workers, to assess their antimicrobial susceptibility patterns and associated factors. Methods A laboratory-based cross-sectional study was conducted involving a total of 572 samples by rubbing swabs of the front screen, back, keypad, and metallic surfaces of mobile phones of healthcare workers using simple random sampling technique. All specimens were screened for ESBL using ESBL CHROME agar and confirmed using double-disk diffusion test (DDDT). Antibiotic susceptibility testing was done by the Kirby–Bauer disk diffusion technique on Mueller–Hinton agar. Data were analyzed using SPSS version 25, odds ratio and p-value was calculated to determine the association among variables. Results Overall, the number of mobile phones contaminated by gram-negative bacteria was 454 out of 572 (79.4%). Female sex (OR 0.651, p-value=0.039) and service year (OR 0.468, p-value=0.038) of healthcare workers were found to be the most significant factors associated with healthcare professionals’ mobile phone and bacterial contamination. Nine percent of the isolates were ESBL-producers. K. pneumoniae (27%) was the dominant ESBL-producing isolate followed by Acinetobacter spp. (14.5%) and E.coli (14.5%). ESBL-producers were highly resistant to ampicillin (95.8%), piperacillin (83.3%), cotrimoxazole (70.8%), and chloramphenicol (54.2%), but highly sensitive to meropenem (87.5%), amikacin (85.4%), and piperacillin-tazobactam (81.2%). Conclusion ESBL-producing Gram-negative bacteria were isolated from 8.3% of HCWs’ mobile phones. As high as 79.4% of the isolates were multidrug resistant. Mobile phones can lead to bacterial cross-contamination and could be a source of nosocomial infections.
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Affiliation(s)
- Shambel Araya
- Department of Medical Laboratory Sciences, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kassu Desta
- Department of Medical Laboratory Sciences, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yimtubezinash Woldeamanuel
- Department of Medical Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Robinson JM, Pasternak Z, Mason CE, Elhaik E. Forensic Applications of Microbiomics: A Review. Front Microbiol 2021; 11:608101. [PMID: 33519756 PMCID: PMC7838326 DOI: 10.3389/fmicb.2020.608101] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/14/2020] [Indexed: 01/04/2023] Open
Abstract
The rise of microbiomics and metagenomics has been driven by advances in genomic sequencing technology, improved microbial sampling methods, and fast-evolving approaches in bioinformatics. Humans are a host to diverse microbial communities in and on their bodies, which continuously interact with and alter the surrounding environments. Since information relating to these interactions can be extracted by analyzing human and environmental microbial profiles, they have the potential to be relevant to forensics. In this review, we analyzed over 100 papers describing forensic microbiome applications with emphasis on geolocation, personal identification, trace evidence, manner and cause of death, and inference of the postmortem interval (PMI). We found that although the field is in its infancy, utilizing microbiome and metagenome signatures has the potential to enhance the forensic toolkit. However, many of the studies suffer from limited sample sizes and model accuracies, and unrealistic environmental settings, leaving the full potential of microbiomics to forensics unexplored. It is unlikely that the information that can currently be elucidated from microbiomics can be used by law enforcement. Nonetheless, the research to overcome these challenges is ongoing, and it is foreseeable that microbiome-based evidence could contribute to forensic investigations in the future.
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Affiliation(s)
- Jake M Robinson
- Department of Landscape, University of Sheffield, Sheffield, United Kingdom.,Healthy Urban Microbiome Initiative (HUMI), Adelaide, SA, Australia
| | - Zohar Pasternak
- Quality Assurance and Evidence Unit, Division of Identification and Forensic Science (DIFS), National Headquarters of the Israel Police, Jerusalem, Israel
| | - Christopher E Mason
- Department of Physiology and Biophysics, Weill Cornell Medicine, New York, NY, United States.,The HRH Prince Alwaleed Bin Talal Bin Abdulaziz Alsaud Institute for Computational Biomedicine, Weill Cornell Medicine, New York, NY, United States.,The WorldQuant Initiative for Quantitative Prediction, Weill Cornell Medicine, New York, NY, United States
| | - Eran Elhaik
- Department of Biology, Lund University, Lund, Sweden
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Cicciarella Modica D, Maurici M, D’Alò GL, Mozzetti C, Messina A, Distefano A, Pica F, De Filippis P. Taking Screenshots of the Invisible: A Study on Bacterial Contamination of Mobile Phones from University Students of Healthcare Professions in Rome, Italy. Microorganisms 2020; 8:microorganisms8071075. [PMID: 32707676 PMCID: PMC7409191 DOI: 10.3390/microorganisms8071075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 01/07/2023] Open
Abstract
Mobile phones (MPs) are commonly used both in the personal and professional life. We assessed microbiological contamination of MPs from 108 students in healthcare professions (HPs), in relation to their demographic characteristics and MPs handling habits, collected by means of a questionnaire. Cultural and biochemical tests were performed, and statistical analyses were carried out. Staphylococci were present in 85% of MPs, Enterococci in 37%, Coliforms in 6.5%; E. coli was never detected. Staphylococcus epidermidis was the most frequently isolated staphylococcal species (72% of MPs), followed by S. capitis (14%), S. saprophyticus, S. warneri, S. xylosus (6%), and by S. aureus (4%). Heterotrophic Plate Counts (HPC) at 37 °C, ranged from 0 to 1.2 × 104 CFU/dm2 (mean = 362 CFU/dm2). In univariate analysis, the male gender only was significantly associated with higher HPCs and enterococcal contamination. Multiple linear regression models explained only 17% and 16% of the HPC 37 °C and staphylococcal load variability, respectively. Developing specific guidelines for a hygienic use of MPs in clinical settings, for preventing cross-infection risks, is advisable, as well as introducing specific training programs to HP students. MPs decontamination procedures could also be implemented in the community.
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Affiliation(s)
| | - Massimo Maurici
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy; (C.M.); (A.M.); (A.D.); (P.D.F.)
- Correspondence: (M.M.); (G.L.D.); Tel.: +39-327-8218-514 (G.L.D.)
| | - Gian Loreto D’Alò
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy; (C.M.); (A.M.); (A.D.); (P.D.F.)
- Department of Epidemiology, Lazio Regional Health Service, 00154 Rome, Italy
- Correspondence: (M.M.); (G.L.D.); Tel.: +39-327-8218-514 (G.L.D.)
| | - Cinzia Mozzetti
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy; (C.M.); (A.M.); (A.D.); (P.D.F.)
| | - Alessandra Messina
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy; (C.M.); (A.M.); (A.D.); (P.D.F.)
| | - Alessandra Distefano
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy; (C.M.); (A.M.); (A.D.); (P.D.F.)
| | - Francesca Pica
- Department of Experimental Medicine, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Patrizia De Filippis
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy; (C.M.); (A.M.); (A.D.); (P.D.F.)
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11
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Qureshi NQ, Mufarrih SH, Irfan S, Rashid RH, Zubairi AJ, Sadruddin A, Ahmed I, Noordin S. Mobile phones in the orthopedic operating room: Microbial colonization and antimicrobial resistance. World J Orthop 2020; 11:252-264. [PMID: 32477902 PMCID: PMC7243480 DOI: 10.5312/wjo.v11.i5.252] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/01/2020] [Accepted: 04/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Surgical site infections are a major cause of morbidity and mortality following orthopedic surgery. Recent efforts to identify sources of contamination in the operating rooms have implicated mobile phones. AIM To investigate microbial colonization on the mobile phones of health care professionals in the orthopedic operating room. METHODS We conducted a cross-sectional study involving culture and sensitivity analysis of swabs taken from the mobile phones of orthopedic and anesthesia attendings, residents, technicians and nurses working in the orthopedic operating rooms over a period of two months. Demographic and cell phone related factors were recorded using a questionnaire and the factors associated with contamination were analyzed. RESULTS Ninety-three of 100 mobile phones were contaminated. Species isolated were Coagulase-negative Staphylococcus (62%), Micrococcus (41%) and Bacillus (26%). The risk of contamination was increased with mobile covers and cracked screens and decreased by cell phone cleaning. CONCLUSION Mobile phones belonging to health care workers are frequently contaminated with pathogenic bacteria with the potential of transferring drug resistance to nosocomial pathogens. Studies investigating the relationship to surgical site infections need to be conducted. The concept of "mobile hygiene" involving the change of mobile covers, replacement of cracked screens or even wiping the phone with an alcohol swab could yield the cost-effective balance that contaminated cell phones deserve until they are established as a direct cause of surgical site infections.
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Affiliation(s)
- Nada Qaisar Qureshi
- Department of Medicine, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Syed Hamza Mufarrih
- Department of Basic and Biomedical Sciences, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Seema Irfan
- Department of Pathology and Microbiology, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Rizwan Haroon Rashid
- Department of Orthopedic Surgery, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Akbar Jaleel Zubairi
- Department of Orthopedic Surgery, Combined Military Hospital, Rawalpindi 46000, Pakistan
| | - Anum Sadruddin
- Department of Orthopedic Surgery, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Israr Ahmed
- Department of Pathology and Microbiology, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Shahryar Noordin
- Department of Orthopedic Surgery, Aga Khan University Hospital, Karachi 74800, Pakistan
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12
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Olsen M, Campos M, Lohning A, Jones P, Legget J, Bannach-Brown A, McKirdy S, Alghafri R, Tajouri L. Mobile phones represent a pathway for microbial transmission: A scoping review. Travel Med Infect Dis 2020; 35:101704. [PMID: 32360322 PMCID: PMC7187827 DOI: 10.1016/j.tmaid.2020.101704] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Mobile phones have become an integral part of modern society. As possible breeding grounds for microbial organisms, these constitute a potential global public health risk for microbial transmission. OBJECTIVE Scoping review of literature examining microbial's presence on mobile phones in both health care (HC) and community settings. METHODS A search (PubMed&GoogleScholar) was conducted from January 2005-December 2019 to identify English language studies. Studies were included if samples from mobile phones were tested for bacteria, fungi, and/or viruses; and if the sampling was carried out in any HC setting, and/or within the general community. Any other studies exploring mobile phones that did not identify specific microorganisms were excluded. RESULTS A total of 56 studies were included (from 24 countries). Most studies identified the presence of bacteria (54/56), while 16 studies reported the presence of fungi. One study focused solely on RNA viruses. Staphylococcus aureus, and Coagulase-Negative Staphylococci were the most numerous identified organisms present on mobile phones. These two species and Escherichia coli were present in over a third of studies both in HC and community samples. Methicillin-resistant S. aureus, Acinetobacter sp., and Bacillus sp. were present in over a third of the studies in HC settings. CONCLUSIONS While this scoping review of literature regarding microbial identification on mobile phones in HC and community settings did not directly address the issue of SARS-CoV-2 responsible for COVID-19, this work exposes the possible role of mobile phones as a 'Trojan horse' contributing to the transmission of microbial infections in epidemics and pandemics.
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Affiliation(s)
- Matthew Olsen
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Mariana Campos
- Harry Butler Institute, Murdoch University, Murdoch, WA, 6150, Australia
| | - Anna Lohning
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Peter Jones
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - John Legget
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | | | - Simon McKirdy
- Harry Butler Institute, Murdoch University, Murdoch, WA, 6150, Australia
| | - Rashed Alghafri
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia; Dubai Police, Dubai, United Arab Emirates; Dubai Police Scientists Council, Dubai Police, Dubai, United Arab Emirates; Dubai Future Council on Community Security, Dubai, United Arab Emirates
| | - Lotti Tajouri
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia; Dubai Police Scientists Council, Dubai Police, Dubai, United Arab Emirates; Dubai Future Council on Community Security, Dubai, United Arab Emirates.
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13
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Sailo CV, Pandey P, Mukherjee S, Zami Z, Lalremruata R, Nemi L, Kumar NS. Pathogenic microbes contaminating mobile phones in hospital environment in Northeast India: incidence and antibiotic resistance. Trop Med Health 2019; 47:59. [PMID: 31889887 PMCID: PMC6905087 DOI: 10.1186/s41182-019-0190-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/02/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The present study attempts to identify and determine the pattern of drug susceptibility of the microorganisms present in mobile phones of health care workers (HCWs) and non-HCWs in a hospital environment. Mobile phones of 100 participants including both genders were randomly swabbed from nine different wards/units and the bacterial cultures were characterized using VITEK 2 system. RESULTS Forty-seven mobile phones were culture positive and a total of 57 isolates were obtained which consisted of 28 Gram-positive organisms and 29 Gram-negative organisms. The predominating organisms were Acinetobacter baumannii and Staphylococcus hominis. Among all the isolates from the mobile phones of HCW and non-HCWs, five isolates had ESBL and three isolates had colistin resistance. Incidentally, MRSA was not found on the mobile phones tested. The isolated organisms showed 100% susceptibility to linezolid, daptomycin, vancomycin, imipenem, meropenem, gentamicin, amikacin, ciprofloxacin and tigecycline, while high resistance was shown against benzylpenicillin (75.0%), cefuroxime and cefuroxime axetil (56.5%). Non-HCWs' mobile phones were more contaminated as compared to HCWs (P = 0.001) and irrespective of individuals' gender or toilet habits, both Gram-positive and Gram-negative organisms were present on the mobile phones. CONCLUSION This study reports for the first time that the mobile phones of non-health care workers harbour more bacterial diversity and are more prone to cause transmission of pathogens. This study can serve to educate the public on personal hand hygiene practices and on maintaining clean mobile phones through antiseptic measures.
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Affiliation(s)
| | - Puja Pandey
- 0000 0000 9217 3865grid.411813.eDepartment of Biotechnology, Mizoram University, Aizawl, Mizoram 796004 India
| | - Subhajit Mukherjee
- 0000 0000 9217 3865grid.411813.eDepartment of Biotechnology, Mizoram University, Aizawl, Mizoram 796004 India
| | - Zothan Zami
- 0000 0000 9217 3865grid.411813.eDepartment of Biotechnology, Mizoram University, Aizawl, Mizoram 796004 India
| | - Ralte Lalremruata
- grid.460962.fDepartment of Microbiology, Synod Hospital, Durtlang, Aizawl, Mizoram 796025 India
| | - Lalnun Nemi
- grid.460962.fDepartment of Pathology, Synod Hospital, Durtlang, Aizawl, Mizoram 796025 India
| | - Nachimuthu Senthil Kumar
- 0000 0000 9217 3865grid.411813.eDepartment of Biotechnology, Mizoram University, Aizawl, Mizoram 796004 India
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14
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Parthasarathy A, Wong NH, Weiss AN, Tian S, Ali SE, Cavanaugh NT, Chinsky TM, Cramer CE, Gupta A, Jha R, Johnson LK, Tuason ED, Klafehn LM, Krishnadas V, Musich RJ, Pfaff JM, Richman SC, Shumway AJ, Hudson AO. SELfies and CELLfies: Whole Genome Sequencing and Annotation of Five Antibiotic Resistant Bacteria Isolated from the Surfaces of Smartphones, An Inquiry Based Laboratory Exercise in a Genomics Undergraduate Course at the Rochester Institute of Technology. J Genomics 2019; 7:26-30. [PMID: 30820259 PMCID: PMC6389494 DOI: 10.7150/jgen.31911] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/05/2019] [Indexed: 01/06/2023] Open
Abstract
Are touchscreen devices a public health risk for the transmission of pathogenic bacteria, especially those that are resistant to antibiotics? To investigate this, we embarked on a project aimed at isolating and identifying bacteria that are resistant to antibiotics from the screens of smartphones. Touchscreen devices have become ubiquitous in society, and it is important to evaluate the potential risks they pose towards public health, especially as it pertains to the harboring and transmission of pathogenic bacteria that are resistant to antibiotics. Sixteen bacteria were initially isolated of which five were unique (four Staphylococcus species and one Micrococcus species). The genomes of the five unique isolates were subsequently sequenced and annotated. The genomes were analyzed using in silico tools to predict the synthesis of antibiotics and secondary metabolites using the antibiotics and Secondary Metabolite Analysis SHell (antiSMASH) tool in addition to the presence of gene clusters that denote resistance to antibiotics using the Resistance Gene Identifier (RGI) tool. In vivo analysis was also done to assess resistance/susceptibility to four antibiotics that are commonly used in a research laboratory setting. The data presented in this manuscript is the result of a semester-long inquiry based laboratory exercise in the genomics course (BIOL340) in the Thomas H. Gosnell School of Life Sciences/College of Science at the Rochester Institute of Technology.
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Affiliation(s)
- Anutthaman Parthasarathy
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Narayan H Wong
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Amanda N Weiss
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Susan Tian
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Sara E Ali
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Nicole T Cavanaugh
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Tyler M Chinsky
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Chelsea E Cramer
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Aditya Gupta
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Rakshanda Jha
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Loryn K Johnson
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Elizabeth D Tuason
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Lauren M Klafehn
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Varada Krishnadas
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Ryan J Musich
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Jennifer M Pfaff
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Spencer C Richman
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - Alexandria J Shumway
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
| | - André O Hudson
- The Thomas H. Gosnell School of Life Sciences, Rochester Institute of Technology, Rochester NY, USA
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15
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Koscova J, Hurnikova Z, Pistl J. Degree of Bacterial Contamination of Mobile Phone and Computer Keyboard Surfaces and Efficacy of Disinfection with Chlorhexidine Digluconate and Triclosan to Its Reduction. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E2238. [PMID: 30322055 PMCID: PMC6210060 DOI: 10.3390/ijerph15102238] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 09/14/2018] [Accepted: 09/26/2018] [Indexed: 11/16/2022]
Abstract
The main aim of our study was to verify the effectiveness of simple disinfection using wet wipes for reduction of microbial contamination of mobile phones and computer keyboards. Bacteriological swabs were taken before and after disinfection with disinfectant wipes with active ingredients chlorhexidine digluconate and triclosan. The incidence and type of microorganisms isolated before and after disinfection was evaluated; the difference was expressed as percentage of contamination reduction. Our results confirmed the high degree of surface contamination with bacteria, some of which are opportunistic pathogens for humans. Before the process of disinfection, on both surfaces, mobile phones, and computer keyboards, the common skin commensal bacteria like coagulase-negative staphylococci were diagnosed most frequently. On the keyboards, species of the genus Bacillus and representatives of the family Enterobacteriaceae were abundant. The potentially pathogenic species were represented by Staphylococcus aureus. Cultivation of swabs performed 5 min after disinfection and subsequent calculation of the reduction of contamination have shown that simple wiping with antibacterial wet wipe led to a significant reduction of microbial contamination of surfaces, with effect ranging from 36.8 to 100%.
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Affiliation(s)
- Jana Koscova
- Department of Microbiology and Immunology, Institute of Microbiology and Gnotobiology, University of Veterinary Medicine and Pharmacy in Košice, Komenského 73, 041 81 Košice, Slovakia.
| | - Zuzana Hurnikova
- Institute of Parasitology, Slovak Academy of Sciences, Hlinkova 3, 040 01 Košice, Slovakia.
| | - Juraj Pistl
- Department of Microbiology and Immunology, Institute of Microbiology and Gnotobiology, University of Veterinary Medicine and Pharmacy in Košice, Komenského 73, 041 81 Košice, Slovakia.
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16
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Bacteriological Evaluation of Hand Contact Surfaces at Bus Terminals in Uyo Metropolis. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2018. [DOI: 10.22207/jpam.12.3.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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17
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Hygienemaßnahmen zur Prävention der Infektion durch Enterokokken mit speziellen Antibiotikaresistenzen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:1310-1361. [DOI: 10.1007/s00103-018-2811-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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18
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Graveto JM, Costa PJ, Santos CI. CELL PHONE USAGE BY HEALTH PERSONNEL: PREVENTIVE STRATEGIES TO DECREASE RISK OF CROSS INFECTION IN CLINICAL CONTEXT. ACTA ACUST UNITED AC 2018. [DOI: 10.1590/0104-07072018005140016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Paulo Jorge Costa
- Barking, Havering and Redbridge University Hospitals Trust, United Kingdom
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