Healthcare-acquired clusters of COVID-19 across multiple wards in a Scottish health board.

BACKGROUND: Healthcare-acquired COVID-19 has been an additional burden on hospitals managing increasing numbers of patients with SARS-CoV-2. One acute hospital (W) among three in a Scottish healthboard experienced an unexpected surge of COVID-19 clusters. AIM: To investigate possible causes of COVID-19 clusters at Hospital W. METHODS: Daily surveillance provided total numbers of patients and staff involved in clusters in three acute hospitals (H, M and W) and care homes across the healthboard. All clusters were investigated and documented, along with patient boarding, community infection rates and outdoor temperatures from October 2020 to March 2021. Selected SARS-CoV-2 strains were genotyped. FINDINGS: There were 19 COVID-19 clusters on 14 wards at Hospital W during the six-month study period, lasting from two to 42 days (average, five days; median, 14 days) and involving an average of nine patients (range 1-24) and seven staff (range 0-17). COVID-19 clusters in Hospitals H and M reflected community infection rates. An outbreak management team implemented a control package including daily surveillance; ward closures; universal masking; screening; restricting staff and patient movement; enhanced cleaning; and improved ventilation. Forty clusters occurred across all three hospitals before a January window-opening policy, after which there were three during the remainder of the study. CONCLUSION: The winter surge of COVID-19 clusters was multi-factorial, but clearly exacerbated by moving trauma patients around the hospital. An extended infection prevention and control package including enhanced natural ventilation helped reduce COVID-19 clusters in acute hospitals.

Surgical site infections linked to contaminated surgical instruments.

BACKGROUND: This study describes an investigation into a sudden increase in surgical site infection rate following 'clean' surgery. The outbreak involved 15 orthopaedic patients following metal insertion, and five ophthalmology patients who developed endophthalmitis. AIM: An outbreak committee was convened in order to find the cause of the sudden increase in surgical infections. METHODS: The investigation included epidemiological and patient analyses, and environmental and clinical audits of wards and theatres. Following reports of contaminated surgical sets, surgical instruments and their packaging were examined using a standardized laboratory protocol. Clinical staff visited the sterilization plant. FINDINGS: Skin flora including coagulase-negative staphylococci (CoNS) and Bacillus spp. were recovered from a range of patient specimens. Eleven patients required further surgical attention. Microbiological processing of surgical packs revealed CoNS and Bacillus spp. from inner packaging as well as from instruments themselves. Inspection of the sterilization plant highlighted inadequate maintenance of autoclave components and poor handling practices by staff. This was compounded by lapses in inspection of surgical sets by theatre staff. Cases terminated following a review of operator training, supervision and staffing at the sterilization plant, in conjunction with formal inspection and reporting of damp/stained sets by theatre staff. CONCLUSIONS: Post-sterilization contamination of sets containing surgical instruments was linked with an increased rate of deep surgical site infections in orthopaedic and ophthalmic patients. The investigation demonstrates the importance of close collaboration and co-operation between sterile services providers, managers and clinical staff and offers guidance for reducing the risk of contaminated sterile surgical instruments.

Home-care programmes for older adults with disabilities in Canada: how can we assess the adequacy of services provided compared with the needs of users?

The need for home care will probably continue to increase over the next decade as one response to innovative health practices designed to help people receive services at home instead of in institutions. However, there are no data for determining whether home-care programmes can meet user needs. The objectives of the present study were to describe the functional autonomy profile of the users of public home-care programmes in Québec, Canada, and to compare the level of adequacy between required and provided services in public home-care programmes for older adults with disabilities. This study was based on a cross-sectional design from September to December 2002. The population studied consisted of all users of public home-care services in one administrative region in the province of Québec over this 3-month period. Each user was assessed with the Functional Autonomy Measurement System (SMAF) and then classified into one of the 14 Iso-SMAF profiles. The total number of hours of care required was determined using the median number of hours of nursing care, personal care and support services associated with each profile. For the sake of comparison with the services required, the services provided were calculated from an administrative databank that included statistics of the time spent by health professionals on caring for home-care users. The ratio of hours of services provided to the number of hours of services required by home-care users highlights a discrepancy between the services provided and user needs. The results of this study show the feasibility of describing users of public home-care programmes and the adequacy of services provided in relation to user needs. Based on these results, public home-care programmes in the province of Québec appear to be under-funded.

Nutrition risk factors for institutionalization in a free-living functionally dependent elderly population.

Risk factors for institutionalization of frail elderly have been studied but the role of nutritional status has not been addressed. A prospective cohort of 288 frail elderly (81 male; 207 female; mean age: 78.2 +/- 7.6 years) were recruited from the current list of those receiving home help services and followed for 3-5 years. At baseline, height, weight, and arm muscle circumference were measured. Self-reported weight loss prior to baseline, energy, and protein intake were recorded. Covariates included sociodemographic factors, social network variables, functional and health status. Cox's multivariate survival analysis was used to identify independent predictors of institutionalization. Over the period of observation, 46% of subjects were institutionalized. Univariate predictors included weight loss >/=5 kg, functional status, and not living alone. In multivariate analysis, weight loss significantly increased the likelihood of institutionalization [Hazard Ratio (HR) = 1.71 (95% CI: 1.08-2.73)] as did limited functional capacities [HR = 1.26 (95% CI: 1.02-1.55)]. Among the free-living frail elderly, weight loss >/=5 kg is an important predictor of early institutionalization after controlling for social network, health, and functional status.

Weight loss and mortality among free-living frail elders: a prospective study.

BACKGROUND: Numerous studies of the elderly population have indicated that body weight and weight changes are related to mortality, but the one group at particularly high risk of nutritional inadequacies--frail elders receiving home help services--has not been studied. METHODS: A prospective cohort of 288 frail elders (81 men; 207 women; mean age: 78.2 +/- 7.6 yrs) receiving home support services was followed for 3-5 years. Nutritional variables included baseline body mass index (BMI), weight loss prior to baseline, and energy and protein intake. Covariates included age, gender, smoking, and health and functional status. Cox's multivariate survival analysis was used to identify independent predictors of mortality. RESULTS: There were 102 deaths (35.4%) over the follow-up period. Univariate predictors included age, sex, BMI, weight loss, and functional status. In multivariate analysis, weight loss at baseline was a significant predictor of mortality, RR = 1.76 (95% CI: 1.15-2.71), as was male gender, RR = 2.71 (95% CI: 1.73-4.24), and age at baseline, RR = 1.40 (95% CI: 1.06-1.86). CONCLUSION: Among free-living frail elders, weight loss is a predictor of early mortality after controlling for smoking, and functional and health status indicators. From our observations, however, we cannot conclude that prevention of weight loss would lead to increased survival. This needs to be explored in an intervention study.

Ability of the Higgins Nutrition Intervention Program to improve adolescent pregnancy outcome.

OBJECTIVES: To determine the extent to which birth weight can be increased and the risk for adverse pregnancy outcome decreased when pregnant adolescents participated in the Higgins Nutrition Intervention Program; and to describe the dietary components of the program, including their variation as a function of diagnosed risk for adverse pregnancy outcome. DESIGN: Retrospective cohort study involving review of medical charts. SUBJECTS/SETTING: Developed as an adjunct to routine prenatal care, the Higgins Nutrition Intervention Program consists of an assessment of each pregnant adolescent's risk profile for adverse pregnancy outcomes and an individualized nutritional rehabilitation program based on that profile. The intervention group for this evaluation consisted of 1,203 pregnant adolescents who participated in the Higgins program at the Montreal Diet Dispensary between 1981 and 1991. The nonintervention group consisted of a randomly selected group of 1,203 pregnant adolescents known not to have participated in the program. OUTCOMES MEASURED: Birth weight; rates of low birth weight, very low birth weight, preterm delivery, fetal growth retardation, perinatal morbidity and mortality; and maternal morbidity. STATISTICAL ANALYSIS: Means and proportions were used to describe risk profiles and pregnancy outcomes in the two groups. Analysis of covariance and logistic regression were used to compare pregnancy outcomes while controlling for the effect of key confounding variables. RESULTS: Results from multivariable analyses showed that infants in the intervention group weighed an average of 55 g more (P < .05) than infants in the nonintervention group; their low-birth-weight rate was 39% lower (P < .001) and their very-low-birth-weight rate was 56% lower (P < .01). Individually determined dietary prescriptions for the adolescents in the intervention group recommended increases in daily consumption averaging approximately 900 kcal energy and 52 g protein. The lowest daily increases (approximately 150 kcal energy and 2 g protein) were recommended to the group with no diagnosed risks; the greatest increases (approximately 1,300 kcal energy and 76 g protein) were recommended to the group with multiple risk conditions. Although none of the risk/intervention groups achieved their prescribed increases during intervention, increases in actual intake generally followed the pattern of the prescribed increases; that is, the greater the prescribed increase, the greater the actual increase. CONCLUSIONS: These results suggest that the Higgins Nutrition Intervention Program, in which nutrition intervention is individualized as a function of diagnosed risk, significantly improves the outcome of adolescent pregnancy.

Colonization of the oral cavity of mice by an unidentified streptococcus.

While studying the oral bacterial biota of mice, we observed an unidentified streptococcus (TG) that eventually became the dominant species of the oral cavities of all other mice in our animal facility. We found that the strain is indigenous to Jackson Laboratory mice but is absent in animals from Charles River Laboratories. TG was also transmitted from artificially contaminated BALB/c mice to the oral cavities of 4 other mouse strains. Streptococcus sp. TG stimulated the secretory and systemic immune systems of artificially contaminated Charles River BALB/c mice but did not provoke clinical symptoms. The increase in antibody level to TG did not prevent its colonization and persistence in these mice. In mice from Jackson Laboratory, the secretory and systemic immune response to TG was significantly lower. In vitro, Streptococcus sp. TG inhibited murine oral lactobacilli and staphylococci, probably due to the production of hydrogen peroxide.

Topical application of a corticosteroid destabilizes the host-parasite relationship in an experimental model of the oral carrier state of Candida albicans.

Using an experimental model in the mouse we have shown that both local and central lines of defense, involving CD4+ T cells, participate in a dynamic interaction to maintain a long-term carrier state of Candida albicans in the oral cavity. We have tested the impact of a predisposing factor to oral candidiasis in the form of a topical application of a corticosteroid (Topsyn gel) to the oral mucosa for 75 mice twice a day for a 20-day period. Very rapidly after the treatment was initiated, i.e. on day 4, the residual population of Candida increased up to 40-fold and by day 21, the population was 400-fold that of the carrier state. The resident population of intraepithelial CD4+ T cells in the oral mucosa virtually disappeared during the treatment. A topical corticosteroid application also resulted in a massive depletion of T cells in the lymph nodes and in the transient abrogation of the DTH reaction to Candida antigens. On cessation of treatment, normal levels of both Candida and intraepithelial CD4+ T cells were also quickly restored. These results suggest that resistance to superficial invasion by Candida is linked to the presence of an oral mucosal line of defense and that topical application of corticosteroids may dramatically shift the host-parasite relationship in favor of Candida.

Evolution of resident oral bacterial biota in BALB/c mice during pregnancy and lactation.

To assess the influence of pregnancy and lactation on the oral microbial ecology of BALB/c mice, we followed the distribution of the predominant oral bacteria of four groups of these mice during these two periods. Compared with nonpregnant control female mice of the same age maintained under the same conditions, the distribution of the resident oral bacterial species differed significantly only during the lactation period (8-16 days after parturition). This difference could possibly be attributed to hormonal influences and/or grooming habits.

Differential pattern of infection and immune response during experimental oral candidiasis in BALB/c and DBA/2 (H-2d) mice.

We used an experimental model of oral candidiasis in the mouse to investigate the impact of the introduction of Candida albicans into a Candida-free system. We report that 2 strains of mice with the same major histocompatibility complex haplotype (H-2d) display different kinetics of primary oral infection after topical application of the same inoculum. The mucosal reactions in both DBA/2 and BALB/c mice involve a similar recruitment of CD4+ and CD8+ T cells and of MAC-1+ cells in mucosal tissue during the infection. A carrier state is maintained following the resolution of the infection in both strains and is associated with the persistence of intraepithelial CD4+ T cells. However, there is a time-specific recruitment of gamma delta T cells that coincides with a dramatic decrease in viable Candida in the mucosal tissue; this occurs on day 3 in BALB/c mice and on day 6 in DBA/2 mice. The denouement of an oral contact with Candida is also different in the 2 mouse strains, cell-mediated immunity being triggered in DBA/2 mice but not in BALB/c mice. The different kinetics of Candida clearance in BALB/c vs DBA/2 mice may therefore signal a differential priming of T cell subsets whose modalities do not appear to be associated with the H-2 complex.