Lessons learned from a prolonged and costly norovirus outbreak at a Scottish medicine of the elderly hospital: case study.

BACKGROUND: Norovirus outbreaks are a major burden for healthcare facilities globally. AIM: Lessons learned to inform an action plan to improve facilities as well as responses to norovirus within the medicine of the elderly (MoE) hospital as well as other NHS (National Health Service) Lothian facilities. METHODS: This study investigated the impact of a prolonged outbreak at an MoE hospital in one of the 14 Scottish health boards between February and March 2013. FINDINGS: In all, 143 patients (14.80 cases per 1000 inpatient bed-days) and 30 healthcare staff (3.10 cases per 1000 inpatient bed-days) were affected clinically and 63 patients were confirmed virologically. Restricting new admissions to affected units resulted in 1192 lost bed-days. The cost due to lost bed-days in addition to staff absence and management of the outbreak was estimated at £341,534 for this incident alone. At certain points during the outbreak, the whole facility was closed with resulting major impact on the health board's acute care hospitals. CONCLUSION: Due to the outbreak, new measures were implemented for the first time within NHS Lothian that included floor-by-floor (instead of individual) ward closures, enhanced cleaning with chlorine-based products throughout the hospital, reduction in bed capacity with enhanced bed-spacing and interruption to direct admissions from the Board's general practice surgeries, and temporary suspension of visitors to affected areas. Together with regular communication to staff, patients, relatives, and the public throughout the outbreak and good engagement of staff groups in management of the incident, the outbreak was gradually brought under control.

Influence of HPV type on prognosis in patients diagnosed with invasive cervical cancer.

While much is known about the influence of HPV type on the progression of pre-invasive cervical lesions, the impact of HPV type on cervical cancer prognosis is less evidenced. Thus, we assessed the impact of HPV type on the survival of women diagnosed with cervical cancer. A total of 370 cases of cervical cancer were assessed. Univariate analysis is presented using Kaplan-Meier survival curves and log-rank statistics and multivariable Cox proportional hazard models were generated using age group, socio-economic deprivation, FIGO stage, differentiation and HPV type. HPV grouping was considered in a number of ways with particular reference to the presence or absence of HPV 16 and/or 18. In the univariate analysis, FIGO, age at diagnosis and treatment were associated with poorer survival (p < 0.0001) as was absence of HPV 16 and/or 18 (p = 0.0460). The 25% mortality time in the non-HPV 16/18 vs. HPV16/18 positive group was 615 days and 1,307 days respectively. An unadjusted Cox PH model based HPV16/18 vs. no HPV 16/18 resulted in a hazard ratio of 0.669 (0.450, 0.995). Adjusting for deprivation, FIGO and age group resulted in a hazard ratio of 0.609 (0.395, 0.941) p = 0.025. These data indicate that cancers associated with HPV 16 and/or 18 do not confer worse survival compared to cancers associated with other types, and may indicate improved survival. Consequently, although HPV vaccine is likely to reduce the incidence of cervical cancer it may not indirectly improve cervical cancer survival by reducing the burden of those cancers caused by HPV16/18.

Development of a PCR-free electrochemical point of care test for clinical detection of methicillin resistant Staphylococcus aureus (MRSA).

An MRSA assay requiring neither labeling nor amplification of target DNA has been developed. Sequence specific binding of fragments of bacterial genomic DNA is detected at femtomolar concentrations using electrochemical impedance spectroscopy (EIS). This has been achieved using systematic optimisation of probe chemistry (PNA self-assembled monolayer film on gold electrode), electrode film structure (the size and nature of the chemical spacer) and DNA fragmentation, as these are found to play an important role in assay performance. These sensitivity improvements allow the elimination of the PCR step and DNA labeling and facilitate the development of a simple and rapid point of care test for MRSA. Assay performance is then evaluated and specific direct detection of the MRSA diagnostic mecA gene from genomic DNA, extracted directly from bacteria without further treatment is demonstrated for bacteria spiked into saline (10(6) cells per mL) on gold macrodisc electrodes and into human wound fluid (10(4) cells per mL) on screen printed gold electrodes. The latter detection level is particularly relevant to clinical requirements and point of care testing where the general threshold for considering a wound to be infected is 10(5) cells per mL. By eliminating the PCR step typically employed in nucleic acid assays, using screen printed electrodes and achieving sequence specific discrimination under ambient conditions, the test is extremely simple to design and engineer. In combination with a time to result of a few minutes this means the assay is well placed for use in point of care testing.

The treatment of unstable fractures of the ankle using the Acumed fibular nail: development of a technique.

Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications. We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion. Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

The role of the left inferior frontal gyrus in social perception: an rTMS study.

Perceiving and interpreting social information richness is something that humans do automatically whenever they engage in social interactions. Numerous studies have identified neural substrates, including mirror neurons that may enable such social perception. In this study, we temporarily disrupted activity in the left inferior frontal gyrus (LIFG) using repetitive transcranial magnetic stimulation (rTMS). We investigated whether this cortical region, that is hypothesized to include mirror neurons, plays a central role in social perception. The LIFG was stimulated in the experimental condition (n=18), the vertex was targeted in the control condition (n=19). Disrupting LIFG, but not vertex, increased reaction times during an emotion recognition task, and eliminated the suppression of the 8-12Hz EEG µ rhythm, postulated as an index of mirroring activity. The results of this study provide further evidence for the role of the human mirror neuron system (MNS) in social perception, and indicate that the MNS can be measured with EEG.

Epidemiology and clinical presentations of the four human coronaviruses 229E, HKU1, NL63, and OC43 detected over 3 years using a novel multiplex real-time PCR method.

Four human coronaviruses (HCoV-229E, HCoV-HKU1, HCoV-NL63, and HCoV-OC43) are associated with a range of respiratory outcomes, including bronchiolitis and pneumonia. Their epidemiologies and clinical characteristics are poorly described and are often reliant on case reports. To address these problems, we conducted a large-scale comprehensive screening for all four coronaviruses by analysis of 11,661 diagnostic respiratory samples collected in Edinburgh, United Kingdom, over 3 years between July 2006 and June 2009 using a novel four-way multiplex real-time reverse transcription-PCR (RT-PCR) assay. Coronaviruses were detected in 0.3 to 0.85% of samples in all age groups. Generally, coronaviruses displayed marked winter seasonality between the months of December and April and were not detected in summer months, which is comparable to the pattern seen with influenza viruses. HCoV-229E was the exception; detection was confined to the winter of 2008 and was sporadic in the following year. There were additional longer-term differences in detection frequencies between seasons, with HCoV-OC43 predominant in the first and third seasons and HCoV-HKU1 dominating in the second (see Results for definitions of seasons). A total of 11 to 41% of coronaviruses detected were in samples testing positive for other respiratory viruses, although clinical presentations of coronavirus monoinfections were comparable to those of viruses which have an established role in respiratory disease, such as respiratory syncytial virus, influenza virus, and parainfluenza viruses. The novel multiplex assay for real-time pan-coronavirus detection enhances respiratory virus diagnosis, overcomes potential diagnostic problems arising through seasonal variation in coronavirus frequency, and provides novel insights into the epidemiology and clinical implications of coronaviruses.

The emergence of oseltamivir-resistant pandemic influenza A (H1N1) 2009 virus amongst hospitalised immunocompromised patients in Scotland, November-December, 2009.

To investigate the frequency of oseltamivir resistance in circulating strains of the 2009 influenza A(H1N1) pandemic virus in Scotland, 1,802 samples from 1,608 infected hospitalised patients were screened by the H275Y discriminatory RT-PCR. Among these, we identified 10 patients who developed the H275Y mutation. All of them were immunocompromised and were under treatment or had been treated previously with oseltamivir.

Distribution of HPV types associated with cervical cancers in Scotland and implications for the impact of HPV vaccines.

BACKGROUND/METHODS: This study evaluated human papillomavirus (HPV) type prevalence in 370 Scottish invasive cervical cancers (ICCs) using HPV genotyping and HPV mRNA detection. RESULTS: HPV 16 and/or 18 was detected in 72% of cancers overall and in 82% of HPV-positive cancers. HPV 45 and 16 were the most frequently transcribed types. CONCLUSION: A significant reduction in ICC in Scotland should be achieved through the HPV immunisation programme.

High-risk HPV detection in specimens collected in SurePath preservative fluid: comparison of ambient and refrigerated storage.

OBJECTIVE: With moves to introduce human papillomavirus (HPV) triage at sentinel sites in England, it is essential that optimal storage and transport conditions are determined for efficient HPV detection using residual liquid-based cytology specimens. METHODS: Two cytology laboratories with comparable workloads sent residual cervical cytology specimens collected in BD Surepath Preservative Fluid to the Specialist Virology Centre for HPV testing. Storage and transport of specimens was at ambient (site A) or refrigerated (site R) temperatures. The effect of temperature on the ability to detect high-risk human papillomavirus (HR-HPV) using Digene Hybrid Capture 2 High-Risk HPV DNA Test (hc2) and Roche AMPLICOR HPV Test (AMPLICOR) was assessed. All specimens with discordant results were tested using Roche Linear Array HPV Genotyping test. RESULTS: A total of 796 residual cytology specimens, with cytology ranging from normal to severe dyskaryosis, were provided (399 from site A and 397 from site R). Ambient storage and transit of cervical specimens in SurePath medium did not appear to affect significantly the suitability of the specimen for HPV testing, as measured by the concordance of the HR-HPV screening assays for ambient versus refrigerated specimens and by the proportion of specimens which tested invalid. CONCLUSION: Residual cytology specimens in SurePath medium, stored and transported at ambient temperature, appear suitable for HR-HPV detection by AMPLICOR beyond the manufacturer's recommended time and potentially up to four weeks.

Detection of meticillin-resistant Staphylococcus aureus and Panton-Valentine leukocidin directly from clinical samples and the development of a multiplex assay using real-time polymerase chain reaction.

Meticillin-resistant Staphylococcus aureus (MRSA) is a major pathogen responsible for significant numbers of healthcare-associated infections and isolates containing Panton-Valentine leukocidin (PVL) that cause severe skin infections are emerging as a serious problem. The rapid detection of MRSA would be an invaluable tool in a diagnostic laboratory. The aim of this study is to develop real-time polymerase chain reaction (PCR) assays for the detection of MRSA and PVL directly from clinical samples, and then combining these assays. Individual assays for MRSA (SCCmec) and PVL (lukF and lukS) were optimised and evaluated with screening and wound swabs, respectively. MRSA- and PVL-positive isolates were detected by the assays with an analytical sensitivity of 100 cfu per reaction. No other bacterial species were amplified. Fifty of 402 (12.4%) nasal swabs were positive by culture and PCR. Four of the 402 (1.0%) swabs were PCR-positive/culture-negative. Three of the 402 (0.7%) swabs were PCR-negative/culture-positive. The sensitivity of the MRSA assay is 95% and the specificity is 99% using conventional culture as the gold standard. Five of 240 wound swabs (2.1%) were positive for PVL. Three of the PVL-positive swabs were meticillin-sensitive Staphylococcus aureus (MSSA) and two were MRSA. The MRSA assay is a powerful and sensitive diagnostic tool, giving rapid results and could allow more timely treatment and infection control decisions to be taken. It can also, when combined with the PVL assay, provide valuable epidemiological information.

The impact of expansive arterial remodeling on clinical presentation in carotid artery disease: a multidetector CT angiography study.

BACKGROUND AND PURPOSE: Atherosclerotic arterial remodeling has been described in the coronary circulation but has not been studied extensively for carotid atherosclerosis. The purpose of our study was to examine the association between carotid artery remodeling and clinical presentation in patients with significant stenosis by using multidetector row CT (MDCT). MATERIALS AND METHODS: One hundred eight patients with >or=50% stenosis (North American Symptomatic Carotid Endarterectomy Trial criteria) by MDCT angiography between January 2004 and June 2006 were identified. The study group included 37 symptomatic (65.9 +/- 13.0 years; 12 women; stenosis, 81.5 +/- 12.2%; 17 with stroke; 15 with transient ischemic attack; 5 with amaurosis fugax) and 71 asymptomatic patients (70.5 +/- 10.5 years; 28 women; stenosis, 78.8 +/- 11.1%). Remodeling ratio (RR) was calculated by dividing the outer vessel circumference at the site of greatest stenosis by a normal reference-segment vessel circumference. Maximum vessel thickness (MxVT) and eccentricity index (EI) of the plaque, defined as maximal thickness/minimal thickness at the site of greatest luminal narrowing, were also determined. Data were analyzed by using an independent t test. RESULTS: The RR was significantly higher in symptomatic patients (1.64 +/- 0.44) than in asymptomatic patients (1.41 +/- 0.5) (P=.02). There was no significant difference in MxVT in symptomatic (5.9 +/- 2.1 mm) and asymptomatic patients (5.6 +/- 2.4 mm) (P=.45) and no significant difference in EI (symptomatic, 4.7 +/- 2.7; asymptomatic, 4.3 +/- 2.2; P=.38). CONCLUSION: In this series of subjects with significant internal carotid artery stenosis, expansive carotid remodeling was significantly greater in patients with cerebral ischemic symptoms than in asymptomatic patients. The extent of expansive remodeling may indicate underlying atherosclerotic plaque vulnerability. MDCT has a role in the evaluation of carotid artery disease beyond examining luminal stenosis.

Evaluation of antibody- and antigen-coated enzymeimmunoassays for measuring oestrone-3-glucuronide concentrations in urine.

A monoclonal antibody to oestrone-3-glucuronide (OG) was generated and incorporated into antigen- and antibody-coated competitive enzymeimmunoassays (EIAs) using OG-, 6-ketoestrone-6-O-carboxymethyl-oxime (OCMO) and oestrone-3-hemisuccinate (OHS) as the steroid coating antigens or 'tracers' in each format respectively. In the coated-antigen format, standard curves with the lowest mean values (pg/well) for sensitivity (1.1 +/- 0.1), mid-point (ED50; 8.2 +/- 0.7) and high-point (ED20; 31 +/- 2) were obtained using OCMO coupled to bovine serum albumin (BSA) as the coating antigen, and horseradish peroxidase (HRP) as the enzyme label coupled directly to the monoclonal antibody. Standard curves generated using enzyme-labelled OG, OCMO and OHS as 'tracers' in the antibody-coated EIA format were all similar, but had higher mean sensitivity, ED50 and ED20 values than those obtained in the optimal coated-antigen format. In both EIA formats alkaline phosphatase (AP) was found to be inferior to HRP as an enzyme label. Measurement of OG concentrations in early morning urine samples from women with natural, regular menstrual cycles, using the antigen-coated EIA, demonstrated the characteristic elevation in OG concentrations associated with the onset of the urinary LH surge. This technically straightforward and robust antigen-coated EIA may be of interest to laboratories with a requirement to measure OG concentrations in urine, or other biological samples.

Removal of within-cow differences between morning and evening milk yields.

Methods were explored for removing within-cow differences between a.m. and p.m. milk yields to allow direct comparison of consecutive milk yields. Daily a.m. to p.m. ratios of milk yield were studied for 504 lactations of 310 Holstein cows. Ratios varied within lactations and among cows. When the incomplete gamma function was used to characterize lactation curves, 89% of the variation in individual milk yields was explained when an a.m.-p.m. term was included. The a.m. to p.m. ratios increased over the course of lactations. Within-cow adjustment factors for a.m.-p.m. milking, based on weighted and unweighted averages of previous a.m. to p.m. ratios, changed as lactation length increased. A weighted moving average technique, which weighted the last a.m. to p.m. ratio by .15, compared with .85 for previous ratios, was considered to be the optimal method of calculating a factor for removing a.m.-p.m. effects.

Application of enzymeimmunoassay to measure oestrone sulphate concentrations in cow's milk during pregnancy.

The characteristics of antigen- and antibody-coated enzymeimmunoassay (EIA) formats to measure oestrone sulphate (OS) were studied using a murine monoclonal antibody as the primary antibody. In an antigen-coated format the most sensitive EIA (9 fmol/well) was achieved using 6-ketoestrone-6-O-carboxymethyloxime (OCMO) coupled to bovine serum albumin (BSA), as the coating antigen, and horseradish peroxidase (HRP), as the enzyme label. In an antibody-coated format, comparable sensitivity could be achieved using HRP conjugated to either OCMO, oestrone-3-glucuronide (OG) or oestrone-3-hemisuccinate (OHS) as the steroid 'tracer'. In both the antigen- and antibody-coated formats replacing HRP with alkaline phosphatase (AP) markedly aggravated the assay sensitivity. The antigen-coated EIA format was used to measure OS concentrations in cow's milk directly without an initial defatting step, and a progressive increase in OS concentrations in milk as pregnancy progressed was observed. Median OS concentrations rose from 1.1 nmol/l at days 70-99 of pregnancy (n = 44) to 3.2 nmol/l at days 140-160 (n = 92). Oestrone sulphate concentrations in milk from non-pregnant cows (n = 51) ranged from non-detectable to 1.3 nmol/l with a median value of 0.4 nmol/l. Only 5% of cows 120 or more days pregnant had milk OS concentrations within the range of values found in milk from non-pregnant cows. Accurate discrimination of non-pregnant and pregnant cows can thus be achieved on the basis of OS concentrations in milk samples taken at least 120 days after mating/insemination. This EIA for OS may have a role in the dairy industry as an alternative non-invasive means of determining pregnancy status in cows.

Establishment of a bovine leukosis virus-free dairy herd.

A large dairy herd was established free of bovine leukosis virus (BLV) infection at the US Dairy Forage Research Center, Madison, Wis. Cattle introduced into the herd originated from BLV-infected herds, but only those negative for BLV antibodies by an agar gel immunodiffusion test were accepted there. Cattle that were found to be seropositive after their arrival at the new facility were promptly removed. Embryo transfer and artificial insemination were used to introduce new genetic stock into the herd. All recipients receiving embryos from BLV-positive donors and the 30 calves born from the successful transfers were seronegative at 21 months for BLV antibodies. Thus, under these conditions, embryo transfer and artificial insemination did not spread BLV. The agar gel immunodiffusion test was effective in screening cattle for BLV antibodies.

Influence of dietary protein concentration on milk production by dairy cattle during early lactation.

In a 3 X 2 factorial experiment 75 Holstein cows in first, second, or third lactation were fed rations containing either 12.2% or 16.2% crude protein in total ration dry matter. On the average, 26% of dry matter intake was from corn silage, 22% from alfalfa-grass hay, and 52% from a grain mix. Protein was controlled by feeding a 13.7% crude protein grain mix with 1.4% urea for the 12% ration and a 19.8% crude protein grain mix with natural protein for the 16% ration. Average daily milk production (kg/day) for wk 2 through 12 of lactation for 12% and 16% rations by lactations were: first, 21.6 and 21.9; second, 25.7 and 31.5; and third, 27.5 and 34.0. Dry matter intakes by lactations were .42, 1.18, and 2.05 kg/day higher for cows fed the high protein compared to low protein rations. Milk composition was not influenced by protein treatment. The markedly different response to protein supplementation in milk production between heifers in first lactation and more mature cows is unexplained.