An outbreak of livestock-associated meticillin-resistant Staphylococcus aureus (LA-MRSA) clonal complex 398 in a regional burns centre.

BACKGROUND: Meticillin-resistant Staphylococcus aureus (MRSA) outbreaks have been reported previously in burns centres with resulting mortality and morbidity. This article describes the first human-associated outbreak in the UK caused by a strain of mupirocin-resistant (MuR) livestock-associated MRSA clonal complex 398 (LA-MRSA CC398) in an adult burns centre. The centre historically had a very low prevalence of MRSA infections. AIM: To describe the clinical and epidemiological context of how the outbreak was identified and contained using a range of infection prevention and control (IPC) measures guided by both traditional and genetic methods. METHODS: A cluster of MuR-MRSA led to an outbreak investigation. Cases were detected via retrospective search and real-time laboratory surveillance. Isolates were sent continuously for whole-genome sequencing (WGS). A live timeline of cases and interventions was produced throughout the period. FINDINGS: The outbreak consisted of 12 cases (seven males and five females) aged between 22 and 70 years. Patients were identified between May and October 2020. All patients were colonized rather than infected. The strain acquired the plasmid bearing MupA while colonizing the index case before dissemination. The index case was found to be a chicken farmer. This outbreak was eventually controlled using IPC measures, audits, and blind staff decolonization guided by insight from WGS. CONCLUSION: It was not possible to determine how the strain entered the centre, or if a staff carrier was involved. The outbreak demonstrated the potential for continued transmissions for months despite active surveillance and stringent control measures.

Keeping physically active with rheumatoid arthritis: semi-structured interviews to explore patient perspectives, experiences and strategies.

BACKGROUND: Regular physical activity is safe and beneficial for people with rheumatoid arthritis (RA) but the majority of people with RA are less active than the general population and have a higher risk of co-morbidities. Exploring strategies used by physically active people with RA could inform effective methods to support those who are less active. OBJECTIVE: To explore the perspectives, experiences and strategies employed by people with RA who successfully engage with regular physical activity. DESIGN: Individual semi-structured interviews and thematic analysis. PARTICIPANTS: A purposive sample of physically active people with RA. RESULTS: Twelve females and three males participated (mean age 56, range 29 to 80; mean disease duration 13 years, range 10 months to 46 years). Analysis revealed eight constructs clustered into three themes. Theme 1: 'the individual' incorporated constructs of symptoms, feelings and role; theme 2: 'management' incorporated medical and self-management; theme 3: 'physical activity' incorporated constructs of type of physical activity, including barriers or facilitators. Participants reported a long history of physical activity prior to diagnosis and good support networks. All participants recognised that physical activity was key to their RA management, acknowledged the benefits from engaging in physical activity and were able to overcome barriers. Participants had strong beliefs that physical function would decline without regular physical activity. CONCLUSIONS: People with RA who successfully maintain physical activity are motivated by a desire to manage symptoms, resist functional decline and maintain health and independence. These findings should be explored with a wider range of people with RA.

Open access colonoscopy in the training setting: which factors affect patient satisfaction and pain?

BACKGROUND AND STUDY AIM: Patient satisfaction with colonoscopy is important for quality assurance; it may be affected by various factors, including patient characteristics, physician training level, and procedural or organizational features. We aimed to analyze how these factors influenced patient satisfaction and pain in an outpatient training setting. METHODS: Consecutive patients for open access colonoscopy (OAC) were enrolled in a prospective, single-blinded, controlled study. Primary and secondary outcomes were satisfaction and pain scores with and without trainee participation. A multivariate analysis was designed to achieve an 80 % power with an alpha value of 0.05. RESULTS: 368 patients were enrolled. Satisfaction with the procedure was high (mean score 1.36; 1 = best to 5 = worst). In the multivariate analysis only waiting time in the endoscopy suite was significantly associated with lower satisfaction scores ( P = 0.024). Satisfaction was unaffected by patient factors (gender, American Society of Anesthesiologists' [ASA] score, anxiety, etc). Higher pain scores were associated with higher anxiety levels ( P = 0.02), female gender ( P = 0.02), longer procedure ( P< 0.001), and lower sedation levels ( P = 0.001); trainee involvement (49 % of procedures) did not adversely affect satisfaction or pain scores. CONCLUSIONS: Patient satisfaction with OAC using sedation appears to depend primarily on organizational factors (waiting time beforehand). In contrast, pain is associated with patient characteristics (female gender, anxiety) and procedural factors (lower sedation, longer procedure). Trainee participation did not affect satisfaction or pain scores, a finding which may help to reassure patients undergoing OAC with trainee participation.

Occupational asthma caused by cellulase and lipase in the detergent industry.

Three employees from two different detergent companies were investigated for occupational asthma, using skin prick tests, serum specific IgE, and specific bronchial challenge. Two were challenged with lipase and one with cellulase. All three cases had immunological evidence of sensitisation to the detergent enzymes with which they worked. Bronchial challenge in each provoked a reproducible dual asthmatic response, which reproduced their work related symptoms. These are the first reported cases of occupational asthma attributable to cellulase and lipase in the detergent industry. Four of the most common enzymes used in this industry have now been reported to cause occupational asthma; continued vigilance and caution are needed when working with these or other enzymes.

Maternal and fetal immune responses of cattle inoculated with Neospora caninum at mid-gestation.

The humoral and cell-mediated immune responses of pregnant cattle and their fetuses were examined at intervals after infection with Neospora caninum tachyzoites at mid-gestation (day 140). All cattle seroconverted and interferon gamma was detected in supernatants of peripheral blood mononuclear cells stimulated with specific antigen. At day 14 post-inoculation (pi), specific cell proliferation responses were detected in the lymph node draining the site of inoculation and in the uterine lymph node. The peak response was recorded in the majority of maternal lymph nodes by day 28 pi and cells from the maternal retropharyngeal lymph node, which in part drains the central nervous system, showed no specific activity to N. caninum until day 42 pi. This changing pattern of immune responsiveness may reflect parasite invasion and development within different host tissues. Fetal lymph node cells showed mitogen responsiveness from day 14 pi (day 154 of gestation) and also showed N. caninum-specific cell proliferation and interferon-gamma responses by day 28 pi (day 168 of gestation). At day 42 pi, specific cell-mediated immune responses were not apparent; however, N. caninum-specific fetal IgG and IgM antibodies were detected.

The pathogenesis of neosporosis in pregnant cattle: inoculation at mid-gestation.

To investigate the pathogenesis of bovine neosporosis, 14 pregnant cattle were each inoculated subcutaneously with either 10(7) or 5 x 10(8) Neospora caninum (strain NC1) tachyzoites at 140 days' gestation. Serial necropsies were then carried out over an 8-week period. In the placenta, Neospora DNA and histopathological changes were observed in samples taken 14 days post-inoculation (dpi), with focal necrosis of maternal caruncular septa and fetal placental villi, serum leakage, and a maternal and fetal inflammatory response. At subsequent samplings, pathological changes in the placenta showed signs of resolution. No parasitaemia was detected in the dams in the two weeks following inoculation. In the fetus, Neospora DNA was detected at 14 dpi, and histopathological changes in the fetal central nervous system at 28 and 42 dpi consisted of small foci of necrosis and inflammation. Resolution of placental lesions during the experiment indicated that the disease was being controlled, and fetal infection, although established, did not appear to be progressing to a fatal outcome. The two doses of tachyzoites produced similar results, but the higher dose elicited earlier and more extensive lesions in the placenta and fetus. Control animals remained negative for all parameters recorded. It is concluded that in bovine neosporosis the placenta plays a central role in the pathogenesis and epidemiology of the infection, and that while primary tissue destruction by the parasite may endanger the fetus, the maternal and fetal inflammatory responses may also be damaging.

The gametocyte-activating factor xanthurenic acid stimulates an increase in membrane-associated guanylyl cyclase activity in the human malaria parasite Plasmodium falciparum.

Sex is an obligate step in the life cycle of the malaria parasite and occurs in the midgut of the mosquito vector. With both Plasmodium falciparum and Plasmodium berghei, the tryptophan metabolite xanthurenic acid induces the release of motile male gametes from red blood cells (exflagellation), a prerequisite for fertilization. The addition of cGMP or phosphodiesterase inhibitors to cultures of mature gametocytes has also been shown to stimulate exflagellation. Here, we demonstrate that there is a guanylyl cyclase activity associated with mature P. falciparum gametocyte membrane preparations, which is dependent on the presence of Mg(2+)/Mn(2+) but is inhibited by Ca(2+). Significantly, this activity is increased on addition of xanthurenic acid. In contrast, a xanthurenic acid precursor (3-hydroxykynurenine), which is not an inducer of exflagellation, does not induce this guanylyl cyclase activity. These results therefore suggest that xanthurenic acid-induced exflagellation may be mediated by activation of the parasite cGMP signalling pathway.

Surveillance of occupational skin disease: EPIDERM and OPRA.

Consultant dermatologists in the U.K. have been reporting to EPIDERM, a voluntary surveillance scheme for occupational skin disease, since February 1993; reporting by occupational physicians to the scheme began in May 1994 and was superseded in January 1996 by OPRA (Occupational Physicians Reporting Activity). Currently 244 dermatologists and 790 occupational physicians report incident cases to these schemes. During the 6 years to January 1999 a total of 12, 574 new cases of occupational skin disease was estimated from reports by consultant dermatologists and 10,136 cases estimated from occupational physicians (since May 1994). The annual incidence of occupational contact dermatitis using data from both schemes was 12. 9 per 100,000 workers. The incidence of contact dermatitis per 100, 000 workers increased with age in men from 4.9 (age 16-29 years) to 6.6 (age 45-60 years); in women a higher rate (9.5) was apparent in the younger age group, with lower rates in older female workers. High rates in young workers were associated with wet work and in older workers with exposure to oils. For men, high rates of contact dermatitis were seen in reports from both schemes for chemical operatives, machine tool setters and operatives, coach and spray painters and metal workers. For women, high rates were found for hairdressers, biological scientists and laboratory workers, nurses and those working in catering. The most frequent agents for contact dermatitis were rubber chemicals and materials (14.1% of cases reported by dermatologists), soaps and cleaners (12.7%), nickel (11. 9%), wet work (11.1%), personal protective equipment (6.2%), petroleum products (6.3%), cutting oils and coolants (5.6%), and epoxy and other resins (6.1%). In the 1608 estimated cases of skin cancer all but 4% were attributed to ultraviolet radiation. Cases of contact urticaria attributed to latex peaked in 1996, with a decline in cases since that time.