Zostera virus T - a novel virus of the genus Tepovirus identified in the eelgrass, Zostera muelleri.

Analysis of a transcriptome dataset obtained from tissue samples of the eelgrass Zostera muelleri, an aquatic flowering plant species of the family Zosteraceae, yielded three genome sequence contigs of a novel RNA virus. Sequence comparison and phylogenetic analysis revealed that the novel RNA virus, named Zostera virus T (ZoVT), belongs to the genus Tepovirus of the family Betaflexiviridae. The three genome contigs of ZoVT showed 88.2‒97.2% nucleotide sequence identity to each other, indicating that they descended from a common ancestor. The ZoVT genome contains three open reading frames (ORFs): ORF1 encodes a 1816 amino acid (aa) replicase (REP) with RNA-dependent RNA polymerase (RdRp) activity; ORF2, a 398 aa movement protein (MP); and ORF3, a 240 aa coat protein (CP). The phylogenetic analysis using REP sequences of ZoVT and other Betaflexiviridae viruses showed that Prunus virus T is the closest known virus to ZoVT, whereas potato virus T, the type species of the genus Tepovirus, is the second closest virus. Genome sequences of ZoVT, which is the third tepovirus species identified to date, may be useful for investigating the evolution and molecular biology of tepoviruses. Keywords: Zostera virus T; Tepovirus; Betaflexiviridae; eelgrass; Zostera muelleri.

Residual effect of community antimicrobial exposure on risk of hospital onset healthcare-associated Clostridioides difficile infection: a case-control study using national linked data.

BACKGROUND: Associations between antimicrobial exposure in the community and community-associated Clostridioides difficile infection (CA-CDI) are well documented but associations with healthcare-associated CDI (HA-CDI) are less clear. This study estimates the association between antimicrobial prescribing in the community and HA-CDI. METHODS: A matched case-control study was conducted by linking three national patient level datasets covering CDI cases, community prescriptions and hospitalizations. All validated cases of HA-CDI (August 2010 to July 2013) were extracted and up to three hospital-based controls were matched to each case on the basis of gender, age, hospital and date of admission. Conditional logistic regression was applied to estimate the association between antimicrobial prescribing in the community and HA-CDI. A sensitivity analysis was conducted to consider the impact of unmeasured hospital antimicrobial prescribing. RESULTS: Nine-hundred and thirty unique cases of HA-CDI with onset in hospital and no hospital discharge in the 12 weeks prior to index admission were linked with 1810 matched controls. Individuals with prior prescription of any antimicrobial in the community had an odds ratio (OR) = 1.41 (95% confidence interval (CI) 1.13-1.75) for HA-CDI compared with those without. Individuals exposed to high-risk antimicrobials (cephalosporins, clindamycin, co-amoxiclav or fluoroquinolones) had an OR = 1.86 (95% CI: 1.33-2.59). After accounting for the likely impact of unmeasured hospital prescribing, the community exposure, particulary to high-risk antimicrobials, was still associated with elevated HA-CDI risk. CONCLUSIONS: Community antimicrobial exposure is an independent risk factor for HA-CDI and should be considered as part of the risk assessment of patients developing diarrhoea in hospital.

Implementation of antibiotic stewardship in different settings - results of an international survey.

Background: Antibiotic stewardship interventions are being implemented across different healthcare settings. We report the findings of a global survey of healthcare professionals on the implementation of antibiotic stewardship programmes. Methods: Learners of a Massive Online Open Course (MOOC) on antibiotic stewardship were invited to complete an online survey on the core available organisational resources for stewardship. The categorical variables were analysed using chi-squared test, and Likert questions were analysed using an ordinal regression model. The p-values were considered as two-tailed. Significance was set at p-value of < 0.05. Results: The response rate was 55% (505/920), from 53 countries. The responders were 36% (182) doctors, 26% (130) pharmacists, 18% (89) nurses and 20% (104) other (researchers, students and members of the public). Post-graduate training in infection management and stewardship was reported by 56% of doctors compared with 43% (OR 0.59, 95%CI 0.35-1.00) nurses and 35% (OR 0.39, 95%CI 0.24-0.62) of pharmacists. Hospitals were significantly (83% in teaching hospitals, 79% in regional hospitals, p = < 0.01) more likely to have antibiotic policies, when compared to primary care. A surveillance mechanism for antibiotic consumption was reported in 58% (104/178) of teaching hospitals and 62% (98/159) of regional hospitals. Antimicrobial resistance, patient needs, policy, peer influence and specialty level culture and practices were deemed important determinants for decision-making. Conclusion: Postgraduate training and support in antibiotic prescribing remains low amongst nurses and pharmacists. Whilst antibiotic policies and committees are established in most institutions, surveillance of antibiotic use is not. The impact of specialty level culture, and peer influence appears to be important factors of antibiotic prescribing.

Prioritizing research areas for antibiotic stewardship programmes in hospitals: a behavioural perspective consensus paper.

SCOPE: Antibiotic stewardship programmes (ASPs) are necessary in hospitals to improve the judicious use of antibiotics. While ASPs require complex change of key behaviours on individual, team organization and policy levels, evidence from the behavioural sciences is underutilized in antibiotic stewardship studies across the world, including high-income countries (HICs). A consensus procedure was performed to propose research priority areas for optimizing effective implementation of ASPs in hospital settings using a behavioural perspective. METHODS: A workgroup for behavioural approaches to ASPs was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). Eighteen clinical and academic specialists in antibiotic stewardship, implementation science and behaviour change from four HICs with publicly funded healthcare systems (e.g. Canada, Germany, Norway and the UK) met face-to-face to agree on broad research priority areas using a structured consensus method. Question addressed and recommendations: The consensus process assessing the ten identified research priority areas resulted in recommendations that need urgent scientific interest and funding to optimize effective implementation of ASPs for hospital inpatients in HICs with publicly funded healthcare systems. We suggest and detail behavioural science evidence-guided research efforts in the following areas: (a) comprehensively identifying barriers and facilitators to implementing ASPs and clinical recommendations intended to optimize antibiotic prescribing; (b) identifying actors ('who') and actions ('what needs to be done') of ASPs and clinical teams; (c) synthesizing available evidence to support future research and planning for ASPs; (d) specifying the activities in current ASPs with the purpose of defining a control group for comparison with new initiatives; (e) defining a balanced set of outcomes and measures to evaluate the effects of interventions focused on reducing unnecessary exposure to antibiotics; (f) conducting robust evaluations of ASPs with built-in process evaluations and fidelity assessments; (g) defining and designing ASPs; (h) establishing the evidence base for impact of ASPs on resistance; (i) investigating the role and impact of government and policy contexts on ASPs; and (j) understanding what matters to patients in ASPs in hospitals. CONCLUSIONS: Assessment, revisions and updates of our priority-setting exercise should be considered at intervals of 2 years. To propose research priority areas in low- and middle-income countries, the methodology reported here could be applied.

Using chiral ionic liquid additives to enhance asymmetric induction in a Diels-Alder reaction.

A bis-oxazoline ligand has been complexed using Cu(ii) and Zn(ii) trifluoromethanesulfonate and a range of chiral ionic liquid (CIL) additives based on natural products were used as a co-catalyst for a Diels-Alder reaction. The catalytic performance of these systems was compared for the asymmetric Diels-Alder reaction between N-acryloyloxazolidinone and cyclopentadiene with and without the presence of a CIL additive. In the absence of the CIL, both catalysts resulted in low enantioselectivities in conventional solvents and ionic liquids. However, whilst only a minor effect of the CIL was observed for the Cu based catalyst, in the case of the Zn based catalyst, significant enhancements in endo enantioselectivity of up to 50% were found on the addition of a CIL.

Breaking the Mold: A Review of Mucormycosis and Current Pharmacological Treatment Options.

OBJECTIVE: To review the current literature for the pathogenesis of mucormycosis, discuss diagnostic strategies, and evaluate the efficacy of polyenes, triazoles, and echinocandins as pharmacological treatment options. DATA SOURCES: An electronic literature search was conducted in PubMed using the MESH terms Rhizopus, zygomycetes, zygomycosis, Mucorales and mucormycosis, with search terms amphotericin B, micafungin, anidulafungin, caspofungin, extended infusion amphotericin B, liposomal amphotericin B, combination therapy, triazole, posaconazole, isavuconazole, diagnosis, and clinical manifestations. STUDY SELECTION AND DATA EXTRACTION: Studies written in the English language from January 1960 to March 2016 were considered for this review article. All search results were reviewed, and the relevance of each article was determined by the authors independently. DATA SYNTHESIS: Mucormycosis is a rare invasive fungal infection with an exceedingly high mortality and few therapeutic options. It has a distinct predilection for invasion of endothelial cells in the vascular system, which is likely important in dissemination of disease from a primary focus of infection. Six distinct clinical syndromes can occur in susceptible hosts, including rhino-orbital-cerebral, pulmonary, gastrointestinal, cutaneous, widely disseminated, and miscellaneous infection. CONCLUSION: Diagnosis of mucormycosis is typically difficult to make based on imaging studies, sputum culture, bronchoalveolar lavage culture, or needle aspirate. Surgical debridement prior to dissemination of infection improves clinical outcomes. Surgery combined with early, high-dose systemic antifungal therapy yields greater than a 1.5-fold increase in survival rates. The Mucorales are inherently resistant to most widely used antifungal agents. Amphotericin B is appropriate for empirical therapy, whereas posaconazole and isavuconazole are best reserved for de-escalation, refractory cases, or patients intolerant to amphotericin B.

Validation of a Trunk-mounted Accelerometer to Measure Peak Impacts during Team Sport Movements.

This study assessed the validity of an accelerometer to measure impacts in team sports. 76 participants completed a team sport circuit. Accelerations were collected concurrently at 100 Hz using an accelerometer and a 36-camera motion analysis system. The largest peak accelerations per movement were compared in 2 ways: i) pooled together and filtered at 13 different cut-off frequencies (range 6-25 Hz) to identify the optimal filtering frequency, and ii) the optimal cut-off frequency split into the 7 movements performed (n=532). Raw and 25-16 Hz filtering frequencies significantly overestimated and 6 Hz underestimated motion analysis peak accelerations (P <0.007). The 12 Hz filtered accelerometer data revealed the strongest relationship with motion analysis data (accuracy - 0.01±0.27 g, effect size - 0.01, agreement - 0.55 to 0.53 g, precision 0.27 g, and relative error 5.5%; P=1.00). The accelerometer underestimated peak accelerations during tackling and jumping, and overestimated during walking, jogging, sprinting and change of direction. Lower agreement and reduced precision were associated with sprinting, jumping and tackling. The accelerometer demonstrated an acceptable level of concurrent validity compared to a motion analysis system when filtered at a cut-off frequency of 12 Hz. The results advocate the use of accelerometers to measure movements in team sport.

Differentiation of gluteus medius and minimus activity in weight bearing and non-weight bearing exercises by M-mode ultrasound imaging.

BACKGROUND: Knowledge on task-specific activity of the deep hip abductor muscles is limited and is required for determining appropriate hip abductor exercises. OBJECTIVES: To assess the temporal differentiation of activity of gluteus minimus and the deep and the superficial regions of gluteus medius during weight bearing and non-weight bearing exercises. DESIGN: Repeated measures design on a single recording occasion. METHOD: M-mode ultrasound was used to capture activity-related muscle motion of the gluteus minimus and medius muscles in 20 healthy volunteers during weight shift, hip hitch, side-lying abduction and active leg lengthening exercises. M-mode traces were computer-processed for detecting muscle motion onsets. Mean onset differences between muscle regions and their intra-individual variability were assessed. RESULTS: In contrast to side-lying abduction, the weight shift and hip hitch exercises resulted in larger onset variability between the gluteus minimus and deep gluteus medius (P < 0.001) and also between the deep and superficial regions of the gluteus medius (P < 0.05). CONCLUSIONS: Weight bearing exercises promoted a greater functional differentiation between deep and superficial hip abductor muscles.

The Use of the S-MART Tourniquet in Hand Surgery: A Safe and Effective Way to Provide a Bloodless Field.

We have retrospectively reviewed our use of the S-MART sterile silicon ring self-exsanguinating tourniquet in 300 consecutive minor hand surgical procedures. A total of 3 postoperative complications were identified, only 1 of which was directly related to the tourniquet's use. We outline the reasons of why we feel that this device provides a safe and effective bloodless field and the benefits of its use.

The use of infliximab in X-linked agammaglobulinaemia associated enteropathy.

Granulomatous small bowel enteropathy is an unusual presentation associated with X-linked agammaglobulinaemia. We present a rare case of this condition that was further complicated by an enterocutaneous fistula and report our experience managing this condition successfully with infliximab, which has not been documented in the literature previously.

Antibiotic hypersensitivity reactions and approaches to desensitization.

Before initiating antibiotic therapy, drug hypersensitivity is an important consideration, and a common strategy is to avoid giving patients medications when a high likelihood of severe reactions exists. With an increase in antibiotic resistance and a decrease in novel antibiotics, there is greater pressure to consider antibiotics in patients with a history of adverse reactions. The major concerns include IgE-mediated, or type I, reactions, anaphylaxis, Stevens-Johnson syndrome, and toxic epidermal necrolysis. Some antibiotics with similar characteristics, such as cephalosporins and penicillins, may be given safely to patients with a certain allergy profile. There is still greater concern when considering antibiotics for patients with reported allergy. Desensitization is a strategy to safely induce drug tolerance to a specific drug to limit the possibility of a type I reaction.

Learning safe practice by improving care: student-led intervention on oxygen prescribing in a respiratory ward.

BACKGROUND AND OBJECTIVE: The primary aim of this intervention was to improve oxygen prescribing in accordance with the 2008 British Thoracic Society guidelines for the prescription of emergency oxygen in adults. METHODS: Eight final year medical students reviewed the drug charts of all patients admitted to the respiratory ward on a daily basis in order to collect data on five audit questions: (1) Has oxygen (O2) been prescribed? (2) Has an O2 target saturation level been indicated? (3) Has O2 been prescribed as an 'as required' (PRN) or 'continuous therapy'? (4) Has the prescription been signed? (5) Has O2 been signed for in every drug round since the original prescription? Following an initial audit cycle an educational poster was distributed to all clinical staff via email and hard copies of the poster were placed strategically throughout the ward before its effectiveness was measured. RESULTS: During the pre-intervention phase, compliance with all five measures varied from 0 to 25%. There was an increase in the variation in compliance after the poster intervention to 14-44%; however, this masked better overall compliance with all five investigative questions with figures of 44%, 39% and 42% being recorded in three of the four post-intervention days. Overall there was increased compliance with four of the five audit questions. Indeed compliance with question 3 rose from 14% to 83%. CONCLUSIONS: The poster intervention was marginally effective while also showing that students can improve prescribing in a clinical setting.

An internal carotid artery aneurysm presenting with dysarthria.

A 72-year-old woman presented to her general practitioner with a 4-week history of right neck swelling. Clinical examination elicited a pulsatile mass consistent with a carotid artery aneurysm. Five days later the patient noticed her tongue movements had become awkward with associated dysarthria. Computed tomography confirmed a 4cm internal carotid artery aneurysm arising just distally to the carotid bifurcation. She proceeded to transfemoral diagnostic carotid angiography. Balloon occlusion of the right internal carotid artery origin was performed for a ten-minute period without any neurological deficit. The decision was taken to proceed to surgical ligation of the origin of the internal carotid artery. Her symptoms of dysarthria have resolved.

A novel system for spatial and temporal imaging of intrinsic plant water use efficiency.

Instrumentation and methods for rapid screening and selection of plants with improved water use efficiency are essential to address current issues of global food and fuel security. A new imaging system that combines chlorophyll fluorescence and thermal imaging has been developed to generate images of assimilation rate (A), stomatal conductance (gs), and intrinsic water use efficiency (WUEi) from whole plants or leaves under controlled environmental conditions. This is the first demonstration of the production of images of WUEi and the first to determine images of g s from themography at the whole-plant scale. Data are presented illustrating the use of this system for rapidly and non-destructively screening plants for alterations in WUEi by comparing Arabidopsis thaliana mutants (OST1-1) that have altered WUEi driven by open stomata, with wild-type plants. This novel instrument not only provides the potential to monitor multiple plants simultaneously, but enables intra- and interspecies variation to be taken into account both spatially and temporally. The ability to measure A, gs, and WUEi progressively was developed to facilitate and encourage the development of new dynamic protocols. Images illustrating the instrument's dynamic capabilities are demonstrated by analysing plant responses to changing photosynthetic photon flux density (PPFD). Applications of this system will augment the research community's need for novel screening methods to identify rapidly novel lines, cultivars, or species with improved A and WUEi in order to meet the current demands on modern agriculture and food production.

Clinical evaluation of multiparameter correction equations for Goldmann applanation tonometry.

PURPOSE: To evaluate and compare the multiparameter equations in correcting intraocular pressure (IOP) measurements obtained using the Goldmann applanation tonometer (IOPG) for the effects of central corneal thickness (CCT), corneal curvature (R), and age in different ethnic populations. METHODS: Data of IOPG, CCT, R, and age were collected from three clinical centers. The sample size consisted of 945 eyes of 945 glaucoma patients or suspects (669 Europeans, 127 African Americans, and 149 Indians). The 'corrected IOP' was calculated using five multiparameter equations to decrease the association of CCT, R, and age with measured IOP. Regression analyses were performed to calculate variance (r(2)) and determine the association of CCT, R, and age with IOPG and corrected IOP (residual association). RESULTS: Overall, CCT accounted for the majority of variance in IOPG, while R and age had a much smaller effect, with the combined effect on IOPG ranging from 4.7 to 7.5% in the three data sets. The residual association of CCT, R, and age with corrected IOP in the three groups ranged from 0.2 to 1.3% and 0.5 to 1.8% with the application of the Elsheikh and the Chihara equations, respectively. The residual association of CCT, R, and age with corrected IOP calculated using the Ehlers, Orssengo and Pye, and Shimmoyo equations were 7-11.5, 1.8-11.7, and 4.6-8.3%, respectively. CONCLUSION: The Elsheikh and the Chihara equations better decreased the association of CCT, R, and age with measured IOP than the Ehlers, Orssengo and Pye, and Shimmoyo equations.

Significant reduction in vancomycin-resistant enterococcus colonization and bacteraemia after introduction of a bleach-based cleaning-disinfection programme.

BACKGROUND: Vancomycin-resistant enterococcus (VRE) colonization and infection have increased at our hospital, despite adherence to standard VRE control guidelines. AIM: We implemented a multi-modal, hospital-wide improvement programme including a bleach-based cleaning-disinfection programme ('Bleach-Clean'). VRE colonization, infection and environmental contamination were compared pre and post implementation. METHODS: The programme included a new product (sodium hypochlorite 1000 ppm + detergent), standardized cleaning-disinfection practices, employment of cleaning supervisors, and modified protocols to rely on alcohol-based hand hygiene and sleeveless aprons instead of long-sleeved gowns and gloves. VRE was isolated using chromogenic agar and/or routine laboratory methods. Outcomes were assessed during the 6 months pre and 12 months post implementation, including proportions (per 100 patients screened) of VRE colonization in high-risk wards (HRWs: intensive care, liver transplant, renal, haematology/oncology); proportions of environmental contamination; and episodes of VRE bacteraemia throughout the entire hospital. FINDINGS: Significant reductions in newly recognized VRE colonizations (208/1948 patients screened vs 324/4035, a 24.8% reduction, P = 0.001) and environmental contamination (66.4% reduction, P = 0.012) were observed, but the proportion of patients colonized on admission was stable. The total burden of inpatients with VRE in the HRWs also declined (median percentage of colonized inpatients per week, 19.4% vs 17.3%, P = 0.016). Hospital-wide VRE bacteraemia declined from 14/2935 patients investigated to 5/6194 (83.1% reduction; P < 0.001), but there was no change in vancomycin-susceptible enterococcal bacteraemia (P = 0.54). CONCLUSION: The Bleach-Clean programme was associated with marked reductions in new VRE colonizations in high-risk patients, and VRE bacteraemia across the entire hospital. These findings have important implications for VRE control in endemic healthcare settings.

Common bile duct stones: an unusual case of diarrhoea through a mucous fistula.

We present a very unusual case of diarrhoea in a 77-year-old man. He had a previously complicated surgical history, with a loop ileostomy and a colonic mucous fistula. He developed a sudden onset of diarrhoea from his mucous fistula. A contrast enema suggested a cholecystocolonic fistula and subsequent computed tomography demonstrated a common bile duct stone caused a degree of obstruction. The patient was treated successfully by endoscopic retrograde cholangiopancreatography and stone extraction. This case demonstrated the role that contrast enema may still play in unusual cases of diarrhoea.

Antifungal therapy in European hospitals: data from the ESAC point-prevalence surveys 2008 and 2009.

The study aimed to identify targets for quality improvement in antifungal use in European hospitals and determine the variability of such prescribing. Hospitals that participated in the European Surveillance of Antimicrobial Consumption Point Prevalence Surveys (ESAC-PPS) were included. The WHO Anatomical Therapeutic Chemical (ATC) classification for 'antimycotics for systemic use' (J02) 2009 version was used. Demographic data and information about indications and diagnoses were collected in 2008 and 2009. From 99,053 patients, 29,324 (29.6%) received antimicrobials. Antifungals represented 1529 of 40,878 (3.7%) antimicrobials. Antifungals were mainly (54.2%) administered orally. Hospital-acquired infections represented 44.5% of indications for antifungals followed by medical prophylaxis at 31.2%. The site of infection was not defined in 36.0% of cases but the most commonly targeted sites were respiratory (19.2%) and gastrointestinal (18.8%). The most used antifungal was fluconazole (60.5%) followed by caspofungin (10.5%). Antifungal-antibacterial combinations were frequently used (77.5%). The predominance of fluconazole use in participating hospitals could result in an increase in prevalence of inherently resistant fungi, increasing the need for newer antifungals. Although acknowledging that antifungal prophylaxis in the immunocompromised host needs further exploration, repetitive surveys using ESAC-PPS methodology may help to monitor the effects of interventions set to regulate antifungal use.