Molecular and epidemiological evidence of patient-to-patient hepatitis C virus transmission in a Scottish emergency department.

BACKGROUND: Transmission of hepatitis C virus (HCV) in the healthcare setting is rare. Routine infection prevention and control measures mean that this should be a preventable 'never event'. AIM: To investigate the diagnosis of acute healthcare-associated HCV infection. METHODS: Epidemiological and molecular investigation of a case of acute HCV infection associated with nosocomial exposure. FINDINGS: Detailed investigation of the treatment history of a patient with acute HCV infection identified transmission from a co-attending patient in an emergency department as the likely source; this possibility was confirmed by virus sequence analysis. The precise route of transmission was not identified, though both patient and source had minimally invasive healthcare interventions. Review of infection, prevention and control identified potentially contributory factors in the causal pathway including hand hygiene, inappropriate use of personal protective equipment, and blood contamination of the surface of the departmental blood gas analyser. CONCLUSION: We provide molecular and epidemiological evidence of HCV transmission between patients in an emergency department that was made possible by environmental contamination. Patients with HCV infection are higher users of emergency care than the general population and a significant proportion of those affected remain unknown and/or infectious. Equipment, departmental design, staff behaviour, and patient risk require regular review to minimize the risk of nosocomial HCV transmission.

Rational Design of a Water-Soluble, Lipid-Compatible Fluorescent Probe for Cu(I) with Sub-Part-Per-Trillion Sensitivity.

Fluorescence probes represent an attractive solution for the detection of the biologically important Cu(I) cation; however, achieving a bright, high-contrast response has been a challenging goal. Concluding from previous studies on pyrazoline-based fluorescent Cu(I) probes, the maximum attainable fluorescence contrast and quantum yield were limited due to several non-radiative deactivation mechanisms, including ternary complex formation, excited state protonation, and colloidal aggregation in aqueous solution. Through knowledge-driven optimization of the ligand and fluorophore architectures, we overcame these limitations in the design of CTAP-3, a Cu(I)-selective fluorescent probe offering a 180-fold fluorescence enhancement, 41% quantum yield, and a limit of detection in the sub-part-per-trillion concentration range. In contrast to lipophilic Cu(I)-probes, CTAP-3 does not aggregate and interacts only weakly with lipid bilayers, thus maintaining a high contrast ratio even in the presence of liposomes.

The goal of making friends for youth with disabilities: creating a goal menu.

BACKGROUND: Clinicians working with youth with disabilities have acknowledged making friends as a commonly identified client goal. Clinicians find this goal difficult to address, as there are no measures that provide a breakdown of making friends into functional steps. In addition, research on friendship has traditionally focused on characteristics and quality of friendships rather than the friend-making process as a whole. A goal menu, comprised of a variety of steps that address the goal of making friends, would provide guidance to clinicians challenged with this goal in practice. PURPOSE: To develop an understanding of the friend-making process as a first step towards the development of a goal menu for the goal of making friends. METHODS: A literature review, youth focus group and expert clinician semi-structured interviews and consultation were used to generate a comprehensive data set. Established qualitative methods were used to sort and group the data into categories. A thematic analysis of the categories was performed. RESULTS: Analysis revealed four themes integral to the friend-making process: person factors influencing friend-making, making friend-making a priority, opportunity for friend-making and motivation to make friends. An additional theme identified as occasionally involved in the process was a little bit of luck in making friends. CONCLUSIONS: The themes generated by this research indicate that actionable target areas exist for the somewhat abstract notion of friend-making and the authors recommend that clinicians explore beyond person factors when addressing the goal of making friends. As a next step, the identified themes will provide the foundation for a goal menu, ultimately enabling clinicians to address the goal of making friends in a more efficient and effective manner.

Schistosoma prevalence in appendicitis.

BACKGROUND: Schistosomiasis is a waterborne trematode with numerous subtypes affecting different areas of the body. Rob Ferreira Hospital is located in an endemic area for schistosomiasis in the Lowveld region of South Africa. We set out to determine the prevalence of Sch istosoma in appendicitis. METHODS: From 2009 to 2013, all appendix samples removed in theatre were reviewed. A total of 304 cases were retrieved. Viable ova, calcified ova, or schistosomal granulomas was considered proof of exposure. RESULTS: Thirty-one out of the 304 cases revealed evidence of schistosomal exposure, equating to 10.2 %. CONCLUSION: A prevalence of more than 10 % is truly significant seeing as how a delayed diagnosis can lead to serious complications, or how a misdiagnosis can result in unnecessary and often protracted treatment with harmful drugs.

Improving antimicrobial prescribing: implementation of an antimicrobial i.v.-to-oral switch policy.

Antimicrobial stewardship programmes reduce the risk of hospital associated infections (HAI) and antimicrobial resistance, and include early intravenous-to-oral switch (IVOS) as a key stewardship measure. We audited the number of patients on intravenous antimicrobials suitable for oral switch, assessed whether prescribing guidelines were followed and reviewed prescribing documentation in three clinical areas in the Western General Hospital, Edinburgh, in late 2012. Following this, the first cycle results and local guidelines were presented at a local level and at the hospital grand rounds, posters with recommendations were distributed, joint infection consult and antimicrobial rounds commenced and an alert antimicrobial policy was introduced before re-auditing in early 2013. We demonstrate suboptimal prescribing of intravenous antimicrobials, with 43.9% (43/98) of patients eligible for IVOS at the time of auditing. Only 56.1% (55/98) followed empiric prescribing recommendations. Documentation of antimicrobial prescribing was poor with stop dates recorded in 14.3%, indication on prescription charts in 18.4% and in the notes in 90.8%. The commonest reason for deferring IVOS was deteriorating clinical condition or severe sepsis. Further work to encourage prudent antimicrobial prescribing and earlier consideration of IVOS is required.

The effect of a large Legionnaires' disease outbreak in Southwest Edinburgh on acute and critical care services.

OBJECTIVE: The largest outbreak of Legionnaires Disease (LD) in the UK for a decade occurred in Edinburgh in June 2012. We describe the clinical and public health management of the outbreak. SETTING: Three acute hospitals covering an urban area of ~480,000. METHODS: Data were collected on confirmed and suspected cases and minutes of the Incident Management Team meetings were reviewed to identify key actions. RESULTS: Over 1600 urine samples and over 600 sputum samples were tested during the outbreak. 61 patients with pneumonia tested positive for Legionella pneumophila serogroup 1 by urinary antigen detection, culture, respiratory PCR or serology. A further 23 patients with pneumonia were treated as suspected cases on clinical and epidemiological grounds but had no microbiological diagnosis. 36% of confirmed and probable cases required critical care admission. Mean ICU length of stay was 11.3 (±7.6) days and mean hospital length of stay for those who were admitted to ICU was 23.0 (±17.2) days. For all hospitalized patients the mean length of stay was 15.7 (±14) days. In total there were four deaths associated with this outbreak giving an overall case fatality of 6.5%. Hospital and critical care mortality was 6.1% and 9.1%, respectively. CONCLUSION: A significant proportion of patients required prolonged multiple organ support or complex ventilation. Case fatality compared favourably to other recent outbreaks in Europe. Access to rapid diagnostic tests and prompt antibiotic therapy may have mitigated the impact of pre-existing poor health among those affected.

Chronic disease epidemiology, cancer and mobile global approaches to disease prevention.

The focus of this symposium was worldwide prevention of chronic disease through the use of inexpensive Internet pathways, as demonstrated with the Supercourse project, and other initiatives, including promoting mobile phone technology (m-health). This symposium highlighted the need to use the Supercourse to prevent cancer and other chronic diseases. It also highlighted several components of the Supercourse library, including the former Soviet Union network, the Latin American network, and some other initiatives.

Organising a World Congress of Epidemiology (WCE): reflections and lessons from the XIX WCE, Scotland.

The 3-yearly World Congress of Epidemiology is the premier, international, scientific conference organised under the auspices of the International Epidemiological Association (in open competition). This paper explores the justification for seeking to host the Congress and reflects on the structures and processes adopted in making the XIXth Congress in Scotland happen. Preparing the bid was invaluable for forming collaborations, generating scientific ideas, and garnering opinion. After the bid was accepted, we formed a local organising committee, named the Management Executive Committee to signal its decision making authority; and scientific, fundraising, marketing, international and social subcommittees. There was uncertainty about critical matters such as delegate numbers, costs and the total budget. Early decisions had to be made on, for example, the fee and fundraising target (£250,000), despite financial risks. Development of the scientific programme was a critical step that underpinned fundraising and marketing and permitted involvement of the international committee. Overall the 2011 WCE succeeded. The key ingredients to success were: a large collaboration of institutions and individuals; early pledges of financial support mostly from the UK; the valuable and relevant experience of the professional conference organisers; unstinting support and advice from IEA; and the effectiveness of the committee structure. The educational and professional development benefits of this WCE will reach a worldwide community and not just delegates, because of video, PowerPoint and textual accounts being open access on the Internet. This reach is unprecedented for IEA's World Congresses. We anticipate that the Congress will translate into better public health practice, better future Congresses, advances in epidemiology and improved population health.

Non-tuberculous mycobacterial infections in the Scottish Borders: identification, management and treatment outcomes--a retrospective review.

Non-tuberculous mycobacteria are opportunist pathogens increasingly recognised as a cause of pulmonary and extrapulmonary disease. Treatment is complicated, prolonged and potentially toxic, and due to a limited evidence base, potentially contentious and idiosyncratic. This is a retrospective review of non-tuberculous mycobacteria cases in the NHS Borders Health Board between 1992 and 2010. We consider incidence, species identified, drug sensitivity testing and treatment outcome with reference to the British and American Thoracic Society guidelines. Thirty-eight cases of non-tuberculous mycobacteria isolates were identified; 84.21% were pulmonary and 42.11% were Mycobacterium avium complex. Incidence rose from 1.92/100,000 in 1993 to 4.43/100,000 in 2010. The British Thoracic Society guidelines were followed in 45.45% of cases. A total of 36.36% were successfully treated with another 36.36% still being treated with antimicrobials. There is a clear need for more research on treatment for this group of 'emerging pathogens' and it remains to be seen if concordance with current guidelines will improve treatment outcomes.

Controlling an outbreak of MRSA in the neonatal unit: a steep learning curve.

Meticillin resistant Staphylococcus aureus (MRSA) can cause serious infections in the newborn. While audit may show that a neonatal unit's main cause of infective morbidity is the coagulase negative staphylococcus, health authorities and politicians fear the implications of MRSA and its impact on the general public. MRSA causes mortality and morbidity in other areas of hospitals in the UK and in many other countries and there is an uneasy acceptance that this is now the established norm. However, MRSA in the neonatal unit carries sensitivities which have a huge impact on the reactions of health authorities, politicians and the press.

Ascites is a negative prognostic indicator in chronic hepatitis in dogs.

BACKGROUND: Chronic hepatitis (CH) in dogs is common but little is known about factors associated with survival. Ascites is a well-recognized negative prognostic indicator in humans. HYPOTHESIS: Ascites is a negative prognostic indicator in CH in dogs. ANIMALS: Thirty-four dogs with histologically confirmed CH presented to 1 institution between 1996 and 2005. METHODS: Retrospective observational study. CH was diagnosed by histopathology of liver tissue according to the WSAVA criteria. Ascites was diagnosed by abdominal ultrasound. The association of ascites with survival from diagnosis or onset of owner-reported clinical signs until death from any cause or from liver disease was analyzed. Ascitic and nonascitic groups were further analyzed for differences in treatment and sex. RESULTS: Fourteen of 34 dogs had ascites. Survival from diagnosis to death from liver disease was 0.4 months (95% confidence interval [CI], 0.2-0.6) for ascitic dogs and 24.3 months (CI 11.4-37.1) for nonascitic dogs (P < .001), and from onset of signs to death from liver disease was 2.0 months (CI 0.0-5.6) for ascitic dogs and 33.0 months (CI 8.6-57.4) for nonascitic dogs (P= .0020). Diet and spironolactone use differed between groups. CONCLUSIONS AND CLINICAL IMPORTANCE: Ascites is a significant negative prognostic indicator in dogs with CH. Veterinarians and owners can use this information to aid clinical decision making in affected dogs.

Conversion rates for prehospital paroxysmal supraventricular tachycardia (PSVT) with the addition of adenosine: a before-and-after trial.

OBJECTIVE: To determine whether the prehospital administration of adenosine to adults with stable and unstable paroxysmal supraventricular tachycardia (PSVT) influences conversion rate (CR) to sinus rhythm, scene time, use of synchronized electrical cardioversion (SEC), and accuracy of rhythm strip interpretation by paramedics. METHODS: This before-and-after study compared a retrospective control group (CG) prior to the introduction of adenosine with a prospective treatment group (TG) following the addition of adenosine to the PSVT treatment protocol in a large urban advanced life support emergency medical services system. The population represented patients > or = 18 years of age with PSVT diagnosed by the paramedic (defined as spontaneous onset of a regular narrow-complex tachycardia between 140 and 250 beats/minute). RESULTS: The CG comprised 74 calls and the TG 137 calls. The overall CR was higher in the TG (59% vs 32%, p < 0.001). The SEC and spontaneous conversion rates remained unchanged. The proportion of untreated patients with PSVT decreased from 26% CG to 12% TG (p < 0.01). Scene times were longer in the TG (26 vs 19 minutes, p < 0.001). Agreement between paramedic and physician rhythm strip interpretations was fair to moderate (CG kappa 0.43 [95% CI: 0.14, 0.72]; TG kappa 0.37 [95% CI: 0.13, 0.61]). CONCLUSIONS: The introduction of adenosine was associated with a significant increase in the prehospital CR of stable and unstable PSVT, while the SEC and spontaneous conversion rates were similar in each group; however, scene times were longer in the TG and paramedic accuracy in rhythm strip interpretation remained fair to moderate.

Differentiation of the epithelial apical junctional complex during mouse preimplantation development: a role for rab13 in the early maturation of the tight junction.

We have investigated the mechanisms by which the epithelial apicolateral junctional complex (AJC) is generated during trophectoderm differentiation in the mouse blastocyst using molecular, structural and functional analyses. The mature AJC comprises an apical tight junction (TJ), responsible for intercellular sealing and blastocoel formation, and subjacent zonula adherens E-cadherin/catenin adhesion complex which also extends along lateral membrane contact sites. Dual labelling confocal microscopy revealed that the AJC derived from a single 'intermediate' complex formed following embryo compaction at the 8-cell stage in which the TJ-associated peripheral membrane protein, ZO-1alpha- isoform, was co-localized with both alpha- and beta-catenin. However, following assembly of the TJ transmembrane protein, occludin, from the early 32-cell stage when blastocoel formation begins, ZO-1alpha- and other TJ proteins (ZO-1alpha+ isoform, occludin, cingulin) co-localized in an apical TJ which was separate from a subjacent E-cadherin/catenin zonula adherens complex. Thin-section electron microscopy confirmed that a single zonula adherens-like junctional complex present at the AJC site following compaction matured into a dual TJ and zonula adherens complex at the blastocyst stage. Embryo incubation in the tracer FITC-dextran 4 kDa showed that a functional TJ seal was established coincident with blastocoel formation. We also found that rab13, a small GTPase previously localized to the TJ, is expressed at all stages of preimplantation development and relocates from the cytoplasm to the site of AJC biogenesis from compaction onwards with rab13 and ZO-1alpha- co-localizing precisely. Our data indicate that the segregation of the two elements of the AJC occurs late in trophectoderm differentiation and likely has functional importance in blastocyst formation. Moreover, we propose a role for rab13 in the specification of the AJC site and the formation and segregation of the TJ.

Prospective evaluation of the potential role of teleradiology in acute interhospital trauma referrals.

BACKGROUND: Teleradiology is one form of telemedicine that would allow the transmission of radiographs before the transfer of acutely traumatized patients between referring and receiving hospitals. The purpose of this study was to evaluate the potential impact of a prehospital teleradiology system on trauma patient management and transfer. METHODS: Forty-four injured adults referred to a trauma center were included. The history, physical examination, and radiographic findings reported by the referring physician to the receiving physician were documented. The plain radiographs of the chest, pelvis, and cervical spine taken at the referring hospital were obtained after patient transfer. For each case, two reviewers blinded to the case (surgeon [S] and emergency department physician [E]) and one reviewer not blinded to the case were individually presented with the referring physician's report and the radiographs. The reviewers were surveyed as to the implications of viewing the plain radiographs taken at the referring hospital before patient transfer. RESULTS: Overall, the blinded reviewers felt that viewing the radiographs before transfer would have influenced care in 40% and 38% of cases as judged by (S) and (E), respectively, with a crude agreement of 67.5% (kappa level, 0.32). The blinded reviewers (S and E) commonly noted the following four changes in management as a result of viewing the referred radiographs: requested further clinical history (S, 18%; E, 23%), suggested further pretransfer interventions (S, 38%; E, 30%), suggested further pretransfer diagnostic tests (S, 25%; E, 13%), and emphasized precautions during transfer (S, 28%; E, 30%). The nonblinded reviewer suggested potential influence in the management of at least 65% of the cases. CONCLUSION: This study suggests that viewing the radiographs of acutely injured trauma patients has the potential to influence many aspects of the management of interhospital transfer.

An outbreak of Salmonella enteritidis phage type 5a infection in a residential home for elderly people.

The first outbreak of Salmonella enteritidis phage type (PT) 5a infection to be reported occurred after a party in a residential home for elderly people in May 1995. The party was attended attended by 96 residents, staff and guests. S. enteritidis PT5a was isolated from 14 of the 25 clinical cases identified after the party and S. enteritidis PT4 from another clinical case. Two elderly residents with S. enteritidis PT5a infection died. Infection with S. enteritidis PT5a was associated with consumption of prawn in mayonnaise vol-au-vents, sausage rolls, corned beef sandwiches, and sausages. The investigation of this outbreak illustrated the difficulty that elderly people may have in the completion of questionnaires. It also highlighted areas for intervention; such as reminders about basic hygiene precautions to prevent secondary spread and the importance of coordinated reinforcement in the workplace of formal food hygiene training for cooks. The Food Safety Regulations 1995 came into force soon after this outbreak: their implementation would probably have prevented it.

Guidelines for the use of imaging techniques for the investigation of venous thromboembolic disease.

The diagnosis of venous thromboembolic disease remains a difficult challenge. Chest radiography, ventilation/perfusion lung scanning, noninvasive leg testing, and pulmonary angiography were evaluated with regard to sensitivity, specificity, positive and negative predictive values. The need for treatment, observation, or serial testing with respect to risks and benefits of treatment and likelihood of serious outcomes was evaluated. The evidence for conclusions was based on the methodology and values of the Canadian Task Force on the Periodic Health Examination. The Diagnostic Imaging Advisory Group of the Canadian Association of Emergency Physicians developed eight recommendations.

Aspirin use in middle-aged men with cardiovascular disease: are opportunities being missed?

BACKGROUND: Since the 1980s, clinical trial evidence has supported aspirin use in the secondary prevention of cardiovascular disease (CVD). AIM: To explore aspirin use among British men with known CVD in a population-based study. METHOD: Longitudinal study (British Regional Heart Study), in which subjects have been followed up for cardiovascular morbidity and mortality since 1978-1980. Aspirin use was assessed by questionnaires to study participants in November 1992 (Q92); cardiovascular diagnoses are based on general practice notifications to October 1992. A total of 5751 men aged 52-73 years (87% of survivors) completed questions on aspirin use. RESULTS: Overall, 547 men (9.5%) were taking aspirin daily, of whom 321 (59%) had documented CVD. Among men with pre-existing disease, 153 out of 345 (44%) men with myocardial infarction, 42 out of 109 (39%) with stroke, and 75 out of 247 (29%) with angina were taking aspirin daily. Among men with angina (54% versus 26%) or myocardial infarction (59% versus 42%), those who had undergone coronary artery bypass surgery (CABG) or angioplasty were more likely to be receiving aspirin. Higher rates of aspirin use were also found in those whose last major event occurred after January 1990 (47% versus 34%). There was no association between aspirin use and social class or region of residence. CONCLUSION: Despite strong evidence of its effectiveness, many patients with established CVD were not receiving aspirin. Daily aspirin treatment was less likely in men with less recent major CVD events and in those who had not received invasive treatment.

Cardiovascular safety of high doses of inhaled fenoterol and albuterol in acute severe asthma.

BACKGROUND: It has been suggested that overuse of fenoterol metered-dose inhalers (MDIs) may increase the risk of death from asthma due to cardiac arrhythmias. Our primary objective was to compare the cardiovascular safety of fenoterol and albuterol MDIs when administered in maximal bronchodilating or maximal tolerated doses to an absolute maximum of 16 puffs, for the emergency department (ED) treatment of acute severe asthma. METHODS: Asthmatic patients presenting to the ED with acute severe asthma (FEV1 less than 50% of predicted) were enrolled in a multicenter, randomized, double-blind, parallel-group study. Following baseline measurements, (medical history, physical examination, determination of serum potassium and serum theophylline levels, oximetry, 12-lead ECG, and spirometry), each patient received 4 puffs of either fenoterol, 200 micrograms per puff, or albuterol, 100 micrograms per puff, 1 puff every 30 s via an MDI attached to a holding chamber. Additional doses of inhaled beta 2-agonist were administered by dose titration, 2 puffs every 10 min to a maximal cumulative dose of 16 puffs of albuterol or fenoterol, side effects were intolerable to the patient, or an FEV1 plateau (i.e., < 10% improvement for 2 consecutive doses) occurred. ECG was recorded continuously via Holter monitor, and respiratory rate, BP, dyspnea (Borg scale), and FEV1 were assessed after each dose. RESULTS: 128 patients were randomized to receive fenoterol and 129 to receive albuterol. Overall, fenoterol increased FEV1 160 mL more than albuterol. The mean (SEM) FEV1 increase from baseline was 0.75 +/- 0.06 L in the fenoterol group and 0.59 +/- 0.06 L in the albuterol group (p < 0.03). Both beta 2-agonists caused a decrease in serum potassium level that was significantly greater in the fenoterol (0.23 +/- 0.04 mmol/L) than in the salbutamol (0.06 +/- 0.03 mmol/L) group (p = 0.0002). There was also a greater increase in the Q-Tc interval in the fenoterol group, 0.011 +/- 0.003 s compared with 0.003 +/- 0.003 s in the albuterol group (p < 0.05). Differences in hypokalemia and Q-Tc prolongation associated with fenoterol and albuterol were significantly different only after 8 puffs of fenoterol had been given. 32 patients exhibited ventricular premature beats, 14 in the fenoterol group and 18 in the albuterol group. There were 34 patients with episodes of supraventricular premature beats, 17 in each group. No episodes of sustained ventricular tachycardia were detected in either group. CONCLUSIONS: In adequately oxygenated patients, using dose titration of fenoterol, in a formulation of 200 micrograms per puff by MDI valved holding chamber and mask, to a total dose of 3,200 micrograms and salbutamol (100 micrograms per puff) to a total dose of 1,600 micrograms over 90 min, showed cardiovascular safety in acute severe asthma. This was evidenced by absence of cardiovascular mortality or clinically significant arrhythmias in either group. The 100% greater dose of fenoterol improved FEV1 significantly more than salbutamol and was associated with a relatively small but significantly greater prolongation of the Q-Tc interval and decrease in serum potassium level. This study does not exclude the possibility that adverse cardiac events could occur with severe hypoxemia.