Impact of removing the healthcare mask mandate on hospital-acquired COVID-19 rates.

BACKGROUND: Mandatory mask-wearing policies were one of several measures employed to reduce hospital-acquired SARS-CoV-2 infection throughout the pandemic. Many nations have removed healthcare mask mandates, but there remains a risk of new SARS-CoV-2 variants or epidemics of other respiratory viruses. AIM: To demonstrate the impact of removing the healthcare mask mandate. METHODS: SARS-CoV-2 infections were analysed in a large teaching hospital for 40 weeks in 2022 using a controlled interrupted time-series design. The intervention was the removal of a staff/visitor surgical mask-wearing policy for the most wards at week 26 (intervention group) with a subset of specific wards retaining the mask policy (control group). The hospital-acquired SARS-CoV-2 infection rate was adjusted by the underlying community infection rate. FINDINGS: In the context of a surge in SARS-CoV-2 infection, removal of the mask mandate for staff/visitors was not associated with a statistically significant change in the rate of nosocomial SARS-CoV-2 infection in the intervention group (incidence rate ratio: 1.105; 95% confidence interval: 0.523-2.334; P = 0.79) and there was no post-intervention trend (1.013; 0.932-1.100; P = 0.76) to suggest a delayed effect. The control group also showed no immediate or delayed change in infection rate. CONCLUSION: No evidence was found that removal of a staff/visitor mask-wearing policy had a significant effect on the rate of hospital-acquired SARS-CoV-2 infection. This does not demonstrate that masks were ineffective through the pandemic, but provides some objective evidence to justify the removal of healthcare mask mandates once there was widespread immunity and reduced disease severity.

Transmission dynamics and associated mortality of nosocomial COVID-19 throughout 2021: a retrospective study at a large teaching hospital in London.

BACKGROUND: The impact of nosocomial SARS-CoV-2 infections has changed significantly since 2020. However, there is a lack of up-to-date evidence of the epidemiology of these infections which is essential in order to appropriately guide infection control policy. AIMS: To identify the secondary attack rate of SARS-CoV-2 infection and associated mortality across different variants of concern. METHODS: A single-centre retrospective study of all nosocomial SARS-CoV-2 exposure events was conducted between 31st December 2020 and 31st December 2021. A secondary attack rate was calculated for nosocomial acquisition of SARS-CoV-2 infection and time to positivity. Positive contacts were assessed for all-cause 30-day mortality. RESULTS: A total of 346 sequential index exposure events were examined, and 1378 susceptible contacts identified. Two hundred susceptible contacts developed SARS-CoV-2 infection (secondary attack rate of 15.5%). The majority of index cases (59%) did not result in any secondary SARS-CoV-2 infection. Where close contacts developed SARS-CoV-2 infection, 80% were detected within the first five days since last contact with the index case. The overall associated mortality among positive contacts across 2021 was 9%, with an estimated reduction of 68% when comparing periods of high Omicron versus Alpha transmission. CONCLUSION: Our findings describe that most SARS-CoV-2 infections are detected within five days of contact with an index case; we have also demonstrated a considerably lower mortality rate with the Omicron variant in comparison to previous variants. These findings have important implications for informing and supporting infection control protocols to allow movement through the hospital, and ensure patients access care safely.

Prevalence and clinical correlations of genetic subtypes of Giardia lamblia in an urban setting.

The clinical significance of different genetic subtypes or assemblages of Giardia lamblia is uncertain. Cases of giardiasis in south-west London between 1999 and 2005 were studied, comparing molecular-typing results with clinical and epidemiological findings from routine surveillance. We identified 819 cases, of whom 389 returned surveillance questionnaires. A subset of 267 faecal samples was submitted for typing by sequencing of the triose phosphate isomerase (tpi) and ribosomal RNA genes, and/or a separate duplex PCR of the tpi gene. Typing was successful in 199 (75%) samples by at least one of the molecular methods. Assemblage A accounted for 48 (24%) samples and Assemblage B for 145 (73%); six (3%) were mixed. Both assemblages had similar seasonality, age distribution and association with travel. Clinical features were available for 59 successfully typed cases: both assemblages caused similar illness, but Assemblage A was significantly more frequently associated with fever than Assemblage B.

An outbreak of wound infection in cardiac surgery patients caused by Enterobacter cloacae arising from cardioplegia ice.

This paper describes an outbreak of postoperative sternal wound infections. A cardiac surgeon noted a cluster of serious infections leading to wound dehiscence, despite the fact that none of his colleagues had noticed a rise in infection rates. The infections were predominantly with Enterobacter cloacae, and molecular typing and serotyping showed these isolates to be indistinguishable. Observation of the surgeon's practice revealed nothing untoward, and there were no infections among his patients operated on in another hospital. There appeared to be no significant difference between the modes of operation of the different surgeons. The operating theatres were screened to exclude an environmental source, with samples cultured on CHROMagar Orientation, a selective/differential medium designed for urine samples. Further questioning revealed one difference between the practices of the different surgeons; this surgeon used semi-frozen Hartmann's solution to achieve cardioplegia. The freezer used for this was swabbed and yielded E. cloacae, indistinguishable from the clinical isolates. It is hypothesized that this organism contaminated the freezer, and that the contamination was passed on to the ice/slush solution, thus infecting the patients. There have been no more cases since the freezer was replaced, a rigorous cleaning schedule instituted, and steps taken to reduce the possibility of any further contamination.

Branched cells in the epidermis: an overview.

Current knowledge concerning the nature, lineage, and function of the Langerhans cell, Merkel cell, and, to a lesser extent, the melanocyte, are reviewed under headings that emphasize the confederate constitution of the epidermis as a compound tissue composed of a variety of cellular elements; the role of the lymphocyte as a component of normal epidermis is also considered. It appears that the function of the Langerhans cell has finally been established, i.e., it serves as a front-line element in immune reactions of the skin. Developmentally, it is of mesenchymal origin. The Merkel cell still presents a number of problems centering around questions of its lineage, the nature of its characteristic granules, and the "synaptic" relationship between it and the associated neurite. The melanocyte continues to hold the attention of investigators, mainly from the point of view of the chemistry of melanin and the rational treatment of pigmentary disorders based upon findings derived from fundamental research into all aspects of its biology.

Development and differentiation of dermal cells in man.

Development and differentiation of the single free cells of mesenchyme and dermis of human embryos and fetuses from week 6 to term is described. From week 6 to week 14, three cell types are present: stellate general mesenchymal cells with long processes, phagocytic macrophages of probable yolk-sac origin, and a granule-secretory type of cell, which could be either a melanoblast or a mast stem cell. From week 14 to week 21, fibroblasts are numerous and active, and perineurial cells, pericytes, melanoblasts, mast cells, and Merkel cells can be individually identified. There is also present another cell type, possible of bone marrow origin, that may be ancestral to the Langerhans cell and that may be carried over into postanal dermis as the "histiocyte" or fixed dermal macrophage. From week 24 to term there is little change apart from the development of fat cells in the deeper dermis. Neither lymphocyte nor plasma cell was observed at any stage of development. These observations were used in the specification and identification of cells of fully developed postnatal dermis.

Aspects of epidermal ultrastructure.

Some problems posed by primarily ultrastructural studies of the epidermis are highlighted and discussed, and on the whole it is concluded that purely morphologic observations are unlikely further to elucidate such questions as the nature and function of keratohyalin, or the dynamic aspects of the general keratinization process. The contribution of freeze-fracture studies to the understanding of the functional morphology of the epidermis is assessed, with particular reference to specialized contacts, and the stratum corneum. Passing reference is made to the epidermal nonkeratinocytes.

Electron microscopy of cutaneous nerves and receptors.

Recent ultrastructural observations on the connective tissue sheaths of nerves, Schwann cell-axonal relations, and nerve terminals and receptors are reviewed. It seems likely that endoneurial collagen is formed by perineurial cells during development and postnatally. New observations on "collagen pockets" are presented. Attention is drawn to freeze-fracture studies of peripheral nerve, particularly in relation to junctional complexes associated with compact myelin, and further application of the technique is considered. Current views on Merkel cells, encapsulated endings, and free nerve terminals are discussed.

Osmium iodide positive granules in spinous and granular layers of guinea pig epidermis.

The structure and distribution of osmium-iodide positive granules in cells of the spinous and granular layers of the epidermis is described. They are similar in every respect to granules described by previous authors in material not stained by the osmium-iodide technic, and the assumption that these latter granules are phospholipid in nature is augmented by the present observations.

Lipoxygenase activity of Pityrosporum in vitro and in vivo.

Lipid peroxidation has been investigated both in cultures of Pityrosporum supplemented with different lipid classes and in skin surface lipids from patients affected with pityriasis versicolor. Thin-layer chromatography (TLC) and 2 spectrophotometric methods were used: the indirect thiobarbituric acid test and the direct N,N-diethyl-1,4-phenylene-diammonium sulfate (DEPD) test. The coupling of the DEPD test with the TLC technique performed by different eluent systems allowed the detection of the specific lipoperoxides deriving from the oxidation of the different lipid classes. In the cultures, Pityrosporum was capable of peroxidating not only unsaturated free fatty acids, but also unsaturated triglycerides, cholesterol, and squalene. A similar lipid peroxidation was observed in patients with pityriasis versicolor in skin lipids from areas positive for fungal hyphae and spores and fluorescent under the UV lamp (366 nm). The lipoperoxide values were significantly higher (p less than 0.05) than in skin lipids from normal controls. Hyphae and spore-negative areas of patients with pityriasis versicolor, whether apparently normal or achromic, showed no evidence of a significant lipid peroxidation and neither did skin areas of patients with pityriasis alba. Though further investigations are necessary, it seems reasonable to suggest, in analogy with other biologic systems, that the presence in skin lipids of a significant amount of highly reactive and cytotoxic lipoperoxides may play a role in the pathogenesis of skin alterations in pityriasis versicolor, including damage to melanocytes and resulting achromia.

Ultrastructural observations on the effect of 4-hydroxyanisole on normal human melanocytes in tissue culture.

Riley's classic 1970 experiment showing a specific cytotoxic effect of 4-hydroxyanisole (4-OHA) on tissue-cultured melanocytes of black guinea pig ear skin was repeated on normal human melanocytes, and the results were examined by electron microscopy. In dispersed tissue culture, no specific toxic effect on human melanocytes was observed following equally timed exposures to similar (10(-3) M) or even higher (10(-2) M) concentrations of the drug; plasma membrane, nucleus, and cytoplasmic organelles, including melanosomes were unaffected. The same applied to melanocytes of whole epidermis exposed for 5 hr to the same concentrations of 4-OHA in culture medium. Melanocytes of PUVA treated skin similarly exposed for up to 24 hr to 10(-2) and 10(-3) M 4-OHA, likewise exhibited no evident morphological damage at the ultrastructural level. The discrepancy of results between guinea pig and man could have a variety of explanations, one of which could be due to a possible relatively low level of active tyrosinase in the human melanocytes (Riley believes the cytotoxic effect of 4-OHA to be due to the fact that it acts as a substrate for tyrosinase, toxic intermediates being liberated as a result). However, the lack of effect on the PUVA-activated melanocytes indicates that this cannot be the entire explanation.

Effect of L-carnitine on cultured murine melanoma cells exposed to azelaic acid.

The cytotoxic effect of azelaic acid on murine melanoma cells in culture is due, at least in part, to an antimitochondrial action. We investigated the possibility that the addition of carnitine to the medium may increase the transport of azelaic acid into the mitochondria and thereby increase its cytotoxic effect. Using mitochondrial cross-sectional area measured from electron micrographs as a criterion for mitochondrial damage, we found that the addition of L-carnitine to the culture medium had no effect either alone or with a low (10(-3) M) concentration of azelaic acid. At a high concentration (5 X 10(-2) M) azelaic acid caused swelling and disruption of the mitochondria to such an extent that this was not increased by carnitine. At 10(-2) M azelaic acid, however, some swelling of the mitochondria occurred which was significantly increased by the addition of carnitine. This indicates that carnitine-mediated transport of the diacid into the mitochondria had occurred. We conclude that carnitine may reduce the time or concentration needed for azelaic acid to have a toxic effect on the malignant melanocyte.

Effect of dicarboxylic acids on Harding-Passey and Cloudman S91 melanoma cells in tissue culture.

Clinically, dicarboxylic acids have a cytotoxic effect on the abnormally hyperactive and malignant epidermal melanocyte, and diacids from C8 to C13 have been shown to inhibit mitochondrial oxidoreductases. Here, their effect on the growth kinetics and ultrastructure of murine melanoma cells in culture is examined. Cultures of Harding-Passey and Cloudman S91 melanoma cells were exposed to single doses of the disodium salts of C12, C9, and C6 (which does not significantly inhibit mitochondrial enzymes) dicarboxylic acids at concentrations of 10(-3) M to 10(-1) M. With C12 and C9, viability and cell proliferation over 3 days were significantly affected by concentrations greater than 10(-2) M. With exposure to C6 at 10(-1) M and to medium to which NaCl was added to produce equal osmolarity, the effect was much less. Electron microscopy of cells exposed to C9 at 10(-1) M for 1 h and 6 h revealed massive swelling of mitochondria with destruction of cristae, but plasma and nuclear membranes and membranes of endoplasmic reticulum were intact. Similar damage was not seen with C6 at 10(-1) M nor with equiosomolar NaCl. The results confirm (1) the cytotoxicity of dicarboxylic acids for malignant melanocytes, and (2) that the mitochondrion is a prime target for their action.

Effect of dicarboxylic acids (C6 and C9) on human choroidal melanoma in cell culture.

In cell culture, azelaic acid (C9) has been shown to have an antiproliferative and cytotoxic effect on human and murine malignant cutaneous melanocytes. Normal melanocytes are unaffected, as are normal choroidal melanocytes. Here, effects on cell kinetics and ultrastructure of cells of a human choroidal melanoma line have been studied. Cells were exposed to single doses of disodium salts of azelaic (C(9)2Na) and adipic (C(6)2Na) acids at concentrations of 10(-2) M and 5 X 10(-2) M for 48 hr. C(9)2Na at 5 X 10(-2) M had a significant effect on proliferation at 24 and 48 hr and this was not reversible on removal of diacid. At 5 X 10(-2) M for 24 hr, C(6)2Na had no effect and at 5 X 10(-2) M for 48 hr had an effect which was marginally significant, but reversible. Swelling and disruption of mitochondria was seen in cells exposed to C(9)2Na at 5 X 10(-2) M for 1 hr and longer, but even at 10(-1) M, cells exposed to C(6)2Na were minimally affected. The results could encourage further investigations of the feasibility of azelaic acid therapy for uveal and ocular adnexal melanoma.

Activity of azelaic acid on cultures of lymphoma- and leukemia-derived cell lines, normal resting and stimulated lymphocytes and 3T3 fibroblasts.

Azelaic acid (C9- -dicarboxylic acid) is a competitive inhibitor of tyrosinase and some oxidoreductase in vitro, and in vivo has a beneficial effect on lentigo maligna and malignant melanoma. A definite cytotoxic effect in cultures of malignant melanocytes was also reported. In order to establish if the cytotoxic effect of the diacid is exerted equally in the absence of tyrosinase, lymphoma- and leukemia-derived cell lines were cultured for 72 hr with 10(-3) M, 10(-2) M and 5 X 10(-2) M C9 disodium salt. Normal resting lymphocytes, lymphocytes activated by phytohemoagglutinin, and mouse Balb/c 3T3 fibroblasts were also tested to study a possible effect of azelaic acid on DNA synthesis and cell duplication. At 10(-3) M C9 had no effect on the viability of all the cells tested; at 10(-2) M and 5 X 10(-2) M, C9 2Na had a 50-80% cytotoxic effect on lymphoma- and leukemia-derived cell lines, while at the same concentrations it was not toxic to normal lymphocytes, either resting or stimulated, or to 3T3 fibroblasts. The experiments on cellular incorporation of (1-9 14C) azelaic acid showed that the radiocarbon uptake was two to three times higher for lymphoma- and leukemia-derived cell lines than for lymphocytes, either resting or stimulated, or 3T3 fibroblasts. Biochemical analysis revealed that the diacid underwent beta-oxidation in all the cell cultures. Fractionated centrifugations of 3T3 fibroblasts cultured in the presence of radiolabelled azelaic acid (2 X 10(-4) M) plus cold C9 2Na (10(-2) M), showed that the radioactivity was mainly concentrated in the cytoplasm. The results, being similar to those obtained by adding azelaic acid to cultures of melanoma cells, suggest that the cytotoxic effect of azelaic acid may be due to interference with mitochondrial oxido-reductase enzymes, rather than with tyrosinase. The difference in reaction between lymphoma- and leukemia-derived cell lines and normal or stimulated lymphocytes, and 3T3 fibroblasts, could be explained on the basis of a different degree of permeability of the cell membrane, and/or to a possible different sensitivity of reaction of mitochondrial functions. A similar argument could be used to explain the absence of an effect of dicarboxylic acids upon normal as compared with hyperactive or malignant melanocytes in vivo.

Effect of dicarboxylic (C6 and C9) acids on a human squamous carcinoma cell line in culture.

In tissue culture, azelaic acid (C9) has been shown to have an anti-proliferative and cytotoxic effect on human and murine malignant melanocytes, with inhibition of mitochondrial oxido-reductase enzymes and DNA synthesis, and damage to mitochondria. Recent reports of effects on differentiation of normal keratocytes have led to the present study of its effects on a squamous carcinoma cell line. Cells were exposed to single doses of disodium salts of azelaic (C9(2)Na) and adipic (C6(2)Na) acids at concentrations of 10(-2)M and 5 x 10(-2)M for 48 hrs. Only C9(2)Na at 5 x 10(-2) M for 4 hrs., and longer, significantly affected proliferation, and the cells exhibited massive swelling of mitochondria with loss of cristae. The results further confirm the probable value of azelaic acid as a general anti-tumoral agent rather than a specifically melanocytotoxic one. They could justify clinical studies on the effect of topical azelaic acid therapy on squamous cell carcinoma in vivo.

Observations on cell kinetics and viability of a human melanoma cell line exposed to dicarboxylic acids in tissue culture.

Cultures of human melanoma cell line B0008 were exposed to the disodium salts of azelaic acid (C9 2Na), adipic acid (C6 2Na) and dodecanediaic acid (C12 2Na) at 10(-2) M and 5 x 10(-2) M for 24 hrs. None of the diacid salts had a significant effect on growth rate or viability of the cells, at 10(-2) M for 24 hrs nor had C6 2Na any effect at 5 x 10(-2) M. At 5 x 10(-2) M for 24 hrs, both C9 2Na, and C12 2Na had a significant effect in reducing both growth and viability. These effects were accompanied by morphological evidence of cell death, and swelling of mitochondria and accumulation of lipid droplets within cytoplasm of still viable cells.

Scanning electron microscopy of human and murine melanoma cells exposed to medium chain-length (C6-C12) dicarboxylic acids in tissue culture.

Human and murine (Harding-Passey and Cloudman) melanoma cells were exposed to various concentrations (1 x 10(-3) M-1 x 10(-1) M) of adipic (C6), azelaic (C9), and dodecanedioic (C12) acids for 1-6 hours in tissue culture, and the effects on shape and surface topography were examined by scanning electron microscopy. Effects, i.e., rounding up, concentration of microvilli, blebbing, and prominence of retraction fibrils were time and dose dependent, and for the same concentrations and exposure times, C12 had a greater effect than C9, and both a significantly greater effect than C6. These differential reactions to the three diacids parallel previously reported effects on cell kinetics and viability. The changes could be due to a prime effect on the cell membrane, or they might reflect phases of the cell cycle directed by action of the diacids on the nucleus; this latter seems unlikely. An effect on the cytoskeleton is possibly involved.

Culture-negative endocarditis: contribution of bartonella infections.

Two cases of bartonella endocarditis are described: one in a 55 year old homeless alcoholic man, caused by Bartonella quintana; the other in a 41 year old male with a history of exposure to cat fleas, caused by B henselae. Serological testing and polymerase chain reaction of the excised valves were used to identify the organisms. False positive serology for chlamydia was detected in one case.

An outbreak of multi-drug-resistant tuberculosis in a London teaching hospital.

We describe the epidemiology and control of a hospital outbreak of multi-drug-resistant tuberculosis (MDR-TB). A human immunodeficiency virus (HIV)-negative patient with drug-sensitive tuberculosis developed MDR-TB during a period of unsupervised therapy. She was admitted to an isolation room in a ward with HIV-positive patients, but the room, unbeknown to hospital staff, was at positive-pressure relative to the main ward. Seven HIV-positive contacts developed MDR-TB. The diagnosis in the second patient was delayed, partly because acid-fast bacilli in his sputum were assumed to be Mycobacterium avium-intracellulare. All the available Mycobacterium tuberculosis isolates were indistinguishable by molecular typing. Nearly 1400 staff and patient contacts were offered screening, but the screening programme detected only one of the cases. Despite therapy, the index patient and two of the contacts died. HIV-positive patients are more likely than others to develop tuberculosis after exposure, and the disease may progress more rapidly. In these patients the possibility that acid-fast bacilli may represent M. tuberculosis must always be considered. Patients with tuberculosis (suspected or proven) should not be nursed in the same wards as immunosuppressed patients, and should be isolated. MDR-TB cases must be isolated in negative-pressure rooms. Hospital side-rooms may be positive-pressure as a fire safety measure; infection control teams must be aware of the airflows in all isolation rooms, and must be consulted during the design of hospital buildings. Good communication between infection control teams and clinicians is important, and all medical and nursing staff must be aware of the principles of management of patients with proven or suspected tuberculosis and MDR-TB.