A cluster-randomised trial to evaluate an intervention to promote handwashing in rural Nigeria.

Handwashing with soap at critical times helps prevent diarrhoeal diseases. Changing handwashing practices through behaviour change communication remains a challenge. This study designed and tested a scalable intervention to promote handwashing with soap. A cluster-randomised, controlled trial compared our intervention against standard practice. Subjects were men, women and children in 14 villages in Cross-River state, Nigeria. The primary outcome was the proportion of observed key events on which hands were washed with soap. Binomial regression analysis calculated prevalence differences between study arms. The intervention had minimal effect on the primary outcome (+2.4%, p = 0.096). The intervention was associated with increased frequency of handwashes without soap before food contact (+13%, p = 0.017). The intervention failed to produce significant changes in handwashing with soap at key times. The low dose delivered (two contact points) may have increased scalability at the cost of effectiveness, particularly in the challenging context of inconvenient water access.

Comparison of structured observation and pictorial 24 h recall of household activities to measure the prevalence of handwashing with soap in the community.

This study compared structured observation with a 24 h pictorial recall of household activities ('sticker diary') to measure the prevalence of handwashing with soap (HWWS) in the community. The study was done within a cluster-randomised trial evaluating a handwashing promotion programme in Bihar, India. HWWS at key occasions in mothers and school children was measured by structured observation in 299 households from 32 villages. Sticker diaries recalling common activities, including personal hygiene, were used to measure HWWS in 299 households from a further 20 villages. Sticker diary HWWS prevalence estimates were about 13% points higher than structured observation estimates, but the differences varied by the type of handwashing occasion. This study confirms structured observation as the method of choice for the study of handwashing behaviours. The sticker diary method may be useful in large-scale surveys. Sticker diaries may overestimate HWWS at important occasions, but probably less so than conventional questionnaire tools.

Tracheal extubation of the adult intensive care patient with a predicted difficult airway - a narrative review.

Management of the difficult airway is an important, but as yet poorly-studied, component of intensive care management. Although there has been a strong emphasis on prediction and intubation of the difficult airway, safe extubation of the patient with a potentially difficult airway has not received the same attention. Extubation is a particularly vulnerable time for the critically ill patient and, because of the risks involved and the consequences of failure, it warrants specific consideration. The Royal College of Anaesthetists 4th National Audit Project highlighted differences in the incidence and consequences of major complications during airway management between the operating room and the critical care environment. The findings in the section on Intensive Care and Emergency Medicine reinforce the importance of good airway management in the critical care environment and, in particular, the need for appropriate guidelines to improve patient safety. This narrative review focuses on strategies for safe extubation of the trachea for patients with potentially difficult upper airway problems in the intensive care unit.

Case registry systems for pandemic influenza A(H1N1)pdm09 in Europe: are there lessons for the future?

Countries across Europe developed a range of database systems to register pandemic influenza A(H1N1)pdm09 cases. Anecdotal reports indicate that some systems were not as useful as expected. This was a cross-sectional, semi-structured survey of health professionals who collected and reported pandemic influenza A(H1N1)pdm09 cases in 23 countries within the 27 European Union (EU) Member States plus Norway. We describe here the experiences of using pandemic case register systems developed before and during the pandemic, whether the systems were used as intended and, what problems, if any, were encountered. We conducted the survey to identify improvements that could be made to future pandemic case registers at national and EU level. Despite many inter-country differences, 17 respondents felt that a standardised case register template incorporating a limited number of simple standard variables specified in advance and agreed between the World Health Organization and the European Centre for Disease Prevention and Control could be useful. Intra- and inter-country working groups could facilitate information exchange, clearer system objectives and improved interoperability between systems.

Clustered lot quality assurance sampling: a pragmatic tool for timely assessment of vaccination coverage.

OBJECTIVES: To evaluate oral poliovirus vaccine (OPV) coverage of the November 2009 round in five Northern Nigeria states with ongoing wild poliovirus transmission using clustered lot quality assurance sampling (CLQAS). METHODS: We selected four local government areas in each pre-selected state and sampled six clusters of 10 children in each Local Government Area, defined as the lot area. We used three decision thresholds to classify OPV coverage: 75-90%, 55-70% and 35-50%. A full lot was completed, but we also assessed in retrospect the potential time-saving benefits of stopping sampling when a lot had been classified. RESULTS: We accepted two local government areas (LGAs) with vaccination coverage above 75%. Of the remaining 18 rejected LGAs, 11 also failed to reach 70% coverage, of which four also failed to reach 50%. The average time taken to complete a lot was 10 h. By stopping sampling when a decision was reached, we could have classified lots in 5.3, 7.7 and 7.3 h on average at the 90%, 70% and 50% coverage targets, respectively. CONCLUSIONS: Clustered lot quality assurance sampling was feasible and useful to estimate OPV coverage in Northern Nigeria. The multi-threshold approach provided useful information on the variation of IPD vaccination coverage. CLQAS is a very timely tool, allowing corrective actions to be directly taken in insufficiently covered areas.

Education in airway management.

In airway management, poor judgment, education and training are leading causes of patient morbidity and mortality. The traditional model of medical education, which relies on experiential learning in the clinical environment, is inconsistent and often inadequate. Curriculum change is underway in many medical organisations in an effort to correct these problems, and airway management is likely to be explicitly addressed as a clinical fundamental within any new anaesthetic curriculum. Competency-based medical education with regular assessment of clinical ability is likely to be introduced for all anaesthetists engaged in airway management. Essential clinical competencies need to be defined and improvements in training techniques can be expected based on medical education research. Practitioners need to understand their equipment and diversify their airway skills to cope with a variety of clinical presentations. Expertise stems from deliberate practice and a desire constantly to improve performance with a career-long commitment to education.

Changes in airway configuration with different head and neck positions using magnetic resonance imaging of normal airways: a new concept with possible clinical applications.

BACKGROUND: The sniffing position is often considered optimal for direct laryngoscopy. Another concept of airway configuration involving a laryngeal vestibule axis and two curves has also been suggested. We investigated whether this theory can be supported mathematically and if it supports the sniffing position as being optimal for direct laryngoscopy. METHODS: Magnetic resonance imaging scans were performed in 42 normal adult volunteers. The airway passage was divided into two curves-primary (oro-pharyngeal curve) and secondary (pharyngo-glotto-tracheal curve). Airway configuration was evaluated in the neutral, extension, head lift, and sniffing positions. The airway passage, point of inflection (where the two curves meet), its tangent, and the line of sight were plotted on each scan. RESULTS: The point of inflection lay within the laryngeal vestibule in all positions. The head lift and sniffing positions caused the tangent to the point of inflection to approximate the horizontal plane. The sniffing, extension, and head lift positions caused a reduction in the area between the line of sight and the airway curve compared with the neutral position. CONCLUSIONS: A two-curve theory is proposed as a basis for explaining airway configuration. The changes in these curves with head and neck positioning support the sniffing position as optimal for direct laryngoscopy. Application of this new concept to other forms of laryngoscopy should be investigated.

Ongoing mumps outbreak in a student population with high vaccination coverage, Netherlands, 2010.

Since December 2009, mumps incidence has increased in the Netherlands. As of 20 April 2010, 172 cases have been notified on the basis of laboratory confirmation or linkage to a laboratory-confirmed case. Of these, 112 were students, the majority of whom had been vaccinated (81%). Although outbreaks in vaccinated populations have been described before, risk factors for exposure and susceptibility, and dose-dependent vaccine effectiveness in a student population of this nature are relatively unknown.

Nationwide outbreak of STEC O157 infection in the Netherlands, December 2008-January 2009: continuous risk of consuming raw beef products.

The Netherlands experienced a nationwide outbreak of Shiga toxin-producing Escherichia coli (STEC) O157 with onset of symptoms from the end of December 2008 until the end of January 2009. A total of 20 laboratory-confirmed cases were linked to the outbreak strain, serotype O157: H-, stx1, stx2, eae and e-hly positive. The investigation into the source of this outbreak is still ongoing, but evidence so far suggests that infection occurred as a result of consuming contaminated raw meat (steak tartare).

Personal protection equipment for biological hazards: does it affect tracheal intubation performance?

PURPOSE: Personal protection equipment (PPE) is recommended for use during airway management of patients with highly contagious respiratory tract illness. While its use in chemical hazards and its effect on airway management has been assessed previously, there has been no research assessing whether this equipment affects the ability to perform tracheal intubation. It is the intention of this investigation to answer this question. METHODS: Eighteen workers at various level of training were asked to wear three different types of PPE while performing four different types of tracheal intubation. The PPE used included the eye shield, face shield and the "Dustmaster". The intubation techniques were direct laryngoscopy, intubation through the intubating laryngeal mask (Fastrach) and flexible bronchoscopy using the eyepiece and an eyepiece with camera attached. We assessed the time to intubate as well as the incidence of oesophageal intubation. A short questionnaire was used to examine participants' subjective experiences of wearing the various types of PPE. RESULTS: There was no significant effect on the time to intubation for any of the methods studied. However, all subjects found that the face shield was uncomfortably hot to wear. Fibreoptic bronchoscopic intubation using the eyepiece was particularly difficult with all of the PPE used due to the distance of the subjects' eye from the eyepiece. CONCLUSION: Although the use of PPE may not affect the length of time to intubate manikins, certain types of PPE may be uncomfortable to wear and noisy. Further research is needed to investigate whether this could be a problem in the clinical setting or in actual difficult intubations.

The human NAD+-dependent 15-hydroxyprostaglandin dehydrogenase gene promoter is controlled by Ets and activating protein-1 transcription factors and progesterone.

NAD+-dependent 15-hydroxyprostaglandin dehydrogenase (PGDH) is a key catabolic enzyme in the inactivation of PGF2alpha and PGE2 and therefore serves as an important determinant in regulating their local concentrations. To gain insights into the transcriptional regulation of this enzyme, we have isolated 3.5 kb of the 5'-flanking sequence of the human PGDH promoter and characterized its control in hemopoietic cells and cells of myometrial and placental origin. Several potential binding sites for cAMP-responsive element-binding protein (CREB), Ets, and activating protein-1 (AP-1) transcription factors are present within 2368 bp of the 5'-flanking region. This region and deletions thereof were fused to the luciferase reporter gene and used for transient transfection experiments. In Jurkat leukemic T cells, which express PGDH endogenously, the transfected PGDH promoter was strongly induced by phorbol ester. Induction was reversed by coexpression of A-Fos, a dominant negative to AP-1. In primary cultures of myometrial smooth muscle cells (SMC), the Ets family members Ets-1, Ets-2, and PEA3 potently stimulated transcriptional activity of the PGDH promoter. PEA3-mediated activation was partially repressed by A-Fos, suggesting an involvement of AP-1 proteins, which might be conferred by a distal and a proximal Ets/ AP-1 composite element. The distal Ets/AP-1 element is flanked by two CRE-like sequences. Cotransfection of A-CREB, a dominant negative to CREB, inhibited stimulation of PGDH-2368/luc3 by PEA3 in myometrial SMC, whereas treatment with 8-bromo-cAMP moderately enhanced promoter activity. Progesterone is believed to be an important stimulus for PGDH expression in the utero-placental unit, thus contributing to the maintenance of a quiescent uterus during pregnancy. In myometrial SMC, both isoforms of the progesterone receptor, PR-B and PR-A, caused a ligand-dependent activation of PGDH-2368/luc3. Transcriptional activity of PR-B, but not PR-A, was further enhanced by the addition of 8-bromo-cAMP. We could not confirm a recently proposed transcriptional control of PGDH by mineralocorticoid receptor. No effect of mineralocorticoid receptor, in the absence or presence of aldosterone, with or without 8-bromo-cAMP, was observed on PGDH-2368/luc3. Taken together, these findings demonstrate control of the PGDH promoter by multiple pathways and provide evidence for cross-talk among Ets, AP-1, cAMP, and PR-mediated signaling, suggesting complex regulatory mechanisms for the expression of PGDH.

Aberrant cryptic responsiveness of the pCAT 3- and pGL3-promoter reporter vectors.

Transfection analyses are an informative method to assess the activity of specific promoter or enhancer elements in mammalian cells. Commercially available reporter vectors can be extremely useful investigative tools for such studies. This study reports that the pCAT 3- and pGL3-promoter vectors display cryptic responsiveness to androgens when they contain a DNA insert, while the empty vector, a commonly used negative control, is nonresponsive. Our studies initially aimed to characterize novel androgen-responsive DNA sequences in human genomic DNA through transactivational analyses. An isolated DNA fragment, designated ARC-3, contained three putative androgen response element "half-sites" and was androgen-responsive when cloned into the pCAT3-promoter vector. While we originally believed this to be a novel enhancer element, subsequent analyses of this clone revealed that this vector displays cryptic activity in the presence of an androgen. This was confirmed by cloning several unrelated DNA fragments that did not contain any known classic response elements into the pCAT3-promoter vector, all of which were found to be responsive. The empty vector (negative control) was again nonresponsive. The ARC-3 DNA fragment was also weakly responsive to stimulation when cloned into the pGL3-promotor vector, which is identical to the pCAT3-promoter vector, with the exception of an intron located 5' of the chloramphenicol acetyltransferase gene, and the reporter genes. This work demonstrates that both the pCAT3- and pGL3-promoter vectors are inappropriate to assess androgen-responsive enhancers and emphasizes the importance of the careful selection of reporter vectors and controls when conducting transactivational analysis.