Diabetes distress and depression are independently associated with gastrointestinal symptoms in type 2 diabetes in Bangladesh.

BACKGROUND AND AIMS: Gastrointestinal (GI) symptoms, common in type 2 diabetes (T2D), are typically bothersome, socially embarrassing, and impact negatively on quality of life. They may also contribute to diabetes distress (DD), but this has never been formally evaluated. We aimed to investigate the relationships between GI symptoms, DD and depressive symptoms in a large cohort of individuals with T2D in Bangladesh. MATERIALS AND METHODS: 1406 unselected T2D individuals (female 58.8%; mean age 51.0 ± 12.5 years) from four diabetes clinics in Bangladesh completed validated questionnaires evaluating GI symptoms (PAGI-SYM), DD (DDS-17) and depressive symptoms (PHQ-9). RESULTS: 31.1% of participants reported GI symptoms (36.2% females, 23.7% males), while 51.1% had elevated DD and 37.8% depressive symptoms. GI symptoms exhibited independent relationships with both DD and depressive symptoms, and their likelihood was higher among those with DD (OR: 3.6 [2.2-5.6] and with depressive symptoms (OR: 5.9 [3.5-9.9]). CONCLUSIONS: GI symptoms are independently associated with both DD and depressive symptoms in people with T2D in Bangladesh.

Patient perspectives on infection prevention and control in cancer care: a survey of knowledge and attitudes among persons with cancer and their next of kin.

BACKGROUND: With the growing prevalence of antimicrobial resistance, there may be a need to strengthen infection prevention and control (IPC) measures in cancer care. When developing clinical guidelines, it is important to incorporate patient perspectives. AIM: To determine the knowledge of, and attitudes towards, IPC among persons with cancer and their next of kin in Norway. METHODS: Through discussions in expert panels and a pilot study, a survey was developed consisting of 13 knowledge statements to be judged true/false and 40 attitude items to be judged using a Likert scale and was sent to a panel of people with cancer experience on August 22nd, 2023. The mean correct responses and attitude scores were reported. FINDINGS: Of 551 respondents, the mean correct response to IPC-related knowledge questions was 79% (95% confidence interval: 78-80). Respondents were most knowledgeable about hand hygiene (99%, 546/551), but least knowledgeable about its role in preventing antibiotic resistance (41%, 225/551). Strong support was noted for IPC, especially within the patient responsibilities theme, with a mean score of 4.83. However, there was a notable reluctance towards some selected intrusive IPC measures, such as reducing contact with close relations. CONCLUSION: This survey revealed a high level of knowledge and attitudes that support the importance of IPC among persons with cancer in Norway and their next of kin. We recommend including patient perspectives in future development of IPC guidelines.

Universal admission screening: a potential game-changer in hospitals with high prevalence of MRSA.

INTRODUCTION: Despite the perception that meticillin-resistant Staphylococcus aureus (MRSA) is now under control in high-income countries, global prevalence remains high, even increasing in some regions. Universal admission screening and decolonization has been instituted in some hospitals to attempt control but the practice remains controversial. METHODS: In 2014, Mater Dei Hospital in Malta introduced a universal admission screening policy, utilizing a novel, centralized and customized approach to achieve high compliance and low cost. Admissions are screened nasally by designated staff using chromogenic media, irrespective of risk factors. Carriers are decolonized without concurrent isolation or contact precautions. In this study, longitudinal, quasi-experimental evaluation was undertaken using time series analysis to analyse the impact of the intervention on the proportion of MRSA among clinical S. aureus isolates (%MRSA) and incidence per 1000 bed-days. A cost-utility analysis was also attempted to identify approximate quality-adjusted life years (QALYs) gained. RESULTS: A transfer function model approach concluded that the intervention had a significant effect on both %MRSA and incidence. Six years following its introduction, the screening programme had led to an overall 43% long-term reduction in %MRSA from pre-screening levels [R2=0.687; Bayesian information criterion (BIC)=4.063], translating to a decrease in incidence of approximately 0.56 cases/1000 bed-days (R2=0.633, BIC=-3.063). No correlation was identified with consumption of antibiotics or alcohol hand rub. The annual cost-benefit of the programme was calculated at €1058 per QALY gain per year. CONCLUSION: The universal admission screening and decolonization intervention was successful and cost-effective in this high-endemicity setting. It facilitated improvement in the prevalence of MRSA, achieving reduction levels rarely reported by Mediterranean hospitals.

Are healthcare economics a factor behind European MRSA rates?

This study assessed the relationship between meticillin-resistant Staphylococcus aureus (MRSA) prevalence in 26 European countries with two key socioeconomic parameters, namely, gross domestic product per capita (GDP) and infant mortality rate (IMR). Whilst no significant relationship was identified between MRSA and GDP (Spearman correlation: -0.387; 95% confidence interval [CI]: -0.674 to 0.000; p = 0.0528), a significant correlation was evident between MRSA and IMR (Spearman correlation: 0.545; 95% CI: 0.208 to 0.766; p = 0.005). The elimination of a widely outlying data point retained significance. Various studies have shown IMR to be a good marker of healthcare expenditure and it is, therefore, reasonable to postulate that one possible factor in the multi-factorial epidemiology of MRSA in Europe is the level and effectiveness of healthcare expenditure within the individual countries.

Characterisation of MRSA from Malta and the description of a Maltese epidemic MRSA strain.

Malta has one of the highest prevalence rates of methicillin-resistant Staphylococcus aureus (MRSA) in Europe. However, only limited typing data are currently available. In order to address this situation, 45 MRSA isolates from the Mater Dei Hospital in Msida, Malta, were characterised using DNA microarrays. The most common strain was ST22-MRSA-IV (UK-EMRSA-15, 30 isolates). Sporadic strains included ST36-MRSA-II (UK-EMRSA-16, two isolates), PVL-positive ST80-MRSA-IV (European Clone, one isolate), ST228-MRSA-I (Italian Clone/South German Epidemic Strain, one isolate) and ST239-MRSA-III (Vienna/Hungarian/Brazilian Epidemic Strain, one isolate). Ten MRSA isolates belonged to a clonal complex (CC) 5/ST149, spa type t002 strain. This strain harboured an SCCmec IV element (mecA, delta mecR, ugpQ, dcs, ccrA2 and ccrB2), as well as novel alleles of ccrA/B and the fusidic acid resistance element Q6GD50 (previously described in the sequenced strain MSSA476, BX571857.1:SAS0043). It also carried the gene for enterotoxin A (sea) and the egc enterotoxin locus, as well as (in nine out of ten isolates) genes encoding the toxic shock syndrome toxin (tst1) and enterotoxins C and L (sec, sel). While the presence of the other MRSA strains suggests foreign importation due to travel between Malta and other European countries, the CC5/t002 strain appears, so far, to be restricted to Malta.

Correlation between meticillin-resistant Staphylococcus aureus prevalence and infection control initiatives within southern and eastern Mediterranean hospitals.

The Mediterranean region has been identified as an area of hyper-endemicity for multi-resistant hospital pathogens. To better understand potential drivers behind this situation, we attempted to correlate already published meticillin-resistant Staphylococcus aureus (MRSA) data from 27 hospitals, participants in the Antibiotic Resistance Surveillance & Control in the Mediterranean Region (ARMed) project, with responses received from the same institutions to questionnaires which dealt with various aspects of infection control and antibiotic stewardship. No difference could be ascertained between high and low prevalence hospitals in terms of scores from replies to structured questions regarding infection control set-up, hand hygiene facilities and antibiotic stewardship practices. However, we did identify differences in terms of bed occupancy and isolation facilities. Hospitals reporting frequent episodes of overcrowding, particularly involving several departments, and which found regular difficulties sourcing isolation beds, had significantly higher MRSA proportions. This suggests that infrastructural deficits related to insufficient bed availability and compounded by inadequate isolation facilities could potentiate MRSA hyper-endemicity in south-eastern Mediterranean hospitals.

Infection control and antibiotic stewardship practices reported by south-eastern Mediterranean hospitals collaborating in the ARMed project.

The prevalence of multiply resistant organisms (MROs) reported from south-eastern Mediterranean hospitals highlights the need to identify possible contributory factors to help design control interventions. This was investigated through a structured questionnaire, which examined infection control and antibiotic stewardship practices in hospitals participating or collaborating with the Antibiotic Resistance SurveilLance & Control in the Mediterranean Region (ARMed) project. A total of 45 hospitals (78.9% of invited institutions) responded to the questionnaire; 60% indicated that they faced periods of overcrowding when available bed complement was insufficient to cope with hospital admissions and 62% reported difficulties in isolating patients with MROs due to lack of available beds. Most hospitals relied mainly on washing to achieve hand hygiene, whether by non-medicated or disinfectant soaps. Dependence on solid bars of soap (28.9%) and cloth towels (37.8%) were among the problems identified as well as inconvenient distances of sinks from patient beds (66.6%). Alcohol hand rub was the predominant hand hygiene product in only 7% of hospitals. Programmes for better antibiotic use were mostly limited in scope; 33.3% reported having antibiotic prescribing guidelines and 53.3% of hospitals fed back resistance rates to prescribers. Auditing of antibiotic consumption, whether institution- or unit-based, was carried out in 37.8% of responding hospitals. Multi-faceted approaches aimed at improving isolation of patients with MROs, increasing the emphasis on hand hygiene by encouraging greater use of alcohol hand rubs and introducing effective antibiotic stewardship programmes should be encouraged in south-eastern Mediterranean hospitals.

Local ventromedial hypothalamus glucose perfusion blocks counterregulation during systemic hypoglycemia in awake rats.

The ventromedial hypothalamic nucleus (VMH) is necessary for the integrated hormonal response to hypoglycemia. To determine the role of the VMH as a glucose sensor, we performed experiments designed to specifically prevent glucopenia in the VMH, while producing hypoglycemia elsewhere. We used awake chronically catheterized rats, in which local VMH glucose perfusion (100 mM or 15 mM of D-glucose) was combined with a sequential euglycemic-hypoglycemic clamp. In two control groups the VMH was perfused either with (a) an iso-osmotic solution lacking glucose, or with (b) nonmetabolizable L-glucose (100 mM). During systemic hypoglycemia glucagon and catecholamine concentrations promptly increased in the control animals perfused with either 100 mM L-glucose or the iso-osmotic solution lacking glucose. In contrast, glucagon, epinephrine and norepinephrine release was inhibited in the animals in which the VMH was perfused with D-glucose; hormonal secretion was partially suppressed by the VMH perfusion with 15 mM D-glucose and suppressed by approximately 85% when the VMH was perfused with 100 mM D-glucose, as compared with the control groups. We conclude that the VMH must sense hypoglycemia for full activation of catecholamine and glucagon secretion and that it is a key glucose sensor for hypoglycemic counterregulation.

Ventromedial hypothalamic lesions in rats suppress counterregulatory responses to hypoglycemia.

The central nervous system has been implicated in the activation of counterregulatory hormone release during hypoglycemia. However, the precise loci involved are not established. To determine the role of the ventromedial hypoglycemia, we performed hypoglycemic clamp studies in conscious Sprague-Dawley rats with bilateral VMH lesions produced by local ibotenic acid injection 2 wk earlier. Rats with lesions in the lateral hypothalamic area, frontal lobe, sham operated (stereotaxic needle placement into hypothalamus without injection), and naive animals served as control groups. The clamp study had two phases. For the first hour plasma glucose was fixed by a variable glucose infusion at euglycemia (approximately 5.9 mM). Thereafter, for an additional 90 min, glucose was either allowed to fall to (a) mild hypoglycemia (approximately 3.0 mM) or (b) more severe hypoglycemia (approximately 2.5 mM). Glucagon and catecholamine responses of lateral hypothalamic area-, frontal lobe-lesioned, sham operated, and naive animals were virtually identical at each hypoglycemic plateau. In contrast, glucagon, epinephrine, and norepinephrine responses in the VMH-lesioned rats were markedly inhibited; hormones were diminished by 50-60% during mild and by 75-80% during severe hypoglycemia as compared with the other groups. We conclude that the VMH plays a crucial role in triggering the release of glucagon and catecholamines during hypoglycemia.

Survey of infection control infrastructure in selected southern and eastern Mediterranean hospitals.

A structured questionnaire concerning hospital infection control (IC) organisation and initiatives was sent to 45 hospitals in Algeria, Cyprus, Egypt, Jordan, Lebanon, Libya, Malta, Morocco, Tunisia and Turkey. Hospitals bordering the eastern Mediterranean appeared to have more established IC infrastructures than southern Mediterranean hospitals. However, there were no significant differences among hospitals in the two regions in surveillance activities, the presence of an antibiotic policy or feedback of resistance data to prescribers, all of which were at a low level. Only a minority of hospitals had published antimicrobial treatment guidelines or gave feedback on antimicrobial resistance data to prescribers.

Antibiotic resistance in the southeastern Mediterranean - preliminary results from the ARMed project.

Sporadic reports from centres in the south and east of the Mediterranean have suggested that the prevalence of antibiotic resistance in this region appears to be considerable, yet pan-regional studies using comparable methodology have been lacking in the past. Susceptibility test results from invasive isolates of Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Enterococcus faecium and faecalis routinely recovered from clinical samples of blood and cerebrospinal fluid within participating laboratories situated in Algeria, Cyprus, Egypt, Jordan, Lebanon, Malta, Morocco, Tunisia and Turkey were collected as part of the ARMed project. Preliminary data from the first two years of the project showed the prevalence of penicillin non-susceptibility in S. pneumoniae to range from 0% (Malta) to 36% (Algeria) [median: 29%] whilst methicillin resistance in Staphylococcus aureus varied from 10% in Lebanon to 65% in Jordan [median: 43%]. Significant country specific resistance in E. coli was also seen, with 72% of isolates from Egyptian hospitals reported to be resistant to third generation cephalosporins and 40% non-susceptible to fluoroquinolones in Turkey. Vancomycin non-susceptibility was only reported in 0.9% of E. faecalis isolates from Turkey and in 3.8% of E. faecium isolates from Cyprus. The preliminary results from the ARMed project appear to support previous sporadic reports suggesting high antibiotic resistance in the Mediterranean region. They suggest that this is particularly the case in the eastern Mediterranean region where resistance in S. aureus and E. coli seems to be higher than that reported in the other countries of the Mediterranean.

Antibiotic resistance in the southeastern Mediterranean--preliminary results from the ARMed project.

Sporadic reports from centres in the south and east of the Mediterranean have suggested that the prevalence of antibiotic resistance in this region appears to be considerable, yet pan-regional studies using comparable methodology have been lacking in the past. Susceptibility test results from invasive isolates of Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Enterococcus faecium and faecalis routinely recovered from clinical samples of blood and cerebrospinal fluid within participating laboratories situated in Algeria, Cyprus, Egypt, Jordan, Lebanon, Malta, Morocco, Tunisia and Turkey were collected as part of the ARMed project. Preliminary data from the first two years of the project showed the prevalence of penicillin non-susceptibility in S. pneumoniae to range from 0% (Malta) to 36% (Algeria) [median: 29%] whilst methicillin resistance in Staphylococcus aureus varied from 10% in Lebanon to 65% in Jordan [median: 43%]. Significant country specific resistance in E. coli was also seen, with 72% of isolates from Egyptian hospitals reported to be resistant to third generation cephalosporins and 40% non-susceptible to fluoroquinolones in Turkey. Vancomycin non-susceptibility was only reported in 0.9% of E. faecalis isolates from Turkey and in 3.8% of E. faecium isolates from Cyprus. The preliminary results from the ARMed project appear to support previous sporadic reports suggesting high antibiotic resistance in the Mediterranean region. They suggest that this is particularly the case in the eastern Mediterranean region where resistance in S. aureus and E. coli seems to be higher than that reported in the other countries of the Mediterranean.

Carriage of multidrug-resistant organisms in a tertiary university hospital in Albania-a point prevalence survey.

BACKGROUND: Antimicrobial resistance has been recognised as a serious global Public Health problem. Prevalence of Multiple-Drug-Resistant (MDR) organism carriage in Albania is largely unknown since no national surveillance system is in place and few publications are accessible in the literature. METHODS: A 1-day point-prevalence-survey (PPS) screening for nasal methicillin-resistant Staphylococcus aureus (MRSA) and rectal MDR Gram-negative carriage was carried out at the high-dependency wards in the country's only tertiary care hospital, in Tirana. RESULTS: A total of 106 nasal and 104 rectal swabs were collected. 14.2 % of patients (95 % Confidence Interval [95 CI]: 8.1-22.3 %) were MRSA nasal carriers. Resistance to aminoglycosides and fluoroquinolones was common in these isolates (≥80 %) but no resistance was identified against glycopeptides, nitrofurantoin and the relatively newer agents, tigecycline and linezolid. Fifty Enterobacteriaceae isolates were cultivated from 33 of 104 screened patients (31.7 % [95 CI: 22.9-41.6 % 95 CI]). The prevalence of Extended Spectrum Beta-Lactamase (ESBL) production in Enterobacteriaceae was 41.3 % (95 CI: 31.8-51.4 %). The two more commonly isolated Enterobacteriaceae were E. coli ([n = 28], 24 ESBL positive; 1 AmpC positive and 3 without an identified mechanism of resistance) and Klebsiella pneumoniae ([n = 13], all ESBL positive; 1 also AmpC and metallo-ß-lactamase (MBL) positive). Susceptibility to carbapenems (≥98 %), fosfomycin (90 %) and amikacin (70 + 20 % intermediate) was high but a high level of resistance to all other agents tested was noted. Non-fermenting Gram-negative bacilli were less commonly isolated {22 isolates: Acinetobacter baumannii (9); Pseudomonas aeruginosa (8) and Stenotrophomonas maltophilia (5)}. CONCLUSION: Although a significant rate of MRSA carriage was identified, the main resistance challenge in Albania appears to be linked with Gram-negative organisms, particularly ESBL in Enterobacteriaceae.

Local ventromedial hypothalamus glucopenia triggers counterregulatory hormone release.

To test the hypothesis that nuclei of the ventromedial hypothalamus (VMH) play a key role in the detection of counterregulatory responses to hypoglycemia, we delivered the glucopenic agent 2-deoxyglucose via bilaterally placed microdialysis probes into the VMH of conscious, chronically catheterized rats. The goal was to produce cellular glucopenia localized to the VMH. The volume of brain tissue exposed to 2-deoxyglucose was determined by adding [3H]2-deoxyglucose to the dialysate; its distribution in cerebral tissue was almost exclusively limited to the VMH. Rats with microdialysis probes placed into the frontal lobes served as a control group. Local perfusion of 2-deoxyglucose (but not glucose) into the VMH caused a prompt twofold increase in plasma glucose in association with a striking elevation of plasma glucagon (3.5-fold), epinephrine (30-fold), and norepinephrine (3.5-fold). No effect was seen when 2-deoxyglucose was delivered into the frontal lobes. We conclude that glucopenia localized to the VMH triggers the release of counterregulatory hormones that defend against hypoglycemia. Thus, the neurons that sense glucopenia may be situated in the VMH.

Chronic hypoglycemia and diabetes impair counterregulation induced by localized 2-deoxy-glucose perfusion of the ventromedial hypothalamus in rats.

Previous studies have demonstrated that the ventromedial hypothalamus (VMH) plays a critical role in sensing and responding to systemic hypoglycemia. To evaluate the mechanisms of defective counterregulation caused by iatrogenic hypoglycemia and diabetes per se, we delivered 2-deoxy-glucose (2-DG) via microdialysis into the VMH to produce localized cellular glucopenia in the absence of systemic hypoglycemia. Three groups of awake chronically catheterized rats were studied: 1) nondiabetic (with a mean daily glucose [MDG] of 6.9 mmol/l) BB control rats (n = 5); 2) chronically hypoglycemic nondiabetic (3-4 weeks, with an MDG of 2.7 mmol/l) BB rats (n = 5); and 3) moderately hyperglycemic insulin-treated diabetic (with an MDG of 12.4 mmol/l) BB rats (n = 8). In hypoglycemic rats, both glucagon and catecholamine responses to VMH glucopenia were markedly (77-93%) suppressed. In diabetic rats, VMH 2-DG perfusion was totally ineffective in stimulating glucagon release. The epinephrine response, but not the norepinephrine response, was also diminished by 38% in the diabetic group. We conclude that impaired counterregulation after chronic hypoglycemia may result from alterations of the VMH or its efferent pathways. In diabetes, the capacity of VMH glucopenia to activate the sympathoadrenal system is only modestly diminished; however, the communication between the VMH and the alpha-cell is totally interrupted.

Incidence of glycopeptide hetero-intermediate Staphylococcus aureus strains in Maltese hospitals.

The incidence of hetero-intermediate glycopeptide susceptibility among Staphylococcus aureus isolates in Malta, a country with a high incidence of methicillin resistance, was studied by screening 454 non-repetitive S. aureus isolates on teicoplanin-supplemented agar plates, followed by Etests and genotypic studies. All strains were susceptible to vancomycin, but four (0.88%) exhibited teicoplanin MICs of > 12 mg/L. High methicillin-resistant S.aureus endemicity was not an accurate predictor of the emergence of non-susceptibility to glycopeptides.

Quantitative assessment of organizational culture within hospitals and its relevance to infection prevention and control strategies.

It has been suggested that organizational culture (OC) is an important driver of infection prevention and control (IPC) behaviour among healthcare workers. This study examined OC in seven European hospitals using a validated assessment tool based on Hofstede's model, and identified significant variations in OC scores. Hospitals with low prevalence of meticillin-resistant Staphylococcus aureus (MRSA) exhibited high scores for change facilitation and change readiness, whereas hospitals with high prevalence of MRSA exhibited low scores for these determinants. It is possible to use tools, available outside health care, to study OC within hospitals and gain better insight into IPC behaviour change strategies.

Resistance to neuroglycopenia: an adaptive response during intensive insulin treatment of diabetes.

Counterregulation and awareness of hypoglycemia begins at lower plasma glucose levels in insulin-dependent diabetes mellitus (IDDM) subjects given intensive insulin treatment. To determine whether these changes are associated with an alteration in the susceptibility of the brain to mild hypoglycemia, we compared central nervous system responses to hypoglycemia in 8 intensively treated (hemoglobin A1, 8.3 +/- 0.2%; normal, <8%) and 11 conventionally treated IDDM patients (hemoglobin A1, 14.6 +/- 1.3%) with those in 10 healthy subjects. Plasma glucose was lowered from approximately 4.6 mmol/L in 0.5-0.6 steps using the clamp technique. Glucose levels triggering hormonal responses and perception of hypoglycemic symptoms were significantly lower in intensively treated patients compared to their poorly controlled counterparts (P < 0.05), and hormonal responses were suppressed compared to those in healthy controls. Similarly directed changes occurred in the level of circulating glucose required to alter cortical evoked potentials during hypoglycemia. A greater reduction in plasma glucose was required to alter P300 event-related potentials in the intensively treated patients (2.2 mmol/L) compared to those in the conventionally treated and nondiabetic groups (approximately 3.5 and approximately 3.0 mmol/L, respectively). We conclude that intensively treated IDDM patients are resistant to changes in cortical evoked potentials induced by mild hypoglycemia. This may explain why intensively treated IDDM counterregulate and experience hypoglycemic symptoms at a lower glucose level than conventionally treated patients.

Bed occupancy and overcrowding as determinant factors in the incidence of MRSA infections within general ward settings.

Methicillin-resistant Staphylococcus aureus (MRSA) incidence and bed occupancy rates at St Luke's Hospital, Malta, were assessed over a 24-month period. A significant positive correlation was established (r=0.463; P<0.05) between new cases of MRSA infections and overall levels of bed occupancy. This would imply that overcrowding may be a relevant factor in MRSA spread within hospitals, even in non-intensive care settings.