Rapid diagnostic tests for common infection syndromes: less haste, more speed.

Rapid diagnostic tests, which accurately distinguish bacterial from viral infections, are being heralded as the solution to antibiotic overuse, which is a key driver of antimicrobial resistance. We have concerns that this approach is oversimplistic. Rapid diagnostic tests are complex interventions, with clinical context, patient flow, access and timing affecting their impact. There is little robust evidence that they reduce antibiotic prescribing in real-world settings. We suggest that prior to introducing these costly tests, emphasis should be placed on optimizing the implementation of efficient evidence-based antimicrobial stewardship interventions, such as increasing the use of proven automated clinical infection syndrome prediction tools by clinicians, supporting patients to self-care by providing them with high-quality safety-netting resources, providing front-line clinicians with individual prescribing data to facilitate peer benchmarking and setting specific and purposeful antibiotic prescribing targets to improve the quality of antimicrobial prescribing. The stakes are high and time is running out; let's start by getting the basics right.

Appropriateness of acute-care antibiotic prescriptions for community-acquired infections and surgical antibiotic prophylaxis in England: analysis of 2016 national point prevalence survey data.

BACKGROUND: Estimates of inappropriate prescribing can highlight key target areas for antimicrobial stewardship (AMS) and inform national targets. OBJECTIVES: To (1) define and (2) produce estimates of inappropriate antibiotic prescribing levels within acute hospital trusts in England. METHODS: The 2016 national Healthcare-Associated Infections (HAI), Antimicrobial Use (AMU) and AMS point prevalence survey (PPS) was used to derive estimates of inappropriate prescribing, focusing on the four most reported community-acquired antibiotic indications (CAIs) in the PPS and surgical prophylaxis. Definitions of appropriate antibiotic therapy for each indication were developed through the compilation of national treatment guidelines. A Likert-scale system of appropriateness coding was validated and refined through a two-stage expert review process. RESULTS: Antimicrobial usage prevalence data were collected for 25,741 individual antibiotic prescriptions, representing 17,884 patients and 213 hospitals in England. 30.4% of prescriptions for the four CAIs of interest were estimated to be inappropriate (2054 prescriptions). The highest percentage of inappropriate prescribing occurred in uncomplicated cystitis prescriptions (62.5%), followed by bronchitis (48%). For surgical prophylaxis, 30.8% of prescriptions were inappropriate in terms of dose number, and 21.3% in terms of excess prophylaxis duration. CONCLUSIONS: The 2016 prevalence of inappropriate antibiotic prescribing in hospitals in England was approximated to be 30.4%; this establishes a baseline prevalence and provided indication of where AMS interventions should be prioritized. Our definitions appraised antibiotic choice, treatment duration and dose number (surgical prophylaxis only); however, they did not consider other aspects of appropriateness, such as combination therapy - this is an important area for future work.

Detection, survival, and persistence of Staphylococcus capitis NRCS-A in neonatal units in England.

BACKGROUND: The multidrug-resistant Staphylococcus capitis clone, NRCS-A, is increasingly associated with late-onset sepsis in low birthweight newborns in neonatal intensive care units (NICUs) in England and globally. Understanding where this bacterium survives and persists within the NICU environment is key to developing and implementing effective control measures. AIM: To investigate the potential for S. capitis to colonize surfaces within NICUs. METHODS: Surface swabs were collected from four NICUs with and without known NRCS-A colonizations/infections present at the time of sampling. Samples were cultured and S. capitis isolates analysed via whole-genome sequencing. Survival of NRCS-A on plastic surfaces was assessed over time and compared to that of non-NRCS-A isolates. The bactericidal activity of commonly used chemical disinfectants against S. capitis was assessed. FINDINGS: Of 173 surfaces sampled, 40 (21.1%) harboured S. capitis with 30 isolates (75%) being NRCS-A. Whereas S. capitis was recovered from surfaces across the NICU, the NRCS-A clone was rarely recovered from outside the immediate neonatal bedspace. Incubators and other bedside equipment were contaminated with NRCS-A regardless of clinical case detection. In the absence of cleaning, S. capitis was able to survive for three days with minimal losses in viability (<0.5 log10 reduction). Sodium troclosene and a QAC-based detergent/disinfectant reduced S. capitis to below detectable levels. CONCLUSION: S. capitis NRCS-A can be readily recovered from the NICU environment, even in units with no recent reported clinical cases of S. capitis infection, highlighting a need for appropriate national guidance on cleaning within the neonatal care environment.

Paediatric antimicrobial stewardship programmes in the UK's regional children's hospitals.

A survey was conducted in UK regional children's hospitals with paediatric intensive care and paediatric infectious disease (PID) departments to describe the characteristics of paediatric antimicrobial stewardship (PAS) programmes. A structured questionnaire was sent to PAS coordinators. 'Audit and feedback' was implemented in 13 out of 17 centres. Microbiology-led services were more likely to implement antimicrobial restriction (75% vs 33% in PID-led services), to focus on broad-spectrum antibiotics, and to review patients with positive blood cultures. PID-led services were more likely to identify patients from e-prescribing or drug charts and review all antimicrobials. A PAS network has been established.

The inter-examiner variation in rating dental formation from radiographs.

Six examiners evaluated dental formation on 191 radiographs, using an eight-stage system. Discrepancies between these examiners are generally of the order of +/- one stage, in about 20 to 25% of the cases. The authors thus suggest the use of reference radiographs, for the double purpose of ensuring a homogeneous rating by two examiners or more, as well as the assessment of eventual differences between populations.

Sexual differences in dental development and prediction of emergence.

The dental development of a genetically homogeneous French-Canadian group of children ranging in age from 2.5 to 19 years was evaluated from 5,437 panoramic radiographs by the method of Demirjian et al. The maturity of each mandibular tooth was evaluated individually. For each stage of each tooth, the developmental curves of boys and girls were compared. A common pattern was found for each tooth, namely the chronological similarity between boys and girls in the early stages of development and the advancement of girls over boys for the later stages. Development scores were given to the seven mandibular teeth. Up to five to six years of age, no difference was found in the timing of dental development between boys and girls, in contrast to the older ages where girls were always more developed than boys. When the emergence curve was plotted with developmental curves, a close relation was established between the stage of formation of all teeth and their emergence, hence the predictive value of the use of dental maturity curves in clinics.

Sexual dimorphism in the emergence of the deciduous teeth.

Exact ages of emergence of the twenty deciduous teeth have been investigated on a longitudinal sample of 195 French-Canadian children (113 boys and 82 girls). A multivariate analysis of variance yielded a significant overall sex difference (p less than 0.0001). It has been found that the emergence of the deciduous dentition in boys is more precocious than that in girls by about one month; this difference is present at the emergence of the upper central incisor and is maintained henceforth. The only notable exception to this pattern is the emergence of the first molars. Results of the present study, combined with those of previous research, suggest that sexual dimorphism in the emergence of the deciduous teeth could be mediated through ethnic factors.

Adjusting craniofacial correlations for technical error.

Reliability estimates provide a means of adjusting observed correlations for technical error. The results show that the true correlations among 11 craniofacial landmarks are consistently higher than observed values. Consequently, the regression slopes defining these relationships are also increased. The less reliable two measures are, and the closer their joint reliability approximates the observed correlation, the greater the expected change in true correlation. Adjusting craniofacial relationships for technical error may substantially increase the proportion of variation explained, and thereby alter statistical inferences drawn from results.

Mandibular rotation and angular remodeling during childhood and adolescence.

Using the structural method of superimposition, childhood and adolescent rates of mandibular rotation and remodeling are described. The results pertain to a longitudinal sample of French-Canadian children, including 42 females with records at 6, 10, and 14 years of age and 39 males with records at 7, 11, and 15 years of age. There are no sex differences in rates of mandibular rotation and remodeling. Childhood rates of true rotation and angular remodeling are significantly greater than adolescent rates. Children whose first permanent molars had not erupted at the time of the first observation showed significantly greater rates of angular remodeling than children whose molars had already erupted. Over the eight year period, there were approximately 4.8 degrees of forward true rotation, between 5.2 and 6.4 degrees forward angular remodeling, and less than 1 degree of backward apparent rotation. During adolescence and the primary dentition stage, associations are strongest between true and apparent rotation. During the mixed dentition stage, true rotation is most closely correlated with angular remodeling. © 1992 Wiley-Liss, Inc.

Dental maturity in Belgian children using Demirjian's method and polynomial functions: new standard curves for forensic and clinical use.

Dental maturity was studied from dental panoramic radiographs of 2523 Belgian children (1255 girls and 1268 boys) aged 2 to 18 years. The aim was to compare the efficiency of two methods of age prediction: Demirjian's method, using differently weighted scores, and polynomial functions. The two methods present some differences: Demirjian is used to determine the maturity score as a function of age and polynomial functions are used to determine age as a function of the maturity score. We present, for each method, gender-specific dental maturity tables and curves for Belgian children. Girls always present advanced dental maturity compared with boys. The polynomial functions are highly reliable (0.21% of incorrect classifications) and the percentile method, using Belgian weighted scores, is very accurate (+/- 2.08 years on average, between 2 and 16 years of age).

Cephalometric reliability. A full ANOVA model for the estimation of true and error variance.

A detailed description of sampling designs for assessing the reliability of cephalometric measurements, emphasizing distinctions between true and observed variance, random and systemic components of variance, and complete and minimal models for evaluating measurement error.

Effects of premature loss of deciduous molars.

A statistical exploration of space changes following early loss of deciduous molars, developing a picture of closure from both directions with district differences between upper and lower arch changes.

Childhood and pubertal growth changes of the human symphysis.

Longitudinal growth changes of the human symphysis were evaluated for 75 children (37 males and 38 females) between 6 and 15 years old. Childhood growth was described by mean yearly rates of change between 6 and 10 years for females and between 7 and 11 years for males; pubertal changes pertain to growth between 10 and 14 for females and between 11 and 15 for males. Cephalometric tracings of the mandible were superimposed using stable reference structures. Vertical growth changes, particularly for landmarks located in the upper 20% of the symphysis, were most pronounced. Annual rates of vertical growth ranged between 0.9 mm/yr for the lingual incisor contact point to -0.2 mm/yr for gnathion. Males showed significantly greater rates of vertical growth than females, especially for the upper half of the symphysis. Vertical growth rates were also greater during puberty than during childhood. The horizontal growth changes indicated lingual movement of most symphyseal landmarks. Annual rates of growth were greatest for landmarks located in the upper half of the symphysis. B-point showed the greatest lingual drift. During puberty, the mandibular incisors in females moved lingually as the upper anterior half of the symphysis remodeled; in males, the incisors maintained their horizontal position as the labial sulcus developed.

Multimedia approach to dental education in the 21st century.

Today's technology allows educators to design and create tools that enable teachers and students to work with material from different sources and to attend courses at various sites. The personal computer represents perhaps the greatest boon to this movement by providing a vehicle for "user friendly," interactive, multimedia courseware. A discussion of that courseware, its development and implementation, is provided here.