Clinical outcomes and operational impact of a medical photography based teledermatology service with over 8,000 patients in the UK.

A new, store-and-forward, fully digitised Teledermatology (TD) pathway was designed and implemented in an urban setting for non-two-week wait routine patients. In total 8,352 new patients had a TD consultation over 37 months. Of these, 4,748 (56.8%) were referred back to their GP, 1,634 (19.6%) were referred directly for a surgical procedure and 1,970 (23.6%) for a face-to-face review with a Dermatologist (F2F). The average waiting time for a TD appointment was 3 vs. 30 weeks for a routine F2F appointment. Between 2019 and 2018, TD referrals rose by 38%, routine dermatology referrals reduced by 16% and cancer referrals increased by 6%. Using medical photographers proved to be effective with only two cases (0.02%) of images being of insufficient quality to form a clinical opinion. Hitherto, savings for the local Commissioning Groups were estimated at £671,218. Last financial year savings (2019-2020) were £284,671. The average cost savings per TD patient appointment was £80.36. Savings in the Trust's overhead costs were £53,587. TD consultants reviewed almost twice the number of patients vs. F2F for the same amount of consultant programmed activities. 95% of surveyed patients would be likely or extremely likely to recommend this service to friends and family.

Ten years of external quality assessment (EQA) of Neisseria gonorrhoeae antimicrobial susceptibility testing in Europe elucidate high reliability of data.

BACKGROUND: Confidence in any diagnostic and antimicrobial susceptibility testing data is provided by appropriate and regular quality assurance (QA) procedures. In Europe, the European Gonococcal Antimicrobial Susceptibility Programme (Euro-GASP) has been monitoring the antimicrobial susceptibility in Neisseria gonorrhoeae since 2004. Euro-GASP includes an external quality assessment (EQA) scheme as an essential component for a quality-assured laboratory-based surveillance programme. Participation in the EQA scheme enables any problems with the performed antimicrobial susceptibility testing to be identified and addressed, feeds into the curricula of laboratory training organised by the Euro-GASP network, and assesses the capacity of individual laboratories to detect emerging new, rare and increasing antimicrobial resistance phenotypes. Participant performance in the Euro-GASP EQA scheme over a 10 year period (2007 to 2016, no EQA in 2013) was evaluated. METHODS: Antimicrobial susceptibility category and MIC results from the first 5 years (2007-2011) of the Euro-GASP EQA were compared with the latter 5 years (2012-2016). These time periods were selected to assess the impact of the 2012 European Union case definitions for the reporting of antimicrobial susceptibility. RESULTS: Antimicrobial susceptibility category agreement in each year was ≥91%. Discrepancies in susceptibility categories were generally because the MICs for EQA panel isolates were on or very close to the susceptibility or resistance breakpoints. A high proportion of isolates tested over the 10 years were within one (≥90%) or two (≥97%) MIC log2 dilutions of the modal MIC, respectively. The most common method used was Etest on GC agar base. There was a shift to using breakpoints published by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) in the latter 5 years, however overall impact on the validity of results was limited, as the percentage categorical agreement and MIC concordance changed very little between the two five-year periods. CONCLUSIONS: The high level of comparability of results in this EQA scheme indicates that high quality data are produced by the Euro-GASP participants and gives confidence in susceptibility and resistance data generated by laboratories performing decentralised testing.

Multidrug-resistant Neisseria gonorrhoeae isolate, belonging to the internationally spreading Japanese FC428 clone, with ceftriaxone resistance and intermediate resistance to azithromycin, Ireland, August 2018.

We describe a multidrug-resistant Neisseria gonorrhoeae urethritis case with ceftriaxone resistance and azithromycin intermediate resistance in a heterosexual man in Ireland, August 2018. Whole-genome sequencing showed that the isolate IR72 belongs to the internationally spreading multidrug-resistant ceftriaxone-resistant FC428 clade, initially described in Japan in 2015. IR72 was assigned MSLT ST1903, NG-MAST ST17842 and NG-STAR type 1133, including the ceftriaxone resistance-mediating penA-60.001. Global awareness of spreading ceftriaxone-resistant gonococcal strains that threaten recommended dual therapies is essential.

Determining if the prognostic nutritional index can predict outcomes in community acquired bacterial pneumonia.

BACKGROUND: The Prognostic Nutritional Index (PNI) uses albumin levels and total lymphocyte count to predict the relationship between immune-nutritional state and prognosis in a variety of diseases, however it has not been studied in community acquired bacterial pneumonia (CABP). We conducted a historical cohort study to determine if there was an association between PNI and clinical outcomes in patients with CABP. METHODS: We reviewed 204 adult patients with confirmed CABP, and calculated admission PNI and Neutrophil-to-Lymphocyte Ratio (NLR). A comparative analysis was performed to determine the association of these values, as well as other risk factors, with the primary outcomes of 30-day readmissions and death. RESULTS: Of the 204 patients, 56.9% (116) were male, 48% (98) were black/African American and the mean age was 63.2 ± 16.1 years. The NLR was neither associated with death nor 30-day readmission. The mean PNI in those who survived was 34.7 ± 4.5, compared to 30.1 ± 6.5, in those who died, p < 0.001. From multivariable analysis after controlling for the Charlson score and age, every one-unit increase in the PNI decreased the risk of death by 13.6%. The PNI was not associated with readmissions. CONCLUSIONS: These findings suggest that poor immune and nutritional states, as reflected by PNI, both contribute to mortality, with a significant negative correlation between PNI and death in CABP. PNI was predictive of mortality in this patient cohort; NLR was not. Monitoring of albumin and lymphocyte count in CABP can provide a means for prevention and early intervention.

Molecular characterization of clinical isolates of herpes simplex virus type 1 collected in a tertiary-care hospital in Dublin, Ireland.

Herpes simplex virus type 1 (HSV-1) is a ubiquitous human pathogen. While there has been extensive research into the evolutionary relationships among herpesviruses, there is little data on the evolutionary relationship of HSV-1 based on sequence analysis of clinical isolates. The present study aims to be the first to document the molecular epidemiology and genetic diversity and frequency of recombination of HSV-1 (n = 42) clinical isolates in Ireland. The entire 1,171 bp of the gI-1 gene and 717 bp of the gG-1 gene of 42 clinical Irish isolates were amplified, sequenced and the phylogenies reconstructed. Putative recombinants were examined using bootscan analysis. Phylogenetic reconstruction of the nucleotide sequence alignments of the entire genes of amplified glycoproteins gI and gG suggested that three distinct HSV-1 genogroups were circulating in the Irish population. At least 15 HSV-1 intergenic recombinants with a recombination point between gI and gG, and 11 HSV-1 intragenic recombinants were detected. There was no evident association between genetic group and gender, disease recurrence or anatomical site of infection. Genital isolates (n = 30) belonged to all genogroups. However, two HSV-1 isolates, Irl 31 and Irl32, from a patient with severe mucocutaneous infection nonresponsive to acyclovir and isolated over a prolonged period were both intragenic and intergenic recombinants. The detection of variability and recombination in gG and gI genes of both HSV-1 may provide a mechanism to evade the host immune response thereby maintaining the viral genome. The variability and recombination detected may also have implications for the detection, diagnosis and treatment of HSV.

A Rare Case of Rapidly Progressive Extragonadal Mature Cystic Teratoma Presenting With Chest Pain.

Mature cystic teratomas represent the most prevalent subtype of germ cell tumors affecting the ovaries. Typically, these neoplasms are benign and characterized by a slow growth pattern. Nevertheless, malignant transformation of these tumors is a rare event that may occur. Despite their typically indolent behavior, some cases may exhibit rapid growth rates and give rise to a variety of complications, including rupture and consequent manifestation of a wide range of clinical signs and symptoms. This report details the case of a 49-year-old woman who presented to the hospital with a chief complaint of chest pain. The onset of her symptoms occurred several days prior to admission and was associated with fatigue without shortness of breath. Imaging studies, including computed tomography angiography and magnetic resonance imaging of the chest, revealed a mediastinal mass measuring 5.9 x 7.4 cm in a cross-sectional area that displayed features consistent with a mature cystic teratoma, including the presence of soft tissue, fat, fluid, and areas of calcification. Notably, a prior computed tomography scan of the chest, performed 20 months before her presentation, did not reveal any evidence of masses. The patient subsequently underwent successful robot-assisted resection of the mediastinal mass, with complete resolution of her symptoms. Histopathologic examination of the excised mass confirmed the absence of malignancy.

Molecular characterization of varicella-zoster virus clinical isolates from 2006 to 2008 in a tertiary care hospital, Dublin, Ireland, using different genotyping methods.

Varicella-zoster virus (VZV), a herpesvirus, is a ubiquitous organism that causes considerable morbidity worldwide and can cause severe complications on reactivation. Phylogenetic analysis was performed on 19 clinical VZV isolates (16 zoster and 3 varicella) found in Ireland, between December 2006 and November 2008, in order to determine whether previously reported viral heterogeneity was still present and whether viral recombination was evident. Open reading-frames (ORFs) from genes 1, 21, 50, and 54, were sequenced. Clades 1, 2, 3, and 5 were identified. Four putative recombinant isolates were detected (three clade 3/1 and one clade 5/3/1). Further sequencing and examination of ORF 22 and 21/50, did not elucidate the putative recombinant genotypes further. These two previously published genotyping schemes were examined in light of the new consensus genotyping scheme proposed in 2010. Remarkable VZV heterogeneity remains prevalent in Ireland. This is the first evidence of putative VZV recombination found in Ireland.

A PHS pharmacist team's response to Hurricane Katrina.

PURPOSE: The challenges and victories that a team of Public Health Service (PHS) pharmacists experienced in establishing pharmacy operations at a federal medical station and conducting outreach missions are described. SUMMARY: The Gulf coast of Mississippi and southeast Louisiana were struck on August 29, 2005, by Hurricane Katrina, which caused widespread infrastructure damage, flooding, and loss of life. A team of 70 officers, which included 8 pharmacists, arrived on September 3 and 4 to establish a 480-bed federal medical station in an aircraft hangar at the naval air station (NAS) in Meridian, Mississippi. Numerous challenges were encountered, including identifying a secure space for a pharmacy, determining how to manage the immediate shortage of medications, devising a dispensing system specific to controlled medications, handling personal medications brought in by patients, and maintaining adequate pharmacy staffing to provide for hospital needs. Two outreach efforts were also undertaken. The first was to assist the NAS pharmacy department, which was overwhelmed with nearly 800 Navy and Coast Guard personnel who were displaced to the Meridian NAS. The second outreach effort was to augment the staff at a local free clinic in Meridian, which needed help to set up their clinic so they could handle the influx of hurricane victims who were arriving daily. CONCLUSION: A team of PHS pharmacists established a pharmacy, provided pharmaceutical care, and conducted outreach programs to aid victims of Hurricane Katrina.

Benefits and costs of resident males to females in white-faced capuchins, Cebus capucinus.

Some benefits and costs of resident males to females are examined in white-faced capuchins (Cebus capucinus) at Santa Rosa National Park, Costa Rica. A total of 380 hours of focal data were collected on adults in two groups, between January and July 1991. The results of this study suggest that for females, males provide some greater benefits, and impose some higher costs than do other females. Males are more vigilant than females, and are somewhat more successful in detecting predators. To the extent that predator protection is a major benefit of group living, this benefit seems to derive more from males than from females. Increased contest competition is the major cost of group living, and the study suggests that females bear a higher proportion of this cost than males. More foraging related agonism occurs between males and females than between females, more aggression occurs between than within sexes, and female foraging success is negatively associated with agonistic interactions involving males. However, female foraging success is negatively affected by the proximity of other females, and not by the proximity of males. Differences in the distribution of male benefits and costs according to female dominance rank are suggested. © Wiley-Liss, Inc.

Interbirth interval variation in three sympatric species of neotropical monkey.

Relatively few papers have focused on interbirth intervals in primates, even though the spacing between births is one of the primary determinants of female reproductive success in long-lived mammals. We present life history data from a ten-year field study of Costa Rican capuchins (Cebus capucinus), howlers (Alouatta palliata), and spidei monkeys (Ateles geoffroyi). Analyses of intraspecific variability found no significant differences attributable to individual variation in age, parity, weight, or maternal rank. Loss of an infant significantly shortened the interbirth interval in all three species. There was no correlation between annual rainfall and birth rates, but there was a significant clustering of births in the dry season. Survival analyses demonstrated a significant difference between the median interbirth intervals of the three species. Howlers have the shortest intervals (19.9 months), capuchins exhibit longer intervals (26.36 months), and spider monkeys have the longest intervals (34.72 months;. This comparative pattern does not correspond to relative body weights of the three species, but does correspond to relative brain weights. Comparisons to other primates with similar life history characteristics demonstrate that interbirth intervals are best examined at the level of their three component phases: gestation, lactation, and cycling to re-conception. © 1995 Wiley-Liss, Inc.

Cross-site differences in foraging behavior of white-faced capuchins (Cebus capucinus).

Researchers have identified a variety of cross-site differences in the foraging behavior of free-ranging great apes, most notably among chimpanzees (Pan troglodytes) and more recently orangutans (Pongo pygmaeus), that are not due to obvious genetic or ecological differences. These differences are often referred to as "traditions." What is not known is whether this high level of interpopulation variation in behavior is limited to hominoids. In this study, we use long-term data from three Costa Rican field sites that are geographically close and similar ecologically to identify potential foraging traditions in white-faced capuchins (Cebus capucinus). Foraging traditions are predicted in Cebus because of many behavioral and morphological convergences between this genus and the great apes. The processing techniques used for the same food species were compared across sites, and all differences found were classified as present, habitual, or customary. Proximity data were also analyzed to determine if social learning mechanisms could explain variation in foraging behavior. Of the 61 foods compared, we found that 20 of them are processed differently by capuchins across sites. The differences involve pound, rub, tap, "fulcrum," "leaf-wrap," and "army ant following." For most of the differences with enough data to analyze, the average proximity score of the "matched" dyads (two individuals within a group who shared a "different" processing technique) was statistically higher than the average proximity score of the remaining "unmatched" dyads.