An outbreak of SARS-CoV-2 in a public-facing office in England.

BACKGROUND: An outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with an attack rate of 55% (22/40 workers) occurred at a public-facing office in England from August to September 2021. Published evidence regarding outbreaks in office workplaces remains limited. AIMS: To describe an investigation of workplace- and worker-related risk factors following an outbreak of SARS-CoV-2 in a public-facing office. METHODS: The COVID-19 (coronavirus disease 2019) Outbreak Investigation to Understand Transmission (COVID-OUT) study undertook an investigation of the outbreak. This included surface sampling, occupational environmental assessment, molecular and serological testing of workers, and detailed questionnaires. RESULTS: Despite existing COVID-19 control measures, surface sampling conducted during a self-imposed 2-week temporary office closure identified viral contamination (10/60 samples, 17% positive), particularly in a small, shared security office (6/9, 67% positive) and on a window handle in one open-plan office. Targeted enhanced cleaning was, therefore, undertaken before the office reopened. Repeat surface sampling after this identified only one positive (2%) sample. Ventilation was deemed adequate using carbon dioxide monitoring (typically ≤1000 ppm). Twelve workers (30%) responded to the COVID-OUT questionnaire, and all had been vaccinated with two doses. One-third of respondents (4/12) reported direct physical or close contact with members of the public; of these, 75% (3/4) reported a divider/screen between themselves and members of the public. CONCLUSIONS: The results highlight the potential utility of surface sampling to identify SARS-CoV-2 control deficiencies and the importance of evolving, site-specific risk assessments with layered COVID-19 mitigation strategies.

Association between an educational intervention and a reduction in inappropriate troponin testing in patients presenting to an adult emergency department.

BACKGROUND: High-sensitivity troponin replaced the fourth generation assay at our institution in July 2010. Prior experience suggested that the number of positive tests with the new assay may double, and that many troponin requests were inappropriate. AIM: Primarily, this study aims to design and measure the effect of an educational intervention to reduce the number of inappropriate troponin tests. Second, other objectives are to compare weekly totals of troponin tests before and after the intervention, to note patients with missed acute coronary syndrome (ACS) during the study period and to survey clinicians regarding their likely troponin ordering practices in certain clinical scenarios. METHODS: A staff survey informed the content of the educational intervention. Criteria for inappropriate testing were defined prior to the study. Retrospective notes review of pre-and post-intervention cohorts were used to determine the reduction in inappropriate troponin tests. RESULTS: Ninety-six patients were in each cohort. The proportion of inappropriate tests fell from 43% (95% confidence interval (CI) 33-53) pre-intervention to 22% (95% CI 14-31) post-intervention, P = 0.002. Weekly total of troponin tests performed decreased from a mean of 298 (95% CI, 290-307) pre-intervention to 244 (95% CI 232-255) post-intervention, P < 0.001. No cases of missed ACS were found; all cause mortality was unchanged following the intervention. CONCLUSION: Our educational intervention was associated with a reduction in inappropriate use of troponin tests and a reduction in the total number of tests requested, with no known missed ACS. Others faced with a change to a high-sensitivity assay should consider a similar intervention.

Impact of a decision rule on duration of continuous cardiac monitoring of patients with suspected acute coronary syndrome in an emergency department.

BACKGROUND/AIMS: To determine the effect of introducing a decision rule on the duration of continuous cardiac monitoring (CCM) for patients with suspected acute coronary syndrome in an adult emergency department (ED). METHODS: This was a retrospective observational study of 220 patients with suspected acute coronary syndrome made up of two consecutive cohorts collected before and after introduction in July 2010 of a decision rule that made use of a new high-sensitivity troponin T assay. The primary outcome was median CCM duration in the ED (CCMED). Secondary outcomes were median duration of CCM in the first 24 h, rate of adverse events, proportion of patients after the intervention who had the rule adhered to, and estimated median CCMED had the decision rule been adhered to by all patients. RESULTS: The decision rule was adhered to in 59.3% (95% confidence interval 49.8-68.1) of patients post-intervention. There was no statistically or clinically significant difference in median CCMED before (240 min, interquartile range 156-313) and after (230 min interquartile range 145-353) introduction of the decision rule (P = 0.74) nor in CCM in the first 24 h (908 min vs 929 min). Seven (3.2%, 95% confidence interval 1.4-6.6) adverse events occurred overall. All three patients with adverse events after the intervention were monitored in ED according to the decision rule. CONCLUSION: Introduction of this decision rule did not decrease the median CCMED. All adverse events after the intervention occurred in appropriately monitored patients, including patients with initially negative high-sensitivity troponin T, suggesting that the decision rule would not compromise patient safety.

Outcome of the Lima periurethral constrictor in children and adolescents: a European perspective.

PURPOSE: The Lima constrictor was described in 1996 as a less complex and less expensive alternative to the artificial urinary sphincter for use in cases of pediatric neuropathic sphincter incontinence. The device provides a fixed periurethral resistance which creates continence, yet allows urethral catheterization without the need to deflate the cuff. We report our multicenter experience, and continence, revision and erosion rates. MATERIALS AND METHODS: We performed a retrospective review of 14 consecutive patients who underwent insertion of the periurethral constrictor (Silimed, Rio de Janeiro, Brazil) between 2005 and 2011. Data are presented as medians (range). RESULTS: A total of 14 patients (13 male, 1 female) with spina bifida (10), sacral agenesis (3) and Hirschsprung disease (1) underwent insertion of the constrictor at a median age of 12 years (range 8 to 20). All patients were wet despite clean intermittent catheterization, medical therapy and/or previous surgery. Eleven patients underwent simultaneous bladder augmentation and/or Mitrofanoff formation. The constrictor was activated a median of 8 weeks (range 2 to 99) after the procedure in 11 patients whereas 3 became dry without activation. Complications occurred in 4 patients (29%), including spontaneous bladder perforation and constrictor erosion (1), tubing disconnection requiring revision (2) and wound infection (1). At a median of 23 months of followup (range 7 to 77) 13 patients were dry and 1 was damp. All patients performed urethral or Mitrofanoff clean intermittent catheterization. The continence rate with the device in situ was 92%. CONCLUSIONS: At a median followup of 23 months the Lima constrictor provided a 92% continence rate with erosion and revision rates of 7% and 14%, respectively. Interim results suggest that the constrictor provides a safe and effective surgical option, particularly in patients who are unable to void to completion.

Notification of random hyperglycaemia to general practitioners by an emergency medicine team: impact of a simple intervention plan.

AIM: To determine whether general practitioners (GPs) were being appropriately notified of patients' elevated random glucose levels by emergency medicine (EM) staff, and to investigate whether two simple interventions improved the notification rate. METHODS: Patients were included if their random venous plasma glucose (RVPG) at presentation to the Emergency Department (ED) was >or= 7.8 mmol/l and if they were discharged directly to their GP. Patients with known impaired glucose metabolism (IGM) were excluded. Patient discharge summaries were reviewed over a 5-month period before and a 5-week period after two simple interventions: first, a targeted educational session for EM staff and second, modifications to the automated message accompanying laboratory results. RESULTS: Before intervention, the GPs of 120 out of 178 patients received no notification of an elevated RVPG compared with 23 of 62 patients after intervention (P < 0.00001). Notification met a predefined standard in 25 of 178 patients before, and 34 of 62 patients after intervention (P < 0.01). CONCLUSIONS: EM staff education, together with an automated laboratory message, significantly improved the rate and quality of notification of elevated RVPG levels to GPs. These simple measures have the potential to hasten implementation of preventive and therapeutic measures in patients with IGM.

Case-control study of residential radon and lung cancer among New Jersey women.

To evaluate the association of indoor radon exposure with lung cancer risk, yearlong alpha track detector measurements of radon were conducted in dwellings which had been occupied for at least 10 years by 433 New Jersey female lung cancer cases and 402 controls who were subjects in a larger population-based study. Adjusted odds ratios were 1.1 (90% confidence interval, 0.79-1.7), 1.3 (90% confidence interval, 0.62-2.9), and 4.2 (90% confidence interval, 0.99-17.5) for exposures of 1.0-1.9, 2.0-3.9, and 4.0-11.3 pCi/liter, respectively, relative to exposures of less than 1.0 pCi/liter, showing a significant trend (1-sided P = 0.04) with increasing radon concentration. The trend was strongest among light smokers (less than 15 cigarettes/day, 1-sided P = 0.01). The trend for lung cancer risk with estimated cumulative radon exposure was slightly weaker (1-sided P = 0.09). The increase in relative risk for each unit of cumulative exposure, 3.4% (90% confidence interval 0.0-8.0%) per working level month, was consistent with the range of 0.5-4.0% per working level month generally reported for underground miner studies, supporting the extrapolation of the occupational data to the residential setting. However, the possibility of selection biases, the small number of high exposures, and other uncertainties necessitate caution in interpretation of these data.

Angiotensinogen T235 and ACE insertion/deletion polymorphisms associated with albuminuria in Chinese type 2 diabetic patients.

OBJECTIVE: Genetic polymorphisms of the renin-angiotensin system (RAS) have been implicated in the pathogenesis of diabetic proteinuria. Ethnic differences in the frequencies of these genotypes have also been reported. To date, most of these studies have been performed in white and Japanese populations. In this study, we examined the associations between albuminuria and RAS genetic polymorphisms in Chinese patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: In a case-control study, the ACE insertion/deletion (I/D) gene, the angiotensinogen (AGT) gene (M235T), and the angiotensin II (AII) type 1 receptor gene (AT1 A1166C) were examined in 110 Chinese type 2 diabetic patients. Increased urinary albumin excretion (UAE) was defined as > or = 30 mg/day on at least two occasions during a 6-week study period. RESULTS: Compared with whites, there were high frequencies of the AGT TT genotype in Chinese control subjects (120/183 = 70%) and type 2 diabetic patients (74/110 = 67%). The frequencies of the MM genotype were 5 and 3%, respectively, and those of the ACE DD genotype were 13 and 10%, respectively. Although 9% of subjects carried the C allele, the AT1 CC genotype was not found in either group. Chinese type 2 diabetic patients with increased albuminuria (n = 56) had higher systolic blood pressure (160 +/- 26 mmHg vs 145 +/- 27 mmHg, P < 0.001) than the normoalbuminuric patients (n = 54). Both the AGT TT genotype (78.6% [44/56] vs. 55.6% [30/54], odds ratio [OR]: 3.0 [1.3-6.8]) and the T allele (88% [99/112] vs. 77% [83/108], OR: 2.5 [1.3-5.4]) were associated with an increased risk of albuminuria. Patients with the AGT TT genotype (n = 74) had higher 24-h UAE than those with the MT or MM genotypes (n = 36) (median: 37.8 mg/day vs. 17.8 mg/day, P < 0.01). This association remained significant in patients with normotension (56 mg/day [n = 19] for patients with the TT genotype vs. 22 mg/day [n = 14] for those with the MT/MM genotype, P = 0.03). The D allele carriers (DD or DI, n = 61) had higher serum ACE activities (75.5 +/- 29 U/l vs. 60.5 +/- 36.3 U/l, P < 0.01) than the noncarriers (II genotype). The median 24-h UAE also tended to be higher in the D allele carriers (38.9 mg/day vs. 21.4 mg/day, P = 0.07). The lowest UAE was observed in patients with the MM/MT/II genotype (16.3 mg/day [n = 18]) and the highest, in patients with the TT/DD/DI genotype (52.3 mg/day [n = 43]). No association was found between the TT genotype or D allele and hypertension. CONCLUSIONS: The high frequencies of the TT genotype and T allele in Chinese populations may contribute to the high prevalence of albuminuria in patients with type 2 diabetes. The possibility of synergism between the AGT TT genotype and the ACE D allele should also be explored.

Meeting report of the International Society of Hypertension Conference on Hypertension and Diabetes.

Points of agreement: (1) In IDDM, hypertension occurs in patients who have already developed nephropathy, probably in the microalbuminuric phase. (2) Hypertension is an important accelerator of the development of diabetic nephropathy. (3) Hypertension, obesity and NIDDM are often associated, and insulin resistance is commonly observed in all three states. (4) Antihypertensive therapy retards the development of diabetic nephropathy in IDDM and reduces proteinuria in NIDDM. (5) The choice of antihypertensive agent in the diabetic patient must be based upon the efficacy of the drug as well as avoidance of side effects including deleterious influence on glucose, insulin and lipid levels and renoprotection. (6) Carefully conducted long-term comparative trials between different classes of antihypertensive drugs in microalbuminuric IDDM and NIDDM patients are essential. Points of major controversy: (1) Detection of IDDM patients prone to the development of diabetic nephropathy can be performed by measuring specific parameters such as erythrocyte Na(+)-Li+ countertransport activity. (2) Insulin resistance is a pathogenic mechanism rather than purely an association with hypertension and obesity. (3) A certain class of antihypertensive agents--ACE inhibitors--confers a specific renoprotective effect in diabetic nephropathy, in addition to its effects upon systemic blood pressure. (4) Reduction of blood pressure should be considered in the normotensive microalbuminuric diabetic patient. (5) Microalbuminuria is a sufficient 'surrogate endpoint' for the progression of renal failure.

Sexual behavior, knowledge, and attitudes about AIDS among college freshmen.

We surveyed 158 college freshmen on an urban campus to determine their sexual practices and their knowledge and attitudes about acquired immunodeficiency syndrome (AIDS). Many students (47%) were heterosexually active; 1% were homosexual, 1% were bisexual, and 51% had not been sexually active. Among the 77 sexually active students, many engaged in activities that can facilitate transmission of human immunodeficiency virus (HIV): 58% did not always use condoms with a new partner; 31% had had two or more sex partners in the last year; 8% engaged in anonymous sex; and 14% of sexually active women had anal intercourse. Although most sexually active students said they would use condoms more or reduce the number of their sexual partners if they believed these changes would reduce "my risk for getting AIDS," few students had adopted these safer sexual practices. Safer sexual practices were associated with heightened personal concerns about AIDS but not with knowledge, which was at a high level. These findings underscore the need for preventive programs that overcome the gap between knowledge and safer sexual behaviors in this and similar groups of adolescents and suggest that programs that heighten personal concerns may be most effective. Community-based physicians who care for adolescents should develop such preventive programs and integrate them into their practices.

Expression of stressful experiences through writing: effects of a self-regulation manipulation for pessimists and optimists.

This study assessed the effectiveness of a writing task designed to foster self-regulatory coping with stressful experiences to reduce medical clinic visits and to promote adjustment. Students entering college (N = 122) who were classified as optimists or pessimists by using a dispositional optimism measure participated in a self-regulation task (expressing thoughts and feelings about entering college and then formulating coping plans), a disclosure task (expressing thoughts and feelings only), or a control task (writing about trivial topics) for 3 weekly writing sessions. Among optimists, both the self-regulation task and the disclosure task reduced illness-related clinic visits during the following month; among pessimists, only the self-regulation task reduced clinic visits. In general, the self-regulation task beneficially affected mood state and college adjustment whereas the disclosure task increased grade point averages.

Cisapride reduces neonatal postoperative ileus: randomised placebo controlled trial.

AIM: To assess the efficacy of cisapride in reducing ileus persisting to the tenth postoperative day after neonatal abdominal surgery. METHODS: A prospective, randomised, double blind trial comparing rectal cisapride (1.4-2.3 mg/kg/day) with placebo over seven days was undertaken in 33 neonates. RESULTS: Seven of 12 (58%) patients receiving placebo and eight of 11 (73%) receiving cisapride achieved a first sustained feed during treatment. Of those receiving cisapride, the first sustained feed occurred at 2.3 days (SEM 0.6) compared with 4.7 days (SEM 0.8) with placebo. By the seventh day the mean daily net enteral balance was 69 (SEM 18) ml/kg in the cisapride subgroup and 17 (SEM 8) ml/kg for those receiving placebo. Stool was passed on 6.3 (SEM 0.4) treatment days in the cisapride subgroup compared with 4.1 (SEM 1.0) treatment days in the placebo subgroup. CONCLUSION: Cisapride is effective in neonates with a prolonged ileus after abdominal surgery.

Solid-phase extraction and optimized separation of doxorubicin, epirubicin and their metabolites using reversed-phase high-performance liquid chromatography.

A reversed-phase isocratic high-performance liquid chromatographic method is described in which a formal structured procedure was applied to predict the mobile phase composition giving optimal baseline resolution of the clinically important anticancer agents doxorubicin and 4'-epidoxorubicin (epirubicin), their principal metabolites, and daunorubicin (internal standard). These formal statistical procedures included the simultaneous techniques of solvent selectivity triangle and factorial design for range-finding preliminary studies, followed by use of the modified simplex, a sequential procedure. These were used to select the parameters of organic modifier, buffer strength and pH necessary for use with a Spherisorb ODS 1 column, to achieve optimal separation of eight anthracycline solutes. Ultraviolet and fluorescence detection was used (lambda ex = 254 nm, lambda em = 560 nm), and the latter gave a low detection limit for doxorubicin in serum of 1 ng ml-1. The optimal mobile phase composition was determined to be acetonitrile-0.06 M Na2 HPO4 containing 0.05% (v/v) triethylamine adjusted to pH 4.6 with 0.03 M citric acid (35:65, v/v). A solid-phase extraction method was developed to enable the selective isolation of anthracyclines by adsorption onto C8 Bond-Elut cartridges, and is based on extraction of serum spiked with a mixture of the anthracycline solutes. The anthracyclines were eluted using acetonitrile-0.2 M Na2 HPO4 containing 0.05% (v/v) triethylamine adjusted to pH 3.6 with 0.1 M citric acid (67.5:32.5, v/v). Reproducible recoveries for doxorubicin (94 +/- 8%) and for epirubicin (96 +/- 8%) were obtained (n = 5). In particular, recoveries for the 7-deoxyaglycone metabolite (99%) were higher than other extraction methods cited.(ABSTRACT TRUNCATED AT 250 WORDS)

Nitric oxide-producing neurons remain intact after small bowel transplantation.

This study documents the fate of nitric oxide neurons following small bowel transplantation. Heterotopic, syngeneic small bowel transplants were performed in five male Lewis rats. The grafts were harvested 7, 36, 55, 60, and 65 days postoperatively, together with the native bowel for comparison. NADPH diaphorase staining of cryostat sections was used to identify the nitric oxide-producing neurons. NADPH diaphorase activity was concentrated in the myenteric plexus, deep muscular, and submucous plexus. No differences were detected between the transplanted and native bowel at any time after transplantation. This suggests that nitric-oxide-producing neurons are well preserved after transplantation and that posttransplant dysmotility is probably not related to interrupted nitric oxide innervation.

Bench surgery with autotransplantation for bilateral synchronous Wilms' tumor: a report of three cases.

The surgical management of bilateral synchronous nephroblastoma remains controversial. The authors describe three cases treated using ex vivo tumor dissection followed by autotransplantation in an attempt to preserve functioning renal tissue. Two children are alive and tumor free with adequate renal function at 30 months and 3 years, respectively. One died from tumor recurrence with metastases 9 months after surgery. This technique is an acceptable alternative to bilateral nephrectomy followed by transplantation.

Recipient FK506 pretreatment regimens in rat small bowel transplantation: allograft survival, function, and systemic infection.

PURPOSE: Successful small bowel transplantation requires effective immunosuppression that preserves intestinal function but avoids opportunistic infection. This study aims to evaluate FK506 as a single immunosuppressant in different pretreatment regimens in a rat high responder strain combination. METHODS: Lewis --> DA rat heterotopic small bowel transplantation was performed. Studied groups were (1) untreated control, n = 12; (2) FK-1, n = 8; (3) FK-3, n = 8. FK506 (2 mg/kg/d, intramuscularly) was given to the recipients for 1 day (FK-1) and 3 days (FK-3) before small bowel transplantation, followed by 2 weeks of subtherapeutic treatment (0.3 mg/kg/d, intramuscularly) after small bowel transplantation. Syngeneic small bowel transplantation also was performed (n = 8). FK blood levels, maltose absorption test, histology, and bacteriology were performed at different postoperative days. RESULTS: Allograft survival was prolonged significantly with FK pretreatment, being more so in FK-3 group (FK-1, 22.2 +/- 1.5 d; FK-3, 40.7 +/- 14.1 d; control, 6.6 +/- 0.8 d; P< .01). In the first postoperative week, FK blood level was significantly higher in FK-3 group (19.8 +/- 1.5 ng/mL) than in FK-1 group (5.0 +/- 0.4 ng/mL; P < .05). There was no evidence of systemic infection in either FK-treated group. For maltose absorption, control allograft was abnormal on day 7 correlating to severely damaged intestinal architecture. In contrast, FK-treated allografts showed well-protected intestinal structure and normal absorption on days 7 and 21. CONCLUSION: High FK506 blood levels in the first postoperative week, achieved with FK pretreatment, prolonged intestinal allograft survival and preserved intestinal structure and function without allowing systemic infection.

Fetiform teratoma arising from a tubular intestinal duplication.A probable cause of ruptured exomphalos

A neonate who had a ruptured exomphalos with a fetiform teratoma arising from the end of a long intestinal tubular duplication and a short gut is presented. The management is discussed and the literature is reviewed.

Phantom pain: natural history and association with rehabilitation.

All 338 lower limb amputees under the care of one disablement services centre were asked to assess phantom pain severity at different times after amputation. Of 212 (63%) replies, 13 had died, 22 were non-limb wearers and 22 were unable to complete the questionnaire. In all, 176 useful replies were received--96 below-knee, 74 above-knee and 6 through-knee. Of these, 98 amputations were performed for trauma and 78 for vascular disease. Below-knee amputees rehabilitated better than above-knee amputees (P < 0.05) and traumatic better than vascular amputees (P < 0.0001). Preoperative pain was worse in vascular amputees (P < 0.0005), but there was no significant difference in the amount of phantom-pain experienced by vascular and traumatic amputees. Phantom sensations were experienced by 82% and phantom pain by 78%. Phantom pain decreased with time, was present equally in traumatic and vascular amputees, and was related to the amount of preoperative pain (P < 0.005). Only 22% felt phantom pain had impaired their rehabilitation. Rehabilitation score was related to phantom pain severity at the time of questionnaire completion (P < 0.05), but not at other specified times after operation.

Use of bacteriology in anorectal sepsis as an indicator of anal fistula: experience in a distinct general hospital.

The bacteriology of anorectal sepsis in a district general hospital has been reviewed to see whether the information gained helped patient management. Forty-six patients with anorectal sepsis were reviewed, underlying fistulas were identified in nine patients (19.5%). Bacteroides species were not routinely subtyped in the department. It was found that isolation of unspecified Bacteroides species was not helpful in identifying those patients with underlying fistulas. Unless subtyping of Bacteroides species is specifically requested, pus from anorectal sepsis should not routinely be sent for bacteriology.

Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost.

OBJECTIVE: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. DESIGN: A randomised controlled trial of 403 patients with inguinal hernias. SETTING: Two acute general hospitals in London between May 1995 and December 1996. SUBJECTS: 400 patients with a diagnosis of groin hernia, 200 in each group. MAIN OUTCOME MEASURES: Time until discharge, postoperative pain, and complications; patients' perceived health (SF-36), duration of convalescence, and patients' satisfaction with surgery; and health service costs. RESULTS: More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation (chi2 = 6.7; 1 df; P=0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was 335 pounds (95% confidence interval 228 pounds to 441 pounds) more than the cost of open repair. CONCLUSION: This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.