Newly identified risk factors for MRSA carriage in The Netherlands.

OBJECTIVES: To elucidate new risk factors for MRSA carriers without known risk factors (MRSA of unknown origin; MUO). These MUO carriers are neither pre-emptively screened nor isolated as normally dictated by the Dutch Search & Destroy policy, thus resulting in policy failure. METHODS: We performed a prospective case control study to determine risk factors for MUO acquisition/carriage (Dutch Trial Register: NTR2041). Cases were MUO carriers reported by participating medical microbiological laboratories to the RIVM from September 1st 2011 until September 1st 2013. Controls were randomly selected from the community during this period. RESULTS: Significant risk factors for MUO in logistic multivariate analysis were antibiotic use in the last twelve months, aOR 8.1 (5.6-11.7), screened as contact in a contact tracing but not detected as a MRSA carrier at that time, aOR 4.3 (2.1-8.8), having at least one foreign parent, aOR 2.4 (1.4-3.9) and receiving ambulatory care, aOR 2.3 (1.4-3.7). Our found risk factors explained 83% of the MUO carriage. CONCLUSIONS: Identifying new risk factors for MRSA carriers remains crucial for countries that apply a targeted screening approach as a Search and Destroy policy or as vertical infection prevention measure.

Improving hand hygiene compliance in child daycare centres: a randomized controlled trial.

Gastrointestinal and respiratory infections in children attending daycare centres (DCCs) are common and compliance with hand hygiene (HH) guidelines to prevent infections is generally low. An intervention was developed to increase HH compliance and reduce infections in DCCs. The objective of this paper was to evaluate the effectiveness of this intervention on HH compliance. The intervention was evaluated in a two-arm cluster randomized controlled trial in 71 DCCs in The Netherlands. Thirty-six DCCs received the intervention including: (1) HH products; (2) training about HH guidelines; (3) two team training sessions aimed at goal setting and formulating HH improvement activities; and (4) reminders and cues for action (posters/stickers). Intervention DCCs were compared to 35 control DCCs that continued usual practice. HH compliance of caregivers and children was observed at baseline and at 1, 3 and 6 months follow-up. Using multilevel logistic regression, odds ratios (ORs) with 95% confidence intervals (CIs) were obtained for the intervention effect. Of 795 caregivers, 5042 HH opportunities for caregivers and 5606 opportunities for supervising children's HH were observed. At 1 month follow-up caregivers' compliance in intervention DCCs was 66% vs. 43% in control DCCs (OR 6·33, 95% CI 3·71-10·80), and at 6 months 59% vs. 44% (OR 4·13, 95% CI 2·33-7·32). No effect of the intervention was found on supervising children's HH (36% vs. 32%; OR 0·64, 95% CI 0·18-2·33). In conclusion, HH compliance of caregivers increased due to the intervention, therefore dissemination of the intervention can be considered.

A hand hygiene intervention to reduce infections in child daycare: a randomized controlled trial.

Infections are common in children attending daycare centres (DCCs). We evaluated the effect of a hand hygiene (HH) intervention for caregivers on the incidence of gastrointestinal and respiratory infections in children. The intervention was evaluated in a two-arm cluster randomized controlled trial. Thirty-six DCCs received the intervention including HH products, training sessions, and posters/stickers. Thirty-five control DCCs continued usual practice. Incidence of episodes of diarrhoea and the common cold in children was monitored by parents during 6 months. Using multilevel Poisson regression, incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were obtained. Diarrhoeal incidence was monitored in 545 children for 91 937 days. During follow-up, the incidence was 3·0 episodes per child-year in intervention DCCs vs. 3·4 in control DCCs (IRR 0·90, 95% CI 0·73-1·11). Incidence of the common cold was monitored in 541 children for 91 373 days. During follow-up, the incidence was 8·2 episodes per child-year in intervention DCCs vs. 7·4 in control DCCs (IRR 1·07, 95% CI 0·97-1·19). In this study, no evidence for an effect of the intervention was demonstrated on the incidence of episodes of diarrhoea and the common cold.

Emergence of MRSA of unknown origin in the Netherlands.

The Netherlands is known for its low methicillin-resistant Staphylococcus aureus (MRSA) prevalence. Yet MRSA with no link to established Dutch risk factors for acquisition, MRSA of unknown origin (MUO), has now emerged and hampers early detection and control by active screening upon hospital admittance. We assessed the magnitude of the problem and determined the differences between MUO and MRSA of known origin (MKO) for CC398 and non-CC398. National MRSA Surveillance data (2008-2009) were analysed for epidemiological determinants and genotypic characteristics (Panton-Valentine leukocidin, spa). A quarter (24%) of the 5545 MRSA isolates registered were MUO, i.e. not from defined risk groups. There are two genotypic MUO groups: CC398 MUO (352; 26%) and non-CC398 MUO (998; 74%). CC398 MUO needs further investigation because it could suggest spread, not by direct contact with livestock (pigs, veal calves), but through the community. Non-CC398 MUO is less likely to be from a nursing home than non-CC398 MKO (relative risk 0.55; 95% CI 0.42-0.72) and Panton-Valentine leukocidin positivity was more frequent in non-CC398 MUO than MKO (relative risk 1.19; 95% CI 1.11-1.29). Exact transmission routes and risk factors for non-CC398 as CC398 MUO remain undefined.

Large electrodes improve nerve conduction repeatability in controls as well as in patients with diabetic neuropathy.

Recording site is an important cause of variability of compound muscle action potential (CMAP) and conduction parameters, which can be reduced by using large electrodes. Repeatability of CMAP and conduction parameters of conventional and large electrodes was compared in 16 controls and 17 diabetic neuropathic patients, using defined recording sites linked to anatomical landmarks. Right-sided median, peroneal, and tibial nerves were investigated twice with a 1-2 week interval by the same examiner. Compared to previous studies, conventional electrodes on strictly defined recording sites resulted in better repeatability: intraindividual coefficients of variation (CV) varied between 4% and 14.4% for all parameters. CV of conduction parameters, not published previously, was smaller than CV of CMAP parameters. The use of large electrodes improved repeatability further: large electrodes resulted in substantially smaller CV for duration, amplitude, area, and changes of amplitude and area over a length of nerve, which were reduced by 10%, 31%, 29%, 27%, and 16%, respectively. Patients had higher CV than controls; large electrodes reduced patient CV more than control CV, resulting in less contrast between groups. Strictly defined recording sites and large electrodes improve repeatability of motor conduction studies to relevant degrees: all CMAP and conduction parameters are suitable for longitudinal studies of neuropathic patients.

Treatment of diabetic polyneuropathy with the neurotrophic peptide ORG 2766.

The efficacy of the neurotrophic peptide ORG 2766 in diabetic patients with polyneuropathy was evaluated in a double-blind, placebo-controlled, multicentre trial. One hundred and twenty four patients were randomised in five groups to receive 0.1, 0.4, 2 or 5 mg ORG 2766 or placebo, once daily, administered subcutaneously 52 weeks. Thermal discrimination thresholds (TDT) and vibration perception thresholds (VPT), motor and sensory nerve conduction velocity, Hoffmann reflex, heart rate variation during deep breathing and heart rate response after standing up, neurological examination score and neuropathic symptom score were determined at baseline and after 17, 34 and 52 weeks of treatment. Of the nerve function indices studied, at week 52 the TDTwarmth of the hand in the ORG 2766 0.1, 0.4 and 5 mg groups and the TDTcold of the foot in the ORG 2766 0.1 and 0.4 mg groups significantly improved compared with placebo. Further significant improvement as compared with placebo was observed in the paraesthesia score at week 34 and week 52 in the ORG 2766 2 mg group. Only at week 34 had both the heartbeat variation during deep breathing and the VPT of the foot in the ORG 2766 0.1 mg group improved significantly, compared with placebo. No further statistically significant differences were observed at time for the other measures. No adverse reactions were observed. The only recorded drug-induced side effect was pain at the injection site. Taking all measures of efficacy into account, the statistically significant results observed did not show consistency within each measure. Therefore, it is concluded that ORG 2766, in contrast to earlier reports, is not effective in treating diabetic polyneuropathy.

Determinants of vibration perception thresholds in IDDM and NIDDM patients.

The relative influence of diabetes mellitus-related and physiological factors on vibration perception thresholds was assessed in 353 patients in a hospital-based setting (173 insulin-dependent and 180 non-insulin dependent patients, aged 51.1 +/- 15.9 years) and 80 healthy controls (aged 43.3 +/- 15.2 years) employing a Biothesiometer. Vibration perception thresholds were bilaterally measured at the thumbs, medial malleoli and halluces. Sixty (17.0%) older patients had off-scale thresholds (> 50 V). As no systematic side differences were found, values of contralateral sites were averaged. Considering the effects of age, height, gender and skin temperature in controls, age accounted for 46.7 and 52.2% threshold variance at the ankles and halluces, respectively, while height explained 5.1 and 5.1%, respectively. At the thumbs, only age was of relevance. Age relationships with vibration thresholds in health did not differ from published reports at any site. In the patient group, influences of age, height, gender, skin temperature, years from diagnosis, HbAlc, serum creatinine, drop in systolic blood pressure on standing, and ankle/arm blood pressure indices were assessed for each type of diabetes. For both types, age and height again had relevant effects at the lower extremities as did age and gender at the thumbs. Skin temperature was only marginally significant at the halluces of NIDDM patients. Of the disease-related factors, HbAlc had the strongest effect: for both IDDM and NIDDM higher levels were associated with lower vibration sensitivity. Increasing disease duration led to significantly higher thresholds in IDDM patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy of aldose reductase inhibitors in the management of diabetic complications. Comparison with intensive insulin treatment and pancreatic transplantation.

Recently, aldose reductase inhibitors (ARIs) have been registered in several countries for the improvement of glycaemic control. However, their efficacy is still controversial. ARIs inhibit the enhanced flux of glucose through the polyol pathway. As such, they can never be more effective than normoglycaemia, and so their potential benefits and limitations should be considered relative to the effects of prolonged euglycaemia. The clinical effects of ARIs can be put into perspective by assessing the effects of improved glycaemic control attained in randomised trials of intensive insulin treatment [such as the Diabetes Control and Complications Trial (DCCT)] and after pancreatic transplantation. Although direct comparison of these 3 interventions is hampered by differences in patient populations, duration and methods of follow-up and in the potency of ARIs, the effects of these 3 metabolic interventions and their course in time appear remarkably similar. For neuropathy, all 3 interventions induce an increase in average motor nerve conduction velocity of approximately 1 m/sec during the first months of treatment. At the same time, improvement of painful symptoms may occur. These changes probably largely represent a metabolic amelioration of the condition of the nerves. Around the second year of treatment with all 3 forms of metabolic improvement, an acceleration of nerve conduction of a similar magnitude occurs, with signs of structural nerve regeneration and some sensory recuperation. Experience with ARIs in nephropathy is still limited, but similar improvements in glomerular filtration rate and, less consistently, in urinary albumin excretion were found during short term normoglycaemia produced by all 3 forms of treatment. Comparison of a small number of studies, however, shows differences between intensive insulin regimens, pancreatic transplantation and ARIs in effects on retinopathy. Retinopathy often temporarily deteriorates in the early phases of improved glycaemic control, but this is not noted with ARIs. New microaneurysm formation was slightly reduced in a single long term study with the ARI sorbinil, but the preventive effects on the overall levels of retinopathy seemed less strong than in normoglycaemia trials of similar duration. However, the pharmacodynamic effects on inhibiting the polyol pathway differ among ARIs, and the half-life of the inhibiting effect of sorbinil may have been too short for a complete reduction of polyol pathway activity. The trials of prolonged intensive insulin therapy and pancreatic transplantation have demonstrated that very strict metabolic control must be maintained continuously for many years before a significant reduction of complications can be demonstrated.(ABSTRACT TRUNCATED AT 400 WORDS)

CMAP variability as a function of electrode site and size.

The site of the recording electrode influences the amplitude of the compound muscle action potential (CMAP) and its variation over a length of nerve. The effects of large electrodes on this source of intraindividual variability were assessed. Right median nerves of 20 healthy subjects were studied, and recordings made at three sites (at 1-cm intervals) using five electrode sizes (0.01, 1, 2, 4, and 10 cm2). Site-induced variability was defined as the standard deviation (SDi) and coefficient of variation (CVi) of the measurements of the three sites. Site induced variability of all parameters (latency, duration, amplitude, area, MNCV, and the percentile changes of duration, amplitude, and area over the forearm) decreased significantly with electrode size. Decreases were most pronounced for amplitude and area: CVi fell from 29% and 30% (0.01-cm2 electrode) to 10% and 8% (10 cm2). It is argued that large electrodes record activity of more motor units than small electrodes, and that their measurement fields overlap to a greater extent. The use of large electrodes is recommended in order to reduce site-induced CMAP variability.

Effects of supine blood pressure on interpretation of standing up test in 500 patients with diabetes mellitus.

The relationship between fall in blood pressure (BP) on standing and supine BP before standing up was studied in 75 healthy controls and in 500 patients with diabetes mellitus (DM) using conventional BP measurements. The influences of physiological (sex, age, height) and DM-related factors (type, duration, HbA1c-level, use of insulin, oral antidiabetic and anti-hypertensive medication) on BP-fall were assessed. The effects of using a fixed abnormality threshold and a new supine BP-related abnormality definition on interpretation of the test were determined. Highly significant relationships of BP-fall with supine BP were found in control and DM subjects. Slopes did not differ between these groups. Slopes for systolic BP-fall were steeper in type 1 than in type 2 DM patients. A forward stepwise regression procedure revealed that supine BP (explaining 24% of variance) and HbA1c (explaining 1%) had significant influences on systolic BP-fall. Diastolic supine BP explained 14% of diastolic BP-fall, age 3%, and sex 2%. Only supine BP was thus of practical relevance in explaining BP-fall. Taking supine BP into consideration affected test results: of 74 subjects with an abnormal conventional systolic BP-fall, 10 (13.5%) had been misclassified according to the new method, and 4 additional patients had been misclassified as normal. Classification changes were much larger for diastolic BP-fall (63% of conventionally abnormal results were reclassified as normal), but the range of diastolic BP is smaller than for systolic BP, meaning that the measurement error interferes with its clinical utility.(ABSTRACT TRUNCATED AT 250 WORDS)