Effectiveness of deep cleaning followed by hydrogen peroxide decontamination during high Clostridium difficile infection incidence.

BACKGROUND: Clostridium difficile infection (CDI) remains an infection control challenge, especially when environmental spore contamination and suboptimal cleaning may increase transmission risk. AIM: To substantiate the long-term effectiveness throughout a stroke rehabilitation unit (SRU) of deep cleaning and hydrogen peroxide decontamination (HPD), following a high incidence of CDI. METHODS: Extensive environmental sampling (342 sites on each occasion) for C. difficile using sponge wipes was performed: before and after deep cleaning with detergent/chlorine agent; immediately following HPD; and on two further occasions, 19 days and 20 weeks following HPD. C. difficile isolates underwent polymerase chain reaction ribotyping and multi-locus variable repeat analysis (MLVA). FINDINGS: C. difficile was recovered from 10.8%, 6.1%, 0.9%, 0% and 3.5% of sites at baseline, following deep cleaning, immediately after HPD, and 19 days and 20 weeks after HPD, respectively. C. difficile ribotypes recovered after deep cleaning matched those from CDI cases in the SRU during the previous 10 months. Similarly, 10/12 of the positive sites identified at 20 weeks post-HPD harboured the same C. difficile ribotype (002) and MLVA pattern as the isolate from the first post-HPD CDI case. CDI incidence [number of cases on SRU per 10 months (January-October 2011)] declined from 20 before to seven after the intervention. CONCLUSION: HPD, after deep cleaning with a detergent/chlorine agent, was highly effective for removing environmental C. difficile contamination. Long-term follow-up demonstrated that a CDI symptomatic patient can rapidly recontaminate the immediate environment. Determining a role for HPD should include long-term cost-effectiveness evaluations.

Assessment of the significance of respiratory culture of Aspergillus in the non-neutropenic patient. A critique of published diagnostic criteria.

Assessment of the significance of isolation of Aspergillus sp. from respiratory culture in patients who are not neutropenic is a continuing problem in respiratory medicine. In recent years a number of criteria for defining patients with invasive or chronic pulmonary aspergillosis in this group have been proposed. This study sought to assess the value of three sets of these criteria in distinguishing between colonisation and aspergillosis requiring therapy when applied retrospectively to 121 patients with positive sputum or BAL culture for Aspergillus sp. Two patients (1.6%) were identified as having proven or probable aspergillosis by the EORTC criteria, two different patients fulfilled the criteria for invasive aspergillosis in the 62 patients with chronic obstructive pulmonary disease (3.2%), and yet another two different patients met the criteria for chronic pulmonary aspergillosis (1.6%). It is suggested that difficulties in the application of some of these criteria may prevent the accurate diagnosis of aspergillosis in the non-neutropenic patient setting.

Isolation of the fungus Geosmithia argillacea in sputum of people with cystic fibrosis.

We report the repeated isolation of the fungus Geosmithia argillacea from sputum samples of people with cystic fibrosis. Identification was based on morphology and DNA sequence analysis. Isolation of G. argillacea did not appear to be associated with clinical deterioration. The pathogenic potential of G. argillacea is discussed.

Cerebral phaeohyphomycosis caused by Fonsecaea monophora.

We report a case of cerebral phaeohyphomycosis in a 53-year-old immunocompetent diabetic male, caused by Fonsecaea monophora. Computerized tomography of the brain revealed an abscess, which yielded F. monophora in pure culture. The patient's condition deteriorated on treatment with voriconazole and 5-fluorocytosine, and improved subsequently with high-dose itraconazole. The genus Fonsecaea has recently been revised and the new species F. monophora generated from molecular analysis of isolates, most of which were originally identified as Fonsecaea pedrosoi. This is the fourth case of cerebral infection known to have been caused by F. monophora, although only the first reported as such. These cases suggest that the clinical potential of F. monophora differs from that of F. pedrosoi, one of the main agents of chromoblastomycosis, with F. monophora being predominantly neurotropic in the human host.

The global epidemiology of invasive Candida infections--is the tide turning?

Invasive candidiasis is a condition of major medical importance. Its incidence has increased dramatically over the last 50 years, reflecting increasingly interventional standards of medical care. Candida spp. are regularly reported to be the fourth commonest cause of bloodstream infection, and it is perceived that the incidence of invasive Candida spp. infections continues to increase. The global disease burden of invasive Candida spp. infections is difficult to quantify because of wide geographic variation. Data originating from the United States indicate that mortality from candidiasis has been falling since 1989. Data from several locations have shown that the dramatic increases in Candida spp. bloodstream infections seen during the 1980s were not sustained through the 1990s. Some authors have reported a decreasing incidence. The contribution of non-albicans Candida spp. to invasive infection is rising. Invasive infections with Candida spp. continue to represent a major economic burden, increasing both mortality and morbidity in an already expensive group of hospital patients. There remains much scope for ongoing and future research into the epidemiology and basic disease processes underlying these infections.

A negative search for a paramyxoviral etiology of Paget's disease of bone: molecular, immunological, and ultrastructural studies in UK patients.

Paget's disease of bone is a common bone disease characterized by increased and disorganized bone remodeling at focal sites throughout the skeleton. The etiology of the disease is unresolved. A persistent viral infection has long been suggested to cause the disease. Antigen and/or nucleic acid sequences of paramyxoviruses (in particular measles virus [MV], canine distemper virus [CDV], and respiratory syncytial virus [RSV]) have been reported in pagetic bone by a number of groups; however, others have been unable to confirm this and so far no virus has been isolated from patients. Here, we reexamined the question of viral involvement in Paget's disease in a study involving 53 patients with established disease recruited from seven centers throughout the United Kingdom. Thirty-seven patients showed clear signs of active disease by bone scan and/or histological assessment of the bone biopsy specimens and 12 of these had not received any therapy before samples were taken. Presence of paramyxovirus nucleic acid sequences was sought in bone biopsy specimens, bone marrow, or peripheral blood mononuclear cells using reverse-transcription polymerase chain reaction (RT-PCR) with a total of 18 primer sets (7 of which were nested), including 10 primer sets (including 3 nested sets) specifically for MV or CDV. For each patient at least one sample was tested with all primer sets by RT-PCR and no evidence for the presence of paramyxovirus RNA was found in any patient. In 6 patients, bone biopsy specimens with clear histological evidence of active disease tested negative for presence of measles and CDV using immunocytochemistry (ICC) and in situ hybridization (ISH). Intranuclear inclusion bodies, similar to those described by others previously, were seen in pagetic osteoclasts. The pagetic inclusions were straight, smooth tubular structures packed tightly in parallel bundles and differed from nuclear inclusions, known to represent MV nucleocapsids, in a patient with subacute sclerosing panencephalitis (SSPE) in which undulating, diffuse structures were found, arranged loosely in a nonparallel fashion. In the absence of amplification of viral sequences from tissues that contain frequent nuclear inclusions and given that identical inclusions are found in other bone diseases with a proven genetic, rather than environmental, etiology, it is doubtful whether the inclusions in pagetic osteoclasts indeed represent viral nucleocapsids. Our findings in this large group of patients recruited from throughout the United Kingdom do not support a role for paramyxovirus in the etiology of Paget's disease.

The effects of diffusates from the spores of Aspergillus fumigatus and A. terreus on human neutrophils, Naegleria gruberi and Acanthamoeba castellanii.

Diffusates from dormant spores of Aspergillus fumigatus are inhibitory to certain functions of immune phagocytic cells and soil protozoa. An assay of human neutrophil phagocytosis and an in vitro method of measuring inhibition of the growth of free living amoebae are described. The anti-phagocytic and anti-amoebal effects of diffusates from clinical and environmental isolates of A. fumigatus and of A. terreus were measured using these methods. Spore diffusates from all isolates of A. fumigatus and A. terreus tested significantly inhibited neutrophil phagocytosis. Spore diffusates from A. fumigatus, but not A. terreus, significantly inhibited the growth of Naegleria gruberi. Spore diffusate from A. fumigatus did not inhibit the growth of Acanthamoeba castellanii. The relevance of these findings to the pathogenicity of A. fumigatus and A. terreus is discussed.

Are infants with autism socially engaged? A study of recent retrospective parental reports.

The purpose of this study was to identify the specific aspects of social engagement that distinguish infants with autism from infants of similar age and developmental level who do not have autism. Ten parents of preschoolers with autism and 10 parents of matched children without autism were given a semistructured interview, the Detection of Autism by Infant Sociability Interview (DAISI), which elicits reports on whether 19 aspects of social engagement characteristic of typically developing infants were present at some time during the child's first 24 months. The reports of infants with autism differed from those of the control group on 16 items. Findings suggest that infants with autism have marked limitation in both person-to-person and person-person-object social engagement, in keeping with the theory that autism involves impairments in primary as well as secondary intersubjectivity (Hobson, 1993a).

Imitation and identification in autism.

This study was designed to test the prediction that adolescents with autism would have specific limitations in imitating the "style" of another person's actions. In a series of original tasks that tested the delayed imitation of novel nonsymbolic actions, 16 participants with autism and 16 nonautistic participants group-matched for age and verbal ability were proficient in copying goal-directed actions, but in 3 out of 4 tasks, strikingly fewer participants with autism imitated with style with which the demonstrator executed the actions. An additional finding was that on 2 conditions that involved copying self-orientated actions, only 5 of the participants with autism but 15 of the 16 nonautistic participants spontaneously adopted the orientation-to-self on at least 1 occasion. The results are discussed with reference to theories concerning imitation deficits in autism, and with regard to the proposal that autism involves an impairment in intersubjective contact between affected individuals and others (Hobson, 1989, 1993; Rogers & Pennington, 1991).

Individual differences in young children's IQ: a social-developmental perspective.

From a sample of middle-class mothers and their 3-year-old children, a selected group of 36 mothers were divided into 2 groups according to the quality of their responses to the Adult Attachment Interview as a Questionnaire (Crandell, Fitzgerald, & Whipple, 1997). Twenty mothers provided coherent accounts of their early parent-child relationships (secure) and 16 mothers provided idealised, entangled, or otherwise incoherent accounts of their early parent-child relationships (insecure). The mothers were administered an abbreviated version of the WAIS-R and the children were given an abbreviated version of the Stanford-Binet Intelligence Scale. The quality of mother-child interactions was assessed by videotaping a 20-minute play episode and clean-up period, and by rating the degree of synchrony according to a modified version of the Belsky Parent-Child Interaction System (Whipple, Denburg, & Davies, 1993). The results were that children of secure mothers scored 19 points higher on the Stanford-Binet test compared to children of insecure mothers. (The adjusted mean difference was 12 points when maternal IQ, education, and family SES were taken into account.) The group difference in the children's IQ remained significant when comparisons were made between a subgroup of 12 secure and 12 insecure mothers who were matched for maternal IQ. Finally we examined the subgroup of 16 cases where child IQ scores were either 10 points higher or lower than maternal IQ. In all 6 cases where child IQ was at least 10 points below maternal IQ, the child had a mother who was insecure; in contrast, only 4 of the 10 children who had IQ scores 10 points higher than maternal IQ had an insecure mother. In terms of parent-child interaction patterns, there was suggestive evidence that the degree of parent-child synchrony was also related to child IQ. The results suggest important social-developmental contributions to young children's performance on standardised tests of intellectual ability.

Autism and congenital blindness.

The nature of autism in congenitally blind children has long been a source of interest and perplexity. A group of nine congenitally blind children with an autism-like syndrome were closely matched on chronological age and verbal mental age with nine sighted autistic children, and were compared on the Childhood Autism Rating Scale (Schopler, Reichler, & Renner, 1986) and the Behavior Checklist for Disordered Preschoolers, together with the Play Items for Disordered Preschoolers (Sherman, Shapiro, & Glassman, 1983). A checklist of clinical features characteristic of autism (derived from DSM-III-R) was also completed through an interview with teachers. There was substantial similarity between the groups, but also suggestive evidence of possible group differences, specifically in the domain of social-emotional responsiveness. Research on the psychological development of congenitally blind children promises to yield insights into the nature of autism itself.

On developing self-concepts: a controlled study of children and adolescents with autism.

This study employed the self-understanding interview of Damon and Hart (1988) to assess the self-concepts of two groups of children and adolescents: a group of individuals with autism and a group of nonautistic mentally retarded individuals who were matched for age and for verbal ability. On the basis of an hypothesis concerning the interpersonal origins of social and psychological self-concepts (Hobson, 1990; Neisser, 1988), it was predicted that the participants with autism would show a relative dearth of such concepts in their talk about themselves. In accordance with our predictions, there was a significant group difference in the number and quality of statements that fell into the social category of self-concept; contrary to our predictions, however, there was no group difference in the number of statements that fell into the psychological category. In addition, although there were not significant group differences in the overall production of verbally expressed concepts concerning self-attributes of a physical, active, or psychological kind, even within these categories individuals with autism made fewer references to social interactions or qualities. These results are discussed with regard to theories of self-concept development in typically developing as well as autistic and mentally retarded individuals, and with reference to the limitations of interpersonal understanding ("theory of mind") in people with autism.

Objectivity in psychoanalytic judgements.

BACKGROUND: There is widespread scepticism concerning the reliability and validity psychoanalytic judgements of patient-therapist transactions. We predicted that (a) in reviewing the initial part of 14 videotaped assessment interviews with borderline and dysthymic subjects, dynamic psychotherapists would agree in their ratings of psychoanalytically relevant characteristics of subjects' interpersonal relations; (b) inter-correlations among the ratings would conform with those expected from psychoanalytic descriptions of paranoid-schizoid' and 'depressive position' states of mind; and (c) these ratings would differentiate between borderline and dysthymic groups. METHOD: Six trained psychotherapists who were blind to the design of the study, independently rated qualities of interpersonal relatedness during the first 30 minutes of each interview, on a 30-item 'personal relatedness profile'. RESULTS: There was satisfactory interrater reliability in judgements among the raters, and evidence that the items were interrelated. There was also a significant difference between the two subject groups. CONCLUSIONS: It is possible to make reliable psychoanalytic judgements about qualities of interpersonal relatedness. Moreover, there is evidence that paranoid-schizoid and depressive positive aspects of psychological functioning do constitute a meaningful constellation of clinically grounded phenomena.

Multiply-resistant Klebsiella pneumoniae: failure of spread in community-based elderly care facilities.

Thirty-eight patients colonized with multiply-resistant, plasmid-mediated, expanded-spectrum beta-lactamase (SHV-2) producing Klebsiella pneumoniae (MRK), were discharged from hospital to 22 nursing or residential homes during a hospital-based outbreak, in the Grampian region of north-east Scotland. MRK colonized the urinary tract in 74%, stool in 58%, respiratory tract in 29% and wounds in 11%. Mean length of colonization was 160 days (range 7-548). Mean length of stay in the homes after aquisition of MRK was 298 days. Compared with a control group of MRK-negative residents, MRK-positive residents had histories of more hospital admissions, underlying disease and complete immobility. Evaluation of these homes showed high standards of care and good facilities. Despite prolonged carriage of MRK by the index cases there was no evidence of spread to the other 886 residents who were screened, and there was evidence of only minor environmental contamination. Given the available evidence, patients colonized with MRK can be accommodated in good-quality nursing and residential homes, on discharge from hospital, with little fear of spread to other residents.

Hello and goodbye: a study of social engagement in autism.

We videotaped 24 children, adolescents, and young adults with autism, individually matched for chronological age and verbal mental age with 24 nonautistic persons with mental retardation, for their spontaneous and prompted greetings and farewells towards an unfamiliar adult. Compared with control subjects, those with autism were less likely to offer spontaneous verbal and nonverbal gestures of greeting and farewell, and were less likely to establish eye contact even when they were offered a greeting. There were also fewer autistic subjects who smiled, or who waved goodbye. Results corresponded with raters' subjective judgments of participants' interpersonal engagement with the stranger. One interpretation of the findings is that they reflect a relative lack of intersubjective engagement by autistic individuals.

A randomized trial of acidified nitrite cream in the treatment of tinea pedis.

BACKGROUND: Nitric oxide is continually released from normal skin and has antimicrobial effects. An acidified nitrite cream releases supraphysiologic concentrations of nitric oxide and is fungicidal in vitro. OBJECTIVE: The purpose of this study was to assess the efficacy of an acidified nitrite cream as treatment for tinea pedis. METHODS: Sixty patients were recruited with both a clinical diagnosis of tinea pedis and hyphae identified on direct microscopy; they were randomly placed into an active group treated with twice-daily application of a mixture of 3% salicylic acid in aqueous cream and 3% nitrite in aqueous cream for 4 weeks and a control group treated with 3% salicylic acid in aqueous cream and aqueous cream alone. Nineteen patients completed the trial in the active group and 16 patients in the control group. Mycologic cure (negative results on microscopy and culture) and clinical improvement were measured at 0, 2, and 4 weeks and after a 2-week interval with no treatment. RESULTS: At the end of the treatment period, 18 of the 19 patients in the active group were mycologically cured as were 11 of 16 in the control group (p = 0.042). Two weeks after the cessation of treatment, 13 of 19 patients in the active group were mycologically cured and 5 of 16 in the control group (p = 0.028). The initial clinical scores in the active and control groups were 8.1 and 8.19 (two-tailed p = 0.95). At 4 weeks they were 1.66 and 6.0 (two-tailed p = 0.002) and after 2 weeks with no treatment 1.45 and 7.4 (two-tailed p < 0.0002). CONCLUSION: Acidified nitrite is effective therapy for tinea pedis.

Are there "autistic-like" features in congenitally blind children?

Twenty-four congenitally blind children between 3 and 9 years of age were studied for the prevalence of "autistic-like" features, as assessed by teacher reports and by systematic observations of the children's behaviour. A comparison between the 15 blind children who had IQs over 70 and 10 sighted children group-matched for age and verbal ability revealed that a number of autistic-like features were more common in the blind. When the nine blind children who had IQs less than 70 were compared with nine group-matched autistic children, the picture that emerged was of substantial overlap in clinical presentation, despite subtle differences on clinical impression. Similar results were obtained when blind subgroups were reconstituted according to the children's nonautistic or autistic-like clinical presentation, rather than IQ. These findings are discussed in relation to competing theories concerning the development of autism and "theory of mind".

Psychogenic disorders of vision in childhood ("visual conversion reactions"): perspectives from adolescence: a research note.

Fifteen adolescents who had exhibited psychogenic disorders of vision in childhood were compared with a control group of adolescents who had experienced childhood visual dysfunction of organic origin. The principal modes of assessment were clinical interviews, the Parental Bonding Instrument (PBI), and self-report measures concerning specific personality traits. Adolescents who had previously presented with psychogenic disorder were more likely to (1) report having experienced school difficulties and the loss of a significant figure at the time of presentation, (2) rate their mothers as over-involved on the PBI and (3) report adjustment difficulties and obsessional personality traits in adolescence.