Understanding of advance care planning in primary care: a gap analysis.

BACKGROUND: Although primary care is a well suited context for conducting advance care planning (ACP), there are many barriers to initiating discussions regarding future health preference and end-of-life conversations. METHODS: This qualitative study conducted 30 detailed individual interviews with senior administrators, medical and nurse practitioners of a local health district, NSW Ambulance, e-Health NSW, general practitioners and practice nurses to find out about barriers to ACP in South Western Sydney. RESULTS: Thematic analysis was conducted on the interviews. Six major themes were identified: Prevalence; Empowerment of roles and responsibilities; Lack of training/knowledge/confidence; Fragmentation of care; Patient/family readiness; and Prognostication. Half of the participants were willing to use a prognostic tool to identify when a patient was likely to be at the end of their life and provide a prompt to initiate ACP. CONCLUSION: In addition to addressing training and acknowledging resource constraints, these findings suggest that if a prognostic tool was validated and practical in a primary care setting, it may provide valuable assistance to encourage everyone in society to begin discussing this issue and completing ACP.

The effect of injurious compression on the elastic, hyper-elastic and visco-elastic properties of porcine peripheral nerves.

The aim of this study was to characterise the viscoelastic and hyper-elastic properties of the ulnar nerve before and after compression has been induced, in order to aid the understanding of how the mechanical properties of nerves are altered during nerve compression, a contributing factor to cubital tunnel syndrome. Ulnar nerves were dissected from porcine legs and tensile tested to 10% strain. The Young's modulus and Yeoh hyper-elastic model were used to evaluate the materials elastic and hyper-elastic properties respectively. Dynamic mechanical analysis (DMA) was used to evaluate the viscoelastic properties over a range of frequencies between 0.5 Hz and 38 Hz. The nerves were then compressed to 40% for 60 s and the same tests were carried out after compression. The nerves were stiffer after compression, the mean Young's modulus before was 0.181 MPa and increased to 0.601 MPa after compression. The mean shear modulus calculated from the Yeoh hyper-elastic model was also higher after compression increasing from 5 kPa to 7 kPa. After compression, these properties had significantly increased (p < 0.05). The DMA results showed that the nerves exhibit frequency dependent viscoelastic behaviour across all tested frequencies. The median values of storage modulus before compression ranged between 0.605 and 0.757 MPa across the frequencies and after compression between 1.161 MPa and 1.381 MPa. There was a larger range of median values for loss modulus, before compression, median values ranged between 0.073 MPa and 0.216 MPa and after compression from 0.165 MPa to 0.410 MPa. There was a significant increase in both storage and loss modulus after compression (p < 0.05). The mechanical properties of the nerve change following compression, however the response to decompression in vivo requires further evaluation to determine whether the observed changes persist, which may have implications for clinical recovery after surgical decompression in entrapment neuropathy.

Correlating Cleaning Thoroughness with Effectiveness and Briefly Intervening to Affect Cleaning Outcomes: How Clean Is Cleaned?

OBJECTIVES: The most efficient approach to monitoring and improving cleaning outcomes remains unresolved. We sought to extend the findings of a previous study by determining whether cleaning thoroughness (dye removal) correlates with cleaning efficacy (absence of molecular or cultivable biomaterial) and whether one brief educational intervention improves cleaning outcomes. DESIGN: Before-after trial. SETTING: Newly built community hospital. INTERVENTION: 90 minute training refresher with surface-specific performance results. METHODS: Dye removal, measured by fluorescence, and biomaterial removal and acquisition, measured with culture and culture-independent PCR-based assays, were clandestinely assessed for eight consecutive months. At this midpoint, results were presented to the cleaning staff (intervention) and assessments continued for another eight consecutive months. RESULTS: 1273 surfaces were sampled before and after terminal room cleaning. In the short-term, dye removal increased from 40.3% to 50.0% (not significant). For the entire study period, dye removal also improved but not significantly. After the intervention, the number of rooms testing positive for specific pathogenic species by culturing decreased from 55.6% to 36.6% (not significant), and those testing positive by PCR fell from 80.6% to 53.7% (P = 0.016). For nonspecific biomaterial on surfaces: a) removal of cultivable Gram-negatives (GN) trended toward improvement (P = 0.056); b) removal of any cultivable growth was unchanged but acquisition (detection of biomaterial on post-cleaned surfaces that were contaminant-free before cleaning) worsened (P = 0.017); c) removal of PCR-based detection of bacterial DNA improved (P = 0.046), but acquisition worsened (P = 0.003); d) cleaning thoroughness and efficacy were not correlated. CONCLUSION: At this facility, a minor intervention or minimally more aggressive cleaning may reduce pathogen-specific contamination, but not without unintended consequences.

Can the KG1 cell line be used as a model of dendritic cells and discriminate the sensitising potential of chemicals?

The KG1 myeloid leukaemia was used as source of dendritic cells (DC) to discriminate between respiratory and contact sensitising chemicals. A cocktail of cytokines was used to differentiate KG1 to dendritic like cells (termed dKG1) and the effects of nine chemicals (respiratory and contact sensitisers) and an irritant control on surface marker expression, 'antigen presenting' function and cytokine expression investigated. The stability of these chemicals when dissolved was characterised using MALDI ToF MS. A Hill plot model was used with the cellular viability data to quantify the lethal dose 50% (LD50) and a maximum sub toxic concentration of each chemical defined. Cytokine expression by the treated dKG1 was quantified using multiplex immunobead analysis. Whilst dKG1 cells were morphologically similar to DCs, expression of specific surface markers was not typical for DCs derived from healthy precursor cells. When the chemicals were applied at defined sub toxic doses no effects on dKG1 phenotype, function, or cytokine expression, attributable to the sensitisation properties were discriminated. However, dKG1 cells were much more sensitive to the toxic effects of these chemicals compared to the parent KG1 cells. Only 4 of the 9 chemicals tested were stable when dissolved indicating that the effect of sensitising chemicals on antigen presenting cells may be related to species other than the parent compound.

Relationships among cleaning, environmental DNA, and healthcare-associated infections in a new evidence-based design hospital.

OBJECTIVE: Hospital environments influence healthcare-associated infection (HAI) patterns, but the role of evidenced-based design (EBD) and residual bacterial DNA (previously thought to be clinically inert) remain incompletely understood. METHODS: In a newly built EBD hospital, we used culture-based and culture-free (molecular) assays, pulsed-field gel electrophoresis (PFGE), and whole-genome sequencing (WGS) to determine: (1) patterns of environmental contamination with target organisms (TOs) and multidrug-resistant (MDR) target organisms (MDR-TOs); (2) genetic relatedness between environmentally isolated MDR-TO and those from HAIs; and (3) correlation between surface contamination and HAIs. RESULTS: A total of 1,273 high-touch surfaces were swabbed before and after terminal cleaning during 77 room visits. Of the 2,546 paired swabs, 47% had cultivable biomaterial and 42% had PCR-amplifiable DNA. The ratios of TOs detected to surfaces assayed were 85 per 1,273 for the culture-based method and 106 per 1,273 for the PCR-based method. Sinks, toilet rails, and bedside tables most frequently harbored biomaterial. Although cleaned surfaces were less likely to have cultivable TOs than precleaned surfaces, they were not less likely to harbor bacterial DNA. The rate of MDR-TOs to surfaces swabbed was 0.1% (3/2546). Although environmental MDR-TOs and MDR-TOs from HAIs were genetically related by PFGE, WGS revealed that they were unrelated. Environmental levels of cultivable Enterococcus spp. and E. coli DNA were positively correlated with infection incidences (P<.04 and P<.005, respectively). CONCLUSION: MDR-TOs were rarely detected during surveillance and were not implicated in HAIs. The roles of environmental DNA and EBD, particularly with respect to water-associated fixtures or the potential suppression of cultivable environmental MDR-TOs, warrant multicenter investigations.

Perfluoroalkyl acids in the Canadian environment: multi-media assessment of current status and trends.

In Canada, perfluoroalkyl acids (PFAAs) have been the focus of several monitoring programs and research and surveillance studies. Here, we integrate recent data and perform a multi-media assessment to examine the current status and ongoing trends of PFAAs in Canada. Concentrations of perfluorooctane sulfonate (PFOS), perfluorooctanoate (PFOA), and other long-chain perfluorocarboxylates (PFCAs) in air, water, sediment, fish, and birds across Canada are generally related to urbanization, with elevated concentrations observed around cities, especially in southern Ontario. PFOS levels in water, fish tissue, and bird eggs were below their respective Draft Federal Environmental Quality Guidelines, suggesting there is low potential for adverse effects to the environment/organisms examined. However, PFOS in fish and bird eggs tended to exceed guidelines for the protection of mammalian and avian consumers, suggesting a potential risk to their wildlife predators, although wildlife population health assessments are needed to determine whether negative impacts are actually occurring. Long-term temporal trends of PFOS in suspended sediment, sediment cores, Lake Trout (Salvelinus namaycush), and Herring Gull (Larus argentatus) eggs collected from Lake Ontario increased consistently from the start of data collection until the 1990s. However, after this time, the trends varied by media, with concentrations stabilizing in Lake Trout and Herring Gull eggs, and decreasing and increasing in suspended sediment and the sediment cores, respectively. For PFCAs, concentrations in suspended sediment, sediment cores, and Herring Gulls generally increased from the start of data collection until present and concentrations in Lake Trout increased until the late 1990s and subsequently stabilized. A multimedia comparison of PFAA profiles provided evidence that unexpected patterns in biota of some of the lakes were due to unique source patterns rather than internal lake processes. High concentrations of PFAAs in the leachate and air of landfill sites, in the wastewater influent/effluent, biosolids, and air at wastewater treatment plants, and in indoor air and dust highlight the waste sector and current-use products (used primarily indoors) as ongoing sources of PFAAs to the Canadian environment. The results of this study demonstrate the utility of integrating data from different media. Simultaneous evaluation of spatial and temporal trends in multiple media allows inferences that would be impossible with data on only one medium. As such, more co-ordination among monitoring sites for different media is suggested for future sampling, especially at the northern sites. We emphasize the importance of continued monitoring of multiple-media for determining future responses of environmental PFAA concentrations to voluntary and regulatory actions.

Antimicrobial prescribing practices following publication of guidelines for the prevention of infections associated with combat-related injuries.

BACKGROUND: Timely and limited antibiotic prophylaxis (postinjury antimicrobial therapy) targeting specific traumatic injuries is a well-recognized measure to lessen posttraumatic infection. Modern military combat injuries raise significant challenges because of complex multiple injuries and limited data derived directly from well-controlled trials to base recommendations. Expert consensus review of available evidence led to published guidance for selection and duration of antimicrobial therapy for combat-related trauma infection prevention. This analysis evaluates antibiotic-prescribing practices by military physicians in the operational theater relative to the published guidance. METHODS: Trauma history and infectious disease-specific inpatient care information is captured through the Joint Theater Trauma Registry along with a supplemental infectious disease module. Injury patterns are classified based on documented International Classification of Diseases-9th Revision codes with a composite assessment of each patient's injury pattern. Antimicrobial use categorized as prophylaxis is prescribed within the first 48 hours postinjury. Adherence to published guidance is reported along with patient characteristics and injury severity to assess for potential explanations of nonadherence. RESULTS: During June to November 2009, 75% of the 610 eligible trauma patients received antimicrobial prophylaxis. Adherence to the recommended antibiotic agent on the day of injury was in the range of 46% to 50% for the most common extremity injury patterns and <10% in penetrating abdominal injuries. Antibiotics were given in 39% of patients sustaining injuries that are recommendations to not receive antimicrobial prophylaxis. CONCLUSIONS: This first evaluation of combat trauma-related antibiotic prophylaxis shows adherence levels comparable or superior to reported rates in civilian settings despite the austere, frequently mass casualty environment. Areas for interval surveillance and education-based strategies for improved adherence to practice guidance are identified.

Disseminated nocardia cyriacigeorgica presenting as right lung abscess and skin nodule.

Nocardia species are ubiquitous in the environment and can be found worldwide. Direct inhalation remains the most commonly attributed route of infection with Nocardia asteroides complex, causing 50% of invasive infections. Improved molecular methods have identified a significant proportion of N. asteroides complex isolates to be Nocardia cyriacigeorgica. We report a case of a 58-year-old male working as a contractor in Bagram Air Force Base, Afghanistan, with disseminated N. cyriacigeorgica involving the lung, brain, and dermis. Diagnosis was facilitated by early identification of branched, filamentous bacteria using Fite and gram staining along secA DNA sequencing of clinical isolates. Our patient is the first confirmed case of N. cyriacigeorgica infection in Afghanistan.

Multi-drug resistant Bacteroides fragilis recovered from blood and severe leg wounds caused by an improvised explosive device (IED) in Afghanistan.

This report summarizes the case of a 23 year-old otherwise healthy male that was injured in an improvised explosive device (IED) blast in support of Operation Enduring Freedom (OEF). He sustained bilateral open tibia and fibula fractures in the setting of being exposed to water contaminated with raw sewage. Despite long-term carbapenem therapy, the patient's wounds were repeatedly noted to have purulent drainage during surgical debridement and cultures from these wounds were persistently positive for Bacteroides fragilis. Apparent clinical failure persisted despite the addition of metronidazole to his regimen and an eventual trial of tigecycline. Susceptibility testing of the B. fragilis isolate was performed and resistance to penicillin, clindamycin,metronidazole, cefoxitin, meropenem, imipenem, piperacillin/tazobactam, and tigecycline was confirmed. The presence of a nimE gene on a potentially transferrable plasmid was also confirmed by plasmid sequencing. The only antibiotics that displayed in vitro susceptibility were moxifloxacin and linezolid. These antibiotics were initiated in combination with aggressive irrigation and serial surgical debridement. Conversion to left-sided internal fixation became feasible and his left lower extremity was salvaged without residual evidence of infection. The patient completed an eight week course of combination moxifloxacin and linezolid therapy without adverse event. This B. fragilis isolate displayed simultaneous high-level resistance to multiple antibiotics routinely utilized in anaerobic infections. This was evidenced by clinical failure, in vitro susceptibility testing, and demonstration of genes associated with resistance mechanisms. This case warrants review not only due to the rarity of this event but also the potential implications regarding anaerobic infections in traumatic wounds and the success of a novel treatment regimen utilizing combination therapy with moxifloxacin and linezolid.

Lipsosomal amphotericin B for treatment of cutaneous leishmaniasis.

Treatment options for cutaneous leishmaniasis in the United States are problematic because the available products are either investigational, toxic, and/or of questionable effectiveness. A retrospective review of patients receiving liposomal amphotericin B through the Walter Reed Army Medical Center for the treatment of cutaneous leishmaniasis during 2007-2009 was conducted. Twenty patients who acquired disease in five countries and with five different strains of Leishmania were treated, of whom 19 received a full course of treatment. Sixteen (84%) of 19 experienced a cure with the initial treatment regimen. Three patients did not fully heal after an initial treatment course, but were cured with additional dosing. Acute infusion-related reactions occurred in 25% and mild renal toxicity occurred in 45% of patients. Although the optimum dosing regimen is undefined and the cost and toxicity may limit widespread use, liposomal amphotericin B is a viable treatment alternative for cutaneous leishmaniasis.

Increasing rates of obesity among HIV-infected persons during the HIV epidemic.

BACKGROUND: The prevalence and factors associated with overweight/obesity among human immunodeficiency virus (HIV)-infected persons are unknown. METHODS: We evaluated prospective data from a U.S. Military HIV Natural History Study (1985-2004) consisting of early diagnosed patients. Statistics included multivariate linear regression and longitudinal linear mixed effects models. RESULTS: Of 1682 patients, 2% were underweight, 37% were overweight, and 9% were obese at HIV diagnosis. Multivariate predictors of a higher body mass index (BMI) at diagnosis included more recent year of HIV diagnosis, older age, African American race, and earlier HIV stage (all p<0.05). The majority of patients (62%) gained weight during HIV infection. Multivariate factors associated with a greater increase in BMI during HIV infection included more recent year of diagnosis, lower BMI at diagnosis, higher CD4 count, lower HIV RNA level, lack of AIDS diagnosis, and longer HIV duration (all p<0.05). Nucleoside agents were associated with less weight gain; other drug classes had no significant impact on weight change in the HAART era. CONCLUSIONS: HIV-infected patients are increasingly overweight/obese at diagnosis and during HIV infection. Weight gain appears to reflect improved health status and mirror trends in the general population. Weight management programs may be important components of HIV care.

Mortality associated with Acinetobacter baumannii complex bacteremia among patients with war-related trauma.

We investigated the mortality associated with Acinetobacter baumannii complex bacteremia among a cohort of patients hospitalized for war-related trauma. Despite a high prevalence of multidrug-resistant strains, the 30-day mortality rate was 2%. For relatively young patients with war-related trauma, A. baumannii complex bacteremia appears to be associated with a low risk of death.

Infectious disease teleconsultative support of deployed healthcare providers.

Specialty teleconsultation is being provided to deployed healthcare providers in the current wars in Iraq and Afghanistan through the use of the Army Knowledge Online (AKO) e-mail service. We reviewed 374 teleconsults received by the infectious disease (ID) service between January 2005 and June 2008. The patients were 65% male, 12% female, 33% the gender was not stated or the consult did not involve an individual, and 41% were U.S. Army. The average response time was under 5 hours. Ninety-one percent of consults originated from the U.S. Central Command area of responsibility. Consults included questions pertaining to therapy (42%), diagnosis (21%), prevention (13%), or mixed categories (24%). Bacterial infections were the most common (32%), followed by parasitic infections (16%). Tuberculosis and methicillin-resistant Staphylococcus aureus accounted for 13% and 8% of consults, respectively. Data from this program should be useful in focusing predeployment provider training. It also provides the military ID community situational awareness of problems encountered in theater.

Cutaneous malignancies among HIV-infected persons.

BACKGROUND: As the life expectancy of persons infected with human immunodeficiency virus (HIV) increases, cancers have become an important cause of morbidity and mortality. Although cutaneous cancers are the most common malignant neoplasms in the general population, little data exist among HIV-positive persons, especially regarding the impact of HIV-specific factors. METHODS: We evaluated the incidence rates and factors associated with the development of cutaneous malignancies among HIV-infected persons by examining data that were prospectively collected from a large HIV study that included 4490 participants (1986-2006). Poisson regression and Cox proportional hazards models were performed. RESULTS: Six percent of HIV-infected persons (n = 254) developed a cutaneous malignancy during 33 760 person-years of follow-up (mean, 7.5 years). Since the advent of highly active antiretroviral therapy (HAART), the incidence rates of cutaneous non-AIDS-defining cancers (NADCs), in particular basal cell carcinoma, have exceeded the rates of cutaneous AIDS-defining cancers such as Kaposi sarcoma. Factors associated with the development of cutaneous NADCs in the multivariate models included increasing age (hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.7-2.6) and race. Compared with the white/non-Hispanic race, African Americans (HR, 0.03; 95% CI, 0.01-0.14) and other races (HR, 0.14; 95% CI, 0.03-0.57) had a lower risk of cutaneous NADCs. There were no significant associations between cutaneous NADCs and time-updated CD4 lymphocyte counts, HIV RNA levels, or receipt of HAART. CONCLUSIONS: At present, the most common cutaneous malignancies among HIV-infected persons are NADCs. Cutaneous NADCs do not appear to be significantly associated with immune function or HAART but rather are related to traditional factors such as aging and skin color.

The impact of nelfinavir exposure on cancer development among a large cohort of HIV-infected patients.

BACKGROUND: Preclinical studies suggest that the antiretroviral agent, nelfinavir mesylate (NFV), may have antineoplastic properties. The relationship between NFV and cancer incidence among HIV-infected patients is unknown. METHODS: We evaluated the impact of NFV on cancer development in a large cohort of HIV-infected persons with 108 cancer events during 13,421 person-years of follow-up. Using multivariate time-updated Cox proportional hazard models, the risk of cancer among those receiving NFV were compared to those on non-NFV antiretroviral regimens. RESULTS: The risk of cancer among those receiving NFV was similar to those on non-NFV antiretroviral regimens (hazard ratio 1.0, 95% confidence interval 0.5, 1.7, P = 0.90). We also examined AIDS-defining and non-AIDS-defining cancers separately and found no significant associations between NFV use and cancer risk. Antiretroviral use, with or without a protease inhibitor (PI) component, was associated with a reduced risk of AIDS-defining cancers compared with no antiretroviral therapy; however, the risk of cancer was the same among those using PI or PI-sparing regimens. DISCUSSION: Despite reports that NFV may have tumoricidal activity, we found no significant relationship between NFV or PI use compared with other antiretrovirals and the risk of developing cancer among a large cohort of HIV-infected persons.

Is HIV becoming more virulent? Initial CD4 cell counts among HIV seroconverters during the course of the HIV epidemic: 1985-2007.

BACKGROUND: Whether human immunodeficiency virus (HIV) seroconverters have been presenting with progressively lower CD4 cell counts over the course of the HIV epidemic is controversial. Additional data on whether HIV might have become more virulent on a population level (measured by post-seroconversion CD4 cell counts) may provide important insights regarding HIV pathogenesis. METHODS: To determine whether post-seroconversion CD4 cell counts have changed over time, we evaluated 2174 HIV seroconverters as part of a large cohort study during the period 1985-2007. Participants were documented antiretroviral-naive HIV seroconverters who had a CD4 cell count measured within 6 months after receiving a diagnosis of HIV infection. Multiple linear regression models were used to assess trends in initial CD4 cell counts. RESULTS: The mean initial CD4 cell count decreased during the study period from 632 cells/mm(3) in 1985-1990 to 553 cells/mm(3) in 1991-1995, 493 cells/mm(3) in 1996-2001, and 514 cells/mm(3) in 2002-2007. During those periods, the percentages of seroconverters with an initial CD4 cell count <350 cells/mm(3) were 12%, 21%, 26%, and 25%, respectively. In the multiple linear model, the mean decrease in CD4 cell count from 1985-1990 was 65 cells/mm(3) in 1991-1995 (P < .001)), 107 cells/mm(3) in 1996-2001 (P < .001), and 102 cells/mm(3) in 2002-2007 (P < .001). Similar trends occurred with regard to CD4 cell percentage and total lymphocyte count. Similar decreases in initial CD4 cell counts were observed among African American and white persons during the epidemic. DISCUSSION: A significant decrease in initial CD4 cell counts among HIV seroconverters in the United States has occurred during the HIV epidemic. These data provide an important clinical correlate to suggestions that HIV may have adapted to the host, resulting in a more virulent infection.

Trends in the incidence of cancers among HIV-infected persons and the impact of antiretroviral therapy: a 20-year cohort study.

OBJECTIVE: To describe trends in incidence rates of AIDS-defining cancers (ADCs) and non-AIDS-defining cancers (NADCs) during the HIV epidemic and to evaluate predictors, including the impact of antiretroviral therapy, of cancer development. DESIGN: Retrospective analysis of a multicenter, prospective natural history study including 4498 HIV-infected US military beneficiaries with 33 486 person-years of follow-up. METHODS: Predictors evaluated included demographics, clinical data, time-updated CD4 cell counts, HIV viral loads, and antiretroviral history. Time periods were classified as early pre (1984-1990), late pre (1991-1995), early post (1996-2000), and late post (2001-2006) HAART eras. Cox proportional hazard models were used to evaluate the association of specific factors with cancer. RESULTS: Ten percent of HIV-infected persons developed cancer. ADC rates increased between the early and late pre-HAART eras (7.6 and 14.2 cases per 1000 person-years) and have since declined from 5.4 to 2.7 in the early and late HAART eras, respectively (P < 0.001). Rates of NADCs have risen over the four periods (2.9, 2.8, 4.2, 6.7, P = 0.0004). During the late HAART era, 71% of cancers were NADCs. Predictors for ADCs included low CD4 cell count, noncancer AIDS diagnosis, and lack of HAART. NADCs were predicted by increasing age and white race (due to skin cancers). CONCLUSION: Although the rate of ADCs continues to fall, the rate of NADCs is rising and now accounts for the majority of cancers in HIV-infected persons. The development of NADCs is associated with increasing age among HIV patients. HAART use is protective for ADCs, but did not significantly impact NADCs.

Pulmonary blastomycosis diagnosed in Hawai'i.

Blastomycosis, a fungal infection caused by Blastomyces dermatitidis, was once thought to be endemic only to the Central and Great Lakes regions of the United States of America. We present the first reported case series of patients documenting the diagnosis of blastomycosis in the Pacific region. In both cases, exposure to endemic areas was retrospectively identified.