Identification, investigation and management of patient-to-patient hepatitis B transmission within an inpatient renal ward in North West England.

BACKGROUND: Transmission of hepatitis B virus (HBV) is rare within healthcare settings in developed countries. The aim of the article is to outline the process of identification and management of transmission of acute hepatitis B in a renal inpatient ward. METHODS: The case was identified through routine reporting to public health specialists, and epidemiological, virological and environmental assessment was undertaken to investigate the source of infection. An audit of HBV vaccination in patients with chronic kidney disease was undertaken. RESULTS: Investigations identified inpatient admission to a renal ward as the only risk factor and confirmed a source patient with clear epidemiological, virological and environmental links to the case. Multiple failures in infection control leading to a contaminated environment and blood glucose testing equipment, failure to isolate a non-compliant, high-risk patient and incomplete vaccination for patients with chronic kidney disease may have contributed to the transmission. CONCLUSIONS: Patient-to-patient transmission of hepatitis B was shown to have occurred in a renal ward in the UK, due to multiple failures in infection control. A number of policy changes led to improvements in infection control, including reducing multi-function use of wards, developing policies for non-compliant patients, improving cleaning policies and implementing competency assessment for glucometer use and decontamination. HBV vaccination of renal patients may prevent patient-to-patient transmission of HBV. Consistent national guidance should be available, and clear pathways should be in place between primary and secondary care to ensure appropriate hepatitis B vaccination and follow-up testing.

Randomised controlled feasibility trial on the use of medical grade honey following microvascular free tissue transfer to reduce the incidence of wound infection.

The aim of this study was to assess the feasibility of using Leptospermum honey in a randomised trial to reduce the incidence of wound infection after microvascular free tissue reconstruction for cancer of the head and neck. During the one-year study period 70 consecutive patients were admitted to the regional maxillofacial ward for free tissue reconstruction. Of these, 56 (80%) consented to be randomised and 49 (70%) were actually randomised, 25 into the honey dressings group, and 24 into the conventional dressings group (control). Six patients were missed when consent was required, 8 did not consent, and 7 who had given consent were missed at the randomisation stage in theatre. Results of wound swabs were positive in 36% of the honey group and 38% of the control group. Methicillin-resistant Staphylococcus aureus (MRSA) was found in 28% and 25%, respectively. Of these, 38% were deemed to require intervention. Honey dressings were acceptable to both patients and nurses. There was a reduction (p<0.05) in duration of hospital stay in the honey group (median 12 days, IQR 10-21) compared with the control (median 18 days, IQR 13-28). The cost of standard and honey dressings was similar. This feasibility study has shown that a randomised controlled trial (RCT) is possible and that several hundreds of patients would be required to show a clinical benefit for honey. Further research is needed to confirm a shorter duration of hospital admission and if so, whether this is due to more rapid healing.

Psychosexual and body image aspects of quality of life in Turkish breast cancer patients: a comparison of breast conserving treatment and mastectomy.

AIMS AND BACKGROUND: Assessing psychosexual and body image aspects of quality of life in Turkish breast cancer patients treated by either mastectomy or breast conserving treatment (BCT). METHODS: The study group consisted of 112 patients who had undergone all treatment at a single institution under the care of a multidisciplinary breast team. Following surgery, all patients underwent adjuvant radiotherapy with or without chemotherapy and hormone therapy. At the time of this study all patients were disease free with at least 2 years' follow-up. Twenty percent of the patients were premenopausal and 80% postmenopausal. The patients completed a questionnaire consisting of 42 questions related to their sexual relations and body image. RESULTS: Forty-one percent of sexually active patients had experienced a deterioration of sexual functioning after treatment. This was mainly due to loss of libido (80%), loss of interest in partner (54%), and sexual dissatisfaction (59%). Problems tended to develop early in the course of treatment. Decreased sexual desire was significantly more frequent in patients undergoing mastectomy versus BCT (80% vs 61%; P = 0.043) and in premenopausal versus postmenopausal patients (P = 0.024). Although 80% of patients were satisfied with their appearance as a whole, only 54% liked their naked bodies. There was no significant difference in body image scores between patients undergoing mastectomy or BCT apart from a general feeling of physical unattractiveness in mastectomy patients (3.4 vs 2.8; P = 0.03). CONCLUSIONS: Significant, similar psychosexual and body image problems occur in patients treated for breast cancer with either mastectomy or BCT. Problems arise early in the course of the disease and therefore detection and treatment of these problems should be addressed during the patients' initial assessment and at the start of treatment. These findings are similar to those reported on similar groups of treated women in American and European populations.

Which patients are most at risk of methicillin resistant Staphylococcus aureus: a review of admissions to a regional maxillofacial ward between 2001 and 2005.

This study aimed to identify all Staphylococcus aureus (MRSA) cases on a Regional Maxillofacial ward, to estimate incidence and to ascertain who were most at risk. The study also explored clinical and demographic factors associated with MRSA in a subset of consecutive patients managed by primary surgery for previously untreated oral and oropharyngeal squamous cell carcinoma (OOSCC) over the same time period. Patients admitted from 1st April 2001 to 31st March 2006 to the Regional Maxillofacial Unit ward, Liverpool were identified by a retrospective review of the hospital MRSA database and there were 10109 patient admissions. MRSA (1.1%) occurred in 115 patient episodes involving 97 patients. There were 84 patients having a single episode and 13 more than one. There were no cases of mortality due to MRSA. Of the MFU patients 73 were oncology and 7 trauma. In the oncology group the commonest primary sites were wound (41) and sputum (11). Of new patients admitted for definitive treatment for OOSCC, 14% had MRSA and the two main risk factors were stage of cancer (P<0.001) and free flap (P<0.001). The risk of MRSA infection on our maxillofacial ward is low though MRSA infection is more prevalent among oncology patients particularly those requiring free tissue transfer. Careful adherence to infection prevention and control precautions is essential and practical methods to reduce MRSA need further evaluation.

Prognostic factors in early glottic carcinoma implications for treatment.

AIM: In this study we aimed to determine the prognostic factors affecting local control (LC) in limited glottic carcinoma treated with definitive radiotherapy (RT). MATERIAL AND METHODS: Between June 1991 and December 2001, 114 patients with early squamous-cell carcinoma of the glottis were treated with definitive RT at our institution. Only four (3.5%) patients were women. The median age was 60 (27-79). Fifteen percent, 72% and 13% of the patients had Tis, T1 and T2 tumors, respectively. Forty-three (37.7%) patients had anterior commissure invasion. Prior to RT 35 (31%) patients had undergone vocal cord stripping and two (2%) cordectomy. A median dose of 66 Gy (50-70.2) was given over a median period of 46 days (20-60). Univariate and multivariate analyses were performed for LC. The prognostic parameters analyzed for LC were T classification, anterior commissure involvement, total RT dose, and overall treatment time. RESULTS: Five-year local and regional control rates were 84.2% and 97.7%. RTOG grade 3-4 late side effects were observed only in one (0.9%) patient. In 15 patients with local failure, salvage treatment consisted of partial laryngectomy in eight patients and total laryngectomy in five. One of the remaining two patients was medically inoperable, and the other refused salvage surgery. In one of the three patients with regional failure, salvage surgery was applied and the other two were given palliative chemotherapy because of unresectable disease. Following salvage treatments, the ultimate five-year LC rate was 96.9% and the five-year larynx preservation rate was 91.1%. Second primary cancer was diagnosed in 17 (14.9%) patients. Only one patient developed distant metastases and two patients died of laryngeal cancer. While T2 disease and anterior commissure involvement were found to be unfavorable prognostic factors significantly influencing LC in univariate analyses, only T2 disease remained independent in multivariate analysis. CONCLUSION: In patients with early glottic carcinoma, T classification proved to be the only independent prognostic factor affecting LC after primary radiotherapy according to the results of this study.

A prospective evaluation of early thyroid dysfunction on completion of neck radiotherapy.

The purpose of this study was to examine thyroid dysfunction in the early phase of radiotherapy to the head and neck region. Forty-seven patients receiving neck irradiation including the thyroid gland were included. Twenty-eight patients had undergone either a functional or radical neck dissection and in 19 patients radiotherapy was the primary treatment. Compared to the pre-treatment values, there was a significant fall in the TSH level at completion of radiotherapy in the non-operated patients and a non-significant fall in the operated patients. The TSH was also significantly lower in the non-operated group at the end of treatment compared to the operated group. There was a significant fall in the FT3 and significant higher in the FT4 at the end of radiotherapy for both groups. This study shows that even during completion of radiotherapy to the head and neck region changes in thyroid function were observed for both previously operated and non-operated patients.