Salmonella enterica serovar Typhi H58 clone has been endemic in Zimbabwe from 2012 to 2019.

BACKGROUND: Typhoid fever, caused by S. enterica ser. Typhi, continues to be a substantial health burden in developing countries. Little is known of the genotypic diversity of S. enterica ser. Typhi in Zimbabwe, but this is key for understanding the emergence and spread of this pathogen and devising interventions for its control. OBJECTIVES: To report the molecular epidemiology of S. enterica ser. Typhi outbreak strains circulating from 2012 to 2019 in Zimbabwe, using comparative genomics. METHODS: A review of typhoid cases records from 2012 to 2019 in Zimbabwe was performed. The phylogenetic relationship of outbreak isolates from 2012 to 2019 and emergence of antibiotic resistance was investigated by whole-genome sequence analysis. RESULTS: A total 22 479 suspected typhoid cases, 760 confirmed cases were reported from 2012 to 2019 and 29 isolates were sequenced. The majority of the sequenced isolates were predicted to confer resistance to aminoglycosides, ß-lactams, phenicols, sulphonamides, tetracycline and fluoroquinolones (including qnrS detection). The qnrS1 gene was associated with an IncN (subtype PST3) plasmid in 79% of the isolates. Whole-genome SNP analysis, SNP-based haplotyping and resistance determinant analysis showed that 93% of the isolates belonged to a single clade represented by multidrug-resistant H58 lineage I (4.3.1.1), with a maximum pair-wise distance of 22 SNPs. CONCLUSIONS: This study has provided detailed genotypic characterization of the outbreak strain, identified as S. Typhi 4.3.1.1 (H58). The strain has reduced susceptibility to ciprofloxacin due to qnrS carried by an IncN (subtype PST3) plasmid resulting from ongoing evolution to full resistance.

Auditing use of antibiotics in Zimbabwean neonates.

BACKGROUND: Neonatal sepsis is a major cause of morbidity and mortality in low-income settings. As signs of sepsis are non-specific and deterioration precipitous, antibiotics are often used profusely in these settings where diagnostics may not be readily available. Harare Central Hospital, Zimbabwe, delivers 12000 babies per annum admitting ∼4800 to the neonatal unit. Overcrowding, understaffing and rapid staff turnover are consistent problems. Suspected sepsis is highly prevalent, and antibiotics widely used. We audited the impact of training and benchmarking intervention on rationalizing antibiotic prescription using local, World Health Organization-derived, guidelines as the standard. METHODS: An initial audit of admission diagnosis and antibiotic use was performed between 8th May - 6th June 2018 as per the audit cycle. An intern training programme, focusing on antimicrobial stewardship and differentiating between babies 'at risk of' versus 'with' clinically-suspected sepsis was instituted post-primary audit. Re-audit was conducted after 5 months. RESULTS: Sepsis was the most common admitting diagnosis by interns at both time points but reduced at repeat audit (81% versus 59%, P<0.0001). Re-audit after 5 months demonstrated a decrease in antibiotic prescribing at admission and discharge. Babies prescribed antibiotics at admission decreased from 449 (98%) to 96 (51%), P<0.0001. Inpatient days of therapy (DOT) reduced from 1243 to 1110/1000 patient-days. Oral amoxicillin prescription at discharge reduced from 349/354 (99%) to 1% 1/161 (P<0.0001). CONCLUSION: A substantial decrease in antibiotic use was achieved by performance feedback, training and leadership, although ongoing performance review will be key to ensuring safety and sustainability.

Formation Constants and Conformational Analysis of Carbamates in Aqueous Solutions of 2-Methylpiperidine and CO2 from 283 to 313 K by NMR Spectroscopy.

Quantitative 13C nuclear magnetic resonance (NMR) spectroscopy was used to investigate the speciation in (2-methylpiperidine + H2O + CO2) systems at 283.2-313.2 K. The carbamate of 2-methylpiperidine(2-methylpiperidine- N-carboxylate) was shown for the first time to be a stable species in aqueous solutions. The spectroscopic results were used to obtain temperature-dependant formation constants for the carbamate using a simplified model for the activity coefficients from which the standard molar enthalpy of reaction was estimated. The results were incorporated into a self-consistent chemical equilibrium model, which includes vapor-liquid equilibria and all aqueous species, including the formation of carbamate. The predominant conformation of the sterically hindered carbamate, which was determined using two-dimensional exchange spectroscopy NMR, has the methyl group in the axial orientation and is in agreement with the density functional theory quantum chemical calculations.

The Effect of Hearing Loss on Novel Word Learning in Infant- and Adult-Directed Speech.

OBJECTIVES: Relatively little is known about how young children with hearing impairment (HI) learn novel words in infant- and adult-directed speech (ADS). Infant-directed speech (IDS) supports word learning in typically developing infants relative to ADS. This study examined how children with normal hearing (NH) and children with HI learn novel words in IDS and ADS. It was predicted that IDS would support novel word learning in both groups of children. In addition, children with HI were expected to be less proficient word learners as compared with their NH peers. DESIGN: A looking-while-listening paradigm was used to measure novel word learning in 16 children with sensorineural HI (age range 23.2 to 42.1 months) who wore either bilateral hearing aids (n = 10) or bilateral cochlear implants (n = 6) and 16 children with NH (age range 23.1 to 42.1 months) who were matched for gender, chronological age, and maternal education level. Two measures of word learning were assessed (accuracy and reaction time). Each child participated in two experiments approximately 1 week apart, one in IDS and one in ADS. RESULTS: Both groups successfully learned the novel words in both speech type conditions, as evidenced by children looking at the correct picture significantly above chance. As a group, children with NH outperformed children with HI in the novel word learning task; however, there were no significant differences between performance on IDS versus ADS. More fine-grained time course analyses revealed that children with HI, and particularly children who use hearing aids, had more difficulty learning novel words in ADS, compared with children with NH. CONCLUSIONS: The pattern of results observed in the children with HI suggests that they may need extended support from clinicians and caregivers, through the use of IDS, during novel word learning. Future research should continue to focus on understanding the factors (e.g., device type and use, age of intervention, audibility, acoustic characteristics of input, etc.) that may influence word learning in children with HI in both IDS and ADS.

Indeterminate Pulmonary Nodules in Resected Liver Metastases from Colorectal Cancer: A Comparison of Patient Outcomes.

AIMS: Hepatic metastasectomy remains the only potentially curative treatment for colorectal liver metastases (CRLM). Some of these patients develop indeterminate pulmonary nodules (IPNs). This study aimed to compare outcomes of patients with and without IPN undergoing resection of CRLM to ascertain whether their presence is clinically significant. METHODS: Cases and controls were identified from a prospectively maintained database of CRLM resections. Patients with staging radiology demonstrating IPNs were included as cases. Controls were matched to the cases by four primary factors: age, type of resection (primary or redo), clinical risk score (CRS) and chemotherapy. RESULTS: The median disease-free survival (DFS) and overall survival (OS) for the cases were 7.0 months (95% CI 4.8-9.2) and 28.6 months (95% CI 21.2-36.0), respectively, and 12.0 months (95% CI 10.7-13.2) and 30.5 months (95% CI 19.4-41.6) for the controls. The 1-, 3- and 5-year survival rates were 92.7, 39.7 and 0.0% for the IPN group, and 92.4, 32.9 and 21.9% for those without. In total, 60.7% of IPN patients progressed to lung metastases, of which 39.3% underwent pulmonary resections. DFS was significantly shorter in the IPN group (p = 0.022), but OS was not significantly different (p = 0.421). The presence of IPN was independently associated with a shortened DFS (p = 0.027), as was a CRS of 3 or greater (p = 0.007). CONCLUSION: This study suggests that IPN does not significantly affect OS, but may predict earlier disease recurrence. IPN presence alone should not preclude radical resection but could be used to prompt more careful post-operative surveillance to detect lung metastases at a potentially operable stage.

Etiology and risk factors of meningitis in patients admitted at a Central Hospital in Harare.

Objective: To determine etiology and risk factors of meningitis in patients admitted a tertiary referral Hospital in Harare. Design: Cross-Sectional Study. Setting: Urban Referral Health Facility. Subjects: Patients suspected of having Meningitis admitted at Parirenyatwa Hospital were consecutively consented and recruited into the study until sample size accrual. Main Outcome Measures: Prevalence of pathogens associated with Meningitis. Risk factors of meningitis. Results: Two Hundred and Ninety Six (296) clinically suspected meningitis patients were recruited into the study, 51.7 %( n=115) were male. Meningitis was confirmed in 20.6% (n=61) cases with the following pathogen proportions, C. neoformans - 45.9 %( n=28), S. pneumoniae ­ 27.9 % (n=17), TBM ­ 4.9 %( n=3), probable viral meningitis ­ 6.6% (n=4 and other bacteria- 14.8% (n=9). Patients from crowded households were also more likely to suffer from meningitis than those from sparsely populated households (p<0.001). Conclusion: The use of Latex agglutination increases the proportion of detected pathogens both fungal and bacterial when used in conjunction with CSF gram stain and culture. Cryptococcus neoformans and S. pneumoniae are the leading causes of meningitis in patients admitted at Parirenyatwa Hospital.

Cryptococcus gattii: A dilemma in diagnosis and treatment in sub-Saharan Africa an area with high HIV prevalence.

Sub-Saharan Africa contributes at least 70% of the global cryptococcal meningoencephalitis cases each year and the majority of cases are caused by the Cryptococcus neoformans species. We present a case of meningoencephalitis due to Cryptococcus gattii in an 18 year old apparently immunocompetent male patient from Zimbabwe.

Prevalence and some clinical characteristics of equine cheek teeth diastemata in 471 horses examined in a UK first-opinion equine practice (2008 to 2009).

Cheek teeth (CT) diastemata are now recognised as a clinically significant equine disorder, but their prevalence in the general equine population is unknown. There is also limited information on the signalment of affected horses; the more commonly affected Triadan sites; and the shape and clinical characteristics of CT diastemata. During the 12-month study period (2008 to 2009), standardised records were obtained during routine dental examinations performed by five veterinarians in a first-opinion equine practice. Cheek teeth diastemata were identified in 49.9 per cent of all horses (n=471) of mean age 11 years (range one to 30 years), with 83.5 per cent of all diastemata affecting mandibular CT and 16.5 per cent affecting maxillary CT. The mean number of diastemata per case was 1.7 (range one to 20) and the mandibular 07 to 08 position was most commonly affected. Valve diastemata were more common (72.1 per cent prevalence) than open diastemata (27.9 per cent). Food trapping was present in 91.4 per cent of diastemata, with gingivitis and periodontal pockets adjacent to 34.2 per cent and 43.7 per cent, respectively. Halitosis was present in 45.5 per cent of affected horses. There was an age-related increase in both the prevalence of diastemata, and in the numbers of diastemata per affected horse, and horses over 15 years old had a significantly increased proportion of open diastemata.

A national study of the availability and use of electrophysical agents by Australian physiotherapists.

Electrophysical agents (EPAs) are a core part of physiotherapy practice and entry level education. With the increase in the number of EPAs over time, their availability and use in contemporary physiotherapy practice is an important consideration when determining entry level curricula. Thus, the aim of the study was to ascertain the current availability and usage of EPAs in Australian physiotherapy practice. A purpose-designed questionnaire was mailed to all registered physiotherapists in Australia. A response rate of 27% was obtained (n=3,538). Nonresponder analyses indicated that the results were representative of the total population of Australian physiotherapists. Over 70% of respondents had access to ultrasound, cold packs/ice, heat packs, electrical stimulation for sensory stimulation, and interferential therapy. Two main groups of EPAs were used relatively frequently. The first group was used daily or monthly by 60% of respondents (ultrasound, hot packs, and cold packs/ice), and a second group (electromyographic and pressure biofeedback, interferential therapy, and electrical stimulation for sensory stimulation) was used on a daily or monthly basis by between 30% and 45% of the sample. A group of EPAs, including ultraviolet light, microwave, and shortwave diathermy, was not used by over 90% of the sample. The study has provided contemporary national data on EPA availability and use in Australia.

The three-dimensional structural characterization of hexachlorocyclopentenyl-dibromocyclooctane (HCDBCO).

The 1H NMR spectrum and the crystal structure of HCDBCO [(1R,2R,5R,6R,9S,10S)-5,6-dibromo-1,10,11,12,13,13-hexachlorotricyclo[8,2,1,0(2,9)]-tridec-11-ene)] are reported. The measured dihedral angles from the X-ray structure correlate very well with those calculated from the proton-proton coupling constants indicating that the conformations in solution and in the solid state are probably very similar. Attempts at calculating the 3D model structure of HCDBCO only produced a very poor match between the measured dihedral angles between vicinal protons and the observed proton-proton coupling constants from the 1H NMR spectrum. GC/MS analysis with an injector temperature of 250 degrees C produced minor amounts of debrominated HCDBCO. Reducing the temperature to 200 degrees C eliminated this problem.

Theoretical studies of the conformations and 19F NMR spectra of linear and a branched perfluorooctanesulfonamide (PFOSAmide).

Technical perfluorooctanesulfonate (PFOS) and its derivatives, such as perfluorooctanesulfonamide (PFOSA), are not clean compounds but, instead, complex mixtures of linear and branched isomers, and other compounds including sulfonate homologues. Questions have been raised as to whether the linear and the branched isomers behave differently in the environment. However, little is known about the physical properties or the finer details of the structures of the individual branched isomers. This study sought an effective computational method to model the preferred conformations of PFOS derivatives, and the energy differences between them and to determine if these results can be used to explain the temperature dependence of their NMR spectra. Good predictions of the 19F chemical shifts were obtained for some PFOSA-type molecules with a computational approach [B3LYP-GIAO/6-31++G(d,p)//B3LYP/6-31G(d,p)] that is relatively inexpensive. Large 5JFF couplings found in one of the branched isomers could be rationalized on the basis of the relevant F-F distances in the optimized structure. At low temperatures, the splitting observed in the NMR spectrum at C-1 for these sulfonamides can be explained by the existence of the two conformers predicted by the computations.

The high-level mobility assessment tool (HiMAT) for traumatic brain injury. Part 1: Item generation.

PRIMARY OBJECTIVE: To generate a comprehensive list of items for a scale suitable for assessing high-level mobility in people with traumatic brain injury (TBI). RESEARCH DESIGN: High-level mobility items were generated following a critical evaluation of existing adult and paediatric mobility scales and by surveying expert clinicians for opinions about items appropriate for inclusion on a high-level mobility scale. MAIN OUTCOMES AND RESULTS: The critical evaluation identified 18 different items from 31 mobility scales. These included nine walking items in addition to higher level activities such as stair use, running, jumping and hopping. Expert clinicians generated 157 items that were collated and condensed to 88 items for ranking on a questionnaire. Fifteen items on the questionnaire were rated as very important by 80% of the expert clinicians. These included walking forwards, walking on slopes and different surfaces, changing direction, walking long distances and stair use. Running items included forwards, backwards, on slopes and over different surfaces, changing direction, stopping and starting as well as running long distances. Balancing in single limb stance was also included. CONCLUSION: The final list comprised walking, running, hopping, skipping, jumping and balance items. This initial version of the HiMAT has face and content validity although requires further testing to investigate whether it is uni-dimensional and valid for people with TBI.

The high-level mobility assessment tool (HiMAT) for traumatic brain injury. Part 2: content validity and discriminability.

PRIMARY OBJECTIVES: (i) To assess the measurement properties of the high-level mobility assessment tool (HiMAT) for people with traumatic brain injury (TBI), (ii) to measure the extent to which the HiMAT is a uni-dimensional, discriminative hierarchical outcome scale. RESEARCH DESIGN: The content validity was assessed using a three-stage process of investigating internal consistency, factor analysis and Rasch analysis. The uni-dimensionality of the HiMAT items was also tested. Discriminability was investigated by correlating raw and logit scores obtained from Rasch analysis. The study was conducted at a major rehabilitation facility using a convenience sample of 103 adults with TBI. MAIN OUTCOMES AND RESULTS: The internal consistency for the high-level items was very high (Cronbach's alpha = 0.99). Principal axis factoring identified several balance items as belonging to a second factor not related to high-level mobility, hence these items were excluded. Rasch analysis identified several misfitting items, such as walking around a figure of eight and stopping from a run, which were also excluded. Logit scores were used to exclude clustered and, therefore, redundant items. Raw scores correlated very highly (r = 0.98) with logit scores, indicating that raw scores provided good discriminability and were suitable for use by clinicians. CONCLUSION: The HiMAT, which assesses higher-level mobility requirements of people with TBI for return to pre-accident social, leisure and sporting activities, is a uni-dimensional and discriminative scale for quantifying therapy outcomes.

Comparison of surface swab cultures and quantitative tissue biopsy cultures to predict sepsis in burn patients: a prospective study.

This study aimed at evaluating the possibility of predicting septicemia in burn patients by using wound surface and tissue culture techniques as well as blood cultures. Fifty patients with full-thickness burn wounds covering at least 10% of the total body surface area were included. Signs of septicemia were noted in 21 patients (42%) and 29 patients died (58%). The bacterial colonization of the burn wounds consisted mainly of Staphylococcus aureus and Pseudomonas aeruginosa. Sepsis was better correlated to quantitative burn tissue biopsy cultures than surface swab cultures but the time needed for processing limits its predictive and therapeutic value.

Variation in motor threshold with frequency using kHz frequency alternating current.

We investigated the frequency dependence of motor thresholds over the frequency range 1 kHz to 25 kHz. Alternating current (AC), ramped in intensity, was applied transcutaneously, and the induced wrist extensor torque was measured. Plots of log torque versus stimulus voltage were used to accurately determine thresholds. Three kinds of sinusoidal AC stimuli were compared: continuous, 10 ms bursts at 50 Hz, and 50-Hz single-cycle. Differences were attributed to summation of subthreshold depolarizations. The variation in relative thresholds (continuous/single-cycle and burst/single-cycle) indicates that summation occurs more efficiently at higher kHz frequencies. The observed frequency and waveform dependence provides evidence for high-frequency nerve fiber firing rates and fiber dropout when continuous or modulated AC is used, with the effects increasing with AC frequency. The form of the motor response evoked at high frequencies has features that suggest that frequencies above 10-kHz have little or no useful clinical role in rehabilitation procedures.

Occupational health and safety in physiotherapy: guidelines for practice.

Most physiotherapists (91%) experience work related musculoskeletal disorders (WMSDs) at some time, and one in six makes a career change as a consequence. Many of these disorders are attributed to manual handling of patients. This paper proposes guidelines to reduce the risk of WMSDs based on Australian legislative requirements, the results of a survey of Australian physiotherapists and the literature surrounding injury prevention. These guidelines address the areas of environmental and job design, and the personal physical capabilities of physiotherapists, within the context of law. The paper concludes by calling for further research to explore and develop this area of injury prevention in the physiotherapy profession.

A review of therapeutic ultrasound: biophysical effects.

Almost 2 decades ago, it was pointed out that physical therapists tended to overlook the tenuous nature of the scientific basis for the use of therapeutic ultrasound. The purpose of this review is to examine the literature regarding the biophysical effects of therapeutic ultrasound to determine whether these effects may be considered sufficient to provide a reason (biological rationale) for the use of insonation for the treatment of people with pain and soft tissue injury. This review does not discuss articles that examined the clinical usefulness of ultrasound (see article by Robertson and Baker titled "A Review of Therapeutic Ultrasound: Effectiveness Studies" in this issue). The frequently described biophysical effects of ultrasound either do not occur in vivo under therapeutic conditions or have not been proven to have a clinical effect under these conditions. This review reveals that there is currently insufficient biophysical evidence to provide a scientific foundation for the clinical use of therapeutic ultrasound for the treatment of people with pain and soft tissue injury.

A review of therapeutic ultrasound: effectiveness studies.

BACKGROUND AND PURPOSE: Therapeutic ultrasound is one of the most widely and frequently used electrophysical agents. Despite over 60 years of clinical use, the effectiveness of ultrasound for treating people with pain, musculoskeletal injuries, and soft tissue lesions remains questionable. This article presents a systematic review of randomized controlled trials (RCTs) in which ultrasound was used to treat people with those conditions. Each trial was designed to investigate the contributions of active and placebo ultrasound to the patient outcomes measured. Depending on the condition, ultrasound (active and placebo) was used alone or in conjunction with other interventions in a manner designed to identify its contribution and distinguish it from those of other interventions. METHODS: Thirty-five English-language RCTs were published between 1975 and 1999. Each RCT identified was scrutinized for patient outcomes and methodological adequacy. RESULTS: Ten of the 35 RCTs were judged to have acceptable methods using criteria based on those developed by Sackett et al. Of these RCTs, the results of 2 trials suggest that therapeutic ultrasound is more effective in treating some clinical problems (carpal tunnel syndrome and calcific tendinitis of the shoulder) than placebo ultrasound, and the results of 8 trials suggest that it is not. DISCUSSION AND CONCLUSION: There was little evidence that active therapeutic ultrasound is more effective than placebo ultrasound for treating people with pain or a range of musculoskeletal injuries or for promoting soft tissue healing. The few studies deemed to have adequate methods examined a wide range of patient problems. The dosages used in these studies varied considerably, often for no discernable reason.