Impact of a clonal outbreak of extended-spectrum ß-lactamase-producing Klebsiella pneumoniae in the development and evolution of bloodstream infections by K. pneumoniae and Escherichia coli: an 11 year experience in Oxfordshire, UK.

OBJECTIVES: The objectives of this study were: (i) to describe an outbreak of multidrug-resistant Klebsiella pneumoniae in our population; (ii) to identify the potential source of this outbreak by examining antibiotic resistance trends in urocultures; (iii) to evaluate the contribution of this outbreak to resistance patterns over time in the two commonest Gram-negative blood culture isolates, namely K. pneumoniae and Escherichia coli; and (iv) to assess risk factors for multidrug resistance and the impact of this resistance on mortality and length of stay. METHODS: We searched Microbiology and Patient Administration Service databases retrospectively and describe resistance trends in E. coli and K. pneumoniae bloodstream infections (BSIs) in Oxfordshire, UK, over an 11 year period. RESULTS: An outbreak of a multidrug-resistant, CTX-M-15 extended-spectrum ß-lactamase (ESBL)-producing K. pneumoniae clone was identified and shown by multilocus sequence typing to belong to a novel sequence type designated ST490. This was associated with a sporadic change in resistance rates in K. pneumoniae BSIs with rates of multidrug resistance (defined as resistance to three or more antibiotic classes) reaching 40%. A case-control study showed prior antibiotic exposure as a risk factor for infection with this organism. During the same time period, rates of ESBL-producing Klebsiella spp. isolated from urocultures increased from 0.5% to almost 6%. By contrast, the rate of multidrug resistance in E. coli rose more steadily from 0% in 2000 to 10% in 2010. CONCLUSIONS: Changes in resistance rates may be associated with outbreaks of resistant clones in K. pneumoniae. Changing resistance patterns may affect important health economic issues such as length of stay.

Is Clostridium difficile infection a particular problem after reversal of ileostomy?

AIM: Clostridium difficile infection (CDI) is a cause of morbidity and mortality in hospitals. Various independent risk factors have been identified, including age and antibiotic exposure. This study attempted to determine whether surgery and associated antibiotic use influence the development of CDI. METHOD: A retrospective review of all patients with a diagnosis of CDI diagnosed during admission to a colorectal unit was conducted over a 20-month period. Patient records were cross-referenced with a microbiology database to identify previous episodes of infection and cases of recurrence. RESULTS: There were 38 CDI episodes in 29 patients, including nine with recurrence. In 33, the use of antibiotics prior to the onset of CDI was documented, but in 14 (37%) patients this was limited to perioperative prophylaxis. The incidence of CDI after various procedures was as follows: ileostomy closure (4.2%), right hemicolectomy (2.1%) and anterior resection (1%). CONCLUSION: Ileostomy closure may carry a higher risk of CDI.

Multi-site and nasal swabbing for carriage of Staphylococcus aureus: what does a single nose swab predict?

BACKGROUND: Carriage of Staphylococcus aureus is a risk for infections. Targeted decolonization reduces postoperative infections but depends on accurate screening. AIM: To compare detection of S. aureus carriage in healthy individuals between anatomical sites and nurse- versus self-swabbing; also to determine whether a single nasal swab predicted carriage over four weeks. METHODS: Healthy individuals were recruited via general practices. After consent, nurses performed multi-site swabbing (nose, throat, and axilla). Participants performed nasal swabbing twice-weekly for four weeks. Swabs were returned by mail and cultured for S. aureus. All S. aureus isolates underwent spa typing. Persistent carriage in individuals returning more than three self-swabs was defined as culture of S. aureus from all or all but one self-swabs. FINDINGS: In all, 102 individuals underwent multi-site swabbing; S. aureus carriage was detected from at least one site from 40 individuals (39%). There was no difference between nose (29/102, 28%) and throat (28/102, 27%) isolation rates: the combination increased total detection rate by 10%. Ninety-nine patients returned any self-swab, and 96 returned more than three. Nasal carriage detection was not significantly different on nurse or self-swab [28/99 (74%) vs 26/99 (72%); χ2: P=0.75]. Twenty-two out of 25 participants with first self-swab positive were persistent carriers and 69/71 with first self-swab negative were not, giving high positive predictive value (88%), and very high negative predictive value (97%). CONCLUSION: Nasal swabs detected the majority of carriage; throat swabs increased detection by 10%. Self-taken nasal swabs were equivalent to nurse-taken swabs and predicted persistent nasal carriage over four weeks.

Sub-systems for optical frequency measurements: application to the 282-nm (199)Hg(+) transition and the 657-nm Ca line.

We are developing laser frequency measurement technologies that should allow us to construct an optical frequency synthesis system capable of measuring optical frequencies with a precision limited by the atomic frequency standards. The system will be used to interconnect and compare new advanced optical-frequency references (such as Ca, Hg(+ ), and others) and eventually to connect these references to the Cs primary frequency standard. The approach we are taking is to subdivide optical frequency intervals into smaller and smaller pieces until we are able to use standard electronic-frequency-measurement technology to measure the smallest interval.

Quality assurance in Canadian emergency departments: a national survey.

This survey provides a description of quality assurance (QA) in emergency departments of Canadian hospitals, looking at QA structure, processes, outcome measurements, and applications. With survey questions addressing the existence of a written QA plan, chart audits, mortality review, data collection and reporting, the frequency of comprehensive QA programs was measured. All Canadian hospitals with 200 or more beds were surveyed by mail; 66% responded (134 of 204). Teaching and larger hospitals were more likely to respond. QA structure was reported by 81% of respondents, with 59% of these having a written plan. The majority collected data (74%), issued reports (75%), and had QA committees (50%), but only 34% were computerized. QA processes included chart audits (78%), review of laboratory, radiology, or ECG reports (73%, 46%, 54%, respectively), and mortality review (91%). Comprehensive QA existed in only 12% of responding hospitals.

A retrospective study of patient falls in a psychiatric hospital.

1. While falls on medical-surgical units are the focus of extensive research, falls on inpatient psychiatric units are an understudied critical event. 2. The purposes of this study were to identify the variables associated with psychiatric patient falls and to use that information to assess risk and, therefore, prevent falls in this population. 3. The psychiatric patient at risk for falling is described as a woman with a prior history of falls; less than 65 years of age; experiencing anxiety and agitation; and receiving a sedative, a tranquilizer, and a laxative. Additionally, this patient is more likely to fall in a community area.

Does previa location matter? Surgical morbidity associated with location of a placenta previa.

OBJECTIVE: To evaluate the effect of placenta previa location (anterior vs posterior) on cesarean morbidity. STUDY DESIGN: Retrospective cohort of women undergoing cesarean for placenta previa. The rate of hysterectomy and blood transfusion in the setting of anterior previa was compared with posterior previa. Planned stratified analysis based on delivery history was performed. Logistic regression was performed to control for potential confounders. RESULT: Two hundred and eighty-five women undergoing cesarean delivery for placenta previa were identified. Women undergoing primary cesareans with an anterior previa had higher rates of blood transfusion (adjusted odds ratio (aOR) 3.13 95% confidence interval (CI) (1.18 to 8.36) and hysterectomy (7.4% vs 0, P=0.001) compared with those with a posterior previa; similarly, women undergoing repeat cesarean with anterior previa had higher rates of hysterectomy (aOR 4.60 95% CI (1.02 to 20.7). The majority of hysterectomies (93.8%) were due to abnormal placentation. CONCLUSION: An anterior placenta previa increases the risk of hysterectomy for both primary and repeat cesareans due to abnormal placentation. In the absence of accreta, blood transfusion remained a significant cause of maternal morbidity in both anterior and posterior placenta previas. This information may be useful for operative planning.

Care home staff knowledge of oral care compared to best practice: a West of Scotland pilot study.

AIM: To evaluate care home (N) staff knowledge of oral care provision for dependent older people in comparison to guidelines from NHS Quality Improvement Scotland (NHSQIS). This pilot study also aimed to identify barriers to delivering oral care and determine if oral health educator (OHE) training had an effect upon staff knowledge of oral care delivery. SETTING: This cross-sectional analytic investigation was undertaken within the Greater Glasgow & Clyde area between 2005 and 2007. METHODS: From 33 care homes (N), 28 participated in data gathering through an interview schedule involving 109 staff. A 'knowledge check-list' founded upon daily oral care guidelines from the NHSQIS best practice statement (BPS) served as a template for knowledge assessment. An OHE undertook small group discussions related to the BPS in a sub-group of original participants and a second round of data was collected. RESULTS: The majority of surveyed staff (n = 86, 79%) agreed that residents required assistance with oral care and placed oral care (n = 85, 78%) in a moderate to high priority. However, only 57% of managers and 49% of nurses had received training in oral care provision. Most staff (79% of managers, 85% of nurses) were unaware of the NHSQIS BPS. Deficiencies in knowledge were identified in several areas of the BPS. In particular, knowledge in the care of the natural dentition was inadequate. Between pre- and post-OHE training, the research suggests the following areas are liable to change: prioritisation given to oral care (p = 0.01), perceived competence (p <0.0001) and confidence in providing oral care advice (p <0.0001). Following OHE intervention, staff knowledge in oral care procedures compliant with best practice guidelines increased by 45%. CONCLUSIONS: Knowledge of oral health provision by those responsible for the care of home residents was deficient. An OHE training programme structured around the NHSQIS BPS demonstrated a measurable increase in levels of staff knowledge of oral care procedures.

A survey of denture identification marking within the United Kingdom.

AIM: To assess the attitudes of healthcare workers within the UK towards identification marking of removable prostheses, and quantify the frequency with which this is currently undertaken. DESIGN: A postal questionnaire-based study. SETTING: The study was undertaken within the UK between 2002 and 2006 and surveyed prosthodontists working in a wide range of clinical settings. SUBJECTS AND METHODS: Questionnaires were sent to two sample groups: 1. Specialists in prosthodontics registered on the GDC specialist list; 2. Nursing staff in elderly care homes within the locality of Glasgow. RESULTS: Return rate of questionnaires from prosthodontic specialists was high, with 119 from 160 (74%) completed and returned. 54.9% of prosthodontic specialists carried out complete denture marking in their clinical practice and 40.9% undertook identification marking of partial removable prostheses. The vast majority (81.0%) of specialists indicated that denture identification marking was a worthwhile procedure. Furthermore, 68.9% thought the introduction of some form of guideline would be beneficial. Differences in the frequency of denture marking existed between varying clinical environments. Denture marking was not undertaken by healthcare workers within any of the surveyed care homes. CONCLUSION: The overwhelming opinion of prosthodontic specialists within the UK promotes the use of denture marking as a routine procedure.

Diode-Pumped Nd:FAP Laser at 1.126 microm: A Possible Local Oscillator for a Hg+ Optical Frequency Standard.

We report the efficient operation of a continuous-wave, single-frequency, diode-pumped Nd:FAP laser at 1.126 mum. When frequency quadrupled, such a laser might be used as a local oscillator for an optical frequency standard based on the single-photon (2)S(1/2)-(2)D(5/2) electric quadrupole transition of a trapped and laser-cooled (199)Hg(+) ion. Since the frequencies of the atomic transition and the laser are harmonically related, this scheme helps to simplify the measurement of the S-D clock transition frequency by a phase-coherent chain to the cesium primary frequency standard.

Brief inpatient psychiatric treatment: finding solutions.

The shift to a managed care philosophy means that clients with psychiatric needs are likely to have both fewer and briefer inpatient hospitalizations. Identification of focused goals and measurable outcomes may not translate easily into inpatient programs that have been more process oriented or have based definitions of improvement on complete or near-complete remission of the admission diagnosis. In the context of these shifts, nursing's focus on maintaining a safe environment, developing a therapeutic relationship, providing information, and valuing holistic and individualized care may be lost in programs that treat all clients in the same "packaged" programs. The previous article in this issue described the philosophical assumptions that underlie our brief inpatient program. This article describes how solution-focused therapeutic modalities are used in our continuum of care.

Myelination and remyelination of aggregate rat brain cell cultures enriched with macrophages.

We reported previously that accumulation of myelin basic protein (MBP) in foetal brain aggregate cultures is enhanced by supplementation with peritoneal macrophages. The present study demonstrates that the rate of MBP accumulation in macrophage-enriched cultures continues to increase over time unaccompanied by a matching increase in the oligodendrocyte marker cyclic nucleotide phosphodiesterase, while that of control cultures reaches a plateau. These observations are supported by electron microscopic evidence of cumulative numbers of myelinated axons in the aggregates over time and by enhanced expression of myelin protein genes in macrophage-enriched relative to control cultures. Aggregates demyelinate following short-term exposure to cytokines and antimyelin oligodendrocyte glycoprotein antibody, and MBP synthesis resumes following removal of demyelinating agents. Supplementation of cultures with macrophages influences the degree of myelin breakdown and remyelination, drawing attention to the role that macrophage-derived growth factors may play in myelinogenesis and myelin repair in inflammatory demyelinating disease.

Challenge with rubella virus after loss of detectable vaccine-induced antibody.

Studies were conducted of experimental challenge with rubella virus in vaccinees whose possession of vaccine-induced antibody after vaccination had been documented and whose antibody level had become undetectable or very low over time. The challenge virus was the Howell strain, which had been shown to produce typical clinical and laboratory features of rubella in susceptible persons. The challenge of the vaccinees resulted in local viral replication in all but one; in viremia, a primary immunologic response, and a secondary antibody response in some; and usually in illness without a rash or in subclinical infection. The results emphasize the importance of continuing careful clinical and laboratory surveillance of vaccinees for determining the persistence of vaccine-induced immunity and of considering methods for identifying and revaccinating the minority of vaccinees who lose such immunity.