Glucose and Cortisol concentrations in cows treated with a slowly-absorbed betamethasone suspension

A slowly-absorbed aqueous suspension of betamethasone, intended for use in the induction;of parturition, was administered to 10 cows. Each cow received 2ml (mean individual dose, 44.4 +/- 0.5microg/kg) by subcutaneous injection. Plasma samples were collected on six occasions over a seven-day period before treatment and on 21 occasions over a 29 day period after treatment. The mean concentration of betamethasone in plasma, as measured by radioimmunoassay, peaked at 0.6ng/ml24 hours after injection and was detectable for four days. Depression of the endogenous cortisol levels, as recorded with other long-acting synthetic glucocorticoids, was observed with this preparation of betamethasone. Plasma glucose was significantly elevated for eight days after betamethasone administration.

The evolution of thermal physiology in endotherms

Biologists usually refer to mammals and birds as homeotherms, but these animals universally experience regional and temporal variations in body temperature. These variations could represent adaptive strategies of heterothermy, which in turn would favor genotypes that function over a wide range of temperatures. This coadaptation of thermoregulation and thermosensitivity has been studied extensively among ectotherms, but remains unexplored among endotherms. In this review, we apply classical models of thermal adaptation to predict variation in body temperature within and among populations of mammals and birds. We then relate these predictions to observations generated by comparative and experimental studies. In general, optimality models can explain the qualitative effects of abiotic and biotic factors on thermoregulation. Similar insights should emerge when using models to predict variation in the thermosensitivity of endotherms, but the dearth of empirical data on this subject precludes a rigorous analysis at this time. Future research should focus on the selective pressures imposed by regional and temporal heterothermy in endotherms.

Decontamination of the digestive tract and oropharynx in ICU patients

BACKGROUND

Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting.

METHODS

We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance.

RESULTS

A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively.

CONCLUSIONS

In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

Characterizing an outbreak of vancomycin-resistant enterococci using hidden Markov models

BACKGROUND

Antibiotic-resistant nosocomial pathogens can arise in epidemic clusters or sporadically. Genotyping is commonly used to distinguish epidemic from sporadic vancomycin-resistant enterococci (VRE). We compare this to a statistical method to determine the transmission characteristics of VRE.

METHODS AND FINDINGS

A structured continuous-time hidden Markov model (HMM) was developed. The hidden states were the number of VRE-colonized patients (both detected and undetected). The input for this study was weekly point-prevalence data; 157 weeks of VRE prevalence. We estimated two parameters: one to quantify the cross-transmission of VRE and the other to quantify the level of VRE colonization from sporadic sources. We compared the results to those obtained by concomitant genotyping and phenotyping. We estimated that 89% of transmissions were due to ward cross-transmission while 11% were sporadic. Genotyping found that 90% had identical glycopeptide resistance genes and 84% were identical or nearly identical on pulsed-field gel electrophoresis (PFGE). There was some evidence, based on model selection criteria, that the cross-transmission parameter changed throughout the study period. The model that allowed for a change in transmission just prior to the outbreak and again at the peak of the outbreak was superior to other models. This model estimated that cross-transmission increased at week 120 and declined after week 135, coinciding with environmental decontamination.

SIGNIFICANCE

We found that HMMs can be applied to serial prevalence data to estimate the characteristics of acquisition of nosocomial pathogens and distinguish between epidemic and sporadic acquisition. This model was able to estimate transmission parameters despite imperfect detection of the organism. The results of this model were validated against PFGE and glycopeptide resistance genotype data and produced very similar results. Additionally, HMMs can provide information about unobserved events such as undetected colonization.

Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series

OBJECTIVES

To investigate the effect of reinforcing a narrow-spectrum antibiotic policy on antibiotic prescription and Clostridium difficile infection (CDI) rates by feedback of antibiotic use to doctors, as part of a departmental audit and feedback programme.

DESIGN

A prospective controlled interrupted time-series (ITS) study, with pre-defined pre- and post-intervention periods, each of 21 months.

SETTING

Three acute medical wards for elderly people in a teaching hospital.

PARTICIPANTS

Six thousand one hundred and twenty-nine consecutive unselected acute medical admissions aged >or=80 years.

INTERVENTIONS

A 'narrow-spectrum' antibiotic policy (reinforced by an established programme of audit and feedback of antibiotic usage and CDI rates) was introduced, following an unplanned rise in amoxicillin/clavulanate (Augmentin) use. It targeted broad-spectrum antibiotics for reduction (cephalosporins and amoxicillin/clavulanate) and narrow-spectrum antibiotics for increase (benzyl penicillin, amoxicillin and trimethoprim). Changes in the use of targeted antibiotics (intervention group) were compared with those of untargeted antibiotics (control group) using segmented regression analysis. Changes in CDI rates were examined by the Poisson regression model. Methicillin-resistant Staphylococcus aureus (MRSA) acquisition rates acted as an additional control.

RESULTS

There was a reduction in the use of all targeted broad-spectrum antibiotics and an increase in all targeted narrow-spectrum antibiotics, statistically significant for sudden change and/or linear trend. All other antibiotic use remained unchanged. CDI rates fell with incidence rate ratios of 0.35 (0.17, 0.73) (P=0.009). MRSA incidence did not change [0.79 (0.49, 1.28); P=0.32].

CONCLUSIONS

This is the first controlled prospective ITS study to use feedback to reinforce antibiotic policy and reduce CDI. Multicentre ITS or cluster randomized trials of this and other methods need to be undertaken to establish the most effective means of optimizing antibiotic use and reducing CDI.

The ORION statement: guidelines for transparent reporting of Outbreak Reports and Intervention studies Of Nosocomial infection

The quality of research in hospital epidemiology (infection control) must be improved to be robust enough to influence policy and practice. In order to raise the standards of research and publication, a CONSORT equivalent for these largely quasi-experimental studies has been prepared by the authors of two relevant systematic reviews, following consultation with learned societies, editors of journals and researchers. It consists of a 22 item checklist, and a summary table. The emphasis is on transparency to improve the quality of reporting and on the use of appropriate statistical techniques. The statement has been endorsed by a number of professional special interest groups and societies. Like CONSORT, ORION should be considered a 'work in progress', which requires ongoing dialogue for successful promotion and dissemination. The statement is therefore offered for further public discussion. Journals and research councils are strongly recommended to incorporate it into their submission and reviewing processes. Feedback to the authors is encouraged and the statement will be revised in 2 years.

Subspecies differentiation of Moraxella bovis by restriction endonuclease DNA analysis (BRENDA)

A total of 94 strains of Moraxella bovis have been examined by bacterial restriction endonuclease DNA analysis (BRENDA). These strains comprised isolates from the U.S.A., the U.K., in Australia, and from a number of widely separated areas within New Zealand. The strains were classified into a total of 26 different types on the basis of their BRENDA patterns. Fourteen types were present among 34 strains from the U.S.A., eight types from 17 strains in the U.K. three types from five strains in Australia but only one type resulted from all 38 New Zealand strains. Moraxella liquifaciens, M. nonliquifaciens and an atypical Moraxella sp. isolated from cattle eyes in Australia were tested and produced BRENDA patterns clearly different from those of the Moraxella bovis strains. BRENDA, when used with the restriction endonuclease EcoR1, did not provide a means of distinguishing between avirulent, nonhaemolytic M.bovis, and the virulent haemolytic strains.

Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): systematic review of the literature

OBJECTIVE

To evaluate the evidence for the effectiveness of isolation measures in reducing the incidence of methicillin resistant Staphylococcus aureus (MRSA) colonisation and infection in hospital inpatients.

DESIGN

Systematic review of published articles.

DATA SOURCES

Medline, Embase, CINAHL, Cochrane Library, System for Information on Grey Literature in Europe (SIGLE), and citation lists (1966-2000).

REVIEW METHODS

Articles reporting MRSA related outcomes and describing an isolation policy were selected. No quality restrictions were imposed on studies using isolation wards or nurse cohorting. Other studies were included if they were prospective or employed planned comparisons of retrospective data.

RESULTS

46 studies were accepted; 18 used isolation wards, nine used nurse cohorting, and 19 used other isolation policies. Most were interrupted time series, with few planned formal prospective studies. All but one reported multiple interventions. Consideration of potential confounders, measures to prevent bias, and appropriate statistical analysis were mostly lacking. No conclusions could be drawn in a third of studies. Most others provided evidence consistent with a reduction of MRSA acquisition. Six long interrupted time series provided the strongest evidence. Four of these provided evidence that intensive control measures including patient isolation were effective in controlling MRSA. In two others, isolation wards failed to prevent endemic MRSA.

CONCLUSION

Major methodological weaknesses and inadequate reporting in published research mean that many plausible alternative explanations for reductions in MRSA acquisition associated with interventions cannot be excluded. No well designed studies exist that allow the role of isolation measures alone to be assessed. None the less, there is evidence that concerted efforts that include isolation can reduce MRSA even in endemic settings. Current isolation measures recommended in national guidelines should continue to be applied until further research establishes otherwise.

Methicillin-resistant Staphylococcus aureus in hospitals and the community: stealth dynamics and control catastrophes

Methicillin-resistant Staphylococcus aureus (MRSA) represents a serious threat to the health of hospitalized patients. Attempts to reduce the spread of MRSA have largely depended on hospital hygiene and patient isolation. These measures have met with mixed success: although some countries have almost eliminated MRSA or remained largely free of the organism, others have seen substantial increases despite rigorous control policies. We use a mathematical model to show how these increases can be explained by considering both hospital and community reservoirs of MRSA colonization. We show how the timing of the intervention, the level of resource provision, and chance combine to determine whether control measures succeed or fail. We find that even control measures able to repeatedly prevent sustained outbreaks in the short-term can result in long-term control failure resulting from gradual increases in the community reservoir. If resources do not scale with MRSA prevalence, isolation policies can fail "catastrophically."

Systematic review of isolation policies in the hospital management of methicillin-resistant Staphylococcus aureus: a review of the literature with epidemiological and economic modelling

OBJECTIVE

To review the evidence for the effectiveness of different isolation policies and screening practices in reducing the incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonisation and infection in hospital in-patients. To develop transmission models to study the effectiveness and cost-effectiveness of isolation policies in controlling MRSA.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, The Cochrane Library and SIGLE (1966-2000). Hand-searching key journals. No language restrictions.

REVIEW METHODS

Key data were extracted from articles reporting MRSA-related outcomes and describing an isolation policy in a hospital with epidemic or endemic MRSA. No quality restrictions were imposed on studies using isolation wards (IW) or nurse cohorting (NC). Other studies were included if they were prospective or employed planned comparisons of retrospective data. Stochastic and deterministic models investigated long-term transmission dynamics, studying the effect of a fixed capacity IW, producing economic evaluations using local cost data.

RESULTS

A total of 46 studies were accepted: 18 IWs, 9 NC, 19 other isolation policies. Most were interrupted time series, with few planned formal prospective studies. All but one reported multiple interventions. Consideration of potential confounders, measures to prevent bias, and appropriate statistical analysis were mostly lacking. No conclusions could be drawn in a third of studies. Most others provided evidence consistent with reduction of MRSA acquisition. Six long interrupted time series provided the strongest evidence. Four of these provided evidence that intensive control measures which included patient isolation were effective in controlling MRSA. In two others IW use failed to prevent endemic MRSA. There was no robust economic evaluation. Models showed that improving the detection rate or ensuring adequate isolation capacity reduced endemic levels, with substantial savings achievable.

CONCLUSIONS

Major methodological weaknesses and inadequate reporting in published research mean that many plausible alternative explanations for reductions in MRSA acquisition associated with interventions cannot be excluded. No well-designed studies allow the role of isolation measures alone to be assessed. Nonetheless, there is evidence that concerted efforts that include isolation can reduce MRSA even when endemic. Little evidence was found to suggest that current isolation measures recommended in the UK are ineffective, and these should continue to be applied until further research establishes otherwise. The studies with the strongest evidence, together with the results of the modelling, provide testable hypotheses for future research. Guidelines to facilitate design of future research are produced.

Inhibition of apoptosis in cultured porcine granulosa cells by inhibitors of caspase and serine protease activity

Protease inhibitors were used to test the hypothesis that caspases and other proteases were active during apoptosis in cultured porcine granulosa cells. Cells isolated from 3 to 6 mm follicles were cultured for 24 h in Dulbecco's modified Eagles medium: Hams F12 (1:11 containing 1% fetal bovine serum. Final inhibitor concentrations, added in 10 microL of dimethylsulfoxide, were 0, 1, 5, 25 and 125 microM. Cells with compromised plasma membrane integrity, identified by uptake ethidium homodimer, increased during culture in the absence of inhibitors from 37% to 43%. Apoptotic (A0) cells, identified by DNA fluorescence flow cytometry, increased (P < 0.05) from 1.7% to 29%. The serine protease inhibitor N-tosyl-L-phenylalanine chloromethyl ketone (TPCK) at 125 microM was lethal increasing (P < 0.05) cells with compromised membranes to 92%. In response to TPCK, A0 cells decreased from 55% to 1.2%; progesterone and estradiol production were decreased by 94% and 98%, respectively. The general caspase inhibitor, benzyloxycarbonyl-valinyl-alaninyl-aspartyl fluoro methylketone, decreased (P < 0.05) A0 cells linearly from 33% to 3 % between 0 and 125 microM without significant effect on steroidogenesis or on the percentage of cells with compromised plasma membranes. Other inhibitors only had a marginal effect on apoptosis; concentrations of > or = 1 microM decreased (P < 0.05) A0 cells from 29% to 18% to 21% and had no significant effect on membrane integrity or steroid production. We conclude that caspases are associated with apoptosis in cultured porcine granulosa cells. Death induced by TPCK was through a non-apoptotic mechanism.

Expression of resistance to tetracyclines in strains of methicillin-resistant Staphylococcus aureus

A diverse collection of methicillin-resistant Staphylococcus aureus (MRSA) isolates resistant to tetracycline was screened by PCR for the presence of the resistance determinants tetK, tetL, tetM or tetO. Twenty-four of 66 isolates had tetM alone, 21 had tetK alone and 21 had both tetK and tetM (tetKM). All isolates were tetL- and tetO-negative. MICs of tetracycline, doxycycline and minocycline were evaluated for all isolates with or without preincubation in the presence of subinhibitory concentrations of tetracycline or minocycline. All isolates with one or more tetracycline resistance determinants were resistant to tetracycline 8 mg/L without induction of resistance. Some MRSA isolates of each of these three genotypes showed an unexpected lack of resistance to tetracyclines when the disc diffusion or agar dilution method was applied to uninduced cells. Resistance to tetracycline and doxycycline was greater (two- to four-fold) in tetK cells preincubated with tetracycline (tetK MRSA isolates were susceptible to minocycline </=0.25 mg/L under all conditions tested). For isolates with tetM alone, preincubation with tetracycline or minocycline gave up to a four-fold increase in the level of resistance to doxycycline and minocycline. Induction of doxycycline and minocycline resistance was clearly observed for tetKM isolates when cells were preincubated with minocycline. This study suggests that, despite the results of susceptibility testing, all tetracycline-resistant S. aureus isolates should be treated as resistant to doxycycline, and all tetM-positive isolates should be treated as resistant to all tetracyclines. A double disc diffusion method has been developed to identify inducible resistance to minocycline and to distinguish between tetK, tetM and tetKM isolates.

Preliminary analysis of the transmission dynamics of nosocomial infections: stochastic and management effects

A simple mathematical model is developed for the spread of hand-borne nosocomial pathogens such as Staphylococcus aureus within a general medical-surgical ward. In contrast to previous models a stochastic approach is used. Computer simulations are used to explore the properties of the model, and the results are presented in terms of the pathogen's successful introduction rate, ward-level prevalence, and colonized patient-days, emphasizing the general effects of changes in management of patients and carers. Small changes in the transmissibility of the organism resulted in large changes in all three measures. Even small increases in the frequency of effective handwashes were enough to bring endemic organisms under control. Reducing the number of colonized patients admitted to the ward was also an effective control measure across a wide range of different situations. Increasing surveillance activities had little effect on the successful introduction rate but gave an almost linear reduction in colonized patient-days and ward-level prevalence. Shorter lengths of patient stay were accompanied by higher successful introduction rates, but had little effect on the other measures unless the mean time before detection of a colonized individual was large compared to the mean length of stay. We conclude that chance effects are likely to be amongst the most important factors in determining the course of an outbreak. Mathematical models can provide valuable insights into the non-linear interactions between a small number of processes, but for the very small populations found in hospital wards, a stochastic approach is essential.

Prescription drug coverage and spending for Medicare beneficiaries

Outpatient prescription drug coverage is not a Medicare covered benefit. Debate continues in Congress and elsewhere on modernizing the Medicare benefit package, including proposals that would help the Nation's seniors pay for prescription drugs. Very little is known about which persons within the Medicare population have drug coverage from other sources. Using 1995 data from the Medicare Current Beneficiary Survey (MCBS), the authors present information on who has coverage by various sociodemographic categories. The data indicate higher-than-average levels of coverage for minority persons, beneficiaries eligible for Medicare because of disability, and those with higher incomes.

Follicle-stimulating hormone and insulin-like growth factor-I attenuate apoptosis in cultured porcine granulosa cells

Thymocytes and granulosa cells (GC) were cultured up to 48 h to determine the effect of dexamethasone (DEX) on apoptosis in culture (in RPMI containing 10% fetal bovine serum [FBS] at 38 degrees C in a 5% CO2:95% air atmosphere). In experiment 2, GC were cultured for 24 h at a density of 0.5 x 10(6) cells/0.5 ml in Dulbecco's Modified Eagle's medium:Hams F-12 (1:1) containing 1% FBS to determine whether porcine FSH and insulin-like growth factor-I (IGF-I) attenuated apoptosis and to compare two methods of measuring apoptosis: 1) flow cytometry of dispersed cells for subdiploid DNA fluorescence and 2) densitometry of internucleosomal DNA fragments. The percentages of apoptotic (%A0) thymocytes and GC increased (p < 0.01) during 48 h of culture. Compared to no DEX, 0.1 or 1.0 microM DEX in thymocytes caused a 33% further increase (p < 0.01) in %A0 cells but had no effect in GC. In experiment 2, apoptosis, measured by %A0 GC and amount of internucleosomal fragments, decreased (p < 0.01) by 50% during culture in the presence of FSH (4 NIH-S1 mU/ml) or IGF-I (50 ng/ml); results from these techniques were correlated (r = 0.829, n = 44, p < or = 0.0001). We conclude that 1) porcine GC and thymocytes undergo spontaneous apoptosis in culture, 2) two methods of analyzing apoptosis were in excellent agreement, and 3) FSH and IGF-I attenuated spontaneous apoptosis in cultured porcine GC.

Development of an end-stage renal disease managed care demonstration

At present, end-stage renal disease (ESRD) beneficiaries cannot enroll in health maintenance organizations (HMOs) or social health maintenance organizations (SHMOs), but HMO members who develop ESRD may remain enrolled, and the Health Care Financing Administration (HCFA) pays the HMO a state-specific, but otherwise unadjusted, capitation rate that is 95% of fee-for-service (FFS) costs. Thus, more than 6,000 ESRD beneficiaries were enrolled in HMOs in 1993, when Congress mandated an ESRD SHMO demonstration in which not only Medicare-covered services, but extra benefits were to be provided to Medicare beneficiaries, with the SHMO receiving a capitation rate based on 100% of FFS costs. The demonstration will test (1) the feasibility of year-round open enrollment of ESRD beneficiaries in HMOs; (2) a capitation system based on treatment status--dialysis, transplant, or functioning graft--and adjusted for age and whether diabetes was the cause of renal failure; (3) the effect of the additional benefits; and (4) whether managed care can improve ESRD quality outcomes. HCFA made demonstration awards in September 1996 to Kaiser-Permanente in Southern California; Health Options in Southern Florida; and Phoenix Healthcare in Central Tennessee. The sites are expected to have 1 year of planning and development before beginning the congressionally mandated 3 years of service delivery. There will be an independent evaluation.

Follicular Atresia, follicular fluid hormones, and circulating hormones during the midluteal phase of the estrous cycle in pigs

The incidence of atresia, concentrations of follicular fluid steroids, and circulating concentrations of estradiol, FSH, and progesterone were investigated to determine whether there was any evidence for a wave of follicular activity or atresia between Days 7 and 15 of the estrous cycle in pigs, Cyclic pigs (gilts) were slaughtered on Days 7, 9, 11, 13, and 15 (4, 4, 4, 4, and 3 pigs per day), and 287 follicles > 2 mm were dissected from ovaries to recover follicular fluid and granulosa cells. Apoptotic (Ao) granulosa cells were those containing sub-diploid DNA fluorescence as determined by flow cytometry. follicles with > or = 10% Ao granulosa cells were classified as atretic, and those with < 10% Ao granulosa cells were designated nonatretic. The percentage of atretic follicles (AF) per pig was 35.5 +/- 4.7 (mean +/- SEM), and while the percentage of AF ranged from 12% to 73%, means did not differ significantly among days. Mean follicular estradiol concentration was higher (p < 0.05) in nonatretic follicles (NAF) than in AF; in NAF, the concentration decreased (p < 0.05) from 15 ng/ml on Day 7 to 2.5 ng/ml on Day 11 and then increased (p < 0.05) to 10 ng/ml on Day 15 of the cycle. Mean follicular progesterone concentration was higher (p < 0.05) in AF than in NAF, while follicular androstenedione concentration (20 +/- 1.5 ng/ml, overall mean +/- SEM) did not differ between AF and NAF. Mean plasma estradiol, FSH, and progesterone concentrations did not differ among days of the cycle or differ significantly during the last 42 h before slaughter. Plasma estradiol and FSH concentrations were not significantly correlated with percentage of AF or with follicular steroid concentrations. These results support the notion of continuous growth and atresia of ovarian follicles in pigs independent of changes in plasma FSH and follicular steroid concentration, without evidence for a dominant cohort of follicles during the luteal phase of the estrous cycle.