Key lessons from the establishment of a nurse-led infection prevention and control program for COVID-19 in an Australian hotel quarantine and isolation service

BACKGROUND

A key aspect of Australia's response to the COVID-19 pandemic was to control transmission through legislated quarantine and isolation of overseas returning travellers and potentially infectious community members. In New South Wales, Special Health Accommodation (SHA) was rapidly established as a comprehensive health service for individuals that were at risk of having COVID-19, were confirmed to have COVID-19 or for those with complex health needs that were deemed inappropriate for management in Police managed Quarantine Hotels. SHA services were later expanded to care for community members who were COVID-19 positive and unable to effectively isolate, or contacts of individuals who were unable to quarantine effectively in their homes. SHA's unique nurse-led Infection Prevention and Control (IPC) program offers key lessons that may impact future programs.

METHODS

A reflection on the experience of leading an Infection Prevention and Control program in SHA was undertaken. This was supported by a review of SHA admission, workforce and transmission data and data obtained from a cross-sectional questionnaire aimed to better understand the experiences of a novel population of health workers (HW) in a comprehensive health-led quarantine and isolation service.

RESULTS

SHA program data demonstrates how its IPC program implementation prevented transmission of COVID-19 to SHA staff and patients. Responses from the questionnaire suggested staff felt safe and well-prepared through the IPC education they received. They also gained transferrable knowledge and skills, which they intend to use in future healthcare roles.

CONCLUSION

The SHA nurse-led IPC program offered successful quarantine and isolation for COVID-19 in non-purpose-built facilities. A review of IPC strategies and key lessons from the establishment of the SHA IPC program are of critical importance to planning and management of current and future pandemics.

Pragmatic intervention for increasing self-directed exercise behaviour and improving important health outcomes in people with multiple sclerosis: a randomised controlled trial

Background:

Exercise programmes that can demonstrate evidence of long-lasting clinical effectiveness are needed for people with multiple sclerosis (P wMS).

Objective:

The objective of this study was to assess the effects of a practically implemented exercise programme on self-directed exercise behaviour and important health outcomes in P wMS to nine months of follow-up.

Methods:

We conducted a parallel-arm, randomised controlled trial: 120 P wMS (Expanded Disability Status Scale (EDSS) 1.0–6.5) randomised to a three-month exercise intervention plus usual care, or usual care only. Two supervised plus one home-exercise session (weeks 1–6) were followed by one supervised and two home-exercise sessions (weeks 7–12). Cognitive-behavioural techniques promoted long-term exercise behaviour change. Outcomes were blindly assessed at baseline and at three and nine months after randomisation. The primary outcome was self-reported exercise behaviour (Godin Leisure Time Exercise Questionnaire (GLTEQ)). Secondary outcomes included fatigue and health-related quality of life (HRQoL).

Results:

The intervention increased self-reported exercise (9.6 points; 95% CI: 2.0 to 17.3 points; p = 0.01) and improved fatigue ( p < 0.0001) and many HRQoL domains ( p ≤ 0.03) at three months. The improvements in emotional well-being ( p = 0.01), social function ( p = 0.004) and overall quality of life ( p = 0.001) were sustained for nine months.

Conclusion:

This pragmatic approach to implementing exercise increases self-reported exercise behaviour, improves fatigue and leads to a sustained enhancement of HRQoL domains in P wMS.

Cost effectiveness of a pragmatic exercise intervention (EXIMS) for people with multiple sclerosis: economic evaluation of a randomised controlled trial

Background:

Exercise is a safe, non-pharmacological adjunctive treatment for people with multiple sclerosis but cost-effective approaches to implementing exercise within health care settings are needed.

Objective:

The objective of this paper is to assess the cost effectiveness of a pragmatic exercise intervention in conjunction with usual care compared to usual care only in people with mild to moderate multiple sclerosis.

Methods:

A cost-utility analysis of a pragmatic randomised controlled trial over nine months of follow-up was conducted. A total of 120 people with multiple sclerosis were randomised (1:1) to the intervention or usual care. Exercising participants received 18 supervised and 18 home exercise sessions over 12 weeks. The primary outcome for the cost utility analysis was the incremental cost per quality-adjusted life year (QALY) gained, calculated using utilities measured by the EQ-5D questionnaire.

Results:

The incremental cost per QALY of the intervention was £10,137 per QALY gained compared to usual care. The probability of being cost effective at a £20,000 per QALY threshold was 0.75, rising to 0.78 at a £30,000 per QALY threshold.

Conclusion:

The pragmatic exercise intervention is highly likely to be cost effective at current established thresholds, and there is scope for it to be tailored to particular sub-groups of patients or services to reduce its cost impact.

Psychological well-being in parents of children with Angelman, Cornelia de Lange and Cri du Chat syndromes

BACKGROUND

The current study focuses on mothers and fathers of children with three rare genetic syndromes that are relatively unexplored in terms of family experience: Angelman syndrome, Cornelia de Lange syndrome and Cri du Chat syndrome.

METHOD

Parents of children with Angelman syndrome (n =15), Cornelia de Lange syndrome (n = 16) and Cri du Chat syndrome (n = 18), and a matched comparison group of parents of children with autism and intellectual disabilities (n = 20) completed questionnaires on both psychological distress (stress, anxiety, depression) and positive psychological functioning.

RESULTS

Parents of children with Angelman syndrome consistently reported the highest levels of psychological distress, and parents of children with Cornelia de Lange syndrome the lowest, with parents of children with Cri du Chat syndrome and autism scoring between these two. Positive psychological functioning was similar across the four aetiology groups.

CONCLUSIONS

Parents of children with rare genetic syndromes are at risk for high levels of stress and mental health problems. Methodological issues and the practical applications of these results are discussed.

Gefitinib (ZD-1839) with concurrent docetaxel and conformal three-dimensional thoracic radiation followed by consolidative docetaxel/gefitinib for patients with stage III NSCLC: A phase I study

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Background: The safety of 3-dimensional (3D) conformal thoracic radiation delivered with concurrent gefitinib/docetaxel chemotherapy in patients with inoperable stage III NSCLC has not been evaluated. Methods: Patients with inoperable stage III NSCLC received weekly intravenous (i.v.) docetaxel starting at a dose of 15 mg/m2 escalating to 30 mg/m2 in 5 mg/m2 increments and daily gefitinib (250 mg given orally). Patients recieved concurrent thoracic radiation to a dose of 70 Gy utilizing 3-D techniques. The chemoradiation therapy was followed by 2 cycles of consolidative docetaxel (75 mg/m2) given q 21 days and gefitinib 250 mg p.o. for 1 year or until disease progression. Results: Beginning December 2003, 15 patients have been entered to date to this IRB approved phase I trial to determine the maximum tolerated dose of weekly docetaxel when given concurrent with gefitinib and thoracic radiation. The dose-limiting toxicities (DLT) observed were primarily non-hematologic and occured at dose level 3 (25 mg/m2). One patient experienced grade III esophagitis that resulted in a grade III dehydration, a second patient experienced grade III diarrhea while a third patient suffered a grade V interstitial pneumonitis, believed to be related to the gefinitib. While 14 of 15 patients completed the chemoradiation portion of the study and 2 patients completed all planned therapy, 4 patients progressed during therapy, 3 patients discontinued treatment due to toxicity, and 2 patients refused to continue treatment. The median and 1-year survival thus far is 21 months and 56%, respectively. Conclusions: 70 Gy conformal thoracic radiation and concurrent gefitinib/docetaxel thus far appears feasible but with modest toxicity. The study is currently enrolling patients at the weekly 20 mg/m2 docetaxel dose level concurrent with 250 mg of daily gefitinib. This study was supported in-part by Sanofi-Aventis and Astra Zeneca.

No significant financial relationships to disclose.

The association between environmental events and self-injurious behaviour in Cornelia de Lange syndrome

BACKGROUND

There has been limited empirical research into the environmental causes of self-injury in Cornelia de Lange syndrome. The present study examined the variability of self-injurious behaviour in Cornelia de Lange syndrome across environmental setting events. Additionally, the association between setting events and more specific environmental events was examined.

METHOD

A descriptive analysis of observational data on eight children with Cornelia de Lange syndrome aged between 4 and 14 years was carried out. The association between self-injurious behaviour and four environmental setting events and between specific environmental events and setting events was examined using established statistical methods for observational data.

RESULTS

Seven out of eight of the participants showed at least one form of self-injurious behaviour that was associated with a particular setting event. The study also demonstrated that the relationship between setting events and environmental events is extremely variable across individuals.

CONCLUSIONS

Self-injurious behaviour in some individuals with Cornelia de Lange syndrome is associated with environmental events although the precise nature of the association warrants clarification. Using broad setting events as a methodological tool in isolation provides some insight into the role of specific environmental factors in maintaining self-injurious behaviour but the integrity of setting events must be established.

Transcriptome profiling of a Saccharomyces cerevisiae mutant with a constitutively activated Ras/cAMP pathway

Often changes in gene expression levels have been considered significant only when above/below some arbitrarily chosen threshold. We investigated the effect of applying a purely statistical approach to microarray analysis and demonstrated that small changes in gene expression have biological significance. Whole genome microarray analysis of a pde2Delta mutant, constructed in the Saccharomyces cerevisiae reference strain FY23, revealed altered expression of approximately 11% of protein encoding genes. The mutant, characterized by constitutive activation of the Ras/cAMP pathway, has increased sensitivity to stress, reduced ability to assimilate nonfermentable carbon sources, and some cell wall integrity defects. Applying the Munich Information Centre for Protein Sequences (MIPS) functional categories revealed increased expression of genes related to ribosome biogenesis and downregulation of genes in the cell rescue, defense, cell death and aging category, suggesting a decreased response to stress conditions. A reduced level of gene expression in the unfolded protein response pathway (UPR) was observed. Cell wall genes whose expression was affected by this mutation were also identified. Several of the cAMP-responsive orphan genes, upon further investigation, revealed cell wall functions; others had previously unidentified phenotypes assigned to them. This investigation provides a statistical global transcriptome analysis of the cellular response to constitutive activation of the Ras/cAMP pathway.

Stroke nursing: a national perspective

Several consensus agreements have been issued by the royal colleges in the past on specific aspects of stroke. The new guidelines, however, go much further and are far more comprehensive. Healthcare workers now have a much needed instrument and backing to develop high-quality stroke services in the light of clinical governance and evidence-based practice initiatives. These guidelines are particularly important in forming the basis for clinical governance in stroke. Nursing methodologies have not been covered directly; however, there is much in the document that nurses can seize upon and develop. A huge need exists in terms of robust nursing research in this area (Thorn, 2000) and, in order to contribute in the future to the debate, nurses must co-ordinate their efforts in building a credible knowledge base.

An integrated approach to studying regulation of production of the antibiotic methylenomycin by Streptomyces coelicolor A3(2)

A physiological and molecular biological study was made of the control of methylenomycin biosynthesis by Streptomyces coelicolor A3(2). A simple and reliable assay for this antibiotic was developed. Conditions that permit the synthesis of methylenomycin by S. coelicolor cultures grown in defined medium were elucidated: a readily assimilated carbon and nitrogen source is required. Under these conditions methylenomycin is produced late in the growth phase, at the time of transition from exponential to linear growth. Provided that the phosphate concentration in the medium is kept high, there is synthesis of methylenomycin but not of the other secondary metabolites that this strain can produce. These conditions were used to study the transcription of the methylenomycin gene cluster during the transition from primary to secondary metabolism. The biosynthetic genes of at least one of the mmy transcription units appear to be transcribed before the mmr resistance determinant. The possibility that methylenomycin induces the transcription of mmr is discussed.

A videofluoroscopy chair for the evaluation of dysphagia in patients with severe neuromotor disease

Due to the difficulties encountered in positioning severely neurologically impaired individuals for videofluoroscopic studies, the Rehab Tech Video FluoroChair was developed. The purpose of the chair is to provide the severely disabled patient with safe, stable postural support in an upright position for videofluoroscopic studies, with anterior-posterior, lateral, and rotational views easily performed. The chair features a removable headrest, a full back support, armrests, lateral truncal supports, and a patented base which is clamped to the footboard of the radiology table and allows for 200 degrees rotation of the patient. Two case studies illustrate the practical use and versatility of the Rehab Tech Video FluoroChair.

Streptomyces griseus streptomycin phosphotransferase: expression of its gene in Escherichia coli and sequence homology with other antibiotic phosphotransferases and with eukaryotic protein kinases

The aphD gene of Streptomyces griseus, encoding a streptomycin 6-phosphotransferase (SPH), was sub-cloned in the pBR322-based expression vector pRK9 (which contains the Serratia marcescens trp promoter) with selection for expression of streptomycin resistance in Escherichia coli. Two hybrid plasmids, pCKL631 and pCKL711, were isolated which conferred resistance. Both contained a approximately 2 kbp fragment already suspected to include aphD. The properties of in vitro deletion derivatives of these plasmids were consistent with the presumed location of aphD. In vitro deletion of a sequence including most of the trp promoter largely, but not quite completely, abolished the ability of the plasmid to confer streptomycin resistance, confirming that expression was indeed principally from the trp promoter. A polypeptide of approximately 34.5 kDa was present in minicells containing plasmids that conferred streptomycin resistance, but was absent when the plasmids contained in vitro deletions removing streptomycin resistance. Part of the fragment was sequenced and an open reading frame corresponding to aphD identified. A computer-assisted comparison of the deduced SPH sequence with those of other antibiotic phosphotransferases suggested a common structure A-B-C-D-E, where B and D were conserved between all sequences compared while A, C and E divided between the streptomycin and hygromycin B phosphotransferases on one hand and kanamycin/neomycin ones on the other. A composite sequence data base was searched for homologues to consensus matrices constructed from five approximately 12-residue subsequences within blocks B and D. For one subsequence, corresponding to the N-terminal portion of block D, those sequences from the database that yielded the highest homology scores comprised almost entirely either antibiotic phosphotransferases or eukaryotic protein kinases. Possible evolutionary implications of this homology, previously described by other groups, are discussed.

Potentiometric combination ion/carbon dioxide sensors for in vitro and in vivo blood measurements

The development and analytical performance of a novel potentiometric combination ion/pCO2 sensor design for in vitro and in vivo measurements are reported. The design is based on incorporating an appropriate ionophore within the outer silicone gas permeable membranes of both conventional macro and new catheter-type pCO2 sensors. Simultaneous measurement of the potentials across the ion-selective/gas permeable membrane and the inner glass or polymer pH sensitive membrane provides the basis for continuous monitoring of both ionic and pCO2 levels with the same device. A macro-sized K+/pCO2 embodiment of the sensor is constructed from a commercial Severinghaus CO2 sensor and is used to demonstrate the principles and capabilities of the proposed design. A flexible, miniaturized (outer diameter = 1.2 mm) combination K+/pCO2 catheter sensor is also described. The catheter-type sensor is fabricated by inserting a tubular polymer membrane pH electrode into an outer silicone rubber tube doped with valinomycin. Continuous measurements of K+ and pCO2 during 6-h blood pump studies using both the macro and catheter-type combination sensors correlate well with those of conventional bench-top analyzers. In addition, continuous (4 h) intravascular measurements with the combination catheter sensor in dogs show good agreement with those of commercial blood analyzers (R = 0.984 and 0.962 for pCO2 and K+, respectively.

Quantitation of T cell antigen-binding molecules (TABM) in the sera of nonimmunized, immunized, and desensitized mice

Heterologous antibodies to non-MHC-restricted T cell antigen-binding molecules (TABM) were used in an ELISA to detect and quantitate TABM levels in the sera of nonimmune mice and in mice immunized and/or desensitized to methylated bovine serum albumin (MBSA). TABM were detected at low levels in sera from nonimmune and immune mice. Amounts of TABM rose 300-fold in MBSA-immune mice within 12 hr of a desensitizing injection of MBSA, and rapidly returned to pre-desensitization levels. Serum TABM were purified by precipitation with 50% (NH4)2SO4 and chromatography in carboxymethylcellulose. The purified TABM were Mr 30,000 to 37,000 reduced, 72,000 nonreduced, and had a pI range of 5.5 to 7.1. A portion of the elevated TABM in desensitized mice bound MBSA specifically, whereas TABM from the sera of nonimmune/nondesensitized mice did not bind MBSA. The timing of the appearance of TABM early in desensitization suggests the possibility that they may play a role in the subsequent appearance of suppressor cells in later stages of this phenomenon. In addition, the results presented here raise the possibility that fluctuations in TABM levels might prove to be a sensitive indicator of immunoregulatory status in general.

Quantitation of T cell antigen-binding molecules (TABM) in the sera of nonimmunized, immunized, and desensitized mice

Heterologous antibodies to non-MHC-restricted T cell antigen-binding molecules (TABM) were used in an ELISA to detect and quantitate TABM levels in the sera of nonimmune mice and in mice immunized and/or desensitized to methylated bovine serum albumin (MBSA). TABM were detected at low levels in sera from nonimmune and immune mice. Amounts of TABM rose 300-fold in MBSA-immune mice within 12 hr of a desensitizing injection of MBSA, and rapidly returned to pre-desensitization levels. Serum TABM were purified by precipitation with 50% (NH4)2SO4 and chromatography in carboxymethylcellulose. The purified TABM were Mr 30,000 to 37,000 reduced, 72,000 nonreduced, and had a pI range of 5.5 to 7.1. A portion of the elevated TABM in desensitized mice bound MBSA specifically, whereas TABM from the sera of nonimmune/nondesensitized mice did not bind MBSA. The timing of the appearance of TABM early in desensitization suggests the possibility that they may play a role in the subsequent appearance of suppressor cells in later stages of this phenomenon. In addition, the results presented here raise the possibility that fluctuations in TABM levels might prove to be a sensitive indicator of immunoregulatory status in general.

Mechanical ventilation of patients with late stage Duchenne muscular dystrophy: management in the home

Death in the late stage of Duchenne muscular dystrophy is most frequently a consequence of respiratory failure. Since muscles of ventilation become weakened the bellows mechanism fails insidiously. Patients exhibit symptoms of ventilatory insufficiency, the first to be noticed are those associated with CO2 retention: dyspnea, nightmares, increased heart rate, and increased blood pressure. Ten patients with late stage Duchenne muscular dystrophy have been supplied with mechanical aid for ventilatory assistance. The age of onset of respiratory distress needing mechanical assistance varied from 10 to 20 years. Meaningful survival after allegedly reaching the end stage has been from 2 to 7.5 years with an average of 3.4 years. With a caring family, these patients can have a meaningful life, even though they require continuous mechanical ventilatory aid.