Pseudomonas aeruginosa infection in augmented care: the molecular ecology and transmission dynamics in four large UK hospitals

BACKGROUND

Pseudomonas aeruginosa is a common opportunistic pathogen and molecular typing in outbreaks has linked patient acquisition to contaminated hospital water systems.

AIM

To elucidate the role of P. aeruginosa transmission rates in non-outbreak augmented care settings in the UK.

METHODS

Over a 16-week period, all water outlets in augmented care units of four hospitals were sampled for P. aeruginosa and clinical isolates were collected. Outlet and clinical P. aeruginosa isolates underwent whole-genome sequencing (WGS), which with epidemiological data identified acquisition from water as definite (level 1), probable (level 2), possible (level 3), and no evidence (level 4).

FINDINGS

Outlets were positive in each hospital on all three occasions: W (16%), X (2.5%), Y (0.9%) and Z (2%); and there were 51 persistently positive outlets in total. WGS identified likely transmission (at levels 1, 2 and 3) from outlets to patients in three hospitals for P. aeruginosa positive patients: W (63%), X (54.5%) and Z (26%). According to the criteria (intimate epidemiological link and no phylogenetic distance), approximately 5% of patients in the study 'definitely' acquired their P. aeruginosa from their water outlets in the intensive care unit. This study found extensive evidence of transmission from the outlet to the patients particularly in the newest hospital (W), which had the highest rate of positive outlets.

CONCLUSIONS

The overall findings suggest that water outlets are the most likely source of P. aeruginosa nosocomial infections in some settings, and that widespread introduction of control measures would have a substantial impact on infections.

Genomic and epidemiological monitoring of yellow fever virus transmission potential

The yellow fever virus (YFV) epidemic in Brazil is the largest in decades. The recent discovery of YFV in Brazilian Aedes species mosquitos highlights a need to monitor the risk of reestablishment of urban YFV transmission in the Americas. We use a suite of epidemiological, spatial, and genomic approaches to characterize YFV transmission. We show that the age and sex distribution of human cases is characteristic of sylvatic transmission. Analysis of YFV cases combined with genomes generated locally reveals an early phase of sylvatic YFV transmission and spatial expansion toward previously YFV-free areas, followed by a rise in viral spillover to humans in late 2016. Our results establish a framework for monitoring YFV transmission in real time that will contribute to a global strategy to eliminate future YFV epidemics.

Establishment and cryptic transmission of Zika virus in Brazil and the Americas

Transmission of Zika virus (ZIKV) in the Americas was first confirmed in May 2015 in northeast Brazil. Brazil has had the highest number of reported ZIKV cases worldwide (more than 200,000 by 24 December 2016) and the most cases associated with microcephaly and other birth defects (2,366 confirmed by 31 December 2016). Since the initial detection of ZIKV in Brazil, more than 45 countries in the Americas have reported local ZIKV transmission, with 24 of these reporting severe ZIKV-associated disease. However, the origin and epidemic history of ZIKV in Brazil and the Americas remain poorly understood, despite the value of this information for interpreting observed trends in reported microcephaly. Here we address this issue by generating 54 complete or partial ZIKV genomes, mostly from Brazil, and reporting data generated by a mobile genomics laboratory that travelled across northeast Brazil in 2016. One sequence represents the earliest confirmed ZIKV infection in Brazil. Analyses of viral genomes with ecological and epidemiological data yield an estimate that ZIKV was present in northeast Brazil by February 2014 and is likely to have disseminated from there, nationally and internationally, before the first detection of ZIKV in the Americas. Estimated dates for the international spread of ZIKV from Brazil indicate the duration of pre-detection cryptic transmission in recipient regions. The role of northeast Brazil in the establishment of ZIKV in the Americas is further supported by geographic analysis of ZIKV transmission potential and by estimates of the basic reproduction number of the virus.

The AUSTRAL VLBI observing program

The AUSTRAL observing program was started in 2011, performing geodetic and astrometric very long baseline interferometry (VLBI) sessions using the new Australian AuScope VLBI antennas at Hobart, Katherine, and Yarragadee, with contribution from the Warkworth (New Zealand) 12 m and Hartebeesthoek (South Africa) 15 m antennas to make a southern hemisphere array of telescopes with similar design and capability. Designed in the style of the next-generation VLBI system, these small and fast antennas allow for a new way of observing, comprising higher data rates and more observations than the standard observing sessions coordinated by the International VLBI Service for Geodesy and Astrometry (IVS). In this contribution, the continuous development of the AUSTRAL sessions is described, leading to an improvement of the results in terms of baseline length repeatabilities by a factor of two since the start of this program. The focus is on the scheduling strategy and increased number of observations, aspects of automated operation, and data logistics, as well as results of the 151 AUSTRAL sessions performed so far. The high number of the AUSTRAL sessions makes them an important contributor to VLBI end-products, such as the terrestrial and celestial reference frames and Earth orientation parameters. We compare AUSTRAL results with other IVS sessions and discuss their suitability for the determination of baselines, station coordinates, source coordinates, and Earth orientation parameters.

Part four: The research dissertation: planning, producing and writing a thesis

Dissertations have become common inclusions to postgraduate degrees in healthcare. To the novice researcher, undertaking an extensive project of this kind can appear daunting. In this final article in the series 'Spotlight on Research', Julie Quick and Susan Hall advise perioperative practitioners on how to plan, produce and write a research dissertation. Guidance is also given on disseminating the results from research studies.

Are you prepared to take the risk: Extending governance for perioperative roles

In the 25 years since the Oxford Heart Centre in England appointed the first British nurse to be formally trained as a non-medically qualified surgical assistant, the number of nurses and allied health professionals (AHPs) undertaking advancing surgical roles has increased in order to backfill the deficit of a surgical workforce (Quick and Hall 2014). Despite initial concerns over nurses and AHPs undertaking roles and responsibilities which were previously performed solely by doctors, the role of non-medical surgical assistants has been shown to maintain surgical services, provide an additional career route for nurses, and enhance patient care (Abraham 2011, Quick 2013, Jones et al 2012). In the early days however, a lack of role specific regulation, practice guidelines and a variety of educational standards led to variances in job titles and role responsibilities for nurses and AHPs performing surgical assistance (Box 1).

Part two: Qualitative research

This second article in the series Spotlight on Research focuses on qualitative research, its applications, principles and methodologies. It provides an insight into how this approach can be used within the perioperative setting and gives advice for practitioners looking to undertake a qualitative research study.

The surgical first assistant: are you compliant?

It is over a century now since the importance of the knowledge and skills of the surgeon's assistant were first considered (Brickner 1907). More recently both the Royal College of Surgeons of England (RCSE 1999, 2011) and the Perioperative Care Collaborative (PCC 2007) have reviewed the role of the non-medically qualified surgical assistant. In 2012, the PCC published their review of the surgical first assistant (SFA) role in response to a call by the RCSE for greater clarity in relation to the plethora of titles afforded to non-medical surgical assistants (RCSE 2011).

The tumour microenvironment: a novel target for cancer therapy

Cancer therapy is in the midst of a major paradigm shift. Traditionally, cancer treatments have focused on tumour cells. However, studies over the past few decades have demonstrated that cancer is a vastly complex entity with multiple components affecting a tumour's growth, invasion and metastasis. These components, collectively termed the 'tumour microenvironment', include endothelial cells, pericytes, fibroblasts, inflammatory cells, leucocytes and elements of the extracellular matrix (ECM). Biological agents that target components of the tumour microenvironment may provide an interesting alternative to traditional tumour cell-directed therapy. Because of the complexity of the tumour milieu, the most beneficial therapy will likely involve the combination of one or more agents directed at this new target. This review highlights recent preclinical and clinical studies involving agents that target tumour vasculature, leucocytes, pericytes, cancer-associated fibroblasts and ECM components. We pay particular attention to combination therapies targeting multiple components of the tumour microenvironment, and aim to demonstrate that this strategy holds promise for the future of cancer treatment.

Identification, Preparation, and Characterization of Several Polymorphs and Solvates of Terazosin Hydrochloride

The phenomenon of polymorphism is prevalent in pharmaceuticals, yet it is unusual to identify more than three or four forms for any particular drug. Terazosin hydrochloride has been found to exist at room temperature in four solvent-free forms that can be isolated directly, one solvent-free form that can be prepared by desolvation of a methanolate, a methanol solvate, and a dihydrate. This study presents characterization and methods for preparation of each of these forms. Data are also presented demonstrating the relative stability of these forms.

The outer membrane localization of the Neisseria gonorrhoeae MsrA/B is involved in survival against reactive oxygen species

The PilB protein of Neisseria gonorrhoeae has been reported to be involved in the regulation of pilin gene transcription, but it also possesses significant homology to the peptide methionine sulfoxide reductase family of enzymes, specifically MsrA and MsrB from Escherichia coli. MsrA and MsrB in E. coli are able to reduce methionine sulfoxide residues in proteins to methionines. In addition, the gonococcal PilB protein encodes for both MsrA and MsrB activity associated with the repair of oxidative damage to proteins. In this work, we demonstrate that the PilB protein of Neisseria gonorrhoeae is not involved in pilus expression. Additionally, we show that wild-type N. gonorrhoeae produces two forms of this polypeptide, one of which contains a signal sequence and is secreted from the bacterial cytoplasm to the outer membrane; the other lacks a signal sequence and is cytoplasmic. Furthermore, we show that the secreted form of the PilB protein is involved in survival in the presence of oxidative damage.

Ritonavir: an extraordinary example of conformational polymorphism

PURPOSE

In the summer of 1998, Norvir semi-solid capsules supplies were threatened as a result of a new much less soluble crystal form of ritonavir. This report provides characterization of the two polymorphs and the structures and hydrogen bonding network for each form.

METHODS

Ritonavir polymorphism was investigated using solid state spectroscopy and microscopy techniques including solid state NMR, Near Infrared Spectroscopy, powder X-ray Diffraction and Single crystal X-ray. A sensitive seed detection test was developed.

RESULTS

Ritonavir polymorphs were thoroughly characterized and the structures determined. An unusual conformation was found for form II that results in a strong hydrogen bonding network A possible mechanism for heterogeneous nucleation of form II was investigated.

CONCLUSIONS

Ritonavir was found to exhibit conformational polymorphism with two unique crystal lattices having significantly different solubility properties. Although the polymorph (form II) corresponding to the "cis" conformation is a more stable packing arrangement, nucleation, even in the presence of form II seeds, is energetically unfavored except in highly supersaturated solutions. The coincidence of a highly supersaturated solution and a probable heterogeneous nucleation by a degradation product resulted in the sudden appearance of the more stable form II polymorph.

Partnerships for health in the 21st century

This paper presents the results of a working group on partnerships in preparation for the WHO Health for All Policy for the 21st Century. The working group aimed to clarify the nature of partnerships for health, proposed six categories of partnerships and outlined principles and criteria for partnerships. It concluded that partnership building was a key strategic component of health development and underlined that WHO must increasingly see its role as one of mustering support for health from many players. In order to do so, WHO must change its organizational culture and mode of operation.

A strategy for promoting improved pharmaceutical use: the International Network for Rational Use of Drugs

Over the last decade, pharmaceutical selection, procurement, distribution, and financing have improved as a result of essential drugs programs. However, despite improved availability, pharmaceuticals are frequently used irrationally. The International Network for the Rational Use of Drugs (INRUD) has been established to help address this problem. The Network joins core groups of researchers from four African and three Asian countries with support groups in Boston, Sweden, WHO, and Australia. The activities of the Network are supported by multilateral, bilateral, foundation donors and by Management Sciences for Health. INRUD functions as a participatory organization in which members are involved in decision-making. The primary objective of the Network is to identify through a coordinated set of country-based research projects a set of effective interventions to recommend as policy options for the promotion of rational drug use. In developing these research projects, INRUD stresses the importance of a multi-disciplinary perspective for adequately understanding the reasons underlying inappropriate use of drugs. To better enable country groups to utilize strong research methodologies and to blend the strengths of multiple disciplines effectively, a major activity of the Network thus far has been the building of local research capacity.

The structure and biological activities of the widely used protein kinase inhibitor, H7, differ depending on the commercial source

The protein kinase inhibitor 1-(5'-isoquinolinesulfonyl)-2-methylpiperazine (H7) has been widely used because of its ability to inhibit cyclic AMP- and cyclic GMP-dependent protein kinases (PKA and PKG) and protein kinase C (PKC) at roughly equal concentrations; it is much less potent on other kinases. Previous studies in other laboratories have found that H7 samples from different commercial sources have different properties in cellular studies and protein kinase C inhibition assays. We now report the results of chemical and biological tests which show that H7 samples also differ in chemical structure, again depending on their commercial source. Chemical synthesis and NMR spectroscopy indicate that H7 from most suppliers has the structure originally proposed for H7, while "H7" from another supplier is in fact its 3-methylpiperazine positional isomer.

Genetic counselling for myotonic dystrophy: a comparison of lens examination and DNA linkage studies

Genetic counselling in presymptomatic individuals with a family history of myotonic dystrophy (DM) is problematic. A genetic test to identify the presymptomatic carrier of the gene for DM would therefore be advantageous. We report studies comparing ophthalmic examination with a genetic test based on DNA linkage studies in nine DM families. The genetic test involved the use of five probes from four loci linked to the DM locus. Some discrepancies between ophthalmic and genetic tests were observed. Genetic counselling following prediction of genetic status was possible for 18 out of 20 patients from seven out of nine families.

Time-resolved pulsed fluorescence immunometric assays of carcinoembryonic antigen

A time-resolved pulsed fluorescence immunometric assay (TR-PFIA) for carcinoembryonic antigen is described in which either Eu(III) or Tb(III) chelate is used as label. Described in detail is the assay involving the well-documented format of microtiter matrix and Eu(III) fluorescence enhanced with a beta-diketone and quantified in a commercial time-resolving fluorometer. We have also used the same basic assay, but one with a Tb(III) chelate as label, and we read the fluorescence signal directly off a surface without the application of enhancement solution. The Tb(III) fluorescence is then brought into solution by using an analog of dipicolinic acid in an enhancement solution. The latter approach demonstrates the scope of the methodology, which invokes the extra complexity of enhancement only when increased sensitivity might be required. The power and versatility of the enhancement methodology are demonstrated.

Time-resolved pulsed fluorescence immunometric assays of carcinoembryonic antigen

A time-resolved pulsed fluorescence immunometric assay (TR-PFIA) for carcinoembryonic antigen is described in which either Eu(III) or Tb(III) chelate is used as label. Described in detail is the assay involving the well-documented format of microtiter matrix and Eu(III) fluorescence enhanced with a beta-diketone and quantified in a commercial time-resolving fluorometer. We have also used the same basic assay, but one with a Tb(III) chelate as label, and we read the fluorescence signal directly off a surface without the application of enhancement solution. The Tb(III) fluorescence is then brought into solution by using an analog of dipicolinic acid in an enhancement solution. The latter approach demonstrates the scope of the methodology, which invokes the extra complexity of enhancement only when increased sensitivity might be required. The power and versatility of the enhancement methodology are demonstrated.

Protein-enhanced fluorescein chemiluminescence used in an immunoassay for rubella antibody in serum

The chemiluminescence of fluorescein derivatives is greatly enhanced when they are conjugated to proteins. We exploited this property in devising a chemiluminescence immunoassay for rubella antibodies. In this sequential "sandwich"-type assay, tubes coated with rubella antigen are used for antibody separation and goat antibody to human IgG conjugated with fluorescein isothiocyanate is used for detection of bound rubella antibodies.

Protein-enhanced fluorescein chemiluminescence used in an immunoassay for rubella antibody in serum

The chemiluminescence of fluorescein derivatives is greatly enhanced when they are conjugated to proteins. We exploited this property in devising a chemiluminescence immunoassay for rubella antibodies. In this sequential "sandwich"-type assay, tubes coated with rubella antigen are used for antibody separation and goat antibody to human IgG conjugated with fluorescein isothiocyanate is used for detection of bound rubella antibodies.

Novel opiates and antagonists. 6. 7-Alkyl-6,7-didehydromorphinans

A method for preparing a variety of 7-alkyl-6,7- didehydromorphinans from the corresponding 6- morphinanones is described. The key intermediates in this sequence are the 7-formyl derivatives. The two epimeric B/C-trans-7-(1- hydroxypentyl ) morphinans ( 16a ,b) are stereochemically similar to the endo- ethanotetrahydrooripavines and are extremely potent in the mouse writhing test. The corresponding B/C-cis -7-(1- hydroxypentyl ) morphinans are inactive in this test.

Gossypol. Synthesis and in vitro spermicidal activity of isomeric hemigossypol derivatives

Three isomeric hemigossypol derivatives (3,4,5) have been synthesized. Two of these derivatives (3,4) and one synthetic intermediate (7) have been shown to have activity comparable to gossypol (1) in a sperm motility assay.

Stability-indicating assay for chlorthalidone formulation: evaluation of the USP analysis and a high-performance liquid chromatographic analysis

An investigation of the USP assay of chlorthalidone tablets showed that variable degradation of chlorthalidone occurred during assay preparation. The degradation products were isolated and identified. A stability-indicating high-performance liquid chromatographic (HPLC) assay which separates the degradation products from chlorthalidone was developed and used to examine the present USP preparation. The HPLC assay is suggested as an alternate.

Novel opiates and antagonists. 4. 7-Alkanoylhydromorphones

A series of 7-alkanoyl-substituted hydromorphone derivatives were prepared by acylation of the morpholine enamines. The most potent compound (6i) of the series was found to have agonist activity of the same order of magnitude as that of buprenorphine. The N-cyclopropylmethyl-substituted series was found to exhibit structure-activity relationships for analgesia and narcotic antagonism similar to those of the endo-ethanotetrahydrooripavines.

Relationships of the polytene chromosomes of Drosophila mediostriata and D. Griseolineata

Comparisons of the polytene chromosomes of late third instar larvae of Drosophila mediostriata (tripunctata group) and D. griseolineata (guaramunu group) revealed that distinct banding and puffing similarities exist between the species. The most impressive similarities were found to exist between the 3rd mediostriata and the 2nd griseolineata chromosomes; almost the entire length of this element of the former species could be homologized with that of the latter. Two simple inversions could account for the differences in banding sequence for this element if one were to disregard the fact that the griseolineata 2nd chromosome was considerably longer than the mediostriata 3rd.The amount of similarity found between the chromosomes of the species considered here is greater by far than that which can be found when mediostriata is compared to other species of the tripunctata group. It is concluded that the grouping of the species of this section of the phylogenetic tree of Drosophila must be reviewed and possibly revised.