Evaluating the cost implications of integrating SARS-CoV-2 genome sequencing for infection prevention and control investigation of nosocomial transmission within hospitals

BACKGROUND

The COG-UK hospital-onset COVID-19 infection (HOCI) trial evaluated the impact of SARS-CoV-2 whole-genome sequencing (WGS) on acute infection, prevention, and control (IPC) investigation of nosocomial transmission within hospitals.

AIM

To estimate the cost implications of using the information from the sequencing reporting tool (SRT), used to determine likelihood of nosocomial infection in IPC practice.

METHODS

A micro-costing approach for SARS-CoV-2 WGS was conducted. Data on IPC management resource use and costs were collected from interviews with IPC teams from 14 participating sites and used to assign cost estimates for IPC activities as collected in the trial. Activities included IPC-specific actions following a suspicion of healthcare-associated infection (HAI) or outbreak, as well as changes to practice following the return of data via SRT.

FINDINGS

The mean per-sample costs of SARS-CoV-2 sequencing were estimated at £77.10 for rapid and £66.94 for longer turnaround phases. Over the three-month interventional phases, the total management costs of IPC-defined HAIs and outbreak events across the sites were estimated at £225,070 and £416,447, respectively. The main cost drivers were bed-days lost due to ward closures because of outbreaks, followed by outbreak meetings and bed-days lost due to cohorting contacts. Actioning SRTs, the cost of HAIs increased by £5,178 due to unidentified cases and the cost of outbreaks decreased by £11,246 as SRTs excluded hospital outbreaks.

CONCLUSION

Although SARS-CoV-2 WGS adds to the total IPC management cost, additional information provided could balance out the additional cost, depending on identified design improvements and effective deployment.

The bovine foot skin microbiota is associated with host genotype and the development of infectious digital dermatitis lesions

BACKGROUND

Bovine Digital Dermatitis (BDD) is a prevalent infectious disease, causing painful foot skin lesions and lameness in cattle. We describe herein the bovine foot skin microbiota and its associations with BDD using 16S rRNA gene amplicon and shotgun metagenomic sequencing on samples from 259 dairy cows from three UK dairy farms.

RESULTS

We show evidence of dysbiosis, and differences in taxonomy and functional profiles in the bovine foot skin microbiome of clinically healthy animals that subsequently develop BDD lesions, compared to those that do not. Our results suggest that taxonomical and functional differences together with alterations in ecological interactions between bacteria in the normal foot skin microbiome may predispose an animal to develop BDD lesions. Using genome-wide association and regional heritability mapping approaches, we provide first evidence for interactions between host genotype and certain members of the foot skin microbiota. We show the existence of significant genetic variation in the relative abundance of Treponema spp. and Peptoclostridium spp. and identify regions in the bovine genome that explain a significant proportion of this variation.

CONCLUSIONS

Collectively this work shows early changes in taxonomic and functional profiles of the bovine foot-skin microbiota in clinically healthy animals which are associated with subsequent development of BDD and could be relevant to prevention of disease. The description of host genetic control of members of the foot skin microbiota, combined with the association of the latter with BDD development offer new insights into a complex relationship that can be exploited in selective breeding programmes. Video Abstract.

Trade-offs between succulent and non-succulent epiphytes underlie variation in drought tolerance and avoidance

Epiphyte communities comprise important components of many forest ecosystems in terms of biomass and diversity, but little is known regarding trade-offs that underlie diversity and structure in these communities or the impact that microclimate has on epiphyte trait allocation. We measured 22 functional traits in vascular epiphyte communities across six sites that span a microclimatic gradient in a tropical montane cloud forest region in Costa Rica. We quantified traits that relate to carbon and nitrogen allocation, gas exchange, water storage, and drought tolerance. Functional diversity was high in all but the lowest elevation site where drought likely limits the success of certain species with particular trait combinations. For most traits, variation was explained by relationships with other traits, rather than differences in microclimate across sites. Although there were significant differences in microclimate, epiphyte abundance, and diversity, we found substantial overlap in multivariate trait space across five of the sites. We found significant correlations between functional traits, many of which related to water storage (leaf water content, leaf thickness, hydrenchymal thickness), drought tolerance (turgor loss point), and carbon allocation (specific leaf area, leaf dry matter content). This suite of trait correlations suggests that the epiphyte community has evolved functional strategies along with a drought avoidance versus drought tolerance continuum where leaf succulence emerged as a pivotal overall trait.

Adarza’s Ziva technology platform enables highly multiplexed label-free detection of serum analytes

New multiplex, label-free methods for the sensitive and quantitative detection of serum proteins are highly desirable, as they have the potential to dramatically accelerate biomedical research in the age of multi-omic, big data driven personalized medicine. We have used Arrayed Imaging Reflectometry (AIR™), a label-free protein microarray technology that relies on the target binding-induced perturbation of an antireflective coating on the surface of a silicon chip, to create a multiplex antibody array for the detection of human serum cytokines and inflammatory markers. The chip is able to provide quantitative information about protein concentrations, with limits of detection in picograms per mL. Provided in a standard 96-well microplate format, the label-free nature of the array will permit rapid expansion in plex size and enable simple, flexible creation of custom panels as there are no secondary antibodies or labels to cross-react. Here we demonstrate validation parameters of sensitivity, precision, and accuracy for inflammatory markers (>20) in a new multiplex technology suitable for analyzing trends across cytokine and inflammatory marker profiles comparable to traditional ELISAs. With array capabilities from low to hundreds of plex combined with a hands-free, automation-friendly workflow enabled by the Ziva instrument, the technology has been designed for the ultimate user-experience.

Women with bulimic eating disorders: When do they receive treatment for an eating problem?

Variables associated with the use of health services were examined in a prospective, community-based study of women with bulimic-type eating disorders who did (n = 33) or did not (n = 58) receive treatment for an eating problem during a 12-month follow-up period. Participants who received treatment for an eating problem differed from those who did not in several respects, including higher body weight, higher levels of eating disorder psychopathology, general psychological distress, and impairment in role functioning, deficits in specific aspects of coping style, greater awareness of an eating problem, and greater likelihood of prior treatment for a problem with weight. However, the variables most strongly associated with treatment seeking were greater perceived impairment in role functioning specifically associated with an eating problem and greater perceived inability to suppress emotional difficulties. These were the only variables that were significantly associated with treatment seeking in multivariable analysis. The findings suggest that individuals' recognition of the adverse effects of eating-disordered behavior on quality of life may need to be addressed in prevention and early intervention programs for eating disorders.

Better psychological health is associated with weight stability in women with eating disorders

AIM

To explore the associations between changes in weight, eating disorder psychopathology and psychological distress in a community sample of women with eating disorders over two years.

METHOD

One hundred and twenty two women identified with disordered eating in a baseline population survey agreed to participate in a follow-up study, of whom 87 (71%), mean age 28+/-6.2, completed the two-year follow-up. Body mass index, eating disorder psychopathology, psychological distress, and demographic details were assessed at both time points.

RESULTS

Over the two years there was a mean weight gain of 1.76 kg (SD=7.03), 11 (13%) women lost > or =5 kg, 25 (29%) gained > or =5 kg, and 49 (58%) remained weight stable (i.e., within 5 kg of baseline weight). Comparisons between those who had lost, gained and remained weight stable showed few significant differences, however, women who remained weight stable were the least psychologically distressed at baseline and those who lost weight had the greatest reduction in shape concern. Body mass index at baseline, and change in level of binge eating episodes were not associated with weight change.

CONCLUSIONS

Disordered eating behaviours have little influence on weight change over two years in community women with disordered eating. Low levels of psychological distress at baseline may promote weight stability. Concerns about shape are likely to increase with increased weight.

Disordered eating behaviours and cognitions in young women with obesity: relationship with psychological status

OBJECTIVE

To examine levels of eating disorder behaviours and cognitions of young women with obesity in the Australian Capital Territory, Australia and assess the impact upon psychological status.

DESIGN

General population cross-sectional survey.

SUBJECTS

A total of 4891 young women from the community aged 18-42 years, of which 630 were in the obese weight range.

MEASUREMENTS

Body mass index (BMI), eating disorder psychopathology (eating disorder examination questionnaire), and psychological distress (K-10).

RESULTS

Women with obesity had significantly higher levels of dietary restraint, eating concern, weight concern, shape concern, binge eating, misuse of diuretics, use of diet pills and fasting compared to other women in the community. These eating disorder cognitions and behaviours were associated with increased levels of psychological distress. In women with obesity, eating concern, weight concern, shape concern, dietary restraint and decreased age predicted psychological distress in a multivariate model. Among other women in the community, behaviours such as laxative misuse, 'hard' exercise and subjective bulimic episodes also contributed to the model predicting psychological distress.

CONCLUSION

As disordered eating psychopathology is high in young obese women and negatively impacts upon psychological status, obesity prevention and treatment should consider eating disorder psychopathology and mental health outcomes.

The Combination of Raltitrexed (Tomudex) and Mitomycin-C in the Treatment of Advanced Colorectal Cancer — A Phase II Study

AIMS

To investigate the combination of raltitrexed and mitomycin-C as first-line chemotherapy treatment in patients with advanced colorectal cancer.

MATERIALS AND METHODS

A phase II study.

RESULTS

In total, 22 patients were treated with a combination of raltitrexed 3 mg/m2 every 3 weeks and mitomycin-C 7 mg/m2 every 6 weeks for up to 24 weeks. The study was closed early for safety reasons as there were three unexpected treatment-related deaths. The overall response rate was 20%, and a further 40% achieved stable disease. The median time to progression was 3.9 months and the median overall survival time was 11.6 months.

CONCLUSION

Owing to the potential for increased toxicity, the combination of raltitrexed and mitomycin-C cannot be recommended as first-line treatment in patients with advanced colorectal cancer.

Pre-operative chemotherapy with epirubicin, cisplatin and 5FU/capecitabine in patients with operable oesophageal cancer

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Background: The MRC OE02 study demonstrated pre-operative chemotherapy in patients with potentially operable oesophageal cancer improved survival. Pre-operative chemotherapy has been widely adopted in the UK. At our institution for the past 5 years patients with operable oesophageal cancer have routinely been given pre-operative chemotherapy with 3 cycles of Epirubicin, Cisplatin and Protracted Venous Infusion (PVI) 5FU (ECF). Recently, PVI 5FU has been replaced by Capecitabine (ECX). Methods: From March 2000 to October 2005, patients with operable oesophageal carcinoma have received 3 cycles of ECF or ECX (Epirubicin 50mg/m2, Cisplatin 60mg/m2, and PVI 5FU 200mg/m2 per day or Capecitabine 625mg/m2 po bd for 21 days). Disease response was assessed by CT scan and surgery was performed 4–6 weeks after completion of chemotherapy. Results: 59 patients received neo-adjuvant chemotherapy (48 received ECF, 11 ECX). Median age was 64. Fifty-three patients (89.8%) completed the planned 3 cycles of chemotherapy. WHO grade 3 or 4 toxicity occurred in 7 patients (11.8%): 6 haematological with 1 toxic death among them (1.7%) and 1 mucositis. Forty-four of 49 patients (89.7%) with dysphagia reported improvement of their symptoms as a result of chemotherapy. Fifty-two patients (88.1%) proceeded to surgery of which 47 (90.3%) underwent complete tumour resection, 4 patients (7.7%) were found to have inoperable/metastatic disease and 1 patient had incomplete excision (1.9%). Median follow-up was 26.8 months with overall median survival of 36.2 months and a 2-year survival of 63.2%. Thirty-four (57.6%) patients remain alive to date of which, 30 are disease-free and 4 are alive with recurrent disease. Conclusions: These encouraging results demonstrate that 3 cycles of preoperative ECF/ECX chemotherapy in patients with operable oesophageal cancer allow surgery to be safely performed in the vast majority of patients and our 2-year survival compare favourably with previously reported series. These results suggest that 3 cycles of pre-operative treatment with ECF/ECX chemotherapy may improve survival in this group of patients and is worthy of further research.

No significant financial relationships to disclose.

Stevens-Johnson syndrome after treatment with rituximab

Rituximab is a chimeric mouse/human anti-CD20 antibody licensed for the treatment of low-grade non-Hodgkin's lymphoma and has recently also been shown to have a role in the treatment of diffuse large B-cell lymphoma. We report a case of Stevens-Johnson syndrome after treatment with rituximab, which occurred in a 36-year-old man with relapsed follicular lymphoma. The patient developed mucositis and fevers after the first two injections, followed by a florid maculopapular rash with severe orogenital ulceration after the third infusion. Over several weeks his symptoms progressed with severe cutaneous, orogenital and conjunctival ulceration, leading to visual problems and malnutrition. No improvement occurred with steroids and immunosuppressant therapy. A review of the literature reveals this to be the first reported case of Stevens-Johnson syndrome associated with rituximab therapy.

Behavioral phenomenology in Alzheimer's disease, frontotemporal dementia, and late-life depression: a retrospective analysis

Often patients in the early stages of Alzheimer's disease (AD), frontotemporal dementia (FTD), and late-life depression can be difficult to differentiate clinically. Although subtle cognitive distinctions exist between these disorders, noncognitive behavioral phenomenology may provide additional discriminating power. In 19 subjects with AD, 19 with FTD, 16 with late-life psychotic depression (LLPD), and 19 with late-life nonpsychotic depression (LLNPD), noncognitive behavioral symptoms were quantified retrospectively using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and compared using both a one-way ANOVA and a multivariate stepwise discriminant analysis, which utilized a jackknife procedure. The FTD group showed the highest mean total SCAN score, while the AD group showed the lowest. ANOVA showed significant differences in the mean total SCAN scores between the four diagnostic groups (P < .0001). With the discriminant analysis, the four disorders demonstrated different clusters of behavioral abnormalities and were differentiated by these symptoms (P < .0001). A subset of 14 SCAN item group symptoms was identified that collectively classified the following percentages of subjects in each diagnostic category: AD 94.7%, FTD 100%, LLPD 87.5%, and LLNPD 100%. These results indicate that AD, FTD, LLPD, and LLNPD were distinguished retrospectively by the SCAN without using cognitive data. Better definition of the longitudinal course of noncognitive behavioral symptoms in different dementias and psychiatric disorders will be valuable both for diagnosis and to help define behavioral syndromes that are associated with selective neuroanatomic and neurochemical brain pathology.

A study of the Lund-Manchester research criteria for frontotemporal dementia: clinical and single-photon emission CT correlations

We evaluated the Lund-Manchester research criteria (LMRC) for frontotemporal dementia (FTD). With single-photon emission CT, we diagnosed 30 patients with FTD. These patients were compared with 30 with a research diagnosis of Alzheimer's disease (AD). We scored every patient on each LMRC item and compared the two groups. A discriminant function showed that loss of personal awareness, hyperorality, stereotyped and perseverative behavior, progressive reduction of speech, and preserved spatial orientation differentiated 100% of FTD and AD subjects. Items relating to affect and physical findings were not different in FTD versus AD. Loss of personal awareness, eating, perseverative behavior, and reduction of speech are the LMRC items that most clearly differentiate FTD from AD.

Aggressive, socially disruptive and antisocial behaviour associated with fronto-temporal dementia

BACKGROUND

Research suggests an association between frontal and temporal injury and antisocial conduct. We studied the frequency of antisocial behaviours in fronto-temporal dementia (FTD) where pathology is anterior frontal-temporal, compared with Alzheimer's disease (AD) where pathology is primarily posterior temporal-parietal.

METHOD

The presence of antisocial conduct was compared in 22 FTD versus 22 AD subjects. All FTD patients had anterior frontal or temporal hypoperfusion with single photon emission computed tomography, whereas those with AD had posterior temporal-parietal hypoperfusion.

RESULTS

Ten FTD and one AD subject showed antisocial behaviours, which included assault, indecent exposure, shoplifting and hit-and-run driving. Three FTD subjects were arrested. This difference was highly significant (P = 0.004).

CONCLUSIONS

Degeneration of frontal and temporal lobes predisposes to antisocial behaviour. This study supports a relationship between frontal-temporal dysfunction and certain types of antisocial activities.

SPECT in dementia: clinical and pathological correlation

BACKGROUND

The clinical diagnosis of dementia continues to be flawed. Although the diagnosis of Alzheimer's disease (AD) is better than 90% at research centers in highly selected patients, the diagnosis of patients with non-AD dementias and atypical AD patients is poor. Single photon emission computed tomography (SPECT) is a functional imaging technique touted as a diagnostic technique for the degenerative disorders. However there have been few clinicopathological studies using SPECT.

METHODS

Twenty-seven consecutive dementia patients were evaluated clinically at a University-based specialty dementia clinic, and a diagnosis of a specific dementia was made. SPECT imaging was used in helping to select a clinical diagnosis. The correlations between clinical, SPECT and autopsy diagnoses were analyzed.

RESULTS

Single photon emission computed tomography predicted pathologic diagnosis in 25 of 27 patients with dementia (92.6%), compared with clinical diagnosis, which was confirmed in 20/27 (74.1%). Distinct patterns were associated with dementia caused by AD, Fronto-Temporal Dementia (FTD), and Jakob-Creutzfeldt Disease (JCD). Vascular insults not seen with computerized tomography (CT) or magnetic resonance imaging (MRI) were found with SPECT. Three different pathologies were found in patients with Parkinsonian-Dementias (PD): Lewy-Body Variant of AD, Diffuse Lewy-bodies without plaques, and substantia nigra neuronal loss without plaques or Lewy-bodies. All showed a temporal-parietal pattern with SPECT that was similar to AD.

CONCLUSION

SPECT provides useful positive information in dementia, particularly the differentiation of AD, FTD, and JCD. However, it does not distinguish PD from AD.

Long-term effects of the menopause and sex hormones on skin thickness

Skin collagen content and skin thickness in a group of postmenopausal women who had been treated with sex hormone implants were compared with those in an untreated group of similar women. Both skin collagen content and thickness were found to be significantly greater in the treated than in the untreated group. In the untreated women skin collagen content declined in relation to menopausal age but not to chronological age. No correlation was found with menopausal age, chronological age or duration of therapy in the treated group. These data suggest that skin collagen is influenced by the sex hormone status and declines after the menopause, contributing to the increase in urinary hydroxyproline excretion that has been reported to occur at this time.

Insulin reversal of diabetes-induced inhibition of vascular contractility in the rat

Contractures induced by 10(-9)-10(-4) M phenylephrine (PE) or 10-70 mM KCl were observed in aortas isolated from untreated and insulin-treated streptozotocin-diabetic rats. The experiments were conducted at 2-wk intervals for a 12-wk period after the induction of diabetes. Diabetes caused an average decrease of 58 and 60% in the K and PE contractures, respectively. Although the PE contractures in aortas from the insulin-treated diabetic animals (81%) were significantly greater than those in aortas from the untreated diabetic animals (60%), they were significantly less than those in control tissues (100%). Insulin treatment completely reversed the diabetes-induced decrease in the K contracture (102%). It appears that the diabetes-induced decreases in tension may result from an altered sensitivity of the tissues to KCl but not PE. Histological examination of the tissues revealed that the diminished contractions were not due to any detectable change in mural structure. The data indicate that diabetes-induced inhibition of the mechanisms involved in mediating the K contracture are completely reversible by insulin treatment, whereas those mediating the PE contracture are only partially reversible.

Contractile and relaxing activity of arterial smooth muscle from streptozotocin-diabetic rats

Contractures induced by 10(-4)M phenylephrine (PE) and 70 mM KCl and their relaxation by 10(-2) M theophylline (theo) were observed in aortae isolated from untreated and insulin-treated streptozotocin-diabetic rats for 12 weeks after the induction of diabetes. Diabetes consistently caused an average decrease of 40% in the PE and K-contractures. Treatment of diabetic animals with 2.0-3.5 units (U) of Neutral Protamine Hagedorn (NPH) insulin/day/partially prevented diabetes-induced decreases in the PE contractures while completely preventing them in the K-contractures. Relaxation of the PE-contracture, which was more susceptible to theo than was the K-contracture in control tissues, was not affected by either untreated or insulin-treated diabetes until 12 weeks after the induction of diabetes. While in vivo insulin treatment did not reverse diabetes-induced decreases in the theo-induced relaxation of the PE contracture, it did prevent the diabetes-induced increase in the relaxation of the K-contracture which was observed after 4 weeks. The results indicate that while the mechanisms involved in mediating the PE and K-contractures are inhibited by diabetes, insulin is more effective at preventing the effects of diabetes on the K-contracture and its relaxation than on the induction and relaxation of the PE-contracture.

Primary neuropathic amyloidosis in three brothers

Neuropathic primary amyloidosis has not been previously described in an English family. We present the clinical and pathological findings in three brothers with this condition and suggest that they have suffered from that form of the disease described originally by Andrade.

Tumoral calcinosis in England

Two cases of tumoral calcinosis are presented in patients living in England. The clinical and pathological features are described and attention is drawn to the need to consider exotic diseases in patients who have originated from or lived in the tropics.The cause of tumoral calcinosis is not known. It may be a metabolic disease of obscure aetiology but local trauma often appears to be a factor in its development.