Adherence to Choosing Wisely Campaign Guidelines at Three Health Systems

Introduction/Objective

With rising healthcare costs in the United States, there has been a push for lab stewardship to improve the quality of patient care while reducing costs. To optimize the use of clinical laboratory testing, the ASCP working with other medical specialty organizations, developed the Choosing Wisely Campaign to promulgate evidence-based guidelines to optimize clinical laboratory testing.

Methods/Case Report

We examined adherence to three Choosing Wisely guidelines over a four-year period (2017- 2020), through queries of internal cost accounting databases to return aggregate volumes as well as variable and total costs at three large academic health systems. We measured concurrent orders for: 1) erythrocyte sedimentation rate (ESR) with C-reactive protein (CRP), 2) serum/plasma amylase with lipase, and 3) free thyroxine (FT4) and/or total triiodothyronine (TT3) with thyroid stimulating hormone (TSH) when the TSH is within the reference range (using an frequency estimate of 85% based on other studies). We also examined another guideline for concurrent orders for serum aldolase with creatine kinase (CK). We also quantified aggregate variable costs for the non-recommended test in each Choosing Wisely guideline (amylase, ESR, FT4 and/or TT3), and for serum aldolase when ordered with CK.

Results (if a Case Study enter NA)

Over the four-year period, there were 322,853 unnecessary tests based on these four guidelines (120,587 ESR and CRP, 30,444 amylase and lipase, 164,818 FT4 and/or TT3 with TSH, and 7,004 aldolase). Overall, unnecessary testing decreased between 2017 and 2020 for amylase with lipase, remained essentially unchanged for aldolase, and increased for the other two test guideline scenarios. The largest changes were concurrent orders for amylase and lipase at one health system (38% decrease), and orders for TT3 with a normal TSH result at another health system (324% increase). The four-year variable cost of these unnecessary tests was $1,215,309 ($303,827 mean annual cost), resulting in potential annual variable cost savings of $101,276 for each health system for the four guidelines we examined. Variable costs for unnecessary testing increased by 16.5% ($45,571) over the four-year period.

Conclusion

Guideline-based unnecessary testing remains as a target to improve laboratory diagnostic testing. There is potential to realize significant achievable cost savings if guidelines are implemented and maintained.

Hospitalization and mortality in heart failure with preserved ejection fraction: real-world data from a US integrated healthcare delivery system

Introduction

Heart Failure with preserved ejection fraction (HFpEF) is a major public health and economic burden, but large real-world incident rates of clinical outcomes are scarce.

Purpose

Calculate adjusted incidence rates of hospitalization and mortality in patients with HFpEF compared with heart failure with reduced ejection fraction (HFrEF) using an integrated healthcare delivery System in the United States.

Methods

Non-interventional longitudinal cohort analysis between 2005 and 2017 of existing data of adult patients with a HF diagnosis (ICD9/ICD10) in the electronic medical record of Kaiser Permanent Northwest. Clinical outcomes of interest were all-cause hospitalizations, heart failure hospitalization (HHF, defined as a discharge diagnosis of HF in the primary position) and all-cause mortality. Age/sex adjusted incidence rates were assessed generalized estimating equations over 15 years of follow-up (2005–2019).

Results

Of the 37,773 patients with HF diagnosis, 36% had no EF available. 46.4% were categorized as HFpEF, 7.2% HFmrEF and 10.4% HFrEF. Compared with patients with HFrEF, those with HFpEF were older (72.1 vs. 68.3 years), more likely to be female (55% vs. 33.2%), had higher BMI (31.9 vs. 29.3 kg/m2), higher SBP (130 vs. 121mmHg) and were less likely to have a history of myocardial infarction (26.1% vs. 43.8%). Patients with HFpEF were less likely to receive RAAS blockade compared with HFrEF (66.0% vs. 86.7%) but use of any HF-related medication (ACE/ARB, diuretics, β-blockers, or aldosterone agonists) was similarly high (89.6% vs 88.8%). As shown in Figure 1, adjusted mortality rates per 1,000 person-years, [95% CI] were lower in HFpEF (107.9 [105.5, 110.3]) vs. HFrEF (143.0 [136.5, 149.7]). Also, HHF were lower in HFpEF (41.6 [40.1, 43.2]) compared to HFrEF (72.6 [67.7, 77.9]). All-cause hospitalization rates were about 12% lower in HFpEF (197.3 [193.9, 200.7]) compared with HFrEF (222.8 [214.1, 231.7]). Nonetheless, due to the much larger size of the HFpEF group, these patients generated 1,982 more HHF, 10,427 more hospitalizations for any reason, and 6,723 more deaths during follow-up.

Conclusions

In a large real-world dataset of HF patients, incidence rates for hospitalization and mortality were relatively lower in HFpEF vs. HFrEF. However, given the greater prevalence of HFpEF (46.4% vs. 10.4% for HFrEF), this diagnosis posed a much higher public health burden.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim

Exploring Campylobacter seasonality across Europe using The European Surveillance System (TESSy), 2008 to 2016

BackgroundCampylobacteriosis is the most commonly reported food-borne infection in the European Union, with an annual number of cases estimated at around 9 million. In many countries, campylobacteriosis has a striking seasonal peak during early/mid-summer. In the early 2000s, several publications reported on campylobacteriosis seasonality across Europe and associations with temperature and precipitation. Subsequently, many European countries have introduced new measures against this food-borne disease.AimTo examine how the seasonality of campylobacteriosis varied across Europe from 2008-16, to explore associations with temperature and precipitation, and to compare these results with previous studies. We also sought to assess the utility of the European Surveillance System TESSy for cross-European seasonal analysis of campylobacteriosis.MethodsWard's Minimum Variance Clustering was used to group countries with similar seasonal patterns of campylobacteriosis. A two-stage multivariate meta-analysis methodology was used to explore associations with temperature and precipitation.ResultsNordic countries had a pronounced seasonal campylobacteriosis peak in mid- to late summer (weeks 29-32), while most other European countries had a less pronounced peak earlier in the year. The United Kingdom, Ireland, Hungary and Slovakia had a slightly earlier peak (week 24). Campylobacteriosis cases were positively associated with temperature and, to a lesser degree, precipitation.ConclusionAcross Europe, the strength and timing of campylobacteriosis peaks have remained similar to those observed previously. In addition, TESSy is a useful resource for cross-European seasonal analysis of infectious diseases such as campylobacteriosis, but its utility depends upon each country's reporting infrastructure.

Waterborne outbreaks in the Nordic countries, 1998 to 2012

A total of 175 waterborne outbreaks affecting 85,995 individuals were notified to the national outbreak surveillance systems in Denmark, Finland and Norway from 1998 to 2012, and in Sweden from 1998 to 2011. Between 4 and 18 outbreaks were reported each year during this period. Outbreaks occurred throughout the countries in all seasons, but were most common (n = 75/169, 44%) between June and August. Viruses belonging to the Caliciviridae family and Campylobacter were the pathogens most frequently involved, comprising n = 51 (41%) and n = 36 (29%) of all 123 outbreaks with known aetiology respectively. Although only a few outbreaks were caused by parasites (Giardia and/or Cryptosporidium), they accounted for the largest outbreaks reported during the study period, affecting up to 53,000 persons. Most outbreaks, 124 (76%) of those with a known water source (n = 163) were linked to groundwater. A large proportion of the outbreaks (n = 130/170, 76%) affected a small number of people (less than 100 per outbreak) and were linked to single-household water supplies. However, in 11 (6%) of the outbreaks, more than 1,000 people became ill. Although outbreaks of this size are rare, they highlight the need for increased awareness, particularly of parasites, correct water treatment regimens, and vigilant management and maintenance of the water supply and distribution systems.

Dolutegravir: clinical and laboratory safety in integrase inhibitor-naive patients

BACKGROUND

The efficacy of dolutegravir (DTG) has been demonstrated in 5 randomized studies in integrase inhibitor (INI)-naive adult populations. To date, a detailed safety review of DTG has not been provided in the literature.

OBJECTIVE

To describe the safety and tolerability profile of DTG in adults based on 5 randomized, controlled trials and comparison with drugs in 3 major antiretroviral (ARV) classes.

METHODS

Safety data from phase IIb/III/IIIb trials in ART-naive and ART-experienced, INI-naive adults were integrated.

RESULTS

In 4 ART-naive (SPRING-1, SPRING-2, SINGLE, FLAMINGO) and 1 ART-experienced, INI-naive study (SAILING), 1,579 individuals received a DTG-containing regimen. The proportion of individuals from DTG treatment arms who withdrew due to adverse events (AEs) was low (≤2%) compared to raltegravir (RAL; 2% SPRING-2, 4% SAILING), efavirenz (EFV)-containing comparator arm (10% SINGLE), and darunavir + ritonavir (DRV/r; 4% FLAMINGO). The most frequently observed AEs (diarrhea, nausea, headache), typically grade 1 or 2 in severity, did not lead to study discontinuation. Psychiatric and nervous system disorders with DTG were comparable to RAL- and DRV/r-containing regimens and favorable to EFV-containing regimens. In hepatitis B and/or C coinfected ART-naive individuals, the incidence of transaminase elevations was lower with DTG versus RAL and EFV comparators, but was similar to DRV/r. In SAILING, transaminase elevations were more commonly observed with DTG, particularly in the setting of inadequate hepatitis B therapy or immune reconstitution. On DTG treatment, mild creatinine elevations occurred and stabilized early. Few cases of hypersensitivity reaction and/or severe rash were seen. Rates of these events were comparable to or lower than with RAL-, EFV-, and DRV/r-containing regimens.

CONCLUSIONS

The safety profile for DTG 50 mg once daily in INI-naive individuals was comparable to RAL- and DRV/r-containing regimens and generally favorable compared with EFV-containing regimens.

Precision measurement of the growth rate and mechanism of ibuprofen {001} and {011} as a function of crystallization environment

The growth rates of the {001} and {011} crystal faces of ibuprofen were measured as a function of the solution crystallisation environment from which the likely interfacial kinetic growth mechanisms were characterised.

Simultaneous increase of Cryptosporidium infections in the Netherlands, the United Kingdom and Germany in late summer season, 2012

Binary file ES_Abstracts_Final_ECDC.txt matches

Simultaneous increase of Cryptosporidium infections in the Netherlands, the United Kingdom and Germany in late summer season, 2012

Starting August 2012, an increase in Cryptosporidium infections was reported in the Netherlands, the United Kingdom and Germany. It represented a 1.8 to 4.9-fold increase compared to previous years. Most samples were C. hominis IbA10G2. A case–control study was performed in the Netherlands but did not identify an endemic source. A case–case study in the north of England found travel abroad to be the most common risk factor.

SU-E-T-588: A Treatment Planning Comparison of Dual-Arc VMAT Vs. Helical Tomotherapy for Post-Mastectomy Radiotherapy

PURPOSE

To investigate the feasibility of volumetric modulated arc therapy (VMAT) for post-mastectomy radiotherapy (PMRT) and to compare dual- arc VMAT treatment plans to helical tomotherapy (HT) plans on the basis of dosimetric quality, radiobiological calculations and delivery efficiency.

METHODS

Dual-arc VMAT and HT treatment plans were created for fifteen patients previously treated at our clinic. Planning target volumes (PTV) included the chest wall (CW) and regional lymph nodes. The following metrics were used to compare treatment plans for each patient: dose homogeneity index (DHI) and conformity index (CI); coverage of the PTV; dose to organs at risk (OAR); tumor control probability (TCP), normal tissue complication probability (NTCP) and secondary cancer complication probability (SCCP); and treatment delivery time. Differences between treatment plans were tested for significance using the paired Student's t-test.

RESULTS

Both modalities produced clinically acceptable PMRT plans. VMAT plans showed better CI (p < 0.01), and better OAR sparing at low doses than HT plans. For example, VMAT plans showed a 26% (p < 0.01) and 9% (p < 0.01) decrease in V5Gy in the lungs and heart respectively. On the other hand, HT plans showed better DHI (p < 0.01) and PTV coverage (p < 0.01). HT plans also showed slightly better OAR sparing at higher doses, including 8% (p < 0.01) and 9% (p < 0.01) lower maximum doses to the lungs and heart, respectively. Both modalities achieved nearly 100% tumor control and approximately 1% NTCP in the lungs and heart, with VMAT showing lower SCCP (p < 0.01). VMAT plans also required 66.2% less time to deliver.

CONCLUSIONS

Both VMAT and HT are suitable treatment options for PMRT. Our study showed that VMAT"'in addition to being significantly faster'"achieved better CI and low dose OAR sparing while HT achieved better DHI. This work was supported in part by a research support from Elekta, Ltd. However, Elekta, Ltd., did not participate in the study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; or in the decision to submit.

COLLAGENOLYTIC ACTIVITY IN RAT BONE CELLS : Characteristics and Intracellular Location

An assay system for estimating quantitatively collagenase-like activity present in bone cells has been developed as part of a more general investigation of mechanisms of bone resorption. Methods are described for preparing from bone a C(14)-labeled collagen which is relatively pure and highly resistant to degradation by trypsin although readily broken down by bacterial collagenase. Collagenolytic activity in homogenates of bone cells harvested from rat metaphyseal bone was measured as the number of counts per minute released in ultrafiltrable form from the C(14)-labeled collagen substrate after 40 minutes' incubation at 37 degrees C and pH 7.3. Using these techniques, the presence of collagenase-like activity in whole bone cell homogenates was confirmed and the heat lability, partial cation dependence, pH optimum, and some other characteristics of the crude material were determined. Moreover, the major portion of the homogenate activity was found in a particulate fraction sedimenting in a centrifugal field between 700 and 15,000 g. The marked enhancement and solubilization of this activity by surface-active agents or freeze-thawing, together with the presence of considerable acid phosphatase activity in the same fraction and its sedimentation characteristics, suggested that it might be contained in lysosomes or similar bodies. The implications of these observations with respect to the physiology of collagen resorption in general and bone resorption in particular are discussed.

The decision making process on public health measures related to passenger ships: the example of influenza pandemic 2009

BACKGROUND

Public health measures at sea ports have posed a challenge for public health competent authorities, especially in the context of the influenza pandemic of 2009. This paper discusses the response of authorities to notifications of infectious diseases on passenger ships and the importance of assessing the risks related to cases of influenza. It further provides options for health measures and considerations for decision making during a pandemic such as the influenza pandemic of 2009.

DISCUSSION

Prevention and control of influenza have included action taken by both competent port authorities and ships' crews. Assessing the public health risk of each event reported from ships to competent authorities at ports is important before advice is given on implementation of control measures. Public health risk assessment involves appraisal of threats to passengers and crew on board the ship as well as to the population in the community.

SUMMARY

Any public health measures taken should be necessary and proportional to the threat. Measures at ports cannot alone be effective in the prevention of the spread of a disease to the community since other means of transport play a major role. Measures taken on board ships can be effective in containing the disease. Consistent policy based on common protocols and carried out by competent authorities at local, national, European, or international levels are essential.

Preparedness for the prevention and control of influenza outbreaks on passenger ships in the EU: the SHIPSAN TRAINET project communication

Passenger ships carry a large number of people in confined spaces. A case of the new influenza A (H1N1) virus aboard a passenger ship is an expected event and would lead to rapid spread of the virus, if preventive measures are not in place. However, many cruise lines have detailed policies and procedures to deal with cases of influenza like illness (ILI). The EU SHIPSAN and SHIPSAN TRAINET projects include in their objectives guidelines for the prevention and control of communicable diseases aboard passenger ships. A literature review showed that from 1997 to 2005, nine confirmed outbreaks of influenza were linked to passenger ships, with attack rates up to 37%. It is important to establish and maintain a surveillance system for ILI aboard passenger ships, in order to systematically collect data that can help to determine the baseline illness levels. Monitoring these will enable early identification of outbreaks and allow timely implementation of control measures.

The microbiological quality of potable water on board ships docking in the UK and the Channel Islands: an association of Port Health Authorities and Health Protection Agency Study

Providing safe potable water onboard vessels presents particular challenges and contamination can occur directly from source waters as well as during loading, storage and distribution. Between May and October 2005, 950 potable water samples were collected from 342 ships docking at ports. Comparison with Guidelines found 9% of samples contained coliforms, Escherichia coli or enterococci and 2.8% had faecal indicators (E. coli or enterococci). Action levels of aerobic colony count (ACC) bacteria were detected in 20% (22 degrees C) and 21.5% (37 degrees C) of samples. ACC results from one-off sampling are not informative as this does not enable port health authorities to monitor ACC trends. They should be removed as a routine criterion for remedial action and vessels should adopt the WHO Water Safety Plan approach, whilst continuing to monitor water quality with public health-based indicators (e.g. chlorine residual, coliforms, E. coli and enterococci). Logistic regression analyses identified practices associated with water quality. Practices protective against coliforms, E. coli or enterococci in potable supplies were: good hose hygiene, processing water onboard, maintaining free chlorine residual at >or=0.2 mg/L. This emphasizes the importance of good hygiene during potable water loading and maintaining adequate disinfection of supplies onboard.

A phase I study of MGCD0103 given as a twice weekly oral dose in patients with advanced leukemias or myelodysplastic syndromes (MDS)

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Background: Small molecule inhibitors of histone deacetylase (HDAC) have emerged as novel anticancer agents. MGCD0103 is an oral isotype selective small molecule inhibitor of HDAC. Methods: Eligible patients had relapsed/refractory (RR) AML or MDS (or newly diagnosed disease in patients >60 yrs, ineligible for induction chemotherapy); RR ALL; RR CML. MGCD0103 was administered 2x/weekly for 3 weeks, with no recovery period between cycles. Patients with stable disease or better were eligible to continue therapy indefinitely. Results: Patients have been treated at 4 dose levels: 40, 53, 66 and 83 mg/m2/day, including 19 enrolled patients with the following demographics: M:F = 15:4, median age (range) = 75 (52–83), ECOG 0:1:2 = 5:12:2, diagnosis of RR MDS= 7, RR AML or RR ALL=8: untreated AML or MDS = 4. Cytogenetics (n=12): Diploid = 3, Complex = 4, Del 7 = 3, Del 12 = 1, Del Y = 1. Nineteen patients are evaluable for safety. A total of 38 cycles have been administered with a median of 2 per patient (range, 1–6); 13 patients have completed =2 cycles. One patient experienced grade 3 fatigue at 53 mg/m2 and 2 patients had grade 3 weakness/fatigue at 83 mg/m2 (exceeded the Maximum Tolerated Dose [MTD]) Non-dose-limiting toxicities included lower grade fatigue, diarrhea, and nausea. Plasma PK in 14 patients revealed t 1/2 of 7–12 hr, tmax 0.6- 1 hr, and a dose proportional average Cmax of 155 ng/mL at 40 mg/m2 and 225 ng/mL at 53 mg/m2. Significant inhibition of whole cell total HDAC activity within PBMC was observed in a majority of patients, at all dosing levels. Four patients have experienced stable disease. Conclusions: MGCD0103 has been well-tolerated in patients with advanced leukemias or MDS. MTD has been reached, and the recommended phase II 2x/week dose is being confirmed. At all dose levels, significant HDAC inhibition was observed.

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Randomized trial of low-dose interleukin-2 vs cyclosporine A and interferon-γ after high-dose chemotherapy with peripheral blood progenitor support in women with high-risk primary breast cancer

High-risk primary breast cancer patients treated with high-dose chemotherapy (HDC) and stem cell support (SCS) have shown prolonged disease-free survival (DFS) in many studies; however, only one trial has demonstrated an overall survival benefit (OS). We hypothesize that the period following myeloablative therapy is ideal for immunologic manipulation and studied the effects of two different methods of immunotherapy following HDC with SCS aimed at the window of immune reconstitution. Seventy-two women with high-risk stage II or III breast cancer were randomized following HDC to receive either interleukin 2 (IL-2) at 1 million units/m(2) SQ daily for 28 days or combined cyclosporine A (CsA) at 1.25 mg/kg intravenously daily from day 0 to +28 and interferon gamma (IFN-gamma) 0.025 mg/m(2) SQ every 2 days from day +7 to +28. At a median follow-up of 67 months, no significant difference was observed in DFS or OS between the two treatment groups. The IL-2 arm had a 59% DFS (95% CI (0.45, 0.78)) and a 72% OS (95% CI (0.58, 0.88)) at 5 years. The CsA/INF-gamma arm had a similar outcome with a 55% DFS (95% CI (0.40, 0.76)) and a 78% OS (95% CI (0.65, 0.94)) at 5 years. Treatment was well tolerated, without increased toxicity.

Cryptosporidiosis surveillance and water-borne outbreaks in Europe

Cryptosporidium causes diarrhoeal disease that can be particularly severe in immuno-compromised individuals. Cryptosporidiosis is a notifiable disease at European Union level, and surveillance data are collected through the European Basic Surveillance Network. The disease distribution in Europe for 2005 showed 7,960 cryptosporidiosis cases reported from 16 countries. The crude incidence rate was 1.9 cases per 100,000, although there were considerable differences in the rates of cryptosporidiosis between countries. Infection was more commonly reported in young children. A pronounced seasonal peak was observed in the autumn of 2005, with 59% of the cases reported between August and November, although Ireland and Spain experienced a peak in spring and summer, respectively. Cryptosporidiosis outbreak investigations and analytic studies have associated the disease with drinking water supplies, animal contact, travel, and swimming pools. Contamination of the source water for drinking water supplies, as well as inadequate water treatment can be responsible for cryptosporidiosis outbreaks. Routine cryptosporidiosis surveillance from North West England over 17 years showed that the cases occurred predominantly in spring and autumn. British drinking water regulations and improvements in drinking water treatment have coincided with a decline in cryptosporidiosis incidence. Improvements in cryptosporidiosis surveillance such as detection, recording and reporting will help to recognise outbreaks and monitor interventions.

The spectrum of myelodysplastic syndromes post-solid organ transplantation: A single institutional experience

An increased incidence of acute myeloid leukemia (AML) has recently been documented in patients post-solid organ transplantation but the incidence and types of myelodysplastic syndromes (MDS) occurring in this patient population are not known. We identified 5 patients (3M, 2F, age 48-64 years) who developed MDS ranging from 1.8 to 25 years (median 4.2 years) post-solid organ transplantation, only 2 patients had received azathioprine. The cumulative incidence of MDS in heart and lung transplant recipients at 15 years was 0.5% and 1.8%, respectively, which is markedly higher compared to the general population. Low-risk types of MDS predominated, 3 of 5 patients are alive (median 3.9 years) since diagnosis. Deletions of chromosome 20q, which have not been previously reported in post-transplant MDS/AML, were identified in 3 cases. Our findings expand the morphologic and cytogenetic spectrum of MDS occurring post-solid organ transplantation and suggest that mechanisms beside azathioprine toxicity might be important in disease pathogenesis.

Mechanisms of Resistance to Imatinib in CML Patients: A Paradigm for the Advantages and Pitfalls of Molecularly Targeted Therapy

One of the challenges of cancer therapeutics is to discover targets unique to the tumor cell population. Constitutively activated tyrosine kinases play a role in the malignant phenotype in a number of different cancers. While the kinases may be present in the normal cell, the cancer cell is often dependent upon the activation of the kinase for the maintenance of malignant growth. Inhibition of kinase activation may therefore selectively inhibit malignant proliferation. In the case of chronic myelogenous leukemia (CML), the activated tyrosine kinase (BCR-ABL) is due to a chromosomal translocation that defines this disease, and is necessary for malignant transformation. Imatinib mesylate (Gleevec, Novartis) is a small molecule tyrosine kinase inhibitor, developed through the chemical modification to be selected for a small number of tyrosine kinases present in human cells. This agent is also orally bioavailable and has been found to be effective in clinical trials. We have learned much through the clinical use of this agent. 1) Specific targeting of activated signal transduction pathways may be effective in inhibiting cancer cells. 2) Cancer cells may not only be inherently resistant to small molecule inhibitors, but may also develop resistance after exposure to the inhibitor. 3) Increased knowledge regarding critical signal transduction pathways, the structure of the molecules that are being targeted and the inhibitors themselves, will allow us to understand resistance as it develops and create new molecules to bypass resistance. We will discuss imatinib as an important example of the success and pitfalls of targeted therapeutics for cancer.

Reducing the risks of transmitting gastrointestinal infections in home paddling pools

The human health risks posed by natural and man-made water environments through contamination with either human or animal faeces was recently been highlighted in an editorial

Genetic analysis of Cryptosporidium from 2414 humans with diarrhoea in England between 1985 and 2000

The characterization of Cryptosporidium using DNA extracted from whole faecal samples collected from 2414 humans with diarrhoea in England between 1985 and 2000 where cryptosporidial oocysts were detected using conventional methods is described. Characterization was achieved by PCR/RFLP and DNA sequencing of fragments of the Cryptosporidium oocyst wall protein and the 18S rDNA genes. Cryptosporidium parvum was detected in 56.1 % of cases, Cryptosporidium hominis in 41.7 % and a mixture of C. parvum and C. hominis in 0.9 %. In the remainder of cases, Cryptosporidium meleagridis (0.9 %), Cryptosporidium felis (0.2 %), Cryptosporidium andersoni (0.1 %), Cryptosporidium canis (0.04 %), Cryptosporidium suis (0.04 %) and the Cryptosporidium cervine type (0.04 %) were detected.

Outbreaks of waterborne infectious intestinal disease in England and Wales, 1992-2003

We reviewed the epidemiological and microbiological characteristics of 89 reported outbreaks of waterborne infectious intestinal disease affecting 4321 people in England and Wales over the period 1992-2003. Public water supplies were implicated in 24 outbreaks (27%), private water supplies in 25 (28%), swimming pools in 35 (39%) and other sources in five outbreaks (6%). Cryptosporidium was implicated in 69% of outbreaks, Campylobacter sp. in 14%, Giardia in 2%, E. coli O157 in 3% and Astrovirus in 1%. From 2000, there was a consistent decline in the number of outbreaks of waterborne disease associated with public water supplies. The incidence rate of outbreaks in recipients of private water supplies may be as high as 35 times the rate in those receiving public water supplies (1830 vs. 53 per million population). Private water suppliers need to be aware of the importance of adequate treatment and the prevention of faecal contamination of storage water. Swimming-pool operators need to ensure chlorination and in particular adequate filtration measures are in place.

Infection risks from water in natural and man-made environments

People can catch diarrhoeal diseases from contamination of both natural and man-made environments with human or animal faeces. Young children are more likely to be susceptible to the agents and to be exposed. While some diarrhoeal diseases acquired in childhood can be relatively mild and give some protection as an adult, others are more severe. The two papers presented in this issue of Eurosurveillance describe, on the face of it, unremarkable small outbreaks; one, from Chikwe Ihekweazu et al, linked to exposure to a stream contaminated with Escherichia coli from animal faeces [1]; the other, from Melanie Jones et al, to exposure to a water feature contaminated with Cryptosporidium parvum from either animal or human faeces [2].

Cryptosporidium outbreak linked to interactive water feature, UK: importance of guidelines

A need for national guidelines relating to interactive water features was highlighted following three outbreaks of cryptosporidiosis in the United Kingdom, all of which were related to public water features. In August 2003 the Health Protection Agency South West of England was notified of an outbreak of cryptosporidiosis associated with an interactive water feature designed for water play within an adventure park. The water feature was implicated following samples with a high coliform count and the presence of faecal coliforms. A case was defined as any child (younger than 16 years of age) who had visited the park during August and who subsequently had gastrointestinal symptoms and a faecal sample positive for cryptosporidium. Seventy one children were identified in the cohort. This outbreak of cryptosporidiosis was characterised by a very high attack rate (89%), relatively severe in duration (median 8 days) and had a relatively high hospital admission (16% of cases). The epidemic curve was consistent with a point source of infection, which corresponded to the date 80% of the cohort visited the park. This outbreak has similarities to two other cryptosporidiosis outbreaks reported in England in 2003 that involved public water features. These outbreaks raise issues about the operation and maintenance of water-based recreational attractions that very often involve children. The paper reflects on the basic control measures that can be taken and highlights the need for guidelines, especially since such attractions are becoming increasingly common. The Pool Water Treatment Advisory Group in United Kingdom has now produced guidelines.

Culture of Helicobacter pylori from domestic water samples--the impact of strain variation on growth on solid and in liquid media

Helicobacter pylori is an important global human pathogen and there is growing evidence from PCR assays that contaminated drinking water might be a possible source of infection in some circumstances. There are no validated protocols for direct isolation but various culture media have been developed for possible environmental sampling. Our aim here was to investigate how inter-strain variation might affect the interpretation of results with such media. Two laboratory adapted reference strains and four recent clinical isolates were tested on four solid media and in ten liquid media. Considerable variation was found between strains in their ability to recover on the different media after stress exposure (suspension in sterile tap water). Generally, clinical isolates were less robust than the laboratory-adapted strains and, overall, the former required longer recovery times. Our findings highlighted the importance of using a range of isolates for evaluations, as examination of laboratory-adapted strains alone did not provide an accurate representation of the utility of media that may be used to recover H. pylori from water.

Cryptosporidium outbreak linked to interactive water feature, UK: importance of guidelines

A need for national guidelines relating to interactive water features was highlighted following three outbreaks of cryptosporidiosis in the United Kingdom, all of which were related to public water features. In August 2003 the Health Protection Agency South West of England was notified of an outbreak of cryptosporidiosis associated with an interactive water feature designed for water play within an adventure park. The water feature was implicated following samples with a high coliform count and the presence of faecal coliforms. A case was defined as any child (younger than 16 years of age) who had visited the park during August and who subsequently had gastrointestinal symptoms and a faecal sample positive for cryptosporidium. Seventy one children were identified in the cohort. This outbreak of cryptosporidiosis was characterised by a very high attack rate (89%), relatively severe in duration (median 8 days) and had a relatively high hospital admission (16% of cases). The epidemic curve was consistent with a point source of infection, which corresponded to the date 80% of the cohort visited the park. This outbreak has similarities to two other cryptosporidiosis outbreaks reported in England in 2003 that involved public water features. These outbreaks raise issues about the operation and maintenance of water-based recreational attractions that very often involve children. The paper reflects on the basic control measures that can be taken and highlights the need for guidelines, especially since such attractions are becoming increasingly common. The Pool Water Treatment Advisory Group in United Kingdom has now produced guidelines.

Variant translocation with a deletion of derivative (9q) in a case of Philadelphia chromosome positive (Ph +) essential thrombocythemia (ET), a variant of chronic myelogenous leukemia (CML) with a poor prognosis

Patients presenting with thrombocytosis require thorough clinical and laboratory evaluation to determine whether they suffer from essential thrombocythemia or another myeloproliferative disorder. This distinction becomes increasingly relevant as targeted agents become available to treat specific myeloproliferative diseases. Cytogenetic testing plays a major role in this analysis. This study presents a patient with Philadelphia chromosome positive (Ph + ) thrombocytosis and a cryptic der(9q)t(5;9)t(9;22) not found by conventional cytogenetics, whose disease progressed within 2 years to typical myeloblastic crisis of CML. It discusses the entity of Ph + ET, the utility of molecular cytogenetic testing in the diagnosis of this unusual disease entity and the importance of cytogenetic testing in the prognosis of ET.

Detection of Helicobacter pylori by PCR but not culture in water and biofilm samples from drinking water distribution systems in England

AIMS

To investigate treated water distribution systems in England as a source of Helicobacter pylori.

METHODS AND RESULTS

Water and biofilms were obtained from 11 domestic and seven educational properties and from hydrants, reservoirs and water meters supplied by three water utilities. Samples were cultured on nonselective and antibiotic containing media combined with immunomagnetic separation concentration. Viable helicobacters were not detected in any of the 151 samples but Helicobacter-specific PCR assays detected DNA in 26% of samples from domestic properties, schools and hydrants with the highest frequency in biofilms (42%). Direct sequencing of six selected amplicons confirmed >95% sequence homology to H. pylori.

CONCLUSIONS

While viable helicobacters were not isolated, evidence was obtained for the presence of Helicobacter DNA, including that of H. pylori. Biofilms on surfaces within water distribution systems may act either as sites for the passive accumulation of helicobacters or as potentially important reservoirs of infection.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our findings strengthen evidence that H. pylori may be transmitted through drinking water. However, there is currently no evidence that viable cells can survive the disinfection levels used in UK mains supplies and the health risk from this source remains unclear.

An outbreak of serious illness and death among injecting drug users in England during 2000

An outbreak of serious illness and death occurred in injecting drug users during 2000 in Scotland, Ireland and England. National and international collaboration was necessary for the investigation and management of this outbreak. In England and Wales active case-finding was initiated, coupled with standardised data collection and microbiological investigation of cases. Twenty-six definite or probable cases were identified in England between 1 April and 31 Aug. 2000; 17 of these occurred in the North. The overall case fatality was 50% (13/26). The principal apparent risk factor was a history of intramuscular or subcutaneous injection of heroin and the limited duration of the outbreak suggested that the problem might have been related to a particular supply of heroin. Clostridium novyi was isolated from two English cases. Taken in conjunction with contemporaneous microbiological and epidemiological results from Scottish and Irish cases, the probable aetiology for this outbreak was infection with C. novyi associated with both a particular supply of heroin and the method of preparation and injection used. A 'toolkit' was distributed in Sept. 2000 to all Consultants for Communicable Disease Control in England and Wales to assist them with the ongoing surveillance, investigation and management of this condition. Lessons learned have been used to produce guidance for the investigation and management of outbreaks of unexplained serious illness of possible infective aetiology.

Therapy-related myelodysplastic syndrome after autologous stem cell transplantation for breast cancer

Therapy-related myelodysplastic syndrome and acute myelogenous leukemia (t-MDS/AML) are serious complications of chemotherapy and radiotherapy for cancer. High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) may be associated with an increased incidence of these complications. The frequency of t-MDS/AML after ASCT for breast cancer is uncertain. We reviewed our database of 379 consecutive breast cancer ASCT patients treated with alkylator-based chemotherapy, followed for a median of 1.52 years (range 0-8.97), with a median survival of 6.16 years. Three patients have developed tMDS/AML. The probability of developing this complication at 5 years is 0.032 in our series. We have used pathologic, cytogenetic and molecular methods to evaluate which portions of therapy may have predisposed to the development of this complication. Cytogenetic abnormalities were not found in the stem cell harvests of these patients by metaphase analysis or by fluorescence in situ hybridization (FISH). One patient demonstrated a clonal X chromosome inactivation pattern in her stem cell harvest, indicating pre-transplant chemotherapy may have been responsible for the development of her leukemia. As two of our patients developed this complication at greater than 4 years post-transplant, the number of cases may increase with longer follow-up. While the incidence appears to be low, further prospective and retrospective analysis will be necessary to determine which portions of therapy predispose to the development of t-MDS/AML in patients undergoing ASCT for treatment of breast cancer.

Phase II trial of sequential high-dose chemotherapy with paclitaxel, melphalan and cyclophosphamide, thiotepa and carboplatin with peripheral blood progenitor support in women with responding metastatic breast cancer

A single high-dose cycle of chemotherapy can produce response rates in excess of 50%. However, disease-free survival (DFS) is 15-20% at 5 years. The single most important predictor of prolonged DFS is achieving a complete response (CR). Increasing the proportion of patients who achieve a complete response may improve disease-free survival. Women with metastatic breast cancer and at least a partial response (PR) to induction chemotherapy received three separate high-dose cycles of chemotherapy with peripheral blood progenitor support and G-CSF. The first intensification was paclitaxel (825 mg/m(2)), the second melphalan (180 mg/m(2)) and the third consisted of cyclophosphamide 6000 mg/m(2) (1500 mg/m(2)/day x 4), thiotepa 500 mg/m(2) (125 mg/m(2)/day x 4) and carboplatin 800 mg/m(2) (200 mg/m(2)/day x 4) (CTCb). Sixty-one women were enrolled and 60 completed all three cycles. Following the paclitaxel infusion most patients developed a reversible, predominantly sensory polyneuropathy. Of the 30 patients with measurable disease, 12 converted to CR, nine converted to a PR*, and five had a further PR, giving an overall response rate of 87%. The toxic death rate was 5%. No patient progressed on study. Thirty percent are progression-free with a median follow-up of 31 months (range 1-43 months) and overall survival is 61%. Three sequential high-dose cycles of chemotherapy are feasible and resulted in a high response rate. The challenge continues to be maintenance of response and provides the opportunity to evaluate strategies for eliminating minimal residual disease.

Reduction of paclitaxel-induced peripheral neuropathy with glutamine

PURPOSE

Dose-limiting toxicity of many newer chemotherapeutic agents is peripheral neuropathy. Prior attempts to reduce this side effect have been unsuccessful. We report on the possible successful reduction of peripheral neuropathy with glutamine administration after high-dose paclitaxel.

EXPERIMENTAL DESIGN

Patients entered a high-dose chemotherapy protocol in which the first high-dose cycle was paclitaxel at 825 mg/m(2) given over 24 h. The first cohort of patients did not receive glutamine, and the second cohort of patients received glutamine at 10 g orally three times a day for 4 days starting 24 h after completion of paclitaxel. Neurological assessment was performed at baseline, and at least 2 weeks after paclitaxel, and consisted of a complete neurological exam and nerve conduction studies.

RESULTS

There were paired pre- and post-paclitaxel evaluations on 33 patients who did not receive glutamine and 12 patients who did. The median interval between pre- and post-exams was 32 days. For patients who received glutamine, there was a statistically significant reduction in the severity of peripheral neuropathy as measured by development of moderate to severe dysesthesias and numbness in the fingers and toes (P < 0.05). The degree and incidence of motor weakness was reduced (56 versus 25%; P = 0.04) as well as deterioration in gait (85 versus 45%; P = 0.016) and interference with activities of daily living (85 versus 27%; P = 0.001). Moderate to severe paresthesias in the fingers and toes were also reduced (55 versus 42% and 64 versus 50%, respectively), although this value was not statistically significant. All of these toxicities were reversible over time.

CONCLUSIONS

Glutamine may reduce the severity of peripheral neuropathy associated with high-dose paclitaxel; however, results from randomized, placebo-controlled clinical trials will be needed to fully assess its impact, if any. Trials are currently ongoing to assess its efficacy for standard-dose paclitaxel in breast cancer and other tumors for which peripheral neuropathy is the dose-limiting toxicity.

Foodborne outbreaks of cyclosporiasis have arisen in North America. Is the United Kingdom at risk?

Cyclospora cayetanensis is a parasitic protozoon that causes prolonged watery diarrhoea. It is endemic in some developing countries, and recent foreign travel is often used as a selection criterion for screening in the United Kingdom (UK). Epidemiological investigations of outbreaks of cyclosporiasis among people in the United States and Canada who had not travelled abroad showed the infection to be foodborne and often associated with foods eaten raw. These included raspberries imported from Guatemala, and pesto (made with basil) and lettuce from other sources. Such foods are also being imported in increasing amounts to the UK, but no outbreaks have been documented, perhaps because none has occurred or because of poor ascertainment. This paper reviews the outbreaks reported from North America, evaluates the risks to the UK population, and suggests how surveillance could be improved.

Microbiological standards for water and their relationship to health risk

Maintenance of the microbiological quality of water has been used as an important means of preventing waterborne disease throughout the twentieth century. The commonest microbiological tests done on water are for coliforms and Escherichia coli (or faecal coliform). This paper reviews the legislative and other guidance for microbial standards in drinking and bathing waters and considers evidence for the relationship between the microbiological quality of water and risk to human health. In the past measures of the microbiological quality of water correlated well with risks of acquiring gastrointestinal disease. More recent work suggests that gastrointestinal disease is more strongly associated with the presence of enterococci than of E. coli. New diseases such as cryptosporidiosis have been shown to cause outbreaks of waterborne disease when levels of conventional microbiological parameters are satisfactory. In response to this, and because of failure of prosecution in one outbreak, the United Kingdom (UK) Government has introduced new legislation that requires water providers to perform a risk assessment on their water treatment facilities and to implement continuous monitoring for cryptosporidium. A new European directive on drinking water has been introduced and legislation on cryptosporidium in drinking water has been proposed in the UK.

Cyclospora infections in England and Wales: 1993 to 1998

The coccidian protozoon Cyclospora cayetanensis is a treatable cause of prolonged, watery diarrhoea in humans. Microbiology laboratories in England and Wales often restrict testing to those who have recently travelled abroad. Only 44 to 66 laboratory reports of C. cayetanensis are made in England and Wales each year and a large proportion are found to have visited developing countries. Large foodborne outbreaks of infection have arisen in North America among people who have not travelled abroad but no such outbreaks have been identified in the United Kingdom. Public health laboratories in England and Wales were surveyed in 1998 to investigate their procedures for identifying C. cayetanensis. Sixty-eight per cent actively looked for the protozoon, but only half used a recommended method of direct microscopy of formol ether concentrates. National external quality assurance results for all participating UK laboratories were reviewed to assess laboratory proficiency in identification. C. cayetanensis was correctly identified in a wet preparation by 58% of laboratories, the lowest rate for specimens containing a single parasite species. Cyclosporiasis could be acquired in the UK from imported food, but current laboratory procedures might fail to identify it. Ascertainment must improve and awareness needs to be raised among food handlers, public and environmental health workers, laboratory staff, and general practitioners. We recommend that laboratories test all patients with watery diarrhoea for > 1 week for cyclospora, use formol ether concentration and microscopy with a calibrated eyepiece graticule, and confirm diagnoses with the help of a reference laboratory.

Characterisation of the influence of micronisation on the crystallinity and physical stability of revatropate hydrobromide

Micronised particles of revatropate hydrobromide were observed to agglomerate when stored in uncontrolled conditions. Dynamic vapour sorption (DVS), isothermal microcalorimetry, microscopy and particle size measurement by laser diffraction have been used to study micronised revatropate hydrobromide. The rate and extent of agglomeration were dependent on the energy of the micronisation process, the sampling point for bulk within the mill and the humidity during storage. The agglomeration was attributed to the recrystallisation of disordered regions on the particles of revatropate hydrobromide generated during micronisation. This recrystallisation was assessed qualitatively and quantitatively, compared against spray-dried amorphous material, using DVS and isothermal microcalorimetry, respectively. A correlation was established between the energy of micronisation and the level of disorder within the micronised powder. A comparison of the DVS profiles of freshly prepared and aged micronised revatropate hydrobromide suggests an increased physical stability for the aged material.

The microbiological quality of ice used to cool drinks and ready-to-eat food from retail and catering premises in the United Kingdom

A survey of 4,346 samples of ice from retail and catering premises examined 3,528 samples (81%) used to cool drinks and 144 samples (3%) from food displays. For 674 samples (15%), the origin was not recorded. Most samples of ice used to cool drinks or ready-to-eat food on displays did not contain coliforms, Escherichia coli, or enterococci. Of the ice used to cool drinks, 9% contained coliforms, 1% E. coli, and 1% enterococci in excess of 10(2) CFU/100 ml, and 11% had an aerobic plate count at 37 degrees C in excess of 10(3) CFU/ml. The microbiological quality of ice used to cool drinks was poorer when melt water was present in the ice buckets. Ice used in food displays was more contaminated than ice used to cool drinks, with 23% containing coliforms, 5% E. coli, and 8% enterococci at 10(2) CFU/100 ml or more. Twenty-nine percent of samples had an aerobic plate count greater than 10(3) CFU/ml. Ice that had been used to cool shellfish was of a lower microbiological quality than samples used to cool ready-to-eat fish, salads, or dairy produce. Samples of ice produced in commercial production facilities were of higher microbiological quality than samples of ice that were not. The microbiological quality of ice was dependent on the type of use, the type of premises, and the type and place of production. Although most ice samples were of acceptable microbiological quality, evidence from this study suggests that the microbiological quality of ice prepared and used at certain premises in the UK is a cause for concern.