Administration of a Bacterial Lysate to the Airway Compartment Is Sufficient to Inhibit Allergen-Induced Lung Eosinophilia in Germ-free Mice

The nexus between eosinophils and microbes is attracting increasing attention. We previously showed that airway administration of sterile microbial products contained in dust collected from traditional dairy farms virtually abrogated broncho-alveolar lavage (BAL) eosinophilia and other cardinal asthma phenotypes in allergen-sensitized specific pathogen-free (SPF) mice. Interestingly, comparable inhibition of allergen-induced BAL eosinophilia and promotion of airway barrier integrity were found upon administration of a sterile, pharmacological grade bacterial lysate, OM-85, to the airway compartment of allergen-sensitized SPF mice. Here we asked whether intrinsic properties of airway-delivered microbial products were sufficient to inhibit allergic lung inflammation or whether these effects were mediated by reprogramming of the host microbiota. We compared germ-free (GF) mice and offspring of GF mice associated with healthy mouse gut microbiota and maintained under SPF conditions for multiple generations (Ex-GF mice). These mice were treated intra-nasally with OM-85 and evaluated in the OVA and Alternaria models of allergic asthma focusing primarily on BAL eosinophilia. Levels of allergen-induced BAL eosinophilia were comparable in GF and conventionalized Ex-GF mice. Airway administration of the OM-85 bacterial lysate was sufficient to inhibit allergen-induced lung eosinophilia in both Ex-GF and GF mice, suggesting that host microbiota are not required for the protective effects of bacterial products in these models and local airway exposure to microbial products is an effective source of protection. OM-85-dependent inhibition of BAL eosinophilia in GF mice was accompanied by suppression of lung type-2 cytokines and eosinophil-attracting chemokines, suggesting that OM-85 may work at least by decreasing eosinophil lung recruitment.

Multidisciplinary neurosurgical rounds incorporating antimicrobial stewardship. Are they of benefit?

Background

In an era of increasing antimicrobial resistance, appropriate antimicrobials are essential to optimise patient outcomes. In 2017, antimicrobial use prevalence (AMU) on the two neurosurgical wards in our tertiary teaching hospital varied from 23% on ward A to 33% on ward B with 67% and 100% ‘appropriate’ prescriptions, respectively. In July 2018, a weekly antimicrobial stewardship multidisciplinary round led by a senior neurosurgery registrar commenced, attended by the antimicrobial stewardship team (AST).

Research question

This report evaluates whether a multi-disciplinary approach on neurosurgical prescribing was beneficial, specifically in reducing AMU.

Materials and methods

The following data was collected on AST rounds for 30 weeks in total from August 2018 to July 2019: number of patients on antimicrobials, appropriateness and stewardship actions. A questionnaire was distributed to neurosurgical doctors on two occasions to canvass opinions and attitudes on antimicrobial prescribing.

Results

1716 prescriptions were reviewed (mean 57.2 per week). Of these 321 (18.7%) included antimicrobial prescriptions; 200 on ward A (19.8%), and 121 on ward B (17%), representing a decrease in AMU from 2017. The majority of antimicrobial prescriptions, 271 (84.4%) were deemed appropriate. Stewardship actions were taken in 215 (67%) prescriptions.

Fifteen questionnaires were completed by neurosurgical doctors. The majority, 87%, stated the AST round was helpful overall. 93% indicated that informal training on the AST round was a source of education in antibiotic prescribing.

Discussion and conclusion

The weekly AST round provided a timely opportunity for multidisciplinary discussion, implementation of antimicrobial stewardship actions and opportunistic antimicrobial stewardship education.

-

Surgeons need to be directly involved in antimicrobial stewardship to optimise patient outcomes and reduce antimicrobial resistance.

-

A multidisciplinary antimicrobial stewardship (AST) ward round led by neurosurgery commenced in our hospital in 2018.

-

Antimicrobial stewardship actions were taken in 67% of prescriptions, and antimicrobial use prevalence reduced in 2018 compared to 2017.

-

A questionnaire distributed to neurosurgical doctors on the value of the AST round indicated that 87% of neurosurgical doctors found it helpful.

-

We ​believe leadership and accountability were crucial to the success of the ward round, as neurosurgeons contributed directly to decision making.

Evolving epidemiology of carbapenemase-producing Enterobacterales: one hospital's infection prevention and control response over nine years

BACKGROUND

Preventing carbapenemase-producing Enterobacterales (CPE) transmission is a significant challenge for hospital infection prevention and control teams (IPCTs). Control measures include screening at-risk patients, contact tracing, and the isolation of carriers with contact precautions.

AIM

The evolution of infection prevention and control measures was assessed in a tertiary acute care hospital with predominately multi-bedded patient accommodation, from 2011 to 2019 as cases of CPE increased. The implications for, and the response and actions of, the IPCT were also reviewed.

METHODS

CPE data collected prospectively from our laboratory, IPCT, and outbreak meeting records were reviewed to assess how the IPCT adapted to the changing epidemiology, from sporadic cases, to outbreaks and to localized endemic CPE.

FINDINGS

Of 178 cases, 152 (85%) were healthcare-associated and there was a marked increase in cases from 2017. The number of screening samples tested annually increased from 1190 in 2011 to 16,837 in 2019, and six outbreaks were documented, with larger outbreaks identified in later years. OXA-48 carbapenemase was detected in 88% of isolates and attendance at outbreak meetings alone accounted for 463.5 h of IPCT members, and related staff time.

CONCLUSION

Despite considerable efforts and time invested by the IPCT, the number of CPE cases is increasing year-on-year, with more outbreaks being reported in later years, albeit partly in response to increased screening requirements. Infrastructural deficits, the changing epidemiology of CPE, and national policy are major factors in the increasing number of cases.

Emergence and Magnitude of ML336 Resistance in Venezuelan Equine Encephalitis Virus Depend on the Microenvironment

Venezuelan equine encephalitis virus (VEEV) is a New World Alphavirus that can cause neurological disease and death in humans and equines following transmission from infected mosquitoes. Despite the continued epidemic threat of VEEV, and its potential use as a bioterrorism agent, there are no FDA-approved antivirals or vaccines for treatment or prevention. Previously, we reported the discovery of a small molecule, ML336, with potent antiviral activity against VEEV. To further explore the population-level resistance profiles of ML336, we developed a whole-genome next-generation sequencing (NGS) approach to examine single nucleotide polymorphisms (SNPs) from virus passaged in dose escalation studies in a nonhuman primate kidney epithelial and a human astrocyte cell line, Vero 76 and SVGA, respectively. We passaged VEEV TC-83 in these two cell lines over seven concentrations of ML336, starting at 50 nM. NGS revealed several prominent mutations in the nonstructural protein (nsP) 3 and nsP4 genes that emerged consistently in these two distinct in vitro environments-notably, a mutation at Q210 in nsP4. Several of these mutations were stable following passaging in the absence of ML336 in Vero 76 cells. Network analyses showed that the trajectory of resistance differed between Vero and SVGA. Moreover, the penetration of SNPs was lower in SVGA. In conclusion, we show that the microenvironment influenced the SNP profile of VEEV TC-83. Understanding the dynamics of resistance in VEEV against newly developed antiviral compounds will guide the design of optimal drug candidates and dosing regimens for minimizing the emergence of resistant viruses.IMPORTANCE RNA viruses, including Venezuelan equine encephalitis virus (VEEV), have high mutation rates that allow for rapid adaptation to selective pressures in their environment. Antiviral compounds exert one such pressure on virus populations during infections. Next-generation sequencing allows for examination of viruses at the population level, which enables tracking of low levels of single-nucleotide polymorphisms in the population over time. Therefore, the timing and extent of the emergence of resistance to antivirals can be tracked and assessed. We show here that in VEEV, the trajectory and penetration of antiviral resistance reflected the microenvironment in which the virus population replicates. In summary, we show the diversity of VEEV within a single population under antiviral pressure and two distinct cell types, and we show that population dynamics in these viruses can be examined to better understand how they evolve over time.

Food for thought. Malnutrition risk associated with increased risk of healthcare-associated infection

BACKGROUND

Infection and malnutrition are interconnected. UK and Irish guidelines recommend the Malnutrition Universal Screening Tool (MUST) for nutritional risk screening. Patients with a MUST score of ≥2 are considered at high risk of malnutrition and referral for nutritional assessment is recommended.

AIM

To explore the association between healthcare-associated infection (HCAI) and the MUST score categories of patients.

METHODS

This was a cross-sectional study in May 2017 on ten representative wards in our institution. Patient demographics, MUST score, presence of medical devices, HCAI and antimicrobial use were collected.

FINDINGS

Of 240 patients, the HCAI prevalence was 10.4% (N = 25) and 26% (N = 63) were at high risk of malnutrition (MUST score ≥2). Patients with HCAI were more likely to have had surgery (odds ratio (OR): 5.5; confidence interval (CI): 2.1-14.3; P < 0.001), a central vascular catheter (OR: 10.0; CI: 3.6-27.2; P < 0.001), or a urinary catheter in situ (OR: 7.5; CI: 2.8-20.0; P < 0.001), and to have a high risk of malnutrition (OR: 4.3; CI: 1.7-11.2; P < 0.001). A higher MUST score remained a significant predictor of a patient having HCAI on multivariate regression analysis (CI: 0.2-0.6; P < 0.001).

CONCLUSION

Patients at risk of malnutrition when assessed with the MUST were more likely to have HCAI. However, prospective studies are required to investigate the temporal association between MUST and HCAI and which interventions best address malnutrition risk and HCAI reduction in different settings.

Cognitive dysfunction in early multiple sclerosis: a review

Cognitive impairment is a common and disabling feature of Multiple Sclerosis (MS), including early MS, and may even pre-date any physical symptoms. It contributes even more to withdrawal from work than physical disability. Here, we provide an overview of cognitive impairment in MS, particularly in early MS where it is most commonly under-reported and under-treated. We address the presenting features of CI, its impact on quality of life, and its validated assessments (in particular the use of Brief International Cognitive Assessment in MS for use in a clinical setting). We review the insights radiology has given us into the pathogenesis of cognitive impairment in MS, particularly in early CI and in cognitively preserved MS patients. We review current treatments for cognitive impairment, primarily cognitive rehabilitation. We address the evidence for its associated co-morbidities, which may exacerbate or trigger CI, and should therefore be addressed early in the disease course (smoking, alcohol, mood, fatigue and potential co-existing sleep disorders, exercise, and vitamin D). The article supports the importance for early recognition and management of cognitive impairment in MS, before it becomes an established and irreversible entity.

The potential contribution of 16S ribosomal RNA polymerase chain reaction to antimicrobial stewardship in culture-negative infection

Empiric broad-spectrum antimicrobial therapy frequently results in culture-negative specimens making rationalization of therapy difficult. We retrospectively reviewed 16S rRNA polymerase chain reaction (PCR) results from 78 specimens in 60 patients. 16S rRNA was detected in 28 (47%) patients with de-escalation of therapy in five (21%). Microbial DNA was not detected in 32 (53%) patients with antimicrobials discontinued in two (8%). Neurosurgical patients had a higher proportion of positive results (53% vs 34%) and treatment rationalizations (17% vs 12%). In specific patient groups, 16s rRNA PCR is a useful antimicrobial stewardship tool for targeting antimicrobial therapy.

The Affordable Medicines Facility-malaria (AMFm): are remote areas benefiting from the intervention?

Background

To assess the availability, price and market share of quality-assured artemisinin-based combination therapy (QAACT) in remote areas (RAs) compared with non-remote areas (nRAs) in Kenya and Ghana at end-line of the Affordable Medicines Facility-malaria (AMFm) intervention.

Methods

Areas were classified by remoteness using a composite index computed from estimated travel times to three levels of service centres. The index was used to five categories of remoteness, which were then grouped into two categories of remote and non-remote areas. The number of public or private outlets with the potential to sell or distribute anti-malarial medicines, screened in nRAs and RAs, respectively, was 501 and 194 in Ghana and 9980 and 2353 in Kenya. The analysis compares RAs with nRAs in terms of availability, price and market share of QAACT in each country.

Results

QAACT were similarly available in RAs as nRAs in Ghana and Kenya. In both countries, there was no statistical difference in availability of QAACT with AMFm logo between RAs and nRAs in public health facilities (PHFs), while private-for-profit (PFP) outlets had lower availability in RA than in nRAs (Ghana: 66.0 vs 82.2 %, p < 0.0001; Kenya: 44.9 vs 63.5 %, p = <0.0001. The median price of QAACT with AMFm logo for PFP outlets in RAs (USD1.25 in Ghana and USD0.69 in Kenya) was above the recommended retail price in Ghana (US$0.95) and Kenya (US$0.46), and much higher than in nRAs for both countries. QAACT with AMFm logo represented the majority of QAACT in RAs and nRAs in Kenya and Ghana. In the PFP sector in Ghana, the market share for QAACT with AMFm logo was significantly higher in RAs than in nRAs (75.6 vs 51.4 %, p < 0.0001). In contrast, in similar outlets in Kenya, the market share of QAACT with AMFm logo was significantly lower in RAs than in nRAs (39.4 vs 65.1 %, p < 0.0001).

Conclusion

The findings indicate the AMFm programme contributed to making QAACT more available in RAs in these two countries. Therefore, the AMFm approach can inform other health interventions aiming at reaching hard-to-reach populations, particularly in the context of universal access to health interventions. However, further examination of the factors accounting for the deep penetration of the AMFm programme into RAs is needed to inform actions to improve the healthcare delivery system, particularly in RAs.

Posterior reversible encephalopathy syndrome (PRES) associated with liquorice consumption

IMPORTANCE

Posterior reversible encephalopathy syndrome (PRES) is a medical emergency but prompt recognition, early institution of supportive care and identifying and removing potential triggers are associated with a good clinical outcome. We report an unusual case of PRES associated with liquorice consumption.

OBSERVATIONS

A 56-year-old lady presented with thunderclap headache, visual disturbance and a generalised tonic-clonic seizure. Blood pressure on admission was markedly elevated but improved within 24 h. Cranial CT and lumbar puncture were normal (no xanthochromia). She had hypokalaemia. Cranial MRI revealed abnormalities in the occipital lobes consistent with PRES. There was no evidence of restricted diffusion or vasoconstriction. Follow-up MRI 3 weeks later demonstrated complete resolution. On direct questioning she revealed in recent months she had habitually eaten liquorice sweets each day; they were "on special offer" in her local shop.

CONCLUSION AND RELEVANCE

Liquorice contains a biologically active compound glycyrrhizic acid which inhibits 11β hydroxysteroid dehydrogenase. Excessive liquorice consumption can cause mineralocorticoid excess and has been recently reported to cause PRES. We propose that in the absence of other triggers, frequent liquorice consumption precipitated the development of PRES in our patient and should be considered as a possible cause of this condition.

Industrial perspective: capturing the benefits of genomics to Irish cattle breeding

Genomics is a technology for increasing the accuracy with which the genetic merit of young potential breeding animals can be determined. It enables earlier selection decisions, thus reducing generation intervals and gives rise to more rapid annual rates of genetic gain. Recently, the cost of genomics has reduced to the point where it enables breeding-program costs to be reduced substantially. Ireland has been a rapid adopter of genomics technology in its dairy-cattle breeding program, with 40% of dairy-cow artificial inseminations in 2010 being from bulls evaluated using genomic information. This rapid adoption has been facilitated by a comprehensive database of phenotypes and genotypes, strong public funding support for applied genomics research, an international network of collaborators, a short path between research and implementation, an overall selection index which farmers use in making breeding decisions, and a motivated and informed breeding industry. The shorter generation interval possible with genomic selection strategies also allows exploitation of the already accelerating rate of genetic progress in Ireland, because elite young dairy bulls are considerably superior to the small numbers of bulls that entered progeny test 6 years ago. In addition, genomics is having a dramatic impact on the artificial-insemination industry by substantially reducing the cost of entry, the cost of operation, and shifting the focus of breeding from bulls to cows. We believe that the current industry structures must evolve substantially if Irish cattle farmers are to realise the full benefits of genomics and be protected from related risks. Our model for future dairy breeding envisages a small number of ‘next generation research herds’, 1000 ‘bull breeder herds’ and an artificial-insemination sector using 30 new genomically selected bulls per year to breed the bulk of replacements in commercial milk-producing herds. Accurate imputation from a low-density to a higher-density chip is a key element of our strategy to enable dairy farmers to afford access to genomics. This model is capable of delivering high rates of genetic gain, realising cost savings, and protecting against the risks of increased inbreeding and suboptimal breeding goals. Our strategy for exploiting genomic selection for beef breeding is currently focussed on genotyping, using a high-density chip, a training population of greater than 2000 progeny-tested bulls representing all the main beef breeds in Ireland. We recognise the need for a larger training population and are seeking collaboration with organisations in other countries and populations.

Using and joining a franchised private sector provider network in Myanmar

Background

Quality is central to understanding provider motivations to join and remain within a social franchising network. Quality also appears as a key issue from the client's perspective, and may influence why a client chooses to use a franchised provider over another type of provider. The dynamic relationships between providers of social franchising clinics and clients who use these services have not been thoroughly investigated in the context of Myanmar, which has an established social franchising network. This study examines client motivations to use a Sun Quality Health network provider and provider motivations to join and remain in the Sun Quality Health network. Taken together, these two aims provide an opportunity to explore the symbiotic relationship between client satisfaction and provider incentives to increase the utilization of reproductive health care services.

Methods and Findings

Results from a series of focus group discussions with clients of reproductive health services and franchised providers shows that women chose health services provided by franchised private sector general practitioners because of its perceived higher quality, associated with the availability of effective, affordable, drugs. A key finding of the study is associated with providers. Provider focus group discussions indicate that a principle determinate for joining and remaining in the Sun Quality Health Network was serving the poor.

COL6A1 gene and Ironman triathlon performance

Mutations in the type VI collagen gene ( COL6A1) cause myopathy and muscle weakness. In addition, COL6A1 knockout mice were shown to have impaired running performance and reduced muscle strength. The COL6A1 rs35796750 polymorphism (IVS32-29 T/C) has been associated with complex phenotypes. The aim of this study was therefore to determine if this polymorphism is associated with performance during the 226 km Ironman triathlon. Participants (n=661) were recruited during 4 South African Ironman triathlons. Finishing times for the 3.8 km swim, 180 km bike, 42.2 km run, and overall race were provided by the race organisers. All participants were genotyped for the COL6A1 rs35796750 polymorphism. Participants with the COL6A1 TT genotype were significantly faster during the bike (p=0.014) and overall race (p=0.030). When participants were grouped into fast, middle and slow bike finishing time tertiles, there was a significant linear trend for the TT genotype (Fast: TT=35.7%; Middle: TT=29.0%; Slow: TT=23.8%; p=0.008). No significant genotype frequency differences were observed for the swim or run of the triathlon. In conclusion, the COL6A1 gene is therefore a potential marker for endurance cycling performance. These effects may be mediated through changes to the composition of type VI collagen containing tissues, such as muscle and tendon.

The role of social support and parity in contraceptive use in Cambodia

CONTEXT

In Cambodia, unmet need for contraception is high. Studies suggest that social support and parity each play a role in contraceptive decision making.

METHODS

A representative sample of 706 married women aged 15-49 from two rural provinces in Cambodia who wished to delay childbirth were interviewed about their contraceptive use and their perceptions of their husband's, peers' and elders' support of contraception. Multivariate analyses examined associations between support measures and women's current use of modern methods, among all women and by parity.

RESULTS

Overall, 43% of women were currently using a modern method. Women who believed that their husband had a positive attitude toward contraception were more likely than those who did not to use a method (odds ratio, 3.4), whereas women who were nervous about talking with their husband about contraception were less likely than others to use a method (0.6); these associations remained in analyses by parity. Among all women and high-parity women, those whose husband made the final decision about contraception were less likely than other women to use a method (0.6 and 0.4, respectively). Perceiving that most of one's peers practice contraception was strongly associated with method use among low-parity women (4.4). Among all groups, women who agreed that one should not practice contraception if an elder says not to had decreased odds of method use (0.5 each).

CONCLUSIONS

To promote contraceptive use, family planning programs should focus on increasing men's approval of contraception, improving partner communication around family planning and bolstering women's confidence in their reproductive decision making.

Antifungal susceptibility testing and candidaemia at a tertiary referral hospital

Candidaemia is associated with a high mortality. We have reviewed cases of candidaemia over a 2-year period at a tertiary referral hospital in association with the introduction of routine antifungal susceptibility testing. The aim of the study was two fold; firstly to establish the typical profile of a patient who might experience a Candida bloodstream infection and secondly, to evaluate methods of antifungal susceptibility testing. In 2008-2009, 31 patients with candidaemia were retrospectively identified using the Laboratory Information Systems (Apex). Clinical data were obtained by chart review. Antifungal susceptibility testing to fluconazole and voriconazole was carried out on 20 of the clinical isolates using three different methods. These isolates were also sent to the mycology reference laboratory at Bristol and results were compared. The male-to-female ratio was 2.1:1 with an age range from 6 weeks to 89 years. Candida albicans was the predominant species (n= 17). Patients were predominantly general surgical (39%), oncology (16%) and urology (13%). Identified risk factors included treatment with broad-spectrum antimicrobial agents (89%), central venous catheters (CVCs) (89%), and surgery during the current admission (54%). The crude mortality rate (death prior to discharge) was 42%. Only 1 of the 20 isolates tested, a Candida glabrata, tested resistant to fluconazole. Of 3 antifungal susceptibility test systems evaluated (VITEK 2, TREK Sensititre YeastOne and CLSI disk diffusion); the VITEK 2 system was considered most appropriate for routine use in our laboratory. Retrospective review of therapy identified 7 patients treated with echinocandins in whom susceptibility testing indicated that fluconazole could have been used with significant reduction in cost of therapy.

Hepatitis B virus infection in children

Recent increases in Hepatitis B virus (HBV) infection prompted us to characterize HBV-infected children in Ireland and to audit management, by reviewing prospectively gathered data. Of 46 children (29 [63%] male), median age at presentation was 8.1 years (range 0.6-17.6), monitoring duration was 22.5 months (range 1-101), 23/46 (50%) were European (including 9 [19.6%] Irish), 15 (32.6%) African and 9 (19.6%) Asian. Acquisition was vertical (25/46 [54.3%]), horizontal (5/46 [10.9%]), unknown (16/46 [34.8%]). HBV-DNA was >100,000,000 cpm in 20/32 (62.5%) with chronic infection. Hepatitis B e antigen (HBeAg) was detected in 32/44 (72.7%). We estimate that universal neonatal vaccination (UNV-HBV) could have prevented 22% of cases, and could limit further horizontal HBV spread. This supports the recent introduction of UNV-HBV.

Preventable mix-ups of tuberculin and vaccines: reports to the US Vaccine and Drug Safety Reporting Systems

BACKGROUND

Errors involving the mix-up of tuberculin purified protein derivative (PPD) and vaccines leading to adverse reactions and unnecessary medical management have been reported previously.

OBJECTIVES

To determine the frequency of PPD-vaccine mix-ups reported to the US Vaccine Adverse Event Reporting System (VAERS) and the Adverse Event Reporting System (AERS), characterize adverse events and clusters involving mix-ups and describe reported contributory factors.

METHODS

We reviewed AERS reports from 1969 to 2005 and VAERS reports from 1990 to 2005. We defined a mix-up error event as an incident in which a single patient or a cluster of patients inadvertently received vaccine instead of a PPD product or received a PPD product instead of vaccine. We defined a cluster as inadvertent administration of PPD or vaccine products to more than one patient in the same facility within 1 month.

RESULTS

Of 115 mix-up events identified, 101 involved inadvertent administration of vaccines instead of PPD. Product confusion involved PPD and multiple vaccines. The annual number of reported mix-ups increased from an average of one event per year in the early 1990s to an average of ten events per year in the early part of this decade. More than 240 adults and children were affected and the majority reported local injection site reactions. Four individuals were hospitalized (all recovered) after receiving the wrong products. Several patients were inappropriately started on tuberculosis prophylaxis as a result of a vaccine local reaction being interpreted as a positive tuberculin skin test. Reported potential contributory factors involved both system factors (e.g. similar packaging) and human errors (e.g. failure to read label before product administration).

CONCLUSIONS

To prevent PPD-vaccine mix-ups, proper storage, handling and administration of vaccine and PPD products is necessary.

Characterisation of Yersinia pestis isolates from natural foci of plague in the Republic of Georgia, and their relationship to Y. pestis isolates from other countries

Forty Yersinia pestis isolates from endemic foci of plague in the Republic of Georgia, and six Y. pestis isolates from neighbouring former Soviet Union countries, were analysed for their biochemical and phenotypic properties, and their genetic relatedness was compared with Y. pestis strains KIM and CO92 by pulsed-field gel electrophoresis (PFGE). In addition, 11 Y. pestis isolates from the USA, together with published nucleotide sequences from Y. pestis strains KIM, CO92 and 91001, were compared with the 46 isolates in the present collection using multilocus sequence typing (MLST), based on sequence data for the 16S rRNA, hsp60, glnA, gyrB, recA, manB, thrA and tmk loci. Four virulence gene loci (caf1, lcrV, psaA and pla) were also sequenced and analysed. Two sequence types (ST1 and ST2), which differed by a single nucleotide, were identified by MLST. With the exception of a single isolate (771G), all of the Georgian Y. pestis isolates belonged to ST2. PFGE also grouped the Georgian Y. pestis isolates separately from the non-Georgian isolates. Overall, PFGE discriminated the Y. pestis isolates more effectively than MLST. The sequences of three of the four virulence genes (lcrV, psaA and pla) were identical in all Georgian and non-Georgian isolates, but the caf1 locus was represented by two allele types, with caf1 NT1 being associated with the non-Georgian isolates and caf1 NT2 being associated with the Georgian isolates. These results suggest that Georgian Y. pestis isolates are of clonal origin.

Blood use by inpatient elderly population in the United States

BACKGROUND

Our objective was to characterize inpatient blood use by the US elderly population during 2001. As the US population ages the demand for blood is expected to grow. There have been no comprehensive studies, however, detailing blood use by the elderly in the United States.

STUDY DESIGN AND METHODS

A descriptive cross-sectional study of blood utilization was conducted with the 5 percent Medicare Provider Analysis and Review (MedPAR) data file obtained from the Centers for Medicare and Medicaid Services (CMS). Each record of the file represented a billing record of an inpatient stay. Blood use was identified by either a nonzero blood pints furnished quantity or a procedure code for transfusion of whole blood or red blood cells (RBCs).

RESULTS

Among 635,700 stays, 43,220 (6.8%) recorded transfusion of whole blood or RBCs. Blood use prevalence was approximately 4.5 times higher for stays with at least one medical procedure compared to stays without procedures. Of 15,579 stays with number of blood pints furnished recorded, the top 20 principal procedures with the largest quantities of blood accounted for about 56 percent of total blood pints furnished; however, these procedures represented only about 19 percent of all stays.

CONCLUSION

Our study shows a strong association between medical procedures and blood use among inpatient stays for the elderly. Some of the highest blood utilization occurred with surgical procedures. More precise information on blood utilization may serve as the basis for estimating risks associated with blood transfusion and may inform decisions that maintain an adequate supply of blood.

Tinea capitis in a paediatric population

Tinea capitis is an increasing problem in Europe. The pattern of infection is changing with an increase in pathogenic anthropophilic dermatophytes particularly Trichophyton tonsurans. We aimed to determine the frequency of tinea capitis in a paediatric population attending dermatology outpatients and examine the clinical spectrum of disease. A retrospective analysis was performed of all laboratory proven tinea capitis cases presenting to the dermatology outpatient department at The Children's University Hospital, Temple Street over an 18-month period (1st January 2004 to 30th of June 2005 inclusive). Sixty-two children had tinea capitis of whom 53 (85.5%) were of African descent. Thirty-five (56%) were male and 27 female (44%). The average age at presentation was 4.02 years (age range 1-163 months) with five cases occurring in children less than one year of age. The most common pathogen was the anthropophilic dermatophyte Trichophyton tonsurans, accounting for 47 (75.8%) of all cases of tinea capitis. Eight (12.9%) were secondary to Microsporum ferrigineum, 2 (3.2%) secondary to Trichophyton violaceum, both Trichophyton soudanese and Trichophyton verruosum accounted for 1.6% each. The zoophilic organism Microsporum canis was diagnosed in 3 cases (4.8%). Presenting signs included scaling of the scalp (35.47%), scaling of the scalp and alopecia (53.24%), and alopecia and kerion (11.29%/o). The duration of symptoms was recorded in 52 patients with the average duration 8.38 months (range 0.5-72 months). In 20 cases an associated skin involvement on other areas of the body was recorded. All patients at diagnosis were either on no, suboptimal or inappropriate treatment. The prevalence of tinea capitis is increasing in this hospital based cohort. The main pathogen is now Trichophyton tonsurans. Children of African descent are at increased risk of infection. The diagnosis is poorly recognized and needs to be highlighted as a public health issue. There is a need for community based prevalence studies.

Pulsed-field gel electrophoresis of Campylobacter jejuni sheep abortion isolates

Campylobacter species are a significant cause of sheep abortion in most sheep-raising countries. In New Zealand, Campylobacter fetus subsp. fetus is the leading cause of diagnosed sheep abortion and the species C. jejuni and C. coli have also been implicated. To date, strain typing information of C. jejuni sheep abortion isolates is limited. The objective of the present study was to genotype C. jejuni isolates cultured from sheep abortions submitted to diagnostic laboratories in New Zealand during the 2000 breeding season, using pulsed-field gel electrophoresis (PFGE). In this study, C. jejuni isolates were cultured from approximately 10% of farms from which Campylobacter species were isolated from sheep abortions in the year 2000. This equated to 25 C. jejuni isolates from 21 farms. These isolates were obtained from the veterinary diagnostic laboratories and strain typed using the molecular typing technique PFGE. Ten distinct PFGE types were identified amongst the isolates. No particular PFGE type was found most frequently amongst these C. jejuni sheep abortion isolates. However, indistinguishable or similar C. jejuni PFGE types were identified from different aborted foetuses from the same flock, consistent with the role of C. jejuni as an infectious cause of abortion in sheep. These strain types were similar or indistinguishable from C. jejuni sheep abortion isolates obtained in 1999 in a smaller study (Mannering, S.A., Marchant, R.M., Middelberg, A., Perkins, N.R., West, D.M., Fenwick, S.G., 2003. Pulsed-field gel electrophoresis typing of C. fetus subsp. fetus from sheep abortions in the Hawke's Bay region of New Zealand. NZ Vet. J. 51, 33-37).

Passive surveillance for generalized vaccinia in the United States using the Vaccine Adverse Event Reporting System (VAERS)

BACKGROUND

Generalized vaccinia (GV) is an adverse event specifically associated with smallpox vaccination, but shares clinical features with many common non-vaccine related rashes. We assessed the utility of passive reporting for GV surveillance by reviewing all Vaccine Adverse Event Reporting System (VAERS) reports of any post-smallpox vaccination rash in civilians and military personnel.

METHODS

We reviewed all reports submitted to VAERS between 12/12/2002 and 3/1 2004 for post-smallpox vaccine (SPV) rashes concerning civilians and military personnel. We evaluated the information contained in the reports independent of VAERS adverse event coding (GV or not GV). We classified the rash reports based on the recently published GV case definition from the Centers for Disease Control and Prevention.

RESULTS

Of the 936 rash reports after SPV, 92 were coded as GV. We classified 12 of the 92 as probable GV, and 1 as confirmed GV (14% probable or confirmed). Among the 844 reports not coded as GV, we classified 32 as either probable or confirmed GV (4%). Probable or confirmed reports that were coded as GV were similar to probable or confirmed reports not coded as GV with respect to demographic characteristics of the report subjects, and the location and phenotype (e.g., pustular, vesicular, etc.) of the rashes.

CONCLUSIONS

A prospective study that applies well-defined clinical, histopathological, and laboratory criteria to smallpox-vaccinated patients with rashes would be necessary to distinguish GV from common alternative diagnoses with which it is easily confused.

Preliminary development of the World Health Organsiation's Quality of Life HIV instrument (WHOQOL-HIV): analysis of the pilot version

The assessment of quality of life (QoL) is central to understanding how people's lives are affected by HIV infection. A reliable and valid measurement tool developed for cross-cultural use will be important in evaluating the global impact of the disease. This paper reports on the development and preliminary assessment of the WHOQOL-HIV pilot instrument that is designed for use with the WHOQOL-100 for persons living with HIV and AIDS (PLWHA). In this study, 900 people with a mean age of 32 from six culturally diverse sites completed the WHOQOL-100 along with 115 HIV specific items. Respondents were HIV asymptomatic (23%), HIV symptomatic (23%), had AIDS (20%) or were well (34%). Analyses to select the best items from the piloted instrument resulted in the inclusion of 33 items covering 12 new facets for a field trial version of the WHOQOL-HIV instrument; e.g. symptoms of HIV, body image, social inclusion, death and dying, and forgiveness. The results indicate excellent internal consistency for the scale (alpha=0.98) and its domains (alpha=0.87-0.94). For PLWHA, pain and discomfort, positive feelings, dependence on medication, sexual activity, financial resources and spiritual connection were particularly poor, indicating that the severest impact of HIV extends beyond physical well-being to the psycho-social-spiritual and environmental areas of QoL. Comparisons using ANOVA showed that persons who are at later stages of HIV infection, or are currently ill report poorer QoL than those that were well (p<0.01). Women report poorer QoL than men for almost every facet (p<0.01) and older persons (>30) reported lower negative feelings, and better social inclusion, spiritual connection, forgiveness and spiritual experience than younger persons. Finally, those with no education, or only primary education showed some of the poorest means. It is concluded that these new items and facets add value for measurement of QoL in PLWHA.

Isotype-specific antibody responses of cattle to Salmonella Dublin lipopolysaccharide and porin following Salmonella Dublin vaccination and acute and chronic infection

Stimulation of different T-cell subsets during antigen presentation influences the antibody isotype response to an antigen. Salmonella infection and Salmonella bacterin vaccination are likely to stimulate different T-cell subtypes. The objective of this study was to determine whether there are differences in the isotype response of cattle to Salmonella antigens following Salmonella infection and Salmonella bacterin vaccination. Sera from Salmonella bacterin-vaccinated, experimentally infected, and chronically infected (carrier) adult cattle collected during previous studies was used to evaluate the IgG1, IgG2, and IgM isotype responses of cows to Salmonella serotype Dublin lipopolysaccharide (LPS) and porin. Following vaccination and experimental oral infection, IgG1 titers to LPS and porin rose more quickly and persisted longer than did IgG2 titers. In contrast to Salmonella infection, bacterin vaccination stimulated a weak response to Salmonella porin. Salmonella infection also induced a higher IgG2:IgG1 titer ratio to LPS than did bacterin vaccination. Chronic Salmonella infection induced the highest LPS and porin IgG2:IgG1 titer ratios and the highest correlation between LPS and porin titers. Response operating characteristic curves for each isotype-specific enzyme-linked immunosorbent assay (ELISA) were determined to evaluate the effect of isotype on the sensitivity and specificity of Salmonella ELISA serology for distinguishing sera of Salmonella carriers from those of vaccinated and acutely infected cows. IgG2 titers to LPS and porin provide a more specific indicator of chronic Salmonella infection status than do IgG1 titers to the same antigens with little to no loss in sensitivity.