International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Anorexia nervosa: a mistaken diagnosis

Eating disorders in the form of anorexia and bulimia are becoming increasingly common in young adults and children. Most of the patients are initially seen by their general practitioner (GP) and it may take several months before the facts are pieced together and an underlying eating disorder is identified. However, other medical conditions, albeit rare, should be considered when assessing these young adults as potentially missing them can lead to devastating consequences. This case highlights how a 15-year-old girl who presented to her GP with a history suggestive of an eating disorder and had a body mass index below the 0.4th centile, in fact had classical symptoms and clinical signs of primary adrenal failure, or Addison's disease.

A case of panic to pulmonary embolism

Pulmonary embolism (PE) is a rare paediatric diagnosis, but its presence is likely to be underestimated due to the subtle and non-specific nature of its symptoms. Common clinical features of PE include shortness of breath, pleuritic chest pain and acute cardiovascular collapse. Less common symptoms can include persistent unexplained tachycardia, fever or deep vein thrombosis. Rarely do patients present with abdominal pain and self-resolving shortness of breath; symptoms our patient experienced. However, in contrast to popular belief, having normal vital signs does not necessarily lower the probability of PE. D-dimer, a specific fibrin degradation product, has a good negative predictive value for venous thromboembolism diagnosis but its use in children is less clear, with up to 40% of children with PE having a normal D-dimer level. CT pulmonary angiography remains the gold standard in diagnosis.

Empty scrotum: undescended testis or ectopic?

This case of ectopic testis highlights the importance of a thorough first newborn examination followed by senior review when appropriate, and the expertise required to interpret neonatal ultrasounds. Following a provisional diagnosis of unilateral undescended testicle in a newborn, an ultrasound scan was unable to correctly identify the condition, resulting in a delay in diagnosis. The condition was later recognised incidentally, which led to a successful surgical correction. The early clinical examination and recognition of ectopic testis allows a timely surgical intervention preventing potential complications.

Chest pain in a 12-year-old girl with ulcerative colitis after therapy with mesalazine

This case of chest pain complicating therapy received for ulcerative colitis in a young patient highlights the importance of a thorough history and clinical examination. The complication can be rapidly fatal if not recognised and treated quickly.

Genital ulceration in a 4 year old--a case of safeguarding? From social services to pathology

This case of genital ulceration and social concerns in a preschool aged child was highly suspicious for child sexual abuse. However, the lesions presumed to be herpes simplex did not respond to antiviral medication. Specialist input from paediatric oncology and endocrinology resulted in a rare diagnosis of langerhans cell histiocytosis. Furthermore, the complication of diabetes insipidus later developed, making this the youngest child described to our knowledge with vulval lesions of langerhans cell histiocytosis and a central nervous system complication.

Periorbital cellulits--a mistaken diagnosis!

A 12-year-old girl presented with a 1 week history of orbital swelling associated with granuloma, purulent discharge from the eye and preauricular and submandibular lymphadenopathy. Initial conventional treatment for presumed preseptal cellulitis was unsuccessful. Despite treatment with broad spectrum antibiotics, the preseptal cellulitis progressed to orbital cellulitis with restriction of eye movements in addition to the marked conjunctival chemosis and haemorrhage. A detailed history revealed she had been in close contact with newborn kittens at home and biopsy of the granuloma demonstrated Bartonella species, confirming the diagnosis of cat scratch disease. The child received a course of appropriate oral and topical antibiotics and steroids. Unfortunately eyesight in the right eye remains poor on follow-up.

Preparation and in vitro Characterization of Porous Carrier-Based Glipizide Floating Microspheres for Gastric Delivery

Floating microspheres have been utilized to obtain prolonged and uniform release of drug in the stomach for development of once-daily formulations. A controlled-release system designed to increase residence time in the stomach without contact with the mucosa was achieved through the preparation of floating microspheres by the emulsion solvent diffusion technique, using (i) calcium silicate (CS) as porous carrier; (ii) glipizide, an oral hypoglycemic agent; and (iii) Eudragit^® S as polymer. The effects of various formulations and process variables on the internal and external particle morphology, micromeritic properties, in vitro floating behavior, drug loading, and in vitro drug release were studied. The microspheres were found to be regular in shape and highly porous. The prepared microspheres exhibited prolonged drug release (~8 h) and remained buoyant for >10 h. The mean particle size increased and the drug release rate decreased at higher polymer concentrations. No significant effect of the stirring rate during preparation on drug release was observed. In vitro studies demonstrated diffusion-controlled drug release from the microspheres. Microsphere formulation CS4, containing 200 mg calcium silicate, showed the best floating ability (88% buoyancy) in simulated gastric fluid. The release pattern of glipizide in simulated gastric fluid from all floating microspheres followed the Higuchi matrix model and the Peppas-Korsmeyer model.

Patient Characteristics Associated with Use of Monoclonal Antibody Treatment in Women with Metastatic Breast Cancer: A Population-Based Analysis

Introduction: Monoclonal antibodies (MoATB) were FDA approved for the treatment of patients with breast cancer (BrCA) whose tumors over expressed the human epidermal growth factor receptor 2 (HER2) in 1998. We sought to determine if certain patient characteristics and co-morbidities influenced MoATB use in a population-based practice setting of elderly women with metastatic BrCA. Methods: We identified female Medicare beneficiaries aged 66+ years diagnosed with incident metastatic BrCA without prior history for any cancer between 1999 and 2005 in the Surveillance, Epidemiology and End Results cancer registries (SEER). Charlson Co-morbidity index (CCI) and separate conditions within the index were created using linked Medicare claims in the year prior to the BrCA diagnosis. We identified both oral and infused chemotherapy (CH) from the Medicare claims from 1999 to 2006. Patients were categorized into three groups: no CH, MoATB+/-CH, and CH w/out MoATB. We performed bivariate statistics to compare the patient characteristics and comorbidities between the three groups, and the treatments groups only. Results: There were 3,820 women with metastatic BrCA, mean age 77 (SD 7.3) years, 81% were white race, 29% were married and 91% lived in an urban setting. 67% of these women (n=2,562) received no CH, 26% received CH w/out MoATB (n=994) and 7% received MoATB+/-CH (n=264). Overall the CCI was lower for women receiving either treatment as compared to no chemotherapy and between treatment groups for the young old (66-75 years) but not those aged 80+ years. The prevalence of congestive heart failure (CHF) and cerebrovascular disease was significantly lower in women receiving MoATB +/-CH, as compared to only CH, and also lower in both compared to no CH (n=2,462). Few women presenting with COPD or dementia were likely to be treated with either CH and/or MoATB compared to No CH. Other co-morbidity conditions within the CCI were not statistically different between the groups or the cell numbers were too small to analyze. Conclusion: MoATB use in the treatment of metastatic breast cancer steadily increased from 5% in 1999 to 23% in 2004. Use in 2005 was slightly lower but will be recalculated once the 2007 claims are available. In 2008, FDA released a black box warning for trastuzumab, the most frequently prescribed MoATB for BrCA, regarding the potential for the development of cardiomyopathy. Our results suggest that co-morbidities in particular CHF and cerebrovascular disease may influence the decision to use MoATB. Further research is necessary to examine the relationship between co-morbidities and the use of MoATB in the treatment of metastatic breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2057.

Taxane Treatment in Women with Incident Stage IV Breast Cancer

Introduction: The overall benefit of chemotherapy for late stage breast cancer treatment has been demonstrated in clinical trials and “real world” observational studies, but there is less data on chemotherapy use among older women. In addition, estrogen receptor status can influence treatment decisions. Our objective was to explore the clinical and demographic characteristics of women who received chemotherapy, particularly taxanes, in a large population-based cohort of older patients with incident stage IV breast cancer.Methods: Older women (age 66 and over) diagnosed with incident stage IV breast cancer from 1999 to 2005 were identified in the Surveillance, Epidemiology and End Results (SEER) cancer registries. Treatment-related data were linked from Medicare claims. We limited our analysis to ER negative (ER-) women with the assumption that these women would not be receiving tamoxifen as SEER data do not have complete information on receipt of tamoxifen. Receipt of chemotherapy was identified from claims files. Bivariate analyses were performed to compare clinical and demographic characteristics of those who received taxanes, other chemotherapy, or no chemotherapy.Results: Of 3,820 older women diagnosed with incident stage IV breast cancer, 1,518 women (40%) were identified as ER negative, of whom 247 (16%) were treated with taxanes, 312 (21%) with other chemotherapy, and the remainder received neither. Mean age was 78, 84% of the study cohort was white, 27% were married, and 91% lived in urban areas. Fifty four percent of women had HER2 assays performed. Women who received taxanes were substantially younger (Mean=74, SD=5.49) than those who did not (Mean=80, SD=7.79) and had fewer co-morbidities (measured by Charlson co-morbidity index) (bivariate [see above] p=0.0003) than any other group. Individuals who received taxanes were less likely to be married, receive radiation or undergo surgery. Only 8% of those treated with taxanes had 2 or more medical conditions compared to 18% of those receiving other chemotherapy and 74% of those with no chemotherapy. Treatment groups varied in regard to some medical conditions including CHF, cerebrovascular disease, and dementia. For example, only 8% of those receiving taxanes had CHF, compared to 13% among the 'other chemotherapy' group and 78% among those receiving no treatment (bivariate [see above] p=0.0003). A similar trend was revealed with the other medical conditions, with taxane users consistently presenting with lower prevalence for each condition. Interestingly, no one who had dementia received any chemotherapy.Conclusion: Findings from this descriptive study showed that age and co-morbidity were the most important factors associated with receipt of taxanes as well as of other chemotherapy. However, those who received taxanes were the youngest and evidenced the least comorbidity of the 2 groups. Further study is needed to help inform clinicians in making optimum treatment recommendations for their older female patients with incident advanced breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2068.

Chemotherapy Treatment and Survival in Estrogen Receptor Negative Metastatic Breast Cancer: A Population-Based Analysis

Introduction: Although controlled clinical trials have demonstrated a beneficial effect of various chemotherapy regimens on survival in breast cancer (BC), little is known about treatment patterns and survival benefit in the “real world” population of elderly women with metastatic BC. Methods: We identified female Medicare beneficiaries aged ≥66 years with metastatic BC diagnosed from 1999 to 2005 in the Surveillance, Epidemiology and End Results cancer registries (SEER). Patients with a prior history of any cancer were excluded. Treatment-related data were abstracted from linked Medicare claims. Since Medicare claims have incomplete information on oral selective estrogen receptor modulators, we limited our study cohort to estrogen receptor negative (ER-) women. Chemotherapy was defined as the receipt of any chemotherapeutic regimen within 6 months after diagnosis. Initial regimens were characterized based on drugs given during the first 30 days of chemotherapy. We used a continuous-time interval-censored survival analysis to determine the effect of chemotherapy on hazard of any-cause death, controlling for sociodemographic and clinical factors, including proxy measures for performance status. Results: We identified 1518 ER(-) women diagnosed with metastatic BC in SEER. Mean age was 77.6 (SD 7.6) years, 84% were white race and 27% were married at the time of diagnosis. Of the 1518 metastatic ER(-) BC patients, 493 (32%) received chemotherapy. As compared to women who did not receive chemotherapy, women who received chemotherapy were more likely to be younger, married, have lower pre-cancer comorbidity as measured by the Charlson comorbidity index, have seen an oncology specialist and have cancer-directed surgery or radiation prior to chemotherapy. Initial regimens comprised predominantly one (31%) or two (46%) drug classes. The most common regimens were taxanes only (18%), anthracycline+alkylating agents (17%) and antimetabolite+alkylating agent (9%). Overall median followup time was 7 months; 1223 women (81%) died during followup. Median survival time was 5 months among women who did not receive chemotherapy and 15 months among women who received chemotherapy. Chemotherapy was associated with a statistically significant survival benefit (adjusted Hazard Ratio 0.61, 95% confidence interval 0.54, 0.70). Conclusion: In this population-based study of older women, there was a variety of chemotherapy regimens used for metastatic ER(-) BC. Chemotherapy received within 6 months after diagnosis was associated with a 39% reduction in hazard of death. These findings reflect chemotherapy use outside of the clinical trial setting and have important clinical and policy implications for the study of treatments among older women with advanced BC.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2064.

Acute pyelonephritis: comparison of diagnosis with 99mTc-DMSA, SPECT, spiral CT, MR imaging, and power Doppler US in an experimental pig model

PURPOSE

To compare the sensitivity and specificity of technetium-99m dimercaptosuccinic acid (DMSA) single photon emission computed tomography (SPECT), spiral computed tomography (CT), magnetic resonance (MR) imaging, and power Doppler ultrasonography (US) for the detection and localization of acute pyelonephritis by using histopathologic findings as the standard of reference.

MATERIALS AND METHODS

Bilateral vesicoureteric reflux was surgically created in 35 piglets (70 kidneys). One week later, a liquid bacterial culture of Escherichia coli was injected into the bladder. Three days after induction of urinary infection, imaging studies were performed, and the kidneys were removed for histopathologic examination. SPECT images were obtained 2-3 hours after injection of 99mTc-DMSA. Transverse and coronal MR images were obtained with gadolinium-enhanced fast inversion recovery. Transverse CT images were obtained before and after injection of contrast agent. Power Doppler US was performed in longitudinal, transverse, and coronal planes. Each kidney was divided into three zones for correlation of findings.

RESULTS

Histopathologic examination revealed pyelonephritis in 102 zones in 38 kidneys. Sensitivity and specificity for detecting pyelonephritis in the kidneys were 92.1% and 93.8% for SPECT, 89.5% and 87.5% for MR imaging, 86.8% and 87.5% for CT, and 74.3% and 56.7% for US. Sensitivity and specificity for detecting pyelonephritis in the zones were 94.1% and 95.4% for SPECT, 91.2% and 92.6% for MR imaging, 88.2% and 93.5% for CT, and 56.6% and 81.4% for US. The pairwise comparison of these modalities showed no statistically significant difference among them except for US.

CONCLUSION

99mTc-DMSA SPECT, spiral CT, and MR imaging appear to be equally sensitive and reliable for the detection of acute pyelonephritis; power Doppler US is significantly less accurate.

Growth hormone (GH)-releasing peptide-6 requires endogenous hypothalamic GH-releasing hormone for maximal GH stimulation

GH-releasing peptide-6 (GHRP-6) is a potent GH secretagogue that releases GH by uncertain mechanisms. To assess whether GHRH is required for GH release by GHRP-6 in humans, we used the specific antagonist to GHRH (N-Ac-Tyr1,D-Arg2)GHRH(1-29)NH2 (GHRH Ant). We have previously shown that GHRH-Ant (400 microg/kg) blocked the GH response to 0.33 and 3.3 microg/kg boluses of GHRH by 95% and 81%, respectively. Nine healthy men between the ages of 20 and 30 yr were studied on two occasions. They received either saline or GHRH-Ant (400 microg/kg, i.v.) at 0840 h, followed by GHRP-6 (1 microg/kg, i.v. bolus) at 0900 h. Blood was sampled every 10 min from 0800-1100 h. GH responses were measured as the maximal increase over the baseline GH concentration and as the area under the curve. GHRH-Ant eliminated most of the GH response to GHRP-6 [maximal increase over the baseline GH concentration, 33.8 +/- 4.8 vs. 6.2 +/- 1.8 microg/L (mean +/- SEM; P < 0.0001); area under the curve, 1701 +/- 278 vs. 376 +/- 113 microg/min x L (P < 0.001)]. These data show that endogenous GHRH is necessary for most of the GH response to GHRP-6 in humans.

An uncommon cause of peripheral neuropathy

The following case report is of a middle aged man with a progressive neurologic disability who was brought to our emergency department. Caregivers could no longer manage him once he lost the ability to ambulate and became incontinent. At that time his neurologic and hematologic parameters were fairly typical of cobalamin deficiency. We are reporting this case to emphasize that cobalamin deficiency is not always due to pernicious anemia in the elderly or the malnourished alcoholic. Deficiency from uncommon causes can manifest at any age and result in severe morbidity.

Ethnic minorities. The role of health advocates in health visiting teams

An east London project placed health advocates in health visiting teams to explore ways to deliver a better service to ethnic minority clients. Sonia Harding and Neeta Pandya report on the project, funded by London Implementation Zone monies, which resulted in recommendations for the development of the role and practice of health advocates, including independent home visiting.

Feeding, illness and nutritional status of young children in rural Gujarat

Eighty children, aged 0-18 months, were studied over a period of 6 months. Information was obtained from monthly interviews with mothers, when the children were also weighed. Feeding practices, incidence of illness and weight gain were described. The children who were nutritionally most at risk were identified. The average weight of the children was 1 kg less than the NCHS international reference by 3 months, 1.7 kg by 9 months. The majority of mothers did not introduce foods other than breast milk before 9 months. The children from labourers' households gained less weight between 3 and 6 months, had a higher prevalence of malnutrition and more reports of illness than children from non-labourers' households. The implications of these results for workers in child health and nutrition programmes are discussed.