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To describe an outbreak of bacteremia caused by vancomycin-sensitive Enterococcus faecalis (VSEfe).
An investigation by retrospective case control and molecular typing by whole-genome sequencing (WGS).
A tertiary-care neonatal unit in Melbourne, Australia.
Risk factors for 30 consecutive neonates with VSEfe bacteremia from June 2011 to December 2014 were analyzed using a case control study. Controls were neonates matched for gestational age, birth weight, and year of birth. Isolates were typed using WGS, and multilocus sequence typing (MLST) was determined.
Bacteremia for case patients occurred at a median time after delivery of 23.5 days (interquartile range, 14.9–35.8). Previous described risk factors for nosocomial bacteremia did not contribute to excess risk for VSEfe. WGS typing results designated 43% ST179 as well as 14 other sequence types, indicating a polyclonal outbreak. A multimodal intervention that included education, insertion checklists, guidelines on maintenance and access of central lines, adjustments to the late onset sepsis antibiotic treatment, and the introduction of diaper bags for disposal of soiled diapers after being handled inside the bed, led to termination of the outbreak.
Typing using WGS identified this outbreak as predominately nonclonal and therefore not due to cross transmission. A multimodal approach was then sought to reduce the incidence of VSEfe bacteremia.
Metastatic cutaneous squamous cell carcinoma is the most common parotid malignancy in Australasia. Prognostic indicators are not clearly defined and the extent of surgical resection required is controversial.
A retrospective analysis was conducted of 63 patients who underwent surgery for metastatic cutaneous squamous cell carcinoma of the parotid gland at a tertiary hospital over a 10-year period.
The five-year overall survival rate was 53 per cent, the disease-specific survival rate was 78 per cent and the locoregional control rate was 72 per cent. Immunosuppression and no adjuvant radiotherapy were associated with a significant reduction in disease-specific survival. None of the factors analysed had a significant effect on locoregional control rates.
More extensive surgery, including lateral temporal bone resection, may improve local control rates in cases of more advanced disease. The reduced survival of immunocompromised patients must be considered when planning their management.
Diverse strain types of methicillin-resistant Staphylococcus aureus (MRSA) cause infections in community settings worldwide. To examine heterogeneity of spread within households and to identify common risk factors for household transmission across settings, primary data from studies conducted in New York (USA), Breda (The Netherlands), and Melbourne (Australia) were pooled. Following MRSA infection of the index patient, household members completed questionnaires and provided nasal swabs. Swabs positive for S. aureus were genotyped by spa sequencing. Poisson regression with robust error variance was used to estimate prevalence odds ratios for transmission of the clinical isolate to non-index household members. Great diversity of strain types existed across studies. Despite differences between studies, the index patient being colonized with the clinical isolate at the home visit (P < 0·01) and the percent of household members aged <18 years (P < 0·01) were independently associated with transmission. Targeted decolonization strategies could be used across geographical settings to limit household MRSA transmission.
Community-acquired Staphylococcus aureus infections are a public health concern, yet little is known about infections that do not present to hospital. We identified community-onset S. aureus infections via specimens submitted to a community-based pathology service. Referring doctors confirmed eligibility and described infection site, severity and treatment. Isolates were characterized on antibiotic resistance, PFGE, MLST/SCCmec, and Panton–Valentine leukocidin (PVL), representing 106 community-onset infections; 34 non-multiresistant methicillin-resistant S. aureus (nmMRSA) (resistant to <3 non-β-lactam antibiotics), 15 multiply antibiotic-resistant MRSA (mMRSA) and 57 methicillin-sensitive S. aureus (MSSA). Most (93%) were skin and soft tissue infections. PVL genes were carried by 42% of nmMRSA isolates [95% confidence interval (CI) 26–61] and 15% of MSSA (95% CI 8–28). PVL was associated with infections of the trunk, head or neck (56·4% vs. 24·3%, P = 0·005) in younger patients (23 vs. 52 years, P < 0·001), and with boils or abscesses (OR 8·67, 95% CI 2·9–26·2), suggesting underlying differences in exposure and/or pathogenesis.
Voice rest is commonly recommended after vocal fold surgery, but there is a lack of evidence base and no standard protocol. The aim of this study was to establish common practice regarding voice rest following vocal fold surgery.
An online survey was circulated via e-mail invitation to members of the ENT UK Expert Panel between October and November 2011.
The survey revealed that 86.5 per cent of respondents agreed that ‘complete voice rest’ means no sound production at all, but there was variability in how ‘relative voice rest’ was defined. There was no dominant type of voice rest routinely recommended after surgery for laryngeal papillomatosis or intermediate pathologies. There was considerable variability in the duration of voice rest recommended, with no statistically significant, most popular response (except for malignant lesions). Surgeons with less than 10 years of experience were more likely to recommend fewer days of voice rest.
There is a lack of consistency in advice given to patients after vocal fold surgery, in terms of both type and length of voice rest. This may arise from an absence of robust evidence on which to base practice.
1. Six cases of haemolytic disease in newborn foals apparently due to iso-immunization of pregnancy are described from their clinical, serological, haematological and pathological aspects. The findings agree closely with those seen in the same disease in newborn mules.
2. The disease may be diagnosed serologically by demonstrating the in vivo iso-sensitization of the foal's red cells by means of the direct antiglobulin-sensitization test. It is quite possible that after further investigation a modification of Diamond's albumin tube test may also be of value. Immune anti-red cell iso-antibodies of more than one specificity may be demonstrated in the dams' sera.
3. Despite the acute haemolytic process, very few reticulocytes and no erythroblasts are seen in the peripheral blood.
4. The morbid histology of the tissues of foals dying with the disease exhibits various points of interest which are discussed.
5. The clinical aspect is not described in this paper in any detail. However, a programme is suggested which would enable a successful exsanguino-transfusion of compatible blood to be carried out at very short notice. At present this seems to be the logical and most practical method of specific treatment.
Governments of democratic countries during the war have accepted a new responsibility – that of maintaining a high and stable level of employment within their borders.
It is of course not a new thing for governments, as far as lies within their power, to seek governmentally determined results from the workings of the economic system. The writings of those early economic thinkers, the Mercantilists, show that it was generally believed that the course of trade, in addition to enriching the individuals who carried it on, should lead to the accumulation of “treasure” within the nation and increase its economic and therefore its military strength in relation to that of its actual and potential rivals.
Gradually, however, these beliefs gave way to the general view that the economic system could generally be left to run itself, and that governments should confine their intervention to making the rules, and to some extent to protecting the weak and succouring the injured. This non-interventionist attitude of governments of course had its exceptions – defence and the promotion of industrial development have long been recognized as at least plausible excuses. And of course during wars the workings of the economic system have always been subordinated to a greater or less extent to the over-riding purpose of winning the war.
To describe an outbreak of invasive methicillin-resistant Staphylococcus aureus (MRSA) infection after percutaneous needle procedures (acupuncture and joint injection) performed by a single medical practitioner.
A medical practitioner's office and 4 hospitals in Perth, Western Australia.
Eight individuals who developed invasive MRSA infection after acupuncture or joint injection performed by the medical practitioner.
We performed a prospective and retrospective outbreak investigation, including MRSA colonization surveillance, environmental sampling for MRSA, and detailed molecular typing of MRSA isolates. We performed an infection control audit of the medical practitioner's premises and practices and administered MRSA decolonization therapy to the medical practitioner.
Eight cases of invasive MRSA infection were identified. Seven cases occurred as a cluster in May 2004; another case (identified retrospectively) occurred approximately 15 months earlier in February 2003. The primary sites of infection were the neck, shoulder, lower back, and hip: 5 patients had septic arthritis and bursitis, and 3 had pyomyositis; 3 patients had bacteremia, including 1 patient with possible endocarditis. The medical practitioner was found to be colonized with the same MRSA clone [ST22-MRSA-IV (EMRSA-15)] at 2 time points: shortly after the first case of infection in March 2003 and again in May 2004. After the medical practitioner's premises and practices were audited and he himself received MRSA decolonization therapy, no further cases were identified.
This outbreak most likely resulted from a breakdown in sterile technique during percutaneous needle procedures, resulting in the transmission of MRSA from the medical practitioner to the patients. This report demonstrates the importance of surveillance and molecular typing in the identification and control of outbreaks of MRSA infection.
To describe the control of an outbreak of infection and colonization with the New York/Japan methicillin-resistant Staphylococcus aureus (MRSA) clone in multiple healthcare facilities, and to demonstrate the importance of making an MRSA management policy involving molecular typing of MRSA into a statewide public health responsibility.
A range of healthcare facilities, including 2 metropolitan teaching hospitals and a regional hospital, as well as several community hospitals and long-term care facilities in a nonmetropolitan healthcare region.
A comprehensive, statewide MRSA epidemiological investigation and management policy.
In May 2005, there were 3 isolates referred to the Western Australian Gram-Positive Bacteria Typing and Research Unit that were identified as the New York/Japan MRSA clone, a pandemic MRSA clone with the ability to spread and replace existing clones in a region. Subsequent investigation identified 28 additional cases of infection and/or colonization dating from 2002 onward, including 1 involving a colonized healthcare worker (HCW) who had previously been hospitalized overseas. Of the 31 isolates detected, 25 were linked epidemiologically and via molecular typing to the isolate recovered from the colonized HCW. Four isolates appeared to have been introduced separately from overseas. Although the isolate from the single remaining case patient was genetically indistinct from the isolates that spread within Western Australia, no specific epidemiological link could be established. The application of standard outbreak management strategies reduced further spread.
The elimination of the New/York Japan MRSA clone in a healthcare region demonstrates the importance of incorporating MRSA management policy into statewide public health programs. The mainstays of such programs should include a comprehensive and effective outbreak identification and management policy (including pre-employment screening of HCWs, where applicable) and MRSA clone identification by multilocus sequence typing.
A gonnardite-thomsonite-chabazite-calcite assemblage forms a cement in the Foveaux Formation, a fossiliferous gabbroic boulder bed that accumulated at the base of a sea cliff cut in a Permian igneous complex during late Oligocene±early Miocene time. Gonnardite was the earliest zeolite to form, locally following minor calcite. It was followed epitaxially by thomsonite, co-precipitating with chabazite. Crystal habits indicate a low-temperature origin. The maximum temperature to which the deposit may have been subjected is estimated as not more than ∽30°C. The chabazites are Ca-poor chabazite-K and chabazite-Na. Representative electron microprobe analyses are as follows, all + nH2O:
thomsonite: Na3.77Ca7.73(Al19.39Si20.65)O80 and Na3.78K0.04Ca7.25Mg0.05(Al19.13Si21.05)O80;
gonnardite: Na6.95K0.03Ca4.73(Al16.99Si23.15)O80 and Na8.56K0.03Ca4.05(Al17.32Si22.84)O80;
chabazite-K: Na1.18K1.72Ca0.08Mg0.23(Al3.51Si8.49)O24 and Na1.67K1.92Ca0.18Mg0.17(Al4.11Si7.85)O24;
Such a Si-poor zeolite assemblage is unusual for marine sediments and is attributed to precipitation from marine water impoverished in silica in the gabbroic boulder bed and interacting with shell material and calcic plagioclase. In contrast, a dioritic clast in the boulder bed provides an example of less silica-poor zeolites originally formed in the parent igneous complex. Veinlets in the clast contain scolecite averaging Na1.19Ca7.36(Al15.84Si24.14)O80.nH2O, and mesolite averaging Na5.13K0.03Ca5.24 (Al15.93Si24.13)O80.nH2O, in part as sub-microscopic intergrowths. The composition of scolecite closely corresponds to the most Na-rich scolecite reported hitherto.
To demonstrate that nosocomial transmission of vancomycin-resistant enterococci (VRE) can be terminated and endemicity prevented despite widespread dissemination of an epidemic strain in a large tertiary-care referral hospital.
Two months after the index case was detected in the intensive care unit, 68 patients became either infected or colonized with an epidemic strain of vanB vancomycin-resistant Enterococcus faecium despite standard infection control procedures. The following additional interventions were then introduced to control the outbreak: (1) formation of a VRE executive group; (2) rapid laboratory identification (30 to 48 hours) using culture and polymerase chain reaction detection of vanA and vanB resistance genes; (3) mass screening of all hospitalized patients with isolation of carriers and cohorting of contacts; (4) environmental screening and increased cleaning; (5) electronic flagging of medical records of contacts; and (6) antibiotic restrictions (third-generation cephalosporins and vancomycin).
A total of 19,658 patient and 24,396 environmental swabs were processed between July and December 2001. One hundred sixty-nine patients in 23 wards were colonized with a single strain of vanB vancomycin-resistant E. faecium. Introducing additional control measures rapidly brought the outbreak under control. Hospital-wide screening found 39 previously unidentified colonized patients, with only 7 more nonsegregat-ed patients being detected in the next 2 months. The outbreak was terminated within 3 months at a cost of $2.7 million (Australian dollars).
Despite widespread dissemination of VRE in a large acute care facility, eradication was achievable by a well-resourced, coordinated, multifaceted approach and was in accordance with good clinical governance.
Promastigotes of Leishmania mexicana mutants lacking the multicopy CPB
cysteine proteinase genes (ΔCPB) are markedly
less able than wild-type parasites to infect macrophages in vitro. ΔCPB promastigotes invade macrophages in large
numbers but are unable to survive in the majority of the cells. In contrast, ΔCPB amastigotes invade and survive within
macrophages in vitro. This extreme in vitro stage-specific difference was not mimicked in vivo; both promastigotes and
amastigotes of ΔCPB produced lesions in BALB/c mice, but in each case the lesions grew considerably more slowly than
those caused by wild-type parasites and only small lesions resulted. Inhibition of CPB in situ using cell-permeant
peptidyldiazomethylketones had no measurable effect on parasite growth or differentiation axenically in vitro. In contrast,
N-benzoyloxycarbonyl-phe-ala-diazomethylketone reduced the infectivity of wild-type parasites to macrophages by 80%.
Time-course experiments demonstrated that application of the inhibitor caused effects not seen with ΔCPB, suggesting
that CPB may not be the prime target of this inhibitor. The data show that the CPB genes of L. mexicana encode enzymes
that have important roles in intracellular survival of the parasite and more generally in its interaction with its mammalian
There have been many definitions to describe the sudden and unexpected death of an infant or child. Most exclude deaths in the first week and after the first year.
Most people use the term sudden unexpected death in infancy (SUDI) to mean a death that was not anticipated as a significant possibility 24 hours before the death. It would include deaths occurring as a result of an acute illness not anticipated 24 hours before the death, deaths arising from a previously known condition not expected to lead to death, or deaths arising from a pre-existing condition not previously recognized. It usually includes those deaths resulting from accident, trauma, or poisoning.
The cases where the cause of death is not known after a full and detailed history, death scene investigation, full pathology using a standardized protocol, and multi-agency review are then described as sudden infant death syndrome (SIDS). Of course, if a cause is found then the death does not belong to the category of SIDS.
The diagnosis of SIDS should not be used unless there is a full post mortem with no positive findings.
The term cot death was used in the past. This is no longer a useful term as the majority of infants are not found in the cot and some parents believe that if the child is not in its cot it will not be a cot death.
Lateral thinking in biomimetic materials chemistry has permitted chemists to create fascinating structures that mimic the biomaterials optimized by Nature. The integration of organic and inorganic chemistry at multiple length scales gives optimal performance characteristics to biomaterials, such as bone. In a similar fashion, lateral thinking in our lab has enabled us to consolidate the chemistry of inorganic surfactant-templated mesoporous materials with the organic-inorganic hybrid structure of amorphous xerogels. A new class of materials, periodic mesoporous organosilicas (PMOs), has emerged that marries organic and solid-state chemistry in the channels of hexagonally ordered mesoporous materials. Various organic and organometallic groups may be integrated into the framework, creating materials with novel, tunable properties. Surfactant can be solvent-extracted or ion-exchanged to create a high surface area PMO with the framework and the organic group intact. This renders the organic groups accessible for reaction to give a new type of “chemistry of the channels”.
In four genera of schizotheriine Chalicotheriidae—Moropus, Tylocephalonyx, Phyllotillon, and Ancylotherium–proximal and middle phalanges of digit II of the manus fuse to form a duplex bone. Fusion of proximal and middle phalanges of digit II of the pes also occurs in many species of these genera. Radiographic and sagittal-sectional study of the fused duplex phalanges of Moropus elatus and Tylocephalonyx skinneri shows that the joint between the two bones formed fully prior to fusion but had little movement. Fusion proceeded by external enthesial interactions at the insertion of the ligament capsule and by disruption of cortical bone with trabecular bridging along the internal part of the original articular surface. Cortical disruption is more rapid on the middle than on the proximal phalangeal component of the duplex. In M. elatus, the degrees of external and internal fusion roughly correspond, and a ventral surficial groove sometimes traces the former facet, whereas in T. skinneri external fusion is much more developed than internal fusion. Phalangeal fusion seems to have strengthened the digit against strong forces applied along the medial (radial or tibial) side of the foot.
Parasite enzymes involved in proteolysis and amino
acid metabolism have attracted considerable attention over the last
decade. Nevertheless, current
knowledge is extensive for just a few parasites and
several enzymes. Most enzymes remain largely
unexplored. This review concentrates upon a selection of the better
studied enzymes and the potentially
valuable approaches now being adopted in their
study. We present a personal view on the most
suitable strategies for exploiting this area of parasite
biochemistry with novel antiparasite drugs. The
content of the review reflects our own work and
interests, but we have aimed to include a sufficiently
broad range of topics so that this overview serves as
a useful introduction for those new to the subject.
There have been several reviews that provide good
coverage of the appropriate literature (Barrett, 1991;
McKerrow et al. 1993; North & Lockwood, 1995;
Sakanari et al. 1995; Robertson et al. 1996; Vial,
1996; Coombs & Mottram, 1997; Walker & Barrett,
1997), therefore we detail here just some of the
publications and refer readers to the reviews quoted
for further information. This treatise mainly highlights progress
made in studies with parasitic
protozoa. Parasitic worms present more difficult
problems for drug designers and there has been only
limited progress to date in this area of biochemistry;
we include here mention of just some of the more
exciting advances so far.
The laboratory experiments described here, were aimed at examining the interaction of microbes with mineralogical surfaces involved with groundwater flow. These experiments were designed to study simple systems and were aimed at identifying relevant reactions both chemical and biological. They contained groundwater with either sulphate reducing bacteria (SRB), iron reducing bacteria (IRB) or a mixture of both, together with control experiments without bacteria. The results of the chemical analyses of fluid phases showed evidence for dissolution of primary minerals. Microbial analysis showed both SRB and IRB appeared to be active albeit for a limited period due to exhaustion of nutrient and energy supplies. SRB seem to have a greater effect on groundwater chemistry than IRB with sulphide being produced. However, when the two types of bacteria are mixed together, the IRB appear to dominate the system. Further work is underway to give detailed mineralogical analysis of the solids in order to better understand the influence of microbial interaction on the redox reactions.
A series of batch laboratory experiments were set up to study the gross effects of microbial activity on repository geochemistry, radionuclide sorption and integrity of repository and host rock materials. The experiments were fully monitored for 550 days and some were continued, under apparently aerobic conditions, for 1700 days. Geochemical modelling of the experiments reproduced many of their features, but showed that the contents were not in chemical equilibrium after 1700 days with redox disequilibrium a likely feature. The models could not predict localised reactions such as enhanced pitting of steel which appeared to be microbially mediated.