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Shiga toxin-producing Escherichia coli (STEC) infection can cause serious illness including haemolytic uraemic syndrome. The role of socio-economic status (SES) in differential clinical presentation and exposure to potential risk factors amongst STEC cases has not previously been reported in England. We conducted an observational study using a dataset of all STEC cases identified in England, 2010–2015. Odds ratios for clinical characteristics of cases and foodborne, waterborne and environmental risk factors were estimated using logistic regression, stratified by SES, adjusting for baseline demographic factors. Incidence was higher in the highest SES group compared to the lowest (RR 1.54, 95% CI 1.19–2.00). Odds of Accident and Emergency attendance (OR 1.35, 95% CI 1.10–1.75) and hospitalisation (OR 1.71, 95% CI 1.36–2.15) because of illness were higher in the most disadvantaged compared to the least, suggesting potential lower ascertainment of milder cases or delayed care-seeking behaviour in disadvantaged groups. Advantaged individuals were significantly more likely to report salad/fruit/vegetable/herb consumption (OR 1.59, 95% CI 1.16–2.17), non-UK or UK travel (OR 1.76, 95% CI 1.40–2.27; OR 1.85, 95% CI 1.35–2.56) and environmental exposures (walking in a paddock, OR 1.82, 95% CI 1.22–2.70; soil contact, OR 1.52, 95% CI 2.13–1.09) suggesting other unmeasured risks, such as person-to-person transmission, could be more important in the most disadvantaged group.
A total of 592 people reported gastrointestinal illness following attendance at Street Spice, a food festival held in Newcastle-upon-Tyne, North East England in February/March 2013. Epidemiological, microbiological and environmental investigations were undertaken to identify the source and prevent further cases. Several epidemiological analyses were conducted; a cohort study; a follow-up survey of cases and capture re-capture to estimate the true burden of cases. Indistinguishable isolates of Salmonella Agona phage type 40 were identified in cases and on fresh curry leaves used in one of the accompaniments served at the event. Molecular testing indicated entero-aggregative Escherichia coli and Shigella also contributed to the burden of illness. Analytical studies found strong associations between illness and eating food from a particular stall and with food items including coconut chutney which contained fresh curry leaves. Further investigation of the food supply chain and food preparation techniques identified a lack of clear instruction on the use of fresh uncooked curry leaves in finished dishes and uncertainty about their status as a ready-to-eat product. We describe the investigation of one of the largest outbreaks of food poisoning in England, involving several gastrointestinal pathogens including a strain of Salmonella Agona not previously seen in the UK.
Introduction: It is estimated that up to 30% of medical services in Canada are potentially unnecessary, not supported by current evidence or may cause patient harm. This type of practice negatively impacts patients and the healthcare system. Evidence suggests that medical education strongly impacts resource utilization in future practice. Our objective was to integrate Choosing Wisely (CW) recommendations into the undergraduate medical education curriculum to improve students understanding of resource stewardship in their pre-clerkship training. Methods: Post-course survey data and written feedback were collected from the Cumming School of Medicines 2019 class. Qualitative analysis of written feedback was used to identify perceived strengths and areas of improvement to inform additional changes for the 2020 class through a Plan-Do-Study-Act (PDSA) cycle. Results: The post-course survey was completed by 143 students. 60% reported the inclusion of CW improved their ability to develop a clinical management plan. Using the information gathered from the qualitative analysis, we made the following changes for the 2020 class: create an introductory lecture on resource stewardship, incorporate relevant CW recommendations into case study learning objectives, and create standardized slides on CW recommendations for lecturers. Feedback from the 2020 class revealed that the changes were well received and students reported feeling more comfortable with resource stewardship concepts. Conclusion: This data reveals that our efforts have increased students confidence in creating a management plan that integrates resource stewardship and patient safety, and elicited strong faculty support. We will continue to integrate these changes and to obtain student and faculty feedback to help inform additional iterative changes for the subsequent cohort. Our findings are valuable for other medical schools across Canada seeking to incorporate CW material.
Background: Planning for neurology training necessitated a reflection on the experience of graduates. We explored practice characteristics, and training experience of recent graduates. Methods: Graduates from 2010-2014 completed a survey. Results: Response rate was 37% of 211. 56% were female. 91% were adult neurologists. 65% practiced in an outpatient setting. 63% worked in academics. 85% completed subspecialty training (median 1 year). 36% work 3 days a week or less. 82% took general call (median 1 night weekly). Role preparation was considered very good or excellent for most; however poor or fair ratings were 17% in advocacy and 8% in leadership. Training feedback was at least “good” for 87%. Burnout a few times a week or more was noted by 5% (6% during residency, particularly PGY1 and 5). 64% felt overly burdened by paperwork. Although most felt training was adequate, it was poor or fair at preparing for practice management (85%) and personal balance (55%). Most conditions were under-observed in training environment. Many noted a need for more independent practice development and community neurology. Conclusions: Although our training was found to be very good, some identified needs included advocacy training, and more training in general neurology in the longitudinal outpatient/community settings.
Echinococcus granulosus (sensu lato) is now recognized as an assemblage of cryptic species, which differ considerably in morphology, development, host specificity (including infectivity/pathogenicity for humans) and other aspects. One of these species, E. granulosus sensu stricto (s.s.), is now clearly identified as the principal agent causing cystic echinococcosis in humans. Previous studies of a small section of the cox1 and nadh1 genes identified two variants of E. granulosus s.s. to be present in Australia; however, no further work has been carried out to characterize the microdiversity of the parasite in its territory. We have analysed the sequence of the full length of the cox1 gene (1609 bp) from 37 isolates of E. granulosus from different hosts and geographic regions of Australia. The analysis shows that seven haplotypes of E. granulosus s.s. not previously described were found, together with five haplotypes known to be present in other parts of the world, including the haplotype EG01 which is widespread and present in all endemic regions. These data extend knowledge related to the geographical spread and host range of E. granulosus s.s. in a country such as Australia in which the parasite established around 200 years ago.
Recent meta-analyses of resting-state networks in major depressive disorder (MDD) implicate network disruptions underlying cognitive and affective features of illness. Heterogeneity of findings to date may stem from the relative lack of data parsing clinical features of MDD such as phase of illness and the burden of multiple episodes.
Resting-state functional magnetic resonance imaging data were collected from 17 active MDD and 34 remitted MDD patients, and 26 healthy controls (HCs) across two sites. Participants were medication-free and further subdivided into those with single v. multiple episodes to examine disease burden. Seed-based connectivity using the posterior cingulate cortex (PCC) seed to probe the default mode network as well as the amygdala and subgenual anterior cingulate cortex (sgACC) seeds to probe the salience network (SN) were conducted.
Young adults with remitted MDD demonstrated hyperconnectivity of the left PCC to the left inferior frontal gyrus and of the left sgACC to the right ventromedial prefrontal cortex (PFC) and left hippocampus compared with HCs. Episode-independent effects were observed between the left PCC and the right dorsolateral PFC, as well as between the left amygdala and right insula and caudate, whereas the burden of multiple episodes was associated with hypoconnectivity of the left PCC to multiple cognitive control regions as well as hypoconnectivity of the amygdala to large portions of the SN.
This is the first study of a homogeneous sample of unmedicated young adults with a history of adolescent-onset MDD illustrating brain-based episodic features of illness.
Hospitalizations for acute bacterial skin and skin structure infection (ABSSSI) are common. Optimizing antibiotic use for ABSSSIs requires an understanding of current management. The objective of this study was to evaluate antibiotic prescribing practices and factors affecting prescribing in a diverse group of hospitals
Multicenter, retrospective cohort study.
Seven community and academic hospitals.
Children and adults hospitalized between June 2010 and May 2012 for cellulitis, wound infection, or cutaneous abscess were eligible. The primary endpoint was a composite of 2 prescribing practices representing potentially avoidable antibiotic exposure: (1) use of antibiotics with a broad spectrum of activity against gram-negative bacteria or (2) treatment duration greater than 10 days.
A total of 533 cases were included: 320 with nonpurulent cellulitis, 44 with wound infection or purulent cellulitis, and 169 with abscess. Of 492 cases with complete prescribing data, the primary endpoint occurred in 394 (80%) cases and varied significantly across hospitals (64%–97%; P < .001). By logistic regression, independent predictors of the primary endpoint included wound infection or purulent cellulitis (odds ratio [OR], 5.12 [95% confidence interval (CI)], 1.46–17.88), head or neck involvement (OR, 2.83 [95% CI, 1.17–6.82]), adult cases (OR, 2.20 [95% CI, 1.18–4.11]), and admission to a community hospital (OR, 1.90 [95% CI, 1.05–3.44]).
Among patients hospitalized for ABSSSI, use of antibiotics with broad gram-negative activity or treatment courses longer than 10 days were common. There may be substantial opportunity to reduce antibiotic exposure through shorter courses of therapy targeting gram-positive bacteria.
Infect Control Hosp Epidemiol 2014;35(10):1241–1250
Hardwood forests in eastern North America are being colonized by multiple nonnative plant and animal species. Colonization rates can be affected by stand structure and distance from edge. We sampled earthworm densities and understory plant species cover in transects located in paired old- and second-growth forests in Indiana. Two 100-m transects were established within each forest stand during late April to early May in each year. One transect was placed parallel to and within 5 m of a south- or west-facing edge. The second transect was placed parallel to the first. but at no less than 100 m from any edge. Nonnative earthworms and plants were found in forest edge and interior regardless of structural stage (second-growth vs. old-growth). The number of native plant species decreased linearly as the densities of adult Lumbricus and Aporrectodea earthworms and the percent cover of multiflora rose (an invasive plant species) increased. Densities of L. terrestris and Aporrectodea earthworms and percent cover of multiflora rose cumulatively explained 39% of the variation in the number of native plant species found in transects across the state. However, multivariate analyses suggested that the species composition of Indiana understory plant communities was affected more by geography than by earthworm densities. Our results suggest that nonnative earthworms and plants are ubiquitous in Indiana hardwood forests and that they may reduce the number of native plant species.
The aim of this study was to retrospectively assess the value of whole genome sequencing (WGS) compared to conventional typing methods in the investigation and control of an outbreak of Shigella sonnei in the Orthodox Jewish (OJ) community in the UK. The genome sequence analysis showed that the strains implicated in the outbreak formed three phylogenetically distinct clusters. One cluster represented cases associated with recent exposure to a single strain, whereas the other two clusters represented related but distinct strains of S. sonnei circulating in the OJ community across the UK. The WGS data challenged the conclusions drawn during the initial outbreak investigation and allowed cases of dysentery to be implicated or ruled out of the outbreak that were previously misclassified. This study showed that the resolution achieved using WGS would have clearly defined the outbreak, thus facilitating the promotion of infection control measures within local schools and the dissemination of a stronger public health message to the community.
Temperate and boreal forests in Canada and the northeastern United States have been invaded by several exotic species, including European earthworms (family Lumbricidae) and garlic mustard. Earthworms and garlic mustard co-occur and are both known to adversely impact some native plant species. However, relatively little is known about potential interactions between these two invaders. In a series of growth chamber experiments, we determined the palatability of garlic mustard and six native herbaceous forest species (shooting star, columbine, wild geranium, sweet cicely, butterfly milkweed, and yellow jewelweed) to the common nightcrawler. We also assessed the ability of the common nightcrawler to bury and digest garlic mustard and wild geranium. When offered seeds from garlic mustard and a native plant species, the earthworms ingested more garlic mustard seeds than seeds from four of the six native species. In a mesocosm experiment, the common nightcrawlers apparently digested 72 and 27% of garlic mustard and wild geranium seeds, respectively, that were placed on the soil surface. No seeds were observed on the soil surface at the end of the experiment but the majority of recovered seeds for both species were found within the top 10 cm (3.94 in). More seeds were recovered in 0- to 10-cm and 31- to 40-cm sections for wild geranium than for garlic mustard. No difference in seed recovery was detected at the other depths. Garlic mustard seed is readily consumed by common nightcrawlers and appears to be preferred over some native plant species suggesting that common nightcrawlers may reduce the size of the garlic mustard seed bank.
Contrary to concerns that fructose may have adverse metabolic effects, there is evidence that small, ‘catalytic’ doses ( ≤ 10 g/meal) of fructose decrease the glycaemic response to high-glycaemic index meals in human subjects. To assess the longer-term effects of ‘catalytic’ doses of fructose, we undertook a meta-analysis of controlled feeding trials. We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library. Analyses included all controlled feeding trials ≥ 7 d featuring ‘catalytic’ fructose doses ( ≤ 36 g/d) in isoenergetic exchange for other carbohydrates. Data were pooled by the generic inverse variance method using random-effects models and expressed as mean differences (MD) with 95 % CI. Heterogeneity was assessed by the Q statistic and quantified by I2. The Heyland Methodological Quality Score assessed study quality. A total of six feeding trials (n 118) met the eligibility criteria. ‘Catalytic’ doses of fructose significantly reduced HbA1c (MD − 0·40, 95 % CI − 0·72, − 0·08) and fasting glucose (MD − 0·25, 95 % CI − 0·44, − 0·07). This benefit was seen in the absence of adverse effects on fasting insulin, body weight, TAG or uric acid. Subgroup and sensitivity analyses showed evidence of effect modification under certain conditions. The small number of trials and their relatively short duration limit the strength of the conclusions. In conclusion, this small meta-analysis shows that ‘catalytic’ fructose doses ( ≤ 36 g/d) may improve glycaemic control without adverse effects on body weight, TAG, insulin and uric acid. There is a need for larger, longer ( ≥ 6 months) trials using ‘catalytic’ fructose to confirm these results.
Immunohistochemistry and immunogold labelling techniques were used to localize the EG95 vaccine antigen in Echinococcus granulosus oncospheres. In non-activated oncospheres, the cytoplasm of 2 pairs of bilateral cells exhibited specific positive labelling for the presence of EG95. No surface localization was seen in non-activated or recently activated oncospheres. Besides the staining of 2 pairs of bilateral cells, there was also a generalized distribution of specific staining for EG95 throughout the parenchyma of activated oncospheres. Immunogold labelling of non-activated oncosphere revealed specific reactivity for EG95 involving 2 pairs of bilateral cells and the ultrastructural characteristics of these cells were consistent with them being penetration gland cells. No other oncospheral structures stained specifically for the presence of EG95. The absence of surface location of EG95 in oncospheres suggests that the parasite may not be susceptible to vaccine-induced antibody and complement mediated attack until some post-oncospheral development has occurred. Further studies would be required to determine when the EG95 antigen associates with the parasite's surface, thus making them susceptible to immune attack.
There is concern surrounding the psychological health and uptake of treatment services among veterans of the UK Armed Forces.
Data from a cross-sectional, nationally representative sample were used to compare health outcomes and treatment seeking among 257 post-national service veterans aged 16–64 years and 504 age and sex frequency-matched non-veterans living in the community in England. Early leavers (<4 years service) were compared with longer serving veterans.
Male veterans reported more childhood adversity and were more likely to have experienced a major trauma in adulthood than non-veterans. There was no association between any measure of mental health and veteran status in males, except reporting more violent behaviours [adjusted odds ratio (aOR) 1.44, 95% confidence interval (CI) 1.01–2.06]. In females, a significant association was found between veteran status and ever having suicidal thoughts (aOR 2.82, 95% CI 1.13–7.03). No differences in treatment-seeking behaviour were identified between veterans and non-veterans with any mental disorder. Early service leavers were more likely to be heavy drinkers (aOR 4.16, 95% CI 1.08–16.00), to have had suicidal thoughts (aOR 2.37, 95% CI 1.21–4.66) and to have self-harmed (aOR 12.36, 95% CI 1.61–94.68) than longer serving veterans.
The findings of this study do not suggest that being a veteran is associated with adversity in terms of mental health, social disadvantage or reluctance to seek treatment compared with the general population. Some evidence implies that early service leavers may experience more mental health problems than longer-serving veterans.