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Culture-based studies, which focus on individual organisms, have implicated stethoscopes as potential vectors of nosocomial bacterial transmission. However, the full bacterial communities that contaminate in-use stethoscopes have not been investigated.
We used bacterial 16S rRNA gene deep-sequencing, analysis, and quantification to profile entire bacterial populations on stethoscopes in use in an intensive care unit (ICU), including practitioner stethoscopes, individual-use patient-room stethoscopes, and clean unused individual-use stethoscopes. Two additional sets of practitioner stethoscopes were sampled before and after cleaning using standardized or practitioner-preferred methods.
Bacterial contamination levels were highest on practitioner stethoscopes, followed by patient-room stethoscopes, whereas clean stethoscopes were indistinguishable from background controls. Bacterial communities on stethoscopes were complex, and community analysis by weighted UniFrac showed that physician and patient-room stethoscopes were indistinguishable and significantly different from clean stethoscopes and background controls. Genera relevant to healthcare-associated infections (HAIs) were common on practitioner stethoscopes, among which Staphylococcus was ubiquitous and had the highest relative abundance (6.8%–14% of contaminating bacterial sequences). Other HAI-related genera were also widespread although lower in abundance. Cleaning of practitioner stethoscopes resulted in a significant reduction in bacterial contamination levels, but these levels reached those of clean stethoscopes in only a few cases with either standardized or practitioner-preferred methods, and bacterial community composition did not significantly change.
Stethoscopes used in an ICU carry bacterial DNA reflecting complex microbial communities that include nosocomially important taxa. Commonly used cleaning practices reduce contamination but are only partially successful at modifying or eliminating these communities.
The benefit of mandibular advancement devices in patients with sleep-disordered breathing and as a potential option for obstructive sleep apnoea syndrome is well recognised. Their use in the setting of epilepsy or other seizure disorders is typically contraindicated.
A 48-year-old patient with a history of poorly controlled epilepsy and obstructive sleep apnoea syndrome was referred for ENT review for possible tracheostomy. The patient was wheelchair-bound with 24-hour continuous positive airway pressure, but sleep studies demonstrated persistent, severe episodes of apnoea and notable sleep disturbance. Sleep nasendoscopy demonstrated marked improvement on capnography with the laryngeal mask airway in situ, and this was maintained with mandibular advancement using jaw thrust following removal of the laryngeal mask airway. A mandibular advancement device was subsequently trialled; this had no subjective benefit for the patient, but the seizures resolved and control of apnoea was achieved with the combination of a mandibular advancement device and continuous positive airway pressure.
This paper highlights a novel application of mandibular advancement devices, used in combination with continuous positive airway pressure, which resulted in complete resolution of sleep deprivation and apnoea-induced epileptic events.
Not only is depression associated with increased inflammation but inflammation is a risk factor for the genesis of depression. Many of the environmental risk factors for depression are transduced through inflammatory signaling. Anti-inflammatory agents show promise for the management of depression in preclinical, epidemiological, and early clinical studies. This opens the door to the potential for anti-inflammatory agents to treat and prevent depression. There are no evidence-based pharmacotherapies for depression prevention.
ASPREE-D, aspirin in the prevention of depression in the elderly, is a sub study of ASPREE, which explores the potential of aspirin to prevent a range of inflammation related disorders in the elderly. With a sample size of 19,114, and a duration of 5 years, this placebo controlled study will be one of the largest randomized controlled trials in psychiatry and will provide definitive evidence on the ability of aspirin to prevent depression.
This paper presents the rationale for the study and presents a summary of the study design.
ASPREE-D may not only define novel therapy but will provide mechanistic proof of concept of the role of inflammation in depression.
Metamorphic epitaxy offers the possibility of growing devices on wafers composed of different materials that might be larger than the native bulk substrates for a potential cost-reduction of III–V components; this is especially important when native substrates with desired lattice constants are not available. This article reviews the concepts of metamorphic epitaxy of III–V compound semiconductor materials and examines how they have been applied to the development of advanced transistor devices. These metamorphic devices are expected to be a key enabler of future heterogeneous integrated circuits in which Si and III–V devices are monolithically integrated on a wafer scale using complementary metal oxide semiconductor-like process flows.
This study aimed to undertake a systematic review of the literature about pre-operative counselling for laryngectomy patients, identify its practice and patient and (where possible) carer perceptions.
A search strategy was formulated using a concept map and a Population, Intervention, Comparative Interaction and Outcomes (‘PICO’) schema. All publications from 1975 to 2015 reporting pre-operative counselling of laryngectomy patients were included. Papers were retrieved and critiqued, and those included were assigned a level of evidence (according to the Joanna Briggs Institute schema).
Of the 56 papers retrieved, 21 were included in the review. The literature is limited: studies demonstrate bias and are of poor methodological quality. There are clear, persistent reports by patients and carers of shortfalls in clinical practice.
Studies on pre-operative counselling for laryngectomees are flawed in design and represent weak levels of evidence. Pre-operative counselling has not been operationalised, resulting in differing paradigms being examined. Aggregation of data and/or results is not possible and the veracity of many studies is questioned.
We describe two cases of infant botulism due to Clostridium butyricum producing botulinum type E neurotoxin (BoNT/E) and a previously unreported environmental source. The infants presented at age 11 days with poor feeding and lethargy, hypotonia, dilated pupils and absent reflexes. Faecal samples were positive for C. butyricum BoNT/E. The infants recovered after treatment including botulism immune globulin intravenous (BIG-IV). C. butyricum BoNT/E was isolated from water from tanks housing pet ‘yellow-bellied’ terrapins (Trachemys scripta scripta): in case A the terrapins were in the infant's home; in case B a relative fed the terrapin prior to holding and feeding the infant when both visited another relative. C. butyricum isolates from the infants and the respective terrapin tank waters were indistinguishable by molecular typing. Review of a case of C. butyricum BoNT/E botulism in the UK found that there was a pet terrapin where the infant was living. It is concluded that the C. butyricum-producing BoNT type E in these cases of infant botulism most likely originated from pet terrapins. These findings reinforce public health advice that reptiles, including terrapins, are not suitable pets for children aged <5 years, and highlight the importance of hand washing after handling these pets.
Sustaining performance is a difficult and often overlooked aspect of quality improvement and implementation science. Over a 4-year period, we observed that monthly feedback of performance data in face-to-face meetings with frontline personnel was crucial in maintaining environmental-cleaning effectiveness in adult critical care units.
The objective of this study was to identify detailed fertility traits in dairy and beef cattle from transrectal ultrasonography records and quantify the associated risk factors. Data were available on 148 947 ultrasound observations of the reproductive tract from 75 949 cows in 843 Irish dairy and beef herds between March 2008 and October 2012. Traits generated included (1) cycling at time of examination, (2) cystic structures, (3) early ovulation, (4) embryo death and (5) uterine score; the latter was measured on a scale of 1 (good) to 4 (poor) characterising the tone of the uterine wall and fluid present in the uterus. After editing, 72 773 records from 44 415 dairy and beef cows in 643 herds remained. Factors associated with the logit of the probability of a positive outcome for each of the binary fertility traits were determined using generalised estimating equations; linear mixed model analysis was used for the analysis of uterine score. The prevalence of cycling, cystic structures, early ovulation and embryo death was 84.75%, 3.87%, 7.47% and 3.84%, respectively. The occurrence of the uterine heath score of 1, 2, 3 and 4 was 70.63%, 19.75%, 8.36% and 1.26%, respectively. Cows in beef herds had a 0.51 odds (95% CI=0.41 to 0.63, P<0.001) of cycling at the time of examination compared with cows in dairy herds; stage of lactation at the time of examination was the same in both herd types. Furthermore, cows in dairy herds had an inferior uterine score (indicating poorer tone and a greater quantity of uterine fluid present) compared with cows in beef herds. The likelihood of cycling at the time of examination increased with parity and stage of lactation, but was reduced in cows that had experienced dystocia in the previous calving. The presence of cystic structures on the ovaries increased with parity and stage of lactation. The likelihood of embryo/foetal death increased with parity and stage of lactation. Dystocia was not associated with the presence of cystic structures or embryo death. Uterine score improved with parity and stage of lactation, while cows that experienced dystocia in the previous calving had an inferior uterine score. Heterosis was the only factor associated with increased likelihood of early ovulation. The fertility traits identified, and the associated risk factors, provide useful information on the reproductive status of dairy and beef cows.
Feet and legs issues are some of the main causes for sow removal in the US swine industry. More timely lameness detection among breeding herd females will allow better treatment decisions and outcomes. Producers will be able to treat lame females before the problem becomes too severe and cull females while they still have salvage value. The objective of this study was to compare the predictive abilities and accuracies of weight distribution and gait measures relative to each other and to a visual lameness detection method when detecting induced lameness among multiparous sows. Developing an objective lameness diagnosis algorithm will benefit animals, producers and scientists in timely and effective identification of lame individuals as well as aid producers in their efforts to decrease herd lameness by selecting animals that are less prone to become lame. In the early stages of lameness, weight distribution and gait are impacted. Lameness was chemically induced for a short time period in 24 multiparous sows and their weight distribution and walking gait were measured in the days following lameness induction. A linear mixed model was used to determine differences between measurements collected from day to day. Using a classification tree analysis, it was determined that the mean weight being placed on each leg was the most predictive measurement when determining whether the leg was sound or lame. The classification tree’s predictive ability decreased as the number of days post-lameness induction increased. The weight distribution measurements had a greater predictive ability compared with the gait measurements. The error rates associated with the weight distribution trees were 29.2% and 31.3% at 6 days post-lameness induction for front and rear injected feet, respectively. For the gait classification trees, the error rates were 60.9% and 29.8% at 6 days post-lameness induction for front and rear injected feet, respectively. More timely lameness detection can improve sow lifetime productivity as well as animal welfare.
Delirium is a common neuropsychiatric syndrome with considerable heterogeneity in clinical profile. Identification of clinical subtypes can allow for more targeted clinical and research efforts. We sought to develop a brief method for clinical subtyping in clinical and research settings.
A multi-site database, including motor symptom assessments conducted in 487 patients from palliative care, adult and old age consultation-liaison psychiatry services was used to document motor activity disturbances as per the Delirium Motor Checklist (DMC). Latent class analysis (LCA) was used to identify the class structure underpinning DMC data and also items for a brief subtyping scale. The concordance of the abbreviated scale was then compared with the original Delirium Motor Subtype Scale (DMSS) in 375 patients having delirium as per the American Psychiatric Association's Diagnostic and Statistical Manual (4th edition) criteria.
Latent class analysis identified four classes that corresponded closely with the four recognized motor subtypes of delirium. Further, LCA of items (n = 15) that loaded >60% to the model identified four features that reliably identified the classes/subtypes, and these were combined as a brief motor subtyping scale (DMSS-4). There was good concordance for subtype attribution between the original DMSS and the DMSS-4 (κ = 0.63).
The DMSS-4 allows for rapid assessment of clinical subtypes in delirium and has high concordance with the longer and well-validated DMSS. More consistent clinical subtyping in delirium can facilitate better delirium management and more focused research effort.
The human intestine is colonised by 1013 to 1014 micro-organisms, the vast majority of which belong to the phyla Firmicutes and Bacteroidetes. Although highly stable over time, the composition and activities of the microbiota may be influenced by a number of factors including age, diet and antibiotic treatment. Although perturbations in the composition or functions of the microbiota are linked to inflammatory and metabolic disorders (e.g. inflammatory bowel diseases, irritable bowel syndrome and obesity), it is unclear at this point whether these changes are a symptom of the disease or a contributing factor. A better knowledge of the mechanisms through which changes in microbiota composition (dysbiosis) promote disease states is needed to improve our understanding of the causal relationship between the gut microbiota and disease. While evidence of the preventive and therapeutic effects of probiotic strains on diarrhoeal illness and other intestinal conditions is promising, the exact mechanisms of the beneficial effects are not fully understood. Recent studies have raised the question of whether non-viable probiotic strains can confer health benefits on the host by influencing the immune system. As the potential health effect of these non-viable bacteria depends on whether the mechanism of this effect is dependent on viability, future research needs to consider each probiotic strain on a case-by-case basis. The present review provides a comprehensive, updated overview of the human gut microbiota, the factors influencing its composition and the role of probiotics as a therapeutic modality in the treatment and prevention of diseases and/or restoration of human health.
Environmental surfaces in hospital rooms often become contaminated with microbes, and evidence has linked the patient care environment to transmission of potential pathogens. Despite attempts at standardization of training and cleaning techniques, there is great variation between housekeepers with regard to room cleaning practices. Environmental cleanliness can be assessed by direct observation, surface cultures, detection of adenosine triphosphate, or use of a fluorescent marking solution. Each monitoring technique has limitations.
We participated in a multicenter study that demonstrated improved cleaning of high-touch surfaces through the use of a fluorescent marking solution and rapid-cycle performance feedback. As part of an earlier study, housekeepers were instructed about the importance of environmental cleanliness and appropriate cleaning of high-touch surfaces, and a room cleaning checklist was introduced. In this study, we sought to examine the relationship between the amount of time that a housekeeper spent cleaning a hospital room and the thoroughness of surface cleaning.
Chlorhexidine gluconate (CHG) bathing has been used primarily in critical care to prevent central line-associated bloodstream infections and infections due to multidrug-resistant organisms. The objective was to determine the effect of hospital-wide CHG patient bathing on healthcare-associated infections (HAIs).
Quasi-experimental, staged, dose-escalation study for 19 months followed by a 4-month washout period, in 3 cohorts.
Academic medical center.
All patients except neonates and infants.
Intervention and Measurements.
CHG bathing in the form of bed basin baths or showers administered 3 days per week or daily. CHG bathing compliance was monitored, and the rate of HAIs was measured.
Over 188,859 patient-days, 68,302 CHG baths were administered. Adherence to CHG bathing in the adult critical care units (90%) was better than that observed in other units (57.7%, P< .001). A significant decrease in infections due to Clostridium difficile was observed in all cohorts of patients during the intervention period, followed by a significant rise during the washout period. For all cohorts, the relative risk of C. difficile infection compared to baseline was 0.71 (95% confidence interval [CI], 0.57–0.89; P = .003) for 3-days-per-week CHG bathing and 0.41 (95% CI, 0.29–0.59; P < .001) for daily CHG bathing. During the washout period, the relative risk of infection was 1.85 (95% CI, 1.38–2.53; P =< .001), compared to that with daily CHG bathing. A consistent effect of CHG bathing on other HAIs was not observed. No adverse events related to CHG bathing were reported.
CHG bathing was well tolerated and was associated with a significant decrease in C. difficile infections in hospitalized patients.