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To describe the transmission dynamics of the emergence and persistence of vanA vancomycin-resistant enterococcus (VRE) in an intensive care unit (ICU) using whole-genome sequencing of patient and environmental isolates.
Retrospective cohort study.
ICU in a tertiary referral center.
Patients admitted to the ICU over an 11-month period.
VanA VRE isolated from patients (n=31) were sequenced using the Illumina MiSeq platform. Environmental samples from bed spaces, equipment, and waste rooms were collected. All vanA VRE-positive environmental samples (n=14) were also sequenced. Data were collected regarding patient ward and bed movements.
The 31 patient vanA VRE isolates were from screening (n=19), urine (n=4), bloodstream (n=3), skin/wound (n=3), and intra-abdominal (n=2) sources. The phylogeny from sequencing data confirmed several VRE clusters, with 1 group accounting for 38 of 45 isolates (84%). Within this cluster, cross-transmission was extensive and complex across the ICU. Directionality indicated that colonized patients contaminated environmental sites. Similarly, environmental sources not only led to patient colonization but also to infection. Notably, shared equipment acted as a conduit for transmission between different ICU areas. Infected patients, however, were not linked to further VRE transmission.
Genomic sequencing confirmed a predominantly clonal outbreak of VRE with complex transmission dynamics. The environmental reservoir, particularly from shared equipment, played a key role in ongoing VRE spread. This study provides evidence to support the use of multifaceted strategies, with an emphasis on measures to reduce bacterial burden in the environment, for successful VRE control.
Computerised cognitive–behavioural therapy (cCBT) for depression has the potential to be efficient therapy but engagement is poor in primary care trials.
We tested the benefits of adding telephone support to cCBT.
We compared telephone-facilitated cCBT (MoodGYM) (n = 187) to minimally supported cCBT (MoodGYM) (n = 182) in a pragmatic randomised trial (trial registration: ISRCTN55310481). Outcomes were depression severity (Patient Health Questionnaire (PHQ)-9), anxiety (Generalized Anxiety Disorder Questionnaire (GAD)-7) and somatoform complaints (PHQ-15) at 4 and 12 months.
Use of cCBT increased by a factor of between 1.5 and 2 with telephone facilitation. At 4 months PHQ-9 scores were 1.9 points lower (95% CI 0.5–3.3) for telephone-supported cCBT. At 12 months, the results were no longer statistically significant (0.9 PHQ-9 points, 95% CI −0.5 to 2.3). There was improvement in anxiety scores and for somatic complaints.
Telephone facilitation of cCBT improves engagement and expedites depression improvement. The effect was small to moderate and comparable with other low-intensity psychological interventions.
Symptoms of anxiety relating to Parkinson's disease (PD) occur commonly and include symptomatology associated with motor disability and complications arising from PD medication. However, there have been relatively few attempts to profile such disease-specific anxiety symptoms in PD. Consequently, anxiety in PD is underdiagnosed and undertreated. The present study characterizes PD-related anxiety symptoms to assist with the more accurate assessment and treatment of anxiety in PD.
Ninety non-demented PD patients underwent a semi-structured diagnostic assessment targeting anxiety symptoms using relevant sections of the Mini International Neuropsychiatric Interview (MINI-plus). In addition, they were assessed for the presence of 30 PD-related anxiety symptoms derived from the literature, the clinical experience of an expert panel and the PD Anxiety-Motor Complications Questionnaire (PDAMCQ). The onset of anxiety in relation to the diagnosis of PD was determined.
Frequent (>25%) PD-specific anxiety symptoms included distress, worry, fear, agitation, embarrassment, and social withdrawal due to motor symptoms and PD medication complications, and were experienced more commonly in patients meeting DSM-IV criteria for an anxiety disorder. The onset of common anxiety disorders was observed equally before and after a diagnosis of PD. Patients in a residual group of Anxiety Not Otherwise Specified had an onset of anxiety after a diagnosis of PD.
Careful characterization of PD-specific anxiety symptomatology provides a basis for conceptualizing anxiety and assists with the development of a new PD-specific measure to accurately assess anxiety in PD.
The excavations of Frans Blom and Clarence Weiant at the small hilltop site of Moxviquil in the early 1950s represent one of the pioneering archaeological projects in highland Chiapas. The results of their excavations, which were minimally published, provide important data on one of the largest Late Classic-Early Postclassic communities in the region. In this paper, we reconsider Moxviquil in light of recent scholarship on Maya urbanism, and present new interpretations of the site as a small city that fulfilled a diversified set of urban functions for residents both within the monumental zone itself, and in the surrounding hinterland areas. Consistent with its likely role as the administrative center of a small, independent highland polity, the monumental center of Moxviquil likely served political, economic, and ritual functions; was an important nucleus of residential settlement; and supported a wide range of household-based craft production and food preparation activities.
Between 30 and 60% of adults with unipolar or bipolar disorders exhibit
impairments across multiple domains. However, little is known about
impaired functioning in youth with mood disorders.
To examine the prevalence of objective, subjective and observer-rated
disability in a large, representative sample of young people with a
primary mood disorder.
Individuals aged 16–25 years presenting to youth mental health services
for the first time with a primary mood disorder participated in a
systematic diagnostic and clinical assessment. Impairment was assessed
using objective (unemployment or disability payments), observer- (Social
and Occupational Functioning Assessment Scale; SOFAS) and self-rated
measures (role functioning according to the Brief Disability
Of 1241 participants (83% unipolar; 56% female), at least 30% were
functionally impaired on the objective, self-rated and/or observer-rated
measures, with 16% impaired according to all three criteria. Even when
current distress levels were taken into account, daily use of cannabis
and/or nicotine were significantly associated with impairment, with odds
ratios (OR) ranging from about 1.5 to 3.0. Comorbid anxiety disorders
were related to lower SOFAS scores (OR = 2–5).
Levels of disability were significant, even in those presenting for
mental healthcare for the first time. Functional impairment did not
differ between unipolar and bipolar cases, but some evidence suggested
that females with bipolar disorder were particularly disabled. The
prevalence of comorbid disorders (50%) and polysubstance use (28%) and
their association with disability indicate that more meaningful
indicators of mood episode outcomes should focus on functional rather
than symptom-specific measures. The association between functioning and
nicotine use requires further exploration.
Dementia is common in older people admitted to acute hospitals. There are
concerns about the quality of care they receive. Behavioural and
psychiatric symptoms of dementia (BPSD) seem to be particularly
challenging for hospital staff.
To define the prevalence of BPSD and explore their clinical
Longitudinal cohort study of 230 people with dementia, aged over 70,
admitted to hospital for acute medical illness, and assessed for BPSD at
admission and every 4 (±1) days until discharge. Other measures included
length of stay, care quality indicators, adverse events and
Participants were very impaired; 46% at Functional Assessment Staging
Scale (FAST) stage 6d or above (doubly incontinent), 75% had BPSD, and
43% had some BPSD that were moderately/severely troubling to staff. Most
common were aggression (57%), activity disturbance (44%), sleep
disturbance (42%) and anxiety (35%).
We found that BPSD are very common in older people admitted to an acute
hospital. Patients and staff would benefit from more specialist
Interventions that prevent healthcare-associated infection should lead to fewer deaths and shorter hospital stays. Cleaning hands (with soap or alcohol) is an effective way to prevent the transmission of organisms, but rates of compliance with hand hygiene are sometimes disappointingly low. The National Hand Hygiene Initiative in Australia aimed to improve hand hygiene compliance among healthcare workers, with the goal of reducing rates of healthcare-associated infection.
We examined whether the introduction of the National Hand Hygiene Initiative was associated with a change in infection rates. Monthly infection rates for healthcare-associated Staphylococcus aureus bloodstream infections were examined in 38 Australian hospitals across 6 states. We used Poisson regression and examined 12 possible patterns of change, with the best fitting pattern chosen using the Akaike information criterion. Monthly bed-days were included to control for increased hospital use over time.
The National Hand Hygiene Initiative was associated with a reduction in infection rates in 4 of the 6 states studied. Two states showed an immediate reduction in rates of 17% and 28%, 2 states showed a linear decrease in rates of 8% and 11% per year, and 2 showed no change in infection rates.
The intervention was associated with reduced infection rates in most states. The failure in 2 states may have been because those states already had effective initiatives before the national initiative’s introduction or because infection rates were already low and could not be further reduced.
Many patients with suspected scaphoid fractures but negative radiographs are immobilized for ≥ 2 weeks and are eventually found to have no fracture. Bone scans are reportedly 99% sensitive for these injuries if done ≥ 72 hours postinjury.
The purpose of this study was to determine if early bone scans would allow for shorter cast immobilization periods in patients with suspected scaphoid fractures.
Twenty-seven patients with clinically suspected scaphoid fractures and negative radiographs were randomized to early diagnosis (bone scan within 3–5 days; n 5 12) or traditional diagnosis (radiographs 10–14 days postinjury; n 5 15). The primary outcome was number of days immobilized in a cast.
The mean number of days immobilized was 26 in the traditional group and 29 in the bone scan group. Overall, 6 patients had scaphoid fractures (2 in the traditional diagnosis group and 4 in the bone scan group; p > 0.05), and 8 had other types of fractures. These other types of fractures included four distal radius fractures, two triquetral fractures, one trapezoid fracture, and one hamate fracture. There was no significant difference in the number of other types of fractures between groups. The Kaplan-Meier survival analysis using the log-rank test revealed that there was no statistically significant difference between days immobilized between the radiograph and bone scan groups (p 5 0.38).
The current study suggests that the use of bone scans to help diagnose occult scaphoid fractures does not reduce the number of days immobilized and that the differential diagnosis of occult scaphoid fractures should remain broad because other injuries are common.
To examine the use of vitamin D supplements during infancy among the participants in an international infant feeding trial.
Information about vitamin D supplementation was collected through a validated FFQ at the age of 2 weeks and monthly between the ages of 1 month and 6 months.
Infants (n 2159) with a biological family member affected by type 1 diabetes and with increased human leucocyte antigen-conferred susceptibility to type 1 diabetes from twelve European countries, the USA, Canada and Australia.
Daily use of vitamin D supplements was common during the first 6 months of life in Northern and Central Europe (>80 % of the infants), with somewhat lower rates observed in Southern Europe (>60 %). In Canada, vitamin D supplementation was more common among exclusively breast-fed than other infants (e.g. 71 % v. 44 % at 6 months of age). Less than 2 % of infants in the USA and Australia received any vitamin D supplementation. Higher gestational age, older maternal age and longer maternal education were study-wide associated with greater use of vitamin D supplements.
Most of the infants received vitamin D supplements during the first 6 months of life in the European countries, whereas in Canada only half and in the USA and Australia very few were given supplementation.
Posterior sub-talar joint (PSTJ). The PSTJ is a synovial joint formed by the articulation of the posterior articular facets of the talus and calcaneum. Intra-articular extension into the PSTJ is often seen in comminuted calcaneal compression fractures and represents an important factor in the surgical classification of these injuries.
Cuboid. The cuboid possesses a proximal articular surface that only articulates with the calcaneum. Distally the cuboid articulates with the fourth and fifth metatarsals.
Neck of the talus. The talar neck is an important review area when evaluating ankle radiographs and CT in the setting of trauma. Missed talar neck fractures can result in avascular necrosis of the talar dome due to its blood supply being derived from vessels that enter the talar head and travel proximally within the neck.
The sinus tarsi. This is a fatty space beneath the talar neck and above the calcaneal body. The sinus tarsi also contains the cervical and interosseous ligaments along with traversing nerves and vessels. Inflammation and cyst formation in this space following trauma may produce a painful ‘sinus-tarsi syndrome’.
Os trigonum. This is present in 10% of individuals and when present, is bilateral in 50%. It may be present as a separate ossicle or be partly fused with the posterior talar process forming a synchrondrosis. The os trigonum may produce repetitive soft tissue impingment in the ankle due to repetitive plantar-flexion resulting in a painful ‘os-trigonum syndrome’.
Transverse ultrasound through stomach pylorus and upper abdomen
Lesser trochanter of the right femur. The iliopsoas tendon attaches here. This is a powerful flexor of the hip.
Greater trochanter of the right femur. Gluteus medius and gluteus minimis attach here. These tendons act to perform hip abduction and lateral rotation. They can produce avulsion fractures of the greater trochanter in trauma.
Left L5 transverse process. The ilio-lumbar ligament attaches here. Traction of this ligament in pelvic trauma can cause an avulsion fracture of the transverse process. It also acts as an anatomical landmark on MRI for identifying the L5 vertebral body.
Pubic symphysis. It is a secondary cartilaginous joint.
Left inferior pubic ramus. Adductor magnus and adductor brevis attach here acting to adduct the hip.
Axial T2-weighted lumbar spine through L5
Left L5 nerve. At the level of the L5/S1 disc, the L5 nerve has already left the neural exit foramen. It may become compromised by a far lateral L5 disc herniation in this position.
Nucleus pulposus of L5/S1 disc. This soft central component of the disc is surrounded by the tough outer annulus fibrosus. Annular defects result in herniation of the nucleus pulposus referred to as protrusions or extrusions, based upon their morphology. On T2-weighted images the nucleus pulposus is of high signal and the annulus fibrosus is of low signal intensity.
Left lamina of L5 vertebra. Each lamina fuses in the midline to form the spinous process. The lamina is partly or completely resected (laminectomy) during lumbar disc surgery to facilitate access to the disc.
Right psoas major muscle. This is a powerful hip flexor. In the clinical setting of lumbar discitis it is common to see infection tracking from the disc space into the psoas muscle to form a psoas abscess.