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To develop a pediatric research agenda focused on pediatric healthcare-associated infections and antimicrobial stewardship topics that will yield the highest impact on child health.
The study included 26 geographically diverse adult and pediatric infectious diseases clinicians with expertise in healthcare-associated infection prevention and/or antimicrobial stewardship (topic identification and ranking of priorities), as well as members of the Division of Healthcare Quality and Promotion at the Centers for Disease Control and Prevention (topic identification).
Using a modified Delphi approach, expert recommendations were generated through an iterative process for identifying pediatric research priorities in healthcare associated infection prevention and antimicrobial stewardship. The multistep, 7-month process included a literature review, interactive teleconferences, web-based surveys, and 2 in-person meetings.
A final list of 12 high-priority research topics were generated in the 2 domains. High-priority healthcare-associated infection topics included judicious testing for Clostridioides difficile infection, chlorhexidine (CHG) bathing, measuring and preventing hospital-onset bloodstream infection rates, surgical site infection prevention, surveillance and prevention of multidrug resistant gram-negative rod infections. Antimicrobial stewardship topics included β-lactam allergy de-labeling, judicious use of perioperative antibiotics, intravenous to oral conversion of antimicrobial therapy, developing a patient-level “harm index” for antibiotic exposure, and benchmarking and or peer comparison of antibiotic use for common inpatient conditions.
We identified 6 healthcare-associated infection topics and 6 antimicrobial stewardship topics as potentially high-impact targets for pediatric research.
Background: Carbapenem-resistant Enterobacteriaceae (CRE) are endemic in the Chicago region. We assessed the regional impact of a CRE control intervention targeting high-prevalence facilities; that is, long-term acute-care hospitals (LTACHs) and ventilator-capable skilled nursing facilities (vSNFs). Methods: In July 2017, an academic–public health partnership launched a regional CRE prevention bundle: (1) identifying patient CRE status by querying Illinois’ XDRO registry and periodic point-prevalence surveys reported to public health, (2) cohorting or private rooms with contact precautions for CRE patients, (3) combining hand hygiene adherence, monitoring with general infection control education, and guidance by project coordinators and public health, and (4) daily chlorhexidine gluconate (CHG) bathing. Informed by epidemiology and modeling, we targeted LTACHs and vSNFs in a 13-mile radius from the coordinating center. Illinois mandates CRE reporting to the XDRO registry, which can also be manually queried or generate automated alerts to facilitate interfacility communication. The regional intervention promoted increased automation of alerts to hospitals. The prespecified primary outcome was incident clinical CRE culture reported to the XDRO registry in Cook County by month, analyzed by segmented regression modeling. A secondary outcome was colonization prevalence measured by serial point-prevalence surveys for carbapenemase-producing organism colonization in LTACHs and vSNFs. Results: All eligible LTACHs (n = 6) and vSNFs (n = 9) participated in the intervention. One vSNF declined CHG bathing. vSNFs that implemented CHG bathing typically bathed residents 2–3 times per week instead of daily. Overall, there were significant gaps in infection control practices, especially in vSNFs. Also, 75 Illinois hospitals adopted automated alerts (56 during the intervention period). Mean CRE incidence in Cook County decreased from 59.0 cases per month during baseline to 40.6 cases per month during intervention (P < .001). In a segmented regression model, there was an average reduction of 10.56 cases per month during the 24-month intervention period (P = .02) (Fig. 1), and an estimated 253 incident CRE cases were averted. Mean CRE incidence also decreased among the stratum of vSNF/LTACH intervention facilities (P = .03). However, evidence of ongoing CRE transmission, particularly in vSNFs, persisted, and CRE colonization prevalence remained high at intervention facilities (Table 1). Conclusions: A resource-intensive public health regional CRE intervention was implemented that included enhanced interfacility communication and targeted infection prevention. There was a significant decline in incident CRE clinical cases in Cook County, despite high persistent CRE colonization prevalence in intervention facilities. vSNFs, where understaffing or underresourcing were common and lengths of stay range from months to years, had a major prevalence challenge, underscoring the need for aggressive infection control improvements in these facilities.
Funding: The Centers for Disease Control and Prevention (SHEPheRD Contract No. 200-2011-42037)
Disclosures: M.Y.L. has received research support in the form of contributed product from OpGen and Sage Products (now part of Stryker Corporation), and has received an investigator-initiated grant from CareFusion Foundation (now part of BD).
Vestibular schwannomas (VS) are benign slow-growing tumours treated either with microsurgery or stereotactic radiosurgery (SRS) or both. The aim of this study was to correlate the outcome factors—tumour control and adverse factors—facial nerve function and hearing loss with patient and treatment factors.
Materials and methods:
A retrospective review of the records of 98 patients with 99 VS treated from June 2007 to June 2014, all patients receiving Linear Accelerator (LINAC)-based SRS.
Median follow-up period was 5·6 years (range: 1–12 years). The response to treatment was stable disease in 37 (37·4%), regression in 46 (46·5%), asymptomatic minimal progression in 9 (9·1%) and symptomatic progression in 5 (5%) and unknown in 2 (2%) patients. There was no evidence of SRS induced tissue damage on magnetic resonance scans for any. Hearing preservation rate after SRS was 92%. The patients who developed worsening of facial function were predominantly in the cohort that had prior surgery.
SRS is an effective modality to treat VS lesser than 3 cm in size. Tumour control rate was 95% with a median follow-up period of 5·6 years. The complication rates were 8% each for facial function worsening and worsening of hearing. Prior surgery was a statistically significant factor that affected facial nerve function deterioration.
Non-medical opioid use (NMOU) is a growing crisis. Cancer patients at elevated risk of NMOU (+risk) are frequently underdiagnosed. The aim of this paper was to develop a nomogram to predict the probability of +risk among cancer patients receiving outpatient supportive care consultation at a comprehensive cancer center.
3,588 consecutive patients referred to a supportive care clinic were reviewed. All patients had a diagnosis of cancer and were on opioids for pain. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), Screener and Opioid Assessment for Patients with Pain (SOAPP-14), and CAGE-AID (Cut Down-Annoyed-Guilty-Eye Opener) questionnaires. “+risk” was defined as an SOAPP-14 score of ≥7. A nomogram was devised based on the risk factors determined by the multivariate logistic regression model to estimate the probability of +risk.
731/3,588 consults were +risk. +risk was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD (morphine equivalent daily dose), and CAGE-AID score. The C-index was 0.8. A nomogram was developed and can be accessed at https://is.gd/soappnomogram. For example, for a male Hispanic patient, married, never smoked, with ESAS scores for depression = 3, anxiety = 3, financial distress = 7, a CAGE score of 0, and an MEDD score of 20, the total score is 9 + 9+0 + 0+6 + 10 + 23 + 0+1 = 58. A nomogram score of 58 indicates the probability of +risk of 0.1.
Significance of results
We established a practical nomogram to assess the +risk. The application of a nomogram based on routinely collected clinical data can help clinicians establish patients with +risk and positively impact care planning.
Fluoroquinolones (FQs) and extended-spectrum cephalosporins (ESCs) are associated with higher risk of Clostridioides difficile infection (CDI). Decreasing the unnecessary use of FQs and ESCs is a goal of antimicrobial stewardship. Understanding how prescribers perceive the risks and benefits of FQs and ESCs is needed.
We conducted interviews with clinicians from 4 hospitals. Interviews elicited respondent perceptions about the risk of ESCs, FQs, and CDI. Interviews were audio recorded, transcribed, and analyzed using a flexible coding approach.
Interviews were conducted with 64 respondents (38 physicians, 7 nurses, 6 advance practice providers, and 13 pharmacists). ESCs and FQs were perceived to have many benefits, including infrequent dosing, breadth of coverage, and greater patient adherence after hospital discharge. Prescribers stated that it was easy to make decisions about these drugs, so they were especially appealing to use in the context of time pressures. They described having difficulty discontinuing these drugs when prescribed by others due to inertia and fear. Prescribers were skeptical about targeting specific drugs as a stewardship approach and felt that the risk of a negative outcome from under treatment of a suspected bacterial infection was a higher priority than the prevention of CDI.
Prescribers in this study perceived many advantages to using ESCs and FQs, especially under conditions of time pressure and uncertainty. In making decisions about these drugs, prescribers balance risk and benefit, and they believed that the risk of CDI was acceptable in compared with the risk of undertreatment.
The DSM-IV criteria recognize the existence of obsessive–compulsive disorder (OCD) with poor insight. However, there is paucity of literature on the clinical correlates and treatment response in poor and good insight OCD. In this study, insight is measured by using the Brown Assessment of Beliefs Scale (BABS) developed specifically to assess insight. One hundred subjects with DSM-IV OCD were ascertained from the OCD clinic of a large psychiatric hospital in India. All subjects were evaluated extensively by using structured instruments and established measures of psychopathology. The subjects were treated with adequate doses of drugs for adequate period. The results showed that 25% of the subjects had poor insight. Poor insight was associated with earlier age-at-onset, longer duration of illness, more number of obsessive–compulsive symptoms, more severe illness and higher comorbidity rate, particularly major depression. Of the subjects who were treated adequately (N = 73), 44 (60%) were treatment responders. Poor insight was associated with poor response to drug treatment. In the step-wise logistic regression analysis, baseline BABS score was highly predictive of poor treatment response. Poor insight appears to be associated with specific clinical correlates and poor response to drug treatment. Further studies are needed in larger samples to replicate our findings.
Pharmacogenetic studies in obsessive-compulsive disorder (OCD) primarily focussing on serotonergic and dopaminergic polymorphisms, provided inconsistent findings. There is recent evidence for glutamatergic abnormalities in OCD.
Examine the association glutamatergic genes with serotonin reuptake inhibitor (SRI) response in OCD.
To study pharmacogenetic association between SLC1A1 and GRIN2B polymorphisms with SRI response in OCD.
DSM-IV OCD patients were recruited from a specialty OCD clinic and evaluated using the Yale-Brown obsessive compulsive scale (YBOCS), Mini International Neuropsychiatric Interview (MINI) plus, Clinical Global Impression scale (CGI). They were subsequently reassessed with YBOCS and CGI. To study extreme phenotypes, we included only full responders (> 35% YBOCS improvement and CGI-I score of 1 or 2) to any SRI (n = 191) and non-responders (< 25% YBOCS improvement and CGI-I score ≥ 4) to adequate trial of at least two SRIs (n = 84). Partial responders were excluded. Genotyping was performed using an ABI9700 PCR machine.
Genotype frequencies did not deviate significantly from the values predicted by the Hardy-Weinberg equation. Case-control association analyses revealed no significant association between genotype/allele frequencies with SRI response.
Our data does not show any association between polymorphisms in glutamatergic genes and SRI response in OCD though such associations have been found in other studies. More SNP's in the same gene could be responsible for the pharmacogenetic associations. More homogenous sample considering symptom dimensions and other phenotypic variables may be needed. It may be critical to go beyond “usual suspect” candidate gene research. In this regard, a novel approach to identify SRI response biomarkers is the use of cellular models.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Contemporary treatment guidelines recommend use of second-generation antipsychotics (SGAs) either as mono therapy or in combination with mood stabilizers as first-line treatment. While these drugs have been established to have superior efficacy compared to placebo, there is very less data comparing these antipsychotics with one another. We sought to study differences in the five-year outcome of first episode of mania (FEM) treated with olanzapine or risperidone, either alone or in combination with mood stabilizer.
We conducted a retrospective chart review of patients diagnosed with FEM (ICD-10) in the year 2008 (n = 88) at our centre. We selected the data of patients prescribed either olanzapine or risperidone for the purpose of this analysis. We extracted data about time to recovery and recurrence after FEM, total episodes, drug compliance and response, and number of follow-up visits from 2008 to 2013. The study was approved by the Institute Ethics Committee.
A total of 88 patients received diagnosis of FEM in the year 2008, of which 50 (56.8%) received risperidone and 35 (39.8%) received olanzapine. The two groups were comparable in socio-demographic and clinical symptomatology of FEM (all P > 0.08). Complete recovery was significantly more in the olanzapine group than the risperidone group (χ2 = 4.84, P < 0.05).
Our study indicates that risperidone and olanzapine, either alone or in combination with mood stabilizers have a similar impact on the five-year course of BD following a first manic episode. However, olanzapine is associated with more complete recovery from FEM than risperidone.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Bell pepper or sweet pepper (Capsicum annuum L. var. grossum) is highly susceptible to high-temperature stress (HT). Hence, search for donor across C. annuum for HT tolerance was undertaken by following Temperature Induction Response (TIR) technique. The induction and challenging temperature requirement for TIR screening were standardized in 1 d-old Capsicum seedlings. Forty Capsicum genotypes were evaluated based on the recovery growth (RG) and per cent reduction in recovery growth (%RRG) of the seedlings. The genotypes Punjab Guchhedar and Ajeet 1 were found to have maximum cellular level tolerance (CLT) to HT with higher RG and lower %RRG compared to the non-induced seedlings and HDC 75 was found to have minimum CLT. In order to confirm the findings, another experiment was conducted under managed stress and control conditions. Absolute yield obtained from both the environments were used to calculate stress tolerance indices such as heat susceptibility index, tolerance index, stress tolerance index, mean productivity, geometric mean productivity and yield stability index. Based on these tolerance indices, Punjab Guchhedar and Ajeet 1 were found to be highly tolerant and HDC 75 as highly susceptible. Further, the combined result of TIR and tolerance indices also gave the same result confirming Punjab Guchhedar and Ajeet 1 can be used as a donor for the future breeding programme aimed at evolving high-temperature-tolerant bell pepper cultivars. The result also confirms the fitness of TIR technique to screen Capsicum genotypes for tolerance to HT based on variability in acquired thermotolerance.
Zuriguel et al. (Phys. Rev. Lett., vol. 95, 2005a, 258002) and Pacheco-Vázquez and Ruiz-Suárez (Nat. Commun., vol. 1, 2010, p. 123) demonstrated that there exists a long-ranged force between intruders placed at a certain distance from each other in granular flow. The origin of these long-ranged forces, induced collectively by the grains, has not been fully understood. In our work, we provide a unified explanation for the origin of both attraction and repulsion between two intruders in terms of the building up of force chains and their subsequent buckling. The surface and shear zone of the other intruder makes a significant contribution to the strength or buckling of the force chains. Bernoulli’s effect used in earlier studies predicts the nature of these forces, viz., attraction or repulsion, correctly but is not well supported as observed in our study. The time-averaged flow fields around the intruders also support our explanation for the origin as evidenced by the burst in kinetic energy and granular temperature. The model proposed in this work predicts the qualitative trend of the sideways force with the separation between the intruders by combining Bernoulli’s equation with a minimum contact criterion of force chains. There exists an equilibrium at which the intruders neither attract nor repel each other and a certain separation distance where maximum attraction occurs between the two intruders. The effects of the static pressure, the velocity of the moving intruders and the friction coefficient on the attraction or repulsion force between the intruders have also been explored in our system.
A central and critical step in the molecular detection of soil-transmitted helminths from environmental sources is the extraction of DNA from the eggs. In this study, we investigated the yield of DNA extracted from known quantities (500, 100, 50, 20, 10 and 5) of Ascaris suum eggs, as well as directly from wastewater and sludge samples containing Ascaris spp. eggs, using six commercial DNA extraction kits. The amount of DNA extracted was quantified with NanoDrop, Qubit and Ct values from quantitative polymerase chain reaction (qPCR) assay using CFX96 Touch™ real-time PCR equipment. The PowerLyzer Ultraclean Microbial DNA isolation kit and PowerSoil DNA isolation kit gave the highest yield of DNA based on the NanoDrop, Qubit and Ct values. However, the qPCR results indicate that in some of the kits, PCR inhibitors may have been carried over to the PCR reaction. DNA extraction kits that incorporate a bead-beating step as well as other mechanical eggshell disruption steps were superior in extracting DNA from Ascaris spp. eggs. Additionally, for the accurate quantification of extracted DNA, the use of Ct values from qPCR and Qubit readings gives better results compared to the NanoDrop readings. For efficient downstream applications, the use of DNA extraction kits with superior inhibitor removal technology is essential, in addition to a high yield of DNA.
Background: The Endoscopic endonasal approach (EEA) has been gaining popularity in the past decade as an alternative to traditional transcranial and transorbital approaches. We have performed orbital apex decompression for a variety of pathological entities. Methods: We performed a retrospective chart review on patients who underwent EEA orbital apex decompression between January 1st 2010 and December 1st 2018 at McMaster University. Results: Eight patients underwent endoscopic endonasal orbital decompression at our center, including five male patients and three female patients. The mean age of our patients was 50.1 years. The different pathologies we treated included nasopharyngeal carcinoma, hemangioma, fibrous dysplasia, IgG4 disease, inverted papilloma, angioleiomyoma, and neuroendocrine paraganglioma. Five patients presented with visual symptoms. Postoperatively, one of these five patients improved to baseline, three had stable vision, another one had progressive visual decline despite surgical intervention. Conclusions: Endoscopic endonasal approach can be used as an alternative to decompress orbital apex pathologies in selected patients.
Background: Central neurocytoma’s are typically located in the lateral ventricles and are optimally treated with surgical resection. Surgical entry into the ventricles are associated with a number of complications, including subdural hygroma and shunt-dependent hydrocephalus. Methods: We report a patient who developed acute bilateral uncal herniation from progessively enlarging subdural hygromas following intraventricular tumour resection. Results: A 60-year-old female underwent minimally invasive transcortical transventricular resection of an intraventricular CN. The patient’s postoperative course was complicated by repeated presentations to the emergency department due to persistent and intractable nausea and headaches, without focal neurological deficits. Imaging demonstrated small bilateral subdural hygromas. The patient eventually presented with acute deterioration in her level of consciousness with clinical and radiologic evidence of bilateral uncal herniation, requiring urgent insertion of a subdural drain to treat elevated intracranial pressure (ICP). After insertion of a ventriculoperitoneal shunt, the patient was discharged in stable condition and is currently followed by the multi-disciplinary neuro-oncology team. Conclusions: Bilateral subdural hygroma could mask underlying external hydrocephalus post transventricular surgeries. Patients who are symptomatic from bilateral subdural hygromas after transventricular resection of tumors should be carefully monitored for radiographic or clinical progression, in order to avoid acute deterioration caused by elevated ICP.
Background: The Endoscopic endonasal approach (EEA) has become increasingly popular in the treatment of suprasellar meningiomas, which often cause visual symptoms due to compression of the anterior optic apparatus. Methods: We performed a retrospective chart review on patients who underwent EEA optic nerve decompression and resection of suprasellar meningiomas between January 1st 2005 and December 1st 2018 at McMaster University. Results: The mean age of our patients was 59.8 years. We treated 9 male and 23 female patients, with a mean follow up of 6.29 years. 23 patients (71.9%) presented with visual symptoms, with a mean duration of 8.65 months. In our patient cohort, 95.5% had stable or improved visual acuity postoperatively. Less than six months of visual decline was more likely to be associated with postoperative improvement of visual acuity, with an odds ratio (OR) of 0.0222 (95% CI: 0.0017–0.289, p<0.05); as well as visual field (OR:0.0625; 95% CI, 0.0042–0.915, p<0.05). Additionally, the absence of RAPD was associated with improved postoperative visual acuity (OR: 0.0675; 95% CI, 0.0354–0.706, p<0.05). Conclusions: Endoscopic endonasal approach can achieve good visual outcome in patients harboring suprasellar meningiomas. Symptom duration of less than six months and absence of RAPD were positive predictor of postoperative visual outcome.
We assessed the impact of personal protective equipment (PPE) doffing errors on healthcare worker (HCW) contamination with multidrug-resistant organisms (MDROs).
Prospective, observational study.
The study was conducted at 4 adult ICUs at 1 tertiary-care teaching hospital.
HCWs who cared for patients on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci, or multidrug-resistant gram-negative bacilli were enrolled. Samples were collected from standardized areas of patient body, garb sites, and high-touch environmental surfaces in patient rooms. HCW hands, gloves, PPE, and equipment were sampled before and after patient interaction. Research personnel observed PPE doffing and coded errors based on CDC guidelines.
We enrolled 125 HCWs; most were nurses (66.4%) or physicians (19.2%). During the study, 95 patients were on contact precautions for MRSA. Among 5,093 cultured sites (HCW, patient, environment), 652 (14.7%) yielded the target MDRO. Moreover, 45 HCWs (36%) were contaminated with the target MDRO after patient interactions, including 4 (3.2%) on hands and 38 (30.4%) on PPE. Overall, 49 HCWs (39.2%) made multiple doffing errors and were more likely to have contaminated clothes following a patient interaction (risk ratio [RR], 4.69; P = .04). All 4 HCWs with hand contamination made doffing errors. The risk of hand contamination was higher when gloves were removed before gowns during PPE doffing (RR, 11.76; P = .025).
When caring for patients on CP for MDROs, HCWs appear to have differential risk for hand contamination based on their method of doffing PPE. An intervention as simple as reinforcing the preferred order of doffing may reduce HCW contamination with MDROs.
Trait-specific characterization of rice landraces has significant potential for germplasm management, varietal identification and mining of novel gene/allele for various traits. In the current study, we have characterized 98 unique rice landraces collected from coastal regions of India, affected by submergence and salinity, based on Sub1 and Saltol quantitative trait loci (QTL) linked microsatellite markers. Among these genotypes, four genotypes (IC536558, IC536559, IC536604 and IC536604-1) collected from Kerala and two genotypes (AC34902 and IC324589) collected from West Bengal were identified with tolerance to submergence and salinity stress. A high level of genetic diversity of He = 0.349 and 0.529 at Sub1 and Saltol QTL region was detected by QTL-linked microsatellite markers, respectively. At Sub1 region one genotype, AC34902, was detected with maximum allelic similarity with FR13A, a known submergence tolerant variety. Besides, five genotypes (IC211188-1, IC536604-1, IC536604, IC536558 and IC536559) showed comparatively close genetic relationship with the salt tolerant variety FL478 for Saltol QTL and were clustered together in the neighbour joining dendrogram. Considering the haplotype structure, five genotypes (IC203801, IC203778, IC324584, IC413608 and IC413638) were identified which did not contain any common allele similar to FR13A but were still tolerant to submergence. These individuals need further characterization for identification of new alleles responsible for their tolerance.
Background: Microvascular decompression (MVD) is commonly used in the treatment of trigeminal neuralgia with positive clinical outcomes. Fully endoscopic microvascular decompression (E-MVD) has been proposed as a minimally invasive, effective alternative, but a comparative review of the two approaches in the literature has not been conducted. Methods: We performed a meta-analysis comparing patient outcome rates and complications for both techniques. From a pool of 1,039 studies, 22 articles were selected for review: 12 open MVD and 10 E-MVD. The total number of patients was 6,734. Results: Good pain relief was achieved in 81% of MVD and 88% of E-MVD patients, with a mean recurrence rate of 14% and 9% respectively. Average rates of complications in MVD versus E-MVD included facial paresis or weakness, 9%, 3%; -hearing loss, 4%, 1%; cerebrospinal leak, both 3%; cerebellar damage and infection, 2%, <1%; and mortality <1%, 0% respectively. Conclusions: The reviewed literature revealed similar clinical outcomes with respect to pain relief for both approaches. Recurrence rate and incidence of complications, notably facial paresis and hearing loss were higher for MVD. We concluded that E-MVD appears to offer at least as good a surgical outcome as MVD, with possibly a shorter operative time, smaller craniectomy and lower recurrence rates.