The largest prison outbreak of TB in Western Europe investigated using whole-genome sequencing

BACKGROUND: In March 2011, the Department of Public Health East in Ireland were notified of two cases of TB in two prisoners sharing a cell. We define the resulting outbreak and highlight the role of public health and laboratory-based molecular epidemiology in mapping and control of a prison outbreak.METHODS: Cases were identified through clinical presentation, contact tracing, case-finding exercise or enhanced laboratory surveillance. Mycobacterium tuberculosis isolates were genotyped and underwent whole-genome sequencing (WGS).RESULTS: Of the 34 cases of TB linked to the outbreak, 27 were prisoners (79%), 4 prison officers (12%) and 3 community cases (9%). M. tuberculosis was isolated from 31 cases (culture positivity: 91%). A maximum of six single-nucleotide polymorphisms separated the isolates, with 22 being identical, suggestive of a highly infectious 'super-spreader´ within the prison. Isolates belonged to the Beijing sub-lineage, and were susceptible to first-line anti-TB agents. A case-finding exercise incidentally detected a prisoner with multidrug-resistant TB. Of the 143 prison officers screened, 52% had latent TB infection. Litigation costs exceeded five million euros.CONCLUSION: This constitutes the largest prison outbreak of TB in Western Europe investigated using WGS. A robust prison entry TB screening and education programme is required to effect better TB control, and prevent future outbreaks and attendant litigation.

Molecular epidemiology of multi- and extensively-drug-resistant Mycobacterium tuberculosis in Ireland, 2001-2014

OBJECTIVES

The primary objective of this work was to examine the acquisition and spread of multi-drug resistant (MDR) tuberculosis (TB) in Ireland.

METHODS

All available Mycobacterium tuberculosis complex (MTBC) isolates (n = 42), from MDR-TB cases diagnosed in Ireland between 2001 and 2014, were analysed using phenotypic drug-susceptibility testing, Mycobacterial-Interspersed-Repetitive-Units Variable-Number Tandem-Repeat (MIRU-VNTR) genotyping, and whole-genome sequencing (WGS).

RESULTS

The lineage distribution of the MDR-TB isolates comprised 54.7% Euro-American, 33.3% East Asian, 7.2% East African Indian, and 4.8% Indo-Oceanic. A significant association was identified between the East Asian Beijing sub-lineage and the relative risk of an isolate being MDR. Over 75% of MDR-TB cases were confirmed in non-Irish born individuals and 7 MIRU-VNTR genotypes were identical to clusters in other European countries indicating cross-border spread of MDR-TB to Ireland. WGS data provided the first evidence in Ireland of in vivo microevolution of MTBC isolates from drug-susceptible to MDR, and from MDR to extensively-drug resistant (XDR). In addition, they found that the katG S315T isoniazid and rpoB S450L rifampicin resistance mutations were dominant across the different MTBC lineages.

CONCLUSIONS

Our molecular epidemiological analyses identified the spread of MDR-TB to Ireland from other jurisdictions and its potential to evolve to XDR-TB.

Mycobacterium avium complex pulmonary disease: characteristics and treatment in an Irish patient cohort

The prevalence of Mycobacterium avium complex (MAC) pulmonary disease is increasing globally. However, reliable national and international data relating to its epidemiology and management is lacking. During the period 2003-2014, MAC was isolated from the pulmonary samples of 75 patients at the Irish Mycobacteria Reference Laboratory (IMRL). Most patients (42, 56%) had underlying pulmonary disease, and 37 (49%) had clinical/radiographic characteristics consistent with MAC pulmonary disease. However, only 18 patients (24%) fulfilled internationally accepted criteria for diagnosis/treatment of this disease. Treatment was started in 13 (72%) of these cases, which is similar to internationally published treatment rates. The diagnosis of significant MAC pulmonary disease can be difficult, and treatment is not always warranted even when diagnostic criteria are met.

An unusual lung mass post stem cell transplantation

We report a case of Mycobacterium kansasii presenting as an obstructing endobronchial mass in a patient post stem cell transplant. The patient had a complete clinical, microbiological, and radiological response to anti-tuberculous treatment. To our knowledge, this is the first case of M. kansasii presenting post transplant with an obstructing lung mass simulating relapse or post-transplant lymphoma.

Barriers to accepting and completing latent tuberculosis infection treatment

Treatment of Latent Tuberculosis Infection (LTBI) is an important component of any TB control strategy. Acceptance and completion of treatment is poor. We undertook this study to identify barriers to acceptance & completion of treatment. Patients attending TB clinics completed a self-administered survey. Medical notes and electronic pharmacy records were reviewed. 143 surveys were completed. 70 (49%) completed treatment. Patients were less likely to accept treatment (p = 0.01, RR 0.781, CI 0.643-0.950) and less likely to complete treatment (p = 0.01, RR 0.640, CI 0.462-0.885) when concerned about the side effects of LTBI medication. Completion of LTBI treatment is sub-optimal. The major barrier identified was fear about side effects caused by LTBI medications.

Alcohol, drug misuse and suicide attempts: unrecognised causes of out of hospital cardiac arrests admitted to intensive care units

AIM

To assess the contribution of alcohol, drug abuse and suicide attempts to out of hospital cardiac arrests (OHCA) who are admitted to our intensive care unit (ICU).

METHODS

Retrospective review of all OHCA admitted to the ICU over a 2-year period.

RESULTS

There were 26 OHCA. Six patients survived, all of whom had a cardiac aetiology for their arrest. Ten patients arrested due to external factors (drug misuse n = 4, alcohol excess n = 1, suicide attempts n = 4 and accidental choking n = 1). All of the patients who arrested secondary to external factors were young (37.2 +/- 13.58 years), 90% were male and all died in hospital. All of the cases of drug misuse involved cocaine.

CONCLUSION

Alcohol, drug misuse and suicide attempts contribute significantly to the number of OHCA which are admitted to ICU. Moreover, cocaine usage has contributed to a number of OHCA in our study.

Evaluation of a Colostrum Supplement, With or Without Trypsin Inhibitor, and an Egg Protein Milk Replacer for Dairy Calves,

Forty-eight Holstein bull calves were assigned to a 2 x 2 x 2 factorial arrangement in a completely randomized block design. Main effects were colostrum versus a serum-derived colostrum supplement, 0 versus 1 g of trypsin inhibitor added at the initial 2 feedings, and milk replacer containing 0 or 50% CP from whole egg. Calves were bled at 0, 6, 12, 18, and 24 h after birth for determination of serum immunoglobulin (Ig). G. Serum IgG concentrations were lower in calves consuming the colostrum supplement compared with calves consuming colostrum. Apparent efficiency of absorption of IgG was similar. Trypsin inhibitor did not affect IgG concentrations or absorption of IgG. Calves were fed either milk replacer for 28 to 35 d (preweaning phase) and weaned when they consumed 0.7 kg of starter grain for 2 consecutive days. The postweaning phase was from weaning to d 56. Feeding colostrum supplement resulted in higher fecal scores postweaning (1.90 vs. 1.58) and overall (1.85 vs. 1.65) and fewer days medicated preweaning (5.1 vs. 2.2 d) and postweaning (3.9 vs. 1.9 d) and overall (9.0 vs. 4.2 d). Calves were treated for upper respiratory tract infections and diarrhea. Dry matter intake and weaning age were not affected by treatment. Postweaning (1.69 vs. 1.2 kg) and overall (1.22 vs. 1.0 kg), calves that received colostrum and egg milk replacer consumed more dry matter and starter. Postweaning, calves fed colostrum and egg milk replacer had similar or greater body weight and gains compared with calves fed colostrum and milk protein milk replacer. Preweaning, feed efficiency was greater for calves fed colostrum (0.44 vs. 0.34), trypsin inhibitor (0.42 vs. 0.36), and milk protein milk replacer (0.48 vs. 0.30) compared with calves fed colostrum supplement, no trypsin inhibitor, and egg milk replacer, respectively. Trypsin inhibitor increased feed efficiency postweaning. Calves fed trypsin inhibitor and milk protein milk replacer were more efficient preweaning and overall than calves fed trypsin inhibitor and egg milk replacer. Results indicate that the blood derived colostrum supplement did not provide as much IgG as colostrum (4.55 g/L vs. 14.6 g/L, respectively), that feeding 1.0 g of trypsin inhibitor did not enhance serum IgG concentrations, and that the egg milk replacer-fed calves fed colostrum performed nearly as well as calves fed colostrum and the milk protein milk replacer.

Supplemental lactoferrin improves health and growth of Holstein calves during the preweaning phase

Lactoferrin is a milk protein that exhibits broad-spectrum antimicrobial properties. Previous studies indicated that supplemental lactoferrin may alter the microbial populations in the gut of nonruminants and increase preweaning weight gains in calves. In the present study, 40 Holstein calves were used to examine the effects of supplemental lactoferrin (0, 1, 2, or 3 g/d) on health, growth, and feed intake from 3 d of age to 2 wk postweaning. Lactoferrin was mixed and fed with a nonmedicated milk replacer. Calves were housed in individual pens and offered a textured, nonmedicated starter and water for ad libitum consumption. Body weight and heart girth were measuredweekly. Intakes of milk replacer and starter were determined daily. Fecal consistency was monitored three times per week. Calves were weaned when they met certain criteria based on body weight gain and starter intake. Preweaning fecal score responded quadratically, with the group fed 1 g/d of lactoferrin having the lowest score. Overall and preweaning number of days medicated responded in the same manner as fecal score. Preweaning average daily gain and gain-to-feed ratio increased linearly with lactoferrin supplementation, whereas postweaning gain-to-feed ratio decreased linearly with lactoferrin. Overall average daily heart girth gain increased linearly with lactoferrin. Body weight, weaning age, and dry matter intake were not different among treatments. Based on the observed improved gain-to-feed ratios, increased average daily gains, improved fecal scores, and reduced morbidity in preweaned calves, it appears that lactoferrin may be a beneficial supplement in the diets of neonatal calves prior to weaning.

The adversarial alliance: developing therapeutic relationships between families and the team in brain injury rehabilitation

Families of individuals who have survived brain injuries experience significant distress, and may resist accepting their relative's neurobehavioural deficits. Staff who work with brain-injured patients and their relatives are charged with the seemingly paradoxical task of helping families support rehabilitative efforts and be goal-oriented, while simultaneously communicating often negative realities about prognosis. In the midst of what may be an intermittently conflict-laden relationship, families and staff must become synergistically involved in a therapeutic partnership. This paper defines aspects of this 'adversarial alliance' which is often established between families and staff. The relationship between patient discharge outcome and perceived family stress and satisfaction with the rehabilitation programme was reviewed. Data analyses yielded the following conclusions: families evaluated retrospectively to have been 'highly stressed' were also perceived to experience more conflict with the rehabilitation team; family stress was related to poorer adjustment to the patient's disability (at admission); greater family/team conflict correlated with lower cognitive and physical functioning at admission, longer length of stay, younger patient age, and lower programme satisfaction. Implications for programme development and treatment guidelines are discussed.

Evaluation of an innovative cost-effective programme for brain injury patients: response to a need for flexible treatment planning

There is clinical support for the hypothesis that brain-injured patients benefit from the high degree of structure provided by an inpatient rehabilitation programme. However, they often experience mild to moderate regression in behavioural and functional skills when they are discharged to home. This paper presents an evaluation of an innovative phase within an acute brain injury programme designed to facilitate the patient's approach towards independence. 'Step-Up' programme patients, who spent the last weeks of their inpatient length of stay residing in a transitional living setting, were compared with inpatients who participated in the regular therapy programme. Eighteen months of descriptive data regarding cognitive (Rancho) and functional (Barthel) levels for 31 patients are compared. Based on survey data, the Step-Up patients reported more independence in activities of daily living than did inpatients. The Step-Up programme also proved to be more cost effective than the inpatient alternative. Challenges to innovative programming presented by payors, families, and clinicians are discussed.

Rehabilitation staff stress as it relates to patient acuity and diagnosis

Significant concern exists regarding occupational stress among nurses; the present study explored the ways in which nurses' clinical symptoms and coping styles may relate to their working on a brain injury unit or a general rehabilitation unit within an acute physical rehabilitation hospital. A comparison of rehabilitation nurses' responses with those of physical therapists within the same setting was also completed. Staff members completed questionnaires related to job stress and satisfaction, coping (Ways of Coping Checklist) and adjustment (Symptom Checklist-90). Staff groups differed with regard to symptomatology. Brain injury nurses reported higher psychological distress than physical therapists on subscales including depression, interpersonal sensitivity and the global severity index. While brain injury nurses' distress in several areas was higher than other staff groups and than a normal non-patient sample, it did not approach the levels reported by a psychiatric outpatient normative group. Although the three staff groups did not differ notably with regard to most styles of coping, data suggest that work with brain injury patients may foster use of a problem-solving style. Lower physical and cognitive functioning of brain patients as compared with general rehabilitation patients may influence the greater psychological distress reported by brain injury nurses. Job stress appears to relate specifically to the perceived stressfulness of cognitive behavioural aspects of care for all staff groups. Implications of these findings, particularly with regard to support interventions, are discussed.

Simultaneous high-performance liquid chromatographic stability-indicating analysis of acetaminophen, codeine phosphate, and sodium benzoate in elixirs

A stability-indicating high-performance liquid chromatographic method has been developed for the simultaneous determination of acetaminophen, codeine phosphate and sodium benzoate in an elixir formulation. The reversed-phase paired-ion method utilizes UV detection at 214 nm, a C18 column at 50 degrees C and requires ca. 10 min per analysis. The method has been validated for use with elixirs containing 120 mg of acetaminophen, 12 mg of codeine phosphate and 7.5 mg sodium benzoate preservative per 5 ml. The known potential degradation products p-aminophenol, codeine N-oxide and codeinone are separated for quantitation simultaneous with the parent compounds. The method has been shown to be linear, reproducible, specific, sensitive and rugged.

Sex role attributes, symptom distress, and defensive style among college men and women

Eighty-four male and 90 female college students completed the PRF-Andro masculinity and femininity scales, a symptom checklist, and a defense mechanism inventory. Results indicated that interrelations among sex role attributes, defense preferences, and symptom distress differed for men and women. Cross-sex-typed persons mostly accounted for differences in symptom distress within each sex: Masculine women reported relatively low and feminine men reported relatively high degrees of symptom distress. In addition, sex roles interacted with sex in determining defense preferences. We also explored the possibility that defensive styles mediated between sex role attributes and symptom distress. Among women, an association between masculine attributes and a rejection of self-blaming defenses accounted for the negative relation between masculinity and symptom distress. Among men, sex role attributes and defensive styles, for the most part, contributed independently to symptom distress.