Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea

BACKGROUND

The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking.

AIM

To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards.

METHODS

A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively.

FINDINGS

Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset.

CONCLUSION

HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

Is Vector Control Sufficient to Limit Pathogen Spread in Vineyards?

Vector control is widely viewed as an integral part of disease management. Yet epidemiological theory suggests that the effectiveness of control programs at limiting pathogen spread depends on a variety of intrinsic and extrinsic aspects of a pathosystem. Moreover, control programs rarely evaluate whether reductions in vector density or activity translate into reduced disease prevalence. In areas of California invaded by the glassy-winged sharpshooter (Homalodisca vitripennis Germar), Pierce's disease management relies heavily on chemical control of this vector, primarily via systemic conventional insecticides (i.e., imidacloprid). But, data are lacking that attribute reduced vector pressure and pathogen spread to sharpshooter control. We surveyed 34 vineyards over successive years to assess the epidemiological value of within-vineyard chemical control. The results showed that imidacloprid reduced vector pressure without clear nontarget effects or secondary pest outbreaks. Effects on disease prevalence were more nuanced. Treatment history over the preceding 5 yr affected disease prevalence, with significantly more diseased vines in untreated compared with regularly or intermittently treated vineyards. Yet, the change in disease prevalence between years was low, with no significant effects of insecticide treatment or vector abundance. Collectively, the results suggest that within-vineyard applications of imidacloprid can reduce pathogen spread, but with benefits that may take multiple seasons to become apparent. The relatively modest effect of vector control on disease prevalence in this system may be attributable in part to the currently low regional sharpshooter population densities stemming from area-wide control, without which the need for within-vineyard vector control would be more pronounced.

Pedicle subtraction osteotomy in the thoracic spine and thoracolumbar junction: a retrospective series of 28 cases

PURPOSE

Pedicle subtraction osteotomy is a well-described surgical technique for treatment of kyphotic deformity in the spine. It is not widely used for treatment of thoracic kyphosis. We present the first documented series of 28 patients who underwent this procedure in 3 international centers. These patients presented with severe deformity with a wide range of aetiologies.

INDICATIONS

Kyphosis larger than 70 degrees, which is demonstrably rigid based on dynamic imaging.

MATERIALS AND METHODS

28 patients underwent surgery following pre-op neurological and radiographic assessment to fully assess the deformity. A triangular osteotomy was carried out using intraoperative navigation techniques. The patients were assessed post-operatively again with clinical and radiographic parameters at regular follow-up.

RESULTS

The mean ODI score after surgery was 24.7 (16-42) while the pre-op was 53.4 (38-76). Mean thoracic kyphosis was improved from 64.2° (±20.1°) to 41.1° (±17.4°) resulting in a mean sagittal correction of 23.1°. Mean segmental correction at the PSO for all 28 cases was 17.8° (±8.1°). Stratified by region we found different values for the PSO correction: between T1 and T5 (6 cases) it was 17.5° (±5.4°) and between T6 and T9 (4 cases) 18.2° (±4.7°) and between T10 and L1 (18 cases) 26.2° (±5.2°). FBI index was 22.3° pre-op and improved to 7.8° post-op. Calculations were performed with Microsoft excel (2011 Microsoft, Redmond, WA).

CONCLUSIONS

Global sagittal balance was statistically improved in this series as demonstrated by FBI and C7 SVA correction.

The economic benefits of providing shelter to reduce the mortality of twin lambs in south-western Victoria

Achieving higher lamb weaning percentages by reducing lamb mortality can improve the profitability of sheep enterprises. In this paper we estimated the financial benefits from providing shelter to reduce the mortality of twin lambs in self-replacing Merino or dual-purpose Merino flock enterprises in south-west Victoria. A whole-farm bio-economic model (MIDAS) was initially used to estimate the increase in profit from reducing mortality of twin lambs and a second analysis included the costs of using perennial grass hedges to provide the shelter during lambing. The economic value of providing shelter was tested at three rates of twinning (10, 30 and 50%), three rates of mortality without shelter (70, 50 and 30%) and two levels of reduction in lamb mortality by providing shelter (25 and 50% reduction). A sensitivity analysis to wool and lamb prices, costs of establishing the grass hedges and stocking rates in the shelter area were also tested. Overall, more than 2500 scenarios were tested. Across the range of twinning rates and levels of twin mortality tested, at standard wool and meat prices, providing shelter to the dual-purpose Merino ewe flock was always profitable ($0.05 to 11.35/ewe) and the profits from providing shelter to the self-replacing Merino ewe flock were generally lower ($0.15 to $6.35/ewe). The impacts of changing wool and lamb prices depended on enterprise type, whereas the costs of establishment of the hedges or stocking rate of ewes in the hedge area during lambing had little impact on profitability. The main factor that determined the economic return from shelter was the reduction in mortality provided by the shelter but the proportion of twin-bearing ewes in the flock and the base rate of lamb mortality without shelter was also important. Overall, based on the assumptions used, we conclude that the profitability of many sheep enterprises lambing during frequent high chill weather conditions in temperate areas of south-eastern Australia could be improved by providing low cost shelter for twin-bearing Merino ewes lambing from July to September.

Irish National Joint Registry: a concept

Despite the well-documented benefits, some countries have yet to agree on the establishment of a national joint register. A questionnaire study was undertaken to ascertain the opinions of the consultant orthopaedic surgeons and specialist registrars, regarding establishment of an Irish National Joint Register. The aim was to find out the possible reasons why a national joint register has not been established in Ireland. A 69% first response rate was recorded. Ninety-seven percent believe it is time to set up a registry and 81% say it should be made compulsory for unwilling surgeons and hospitals to participate. Despite the overwhelming support, privacy and liability issues were major concerns. Fifty-eight percent agree that access to registry report by general public can expose surgeons and hospitals to medico-legal implications. Legislation may be required to protect the integrity of a national joint replacement registry to ensure that the data are used as intended.

"Australia is one of the darkest markets in the world": the global importance of Australian tobacco control

"Australia is one of the darkest markets in the world... it probably is the darkest, I mean ourselves and Canada fight every month for who's got the darkest conditions to do tobacco manufacturing and marketing. And one of the things we can offer the world is what we do best, which is how to work, maximize, proactively drive our market position in a market that's completely dark. Now that takes a different skillset... a different type of learning. We need to export that... we know we have a lot of expatriates who come down to Australia for learning. they can come here and learn these techniques and take them back to Europe or Latin America or to the United States or to Africa... But the other thing that is really good for us is that we are also a huge net exporter of Australian talent. about 30 or 40 people currently off-shore... We do things really differently here than most other BAT organizations." David Crowe, Marketing Director, British American Tobacco (BAT) Australia(1).

Systemic activation and antigen-driven oligoclonal expansion of T cells in a mouse model of colitis

Transfer of CD4+CD45RBhigh T cells into immunodeficient mice results in both the expansion of the transferred T cells and colitis. Here we show that colitis pathogenesis requires expression of MHC class II molecules by the immune-deficient host. Analysis of the TCRbeta repertoire of the cells found in the large intestine of diseased mice revealed a population with restricted TCR diversity. Furthermore, nucleotide sequence analysis demonstrated the selection for particular CDR3beta amino acid sequence motifs. Collectively, these data indicate that the expansion of T cells in the intestine and colitis pathogenesis are likely to require the activation of Ag-specific T cells, as opposed to nonspecific or superantigen-mediated events. There is relatively little overlap, however, when the TCR repertoires of different individuals are compared, suggesting that a number of Ags can contribute to T cell expansion and the generation of a T cell population in the intestine. Surprisingly, many of the expanded clones found in the large intestine also were found in the spleen and elsewhere, although inflammation is localized to the colon. Additionally, donor-derived T cells appear to be activated in both the intestine and the spleen at early time points after cell transfer. Together, these results strongly suggest that disease induction in this model involves either the early and systemic activation of antigen-specific T cells or the rapid dispersal of T cells activated at a particular site.

The effect of pregnancy on pulmonary nitrogen washout. A study of pre-oxygenation

Pre-oxygenation times were studied in 30 fit pregnant women during the course of their pregnancy. The mothers were studied in the supine position with a left lateral tilt and breathing through a standard Magill system with an oxygen flow rate of 8 litres/minute. Between 13-26 weeks gestation and 26-42 weeks the times needed to achieve an end-tidal nitrogen of 2% were 104 seconds (SD 30) and 80 seconds (SD 20), respectively. A control group of young women of similar age and weight needed 130 seconds (SD 30) to achieve the same end-tidal nitrogen concentration. A gas-tight mask was found to be essential to achieve effective denitrogenation (end-tidal nitrogen concentration of 2%).