Transferring inpatients between wards drives large nosocomial COVID-19 outbreaks, Wales, 2020-22: a matched case-control study using routine and enhanced surveillance data

BACKGROUND

The role of the hospital environment in the spread of COVID-19 is unclear.

AIM

To measure associations between ward characteristics and outbreak size to inform mitigations.

METHODS

Wards with large (case wards) and small (control wards) outbreaks in three acute hospitals were compared. Cases were healthcare-associated COVID-19 inpatients (positive polymerase chain reaction test ≥8 days post admission). Case wards were adult medical/surgical wards with ≥10 cases within rolling 14-day periods, between April 1st, 2020 and April 30th, 2022. Control wards were equivalents with 2-9 cases. Demographic and laboratory data were extracted from routine surveillance systems. Continuous data were aggregated fortnightly and analysed as binary variables according to median values. Each case ward was compared with two control wards matched on outbreak start date (±14 days) to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) using univariable and conditional multivariable logistic regression.

FINDINGS

From 170 outbreaks (median: 5 cases; interquartile range: 2-9), 35 case wards were identified. Community admissions were lower in case wards vs control wards (5 vs 10 median admissions; P<0.01, respectively), whereas transfers between wards within the same hospital were higher (58 vs 29 median transfers; P<0.01, respectively). Wards with more transfers in the preceding fortnight were significantly more likely to experience a large outbreak (≥35 vs <35 transfers; adjusted OR: 9.08; 95% CI: 2.5-33).

CONCLUSION

We recommend safely minimizing patient movements, such as by asking clinicians to record the rationale for transfer, to reduce the likelihood of disease transmission.

Chronic ataluren (PTC124) treatment of nonsense mutation cystic fibrosis

In a subset of patients with cystic fibrosis (CF), nonsense mutations (premature stop codons) disrupt production of full-length, functional CF transmembrane conductance regulator (CFTR). Ataluren (PTC124) allows ribosomal readthrough of premature stop codons in mRNA. We evaluated drug activity and safety in patients with nonsense mutation CF who took ataluren three times daily (morning, midday and evening) for 12 weeks at either a lower dose (4, 4 and 8 mg·kg(-1)) or higher dose (10, 10 and 20 mg·kg(-1)). The study enrolled 19 patients (10 males and nine females aged 19-57 yrs; dose: lower 12, higher seven) with a classic CF phenotype, at least one CFTR nonsense mutation allele, and an abnormal nasal total chloride transport. Both ataluren doses were similarly active, improving total chloride transport with a combined mean change of -5.4 mV (p<0.001), and on-treatment responses (at least -5 mV improvement) and hyperpolarisations (values more electrically negative than -5 mV) in 61% (p<0.001) and 56% (p = 0.002) of patients. CFTR function was greater with time and was accompanied by trends toward improvements in pulmonary function and CF-related coughing. Adverse clinical and laboratory findings were uncommon and usually mild. Chronic ataluren administration produced time-dependent improvements in CFTR activity and clinical parameters with generally good tolerability.

A multi-perspective concept mapping study of problems associated with traumatic brain injury

OBJECTIVE

To develop a model of the problems of persons with traumatic brain injury that includes multiple perspectives as well as the multi-dimensional nature of the phenomena.

DESIGN

Concept mapping, a multi-variate modelling strategy, was employed to produce an exhaustive inventory and concept map of TBI-related problems based on input from patients, family caregivers and professional providers.

RESULTS

The eight-cluster concept map included the following dimensions: social competence, intimacy, behavioural, maturity/independence, neurophysiological, mood, executive functions and non-executive functions.

CONCLUSIONS

An underlying two-dimensional conceptual model of TBI problems is proposed with relevance for theory, practice and further research.

Bioreactors for guiding muscle tissue growth and development

Muscle tissue bioreactors are devices which are employed to guide and monitor the development of engineered muscle tissue. These devices have a modern history that can be traced back more than a century, because the key elements of muscle tissue bioreactors have been studied for a very long time. These include barrier isolation and culture of cells, tissues and organs after isolation from a host organism; the provision of various stimuli intended to promote growth and maintain the muscle, such as electrical and mechanical stimulation; and the provision of a perfusate such as culture media or blood derived substances. An accurate appraisal of our current progress in the development of muscle bioreactors can only be made in the context of the history of this endeavor. Modern efforts tend to focus more upon the use of computer control and the application of mechanical strain as a stimulus, as well as substrate surface modifications to induce cellular organization at the early stages of culture of isolated muscle cells.

Bilateral capacity for speech sound processing in auditory comprehension: evidence from Wada procedures

Data from lesion studies suggest that the ability to perceive speech sounds, as measured by auditory comprehension tasks, is supported by temporal lobe systems in both the left and right hemisphere. For example, patients with left temporal lobe damage and auditory comprehension deficits (i.e., Wernicke's aphasics), nonetheless comprehend isolated words better than one would expect if their speech perception system had been largely destroyed (70-80% accuracy). Further, when comprehension fails in such patients their errors are more often semantically-based, than-phonemically based. The question addressed by the present study is whether this ability of the right hemisphere to process speech sounds is a result of plastic reorganization following chronic left hemisphere damage, or whether the ability exists in undamaged language systems. We sought to test these possibilities by studying auditory comprehension in acute left versus right hemisphere deactivation during Wada procedures. A series of 20 patients undergoing clinically indicated Wada procedures were asked to listen to an auditorily presented stimulus word, and then point to its matching picture on a card that contained the target picture, a semantic foil, a phonemic foil, and an unrelated foil. This task was performed under three conditions, baseline, during left carotid injection of sodium amytal, and during right carotid injection of sodium amytal. Overall, left hemisphere injection led to a significantly higher error rate than right hemisphere injection. However, consistent with lesion work, the majority (75%) of these errors were semantic in nature. These findings suggest that auditory comprehension deficits are predominantly semantic in nature, even following acute left hemisphere disruption. This, in turn, supports the hypothesis that the right hemisphere is capable of speech sound processing in the intact brain.

Improving treatment response of cognitively impaired veterans with neuropsychological rehabilitation

This pilot study examined the effect of computerized neuropsychological rehabilitation (NR) on cognitively impaired veterans' behavior while in treatment for polysubstance abuse. A group of 10 veterans participated in a 10-session adjunctive program of NR. This group was rated for length of stay in treatment and behavioral change and participation in treatment. Comparisons were made with a group of nine veterans who were in the standard substance abuse treatment with no adjunctive NR. Mild to moderate neuropsychological impairments were present in both groups in the areas of immediate and delayed memory, prospective memory, problem solving, and visual scanning and tracking. Relative to controls, the group that participated in NR was found to remain in treatment significantly longer and rated as having a better overall attitude in the general treatment program. These data suggest that NR may have positive treatment implications in patients with mild to moderate neuropsychological impairment.

Neuropsychological impairment in veterans who are HIV-positive

The purpose of this study was to compare the neuropsychological functioning of 12 veterans who were HIV-positive to 21 age-matched veterans who were HIV-negative. Consistent with expectations, the HIV-positive group was found to perform more poorly in areas related to attention and concentration, immediate and delayed verbal recall, immediate and delayed visual recall, visual learning, and tasks requiring psychomotor speed, while a number of language tasks were left intact. This was similar to dysfunction often seen in HIV-related dementia cases. However, this group was also significantly more impaired in confrontation naming, planning, mental calculations, and abstract thought when compared to the HIV-negative group. Comorbid substance abuse found in the majority of our HIV-positive subjects was thought to contribute to the HIV-related dysfunction.

The influence of ridge migration on the magmatic segmentation of mid-ocean ridges

The Earth's mid-ocean ridges display systematic changes in depth and shape, which subdivide the ridges into discrete spreading segments bounded by transform faults and smaller non-transform offsets of the axis. These morphological changes have been attributed to spatial variations in the supply of magma from the mantle, although the origin of the variations is poorly understood. Here we show that magmatic segmentation of ridges with fast and intermediate spreading rates is directly related to the migration velocity of the spreading axis over the mantle. For over 9,500 km of mid-ocean ridge examined, leading ridge segments in the 'hotspot' reference frame coincide with the shallow magmatically robust segments across 86 per cent of all transform faults and 73 per cent of all second-order discontinuities. We attribute this relationship to asymmetric mantle upwelling and melt production due to ridge migration, with focusing of melt towards ridge segments across discontinuities. The model is consistent with variations in crustal structure across discontinuities of the East Pacific Rise, and may explain variations in depth of melting and the distribution of enriched lavas.

Geomagnetic intensity variations over the past 780 kyr obtained from near-seafloor magnetic anomalies

Knowledge of past variations in the intensity of the Earth's magnetic field provides an important constraint on models of the geodynamo. A record of absolute palaeointensity for the past 50 kyr has been compiled from archaeomagnetic and volcanic materials, and relative palaeointensities over the past 800 kyr have been obtained from sedimentary sequences. But a long-term record of geomagnetic intensity should also be carried by the thermoremanence of the oceanic crust Here we show that near-seafloor magnetic anomalies recorded over the southern East Pacific Rise are well correlated with independent estimates of geomagnetic intensity during the past 780 kyr. Moreover, the pattern of absolute palaeointensity of seafloor glass samples from the same area agrees with the well-documented dipole intensity pattern for the past 50 kyr. A comparison of palaeointensities derived from seafloor glass samples with global intensity variations thus allows us to estimate the ages of surficial lava flows in this region. The record of geomagnetic intensity preserved in the oceanic crust should provide a higher-time-resolution record of crustal accretion processes at mid-ocean ridges than has previously been obtainable.

Hepatitis and transfusions

Hepatitis B virus (HBV) and Hepatitis C virus (HCV) are major causes of liver disease. Chronic infection with these viruses often leads to chronic liver disease, including cirrhosis or primary hepatocellular carcinoma (HCC). Concern is growing among patients and health care workers about possible transmission of bloodborne pathogens during medical procedures. This fear has primarily been focused on nosocomial transmission of human immunodeficiency virus (HIV), but other bloodborne infectious agents may also be transmitted during procedures. Chief among these are the hepatitis viruses, particularly HBVand HCV, both of which are significantly more widespread than HIV Circumstantial evidence suggests that hemodialysis, per se, is an important risk factor for infection with HCV.

Modulation of the action of chorionic gonadotropin in the baboon (Papio anubis) uterus by a progesterone receptor antagonist (ZK 137. 316)

Signals from the developing mammalian blastocyst rescue the corpus luteum (CL) and modulate the uterine environment in preparation for implantation and early pregnancy. Our previous studies demonstrated that both short- and long-term administration of chorionic gonadotropin (CG) markedly alters the morphology and the biochemical activity of the receptive endometrium. Because the effects of CG were superimposed on a progesterone-primed endometrium, this study was undertaken to determine if the inhibition of progesterone action by progesterone receptor antagonists (PRa) in intact and ovariectomized baboons would alter the action of CG on the endometrium at the time of uterine receptivity. In the short-term hCG-treated baboons, the PRa reduced the epithelial plaque reaction, completely inhibited alpha-smooth muscle actin (alphaSMA) expression in stromal fibroblasts, and induced the reappearance of the progesterone (PR) and estrogen (ERalpha) receptors in epithelial cells. However, this treatment protocol had no effect on the expression of glycodelin in the glandular epithelium. In contrast, glycodelin expression in addition to alphaSMA was suppressed in the ovariectomized animals. In the long-term hCG-treated baboons, the PRa had a similar effect on both alphaSMA, PR, and ER. In addition, this treatment also resulted in an inhibition of glycodelin expression in the glandular epithelium. These results indicate that blocking the action of progesterone on the endometrium even for a short period of time has a profound effect on the hCG-induced response in stromal fibroblasts. In contrast, for the diminution of glandular epithelial function in the presence of an ovary requires prolonged inhibition of progesterone action, suggesting a potential paracrine effect on the endometrium from the CL in response to hCG.

Retrieval, automaticity, vocabulary elaboration, orthography (RAVE-O): a comprehensive, fluency-based reading intervention program

The most important implication of the double-deficit hypothesis (Wolf & Bowers, in this issue) concerns a new emphasis on fluency and automaticity in intervention for children with developmental reading disabilities. The RAVE-O (Retrieval, Automaticity, Vocabulary Elaboration, Orthography) program is an experimental, fluency-based approach to reading intervention that is designed to accompany a phonological analysis program. In an effort to address multiple possible sources of dysfluency in readers with disabilities, the program involves comprehensive emphases both on fluency in word attack, word identification, and comprehension and on automaticity in underlying componential processes (e.g., phonological, orthographic, semantic, and lexical retrieval skills). The goals, theoretical principles, and applied activities of the RAVE-O curriculum are described with particular stress on facilitating the development of rapid orthographic pattern recognition and on changing children's attitudes toward language.

Continuous arterial gas monitoring: initial experience with the Paratrend 7 in children

OBJECTIVE

To describe clinical usage of the Paratrend 7 continuous arterial blood gas monitor in children.

DESIGN

Children older than 24 months of age who required significant ventilatory intervention were eligible for sensor placement.

INTERVENTIONS

The sensor was placed via the arterial catheter to measure pH, PCO2, PO2, and temperature. The simultaneous arterial blood gas value was recorded along with the sensor reading.

RESULTS

The sensor functioned for as long as seven days and provided the clinicians with data on the patient's respiratory status. The statistical validity of the device when compared to the arterial blood gas showed that the bias/precision for pH was 0.006/0.024, for PCO2 -0.78/4.68 mmHg, and for PO2 1.9%/17.1% (mmHg).

CONCLUSIONS

This report demonstrates actual clinical use of continuous blood gas monitoring in children. The information obtained is a major asset to the management of critically ill children in the intensive care unit.

Long-term impact of clozapine and psychosocial treatment on psychiatric symptoms and cognitive functioning

OBJECTIVE

The long-term effects of a combination of clozapine and psychosocial treatment were evaluated in a sample of treatment-refractory state hospital patients with schizophrenia.

METHODS

A repeated-measure design was used. Thirty-one patients with schizophrenia received both clozapine and an enhanced psychosocial treatment program. Data were collected at baseline and at one-year, two-year, and three-year follow-ups. Psychiatric symptoms, cognitive functioning, dyskinetic movements, and discharge rate were evaluated.

RESULTS

Significant reductions in psychiatric symptoms and improvement in cognitive functioning were found. Differences in the pattern of reductions in positive and negative symptoms over the course of the study were noted. The majority of subjects improved sufficiently to be discharged.

CONCLUSIONS

Clozapine, when combined with psychosocial treatment, is effective for treatment of patients with schizophrenia who are not responsive to other medications.

The need for three stool specimens in routine laboratory examinations for intestinal parasites

This study was designed to test whether three sequential stool specimens are necessary for reliable detection of intestinal parasites in routine laboratory examinations. There were 175 patients in whom a single species of intestinal parasite or ova was identified on at least one occasion when three stool specimens were examined over a period of 14 days from the first recorded specimen. Examination of a first stool specimen detected parasites and/or ova in 102/175 patients (58.3%); examination of a second specimen identified an additional 36 positive patients (20.6%) and examination of a third specimen yielded a final 37 previously undetected patients (21.1%). These findings indicate that at least three stool specimens should be examined to confirm the presence of intestinal parasites. Even with such practice, it is not possible to guarantee that there is no infestation, but examination of fewer specimens would run a definite risk of false negative results.

Clinical significance of antibodies to bovine and human thrombin and factor V after surgical use of bovine thrombin

Two patients exposed during surgery to bovine thrombin developed antibodies reacting with both bovine and human thrombin and Factor V. Their thrombin times were markedly prolonged with bovine thrombin and modestly prolonged with human thrombin. High titer anti-bovine Factor V created diagnostic confusion in one patient by neutralizing bovine Factor V in a prothrombin assay substrate. Although weaker, antibody activity against human Factor V led to postoperative factor V deficiency in both patients. Such cross-reacting antibodies, recognizable by their higher titer against bovine than human Factor V, should be suspected when a patient surgically exposed to bovine thrombin develops a Factor V anticoagulant after operation. Crossed immunoelectrophoresis of adsorbed bovine plasma with each patient's plasma as antibody revealed many precipitin arcs indicative of immunization of the patients to additional proteins in a commercial thrombin preparation.

Immunological characterization and immunocytochemical localization of oviduct-specific glycoproteins in the baboon (Papio anubis)

Oviducts obtained from estradiol-treated ovariectomized baboons synthesize and release a family of high mol wt (100,000-130,000) glycoproteins during short term explant culture. The objective of this study was to make a polyclonal antibody to these glycoproteins and then use the antibody to determine the presence of the glycoproteins in oviduct flushings, tissue culture media, and tissues obtained from cycling and steroid-treated baboons. Oviduct culture medium proteins from estradiol-treated baboons were separated on one-dimensional polyacrylamide gels and transferred to nitrocellulose membranes. The region containing the glycoproteins was cut out, solubilized in dimethylsulfoxide, mixed with Freund's adjuvant, and injected at 2-week intervals into a male rabbit. The anti-serum used in this study was obtained 6 weeks after the initial injection and cross-reacted with antigens on Western blots of oviduct flushings and oviduct culture media obtained from follicular stage and estradiol-treated baboons. The antigens were absent in oviduct flushings obtained from luteal stage, ovariectomized and estradiol-primed baboons treated with estradiol and progesterone or progesterone alone. The antigens were not detected on Western blots of other reproductive and nonreproductive tract culture media or in serum obtained from follicular stage or estradiol-treated baboons. Immunoperoxidase staining was limited to discrete granules in the apical cytoplasm of secretory cells in oviducts obtained from follicular stage and estradiol-treated baboons. Thus, the secretory cells of the baboon oviduct synthesize and secrete a family of estradiol-dependent oviduct-specific glycoproteins that may have potential functional significance during fertilization and embryo development.

The in vitro synthesis and release of proteins by the human oviduct

The purpose of this study was to identify major proteins synthesized by the human oviduct and to determine if the ability of the human oviduct to synthesize these proteins was correlated with a specific stage(s) of the menstrual cycle. Oviducts, obtained from normal menstrual and immediately postpartum women, were minced and cultured in the presence of labeled precursors. The culture medium was analyzed for newly synthesized proteins by electrophoresis, followed by fluorography. One-dimensional gel electrophoretic analysis of culture medium of oviducts obtained at midcycle revealed a major diffuse band in the 120,000-130,000 mol wt (Mr) region which was greatly diminished in intensity or nondetectable in the media of oviducts obtained at all other stages of the cycle. Two-dimensional gel electrophoresis resolved the 120,000-130,000 Mr region into two major proteins, one basic and one acidic. Both proteins were intensely labeled with glucosamine, and the basic protein also incorporated leucine and methionine. Western blots of culture media incubated with antibodies against human placental proteins (PP) demonstrated that PP4 and PP7 were released throughout the cycle, while PP14 was present only at the late luteal stage of the cycle. This study demonstrates that human oviducts continue to synthesize and release macromolecules during organ culture. Additionally, the synthesis of some of these proteins appeared to be stage specific. The Mr 120,000-130,000 glycoproteins are of particular interest since they were observed in medium from midcycle oviducts, a period when the oviduct participates in gamete transport and embryo development.

A plasma protein C activity assay suitable for a clinical laboratory. Its use to measure activity in hereditary and acquired deficiency states

The authors describe the technic and standardization of an assay to measure plasma protein C activity feasible for clinical laboratory use. It is modified from an assay of Francis and Patch (Thromb Res 1983; 32:605-613) to enhance protein C recovery in the barium citrate eluate, to eliminate the steps of addition and neutralization of heparin, and to use only commercially available reagents. The normal range for plasma protein C in the assay is 72-130% (+/- 2 SD) (0.7-1.30). Hepatocellular disease lengthening the prothrombin time by 3-4 seconds was associated with plasma protein C activity of 25% (0.25) to 35% (0.35). Although the assay is thought to accurately measure protein C activity in patients taking warfarin, one cannot evaluate such patients for hereditary functional protein C deficiency because treatment with warfarin will itself reduce the ratio of protein C activity to antigen. The assay can be used in a patient receiving heparin if the heparin is removed as described.

Children's understanding of the distinction between real and apparent emotion

2 experiments examined children's understanding of the distinction between real and apparent emotion. In Experiment 1, 6- and 10-year-old children listened to stories in which it would be appropriate for the story protagonist to feel either a positive or negative emotion but to hide that emotion. Subjects were asked to say both how the protagonist would look and how the protagonist would really feel, and to justify their claims. The results indicated that 6- and 10-year-olds alike could distinguish quite accurately between real and apparent emotion, although 10-year-olds were somewhat better at justifying this distinction. In Experiment 2, a slightly modified procedure was used to test 4- and 6-year-olds. Again, 6-year-olds demonstrated their grasp of the difference between real and apparent emotion, and even 4-year-olds showed a limited grasp of the distinction. The findings are discussed in relation to recent research concerning children's concept of mind, their grasp of the appearance-reality distinction, their ability to produce complex, embedded justifications, and their ideas about emotion.

Past, present, and future applications of the auditory middle latency response

For many years (auditory) middle latency response (MLR) reportedly has been an excellent electrophysiological procedure for estimating frequency specific auditory thresholds. Currently the 40 Hz potential, a derivative of the MLR, holds even greater promise for threshold testing. MLR also appears to have potentially valuable applications in the evaluation of functional hearing loss and assessment of higher auditory function. However, MLR is not without controversy. Questions of origin, filtering effects, and its use in pediatric assessment are current issues surrounding applications of MLR. The following article analyzes the values and limitations of MLR within the framework of past, present, and future research and clinical uses.

Modification of pancreatic carcinogenesis in the hamster model. 5. Effect of partial pancreatico-colostomy

Studies were conducted to evaluate the possibility of a bile reflux mechanism in the etiology of induced pancreatic cancer. N-Nitrosobis(2-oxopropyl)amine (BOP) was administered to Syrian hamsters after partial pancreatico-colostomy. Either the gastric or the splenic lobe of the pancreas was anastomosed to the transverse colon in groups 1 and 2, respectively. Group 3 were sham-operated controls and group 4 were controls without surgery. Shortly after surgery all 4 groups received a single subcutaneous BOP injection (20 mg/kg body weight) and survivors were sacrificed 46 weeks after BOP treatment. BOP-induced pancreatic tumor patterns were not altered by pancreatico-colostomy when compared with those in sham-operated controls. In all BOP-treated hamsters the number and distribution of benign and malignant lesions were similar in each individual pancreatic segment, including the anastomosed lobe (A-lobe); some hamsters developed tumors only in the A-lobe. As in other pancreatic regions, the initial hyperplasia in the A-lobe primarily affected peri- and intra-insular ductules and less frequently involved the ducts. These findings support the theory that the carcinogen is bloodborne and indicate that BOP-responsive pancreatic cells are distributed on a volume basis in distinct proportions within the pancreatic segments. As in previous experiments a higher incidence of pancreatic neoplasms was found in BOP-treated controls (those not operated upon) than in partially pancreatico-colostomized hamsters, including those with sham operations. Hyperplastic and dyplastic development of colonic mucosa around the anastomosis could be related to a local effect of carcinogen or of its metabolites, which are known to be excreted via pancreatic secretions.

Modification of pancreatic carcinogenesis in the hamster model. 3. Inhibitory effect of alloxan

Alloxan, when given intravenously at a dose of 60 mg/kg body weight 2 hours prior to subcutaneous injection of the potent pancreatic carcinogen N-nitrosobis (2-oxopropyl) amine (BOP), inhibited the induction of hyperplastic and neoplastic pancreatic lesions in a statistically significant fashion (P less than 0.01). The number of lesions per animal affected was markedly less in these animals, compared with BOP-treated control animals. BOP administration 2 weeks after alloxan treatment, at which time pancreatic islet cell regeneration is considered completed, did not alter either the incidence or number of lesions. The results support our view that the pancreatic islet cells are the primary source of BOP metabolism. The concomitant inhibition of gallbladder tumors, but not of common duct neoplasms, in hamsters receiving BOP 2 hours after alloxan could indicate that alloxan's inhibitory effects on BOP carcinogenesis are not restricted to the pancreas.

The neglected alliance: the inpatient unit as a consultant to referring therapists

During two years of work on an inpatient psychiatry unit in a general hospital, the authors became impressed with how often patient-therapist difficulties preceded the need to hospitalize a patient. Difficulties in the therapeutic relationship sometimes precipitated the hospitalization; other times they were complicating factors. Unresolved difficulties in this relationship had to be addressed during hospitalization if inpatient treatment was to be successful. The authors present several typical cases that demonstrate different kinds of difficulties in the patient-therapist relationship and the use of consultation by an inpatient staff in resolving them. They conclude that an inpatient unit with sufficient staff should serve as a consultant to the referring therapist in almost every case.