Influenza vaccination during the 2021/22 season: A data-linkage test-negative case-control study of effectiveness against influenza requiring emergency care in England and serological analysis of primary care patients

We present England 2021/22 end-of-season adjusted vaccine effectiveness (aVE) against laboratory confirmed influenza related emergency care use in children aged 1-17 and in adults aged 50+, and serological findings in vaccinated vs unvaccinated adults by hemagglutination inhibition assay. Influenza vaccination has been routinely offered to all children aged 2-10 years and adults aged 65 years + in England. In 2021/22, the offer was extended to children to age 15 years, and adults aged 50-64 years. Influenza activity rose during the latter half of the 2021/22 season, while remaining comparatively low due to COVID-19 pandemic control measures. Influenza A(H3N2) strains predominated. A test negative design was used to estimate aVE by vaccine type. Cases and controls were identified within a sentinel laboratory surveillance system. Vaccine histories were obtained from the National Immunisation Management Service (NIMS), an influenza and COVID-19 vaccine registry. These were linked to emergency department presentations (excluding accidents) with respiratory swabbing ≤ 14 days before or ≤ 7 days after presentation. Amongst adults, 423 positive and 32,917 negative samples were eligible for inclusion, and 145 positive and 6,438 negative samples among children. Those admitted to hospital were further identified. In serology against the circulating A(H3N2) A/Bangladesh/4005/2020-like strain, 61 % of current season adult vaccinees had titres ≥ 1:40 compared to 17 % of those unvaccinated in 2020/21 or 2021/22 (p < 0.001). We found good protection from influenza vaccination against influenza requiring emergency care in children (72.7 % [95 % CI 52.7, 84.3 %]) and modest effectiveness in adults (26.1 % [95 % CI 4.5, 42.8 %]). Adult VE was higher for A(H1N1) (81 % [95 % CI 50, 93 %]) than A(H3N2) (33 % [95 % CI 6, 53 %]). Consistent protection was observable across preschool, primary and secondary school aged children. Imperfect test specificity combined with very low prevalence may have biased estimates towards null. With limited influenza circulation, the study could not determine differences by vaccine types.

Radiographers' experiences and educational needs in relation to caring for suicidal patients during radiology examinations

INTRODUCTION

Researchers have explored the experiences, attitudes, and educational needs of several healthcare professional groups in relation to caring for suicidal patients. However, radiographers have not been included in these studies. Radiographers are likely to encounter these patients when they present for diagnostic imaging following suicide attempts.

METHODS

An online questionnaire exploring radiographers' experiences and educational needs in caring for suicidal patients was circulated to radiographers working in 23 acute hospitals across Ireland and posted to a Facebook page targeting Irish-based radiographers. Closed-ended questions were used to capture respondents' demographics and five-point Likert scale questions to establish their confidence levels in imaging suicidal patients. Open-ended questions were used to explore their experiences and educational needs. Quantitative data was analysed using descriptives statistics, and qualitative data thematically analysed.

RESULTS

One hundred and four radiographers responded to the questionnaire, 96% of whom had imaged suicidal patients. Radiographers were confident in justifying and optimising these radiographic examinations, however, less confident in communicating with and caring for these patients. Radiographers reported insufficient patient history on imaging referrals and challenges in communicating with suicidal patients, which many attributed to lack of training. Radiographers expressed interest in further education related to caring for patients who've attempted suicide, which they felt should include an introduction to psychiatry, strategies for communicating with suicidal patients and building resilience.

CONCLUSION

Radiographers' experiences of imaging suicidal patients have been reported along with several challenges which could be addressed through further education.

IMPLICATIONS FOR PRACTICE

Further education in caring for suicidal patients should be offered to radiographers which aligns with their educational needs. Referring clinicians should be reminded of the importance of informing radiographers of patients' suicide attempt when referring them for diagnostic imaging.

A Hybrid Architecture (CO-CONNECT) to Facilitate Rapid Discovery and Access to Data Across the United Kingdom in Response to the COVID-19 Pandemic: Development Study

BACKGROUND

COVID-19 data have been generated across the United Kingdom as a by-product of clinical care and public health provision, as well as numerous bespoke and repurposed research endeavors. Analysis of these data has underpinned the United Kingdom's response to the pandemic, and informed public health policies and clinical guidelines. However, these data are held by different organizations, and this fragmented landscape has presented challenges for public health agencies and researchers as they struggle to find relevant data to access and interrogate the data they need to inform the pandemic response at pace.

OBJECTIVE

We aimed to transform UK COVID-19 diagnostic data sets to be findable, accessible, interoperable, and reusable (FAIR).

METHODS

A federated infrastructure model (COVID - Curated and Open Analysis and Research Platform [CO-CONNECT]) was rapidly built to enable the automated and reproducible mapping of health data partners' pseudonymized data to the Observational Medical Outcomes Partnership Common Data Model without the need for any data to leave the data controllers' secure environments, and to support federated cohort discovery queries and meta-analysis.

RESULTS

A total of 56 data sets from 19 organizations are being connected to the federated network. The data include research cohorts and COVID-19 data collected through routine health care provision linked to longitudinal health care records and demographics. The infrastructure is live, supporting aggregate-level querying of data across the United Kingdom.

CONCLUSIONS

CO-CONNECT was developed by a multidisciplinary team. It enables rapid COVID-19 data discovery and instantaneous meta-analysis across data sources, and it is researching streamlined data extraction for use in a Trusted Research Environment for research and public health analysis. CO-CONNECT has the potential to make UK health data more interconnected and better able to answer national-level research questions while maintaining patient confidentiality and local governance procedures.

Microbial epidemiology and clinical risk factors of carbapenemase-producing Enterobacterales amongst Irish patients from first detection in 2009 until 2020

Background

Carbapenemase producing Enterobacterales (CPE) are major public health threats.

Aim

To review microbial epidemiology of CPE, as well as clinical risk factors and infections, amongst CPE positive patients over 12 years in an Irish tertiary hospital.

Methods

Retrospective observational study of data extracted from a laboratory CPE database, electronic healthcare records and manual review of patient charts. Common risk factors, treatment regimens for all CPE related infections, and clinical outcomes were ascertained.

Findings

Among CPE strains isolated from 460 patients, Klebsiella pneumoniae carbapenemase (KPC) was the carbapenemase most frequently detected, accounting for 87.4% (459) of all CPE enzymes. Citrobacter species 177 (33.7%) were the most common species harbouring this enzyme. 428 CPE positive patients (93%) were identified in the acute hospital setting; the most common risk factor for CPE acquisition was history of hospitalisation, observed in 305 (66%) cases. Thirty patients (6.5%) had confirmed infections post-acquisition, of which four were bloodstream infections. There were 19 subsequent episodes of non CPE-related bacteraemia in this cohort. All causal mortality at 30 days was 41 patients (8.9%). However, clinical review determined that CPE was an indirect associative factor in 8 patient deaths.

Conclusions

In this tertiary hospital setting, microbial epidemiology is changing; with both OXA-48 enzymes and KPC-producing Citrobacter species becoming more prevalent. Whilst the burden of CPE related infections, especially bacteraemia, was low over the study period, it remains critical that basic infection prevention and control practices are adhered to lest the observed changes in epidemiology result in an increase in clinical manifestations.

Repeated transmission of SARS-CoV-2 in an overcrowded Irish emergency department elucidated by whole-genome sequencing

AIM

To provide a detailed genomic-epidemiological description of a complex multi-ward SARS-CoV-2 outbreak, which originated in the crowded emergency department (ED) in our hospital during the third wave of the COVID-19 pandemic, and was elucidated promptly by local whole-genome sequencing (WGS).

METHODS

SARS-CoV-2 was detected by reverse transcriptase real-time polymerase chain reaction on viral RNA extracted from nasopharyngeal swabs. WGS was performed using an Oxford MinION Mk1C instrument following the ARTIC v3 sequencing protocol. High-quality consensus genomes were assembled with the artic-ncov2019 bioinformatics pipeline and viral phylogenetic trees were built, inferred by maximum-likelihood. Clusters were defined using a threshold of 0-1 single nucleotide polymorphisms (SNPs) between epidemiologically linked sequences.

RESULTS

In April 2021, outbreaks of COVID-19 were declared on two wards at University Hospital Limerick after 4 healthcare-associated SARS-CoV-2 infections were detected by post-admission surveillance testing. Contact tracing identified 12 further connected cases; all with direct or indirect links to the ED 'COVID Zone'. All sequences were assigned to the Pangolin B.1.1.7 lineage by WGS, and SNP-level analysis revealed two distinct but simultaneous clusters of infections. Repeated transmission in the ED was demonstrated, involving patients accommodated on trolleys in crowded areas, resulting in multiple generations of infections across three inpatient hospital wards and subsequently to the local community. These findings informed mitigation efforts to prevent cross-transmission in the ED.

CONCLUSION

Cross-transmission of SARS-CoV-2 occurred repeatedly in an overcrowded emergency department. Viral WGS elucidated complex viral transmission networks in our hospital and informed infection, prevention and control practice.

Association between tocilizumab treatment of hyperinflammatory patients with COVID-19 in a critical care setting and elevated incidence of hospital-acquired bacterial and invasive fungal infections

Background

Tocilizumab is an interleukin-6 inhibitor that reduces mortality and the need for invasive mechanical ventilation, while increasing the possibility of successful hospital discharge for hyperinflammatory patients with severe coronavirus disease 2019 (COVID-19). No increase in adverse events or serious infections has been reported previously.

Aim

To describe the characteristics and outcomes of patients with severe COVID-19 in critical care who received tocilizumab, and to compare mortality and length of hospital stay for patients who received tocilizumab (N=41) with those who did not (N=33).

Methods

Retrospective review of data related to patients with COVID-19 who received tocilizumab in a critical care setting from 1^st January to 31^st December 2021.

Findings

Amongst COVID-19 survivors, those who had received tocilizumab had longer intensive care unit (ICU) stays (median length 21 vs 9 days) and hospital stays (45 vs 34 days) compared with those who had not received tocilizumab. Thirty-day mortality (29% vs 36%; P=0.5196) and 60-day mortality (37% and 42%; P=0.6138) were not significantly lower in patients who received tocilizumab. Serious bacterial and fungal infections occurred at higher frequency amongst patients who received tocilizumab [odds ratio (OR) 2.67, 95% confidence interval (CI) 1.04–6.86; P=0.042], and at significantly higher frequency than in non-COVID-19 ICU admissions (OR 5.26, 95% CI 3.08–9.00; P<0.0001).

Conclusions

In this single-centre study, patients in critical care with severe COVID-19 who received tocilizumab had a greater number of serious bacterial and fungal infections, but this may not have been a direct effect of tocilizumab treatment.

234 THE IMPACT OF OLDER AGE ON CLINICAL OUTCOMES DURING THE FIRST WAVE OF THE COVID-19 PANDEMIC

Background

Severe acute respiratory coronavirus 2 (SARS-CoV-2) was first recorded in Ireland in February 2020. Several studies have explored the association between age and SARS-CoV-2, showing that there were poorer outcomes in older people. Our objective was to evaluate the impact of age on outcomes such as hospital length of stay, mortality, and re-hospitalisation.

Methods

We performed a single-centre, retrospective observational cohort study, using an electronic microbiology database of recorded index admissions of SARS-CoV-2 positive patients aged 65 years and older during SARS-CoV-2 wave one (March 1^st to May 31^st 2020). PCR testing of nasopharyngeal and/or sputum samples was used to confirm positivity. Our clinical outcomes measured included hospital length of stay, mortality and re-admission rate within 6 months.

Results

153 patients 65 years and above were admitted. The male to female ratio was 1.3 with 90% admitted medically. 79 patients were aged between 65–79 years; 84 patients ≥80 years; and 12 patients ≥90 years. Mortality was 25%, 31% and 42%, respectively. Median length of stay remained 14 days for ages 65–89 rising to 17.5 days for those ≥90 years. Re-hospitalisation rates at 6 months were similar for ages 65–79 and 89–89 years at 42% and 40%, respectively. One patient (14%) over 90 years was re-hospitalised.

Conclusion

SARS-CoV-2 has disproportionately impacted on general medical services treating older hospitalised people. In our centre, mortality for patients ≥65 years was 28.1% which compared favourably with 35.6% internationally as outlined by Victor et al. (2020) based on Spanish data. Treatment of SARS-CoV-2 is not futile in older patients with 58% of nonagenarians and 69% of octogenarians surviving, however re-hospitalisation rates are high at 40%. A targeted approach to discharge support via integrated care may ameliorate this.

Real-world data shows increased reactogenicity in adults after heterologous compared to homologous prime-boost COVID-19 vaccination, March-June 2021, England

Adults receiving heterologous COVID-19 immunisation with mRNA (Comirnaty) or adenoviral-vector (Vaxzevria) vaccines had higher reactogenicity rates and sought medical attention more often after two doses than homologous schedules. Reactogenicity was higher among ≤ 50 than > 50 year-olds, women and those with prior symptomatic/confirmed COVID-19. Adults receiving heterologous schedules on clinical advice after severe first-dose reactions had lower reactogenicity after dose 2 following Vaxzevria/Comirnaty (93.4%; 95% confidence interval: 90.5-98.1 vs 48% (41.0-57.7) but not Comirnaty/Vaxzevria (91.7%; (77.5-98.2 vs 75.0% (57.8-87.9).

Deep learning enables the automation of grading histological tissue engineered cartilage images for quality control standardization

OBJECTIVE

To automate the grading of histological images of engineered cartilage tissues using deep learning.

METHODS

Cartilaginous tissues were engineered from various cell sources. Safranin O and fast green stained histological images of the tissues were graded for chondrogenic quality according to the Modified Bern Score, which ranks images on a scale from zero to six according to the intensity of staining and cell morphology. The whole images were tiled, and the tiles were graded by two experts and grouped into four categories with the following grades: 0, 1-2, 3-4, and 5-6. Deep learning was used to train models to classify images into these histological score groups. Finally, the tile grades per donor were averaged. The root mean square errors (RMSEs) were calculated between each user and the model.

RESULTS

Transfer learning using a pretrained DenseNet model was selected. The RMSEs of the model predictions and 95% confidence intervals were 0.49 (0.37, 0.61) and 0.78 (0.57, 0.99) for each user, which was in the same range as the inter-user RMSE of 0.71 (0.51, 0.93).

CONCLUSION

Using supervised deep learning, we could automate the scoring of histological images of engineered cartilage and achieve results with errors comparable to inter-user error. Thus, the model could enable the automation and standardization of assessments currently used for experimental studies as well as release criteria that ensure the quality of manufactured clinical grafts and compliance with regulatory requirements.

Time to positivity (TTP) of neonatal blood cultures: a trend analysis over a decade from Ireland

Background and aims: Blood culture (BC) remains gold standard for the evaluation and diagnosis of neonatal sepsis. Time when BC becomes positive and the type of microorganism isolated are crucial in deciding the antimicrobial management. Likely pathogenicity of organisms growing in BC could potentially be predicted based on the "time to positivity" (TTP). We aimed to estimate the predictive value of isolating a likely pathogenic organism depending on TTP; evaluate the aetiological trend and neonatal mortality rate due to culture-proven neonatal sepsis for over a decade and verify whether the application of a "36 hour rule" to discontinue empiric antibiotics in well newborn infants with negative BC would be safe.Methods: Retrospective review of BC results over a 14-year period from a regional neonatal unit in Ireland. Laboratory data were independently extracted in relation to BC results from the laboratory information management system (LIMS-iLAB). Neonatal mortality data were collected from multiple sources. Statistical analysis included logistic regression, chi-square, and Mann-Whitney U-test.Results: Over a 14-year period 11,432 neonatal BC specimens were incubated of which 605 (5.3%) turned positive. Overall, the commonest organism grown was coagulase-negative Staphylococcus (CoNS), 416 (68.8%). Main pathogenic organisms were Staphylococcus aureus 23 (3.8%), Enterococcus spp. 22 (3.6%), E.coli 21 (3.5%), group B Streptococcus (GBS) 18 (3.0%), and Klebsiella species 9 (1.5%). Gram-negative organisms had the shortest TTP, with Klebsiella spp. having a median TTP of 10 h and E. coli 11 h. For Gram-positives, GBS had a median TTP of 12 h, Enterococcus species 14 h, with S. aureus growing at a median time of 15 h. All of the Klebsiella spp. and other Coliforms were detected within 24 h, with, 95.2% of E.coli, 94.4% of GBS, 95.5% of Enterococci, and 95.7% of S. aureus, flagging positive in 24 h. Using logistic regression the omnibus test of the coefficients in the resulting model was significant (p < .001). Our observed coefficient (β) for TTP was 0.144; shorter the TTP higher was the likelihood of isolating a pathogenic organism, with an odds ratio (OR) of 1.155. We also report a relatively low blood culture proven sepsis-specific neonatal mortality rate of 0.403/1000 live births and in all such instances observed TTP was less than 24 h.Conclusion: Duration of this study exceeds that of most of the neonatal blood culture TTP analysis published to-date. A shorter TTP is an important adjunct to suggest the growth of a pathogenic organism while managing suspected neonatal sepsis. TTP if < 24 h per se would not necessarily confirm the growth of a highly pathogenic organism; however, if a positive growth is likely to happen for a significant neonatal pathogen, in more than 98% the TTP would be within 24 h. This offers the clinician more of negative predictive value than a positive one; when there is no growth in BC. Our observation on TTP reiterate the National Institute of Health and Care Excellence (NICE) guideline of discontinuation of empiric antibiotics after 36 h in and clinically well and BC negative newborn infants.

Key findings on legal and regulatory barriers to HIV testing and access to care across Europe

OBJECTIVE

The aim of this work within OptTEST by HiE has been to demonstrate the role of legal and regulatory barriers in hindering access to HIV testing, treatment and care across Europe and to produce tools to help dismantle them.

METHODS

An online survey to assess country-specific data on legal and regulatory barriers distributed widely across the WHO Europe region. Literature reviews conducted in January-October 2015 in English, in November 2015 in Russian, and updated in April 2017. Semi-structured interviews were conducted with 25 key actors within the HIV field to feed into case studies and tip sheets on how to dismantle legal and regulatory barriers.

RESULTS

More than 160 individuals and organisations from 49 countries across the WHO European region provided responses which were analysed and cross checked with other data sources and a searchable database produced (legalbarriers.peoplewithhiveurope.org). The conducted literature reviews yielded 88 papers and reports which identify legal and regulatory barriers to key populations' access to HV testing and care. Based on the interviews with key actors, ranging from PLHIV activists to government officials, on lessons-learned, a series of tip sheets and ten case studies were written-up intended to inform and inspire the HIV community to address and overcome existing barriers (opttest.eu/Tools).

CONCLUSION

While some of the barriers identified may require major changes to wider health systems, or long term legal reform, many are open to a simple change in regulations or custom and practice. We have the tools. Why can't we finish the job?

Breast infections - Microbiology and treatment in an era of antibiotic resistance

INTRODUCTION

Primary breast abscesses occur in <1% of non-lactating women, rising to 11% in women with lactational mastitis. In patients undergoing breast cancer surgery, the inflammatory response to post-operative surgical site infection (SSI) has been implicated in recurrence. Anti-microbial resistance increasingly hampers treatment in each group.

AIMS

Describe the demographic and predisposing characteristics of patients with primary breast abscesses and secondary infections, identify the microbial and antimicrobial patterns and formulate an evidence-based protocol for treating breast infections.

METHODS

Retrospective cohort study of all breast infections (primary and post-operative) treated at UHL from 2014 to 2017. Data collected from microbiology databases and patient records was analysed using Minitab V18.

RESULTS

537 cultures from 108 patients were analysed. 47 (43.5%) had primary abscesses, 12 (11.1%) were lactational and 49 (45.4%) were post-operative SSI. For primary infections, the mean age was 41.9 (±12.2) and reinfection rate 33%. For SSIs the mean age was 51.8 (±14.52) and reinfection rate 11.8%. Overall, 29.3% were smokers, 6.4% diabetic and 2.9% pregnant. 60 (43%) patients required radiological drainage and 2 (1%) surgical drainage. 57.5% had mixed growth. The most common isolate was Staphylococcus aureus; cultured in 16.7% of primary abscesses and 24% of SSIs. 13 empiric antibiotic regimes were prescribed before 26.4% of patients changed to 12 different targeted regimes.

CONCLUSION

Breast infections are frequently polymicrobial with a wide variety of organisms isolated, suggesting the need for broad spectrum coverage until culture results become available. Based on our local culture results, the addition of clindamycin to flucloxacillin would provide excellent empiric coverage for all categories of breast infection. An evidence-based treatment guideline is required and should be formulated in close collaboration with microbiology specialists.

Colonisation with extended-spectrum beta-lactamase (ESBL) not detected in a prevalence study

BACKGROUND

The Mid-West of Ireland has higher than average national rates of invasive extended-spectrum beta-lactamase (ESBL) bloodstream infections and carbapenemase-producing Enterobacteriaceae (CPE), with increasing numbers of ESBL isolates detected in community-dwelling patients.

AIMS

To conduct a point prevalence study in a convenience sample of the Mid-West population with the aim of determining the extent of ESBL colonisation.

METHODS

Utilising anonymised community stool samples that had completed routine analysis, we conducted a point prevalence study over a 4-week period on all samples that met defined inclusion and exclusion criteria. Limited epidemiological data was recorded: (1) age of patient, (2) gender, and (3) sender location. From these stool specimens, rectal swabs were inoculated (eSwab™ 480CE, Copan, Italy), which were subsequently cultured on selective chromogenic agar (Colorex™ ESBL). Culture plates were incubated aerobically at 37 °C for 24 h.

RESULTS

Of 195 samples processed, 58 % (n = 112) were from females. The median patient age was 62.4 years (range 20-94 years). 186 samples (95 %) originated from general practitioner clinics. During the study period, only nine eligible stool samples were received from LTCF (6 public). From 195 Colorex™ ESBL chromogenic agar plates cultured, no ESBL-producing organisms were detected.

CONCLUSIONS

This community point prevalence study did not identify ESBL colonisation despite high numbers of patients with invasive ESBL bloodstream infections presenting for admission in our institution. We believe this may be because of our small sample size. Data regarding antimicrobial exposure and other risk factors for ESBL colonisation were also not available. We remain vigilant for ESBL-producing organisms.

An Irish outbreak of New Delhi metallo-β-lactamase (NDM)-1 carbapenemase-producing Enterobacteriaceae: increasing but unrecognized prevalence

BACKGROUND

Carbapenemase-producing Enterobacteriaceae (CPE) may cause healthcare-associated infections with high mortality rates. New Delhi metallo-β-lactamase-1 (NDM-1) is among the most recently discovered carbapenemases.

AIM

To report the first outbreak of NDM-1 CPE in Ireland, including microbiological and epidemiological characteristics, and assessing the impact of infection prevention and control measures.

METHODS

This was a retrospective microbiological and epidemiological review. Cases were defined as patients with a CPE-positive culture. Contacts were designated as roommates or ward mates.

FINDINGS

This outbreak involved 10 patients with a median age of 71 years (range: 45-90), located in three separate but affiliated healthcare facilities. One patient was infected (the index case); the nine others were colonized. Nine NDM-1-producing Klebsiella pneumoniae, an NDM-1-producing Escherichia coli and a K. pneumoniae carbapenemase (KPC)-producing Enterobacter cloacae were detected between week 24, 2014 and week 37, 2014. Pulsed-field gel electrophoresis demonstrated similarity. NDM-1-positive isolates were meropenem resistant with minimum inhibitory concentrations (MICs) ranging from 12 to 32 μg/mL. All were tigecycline susceptible (MICs ≤1 μg/mL). One isolate was colistin resistant (MIC 4.0 μg/mL; mcr-1 gene not detected). In 2015, four further NDM-1 isolates were detected.

CONCLUSION

The successful management of this outbreak was achieved via the prompt implementation of enhanced infection prevention and control practices to prevent transmission. These patients did not have a history of travel outside of Ireland, but several had frequent hospitalizations in Ireland, raising concerns regarding the possibility of increasing but unrecognized prevalence of NDM-1 and potential decline in value of travel history as a marker of colonization risk.

An optimized work-flow to reduce time-to-detection of carbapenemase-producing Enterobacteriaceae (CPE) using direct testing from rectal swabs

Rapid detection of patients with carbapenemase-producing Enterobacteriaceae (CPE) is essential for the prevention of nosocomial cross-transmission, allocation of isolation facilities and to protect patient safety. Here, we aimed to design a new laboratory work-flow, utilizing existing laboratory resources, in order to reduce time-to-diagnosis of CPE. A review of the current CPE testing processes and of the literature was performed to identify a real-time commercial polymerase chain reaction (PCR) assay that could facilitate batch testing of CPE clinical specimens, with adequate CPE gene coverage. Stool specimens (210) were collected; CPE-positive inpatients (n = 10) and anonymized community stool specimens (n = 200). Rectal swabs (eSwab™) were inoculated from collected stool specimens and a manual DNA extraction method (QIAamp® DNA Stool Mini Kit) was employed. Extracted DNA was then processed on the Check-Direct CPE® assay. The three step process of making the eSwab™, extracting DNA manually and running the Check-Direct CPE® assay, took <5 min, 1 h 30 min and 1 h 50 min, respectively. It was time efficient with a result available in under 4 h, comparing favourably with the existing method of CPE screening; average time-to-diagnosis of 48/72 h. Utilizing this CPE work-flow would allow a 'same-day' result. Antimicrobial susceptibility testing results, as is current practice, would remain a 'next-day' result. In conclusion, the Check-Direct CPE® assay was easily integrated into a local laboratory work-flow and could facilitate a large volume of CPE screening specimens in a single batch, making it cost-effective and convenient for daily CPE testing.

Combined education and skin antisepsis intervention for persistently high blood-culture contamination rates in neonatal intensive care

Contaminated blood cultures represent challenges regarding diagnosis, duration of hospitalization, antimicrobial use, pharmacy and laboratory costs. Facing problematic neonatal blood culture contamination (3.8%), we instigated a successful intervention combining skin antisepsis using sterile applicators with 2% chlorhexidine gluconate in 70% isopropanol prior to phlebotomy (replacing 70% isopropanol) and staff education. In the six months prior to intervention, 364 neonatal peripheral blood samples were collected. Fourteen (3.8%) were contaminated. In the post-intervention six months, 314 samples were collected. Three (0.96%) were contaminated, representing significant improvement (Fisher's exact test: P = 0.0259). No dermatological sequelae were observed. The improvement has been sustained.

First report of IMI-1-producing colistin-resistant Enterobacter clinical isolate in Ireland, March 2013

We report the first case in Ireland of an IMI-1 carbapenemase-producing Enterobacter asburiae, which was resistant to both colistin and fosfomycin. The circumstances under which this isolate was acquired were unclear. Several reports of IMI-producing Enterobacter spp. have emerged in recent years, and colistin resistance in Enterobacteriaceae is also increasingly reported. Laboratories should be aware of the unusual antibiograms of IMI-producing isolates.

Dose response to intrathecal diamorphine for elective caesarean section and compliance with a national audit standard

BACKGROUND

This double-blind randomised controlled trial investigated the most appropriate dose of intrathecal diamorphine to use with high-dose diclofenac as part of a multimodal analgesic regimen for caesarean section under subarachnoid block. We also wished to establish whether it was possible to satisfy the Royal College of Anaesthetists postoperative pain audit recommendation for this patient group.

METHODS

One hundred and twenty patients presenting for elective caesarean section under subarachnoid block were recruited and divided into four groups. Treatment was standard except that patients were given either placebo or one of three different doses of intrathecal diamorphine (100 microg, 200 microg or 300 microg). All patients were given regular paracetamol, high-dose diclofenac and an hourly subcutaneous diamorphine regimen for breakthrough pain.

RESULTS

There was a dose-dependent improvement in analgesia with intrathecal diamorphine. Only 37.9% of patients given 300 microg of intrathecal diamorphine had a visual analogue pain score of 3/10 or less throughout the study. There was a dose-dependent increase in the incidence of itching with intrathecal diamorphine although the incidence of nausea and vomiting was similar between groups.

CONCLUSIONS

We found that for elective caesarean section under subarachnoid block with high dose diclofenac, analgesia was optimal with 300 microg of intrathecal diamorphine. Even the highest dose of intrathecal diamorphine did not achieve the Royal College of Anaesthetists postoperative audit target that 90% of patients should have a pain score of no more than 3/10. We believe that this target is too arduous.

Preoperative anxiety and postoperative satisfaction in women undergoing elective caesarean section

BACKGROUND

The primary aim was to investigate whether preoperative anxiety in women undergoing elective caesarean section predicts postoperative maternal satisfaction with the process, perceptions of recovery, analgesic use or length of hospital stay. Other factors that might influence postoperative satisfaction were also explored.

METHOD

In 85 women awaiting elective caesarean section, anxiety, social support and aspects of preparation were measured in the 24 hours preceding surgery. Maternal satisfaction and perceptions of recovery were assessed around the third postoperative day. Satisfaction with the preoperative information from the anaesthetist and postoperative pain relief were also measured at this time. Medical notes were used to gather information on analgesia use and length of hospital stay.

RESULTS

Preoperative anxiety scores were comparable with those of general surgical/medical patients. Preoperative trait anxiety and state anxiety were inversely associated with postoperative maternal satisfaction. State anxiety was also inversely associated with better recovery. Preoperative anxiety was not associated with analgesic use or length of hospital stay. Linear regression analysis indicated the degree of satisfaction with information from the anaesthetist and perceived emotional support from the partner explained 52% of the variance in postoperative maternal satisfaction.

CONCLUSION

Lower preoperative anxiety is associated with greater maternal satisfaction with elective caesarean section and better recovery. Information provided by anaesthetists and perceived emotional support are also of importance. It may be possible to identify women with high anxiety and facilitate satisfaction and recovery through providing additional supportive input.

Need for coronary artery bypass grafting in Newfoundland and Labrador: the impact of increased demand

BACKGROUND

In the past decade, growth of coronary revascularization in Canada has been substantial. It was hypothesized that as coronary angiography (CA) rates increased, referral for necessary coronary artery bypass grafting (CABG) would also increase, and include patients with multivessel disease and class I to III angina who required elective surgery. Furthermore, it was proposed that the number of CABG surgeries needed would increase at a similar rate to that of CA.

METHODS

An incident cohort of patients who received CA in 1998/1999 was identified, and the group referred for CABG was followed. Clinical characteristics, appropriateness and necessity scores using specific criteria, and waiting times were evaluated and compared with a similar cohort from 1994/1995. Utilization data for coronary revascularization procedures from 1994 to 2002 were reviewed.

RESULTS

Between 1994/1995 and 1998/1999, the number of CAs per year increased by 37%. The inappropriateness rate for CA was 4% in 1998/1999. The proportion of patients diagnosed with critical coronary artery disease increased from 68% in 1994/1995 to 74% in 1998/1999. The number referred for CABG increased by 48%, and the number for percutaneous transluminal coronary angioplasty (PTCA) increased by 137%. The increase in the number referred for CABG was attributable to the increase in the number of patients with less severe symptoms who required delayed elective CABG. The necessity rate for CABG in the referred group was 94% in 1994/1995 and 95% in 1998/1999. A further 91 patients were identified who needed CABG but did not receive it, 86% of whom had PTCA. From 1999 to 2002, the annual growth rate in those referred for CABG was higher than the growth rate for CA.

CONCLUSIONS

With the growth in CA, the rate of discovery of high risk coronary anatomy actually increased. Growth in CABG volume was attributable to growth in the need for elective surgery in patients with class I to III angina. The rate of CABG increased disproportionately to the rate of CA, despite higher rates of PTCA with stenting. It is likely that the demand for CABG will continue to rise steadily, as expansion of angiography occurs, and may be higher than expected from the growth in CA.

Effect of previous antimicrobial treatment on fecal shedding of Salmonella enterica subsp. enterica serogroup B in New York dairy herds with recent clinical salmonellosis

The association of herd- and sample-level factors with the isolation of Salmonella group B from cattle fecal samples was analyzed. Study farms were 65 dairy herds with a recent history of laboratory-confirmed clinical salmonella infections. Herds were visited once per month for three months to collect data and samples for bacteriological culture. Herd size varied widely from 34 to 3700 total cattle on the farm (median=370). Salmonella serogroup B was isolated from 270 of 2726 samples tested. The predominant serotypes identified were S. Typhimurium and S. Typhimurium var. Copenhagen. Logistic regression was used to analyze the relationship between potential risk factors and isolating Salmonella serogroup B. The only herd-level factor which was significantly associated with fecal shedding was total herd size (hundreds of cattle OR=1.09; 95% confidence interval (CI): 1.05, 1.14). The probability of a positive sample decreased substantially for longer intervals between the initial clinical case and sampling (interval in months OR=0.5; 95% CI: 0.3, 0.6). The presence of diarrhea increased the risk of shedding (OR=2.1; 95% CI: 1.4, 3.0). The effect of recent treatment with antimicrobial agents depended on age group. For heifers and cows, recent antimicrobial treatment increased the probability of isolating Salmonella (heifers OR=11.8; 95% CI: 2.9, 48.8; cows OR=4.1; 95% CI: 2.0, 8.4), but this effect was not statistically significant for calves before weaning. Among animals without recent antimicrobial treatment, preweaned calves were more likely to have positive samples than cows (OR=3.5; 95% CI: 1.8, 6.9; heifers OR=4.7; 95% CI: 2.3, 9.6).

Group office visits in obesity

A conference convened by the NIH in 1985 officially designated obesity a health hazard, stopping short of calling it a disease; yet its characteristic progressive, debilitating and refractory nature is impressively disease-like. Long-term weight loss occurs in only 5% of patients. Group office visits led by physicians have been used in a number of life-style conditions. In diabetes this format enhances blood sugar control and in obesity it improves five-year weight loss success to 20%. In patients with coronary artery disease risk factor a 21% decrease in angina, 55% improvement of exercise tolerance, and 21% decrease in cholesterol occurred in a pilot study. Group office physician-led visits offer encouraging results for the mitigation of life-style conditions.

Insulin and insulinlike activity in extracts of tumors associated with hypoglycemia

Insulin assays were performed on tissue extracts from ten nonpancreatic tumors and five islet-cell adenomas, all of which were associated with hypoglycemia. Acid alcohol and normal saline extractions were made from tumor tissue as well as from normal tissue. The insulin content of extracts was determined both biologically and immunologically, utilizing the rat epididymal fat pad to measure insulinlike activity (ILA) and the double antibody radioimmunoassay to estimate insulin (IRI).

All five islet-cell adenomas were found to have significant concentrations of biologically and immunologically active insulin. The nonpancreatic tumors had no significant concentration of insulin or insulinlike activity, but results were equivocal in one hepatoma. The mechanism by which such tumors induce hypoglycemia remains unknown. It does not appear to result from the elaboration of insulin or of products with insulinlike activity.