Human Factors Contributing to Infection Prevention in Outpatient Hemodialysis Centers: A Mixed Methods Study

RATIONALE & OBJECTIVE

Infection prevention efforts in dialysis centers can avert patient morbidity and mortality but are challenging to implement. The objective of this study was to better understand how the design of the work system might contribute to infection prevention in outpatient dialysis centers.

STUDY DESIGN

Mixed methods, observational study.

SETTING & PARTICIPANTS

Six dialysis facilities across the United States visited by a multidisciplinary team over 8 months.

ANALYTICAL APPROACH

At each facility, structured macroergonomic observations were undertaken by a multidisciplinary team using the SEIPS 1.0 model. Ethnographic observations were collected about staff encounters with dialysis patients including the content of staff conversations. Selective and axial coding were used for qualitative analysis and quantitative data were reported using descriptive statistics.

RESULTS

Organizational and sociotechnical barriers and facilitators to infection prevention in the outpatient dialysis setting were identified. Features related to human performance, (eg, alarms, interruptions, and task stacking), work system design (eg, physical space, scheduling, leadership, and culture), and extrinsic factors (eg, patient-related characteristics) were identified.

LIMITATIONS

This was an exploratory evaluation with a small sample size.

CONCLUSIONS

This study used a systematic macroergonomic approach in multiple outpatient dialysis facilities to identify infection prevention barriers and facilitators related to human performance. Several features common across facilities were identified that may influence infection prevention in outpatient care and warrant further exploration.

Dialysis Water Supply Faucet as Reservoir for Carbapenemase-Producing Pseudomonas aeruginosa

During June 2017-November 2019, a total 36 patients with carbapenem-resistant Pseudomonas aeruginosa harboring Verona-integron-encoded metallo-β-lactamase were identified in a city in western Texas, USA. A faucet contaminated with the organism, identified through environmental sampling, in a specialty care room was the likely source for infection in a subset of patients.

SARS-CoV-2 Infections among Vaccinated Patients on Maintenance Dialysis, January 1-August 31, 2021, United States

Dialysis facilities voluntarily reported severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in vaccinated dialysis patients detected between January 1, 2021, and August 31, 2021, to the Centers for Disease Control and Prevention.Among 4087 patients reported, most were symptomatic, a third required hospitalization, and 9% died within 30 days of diagnosis.Monitoring SARS-CoV-2 infections and outcomes among vaccinated people on dialysis provides valuable insight into this population.

AAV-monoclonal antibody expression protects mice from Ebola virus without impeding the endogenous antibody response to heterologous challenge

Filoviruses cause severe hemorrhagic fever with case fatality rates as high as 90%. Filovirus-specific monoclonal antibodies (mAbs) confer protection in nonhuman primates as late as 5 days after challenge, and FDA-approved mAbs REGN-EB3 and mAb114 have demonstrated efficacy against Ebola virus (EBOV) infection in humans. Vectorized antibody expression mediated by adeno-associated virus (AAV) can generate protective and sustained concentrations of therapeutic mAbs in animal models for a variety of infectious diseases, including EBOV. Here we demonstrate that AAV6.2FF-mediated expression of murine IgG2a EBOV mAbs, 2G4 and 5D2, protects from mouse-adapted (MA)-EBOV infection with none of the surviving mice developing anti-VP40 antibodies above background. Protective serum concentrations of AAV6.2FF-2G4/AAV6.2FF-5D2 did not alter endogenous antibody responses to heterologous virus infection. AAV-mediated expression of EBOV mAbs 100 and 114, and pan-ebolavirus mAbs, FVM04, ADI-15878, and CA45, as human IgG1 antibodies conferred protection against MA-EBOV at low serum concentrations, with minimum protective serum levels as low as 2 μg/mL. Vectorized expression of murine IgG2a or human IgG1 mAbs led to sustained expression in the serum of mice for >400 days or for the lifetime of the animal, respectively. AAV6.2FF-mediated mAb expression offers an alternative to recombinant antibody administration in scenarios where long-term protection is preferable to passive immunization.

Intranasal vaccination with a Newcastle disease virus-vectored vaccine protects hamsters from SARS-CoV-2 infection and disease

The pandemic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of coronavirus disease 2019 (COVID-19). Worldwide efforts are being made to develop vaccines to mitigate this pandemic. We engineered two recombinant Newcastle disease virus (NDV) vectors expressing either the full-length SARS-CoV-2 spike protein (NDV-FLS) or a version with a 19 amino acid deletion at the carboxy terminus (NDV-Δ19S). Hamsters receiving two doses (prime-boost) of NDV-FLS developed a robust SARS-CoV-2-neutralizing antibody response, with elimination of infectious virus in the lungs and minimal lung pathology at five days post-challenge. Single-dose vaccination with NDV-FLS significantly reduced SARS-CoV-2 replication in the lungs but only mildly decreased lung inflammation. NDV-Δ19S-treated hamsters had a moderate decrease in SARS-CoV-2 titers in lungs and presented with severe microscopic lesions, suggesting that truncation of the spike protein was a less effective strategy. In summary, NDV-vectored vaccines represent a viable option for protection against COVID-19.

Bystander cardiopulmonary resuscitation for paediatric out-of-hospital cardiac arrest in England: An observational registry cohort study

INTRODUCTION

Bystander cardiopulmonary resuscitation (BCPR) is strongly advocated by resuscitation councils for paediatric out-of-hospital cardiac arrests (OHCAs). However, there are limited reports on rates of BCPR in children and its relationship with return of spontaneous circulation (ROSC) or survival outcomes.

OBJECTIVE

We describe the rate of BCPR and its association with any ROSC and survival- to- hospital-discharge.

METHODS

We conducted retrospective analysis of prospectively collected paediatric (<18 years of age) OHCA cases in England; we included specialist registry patients treated by emergency medical services (EMS) with known BCPR status and outcome between January 2014 and November 2018. Data included patient demographics, aetiology, witness status, initial rhythm, EMS, season, time of day and bystander status. Associations between BCPR, and any ROSC and survival-to-hospital-discharge outcomes were explored using multivariable logistic regression.

RESULTS

There were 2363 paediatric OHCAs treated across 11 EMS regions. BCPR was performed in 69.6% (1646/2363) of the cases overall (range 57.7% (206/367) to 83.7% (139/166) across EMS regions). Only 34.9% (550/1572) of BCPR cases were witnessed. Overall, any ROSC was achieved in 22.8% (523/2289) and survival to hospital discharge in 10.8% (225/2066). Adjusted odds ratio (aOR) for any ROSC was significantly improved following BCPR compared to no BCPR (aOR 1.37, 95% CI 1.03-1.81), but adjusted odds ratio for survival-to-hospital-discharge were similar (aOR 1.01, 95% CI 0.66-1.55).

CONCLUSIONS

BCPR was associated with improved rates of any ROSC but not survival-to-hospital-discharge. Variations in EMS BCPR rates may indicate opportunities for regional targeted increase in public BCPR education.

Experiences of diagnostic radiographers through the Covid-19 pandemic

Introduction

Diagnostic Radiography plays a major role in the diagnosis and management of patients with Covid-19. This has seen an increase in the demand for imaging services, putting pressure on the workforce. Diagnostic radiographers, as with many other healthcare professions, have been on the frontline, dealing with an unprecedented situation. This research aimed to explore the experience of diagnostic radiographers working clinically during the Covid-19 pandemic.

Methods

Influenced by interpretative phenomenology, this study explored the experiences of diagnostic radiographers using virtual focus group interviews as a method of data collection.

Results

Data were analysed independently by four researchers and five themes emerged from the data. Adapting to new ways of working, feelings and emotions, support mechanisms, self-protection and resilience, and professional recognition.

Conclusion

The adaptability of radiographers came across strongly in this study. Anxieties attributed to the provision of personal protective equipment (PPE), fear of contracting the virus and spreading it to family members were evident. The resilience of radiographers working throughout this pandemic came across strongly throughout this study. A significant factor for coping has been peer support from colleagues within the workplace. The study highlighted the lack of understanding of the role of the radiographer and how the profession is perceived by other health care professionals.

Implications for practice

This study highlights the importance of interprofessional working and that further work is required in the promotion of the profession.

The impact of varicella vaccination on paediatric herpes zoster epidemiology: a Canadian population-based retrospective cohort study

The impact of universal varicella vaccination on herpes zoster (HZ) risk in unvaccinated and vaccinated children, and its long-term influence on HZ epidemiology, remains unknown. We conducted a retrospective cohort study using population-based administrative health data for children born between 1993 and 2018 (n = 924,124). We calculated age-specific cumulative HZ incidence rates by vaccination status for cohorts born before (1993–1999) and after (2000–2018) programme implementation; results were used to calculate relative risk of HZ by age group, vaccination status and vaccine availability period. Annual HZ incidence rates were calculated for 1993–2018. HZ risk was higher among unvaccinated children compared to vaccinated children across age groups; 64% higher before universal vaccination (RR: 0.36, 95% CI: 0.33, 0.39), and 32% higher after universal vaccination (RR: 0.68, 95% CI: 0.64, 0.73). Among unvaccinated children, HZ risk was 60% lower after vaccine programme implementation (RR: 0.40, 95% CI: 0.38, 0.43). Two-dose receipt corresponded with a 41% lower risk of HZ compared to one-dose receipt (RR: 0.59, 95% CI: 0.53, 0.65). Crude annual HZ incidence rates declined 64% after programme implementation, with decreases observed across age groups. Universal varicella vaccination programme implementation corresponds to decreased paediatric HZ incidence across age groups, in both vaccinated and unvaccinated individuals. Results from this study can be used to help inform varicella vaccination programme decision-making in other countries.

Suggestions for the prevention of Clostridioides difficile spread within outpatient hemodialysis facilities

Clostridioides difficile infections (CDIs) cause substantial morbidity and mortality. Patients on maintenance hemodialysis are 2 to 2.5 times more likely to develop CDI, with mortality rates 2-fold higher than the general population. Hospitalizations due to CDI among the maintenance hemodialysis population are high, and the frequency of antibiotic exposures and hospitalizations may contribute to CDI risk. In this report, a panel of experts in clinical nephrology, infectious diseases, and infection prevention provide guidance, based on expert opinion and published literature, aimed at preventing the spread of CDI in outpatient hemodialysis facilities.

The SPaCE diagnostic: a pilot study to test the accuracy of a novel point of care sensor for point of care detection of burn wound infection

BACKGROUND

Wound infection in burn patients is common and has an impact on outcomes. There is no objective method to diagnose infection at point of care (PoC). Early diagnosis prevents progression to sepsis. Diagnostic subjectivity supports over-diagnosis, unnecessary hospitalization, and antibiotic overuse.

AIM

This pilot study aimed to investigate the accuracy of a novel PoC wound infection diagnostic in burn patients.

METHODS

We produced, and in vitro tested, a PoC diagnostic for early wound infection diagnosis. The prototype SPaCE diagnostic uses a patented lipid vesicle suspension into which a clinical swab is placed. The diagnostic delivers a colour-response to Staphylococcus aureus, Pseudomonas aeruginosa, Candida species and Enterococcus faecalis at toxin release. A pilot clinical diagnostic accuracy study was undertaken. The reference standard was a retrospective decision made by an expert clinical panel using routinely available data.

FINDINGS

Data was available from 33 of 34 patients. Of these, 52% were considered to have a wound infection, 42% not, and two (6%) were equivocal. The diagnostic results showed 24% were infected, 42% were not and 33% produced intermediate results. Agreement between clinical judgement and diagnostic result, assessed using a weighted Kappa, was 0.591 suggesting moderate agreement. If the intermediate results were excluded, 22 sets of data with definitive results achieved a Kappa statistic of 0.81 suggesting 'almost perfect' agreement. Sensitivity and specificity were 57% (8/14) and 71% (12/17), respectively.

CONCLUSION

This pilot study provided evidence that the SPaCE diagnostic could provide valuable and timely data to support clinical decision-making at PoC for wound infection.

Identification of novel risk loci and causal insights for sporadic Creutzfeldt-Jakob disease: a genome-wide association study

BACKGROUND

Human prion diseases are rare and usually rapidly fatal neurodegenerative disorders, the most common being sporadic Creutzfeldt-Jakob disease (sCJD). Variants in the PRNP gene that encodes prion protein are strong risk factors for sCJD but, although the condition has similar heritability to other neurodegenerative disorders, no other genetic risk loci have been confirmed. We aimed to discover new genetic risk factors for sCJD, and their causal mechanisms.

METHODS

We did a genome-wide association study of sCJD in European ancestry populations (patients diagnosed with probable or definite sCJD identified at national CJD referral centres) with a two-stage study design using genotyping arrays and exome sequencing. Conditional, transcriptional, and histological analyses of implicated genes and proteins in brain tissues, and tests of the effects of risk variants on clinical phenotypes, were done using deep longitudinal clinical cohort data. Control data from healthy individuals were obtained from publicly available datasets matched for country.

FINDINGS

Samples from 5208 cases were obtained between 1990 and 2014. We found 41 genome-wide significant single nucleotide polymorphisms (SNPs) and independently replicated findings at three loci associated with sCJD risk; within PRNP (rs1799990; additive model odds ratio [OR] 1·23 [95% CI 1·17-1·30], p=2·68 × 10^-15; heterozygous model p=1·01 × 10^-135), STX6 (rs3747957; OR 1·16 [1·10-1·22], p=9·74 × 10^-9), and GAL3ST1 (rs2267161; OR 1·18 [1·12-1·25], p=8·60 × 10^-10). Follow-up analyses showed that associations at PRNP and GAL3ST1 are likely to be caused by common variants that alter the protein sequence, whereas risk variants in STX6 are associated with increased expression of the major transcripts in disease-relevant brain regions.

INTERPRETATION

We present, to our knowledge, the first evidence of statistically robust genetic associations in sporadic human prion disease that implicate intracellular trafficking and sphingolipid metabolism as molecular causal mechanisms. Risk SNPs in STX6 are shared with progressive supranuclear palsy, a neurodegenerative disease associated with misfolding of protein tau, indicating that sCJD might share the same causal mechanisms as prion-like disorders.

FUNDING

Medical Research Council and the UK National Institute of Health Research in part through the Biomedical Research Centre at University College London Hospitals National Health Service Foundation Trust.

Characterization of a novel STAT 2 knock-out hamster model of Crimean-Congo hemorrhagic fever virus pathogenesis

Crimean-Congo hemorrhagic fever virus (CCHFV) is a tick-borne pathogen causing a febrile illness in humans, which can progress to hemorrhagic manifestations, multi-organ failure, and death. Current mouse models of CCHFV infection reliably succumb to virus challenge but vary in their ability to reflect signs of disease similar to humans. In this study, we established a signal transducer and activator of transcription 2 (STAT2) knockout hamster model to expand the repertoire of animal models of CCHFV pathogenesis that can be used for therapeutic development. These hamsters demonstrated a systemic and lethal disease in response to infection. Hallmarks of human disease were observed including petechial rash, blood coagulation dysfunction, and various biochemistry and blood cell count abnormalities. Furthermore, we also demonstrated the utility of this model for anti-CCHFV therapeutic evaluation. The STAT2 knock-out hamster model of CCHFV infection may provide some further insights into clinical disease, viral pathogenesis, and pave the way for testing of potential drug and vaccine candidates.

Epidemiology and Clinical Outcomes of Hospitalizations for Acute Respiratory or Febrile Illness and Laboratory-Confirmed Influenza Among Pregnant Women During Six Influenza Seasons, 2010-2016

BACKGROUND

Pregnant women are at increased risk of seasonal influenza hospitalizations, but data about the epidemiology of severe influenza among pregnant women remain largely limited to pandemics.

METHODS

To describe the epidemiology of hospitalizations for acute respiratory infection or febrile illness (ARFI) and influenza-associated ARFI among pregnant women, administrative and electronic health record data were analyzed from retrospective cohorts of pregnant women hospitalized with ARFI who had testing for influenza viruses by reverse-transcription polymerase chain reaction (RT-PCR) in Australia, Canada, Israel, and the United States during 2010-2016.

RESULTS

Of 18 048 ARFI-coded hospitalizations, 1064 (6%) included RT-PCR testing for influenza viruses, 614 (58%) of which were influenza positive. Of 614 influenza-positive ARFI hospitalizations, 35% were in women with low socioeconomic status, 20% with underlying conditions, and 67% in their third trimesters. The median length of influenza-positive hospitalizations was 2 days (interquartile range, 1-4), 18% (95% confidence interval [CI], 15%-21%) resulted in delivery, 10% (95% CI, 8%-12%) included a pneumonia diagnosis, 5% (95% CI, 3%-6%) required intensive care, 2% (95% CI, 1%-3%) included a sepsis diagnosis, and <1% (95% CI, 0%-1%) resulted in respiratory failure.

CONCLUSIONS

Our findings characterize seasonal influenza hospitalizations among pregnant women and can inform assessments of the public health and economic impact of seasonal influenza on pregnant women.

An international cohort study of birth outcomes associated with hospitalized acute respiratory infection during pregnancy

OBJECTIVES

Findings during the 2009 pandemic suggest severe maternal infection with pandemic influenza had adverse perinatal health consequences. Limited data exist evaluating the perinatal health effects of severe seasonal influenza and non-influenza infections during pregnancy.

METHODS

A retrospective cohort of pregnant women from Australia, Canada, Israel, and the United States was established using birth records to identify pregnancies and birth outcomes and hospital and laboratory testing records to identify influenza and non-influenza associated acute respiratory or febrile illness (ARFI) hospitalizations. ARFI hospitalized women were matched to non-hospitalized women (1:4) by country and season of conception. Log-binomial regression was used to estimate the relative risk (aRR) of preterm birth (PTB), small-for-gestational-age (SGA), and low birthweight (LBW) birth, adjusting for pre-existing medical conditions, maternal age, and parity.

RESULTS

950 pregnant women hospitalized with an ARFI were matched with 3,800 non-hospitalized pregnant women. Compared to non-hospitalized women, risk of PTB was greater among women hospitalized with influenza-associated ARFI (aRR: 1.57; 95% CI: 1.15-2.15) and non-influenza ARFI (aRR: 2.78; 95% CI: 2.12-3.65). Similar results were observed for LBW; there were no associations with SGA birth.

CONCLUSIONS

ARFI hospitalization during pregnancy was associated with increased risk of PTB and LBW.

Dual RNA-Seq characterization of host and pathogen gene expression in liver cells infected with Crimean-Congo Hemorrhagic Fever Virus

Crimean-Congo hemorrhagic fever virus (CCHFV) is a tick-borne virus that can cause a hemorrhagic fever in humans, with a case fatality rate of up to 40%. Cases of CCHFV have been reported in Africa, Asia, and southern Europe; and recently, due to the expanding range of its vector, autochthonous cases have been reported in Spain. Although it was discovered over 70 years ago, our understanding of the pathogenesis of this virus remains limited. We used RNA-Seq in two human liver cell lines (HepG2 and Huh7) infected with CCHFV (strain IbAr10200), to examine kinetic changes in host expression and viral replication simultaneously at 1 and 3 days post infection. Through this, numerous host pathways were identified that were modulated by the virus including: antiviral response and endothelial cell leakage. Notably, the genes encoding DDX60, a cytosolic component of the RIG-I signalling pathway and OAS2 were both shown to be dysregulated. Interestingly, PTPRR was induced in Huh7 cells but not HepG2 cells. This has been associated with the TLR9 signalling cascade, and polymorphisms in TLR9 have been associated with poor outcomes in patients. Additionally, we performed whole-genome sequencing on CCHFV to assess viral diversity over time, and its relationship to the host response. As a result, we have demonstrated that through next-generation mRNA deep-sequencing it is possible to not only examine mRNA gene expression, but also to examine viral quasispecies and typing of the infecting strain. This demonstrates a proof-of-principle that CCHFV specimens can be analyzed to identify both the virus and host biomarkers that may have implications for prognosis.

Impact of intended and relative dose intensity of R-CHOP in a large, consecutive cohort of elderly diffuse large B-cell lymphoma patients treated with curative intent: no difference in cumulative incidence of relapse comparing patients by age

BACKGROUND

The increasing incidence of diffuse large B-cell lymphoma (DLBCL) in ageing populations places a significant burden on healthcare systems. Co-morbidity, frailty, and reduced organ and physiological reserve contribute to treatment-related complications. The optimal dose intensity of R-CHOP to optimize outcome across different ages with variable frailty and comorbidity burden is unclear.

OBJECTIVES AND METHODS

We examined the influence of intended (IDI) and relative (RDI) dose intensity of the combination of cyclophosphamide and doxorubicin, age and comorbidity on outcomes for DLBCL patients ≥70 years in a representative, consecutive cohort across eight UK centres (2009-2018). We determined predictors of survival using multivariable Cox regression, and predictors of recurrence before death using competing risks regression.

RESULTS

Porgression-free survival (PFS) and overall survival (OS) were significantly inferior in patients ≥80 vs. 70-79 years (P < 0.001). In contrast, 2-year cumulative relapse incidence, when accounting for non-relapse mortality as a competing risk, was no different between 70-79 vs. ≥80 years (P = 0.27) or comorbidity status (CIRS-G: 0-6 vs. >6) (P = 0.27). In 70-79 years, patients with an IDI ≥80% had a significantly improved PFS and OS (P < 0.001) compared to IDI < 80%. Conversely, in patients ≥80 years, there was no difference in PFS (P = 0.88) or OS (P = 0.75) according to IDI <80% vs. ≥80%. On multivariable analysis, when comparing by age, there was a significantly higher cumulative relapse rate for patients aged 70-79 years with an IDI <80% (vs. >80%) (P = 0.04) but not for patients ≥80 years comparing IDI (P = 0.32).

CONCLUSION

'R-mini-CHOP' provides adequate lymphoma-specific disease control and represents a reasonable treatment option in elderly patients ≥80 years aiming for cure.

A recombinant vesicular stomatitis-based Lassa fever vaccine elicits rapid and long-term protection from lethal Lassa virus infection in guinea pigs

The World Health Organization has identified Lassa virus (LASV) as one of the top five pathogens to cause a severe outbreak in the near future. This study assesses the ability of a leading vaccine candidate, recombinant Vesicular stomatitis virus expressing LASV glycoprotein (VSVΔG/LASVGPC), and its ability to induce rapid and long-term immunity to lethal guinea pig-adapted LASV (GPA-LASV). Outbred guinea pigs were vaccinated with a single dose of VSVΔG/LASVGPC followed by a lethal challenge of GPA-LASV at 7, 14, 25, 189, and 355 days post-vaccination. Statistically significant rapid and long-term protection was achieved at all time points with 100% protection at days 7 and 14 post-vaccination. While 83 and 87% protection were achieved at 25 days and 6 months post-vaccination, respectively. When guinea pigs were challenged one year after vaccination 71% protection was achieved. Notable infectious virus was isolated from the serum and tissues of some but not all animals. Total LASVGPC-specific IgG titers were also measured on a monthly basis leading up to LASV challenge however, it is unclear if antibody alone correlates with short and long term survival. These studies confirm that a single dose of VSVΔG/LASVGPC can induce rapid and long-term protection from LASV infection in an aggressive outbred model of infection, and supports further development in non-human primates.

Lassa virus (LASV) is an emerging pathogen that can be associated with high case fatality but for which no clinically-approved vaccine currently exists. David Safronetz and colleagues at the Public Health Agency of Canada and the University of Manitoba investigate the efficacy of a single dose of a recombinant vaccine of LASV glycoproteins vectorized into vesicular stomatitis virus (VSVΔG/LASVGPC). Using guinea pigs lethally challenged with LASV, the protective efficacy of VSVΔG/LASVGPC and LASV-specific IgG is assessed at a number of time points out to approximately one year after vaccination. VSVΔG/LASVGPC elicits stable LASV glycoprotein-specific antibody production and durable protection from lethal LASV challenge, with 71% of animals surviving even at one year following vaccination and complete protection being afforded at earlier (weeks) time points. This pre-clinical model demonstrates the stable protection that can be established by a single dose of VSVΔG/LASVGPC.

Fluctuation, invisibility, fatigue - the barriers to maintaining employment with systemic lupus erythematosus: results of an online survey

Objectives

Systemic lupus erythematosus (SLE) is associated with high levels of workplace disability and unemployment. The objective of this study was to understand the reasons for this and to describe the barriers and facilitators of employment identified by people with SLE to develop appropriate solutions. Unemployment, as well as unsuitable work, has adverse health outcomes.

Methods

Adults with SLE completed a UK-specific online survey, through the LUPUS UK website, designed to find out more about the difficulties and successes that people with SLE have in maintaining employment. The survey was predominantly qualitative, to understand participants’ employment experiences to generate possible solutions.

Results

Three hundred and ninety-three people gave detailed responses to the survey within eight weeks. Every respondent reported a detrimental effect of SLE on their ability to work: 40.45% had left employment because of it. The themes of concern to respondents were unambiguous: (i) the difficulties of working (and career damage) with SLE, (ii) fear and anxiety overshadowing work/family life, (iii) the greater potential to remain in some employment or stay in full employment when modifications of work pattern and support from management and colleagues were available. SLE-related fatigue, its invisibility and fluctuating nature were felt to be the main barriers to maintaining employment. Numerous respondents could work only part-time and anxiety was high regarding their future ability to continue working. Many had taken substantial pay reductions and refused offered promotions to preserve their health. Distress due to loss of work and the benefits it brings were reported by every respondent who had left work.

Conclusion

SLE presents specific difficulties for maintaining employment – fatigue, fluctuation and invisibility – not addressed by current anti-discrimination legislation or currently available ‘reasonable adjustments’. This study demonstrates that (i) employment is an important area of concern for people with SLE, (ii) SLE has significant detrimental effects on individuals’ ability to participate and progress in employment, (iii) legislators and employers need information about SLE as invisibility and fluctuation cause hidden problems, and (iv) more data is needed to inform workplace adjustments if individual distress and societal loss of skills are to be addressed.

Effectiveness of Live Attenuated vs Inactivated Influenza Vaccines in Children During the 2012-2013 Through 2015-2016 Influenza Seasons in Alberta, Canada: A Canadian Immunization Research Network (CIRN) Study

IMPORTANCE

Recent observational studies report conflicting results regarding the effectiveness of live attenuated influenza vaccine (LAIV), particularly against influenza A(H1N1)pdm09.

OBJECTIVE

To compare the effectiveness of LAIV and inactivated influenza vaccine (IIV) against laboratory-confirmed influenza.

DESIGN, SETTING, AND PARTICIPANTS

A test-negative study to estimate influenza vaccine effectiveness (VE) using population-based, linked, individual-level laboratory, health administrative, and immunization data. Data were obtained from 10 169 children and adolescents aged 2 to 17 years (children) who were tested for influenza in inpatient or outpatient settings during periods when influenza was circulating based on a threshold level of 5% weekly test positivity for the province during the 4 influenza seasons spanning from November 11, 2012, to April 30, 2016, in Alberta, Canada. Logistic regression was used to estimate VE by vaccine type, influenza season, and influenza type and subtype. The relative effectiveness of each vaccine type was assessed by comparing the odds of laboratory-confirmed influenza infection for LAIV recipients with that for IIV recipients.

EXPOSURES

The primary exposure was receipt of LAIV or IIV before testing for influenza.

MAIN OUTCOMES AND MEASURES

The primary outcome was influenza case status as determined by reverse-transcriptase polymerase chain reaction testing.

RESULTS

A total of 10 779 respiratory specimens (from 10 169 children) collected and tested for influenza during the 4 influenza seasons were included, with 53.4% from males; the mean (SD) age was 7.0 (4.6) years. Across the 4 influenza seasons, 3161 children tested positive for influenza. Combining the 4 influenza seasons, the adjusted VE against influenza A(H1N1)pdm09 was 69% (95% CI, 56%-78%) for LAIV compared with 79% (95% CI, 70%-86%) for IIV. Vaccine effectiveness against influenza A(H3N2) was 36% (95% CI, 14%-53%) for LAIV and 43% (95% CI, 22%-59%) for IIV. Against influenza B, VE was 74% (95% CI, 62%-82%) for LAIV and 56% (95% CI, 41%-66%) for IIV. There were no significant differences in the odds of influenza infection for LAIV recipients compared with IIV recipients except for influenza B during the 2015-2016 season, when LAIV recipients had lower odds of infection than IIV recipients (odds ratio, 0.36; 95% CI, 0.17-0.76).

CONCLUSIONS AND RELEVANCE

There was no evidence to support the lack of effectiveness of LAIV against influenza A(H1N1)pdm09. These results support administration of either vaccine type in this age group.

A Model for the Conservative Management of Mallet Finger

This prospective study assessed the results of a custom-made thermoplastic splint for treatment of mallet finger deformity. From April 1999 to April 2000, 42 patients with mallet finger deformity were recruited. All patients were seen within 1 week and treated with a thermoplastic splint custom made by the hand therapy department. The splint was simple to make, easy to fit and suitable for all finger shapes and sizes. It improved the deformity in 30 out of 34 cases, and caused no skin irritation.

Prototype Development of the Intelligent Hydrogel Wound Dressing and Its Efficacy in the Detection of Model Pathogenic Wound Biofilms

The early detection of wound infection in situ can dramatically improve patient care pathways and clinical outcomes. There is increasing evidence that within an infected wound the main bacterial mode of living is a biofilm: a confluent community of adherent bacteria encased in an extracellular polymeric matrix. Here we have reported the development of a prototype wound dressing, which switches on a fluorescent color when in contact with pathogenic wound biofilms. The dressing is made of a hydrated agarose film in which the fluorescent dye containing vesicles were mixed with agarose and dispersed within the hydrogel matrix. The static and dynamic models of wound biofilms, from clinical strains of Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, and Enterococcus faecalis, were established on nanoporous polycarbonate membrane for 24, 48, and 72 h, and the dressing response to the biofilms on the prototype dressing evaluated. The dressing indicated a clear fluorescent/color response within 4 h, only observed when in contact with biofilms produced by a pathogenic strain. The sensitivity of the dressing to biofilms was dependent on the species and strain types of the bacterial pathogens involved, but a relatively higher response was observed in strains considered good biofilm formers. There was a clear difference in the levels of dressing response, when dressings were tested on bacteria grown in biofilm or in planktonic cultures, suggesting that the level of expression of virulence factors is different depending of the growth mode. Colorimetric detection on wound biofilms of prevalent pathogens (S. aureus, P. aeruginosa, and E. faecalis) is also demonstrated using an ex vivo porcine skin model of burn wound infection.

The importance of placebo effects in enhancing palliative care interventions

In this narrative review, we examine evidence that may help to explain how placebo effects contribute to the effectiveness of palliative care interventions for the relief of symptoms such as pain, breathlessness and depression, and how they may underlie the impact of complementary therapies. We discuss the different ways of conceptualising placebo phenomena, including the importance of the therapeutic relationship, the context of care and the significance of meaning. There is increasing evidence from neuroscience that the term 'placebo effect' describes a number of phenomena that may explain the effectiveness of therapeutic interventions that affect the perception of symptoms. A greater appreciation of placebo effects emphasises the importance of addressing social, psychological, and spiritual factors with equal rigour. Commissioning bodies, rightly concerned about the evidence base for clinical interventions, need to recognise the multifaceted nature of symptom control measures and to realise that the focus for palliative care research needs to be on the specialty as a complex integrated intervention rather than on a series of individually evaluated measures.

Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report

BACKGROUND

Bloodstream infections (BSIs) cause substantial morbidity in hemodialysis patients. In 2009, the US Centers for Disease Control and Prevention (CDC) sponsored a collaborative project to prevent BSIs in outpatient hemodialysis facilities. We sought to assess the impact of a set of interventions on BSI and access-related BSI rates in participating facilities using data reported to the CDC's National Healthcare Safety Network (NHSN).

STUDY DESIGN

Quality improvement project.

SETTING & PARTICIPANTS

Patients in 17 outpatient hemodialysis facilities that volunteered to participate.

QUALITY IMPROVEMENT PLAN

Facilities reported monthly event and denominator data to NHSN, received guidance from the CDC, and implemented an evidence-based intervention package that included chlorhexidine use for catheter exit-site care, staff training and competency assessments focused on catheter care and aseptic technique, hand hygiene and vascular access care audits, and feedback of infection and adherence rates to staff.

OUTCOMES

Crude and modeled BSI and access-related BSI rates.

MEASUREMENTS

Up to 12 months of preintervention (January 2009 through December 2009) and 15 months of intervention period (January 2010 through March 2011) data from participating centers were analyzed. Segmented regression analysis was used to assess changes in BSI and access-related BSI rates during the preintervention and intervention periods.

RESULTS

Most (65%) participating facilities were hospital based. Pooled mean BSI and access-related BSI rates were 1.09 and 0.73 events per 100 patient-months during the preintervention period and 0.89 and 0.42 events per 100 patient-months during the intervention period, respectively. Modeled rates decreased 32% (P = 0.01) for BSIs and 54% (P < 0.001) for access-related BSIs at the start of the intervention period.

LIMITATIONS

Participating facilities were not representative of all outpatient hemodialysis centers nationally. There was no control arm to this quality improvement project.

CONCLUSIONS

Facilities participating in a collaborative successfully decreased their BSI and access-related BSI rates. The decreased rates appeared to be maintained in the intervention period. These findings suggest that improved implementation of recommended practices can reduce BSIs in hemodialysis centers.

Compressive strength and setting time determination of glass-ionomer cements incorporated with cetylpyridinium chloride and benzalkonium chloride

Because of the relatively frequent occurrence of recurrent caries after a restorative treatment, and because of the huge number of cariogenic microorganisms present in the oral cavity, which present a potential risk factor regarding the development of new carious lesions, attention has increasingly been directed towards the therapeutic antimicrobial effects of restorative materials. The glass ionomer cements distinguish themselves as the most acceptable restorative materials possessing the positive characteristics of fluorine in the processes of remineralisation and antimicrobial action. In addition to the release of fluoride ions, GICs can potentially be used as templates for the release of other active antimicrobial components. The addition of antimicrobial compounds in the glass ionomer cements and analysis of their physical characteristics are very important especially for use in the posterior region of milk teeth. The aim of this study was to analyse the physical characteristics of ChemFlex and Fuji IX, conventional glass ionomer cements incorporated with the antimicrobial components Cetylpyridinium Chloride and Benzalkonium Chloride, through measurements of their setting times, and determination of their compressive strengths. Five samples of each glass ionomer with no antimicrobial compounds added were prepared--to serve as a control group; and collections of five samples of each cement with different concentrations of Cetylpyridinium Chloride and Benzalkonium Chloride--1%, 2% and 3%--added to them were also prepared--a total of 60 samples. The results of the analysis point out that it is possible to incorporate these antimicrobial agents in conventional GICs, and this is especially true when the added amount of the antimicrobial agents is 1%.