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Having a real say: findings from first nations community panels on pandemic influenza vaccine distribution. BMC Public Health 2023; 23:2377. [PMID: 38037021 PMCID: PMC10691077 DOI: 10.1186/s12889-023-17262-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/18/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Recent deliberations by Australian public health researchers and practitioners produced an ethical framework of how decisions should be made to distribute pandemic influenza vaccine. The outcome of the deliberations was that the population should be considered in two categories, Level 1 and Level 2, with Level 1 groups being offered access to the pandemic influenza vaccine before other groups. However, the public health researchers and practitioners recognised the importance of making space for public opinion and sought to understand citizens values and preferences, especially First Nations peoples. METHODS We conducted First Nations Community Panels in two Australian locations in 2019 to assess First Nations people's informed views through a deliberative process on pandemic influenza vaccination distribution strategies. Panels were asked to make decisions on priority levels, coverage and vaccine doses. RESULTS Two panels were conducted with eighteen First Nations participants from a range of ages who were purposively recruited through local community networks. Panels heard presentations from public health experts, cross-examined expert presenters and deliberated on the issues. Both panels agreed that First Nations peoples be assigned Level 1 priority, be offered pandemic influenza vaccination before other groups, and be offered two doses of vaccine. Reasons for this decision included First Nations people's lives, culture and families are important; are at-risk of severe health outcomes; and experience barriers and challenges to accessing safe, quality and culturally appropriate healthcare. We found that communication strategies, utilising and upskilling the First Nations health workforce, and targeted vaccination strategies are important elements in pandemic preparedness and response with First Nations peoples. CONCLUSIONS First Nations Community Panels supported prioritising First Nations peoples for pandemic influenza vaccination distribution and offering greater protection by using a two-dose full course to fewer people if there are initial supply limitations, instead of one dose to more people, during the initial phase of the vaccine roll out. The methodology and findings can help inform efforts in planning for future pandemic vaccination strategies for First Nations peoples in Australia.
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Antimicrobial overuse in COVID-19 - reasons to remain vigilant as we approach the winter 'twindemic'. J Hosp Infect 2023; 131:247-248. [PMID: 36283476 PMCID: PMC9595493 DOI: 10.1016/j.jhin.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/16/2022] [Indexed: 01/25/2023]
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Health professionals as activists: tackling threats to public health. Perspect Public Health 2023; 143:4-5. [PMID: 36694970 PMCID: PMC9896251 DOI: 10.1177/17579139221145607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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DD-06 SPIN (SURGICAL PRACTICES IN INCISIONAL HERNIA REPAIR). A NATIONAL TRAINEE-LED COLLABORATIVE MULTICENTRE PROSPECTIVE OBSERVATIONAL STUDY. Br J Surg 2022. [DOI: 10.1093/bjs/znac308.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Aim
There is currently no established UK database establishing reliable outcome data for surgical repair of incisional herniae (IH). Their heterogeneity (variability in size, patient comorbidity, and multiple repair techniques) has resulted in no surgical management or outcome reporting consensus.
This study aims to utilise national trainee led research collaboratives to perform a multi-centre, observational, prospective study to assess variation in IH defects (by utilising pre-defined criteria from The European Hernia Society (EHS) classification for IH and a Modified Ventral Hernia Working Group) and their subsequent operative management. This study will yield valuable, standardised data on variation in practice and outcomes (complications and 3 and 12-months follow-up) to provide a platform for expanding IH research.
Materials and Methods
All NHS hospitals in England undertaking elective IH repair will be eligible for inclusion. Dissemination of and recruitment to the study will be driven by regional research collaborative networks.
This study will include all elective adult IH repairs with. Data will be collected and managed using REDCap electronic data capture tool. There will be three distinct phases comprising;
The study is currently unfunded. Funds are sought to obtain NHS Trust sponsorship and proceed to phase 3 of the study.
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Changes in Diet Quality and the Home Food Environment: A Food Skills Intervention. J Acad Nutr Diet 2022. [DOI: 10.1016/j.jand.2022.08.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Multidisciplinary neurosurgical rounds incorporating antimicrobial stewardship. Are they of benefit? BRAIN AND SPINE 2022; 2:100885. [PMID: 36248101 PMCID: PMC9560698 DOI: 10.1016/j.bas.2022.100885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/23/2022] [Accepted: 03/27/2022] [Indexed: 01/01/2023]
Abstract
Background In an era of increasing antimicrobial resistance, appropriate antimicrobials are essential to optimise patient outcomes. In 2017, antimicrobial use prevalence (AMU) on the two neurosurgical wards in our tertiary teaching hospital varied from 23% on ward A to 33% on ward B with 67% and 100% ‘appropriate’ prescriptions, respectively. In July 2018, a weekly antimicrobial stewardship multidisciplinary round led by a senior neurosurgery registrar commenced, attended by the antimicrobial stewardship team (AST). Research question This report evaluates whether a multi-disciplinary approach on neurosurgical prescribing was beneficial, specifically in reducing AMU. Materials and methods The following data was collected on AST rounds for 30 weeks in total from August 2018 to July 2019: number of patients on antimicrobials, appropriateness and stewardship actions. A questionnaire was distributed to neurosurgical doctors on two occasions to canvass opinions and attitudes on antimicrobial prescribing. Results 1716 prescriptions were reviewed (mean 57.2 per week). Of these 321 (18.7%) included antimicrobial prescriptions; 200 on ward A (19.8%), and 121 on ward B (17%), representing a decrease in AMU from 2017. The majority of antimicrobial prescriptions, 271 (84.4%) were deemed appropriate. Stewardship actions were taken in 215 (67%) prescriptions. Fifteen questionnaires were completed by neurosurgical doctors. The majority, 87%, stated the AST round was helpful overall. 93% indicated that informal training on the AST round was a source of education in antibiotic prescribing. Discussion and conclusion The weekly AST round provided a timely opportunity for multidisciplinary discussion, implementation of antimicrobial stewardship actions and opportunistic antimicrobial stewardship education. Surgeons need to be directly involved in antimicrobial stewardship to optimise patient outcomes and reduce antimicrobial resistance. A multidisciplinary antimicrobial stewardship (AST) ward round led by neurosurgery commenced in our hospital in 2018. Antimicrobial stewardship actions were taken in 67% of prescriptions, and antimicrobial use prevalence reduced in 2018 compared to 2017. A questionnaire distributed to neurosurgical doctors on the value of the AST round indicated that 87% of neurosurgical doctors found it helpful. We believe leadership and accountability were crucial to the success of the ward round, as neurosurgeons contributed directly to decision making.
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The early test catches the case. Why wait? Frequent testing of close contacts aids COVID-19 control. J Hosp Infect 2021; 116:101-102. [PMID: 34403764 PMCID: PMC8364144 DOI: 10.1016/j.jhin.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 01/24/2023]
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Targeting the opioid pathway for the treatment of chronic kidney disease-associated pruritus: a systematic review and meta-analysis of randomized controlled trials. Br J Dermatol 2021; 186:575-577. [PMID: 34582571 DOI: 10.1111/bjd.20769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/30/2022]
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Evolving epidemiology of carbapenemase-producing Enterobacterales: one hospital's infection prevention and control response over nine years. J Hosp Infect 2021; 112:61-68. [PMID: 33812939 DOI: 10.1016/j.jhin.2021.03.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/28/2021] [Accepted: 03/28/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Preventing carbapenemase-producing Enterobacterales (CPE) transmission is a significant challenge for hospital infection prevention and control teams (IPCTs). Control measures include screening at-risk patients, contact tracing, and the isolation of carriers with contact precautions. AIM The evolution of infection prevention and control measures was assessed in a tertiary acute care hospital with predominately multi-bedded patient accommodation, from 2011 to 2019 as cases of CPE increased. The implications for, and the response and actions of, the IPCT were also reviewed. METHODS CPE data collected prospectively from our laboratory, IPCT, and outbreak meeting records were reviewed to assess how the IPCT adapted to the changing epidemiology, from sporadic cases, to outbreaks and to localized endemic CPE. FINDINGS Of 178 cases, 152 (85%) were healthcare-associated and there was a marked increase in cases from 2017. The number of screening samples tested annually increased from 1190 in 2011 to 16,837 in 2019, and six outbreaks were documented, with larger outbreaks identified in later years. OXA-48 carbapenemase was detected in 88% of isolates and attendance at outbreak meetings alone accounted for 463.5 h of IPCT members, and related staff time. CONCLUSION Despite considerable efforts and time invested by the IPCT, the number of CPE cases is increasing year-on-year, with more outbreaks being reported in later years, albeit partly in response to increased screening requirements. Infrastructural deficits, the changing epidemiology of CPE, and national policy are major factors in the increasing number of cases.
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A prospective cohort study on the safety of checkpoint inhibitors in older cancer patients - the ELDERS study. ESMO Open 2021; 6:100042. [PMID: 33516147 PMCID: PMC7844568 DOI: 10.1016/j.esmoop.2020.100042] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/06/2020] [Accepted: 12/20/2020] [Indexed: 11/30/2022] Open
Abstract
Objective Older cancer patients are underrepresented in the pivotal trials of checkpoint inhibitors (CPIs). This study aimed to investigate the impact of an ageing immune system on CPI-related toxicity and provide evidence for the role of geriatric assessments with CPI. Methods The ELDERS study is a prospective observational study with two cohorts: older (70+ years of age) and younger (<70 years of age). Patients with advanced/metastatic non-small-cell lung cancer or melanoma starting single-agent CPI were eligible. The older cohort was assessed for frailty with Geriatric-8 (G8) screening, which when positive (<15 points) was followed by a holistic set of geriatric assessments. Primary endpoint was the incidence of grade 3-5 immune-related adverse events (irAEs). Results One hundred and forty patients were enrolled with 43% being pretreated and pembrolizumab represented 92% of treatments on study. The older cohort had a significantly higher comorbidity burden (P < 0.001) and polypharmacy (P = 0.004). While 50% of older patients had a positive G8 screening, 60% on this frail subgroup had a performance status score of 0 or 1. There was no significant difference in the incidence of irAEs grade 3-5 between older and younger cohorts (18.6% versus 12.9%; odds ratio 1.55, confidence interval 95% 0.61-3.89; P = 0.353). Exposure to systemic steroids due to irAEs was numerically longer for older patients (22 versus 8 weeks; P = 0.208). A positive G8 screening predicted hospital admissions (P = 0.031) and risk of death (P = 0.01). Conclusions The use of CPI in older patients was not associated with more high-grade toxicity. The G8 screening identified a subgroup with higher risk of AEs and its implementation should be considered in the context of CPI. The ELDERS is the first prospective study designed to address the safety of immunotherapy in older cancer patients. Older cancer patients had no increased risk of high-grade toxicity with immunotherapy. Management of immune toxicity in older patients is often more challenging, particularly for those more vulnerable/frail. Geriatric assessments in the context of immunotherapy predict clinical outcomes. Comorbidity burden, polypharmacy and the G8 screening identified those with worst outcomes.
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Emerging Treatment Options for the Systemic Right Ventricle: A Single Centre Experience of Sacubitril/Valsartan in Transposition of Great Arteries. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Casting the net wide: universal testing of emergency admissions for SARS-CoV-2 to prevent onward transmission. J Hosp Infect 2020; 107:64-66. [PMID: 33176174 PMCID: PMC7832560 DOI: 10.1016/j.jhin.2020.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 12/27/2022]
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National Guidelines on the Provision of Outpatient Parenteral Antimicrobial Therapy (OPAT). IRISH MEDICAL JOURNAL 2020; 113:123. [PMID: 35575598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Aim Outpatient parenteral antimicrobial therapy (OPAT) is an option in patients who require parenteral antimicrobial administration and are clinically well enough for hospital discharge. This is an update of the Irish National OPAT guidelines which were last reviewed in 2011. Methods The guideline was devised through a collaborative process with the national OPAT Working Group and a review of the literature. It is intended for clinicians who prescribe any intravenous (IV) antimicrobials outside of the inpatient setting in the Republic of Ireland. Results Patient care while on OPAT should be provided by a designated OPAT service, with clear managerial and clinical governance lines of responsibility. It should be conducted using a team approach with a clinical lead on each site either as an infection specialist, or a general medical physician with infection specialist input and an OPAT nurse. An antimicrobial pharmacist is also desirable. Several factors must be considered when assessing patient's suitability for OPAT including exclusion criteria, infection-specific factors, and patient specific factors such as physical, social and logistic criteria. Conclusion This updated guideline advocates a more individualised OPAT approach, with the recognition that specific antimicrobials and/or specific delivery models may be more appropriate for certain patient groups. Full guidelines are available through www.opat.ie.
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From bench to bedside - development of an integrated COVID-19 patient flow management system. J Hosp Infect 2020; 106:211-213. [PMID: 32590014 PMCID: PMC7834625 DOI: 10.1016/j.jhin.2020.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/19/2020] [Indexed: 11/30/2022]
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Improving the processing time for the detection of carbapenemase-producing enterobacterales using an evolving algorithm. Br J Biomed Sci 2020; 77:97-100. [DOI: 10.1080/09674845.2019.1704357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Getting the timing right: is it worthwhile to vaccinate long-stay hospital inpatients to prevent influenza? J Hosp Infect 2020; 104:82-84. [DOI: 10.1016/j.jhin.2019.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/06/2019] [Indexed: 11/28/2022]
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Antimicrobial prescribing and infections in long-term care facilities (LTCF): a multilevel analysis of the HALT 2016 study, Ireland, 2017. ACTA ACUST UNITED AC 2019; 23. [PMID: 30458910 PMCID: PMC6247462 DOI: 10.2807/1560-7917.es.2018.23.46.1800278] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background The 2016 point prevalence survey (PPS) of healthcare-associated infections (HAI) and antimicrobial use (AMU) in Irish long-term care facilities (LTCF) (HALT) showed a 9.8% AMU and 4.4% HAI prevalence, based on aggregated data analysis. Aim Our aim was to identify institutional and resident risk factors of AMU and HAI. Methods HALT 2016 gathered information using institutional and resident questionnaires, for residents who met the surveillance definition of active HAI and/or AMU, limiting analysis to the aggregated institutional level. In January 2017, we requested additional data on age, sex, urinary catheter use and disorientation of current residents from HALT 2016 LTCF and matched to 2016 HALT data. Results Of 224 HALT 2016 LTCF, 80 provided additional information on 3,816 residents; prevalence of AMU was 10.6% and HAI was 4.7%. Presence of a coordinating physician (Odds ratio (OR): 0.3; 95% confidence interval (CI): 0.2–0.6), antimicrobial stewardship committee (OR: 0.2; 95%; CI: 0.1–0.6), healthcare assistants (OR: 0.9; 95% CI: 0.9–1.0), antimicrobial consumption feedback (OR: 0.3; 95% CI: 0.1–0.6) and medical care by personal general practitioner (OR: 0.6; 95% CI: 0.7–1.0) were associated with less AMU and feedback on surveillance of infection prevention and control (IPC) practices (OR: 0.6; 95% CI: 0.3–1.0) with less HAI. AMU and HAI varied significantly between LTCF. Conclusions Multilevel modelling identified significant inter-facility variation, as well as institutional factors associated with AMU and HAI. An antimicrobial stewardship committee linked with feedback on IPC and prescribing was associated with reduced AMU and HAI.
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Prognostic value of circulating tumour cells in limited-stage small-cell lung cancer: analysis of the concurrent once-daily versus twice-daily radiotherapy (CONVERT) randomised controlled trial. Ann Oncol 2019; 30:1114-1120. [PMID: 31020334 PMCID: PMC6637373 DOI: 10.1093/annonc/mdz122] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The clinical significance of circulating tumour cells (CTCs) in limited-stage small-cell lung cancer (LS-SCLC) is not well defined. We report a planned exploratory analysis of the prevalence and prognostic value of CTCs in LS-SCLC patients enrolled within the phase III randomised CONVERT (concurrent once-daily versus twice-daily chemoradiotherapy) trial. PATIENTS AND METHODS Baseline blood samples were enumerated for CTCs using CellSearch in 75 patients with LS-SCLC who were enrolled in the CONVERT trial and randomised between twice- and once-daily concurrent chemoradiation. Standard statistical methods were used for correlations of CTCs with clinical factors. Log-rank test and Cox regression analyses were applied to establish the associations of 2, 15 and 50 CTC thresholds with progression-free survival (PFS) and overall survival (OS). An optimal CTC count threshold for LS-SCLC was established. RESULTS CTCs were detected in 60% (45/75) of patients (range 0-3750). CTC count thresholds of 2, 15 and 50 CTCs all significantly correlate with PFS and OS. An optimal CTC count threshold in LS-SCLC was established at 15 CTCs, defining 'favourable' and 'unfavourable' prognostic risk groups. The median OS in <15 versus ≥15 CTCs was 26.7 versus 5.9 m (P = 0.001). The presence of ≥15 CTCs at baseline independently predicted ≤1 year survival in 70% and ≤2 years survival in 100% of patients. CONCLUSION We report the prognostic value of baseline CTC count in an exclusive LS-SCLC population at thresholds of 2, 15 and 50 CTCs. Specific to LS-SCLC, ≥15 CTCs was associated with worse PFS and OS independent of all other factors and predicted ≤2 years survival. These results may improve disease stratification in future clinical trial designs and aid clinical decision making. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00433563.
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High flow nasal cannula compared with conventional oxygen therapy for acute hypoxemic respiratory failure: a systematic review and meta-analysis. Intensive Care Med 2019; 45:563-572. [PMID: 30888444 DOI: 10.1007/s00134-019-05590-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/28/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND This systematic review and meta-analysis summarizes the safety and efficacy of high flow nasal cannula (HFNC) in patients with acute hypoxemic respiratory failure. METHODS We performed a comprehensive search of MEDLINE, EMBASE, and Web of Science. We identified randomized controlled trials that compared HFNC to conventional oxygen therapy. We pooled data and report summary estimates of effect using relative risk for dichotomous outcomes and mean difference or standardized mean difference for continuous outcomes, with 95% confidence intervals. We assessed risk of bias of included studies using the Cochrane tool and certainty in pooled effect estimates using GRADE methods. RESULTS We included 9 RCTs (n = 2093 patients). We found no difference in mortality in patients treated with HFNC (relative risk [RR] 0.94, 95% confidence interval [CI] 0.67-1.31, moderate certainty) compared to conventional oxygen therapy. We found a decreased risk of requiring intubation (RR 0.85, 95% CI 0.74-0.99) or escalation of oxygen therapy (defined as crossover to HFNC in the control group, or initiation of non-invasive ventilation or invasive mechanical ventilation in either group) favouring HFNC-treated patients (RR 0.71, 95% CI 0.51-0.98), although certainty in both outcomes was low due to imprecision and issues related to risk of bias. HFNC had no effect on intensive care unit length of stay (mean difference [MD] 1.38 days more, 95% CI 0.90 days fewer to 3.66 days more, low certainty), hospital length of stay (MD 0.85 days fewer, 95% CI 2.07 days fewer to 0.37 days more, moderate certainty), patient reported comfort (SMD 0.12 lower, 95% CI 0.61 lower to 0.37 higher, very low certainty) or patient reported dyspnea (standardized mean difference [SMD] 0.16 lower, 95% CI 1.10 lower to 1.42 higher, low certainty). Complications of treatment were variably reported amongst included studies, but little harm was associated with HFNC use. CONCLUSION In patients with acute hypoxemic respiratory failure, HFNC may decrease the need for tracheal intubation without impacting mortality.
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Value of a hospital-wide point prevalence survey of carbapenemase-producing Enterobacterales – low-level prevalence confirmed. J Hosp Infect 2019; 101:191-194. [DOI: 10.1016/j.jhin.2018.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
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Identifying hospital-acquired infections using retrospective record review from the Irish National Adverse Events Study (INAES) and European point prevalence survey case definitions. J Hosp Infect 2018; 101:313-319. [PMID: 30590090 DOI: 10.1016/j.jhin.2018.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 12/19/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Point prevalence surveys (PPSs) collect data on hospital-acquired infections (HAIs) at one point in time but do not provide information on incidence over the entire admission or impact on patients or healthcare resources. Retrospective record review examines the entire admission to determine adverse event prevalence, incidence, preventability, physical impairment and additional length of stay. AIM To establish whether European HAI surveillance definitions can be applied to the Irish National Adverse Events Study (INAES) retrospective record review data to determine HAI burden. METHODS In the INAES, 1574 admissions were reviewed using a two-stage methodology and 247 adverse events were found. These were examined against European HAI case definitions to determine whether the event was an HAI. Results were compared with the 2011/12 European PPS data for Ireland. FINDINGS The prevalence of HAI adverse events in INAES was 4.4% (95% confidence interval (CI) 3.1-6.1%) with an incidence of 3.8 (95% CI 2.5-5.2) HAI adverse events per 100 admissions. The PPS HAI prevalence for Ireland was 5.2%. HAI types and micro-organisms were similar in INAES and the PPS. Approximately three-quarters of INAES HAI adverse events were preventable, 7% caused permanent impairment and 7% contributed to death. A mean of 10 additional bed days were attributed to HAI adverse events, equivalent to €9400 per event. CONCLUSION Retrospective record review is an accurate source of information on HAI incidence, preventability and impact that complements PPS prevalence rates. HAI adverse events result in higher costs to the healthcare system than other adverse events.
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Food for thought. Malnutrition risk associated with increased risk of healthcare-associated infection. J Hosp Infect 2018; 101:300-304. [PMID: 30590089 DOI: 10.1016/j.jhin.2018.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 12/19/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Infection and malnutrition are interconnected. UK and Irish guidelines recommend the Malnutrition Universal Screening Tool (MUST) for nutritional risk screening. Patients with a MUST score of ≥2 are considered at high risk of malnutrition and referral for nutritional assessment is recommended. AIM To explore the association between healthcare-associated infection (HCAI) and the MUST score categories of patients. METHODS This was a cross-sectional study in May 2017 on ten representative wards in our institution. Patient demographics, MUST score, presence of medical devices, HCAI and antimicrobial use were collected. FINDINGS Of 240 patients, the HCAI prevalence was 10.4% (N = 25) and 26% (N = 63) were at high risk of malnutrition (MUST score ≥2). Patients with HCAI were more likely to have had surgery (odds ratio (OR): 5.5; confidence interval (CI): 2.1-14.3; P < 0.001), a central vascular catheter (OR: 10.0; CI: 3.6-27.2; P < 0.001), or a urinary catheter in situ (OR: 7.5; CI: 2.8-20.0; P < 0.001), and to have a high risk of malnutrition (OR: 4.3; CI: 1.7-11.2; P < 0.001). A higher MUST score remained a significant predictor of a patient having HCAI on multivariate regression analysis (CI: 0.2-0.6; P < 0.001). CONCLUSION Patients at risk of malnutrition when assessed with the MUST were more likely to have HCAI. However, prospective studies are required to investigate the temporal association between MUST and HCAI and which interventions best address malnutrition risk and HCAI reduction in different settings.
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Abstract No. 607 Incidence of radiation skin reaction after fluoroscopically guided interventions (FGI) during which the patient is exposed to reference air kerma (Ka,r) exceeding 5 Gy. J Vasc Interv Radiol 2018. [DOI: 10.1016/j.jvir.2018.01.652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Unileaflet Mitral Valve: A Rare Case Report and Novel Repair Technique. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control. Antimicrob Resist Infect Control 2017; 6:113. [PMID: 29163939 PMCID: PMC5686856 DOI: 10.1186/s13756-017-0259-z] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/11/2017] [Indexed: 12/25/2022] Open
Abstract
Background Infections with carbapenem-resistant Enterobacteriaceae (CRE) are increasingly being reported from patients in healthcare settings. They are associated with high patient morbidity, attributable mortality and hospital costs. Patients who are “at-risk” may be carriers of these multidrug-resistant Enterobacteriaceae (MDR-E). The purpose of this guidance is to raise awareness and identify the “at-risk” patient when admitted to a healthcare setting and to outline effective infection prevention and control measures to halt the entry and spread of CRE. Methods The guidance was created by a group of experts who were functioning independently of their organisations, during two meetings hosted by the European Centre for Disease Prevention and Control. A list of epidemiological risk factors placing patients “at-risk” for carriage with CRE was created by the experts. The conclusions of a systematic review on the prevention of spread of CRE, with the addition of expert opinion, were used to construct lists of core and supplemental infection prevention and control measures to be implemented for “at-risk” patients upon admission to healthcare settings. Results Individuals with the following profile are “at-risk” for carriage of CRE: a) a history of an overnight stay in a healthcare setting in the last 12 months, b) dialysis-dependent or cancer chemotherapy in the last 12 months, c) known previous carriage of CRE in the last 12 months and d) epidemiological linkage to a known carrier of a CRE. Core infection prevention and control measures that should be considered for all patients in healthcare settings were compiled. Preliminary supplemental measures to be implemented for “at-risk” patients on admission are: pre-emptive isolation, active screening for CRE, and contact precautions. Patients who are confirmed positive for CRE will need additional supplemental measures. Conclusions Strengthening the microbiological capacity, surveillance and reporting of new cases of CRE in healthcare settings and countries is necessary to monitor the epidemiological situation so that, if necessary, the implemented CRE prevention strategies can be refined in a timely manner. Creating a large communication network to exchange this information would be helpful to understand the extent of the CRE reservoir and to prevent infections in healthcare settings, by applying the principles outlined here. This guidance document offers suggestions for best practices, but is in no way prescriptive for all healthcare settings and all countries. Successful implementation will result if there is local commitment and accountability. The options for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources. Electronic supplementary material The online version of this article (10.1186/s13756-017-0259-z) contains supplementary material, which is available to authorized users.
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MA 10.07 Elderly Lung Cancer Patients on Immunotherapy: Preliminary Results from the ELDERS Study. J Thorac Oncol 2017. [DOI: 10.1016/j.jtho.2017.09.538] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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DCRC_ABC RESOURCES TO SUPPORT THE MANAGEMENT OF BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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P441Effects of changing atrial-ventricular delay on electrical synchrony in CRT. Europace 2017. [DOI: 10.1093/ehjci/eux141.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Attributable mortality of hospital-acquired bloodstream infections in Ireland. J Hosp Infect 2017; 96:35-41. [PMID: 28359546 DOI: 10.1016/j.jhin.2017.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 02/04/2017] [Indexed: 12/22/2022]
Abstract
AIM To estimate the attributable mortality of hospital-acquired bloodstream infections (HA-BSI) in Ireland. METHODS A retrospective case-cohort study was conducted, based on notifications from Irish microbiology laboratories and administrative patient records from six Irish hospitals from January 2007 to December 2013. Probabilistic linkage was used to link 1252 cases of bloodstream infection from a cohort of 343,189 hospitalized patients. Independent predictors of mortality were determined using a multi-variable logistic regression model, and included: patient age, emergency or re-admission to hospital, length of stay in an intensive care unit, number of procedures, number of diagnoses, major diagnostic category and presence of HA-BSI. RESULTS Attributable mortality was calculated from the crude mortality of case subjects after adjusting for other predictors of mortality, and was found to be 15.3% (95% confidence interval 14.8-15.8%). The study was further stratified according to the causative organism, including: Escherichia coli, Enterococcus faecium, Enterococcus faecalis, Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus and Streptococcus pneumoniae, and, where available, their antimicrobial resistance patterns. The highest attributable mortality among these organisms was reported for E. faecium at 18.1% and the lowest attributable mortality was reported for E. coli at 13.6%. A significantly higher attributable mortality was found for antimicrobial resistance patterns of some organisms, most notably for meticillin-resistant S. aureus at 19.5%, vs meticillin-susceptible S. aureus at 13.3%. CONCLUSIONS HA-BSI is an important cause of mortality, and attributable mortality differs significantly among causative organisms and antimicrobial resistance patterns.
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Presence of lead on the external surface of lenses in radiation protection eyewear. J Vasc Interv Radiol 2017. [DOI: 10.1016/j.jvir.2016.12.634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Emergency department imaging: are weather and calendar factors associated with imaging volume? Clin Radiol 2016; 71:1312.e1-1312.e6. [DOI: 10.1016/j.crad.2016.06.117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/15/2016] [Accepted: 06/27/2016] [Indexed: 10/21/2022]
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Does written information influence post-operative understanding? Int J Surg 2016. [DOI: 10.1016/j.ijsu.2016.08.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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F18 NaF PET/CT and whole body MRI for the detection of metastases in patients with biochemical recurrence of prostate cancer. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw372.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Haemodynamic effects of parenteral vs. enteral paracetamol in critically ill patients: a randomised controlled trial. Anaesthesia 2016; 71:1153-62. [DOI: 10.1111/anae.13562] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 11/30/2022]
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Klebsiella pneumoniae bloodstream infection, antimicrobial resistance and consumption trends in Ireland: 2008 to 2013. Eur J Clin Microbiol Infect Dis 2016; 35:1777-1785. [PMID: 27488438 DOI: 10.1007/s10096-016-2727-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 07/05/2016] [Indexed: 10/21/2022]
Abstract
This study aimed to describe the epidemiology and antimicrobial resistance trends of Klebsiella pneumoniae bloodstream infection (BSI) in Ireland, in conjunction with national antimicrobial consumption data, during the period 2008 to 2013. A retrospective cohort study of K. pneumoniae BSI cases was conducted, based on notifications from Irish microbiology laboratories to the Health Protection Surveillance Centre (HPSC). In total, 1942 K. pneumoniae BSI cases were identified over 6 years, with 310 reported in 2008 and 326 reported in 2013. From 2008 to 2013, the proportion of isolates resistant to co-amoxiclav (24 % versus 29 %), piperacillin-tazobactam (11 % versus 27 %), third generation cephalosporins (3GC) (11 % versus 21 %), fluoroquinolones (13 % versus 21 %) and gentamicin (11 % versus 17 %) increased overall, concurrent with increasing national rates of antimicrobial consumption in Ireland (acute hospitals: 35.87 versus 39.77 defined daily doses (DDD) per 100 bed days used (BDU); and community: 6.38 versus 7.85 DDD per 1000 inhabitants per day (DID)). Enhanced data on the patient's admission route was available for 735 (38 %) cases. Overall, 51 % (n = 378) were categorised as 'acquired in the reporting hospital'. The all-cause mortality was 20 %, with 115 deaths, 101 (88 %) of whom died within 30 days of blood culture sampling date. K. pneumoniae is the second most common cause of Gram-negative BSI in Ireland, with most cases healthcare-associated and an all-cause mortality of 20 % reported in this study. Annual increases in resistance to different antimicrobial classes and in a multi-drug resistant phenotype have been observed, concurrent with increasing national broad spectrum antimicrobial consumption. These trends portend a risk to patient outcomes and highlight the urgency for individual prescribers to evaluate their antimicrobial prescribing habits in hospitals, long-term care and community settings.
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Severe Hypertension and Bradycardia Secondary to Midodrine Overdose. J Med Toxicol 2016; 13:88-90. [PMID: 27417951 DOI: 10.1007/s13181-016-0574-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 10/21/2022] Open
Abstract
The objective of this case is to describe the pharmacokinetics and toxicity of midodrine in overdose. A 20 year old female ingested up to 350 mg midodrine while recovering in hospital from another overdose. She developed vomiting and severe hypertension (blood pressure [BP], 210/100 mmHg). Remarkable findings included a heart rate with a range of 43-60 beats/min, spontaneous respirations (20 breaths/min), and oxygen saturations of >95 % on FiO2 25 %, and a GS of 8. She was admitted to intensive care and had a normal non-contrast CT brain. She was treated with a glyceryl trinitrate patch (5 mg) and observed for 36 h with subsequent BP reduction to 124/81 mmHg and improved in conscious state. Midodrine and desglymidodrine concentrations were measured with liquid chromatography tandem mass spectrometry and were detected with 2-h post-ingestion at concentrations of 158.4 and 169.7 ng/mL, respectively. The parent drug concentrations rapidly decreased with an elimination of half-life of 1.6 h, and the metabolite initially increased and then decreased. The peak in blood pressure appeared to coincide with peak metabolite concentrations. Midodrine in overdose can potentially cause severe hypertension and reflex bradycardia but given its short half-life treatment with vasodilator agents and supportive care is sufficient.
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Participation in a randomised controlled feasibility study of a complex intervention for the management of the Respiratory Symptom Distress Cluster in lung cancer: patient, carer and research staff views. Eur J Cancer Care (Engl) 2016; 26. [PMID: 27389436 PMCID: PMC5697644 DOI: 10.1111/ecc.12538] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2016] [Indexed: 11/28/2022]
Abstract
This paper reports finding from a nested qualitative study designed to elicit the views and perceptions of those who participated in a randomised controlled feasibility trial testing a non‐pharmacological intervention, Respiratory Distress Symptom Intervention (RDSI), for the management of the breathlessness–cough–fatigue symptom cluster in lung cancer. Semi‐structured interviews were conducted with 11 lung cancer patients, three caregivers and seven researchers involved in recruitment, consent, RDSI training and delivery and participant follow‐up. Thematic analysis identified key considerations including: the importance of informed consent emphasising commitment to completion of paperwork and raising awareness of potential sensitivities relating to content of questionnaires; ensuring screening for the presence of symptoms reflects the language used by patients; appreciation of the commitment required from participants to learn intervention techniques and embed them as part of everyday life; conduct of interviews with patients who decline to participate; and conduct of serial interviews with those receiving RDSI to further inform its routine implementation into clinical practice. This study will inform the development of a fully powered follow‐on trial testing the hypothesis that RDSI plus usual care is superior to usual care alone in the effective management of this symptom cluster in lung cancer.
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196TiP: PREM-LC: Development and pilot testing of a patient reported experience measure in lung cancer. J Thorac Oncol 2016. [DOI: 10.1016/s1556-0864(16)30305-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Point prevalence survey of healthcare-associated infections and use of antimicrobials in Irish intellectual disability long-term care facilities: 2013. J Hosp Infect 2016; 93:410-7. [PMID: 27112050 DOI: 10.1016/j.jhin.2016.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 03/02/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Healthcare-associated infections (HCAIs) and use of antimicrobials are prevalent in long-term care facilities (LTCFs), but few data are available on the burden of these issues in intellectual disability (ID) LTCFs. AIM To assess the prevalence of HCAIs and use of antimicrobials in Irish ID-LTCFs to plan future HCAI prevention programmes. METHODS A national point prevalence survey was conducted in Irish ID-LTCFs in May 2013 using a European protocol. All Irish ID-LTCFs with full-time residents were invited to participate in this voluntary survey. Data were collected locally and analysed at the national coordinating centre. RESULTS Twenty-four Irish ID-LTCFs participated, with 1060 residents surveyed, representing 42% of ID-LTCF residents in Ireland. The crude HCAI prevalence rate was 4.3% (median 2.2, range 0-46.7), with respiratory tract infections (1.6%) and skin infections (1.6%) being the most prevalent types. Antimicrobials were prescribed for 10% of eligible residents (median 7.5, range 3.2-13.9), with 49% of all prescriptions indicated for prophylaxis. Prevention of urinary tract infections (38%), respiratory tract infections (36%) and skin infections (27%) were the most common reasons for prophylaxis. There was considerable variation in the prevalence of prescribing for prophylaxis across ID-LTCFs (range 2-29%), with only 17% of facilities having local antimicrobial guidelines in place. CONCLUSION There is a considerable burden of HCAIs and use of antimicrobials, particularly for skin and respiratory tract infections, in Irish ID-LTCFs. Further surveillance in this population is needed to help guide preventive strategies for ID-LTCF residents at risk of these infections.
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The antimicrobial susceptibility of non-tuberculous mycobacteria. J Infect 2016; 72:324-31. [DOI: 10.1016/j.jinf.2015.12.007] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 12/15/2015] [Accepted: 12/17/2015] [Indexed: 11/17/2022]
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Healthcare-associated infections and antimicrobial use in long-term care facilities: the Irish experience with the HALT surveys. J Hosp Infect 2015; 89:276-80. [DOI: 10.1016/j.jhin.2014.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 12/06/2014] [Indexed: 10/24/2022]
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Chronic kidney disease on hemodialysis is associated with decreased serum PCSK9 levels. Atherosclerosis 2014; 233:123-9. [DOI: 10.1016/j.atherosclerosis.2013.12.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 12/03/2013] [Accepted: 12/09/2013] [Indexed: 02/04/2023]
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Serum PCSK9 in Patients With Chronic Kidney Disease on Hemodialysis. Can J Cardiol 2013. [DOI: 10.1016/j.cjca.2013.07.280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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75 Modulation of Burkholderia cenocepacia virulence factors and biofilm formation by liposomal tobramycin-bismuth. J Cyst Fibros 2013. [DOI: 10.1016/s1569-1993(13)60217-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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No vaccine-no protection: mumps meningoencephalitis and hydrocephalus in an unvaccinated adult. IRISH MEDICAL JOURNAL 2013; 106:61. [PMID: 23472394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Assessing Adverse Cardiac Outcomes in Obstetric Patient With Non-rheumatic Cardiovascular Disease in Pregnancy. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.05.501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Feasibility of a multicenter prospective cohort study on the evaluation of prognosis in severe traumatic brain injury. Crit Care 2012. [PMCID: PMC3363728 DOI: 10.1186/cc10917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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