Abstract Background Respiratory infections cause 7% of deaths globally. Microbial upper respiratory tract (URT) carriage is a precursor to respiratory disease, meningitis, and septicaemia. ...Understanding carriage of URT pathogens is crucial to understanding the spread of respiratory disease. Vaccination against respiratory pathogens has reduced invasive disease rates but also profoundly modified carriage. Previous work shows the importance of individual URT pathogens, especially Streptococcus pneumoniae , and the effects of vaccination on carriage and disease. We aimed to assess carriage of multiple respiratory pathogens within a population benefitting from pneumococcal, Haemophilus influenzae b and meningitis C vaccines. This assessment will enable us to decipher the role of URT community dynamics. Methods We undertook a population-based respiratory carriage pilot study with 1574 participants, 1171 of whom were aged 5 years or older and 385 aged younger than 5 years (18 participants of age unknown because they did not return questionnaire). Patients registered at one of 19 Hampshire general practices, of any age and health status, were randomly selected using the ralloc command in Stata 12. Optimum sample collection method and carriage rates of the above species were assessed in two study groups: a self-swab group, in which participants did their own nose and mouth swabs; and a healthcare professional (HCP) group, in which HCPs did participants' nasopharyngeal and mouth swabs. Participant response rates in each study arm were compared. SPSS and a confidence interval calculator were used in the analysis. Findings Preliminary data suggest that nasal swabbing gave the greatest bacterial recovery at 40%. Nasal carriage rates of S pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa, Staphylococcus aureus, H influenzae , and Neisseria meningitidis were 10·3%, 2·5%, 1·6%, 21·3%, 2·6%, and 1·7%, respectively. Carriage of S pneumoniae and H influenzae were associated with young children whereas S aureus was associated with adults (p<0·0001). Carriage of S pneumoniae and H influenzae were associated with recent respiratory infection (p<0·0001 and p=0·0003, respectively). Co-colonisation of S pneumoniae with other species was common, especially H influenzae . Polymicrobial carriage occurred in 2·5% (n=80) samples. Response rates were higher for self-swabbing (22·3%, 95% CI 21·2–23·4) versus HCP-swabbing (6·6%, 5·9–7·3). However, isolation rates were greater for HCP-swabbing (36·0%, 30·7–41·3) versus self-swabbing (20·2%, 18·0–22·4). Interpretation Preliminary data show URT diversity and will aid continuation of the study in future years. We hope to use molecular methods to further understand the genetic composition and diversity of the URT community. Continuation of such studies will enable us to track changes in the rates of these interacting pathogens with ever-changing use of vaccines and antibiotics within the population. These studies are essential for enabling future improvements in clinical care by informing vaccine and antibiotic development and policy against infections causing meningitis, sepsis, and respiratory disease. Funding Bupa Foundation, The Rosetree's Trust.
Background Clostridium difficile is an important pathogen in Canadian health care facilities, and infection prevention and control (IPC) practices are crucial to reducing C difficile infections ...(CDIs). We performed a cross-sectional study to identify CDI-related IPC practices in Canadian health care facilities. Methods A survey assessing facility characteristics, CDI testing strategies, CDI contact precautions, and antimicrobial stewardship programs was sent to Canadian health care facilities in February 2005. Results Responses were received from 943 (33%) facilities. Acute care facilities were more likely than long-term care ( P < .001) and mixed care facilities ( P = .03) to submit liquid stools from all patients for CDI testing. Physician orders were required before testing for CDI in 394 long-term care facilities (66%)—significantly higher than the proportions in acute care (41%; P < .001) and mixed care sites (49%; P < .001). A total of 841 sites (93%) had an infection control manual, 639 (76%) of which contained CDI-specific guidelines. Antimicrobial stewardship programs were reported by 40 (29%) acute care facilities; 19 (54%) of these sites reported full enforcement of the program. Conclusion Canadian health care facilities have widely varying C difficile IPC practices. Opportunities exist for facilities to take a more active role in IPC policy development and implementation, as well as antimicrobial stewardship.
Background We carried out a survey to identify the infection prevention and control practices in place in Canadian hospitals participating in the Canadian Nosocomial Infection Surveillance Program ...(CNISP). Methods An infection prevention and control practices survey was sent to CNISP hospitals at the beginning of November 2004, the same time that CNISP started a 6-month prospective surveillance for Clostridium difficile infection (CDI) to evaluate their infection prevention and control measures and laboratory methods for C difficile. Results A total of 33 hospitals completed and returned the survey. Infection control precautions were initiated in 18 hospitals (55%) due to the presence of a symptomatic patient before the C difficile laboratory tests were available. All of the hospitals used gloves and gowns as additional precautions. Twenty-three hospitals (70%) tested liquid stools based on a clinician's order, and 8 (24%) tested all liquid stools submitted whether of not C difficile testing was requested. The hospitals used 1 of 3 different products as a standard hospital-wide disinfectant; 24 (73%) used a quaternary ammonium compound, 8 (24%) used accelerated hydrogen peroxide, and 1 (3%) used a hypochlorite solution (1:10 bleach solution). Conclusion Although the hospitals used contact precautions quite uniformly, considerable variation was seen among hospitals in terms of testing strategies, cleaning and disinfection protocols and products, and isolation practices. The timing for the initiation of infection control precautions is important to prevent secondary transmission of CDI. Most of the hospitals implemented precautions while waiting for the toxin assay results.
The anatomic accuracy of Rembrandt’s The Anatomy Lesson of Dr. Nicolaes Tulp (1632) has been debated in the literature for many years. The white cord that courses along the ulnar aspect of the carpus ...and small finger of the cadaver in Dr. Tulp’s dissection conforms to no normal anatomic structure and is believed to represent an anomalous branch of the ulnar nerve, an artistic error, or a combination of both. After the discovery of an accessory abductor digiti minimi (AADM) during a routine dissection of a late-middle-aged male cadaver, we noted that the course of its tendon over the hypothenar eminence resembled the white cord in the painting. After conducting a detailed literature search and anatomic interpretation of the painting, we established 4 criteria for identifying the white cord. Using these criteria, we evaluated the plausibility of an AADM being represented in the painting. We conclude that an AADM should be considered as a possible explanation for the white cord.
Background The use of combination therapies is needed to treat dyslipidemia in patients with both elevated low-density lipoprotein cholesterol (LDL-C) and low high-density lipoprotein cholesterol ...(HDL-C). We conducted a study to assess the efficacy and safety of combination therapy with statin plus extended-release (ER) niacin and colesevelam, aimed at lowering LDL-C and raising HDL-C, in subjects with atherosclerotic disease. Methods This 1-year study randomized 123 subjects with atherosclerotic disease to atorvastatin alone, double therapy with atorvastatin plus ER niacin, or triple therapy with atorvastatin, plus ER niacin and colesevelam. Target LDL-C was ≤80 mg/dL for single and double therapy, and ≤60 mg/dL for triple therapy. Target HDL-C was an increase of ≥10 mg/dL for double and triple therapy. Results Single therapy, with mean atorvastatin dose 30 mg/day, had a 47% reduction in LDL-C ( P < 0.001) from 148 ± 29 mg/dL to 77 ± 15 mg/dL. With the addition of ER niacin, the double therapy had a 25% increase in HDL-C, from 42 ± 11 mg/dL to 53 ± 16 mg/dL ( P < 0.001). The triple therapy decreased LDL-C by 57%, from 157 ± 29 mg/dL to 66 ± 18 mg/dL ( P < 0.001), and increased HDL-C by 29%, from 40 ± 9 mg/dL to 50 ± 14 mg/dL ( P < 0.001). Double and triple therapy required a lower atorvastatin dose of 20 mg/day to reach the target LDL-C levels. On average, 75% and 67% of subjects reached the predefined LDL-C and HDL-C treatment targets. No related myopathy or hepatotoxicity required stopping the therapy. Conclusion This study demonstrated that combination therapy with atorvastatin plus ER niacin and colesevelam can safely and effectively treat dyslipidemia in subjects with atherosclerotic disease.
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