Prevention of tick bites: an evaluation of a smartphone app.

BACKGROUND: Lyme borreliosis (LB) is the most common reported tick-borne infection in Europe, and involves transmission of Borrelia by ticks. As long as a vaccine is not available and effective measures for controlling tick populations are insufficient, LB control is focused on preventive measures to avoid tick bites. To inform citizens about the risk of ticks, motivate them to check for tick bites, and encourage them to remove any attached tick as quickly as possible, a mobile app called 'Tekenbeet' (Dutch for 'tick bite') was developed and released. The aim of this study was to evaluate the usage and user satisfaction of the 'Tekenbeet' app and to investigate whether it affects users' knowledge, perceived severity, perceived susceptibility, self-efficacy, response efficacy, current behavior and intention to comply with preventive measures. METHODS: Usage of the app was evaluated with data obtained from Google Analytics. A survey among the Dutch general adult population with two data collection periods evaluated the usage, user satisfaction and its influence on abovementioned outcomes. RESULTS: Data obtained from Google Analytics showed the app was downloaded almost 40,000 in the 20 months following the launch. The 'tick radar' and 'tick diary' screens were viewed most often. In addition, a total of 554 respondents completed an online survey. The mean user satisfaction score was 7.44 (on a scale of 1-10) and 90.9% of respondents would recommend the app to others. On average, survey respondents who downloaded the app (n = 243) recorded significantly more often higher knowledge scores (OR 3.37; 95% CI 2.02-5.09) and had a higher intention to comply with preventive measures (OR 2.47; 95% CI 1.22-5.85) compared to respondents who did not download the app (n = 311). CONCLUSIONS: The 'Tekenbeet' app is a frequently used and well-appreciated educational tool to increase public knowledge of ticks and tick bites. It also helps to improve the user's intention to apply preventive measures. The use of smartphones and apps is now commonplace in the Netherlands; the 'Tekenbeet' app feeds into this trend and thereby offers a modern day alternative to established formats such as an information leaflet and information provision on the Internet.

Education on tick bite and Lyme borreliosis prevention, aimed at schoolchildren in the Netherlands: comparing the effects of an online educational video game versus a leaflet or no intervention.

BACKGROUND: Lyme disease or Lyme borreliosis (LB) is the most common tick-borne disease both in the United States and Europe. Children, in particular, are at high risk of contracting LB. Since child-specific educational tools on ticks, tick bites and LB are lacking, we developed an online educational video game. In this study, we compared the effectiveness of an online educational video game versus a newly developed leaflet aimed to improve prevention of tick bites and LB among Dutch schoolchildren. METHODS: A total of 887 children, aged 9-13 years and attending the two final years of primary schooling, were recruited from 25 primary schools in June and July 2012. They were assigned through cluster randomization to one of three intervention groups: 'game' (22.4%), 'leaflet' (35.6%) or 'control' (41.9%). Prior to and directly following intervention, the children were asked to complete a short questionnaire. The main outcome measures were knowledge, perception (perceived susceptibility and importance) and preventive behavior in relation to tick bites and LB. Generalized linear mixed models were used to analyze the data. RESULTS: In the game group, the leaflet group and the control group, knowledge about ticks and tick bites improved significantly. The game was also an effective tool for improving preventive behavior; the frequency of checking for ticks increased significantly. However, there were no significant differences in knowledge improvement between the interventions. The game outperformed the leaflet in terms of improving preventive behavior, whereas the frequency of tick checks increased significantly. But this frequency didn't increase more than in the control group. CONCLUSIONS: The positive knowledge effects observed in the control group suggests the presence of a mere measurement effect related to completion of the questionnaire. The game did not outperform the leaflet or control group on all outcome measures. Therefore, the game may be of value as a complementary role, in addition to other media, in child-specific public health education programs on ticks and LB. This trial was retrospectively registered on October 21, 2016 (trial registration number: ISRCTN15142369).

[Possible exposure to rabies in anamnesis: rabies advice in the Netherlands]. / Mogelijke blootstelling aan rabiës in de anamnese: rabiesadvisering in Nederland.

Anamnestic incidences of four patients have highlighted the potential risk ofexposure to rabies. The first patient was a 30-year-old woman who rescued a bat from the mouth of her dog; it bit her on the right wrist. In the Netherlands, bats may be infected with the Lyssa virus. The Preparedness and Response Unit (PRU) of the Centre for Infectious Disease Control (CIDC) advised human rabies immunoglobulin (HRIG) and a full vaccination programme. The second patient was a 37-year-old woman, who caught a 'sick' squirrel and was subsequently bitten on her left hand. The advice was not to use post exposure prophylaxis since rabies is not prevalent amongst squirrels in the Netherlands. The third patient, a 55-year-old man, was bitten on his right calf by a dog in Sri Lanka. He was treated with HRIG and given the full vaccination course. The fourth patient was a 14-month-old boy who was scratched on the face by a cat in Turkey. He immediately received the first vaccination and upon return to the Netherlands was treated with HRIG and the other vaccinations. All patients remained without symptoms. A structured approach for risk assessment of each potential rabies incident is possible. It requires balancing a number of criteria: the species of animal, the endemicity of rabies in a country, the observed health or vaccination status of an animal, whether the animal can be tested for rabies, if the exposure was provoked or unprovoked, the type of injury and its location on the body of the injured, and the time interval between administration of HRIG and vaccine. In the Netherlands all health care providers are expected to perform a proper risk assessment. They may seek advice from regional health departments (Municipal Health Services), who, in turn, can be assisted by the PRU. HRIG and vaccine are only provided by the National Vaccine Institute in Bilthoven.

[Methicillin-resistant Staphylococcus aureus in pig breeders and cattle breeders]. / Meticillineresistente Staphylococcus aureus bij veehouders.

It was recently observed that pig breeders in The Netherlands often carry methicillin-resistant Staphylococus aureus (MRSA). These MRSA strains are related to MRSA strains found in pigs. A case-control study showed that not only pig breeders but also cattle breeders are at risk of carrying MRSA. It is advised to keep pig breeders, if they are admitted to a hospital, in isolation until surveillance cultures are proven negative. This also applies to veterinarians and slaughterhouse personnel. For cattle breeders screening without isolation on admission to a hospital is sufficient.

[Pneumococcal vaccination; arguments for informing parents about the options available]. / Pneumokokkenvaccinatie; argumenten om ouders te informeren over de mogelijkheden.

Invasive pneumococcal disease in childhood causes meningitis, sepsis and pneumonia. Current pneumococcal vaccines are estimated to prevent 50% of Dutch pneumococcal meningitis and 40% of pneumococcal sepsis. In 2001, the Health Council of The Netherlands emphasised the importance of universal pneumococcal vaccination of small children. However, the Dutch Minister of Health, Welfare and Sports stated that the vaccine is too expensive for the national vaccination programme (NVP). Child health clinics do not educate parents about vaccines that are not available in the NVP, and therefore parents are not informed about the availability of an effective pneumococcal vaccine. We argue that child health clinic physicians should inform parents about the limitations of the NVP in order to put expectations about the programme into perspective. Educating parents that the NVP is very worthwhile but does not include every possible or available vaccine will strengthen confidence in the NVP. Parents who then want to know which effective vaccines are available should be provided with the information they request. In view of the Health Council recommendations, the pneumococcal vaccine should then be specifically mentioned.

[Tetanus prophylaxis in general practice]. / Tetanusprofylaxe in de huisartsenpraktijk.

In response to the report 'Immunisation against tetanus following injuries' from the Dutch Health Council, the Dutch College of General Practitioners, the National Coordinating Body for the Control of Infectious Diseases and The Netherlands Vaccine Institute have drawn up guidelines for tetanus prophylaxis in general practice. The number of situations in which the administration of tetanus immunoglobulin or tetanus vaccine is indicated is now considerably lower. Some of the unclear aspects of the report have been further worked out and translated into definite guidelines. The guidelines are not only useful for general practitioners but deserve to be followed by all doctors treating patients with injuries.

Comparison of two surveillance methods for detecting nosocomial infections in surgical patients.

Nosocomial infections play a role in quality and cost control in health care. Surveillance of these infections is the only way to gain more insight into their frequency and causes. Since the results of surveillance may lead to changes in both patient and hospital management, which are sometimes major, it is necessary that all healthcare workers involved agree on the criteria used for the diagnosis and surveillance of these complications. In order to compare the efficacy of two surveillance methods, nosocomial infections in surgical patients were registered by both the Department of Surgery (complication surveillance [CS]) and the Department of Infection Control (nosocomial infection surveillance [NIS]) at the University Medical Center Utrecht, The Netherlands, over a 2-month period. The CS team used the national criteria of the Association of Surgeons of the Netherlands and the NIS team used the international criteria of the Centers for Disease Control and Prevention, USA, to define cases of nosocomial infection. A total of 515 patients were included in both arms of the study. The CS team diagnosed 69 infections in 49 patients, and the NIS team diagnosed 64 infections in 45 patients. Of 104 total infections, 39 were diagnosed by the CS team exclusively, 35 by the NIS team exclusively and only 30 by both. The main reasons for the inconsistent results were as follows: (i) the lack of follow-up after discharge in the NIS arm, (ii) the use of clinical criteria for the definition of a nosocomial infection in the CS arm, and (iii) the use of positive cultures as part of the criteria in the NIS arm. From the perspective of infection control, the CS system cannot be recommended for the surveillance of nosocomial infections.

Anatomical and biochemical evidence for the synthesis of unconjugated and sulfated neurosteroids in amphibians.

Various studies have shown that, in mammals, neurons and glial cells are capable of synthesizing bioactive steroids, or neurosteroids, which regulate the activity of the central nervous system (CNS). However, although steroid hormones are involved in the regulation of behavioral and neuroendocrine processes in amphibians, neurosteroid biosynthesis has never been studied in the CNS of non-mammalian vertebrates. Reviewed here are several data sets concerning the production of unconjugated and sulfated neurosteroids in amphibians. These data were obtained by investigating the immunohistochemical localization and activity of 3beta-hydroxysteroid dehydrogenase (3beta-HSD), 17beta-hydroxysteroid dehydrogenase (17beta-HSD) and hydroxysteroid sulfotransferase (HST), in the frog brain. Numerous 3beta-HSD-immunoreactive neurons were detected in the anterior preoptic area, nucleus of the periventricular organ, posterior tuberculum, ventral and dorsal hypothalamic nuclei. 17beta-HSD-like immunoreactivity was found in ependymal gliocytes bordering the lateral ventricles of the telencephalon. Two populations of HST-immunoreactive neurons were localized in the anterior preoptic area and the dorsal magnocellular nucleus of the hypothalamus. High amounts of progesterone (PROG), 17-hydroxyprogesterone (17OH-PROG), testosterone (T) and dehydroepiandrosterone sulfate (DHEAS) were measured in the frog brain by combining HPLC analysis of tissue extracts with radioimmunoassay detection. Incubation of telencephalic or hypothalamic explants with tritiated pregnenolone ([3H]PREG) yielded the synthesis of various metabolites including PROG, 17OH-PROG, DHEA and T. Incorporation of [35S]3'-phosphoadenosine 5'-phosphosulfate ([35S]PAPS) and [3H]PREG or [3H]DHEA into frog brain homogenates led to the formation of [3H,35S]pregnenolone sulfate ([3H,35S]PREGS) or [3H,35S]DHEAS, respectively. Altogether, these results demonstrate that the process of neurosteroid biosynthesis occurs in amphibians as previously seen in mammals.

Immunohistochemical localization of 3 beta-hydroxysteroid dehydrogenase and 5 alpha-reductase in the brain of the African lungfish Protopterus annectens.

The localization of the enzymes responsible for the biosynthesis of neurosteroids in the brain of dipnoans has not yet been determined. In the present study, we investigated the immunohistochemical distribution of 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD) and 5 alpha-reductase (5 alpha-R) in the brain and pituitary of the African lungfish Protopterus annectens by using antibodies raised against type I human 3 beta-HSD and type I human 5 alpha-R. The 3 beta-HSD and 5 alpha-R immunoreactivities were detected in cell bodies and fibers located in the same areas of the lungfish brain, namely, in the pallium, thalamus, hypothalamus, tectum, and periaqueductal gray. Identification of astrocytes, oligodendrocytes, and neurons with antisera against glial fibrillary acidic protein, galactocerebroside and neurofilaments revealed that, in the lungfish brain, 3 beta-HSD immunolabeling is expressed exclusively by neurons, whereas the 5 alpha-R-immunoreactive material is contained in both neurons and glial cells. In the pituitary gland, 3 beta-HSD- and 5 alpha-R-like immunoreactivity was localized in both the pars distalis and the pars intermedia. The present study provides the first immunocytochemical mapping of two key steroidogenic enzymes in the brain and pituitary of a lungfish. These data strongly suggest that neurosteroid biosynthesis occurs in the brain of fishes, as previously shown for amphibians, birds, and mammals.

Five-year surveillance of patients with communicable diseases nursed in isolation.

During a five year surveillance program of patients with communicable diseases nursed in isolation, we gathered information on 2880 patients who were nursed in isolation for 28 145 days, from January 1994 to December 1998. The mean number of patients nursed in isolation was 575.4 (range, 427-709) per year. On average 2.4% of patients admitted yearly to the University Medical Center (UMC) were nursed in isolation. The mean number of days nursed in isolation was 9.8 days per patient.1996 was a peak year in isolations due to outbreaks of gentamicin-resistant enterobacteriaceae (GRB) and methicillin resistant Staphylococcus aureus (MRSA). The main reasons for requiring isolation were: GRB, MRSA (proven and suspected cases), Clostridium difficile, viral infections and Mycobacterium tuberculosis. Registration of quantitative data on nursing patients in isolation, as presented in this paper, makes it possible to gain insight into the type and number of isolation indications, the required isolation room capacity on different wards, the workload of healthcare workers resulting from isolation and the trends in incidence of communicable diseases.

The octadecaneuropeptide ODN stimulates neurosteroid biosynthesis through activation of central-type benzodiazepine receptors.

Neurosteroids may play a major role in the regulation of various neurophysiological and behavioural processes. However, while the biochemical pathways involved in the synthesis of neuroactive steroids in the central nervous system are now elucidated, the mechanisms controlling the activity of neurosteroid-producing cells remain almost completely unknown. In the present study, we have investigated the effect of the octadecaneuropeptide (ODN), an endogenous ligand of benzodiazepine receptors, in the control of steroid biosynthesis in the frog hypothalamus. Glial cells containing ODN-like immunoreactivity were found to send their thick processes in the close vicinity of neurones expressing the steroidogenic enzyme 3 beta-hydroxysteroid dehydrogenase. Exposure of frog hypothalamic explants to graded concentrations of ODN (10(-10)-10(-5) M) produced a dose-dependent increase in the conversion of tritiated pregnenolone into various radioactive steroids, including 17-hydroxypregnenolone, progesterone, 17-hydroxyprogesterone, dehydroepiandrosterone and dihydrotestosterone. The ODN-induced stimulation of neurosteroid biosynthesis was mimicked by the central-type benzodiazepine receptor (CBR) inverse agonists methyl beta-carboline-3-carboxylate (beta-CCM) and methyl 6,7-dimethoxy-4-ethyl-beta-carboline-3-carboxylate (DMCM). The stimulatory effects of ODN, beta-CCM and DMCM on steroid formation was markedly reduced by the CBR antagonist flumazenil. The ODN-evoked stimulation of neurosteroid production was also significantly attenuated by GABA. Collectively, these data indicate that the endozepine ODN, released by glial cell processes in the vicinity of 3 beta-hydroxysteroid dehydrogenase-containing neurones, stimulates the biosynthesis of neurosteroids through activation of central-type benzodiazepines receptors.

gamma-Aminobutyric acid, acting through gamma -aminobutyric acid type A receptors, inhibits the biosynthesis of neurosteroids in the frog hypothalamus.

Most of the actions of neurosteroids on the central nervous system are mediated through allosteric modulation of the gamma-aminobutyric acid type A (GABA(A)) receptor, but a direct effect of GABA on the regulation of neurosteroid biosynthesis has never been investigated. In the present report, we have attempted to determine whether 3beta-hydroxysteroid dehydrogenase (3beta-HSD)-containing neurons, which secrete neurosteroids in the frog hypothalamus, also express the GABA(A) receptor, and we have investigated the effect of GABA on neurosteroid biosynthesis by frog hypothalamic explants. Double immunohistochemical labeling revealed that most 3beta-HSD-positive neurons also contain GABA(A) receptor alpha(3) and beta(2)/beta(3) subunit-like immunoreactivities. Pulse-chase experiments showed that GABA inhibited in a dose-dependent manner the conversion of tritiated pregnenolone into radioactive steroids, including 17-hydroxy-pregnenolone, progesterone, 17-hydroxy-progesterone, dehydroepiandrosterone, and dihydrotestosterone. The effect of GABA on neurosteroid biosynthesis was mimicked by the GABA(A) receptor agonist muscimol but was not affected by the GABA(B) receptor agonist baclofen. The selective GABA(A) receptor antagonists bicuculline and SR95531 reversed the inhibitory effect of GABA on neurosteroid formation. The present results indicate that steroid-producing neurons of the frog hypothalamus express the GABA(A) receptor alpha(3) and beta(2)/beta(3) subunits. Our data also demonstrate that GABA, acting on GABA(A) receptors at the hypothalamic level, inhibits the activity of several key steroidogenic enzymes, including 3beta-HSD and cytochrome P450(C17) (17alpha-hydroxylase).

A pilot study on infection control in 10 randomly selected European hospitals: results of a questionnaire survey.

We describe and compare the organization of infection control and some infection control practices in 10 hospitals in seven different European countries. Great differences were observed. By evaluating infection control and hygiene practices in different European centers, areas of prime importance for the development of a European infection control standard may be defined.

In vivo evidence for the production of sulfated steroids in the frog brain.

It is well established that sulfated neurosteroids are potent regulators of neuronal activity but the biosynthesis of sulfate esters of steroids in the central nervous system (CNS) has received little attention. In particular, the localization of hydroxysteroid sulfotransferase (HST), the enzyme which is responsible for the formation of sulfated steroids, has never been determined in the brain. We took advantage of the availability of an antiserum raised against rat liver HST to investigate the distribution of this enzyme in the CNS of the frog Rana ridibunda. Two populations of HST-positive neurons were localized in the anterior preoptic area and the magnocellular nucleus of the hypothalamus. Numerous HST-immunoreactive fibers were visualized throughout the telencephalon and the diencephalon. Reversed-phase high performance liquid chromatography (HPLC) analysis of frog telencephalon and hypothalamus extracts combined with radioimmunoasssay (RIA) detection showed the presence of substantial amounts of DHEAS-immunoreactive material which coeluted with synthetic DHEAS. The concentrations of DHEAS detected in the telencephalon and hypothalamus were respectively eight and five times higher than in the serum. The present study demonstrates the occurrence of HST-immunoreactive material in neurons of the frog telencephalon and diencephalon. This report also provides evidence for the presence of HST bioactivity, in vivo, in the frog brain.

Determining risk factors for methicillin-resistant Staphylococcus aureus carriage after discharge from hospital.

At the University Medical Center, Utrecht, methicillin-resistant Staphylococcus aureus (MRSA) patients are considered lifelong MRSA carriers and potentially contagious when readmitted. The purpose of this study was to determine whether patients who become MRSA carriers while in hospital remain colonized after discharge, and whether risk factors for prolonged carriage exist. Thirty-six patients colonized with MRSA during three outbreaks at University Medical Center, Utrecht (group I: 1986-1989), and twenty patients already colonized with MRSA on, or during, admission to the hospital (group II: 1990-1995) were screened for MRSA in two studies. The patients had been discharged from the hospital for periods varying from 15 days to 4.6 years. MRSA was found in five (9%). Four of these patients had skin lesions (wounds), one with an external fixture. The presence of skin- and underlying diseases differed significantly between carriers and non-carriers, supporting the hypothesis that wounds are a major risk factor for long-term MRSA carriage. This study led us to revise our policy concerning readmission of former MRSA patients. We now consider that patients who contracted MRSA in the past no longer need isolation if the following two criteria are met. Absence for at least six months of open wounds, skin lesions, tracheostomy, infections and sources of infection such as abscesses and furuncles, orthopaedic implants, drains, catheters, or tubes. Three MRSA-negative sets of swabs from nose, throat, perineum, urine, and sputum taken at least one hour apart after this six-month period.

Immunocytochemical localization and biological activity of hydroxysteroid sulfotransferase in the frog brain.

Biosynthesis of the neuroactive steroids pregnenolone sulfate (delta5PS) and dehydroepiandrosterone sulfate (DHEAS) is catalyzed by the enzyme hydroxysteroid sulfotransferase (HST), which transfers the sulfonate moiety from 3'-phosphoadenosine 5'-phosphosulfate (PAPS) on the 3-hydroxy site of steroids. Although high concentrations of delta5PS and DHEAS have been detected in the rat brain, the anatomical localization of HST in the CNS has never been determined. Using an antiserum against rat liver HST, we have investigated the distribution of HST-like immunoreactivity in the CNS of the frog Rana ridibunda. Two populations of HST-immunoreactive neurons were observed in the hypothalamus, and several bundles of positive nerve fibers were visualized in the telencephalon and diencephalon. Incubation of frog brain homogenates with [35S]PAPS and [3H]pregnenolone yielded the formation of several 3H,35S-labeled compounds, including delta5PS and testosterone sulfate. When [3H]dehydroepiandrosterone and [35S]PAPS were used as precursors, one of the 3H,35S-labeled metabolites coeluted with DHEAS. Neosynthesis of [3H]delta5PS and [3H]DHEAS was reduced significantly by 2,4-dichloro-6-nitrophenol, a specific inhibitor of sulfotransferases. The present study provides the first immunocytochemical mapping of HST in the brain. Our data also demonstrate for the first time that biosynthesis of the highly potent neuroactive steroids delta5PS and DHEAS occurs in the CNS of nonmammalian vertebrates.