The effectiveness of methicillin-resistant Staphylococcus aureus colonisation screening in asymptomatic healthcare workers in an Irish orthopaedic unit.

Methicillin-resistant Staphylococcus aureus (MRSA) infections are associated with increased mortality, costs and length of stay compared to non-MRSA infections. This observational 4-year study analyses the impact of screening and treating orthopaedic healthcare workers for MRSA colonisation. A total of 1,011 swabs were taken from 566 healthcare workers. Positive healthcare workers were treated with topical mupirocin to both anterior nares. The prevalence of MRSA colonisation on initial testing was 4.77%. The rate of positive MRSA colonisation of those tested on more than one occasion fell from 5.88% to 2.71% (p = 0.055) on subsequent screening. All healthcare workers receiving treatment were successfully cleared of colonisation; however, some required more than one course of treatment. These results show that there could be a role for screening and treating orthopaedic staff for MRSA colonisation as part of a strategy to reduce the prevalence of MRSA infections in orthopaedic units.

Delayed presentation of carotid artery dissection following major orthopaedic trauma resulting in dense hemiparesis.

We report a 30-year-old patient who was involved in a high-velocity road traffic accident and developed a left-sided hemiparesis, which was noted in the post-operative period following bilateral femoral intramedullary nailing. CT scanning of the brain revealed infarcts in the right frontal and parietal lobes in the distribution of the right middle cerebral artery. CT angiography showed occlusion of the right internal carotid artery consistent with internal carotid artery dissection. He was anticoagulated and nine months later was able to walk independently. An awareness of this injury is needed to diagnose blunt trauma to the internal carotid artery. Even in the absence of obvious neck trauma, carotid artery dissection should be suspected in patients with a neurological deficit in the peri-operative period.

Extended lamivudine treatment in patients with chronic hepatitis B enhances hepatitis B e antigen seroconversion rates: results after 3 years of therapy.

A study in Chinese patients with chronic hepatitis B showed that treatment with lamivudine for 1 year significantly improves liver histology and enhances hepatitis B e antigen (HBeAg) seroconversion compared with placebo. Fifty-eight patients from this 1-year study have received long-term treatment with lamivudine 100 mg; the outcome of 3 years of lamivudine is reported here. Before treatment, all patients had detectable HBeAg. HBeAg seroconversion (HBeAg-negative, anti-HBe-positive), hepatitis B virus (HBV)-DNA suppression, alanine transaminase (ALT) normalization, emergence of YMDD variant HBV, liver histology, and long-term safety were assessed. After 3 years of continuous treatment with lamivudine 100 mg daily, 40% (23 of 58) of patients achieved HBeAg seroconversion. In patients with baseline serum ALT >2 x upper limit of normal (ULN), the rate of HBeAg seroconversion was 65% (17 of 26). Median serum HBV-DNA concentrations were below the level of detection, and median ALT concentrations were within the normal range throughout 3 years of treatment. YMDD variant HBV emerged in 33 of 58 (57%) patients during the 3 years, of whom 9 (27%) achieved HBeAg seroconversion (6 after emergence of YMDD variant HBV). ALT levels and histologic scores after emergence of YMDD variant HBV did not show major deterioration. Lamivudine was well tolerated during 3 years of therapy. In conclusion, these data in Chinese patients with chronic hepatitis B show enhanced seroconversion rates with extended lamivudine treatment. Up to two thirds of patients with moderately elevated pretreatment ALT achieved HBeAg seroconversion after 3 years of therapy.

Impact of zanamivir treatment on productivity, health status and healthcare resource use in patients with influenza. Zanamivir Study Group.

OBJECTIVE: This study examined the impact of zanamivir treatment on patient morbidity in patients with influenza. DESIGN AND SETTING: This was a multicentre, randomised, double-blind, parallel-group study conducted in 14 countries in Europe and North America during the winter of 1995/1996. PATIENTS AND PARTICIPANTS: The study included 722 individuals with virologically confirmed influenza. INTERVENTIONS: Two different zanamivir treatment regimens [twice daily (bid) or 4 times daily (qid) for 5 days] were compared with placebo. MAIN OUTCOME MEASURES AND RESULTS: Efficacy was measured using a number of patient-assessment questionnaires. Results showed that significantly fewer patients with influenza who were treated with zanamivir had additional contacts with healthcare professionals compared with those who received placebo (8 vs 14%; p < or = 0.049, bid and qid vs placebo). Individuals treated with zanamivir also spent fewer days absent from work (placebo: mean = 3.28 days; qid: mean = 2.52 days; p = 0.031) or college/school (placebo: mean = 2.90 days; bid: mean = 2.24 days; p = 0.032), and showed significant improvements in productivity compared with placebo. The health status questionnaire revealed significant improvements in patient well-being over the first 5 days of the study in those treated with zanamivir compared with those who received placebo. CONCLUSIONS: Zanamivir treatment reduced absenteeism, improved patient productivity and well-being, and reduced the additional use of healthcare resources in patients with influenza.

Effects of extended lamivudine therapy in Asian patients with chronic hepatitis B. Asia Hepatitis Lamivudine Study Group.

BACKGROUND & AIMS: One-year lamivudine therapy significantly suppressed hepatitis B virus (HBV) replication, improved hepatic necroinflammatory activity, and prevented progression of fibrosis. However, the effects of prolonged therapy are unknown. METHODS: A total of 334 Asian patients with chronic hepatitis B from a previously reported 1-year study were randomized to receive either lamivudine (100 or 25 mg) or placebo for another year. The effects of treatment on serum HBV-DNA suppression, alanine transaminase (ALT) normalization, and hepatitis B e antigen (HBeAg) seroconversion were measured. The presence of YMDD variant HBV and its effect were also determined. RESULTS: A significantly greater proportion of patients achieved sustained HBV-DNA suppression and ALT normalization with 100 mg lamivudine daily for 2 years compared with lamivudine for 1 year followed by placebo for the second year (P<0.001). Daily lamivudine therapy for 2 years was safe and resulted in incremental HBeAg seroconversion from 17% at week 52 to 27% at week 104. HBeAg seroconversion during continued lamivudine therapy increased linearly with increasing pretherapy ALT levels (P< 0.001). Despite the emergence of YMDD mutant in 38% of the patients, they continued to clear serum HBeAg and maintain lower median serum HBV-DNA and ALT levels than baseline values. In contrast, ALT levels increased 8-12 weeks after switching from lamivudine to placebo, but returned to normal once lamivudine treatment was resumed. CONCLUSIONS: Treatment with lamivudine for 2 years is both well tolerated and efficacious in patients with chronic hepatitis B.

Coadministration of orally inhaled zanamivir with inactivated trivalent influenza vaccine does not adversely affect the production of antihaemagglutinin antibodies in the serum of healthy volunteers.

OBJECTIVE: Zanamivir, a clinically proven potent and specific inhibitor of influenza A and B neuraminidase, has been approved in some countries for the treatment of influenza and is in late-stage development for the prophylaxis of influenza. This study investigated whether the coadministration of zanamivir and influenza vaccine affected the development of antibody responses to injected influenza haemagglutinin. DESIGN: This double-blind randomised placebo-controlled study compared the antihaemagglutinin antibody production [haemagglutination inhibition (HAI) titre] after administration of inactivated trivalent influenza vaccine in healthy volunteers receiving zanamivir or placebo once daily for 28 days. STUDY PARTICIPANTS: 138 healthy volunteers (52 men and 86 nonpregnant women, mean age 32.7 years) were randomised to the zanamivir (70 participants) or placebo (68 participants) groups. INTERVENTIONS: Participants received a single intramuscular dose (deltoid muscle) of the 1997/1998 trivalent inactivated influenza vaccine (surface antigen) PhEur (Fluvirin) on day 1, and were then randomised to receive zanamivir 10 mg/day by oral inhalation or placebo for 28 days. Serum samples for determination of HAI titres were obtained before vaccination and on days 15 and 29. Compliance, adverse events and laboratory parameters were monitored. RESULTS: The primary measure of response was the geometric mean increase in HAI titre against the 3 viral antigens contained in the vaccine, calculated as the ratio of the value 4 weeks after vaccination to the baseline value. The means (and 2-sided 95% confidence intervals) for the ratio between the geometric mean increase with placebo and the increase with zanamivir were as follows: 1.1 (0.7, 1.5) for influenza B, 0.7 (0.4, 1.2) for influenza A H1N1, and 0.6 (0.4, 1.1) for influenza AH3N2. (This corresponds to a test level of alpha = 0.025 for the hypothesis that the increase with placebo was > or = 2-fold greater than the increase with zanamivir.) A lack of effect was concluded as values of 2.0 or greater (i.e. a 2-fold difference) were excluded. Comparisons were also made of the increase in titre at 2 weeks, the proportions of participants with at least a 4-fold increase in titre and the proportions of participants with a titre of at least 1:40. These comparisons revealed no differences between zanamivir- and placebo-treated groups. The nature and incidence of adverse events observed with zanamivir were similar to those observed with placebo. CONCLUSIONS: Overall, zanamivir was not associated with a reduced response in HAI titre against the 3 vaccine antigens when compared with placebo. In addition, zanamivir was well tolerated. Inhaled zanamivir 10 mg once daily has been demonstrated to prevent symptomatic laboratory-confirmed influenza in a community outbreak. Zanamivir should have the potential to provide protection during the 2- to 4-week period before full immunity is induced, following vaccination at a time when influenza is circulating in the community.

Acute diarrhoeal disease in India and Indonesia.

Acute diarrhoea is still a leading cause of child mortality and morbidity, second only to pneumonia as a killer of children, in India and Indonesia. Untreated diarrhoea precipitates malnutrition and is often the underlying cause of marasmus and kwashiorkor. Shigella and salmonella dysenteries are responsible for about 60% of all cases in Indonesia and India. These bacillary agents respond well to trimethoprim. Amoebiasis responds well to metronidazole. Most cases can be managed in the home, even if the exact cause is unknown, by giving liquids or a simple rehydration drink. Diarrhoea can be prevented by improving communal sanitation and personal hygiene, and by giving breast as opposed to bottle feeding of infants. Earlier introduction of supplementary feeding could provide the child with higher energy reserves giving it a better chance of survival when diarrhoeal insults occur.

Food intake and work allocation of male and female farmers in an impoverished Indian village.

1. The energy balance and activity allocation of eight male and eight female Indian farmers were measured for 4 d during 10 months in both the dry and wet seasons of 1983. 2. All food prepared and eaten was weighed and nutrient values were calculated from food composition tables. 3. Average energy costs per unit mass for fifteen tasks were estimated from data obtained using a Kofranyi-Michaelis respirometer. Each subject was observed from 05.00 to 20.00 hours and activities were recorded for each minute. The remaining activity was determined by recall. 4. Activity allocation was categorized qualitatively into time spent on economically productive work, free time and body maintenance. 5. The mean weight for male subjects was 48.2 kg; the average female weight was only 36.9 kg. The mean height for male and female subjects was 1.61 m and 1.49 m respectively. 6. For male subjects, the daily mean energy intake of 9.81 MJ (2350 kcal) was close to the calculated energy output of 9.54 MJ (2285 kcal). 7. The women's calculated daily expenditure of 8.22 MJ (1968 kcal) was slightly higher than their mean energy intake of 7.73 MJ (1852 kcal). 8. Although intake and output varied in relation to sex, weight and wealth the mean intake per kg body mass was equal for both males and females at 210 kJ (50 kcal) per kg. This is close to the minimum requirement for active Third World farmers. 9. The women spent significantly more time on economically productive work activities than the men (11.1 v. 8.1 h/d). Although female energy intake was 27% less than males, their productive work time was 27% higher.