The impact of pipeline changes and temperature increase in a hospital historically colonised with Legionella.

Healthcare-related Legionnaires' disease has a devastating impact on high risk patients, with a case fatality rate of 30-50%. Legionella prevention and control in hospitals is therefore crucial. To control Legionella water colonisation in a hospital setting we evaluated the effect of pipeline improvements and temperature increase, analysing 237 samples over a 2-year period (first year: 129, second year: 108). In the first year, 25.58% of samples were positive for Legionella and 16.67% for amoeba. Assessing the distance of the points analysed from the hot water tank, the most distal points presented higher proportion of Legionella colonisation and lower temperatures (nearest points: 6.4% colonised, and temperature 61.4 °C; most distal points: 50% and temperature 59.1 °C). After the first year, the hot water system was repaired and the temperature stabilised. This led to a dramatic reduction in Legionella colonisation, which was negative in all the samples analysed; however, amoeba colonisation remained stable. This study shows the importance of keeping the temperature stable throughout the circuit, at around 60 °C. Special attention should be paid to the most distal points of the circuit; a fall in temperature at these weak points would favour the colonisation and spread of Legionella, because amoeba (the main Legionella reservoir) are not affected by temperature.

Evaluation of an intervention to improve the management of allergens in school food services in the city of Barcelona

BACKGROUND: An intervention to promote the development of an allergen control plan (ACP) and preventive measures for the management of allergens in school food services was implemented in all schools of Barcelona city over a three-year period (2013-2015) by the public health services. The present study aimed to assess changes regarding the management of food allergens in school food services in Barcelona after an intervention conducted by the public health services of the city. METHODS: School meal operators of a random sample of 117 schools were assessed before and after the intervention using a structured questionnaire. The questionnaire collected general information on the students and their demand for special menus, and included 17 closed questions regarding the implementation of specific preventive measures for the management of allergens. Based on these 17 questions, a food safety score was calculated for each school. The improvement in these scores was evaluated. RESULTS: The results showed positive increments in the percentage of implementation of 12 of the 17 preventive measures assessed. The percentage of school food services with an implemented ACP increased by 49%. Schools with external and internal food supplies increased their scores by 16.5% and 19.6%, respectively. The greatest improvements were observed in smaller food services and in schools located in districts with low gross household incomes. CONCLUSIONS: The intervention was effective in improving school food services' management of allergens and in reducing the differences found among food services in the pre-intervention survey. We must also focus efforts on reducing socio-economic inequalities linked to the management of allergens

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Interventions to decrease short-term peripheral venous catheter-related bloodstream infections: impact on incidence and mortality.

BACKGROUND: Short-term peripheral venous catheters are a significant source of healthcare-acquired bloodstream infections and a preventable cause of death. AIM: To assess the effectiveness of interventions applied to reduce the incidence and mortality associated with short-term peripheral venous catheter-related bloodstream infections (PVCR-BSIs). METHODS: The intervention included continuous PVCR-BSI surveillance, implementation of preventive measures related to catheter insertion and maintenance in accordance with evidence-based recommendations and the hospital's own data, front-line staff educational campaigns, and assessment of adherence to hospital guidelines by ward rounds. A Poisson regression model was used to estimate the trend of rate per year. FINDINGS: From January 2003 to December 2016, 227 episodes of PVCR-BSI were identified among hospitalized patients at a university hospital. The mean age of patients was 67 years (standard deviation 14 years), 69% were male and the median Charlson score was 3 (interquartile range 2-5). Staphylococcus aureus caused 115 (50.7%) episodes. Thirty-day mortality was 13.2%. After implementation of the intervention, the incidence of PVCR-BSIs decreased significantly from 30 episodes in 2003 (1.17 episodes/10,000 patient-days) to eight episodes in 2016 (0.36/10,000 patient-days). The number of episodes caused by S. aureus decreased from 18 episodes in 2003 (0.70/10,000 patient-days) to three episodes in 2016 (0.14/10,000 patient-day), and mortality decreased from seven cases in 2003 (0.27/10,000 patient-days) to zero cases in 2016 (0.00/10,000 patient-days). CONCLUSIONS: Surveillance, implementation of a multi-modal strategy and periodical assessment of healthcare workers' adherence to hospital guidelines led to a sustained reduction in PVCR-BSIs. This reduction had a major impact on S. aureus BSI rates and associated mortality.

Evaluation of an intervention to improve the management of allergens in school food services in the city of Barcelona.

BACKGROUND: An intervention to promote the development of an allergen control plan (ACP) and preventive measures for the management of allergens in school food services was implemented in all schools of Barcelona city over a three-year period (2013-2015) by the public health services. The present study aimed to assess changes regarding the management of food allergens in school food services in Barcelona after an intervention conducted by the public health services of the city. METHODS: School meal operators of a random sample of 117 schools were assessed before and after the intervention using a structured questionnaire. The questionnaire collected general information on the students and their demand for special menus, and included 17 closed questions regarding the implementation of specific preventive measures for the management of allergens. Based on these 17 questions, a food safety score was calculated for each school. The improvement in these scores was evaluated. RESULTS: The results showed positive increments in the percentage of implementation of 12 of the 17 preventive measures assessed. The percentage of school food services with an implemented ACP increased by 49%. Schools with external and internal food supplies increased their scores by 16.5% and 19.6%, respectively. The greatest improvements were observed in smaller food services and in schools located in districts with low gross household incomes. CONCLUSIONS: The intervention was effective in improving school food services' management of allergens and in reducing the differences found among food services in the pre-intervention survey. We must also focus efforts on reducing socio-economic inequalities linked to the management of allergens.

Control of endemic multidrug-resistant Gram-negative bacteria after removal of sinks and implementing a new water-safe policy in an intensive care unit.

BACKGROUND: Contaminated handwashing sinks have been identified as reservoirs that can facilitate colonization/infection of patients with multidrug-resistant (MDR) Gram-negative bacteria (GNB) in intensive care units (ICUs). AIM: To assess the impact of removing patients' sinks and implementing other water-safe strategies on the annual rates of ICU-acquired MDR-GNB. METHODS: This six-year quasi-experimental study was conducted from January 2011 to December 2016. The intervention was carried out in August 2014 in two adult ICU wards with 12 rooms each. To assess the changes in annual MDR-GNB rates before and after the intervention, we used segmented regression analysis of an interrupted time-series. Crude relative risk (RR) rates were also calculated. FINDINGS: The incidence rates of MDR-GNB were 9.15 and 2.20 per 1000 patient-days in the pre- and post-intervention periods, respectively. This yielded a crude RR of acquiring MDR-GNB of 0.24 (95% confidence interval: 0.17-0.34). A significant change in level was observed between the MDR-GNB rate at the first point of the post-intervention period and the rate predicted by the pre-intervention time trend. CONCLUSION: The implementation of a new water-safe policy, which included the removal of sinks from all patient rooms, successfully improved the control of MDR-GNB spread in an ICU with endemic infection. Our results support the contribution of sink use with the incidence of MDR-GNB in endemic environments.

Clinical significance of methicillin-resistant Staphylococcus aureus colonization in residents in community long-term-care facilities in Spain.

Methicillin-resistant Staphylococcus aureus (MRSA) is highly prevalent in Spanish hospitals and community long-term-care facilities (LTCFs). This longitudinal study was performed in community LTCFs to determine whether MRSA colonization is associated with MRSA infections and overall mortality. Nasal and decubitus ulcer cultures were performed every 6 months for an 18-month period on 178 MRSA-colonized residents (86 490 patient-days) and 196 non-MRSA carriers (97 470 patient-days). Fourteen residents developed MRSA infections and 10 of these were skin and soft tissue infections. Two patients with respiratory infections required hospitalization. The incidence rate of MRSA infection was 0·12/1000 patient-days in MRSA carriers and 0·05/1000 patient-days in non-carriers (P=0·46). No difference in MRSA infection rate was found according to the duration of MRSA colonization (P=0·69). The mortality rate was 20·8% in colonized residents and 16·8% in non-carriers; four residents with MRSA infection died. Overall mortality was statistically similar in both cohorts. Our results suggest that despite a high prevalence of MRSA colonization in LTCFs, MRSA infections are neither frequent nor severe while colonized residents remain at the facility. The epidemiological impact of an MRSA reservoir is more relevant than the clinical impact of this colonization for an individual resident and supports current recommendations to control MRSA spread in community LTCFs.

Natural history of meticillin-resistant Staphylococcus aureus colonisation among residents in community long term care facilities in Spain.

The spread of meticillin-resistant Staphylococcus aureus (MRSA) is a major problem for both acute care hospitals and among residents in long term care facilities (LTCFs). We performed a cohort study to assess the natural history of MRSA colonisation in LTCF residents. Two cohorts of residents (231 MRSA carriers and 196 non-carriers) were followed up for an 18 month period, with cultures of nasal and decubitus ulcers performed every six months. In the MRSA carrier cohort, 110 (47.8%) residents had persistent MRSA colonisation for six months or longer, 44 (19.0%) had transient colonisation and nine (3.9%) were intermittently colonised. No risk factors for persistent MRSA colonisation could be determined. The annual incidence of MRSA acquisition was around 20% [95% confidence interval (CI): 14.3-25.5]. Antibiotic treatment was independently associated with MRSA acquisition (odds ratio: 2.27; 95% CI: 1.05-4.88; P=0.03). Just two clones were distinguishable by pulsed-field gel electrophoresis and multilocus sequence typing: CC5-MRSA IV, which is widely disseminated in Spanish hospitals, and ST22-MRSA IV. This study adds to the knowledge of the epidemiology of MRSA in community LTCFs, which are important components of long term care in Spain.

Prevalence of methicillin-resistant Staphylococcus aureus and factors associated with colonization among residents in community long-term-care facilities in Spain.

Hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) strains are no longer limited to acute-care hospitals but have now spread to other healthcare settings such as long-term-care facilities (LTCFs), in most of which they are endemic. In Europe, few studies have addressed the MRSA situation in LTCFs. A cross-sectional study to determine MRSA prevalence and factors associated with S. aureus carriage in community LTCF residents is reported here. Nasal and decubitus ulcer cultures were performed for residents of nine community LTCFs. Residents were classified as MRSA carriers, methicillin-susceptible S. aureus carriers and non-carriers. Overall, 1377 nasal swabs and 82 decubitus ulcer cultures were performed. MRSA was isolated from 15.5% and 59.0% of the former and latter, respectively. The prevalence of MRSA colonization was 16.8% (95% CI 14.9-18.8), varying from 6.7% to 35.8% (p <0.001) among LTCFs. Several independent variables were related to MRSA colonization. It is noteworthy that residents in an LTCF with fewer than 150 beds had at least a two-fold higher probability of being MRSA carriers. Modifiable factors were medical devices, decubitus ulcers and previous antibiotic treatment. An age of 85 years or older, a Charlson index >or=2 and transfer from an acute-care facility were non-modifiable factors also related to MRSA colonization. A high MRSA prevalence among residents in community LTCFs in Spain, with great variability among facilities, was found. The factors identified as being associated with MRSA colonization could be prevented by the implementation of several measures. Control strategies need to be coordinated between LTCFs and acute-care hospitals.

Age at first full-term pregnancy, lactation and parity and risk of breast cancer: a case-control study in Spain.

A case-control study was carried out in Spain to assess associations between parity, lactation and age at first full-term pregnancy and breast cancer. From November 1989 to February 1992, 184 incident breast cancer histologically confirmed cases were interviewed and matched by age and residence to 184 hospitalized patients and 184 community controls selected by random digit dialing. Multiple logistic regression was used to assess the independent influence of each factor on the risk of breast cancer in relation to other factors included in the model. Age at first full-term pregnancy was associated with breast cancer risk with an estimated odds ratio of 3.5 (95% CI 1.41-9.83) for women with their first birth after 30 years in comparison with those whose first birth was before age 21. Breast cancer risk decreased with increasing number of full-term pregnancies, OR 0.3 (95% CI 0.16-0.78) for women who had had more than 3 full-term pregnancies in comparison with nulliparous women. Among parous women, the estimated OR for women with more than 3 children was 0.4 (95% CI 0.13-0.81) after allowance for age at first childbirth and lactation. The estimated OR was 2.6 (95% CI 1.4-4.7) for women with a positive history of breast cancer in first-degree relatives. Breast cancer was not associated with total duration of lactation. The study indicates that parity is an independent risk factor associated to breast cancer and that the women with a late age at first full-term pregnancy constitute a high-risk group.

[Agreement between information supplied by the patient and a family member on medical history, consumption of tobacco, alcohol and coffee and diet in cancer of the exocrine pancreas and extrahepatic biliary tract]. / Concordancia entre la información facilitada por el paciente y un familiar sobre antecedentes patológicos, consumo de tabaco, de alcohol, de café, y dieta en el cáncer de páncreas exocrino y del sistema biliar extrahepático.

OBJECTIVE: No study on mutations in the K-ras oncogene and cancer of the exocrine pancreas or cancer of the biliary system has analyzed the reliability of clinical and epidemiological information. METHODS: Agreement between patient and surrogate on factors potentially related to both tumours was evaluated within a multicentre prospective study. Interviews were personally administered to both patient and surrogate (N = 110 pairs). Agreement was examined via the simple kappa index (k), the weighted kappa index (kw), the percentage of simple agreement, and the percentages of positive and negative agreement. RESULTS: Agreement for medical history was excellent (k between 0.89 and 0.76), as it was for tobacco consumption (k = 0.98). Agreement was moderate for coffee consumption (k = 0.68), frequencies of food groups (kw from 0.66 to 0.38), and consumption of alcoholic drinks (k from 0.66 to 0.32). Surrogates indicated a higher consumption of alcohol than patients. CONCLUSION: Surrogates can be an alternative source of information when patients cannot be interviewed, but information on alcohol consumption should be treated with caution.

Transient hypothyroidism after iodine-131 therapy for Grave's disease.

UNLABELLED: We studied 355 patients with Grave's disease to characterize transient hypothyroidism and its prognostic value following 131I therapy. METHODS: The patients received therapeutic 131I treatment as follows: 333 received a dose < 10 mCi (6.6 +/- 1.9 mCi) and 22 received a dose > 10 mCi (12.8 +/- 2.9 mCi). Diagnosis of transient hypothyroidism was based on low T4, regardless of TSH within the first year after 131I followed by recovery of T4 and normal TSH. RESULTS: After administration of < 10 mCi 131I, 40 patients developed transient hypothyroidism during the first year; transient hypothyroidism was symptomatic in 15. There was no transient hypothyroidism after high doses (> 10 mCi) of 131I. Iodine-131 uptake > 70% at 2 hr before treatment was a risk factor for developing transient hypothyroidism (Odds ratio 2.8, 95% confidence interval 0.9-9.4). At diagnosis of transient hypothyroidism, basal TSH levels were high (51%), normal (35%) or low (14%); therefore, the transient hypothyroidism was not centralized. If hypothyroidism developed during the first 6 mo after basal TSH > 45 mU/liter ruled out transient hypothyroidism. CONCLUSION: The development of transient hypothyroidism and its hormonal pattern did not influence long-term thyroid function. Since no prognostic factors reliably predicted transient hypothyroidism before 131I or at the time of diagnosis, if hypothyroidism appears within the first months after 131I, the reevaluation of thyroid function later is warranted to avoid unnecessary chronic replacement therapy.

[The prevalence of cardiovascular risk factors in a population of essential hypertension patients]. / Prevalencia de factores de riesgo cardiovascular en una población de hipertensos esenciales.

INTRODUCTION AND OBJECTIVES: High blood pressure is a cardiovascular risk factor whose coincidence with other risk factors considerably increases the probability for coronary heart disease. This study investigates the prevalence of different risk factors in hypertensive subjects. METHODS: We studied 891 patients with high blood pressure in their first visit to a hospital hypertension unit between 1987 and 1991. We assessed their clinical evolution and the prevalence of obesity, smoking, alcohol consumption, elevated blood pressure, diabetes, sedentary lifestyle, left ventricular hypertrophy and family history of high blood pressure. RESULTS: Sixteen per cent of the hypertensive subjects related previous history of evolutive accident. Stroke was the most frequent one. Prevalences of cardiovascular risk factors were as follows: family history of high blood pressure 53%, sedentary lifestyle 52%, elevated blood cholesterol 37%, smoking 35%, obesity 33%, left ventricular hypertrophy 16%, alcohol consumption 13% and diabetes 11%. Obesity prevalence was twice as high in women than in men. Males had higher prevalence for left ventricular hypertrophy, smoking and alcohol consumption. Diabetes was more prevalent in hypertensive patients older than 50 years. Prevalence of high blood cholesterol was greater in the group of women older than 50 years. CONCLUSIONS: Hypertensive patients have high prevalences of other cardiovascular risk factors. Their treatment should be aimed to improving the individual profile of cardiovascular risk.