Surveillance of carbapenemase-producing Enterobacteriaceae in the Indian Ocean Region between January 2010 and December 2015.

BACKGROUND: The aim of this study was to trace the emergence of carbapenemase-producing Enterobacteriaceae (CPE) on Reunion Island, a French overseas territory well suited for the surveillance of CPE emergence in patients from the entire Indian Ocean Region. METHODS: This retrospective multicenter study was conducted on Reunion Island between 2010 and 2015. RESULTS: A total of 43 CPEs were isolated during the course of the study, in 36 patients (50% in the last year alone). Among these patients, 21 had a link with a foreign country (58%), mainly Mauritius (47.6%). Over the same period, CPEs were isolated from 13 of 1735 (0.7%) repatriated patients to Reunion Island from another country of the Indian Ocean Region. The incidence of isolation of CPEs in the repatriated patients treated in Mauritius was higher (9.2%) than in patients treated in Madagascar or the Comoros Islands (<1%, P<0.001). The most commonly isolated microorganism was Klebsiella pneumoniae (39.5%). The most frequently identified carbapenemase was NDM-1 (81.4%); 100% and 56% of the NDM-1 strains were susceptible to tigecycline and colistin, respectively. In-hospital mortality rate was higher in patients presenting with CPE infection than in patients without CPE infection (75% vs. 25%, P=0.04). CONCLUSION: As elsewhere in the world, the number of CPE cases on Reunion Island is on the rise. Most cases involve patients from Mauritius, which justifies screening and isolating CPE in patients from that country.

THE MALFUNCTIONS OF A NATIONAL TRANSPLANTATION SYSTEM: MULTI-LAYERED EXPLANATIONS FROM WITHIN.

UNLABELLED: Romanja has one of the lowest posthumous organ donation and transplantation rates in Europe. AIM: To explore the perspectives on the national transplantation system deficits shared by the physicians responsible for the identification and referral of potential posthumous organ donors. MATERIAL AND METHODS: The study consists of semi-structured interviews with the key informants (ICU physicians, neurologists and neurosurgeons) in county hospitals in Moldavia. RESULTS: The explanations for the current Romanian organ transplantation rate, as emerged from the participants' answers, are multi-layered. Overall, the national transplantation system is accused of being plagued with serious problems: it is underfunded, understaffed, its resources have been distributed unevenly among medical centers, the communication between its elements is disrupted, leaving the majority of the transplant professionals practically detached from its upper layer and affecting their motivation to perform their transplantation-related tasks. Furthermore, some of the participants point to the strong reluctance of the population to donate their deceased relatives' organs. CONCLUSIONS: The results suggest a set of possible multi-level interventicrnq that could alleviate these problems.

Outcome of surgical treatment for umbilical swellings in bovine youngstock.

Umbilical swellings are commonly identified in calves and can be caused by hernia formation, infection of the remnants of umbilical vessels or a combination of both. Ninety-one cases with umbilical swellings were admitted to the Leahurst Farm Animal Practice (LFAP) between July 2004 and February 2012; 55 were simple hernias and 36 had associated infection. Eighty-seven cases underwent surgery of which 86 survived until discharge. Postoperative complications occurred in 65/86 animals (73 per cent). In 51 cases (81 per cent) this was classified as minor requiring no additional treatment. Placement of a prosthetic mesh was associated with a higher OR for developing severe postoperative complication when compared with those not receiving a mesh (OR=19.3; 95% CI 4.5 to 83.5). Long-term survival results were available for 49 animals, 22 of which were remaining in the herd with a median age of 1346 days (3.7 years). Of the 27 animals which had exited the herd, 16 were adult dairy cows, 7 were dairy heifers, 2 were beef animals and 2 exited at an unknown stage. Umbilical surgery in calves carries a good prognosis, although placement of a mesh increases the risk of complications occurring in the postoperative period.

Factors of the willingness to consent to the donation of a deceased family member's organs among the Romanian urban population.

OBJECTIVES: Romania ranks near the bottom of the European hierarchy of posthumous organ donation rates. Objectives of this study were as follows: (1) to assess the willingness to donate (WTD) a family member's organs in the inhabitants of a large Romanian city (Iasi) and to analyze its factors; and (2) to determine the most important behaviors of the medical staff for our respondents in a hypothetical donation decision scenario. METHODS: The study included a representative sample of the Iasi population. The instrument addressed WTD a family member's organs, both in general and in the particular situation of knowing that the deceased had a positive attitude toward organ donation, knowledge of transplantation-related issues, endorsement of beliefs concerning organ donation, and the importance of a set of medical staff's behaviors. RESULTS: The questionnaire was completed by 1,034 participants, 48% (n = 496) of whom would most likely consent to donate a family member's organs, 18% (n = 191) would most likely refuse and 34% (n = 347) were unsure. The following factors were found to influence this variable: believing in the possible reversibility of brain death (P = .004); believing that body integrity should be preserved after death (P < .001); believing that part of the deceased continues to live through the organ recipients (P = .001); and being concerned about mutilation after donation (P < .001). CONCLUSIONS: The WTD the organs of a deceased next of kin in the Iasi population, even when the deceased had positive attitudes on the matter, is lower than that reported by other studies in other European countries. It is mainly influenced by knowledge and concerns regarding the posthumous manipulation of the body. Consent in a potential donation situation also depends on the way in which the medical staff interacts with the bereaved family.

Magnetic resonance diffusion-weighted imaging: reproducibility of regional apparent diffusion coefficients for the normal fetal brain.

OBJECTIVE: To evaluate the reproducibility of regional apparent diffusion coefficient (ADC) measurements of the normal fetal brain in the second and third trimesters of pregnancy. METHODS: Fifty normal singleton fetuses from healthy pregnant women between 19 and 37 weeks' gestation were studied without sedation. Single-shot diffusion-weighted images of the fetal brain were obtained using a 1.5-Tesla magnetic resonance scanner and a six-channel body array coil. ADC maps were created using 0 and 1000 b-values along three orthogonal directions. Two examiners independently measured ADC values in the cerebellar hemispheres (CH), pons, thalamus, basal ganglia (BG), centrum semiovale (CSO), and frontal (FWM), parietal (PWM), temporal (TWM) and occipital (OWM) white matter. Correlation between ADC values and menstrual age was assessed by linear regression analysis. The bias and agreement of ADC measurements were determined using Bland-Altman plots. RESULTS: ADC values either remained constant (BG, FWM, PWM, TWM, OWM, CSO) or decreased (CH, pons, thalamus) with advancing menstrual age. Mean intraobserver bias for ADC measurements was not significantly different from zero. Small interobserver differences in mean ADC measurements (i.e. a small mean bias) were detected for CH (1.26 ± 0.20 vs 1.20 ± 0.18 µm(2) /ms, P = 0.006), PWM (1.37 ± 0.29 vs 1.33 ± 0.26 µm(2) /ms, P = 0.02) and CSO (1.36 ± 0.29 vs 1.33 ± 0.28 µm(2) /ms, P < 0.0001). Measurement agreement was acceptable. CONCLUSIONS: ADC measurements in normal unsedated fetuses in the second and third trimesters are reproducible except for small differences for PWM, CH and CSO between examiners.

Comparison of oestrus detection methods in dairy cattle.

Sixty-seven Holstein-Friesian cows, from 20 days postpartum, were recruited into the study and fitted with both a pedometer (SAE Afikim) and a Heatime neck collar (SCR Engineers) and allocated a heat mount detector (either scratchcard [Dairymac] or KaMaR [KaMaR]) or left with none, relying only on farm staff observation. Common production stressors and other factors were assessed to determine their impact on the ability of each method to accurately detect oestrus and to investigate effects on the frequency of false-positive detections. Only 74 per cent of all potential oestrus periods (episodes of low progesterone) were identified by combining information from all methods. There was no difference between the methods in terms of sensitivity for detecting 'true oestrus events' (approximately 60 per cent), with the exception of scratchcards, which were less efficient (36 per cent). Pedometers and KaMaRs had higher numbers of false-positive identifications. No production stressors had any consequence on false-positives. The positive predictive values for neck collars or observation by farm staff were higher than those of other methods, and combining these two methods yielded the best results. Neck collars did not detect any of the nine oestrus events occurring in three cows with a body condition score (BCS) of less than 2, and the efficiency of correctly identifying oestrus was also reduced by high milk yield (odds ratio [OR]=0.34). Pedometer efficiency was reduced by lameness, low BCS or high milk yield (OR=0.42, 0.15 or 0.30, respectively).

Hospice care delivered at home, in nursing homes and in dedicated hospice facilities: A systematic review of quantitative and qualitative evidence.

BACKGROUND: Hospice care supports patients and their families physically and emotionally through the dying phase. In many countries a substantial portion of specialised end-of-life care is provided through hospices. Such care has developed outside of general healthcare and is commonly provided in a patient's home or in dedicated facilities. Hospice provision may need to increase in the future due to an ageing population with a greater need for access to end-of-life care. OBJECTIVES: In this systematic review we sought to identify the current evidence on (1) the effectiveness, including cost-effectiveness, of hospices, and hospice care in a patient's home and in nursing homes and (2) the experiences of those who use and of those who provide such services. METHODS: We included quantitative and qualitative studies on hospice care that was provided in a patient's home, nursing home or hospice. We did not include studies on end-of-life care that was provided as part of general healthcare provision, such as by general practitioners in primary care, community nurses or within general hospitals. For quantitative evaluations we included only those that compared hospice care with usual generalist healthcare. The databases CINAHL, MEDLINE, EMBASE, and The Cochrane Library were searched from 2003 to 2009. Evidence was assessed for quality and data extractions double-checked. For quantitative studies we present the outcome data comparing hospice versus usual care. For qualitative evaluations we organise findings thematically. FINDINGS: Eighteen comparative evaluations and four thematic papers were identified. Quantitative evidence, mostly of limited quality in design, showed that hospice care at home reduced general health care use and increased family and patient satisfaction with care. Main themes in the qualitative literature revealed that home hospice services support families to sustain patient care at home and hospice day care services generate for the patient a renewed sense of meaning and purpose. CONCLUSIONS: Although studies had methodological limitations, in this review we found much evidence to support the benefits of hospice care. There were limited evaluations found on the impact of hospice care on psychological well-being, such as symptoms of depression, and on inpatient hospice care and non-hospital related costs.

The roles of telomeres and telomerase in beta-cell regeneration.

Telomerase is a specialized reverse transcriptase that is responsible for extending and preserving the end of the chromosomes (telomeres). Telomerase plays a key role in regulating the lifespan of mammalian cells and is involved in critical aspects of cellular ageing processes. In this review, we will briefly summarize our current understanding of the functions of telomeres, telomerase and their regulation. Considering that compensatory islet hyperplasia and beta-cell regeneration play important roles in the prevention and/or delay of the onset of overt diabetes, we will also examine current literature regarding the effects of diabetes on telomere shortening and provide insights from our own studies on the role of telomerase in beta-cell regeneration.

Costs and outcomes associated with IVF using recombinant FSH.

Cost and outcome estimates based on clinical trial data may not reflect usual clinical practice, yet they are often used to inform service provision and budget decisions. To expand understanding of assisted reproduction treatment in clinical practice, an economic evaluation of IVF/intracytoplasmic sperm injection (ICSI) data from a single assisted conception unit (ACU) in England was performed. A total of 1418 IVF/ICSI cycles undertaken there between October 2001 and January 2006 in 1001 women were analysed. The overall live birth rate was 22% (95% CI: 19.7-24.2), with the 30- to 34-year age group achieving the highest rate (28%). The average recombinant FSH (rFSH) dose/cycle prescribed was 1855 IU. Average cost of rFSH/cycle was 646 pound(SD: 219 pound), and average total cost/cycle was 2932 pound (SD: 422 pound). Economic data based on clinical trials informing current UK guidance assumes higher doses of rFSH dose/cycle (1750-2625 IU), higher average cost of drugs/cycle (1179 pound), and higher average total cost/cycle (3266 pound). While the outcomes in this study matched UK averages, total cost/cycle was lower than those cited in UK guidelines. Utilizing the protocols and (lower) rFSH dosages reported in this study may enable other ACU to provide a greater number of IVF/ICSI cycles to patients within given budgets.

Cost-effectiveness of insulin aspart compared to human insulin in pregnant women with type 1 diabetes in the UK.

OBJECTIVES: In women with type 1 diabetes, poor glycaemic control during pregnancy is associated with high risk of pre-term delivery, perinatal mortality and morbidity. This economic analysis utilises clinical effectiveness data from the Insulin Aspart Pregnancy Study Group Trial to assess costs and outcomes associated with insulin aspart (IAsp) and human insulin (HI) as part of a basal-bolus insulin regimen in pregnant women with type 1 diabetes in the UK. RESEARCH DESIGN AND METHODS: Women with type 1 diabetes were enrolled if or=37 weeks' gestation). We considered costs of insulin, adverse events, delivery, and neonatal care for pre-term infants. Expected need for neonatal care was estimated from gestational age, using data from the literature and a large UK hospital. Costs were calculated from the perspective of the UK National Health Service. RESULTS: A total of 322 pregnant women were enrolled in the study and the outcome of pregnancy was known for 302, 151 in each arm. More women experienced a live birth at term with IAsp (72.8%) than with HI (60.9%), difference 11.9% (95% CI 2.0%, 22.5%, p = 0.028). Mean cost per woman was 3222 pounds for IAsp and 3539 pounds for HI, difference--318 pounds (95% CI--1353 pounds, 576 pounds; p = 0.49). CONCLUSIONS: Compared with HI, the use of IAsp in pregnant women with type 1 diabetes resulted in more live births at term, without increasing total costs of treatment. A prospectively defined study is required to confirm these conclusions.

A cost-minimisation analysis comparing moxifloxacin with levofloxacin plus ceftriaxone for the treatment of patients with community-acquired pneumonia in Germany: results from the MOTIV trial.

OBJECTIVE: This study presents a cost-minimisation analysis of moxifloxacin compared to combination treatment with levofloxacin and ceftriaxone in patients hospitalised with community-acquired pneumonia (CAP) in Germany. RESEARCH DESIGN AND METHODS: In the MOTIV study, 738 adult patients with CAP requiring hospitalisation and initial parenteral antibiotic therapy were randomised to sequential IV/oral therapy with either moxifloxacin (n = 368), or levofloxacin and ceftriaxone (n = 365). The primary effectiveness endpoint was the proportion of patients demonstrating clinical improvement 5-7 days after the completion of study treatment. Subgroup analysis considered patients with severe CAP according to pneumonia severity index (PSI) risk class IV and V, microbiologically proven infection, a history of chronic obstructive pulmonary disease, and a history of cardiovascular disease. The analysis included the cost of study medication, hospital stay, readmission and inpatient procedures and diagnostics. Event frequency in the study was multiplied by German unit costs to estimate per-patient expenditure. The analysis was conducted from a hospital perspective. Sensitivity analysis investigated the effect of costing from an insurer perspective. RESULTS: No significant difference was found in the percentage of successfully treated patients. Average per patient cost was euro 2190 for the moxifloxacin group, and euro 2619 for the levofloxacin + ceftriaxone group (difference -euro 430, 95% CI: -euro 138, -euro 740; p < 0.05). Variability in total costs was wide, with some patients accruing up to euro 18,000. Medication cost was significantly lower with moxifloxacin than levofloxacin + ceftriaxone (-euro 470, 95% CI: -euro 522, -euro 421), and accounted for between 15 and 30% of total costs. CONCLUSIONS: In this analysis of patients hospitalised with CAP in Germany, treatment with moxifloxacin was significantly less costly than treatment with levofloxacin and ceftriaxone.

A hierarchical classes analysis (HICLAS) of primary care patients with medically unexplained somatic symptoms.

This study used a clustering model, Hierarchical Classes Analysis (HICLAS), to examine patient groupings in a multiethnic sample of 1456 patients using primary care services at a university-affiliated community clinic in southern California. Somatic symptoms, psychiatric diagnoses and disability were studied using a survey instrument that included portions of the Composite International Diagnostic Interview (CIDI), the Diagnostic Interview Schedule (DIS) and the RAND-MOS Short Form Health Survey's (SF-36) 'physical functioning' dimension. HICLAS identified 11 clusters of patients with distinct patterns of medically unexplained somatic symptoms. These patient clusters varied with respect to psychiatric diagnoses and symptoms, gender, immigration status and disability. Results of this study suggest that the type of presenting symptom(s) and their various combinations may have diagnostic and prognostic value in primary care settings. These new findings may lead to further refinement of current diagnostic constructs for somatizing syndromes.

Abridged somatization: a study in primary care.

OBJECTIVE: We examined the prevalence, correlates, and predictive value of an abbreviated somatization index, based on specific symptom thresholds, in primary care patients using services at a university-affiliated clinic. METHOD: We interviewed 1456 patients with a survey instrument that included the Composite International Diagnostic Interview (CIDI) to elicit symptoms and diagnoses of several psychiatric disorders as well as demographic information and a measure of disability. Statistical analyses examined the relationship of abridged somatization with physical functioning and various demographic and diagnostic factors. RESULTS: About one fifth of this primary care sample met the abridged somatization criteria. "Somatizers," defined according to these criteria, had significantly higher levels of psychiatric comorbidity and disability than "nonsomatizers". Analyses taking into account the number and type of organ/body systems represented by the unexplained symptoms showed that this dimension adds specificity to the prediction of outcomes. Thus, regardless of the total number of medically unexplained symptoms, abridged somatization with unexplained symptoms attributable to four or more organ/body systems showed the strongest association with disability and psychopathology. CONCLUSIONS: Abridged Somatization is a frequent syndrome in primary care that is strongly associated with psychopathology and physical disability. Our research also yielded a new series of abridged somatization subtypes (eg, "discrete" vs. "comorbid" and "simple" vs. "polymorphous") that may effectively separate among various psychopathologies, and may become useful tools for future research with somatizing patients.

DSM-IV hypochondriasis in primary care.

The object of this study was to assess the prevalence and correlates of the DSM-IV diagnosis of hypochondriasis in a primary care setting. A large sample (N = 1456) of primary care users was given a structured interview to make diagnoses of mood, anxiety, and somatoform disorders and estimate levels of disability. The prevalence of hypochondriasis (DSM-IV) was about 3%. Patients with this disorder had higher levels of medically unexplained symptoms (abridged somatization) and were more impaired in their physical functioning than patients without the disorder. Of the various psychopathologies examined, major depressive syndromes were the most frequent among patients with hypochondriasis. Interestingly, unlike somatization disorder, hypochondriasis was not related to any demographic factor. Hypochondriasis is a relatively rare condition in primary care that is largely separable from somatization disorder but seems closely intertwined with the more severe depressive syndromes.

Somatisation disorder in primary care.

BACKGROUND: Somatisation is a common and frustrating clinical problem in primary care. METHOD: Using structural diagnoses and functional measures, we examined the prevalence and associated features of somatisation disorder defined by three current nosologies and an abridged construct in subjects using primary care services. RESULTS: Somatisation disorder, diagnosed according to the standard criteria, was found to have a very low prevalence (range 0.06-0.5%), while more than one-fifth of the sample (22%) met the criteria for the abridged diagnosis. There was poor agreement between succeeding versions of the DSM system for identifying cases of somatisation disorder, each system ending up with rather disparate sets of individuals as well as variable levels of psychopathology and disability. CONCLUSIONS: According to these data, standard somatisation disorder diagnoses add little to the prediction of disability/psychopathology beyond the contributions of an abridged construct of somatisation.

Shear stress measured on beds and wheelchairs.

Local shear is understood to be one of the principal risk factors for the development of pressure sores. There is a need for a small deformable sensor that can measure the shear force between skin and deformable materials without disturbing the shear phenomenon. In the present study a new shear sensor is introduced with a contact area of 4.05 cm2. A series of validation experiments was performed with ten healthy young subjects. It was demonstrated that with a forward-tilted seat, the sum of the local shear forces between skin and sensormat is equal to the resultant shear force measured with a force plate. This result serves as a validation of the new sensor. The shear values recorded are 4.8 kPa in the longitudinal direction and 8.5 kPa in the transversal direction while sitting in a wheelchair, and 5.6 kPa in the longitudinal direction and 3.1 kPa in the transversal direction on a mattress of a hospital bed, while in sitting position in bed.