Combined throat/nasal swab sampling for SARS-CoV-2 is equivalent to nasopharyngeal sampling.

PURPOSE: PCR on a nasopharyngeal sample is the reference method for the detection of SARS-nCoV-2. However, combined throat/nasal sampling as a testing method has several advantages. We compared the combined throat/nasal sampling with nasopharyngeal sampling for detection of SARS-CoV-2 in healthcare workers suspected of COVID-19. METHODS: In 107 healthcare workers with symptoms of COVID-19, combined throat/nasal sampling and nasopharyngeal sampling was performed. Detection of SARS-CoV-2 was performed by RT-PCR targeting. RESULTS: A total of 80 healthcare workers (74.8%) tested negative with both sampling methods, and 25 healthcare workers (23.4%) tested positive with both sampling methods. There were two discrepant results with positive PCR in combined throat/nasal swabs and negative PCR in nasopharyngeal swabs (1.9%). The κ index for concordance between the 2 sampling methods was high (0.95). The median cycle threshold (Ct) value of PCR on nasopharyngeal samples was significantly lower than the Ct value of PCR on combined throat/nasal samples (19 (IQR 17-20) versus 21 (IQR 18-29) cycles, p value 0.01). CONCLUSION: Combined throat/nasal swabs yield a similar sensitivity to detect SARS-CoV-2 as nasopharyngeal swabs and are a good alternative sampling method, despite a lower Ct value for the nasopharyngeal samples.

Detection and epidemiology of carbapenemase producing Enterobacteriaceae in the Netherlands in 2013-2014.

Laboratory detection of carbapenemase-producing Enterobacteriaceae (CPE) is complicated. Screening with MIC values below clinical breakpoints followed by genotypic confirmation is recommended. We evaluated the application of recommended CPE screening and confirmation methods and provide an overview of CPE epidemiology in E. coli and K. pneumoniae in the Netherlands. Data on E. coli and K. pneumoniae isolates with elevated meropenem (>0.25 mg/L) and/or imipenem (>1 mg/L) MIC values in 2013-2014 were selected from the Infectious Disease Surveillance Information System for Antibiotic Resistance. Laboratories were requested to provide additional results of any confirmatory testing performed. Confirmation of elevated carbapenem MIC values using gradient testing was performed in 59.8 % of eligible isolates. Confirmatory testing showed elevated MIC values in 8 % of E. coli and 32 % of K. pneumoniae isolates. The overall proportion of confirmed non-susceptible E. coli and K. pneumoniae was 0.01 % and 0.16 %, respectively. Genotypic confirmation was performed in 61.0 % of isolates with confirmed elevated carbapenem MIC values. A carbapenemase gene was identified in 47 % of E. coli and 65 % of K. pneumoniae isolates. OXA-48, NDM and KPC were the most frequently found carbapenemase genes. The majority (62 %) of CPE isolates was detected through targeted screening. CPE are a rare finding in the Netherlands. Adherence to the national guideline is suboptimal and differs between laboratories, implying a risk of inadequate CPE detection. Since accurate identification of CPE is the first step in prevention of CPE spread, successful implementation of guidelines for testing and reporting of CPE is essential.

Predictors of objectively identified recurrent reflux after primary Nissen fundoplication.

BACKGROUND: Laparoscopic Nissen fundoplication is the most frequently performed operation for gastro-oesophageal reflux disease (GORD). Studies on predictors of subjective outcome of fundoplication have yielded inconsistent results. This study identified predictors of objective reflux control after Nissen fundoplication. METHODS: This was a retrospective analysis of prospectively collected data from patients who underwent Nissen fundoplication for proton pump inhibitor-refractory GORD with pathological acid exposure in a single centre between 1997 and 2005. The predictive value of demographics, endoscopic hiatal hernia size, oesophagitis, lower oesophageal sphincter pressure, distal oesophageal contraction amplitude, percentage of peristaltic contractions and acid exposure was determined. Endpoints were recurrent pathological acid exposure on 24-h pH monitoring at 6 months and surgical reintervention for recurrent GORD up to 6 years. RESULTS: Of 177 patients, 22 had recurrent pathological acid exposure at 6 months for which 11 had surgery within 6 years. Only low percentage of peristaltic contractions (odds ratio (OR) 0·97, 95 per cent confidence interval 0·95 to 0·99; P = 0·004) and high supine acid exposure (OR 1·03, 1·00 to 1·07; P = 0·025) were independent predictors of recurrent pathological acid exposure. The absolute risk of recurrent exposure was 45·5 per cent in patients with both predictors. High supine acid exposure was also an independent predictor of surgical reintervention (OR 1·05, 1·01 to 1·08; P = 0·006). CONCLUSION: Nissen fundoplication should not necessarily be withheld from patients with poor oesophageal peristalsis or excessive supine acid exposure. As about half of patients with both variables experience recurrent pathological acid exposure after primary Nissen fundoplication, surgery should be restricted in this group.

Blood pressure and white matter lesions in patients with vascular disease: the SMART-MR study.

White matter lesions (WML) are a frequent finding on brain magnetic resonance imaging scans. Elevated blood pressure (BP) is consistently identified as risk factor for WML. However, it is unknown whether BP still is associated with WML in patients with manifest vascular disease. The aim of this cross-sectional study was to investigate associations between BP and WML in patients with manifest vascular disease. A total of 1030 patients with vascular disease (cerebrovascular disease (23%), coronary heart disease (59%), peripheral arterial disease (23%), abdominal aortic aneurysm (9%)) from the Second Manifestations of Arterial Disease study were included. WML volume was calculated using an automated quantitative volumetric method and subsequently divided into quartiles. We investigated associations between BP and WML and examined whether relations between BP and WML were modified by the localization of the symptomatic site or presence of diabetes. Participants had a mean age of 58.7 years. Median volume of WML was 1.70 ml. Mean BP was 141/82 mmHg and 69% suffered hypertension. No significant associations between systolic BP, diastolic BP, mean arterial pressure (MAP) or hypertension presence and moderate or large WML volumes were present. The relation between BP and WML was not modified by the localization of vascular disease or diabetes presence. Among patients with manifest vascular disease, BP was not associated with the presence of WML, irrespective of the presence of diabetes or the localization of vascular disease.

Predictors of symptomatic and objective outcomes after surgical reintervention for failed antireflux surgery.

BACKGROUND: Recurrent gastro-oesophageal reflux disease (GORD) and troublesome dysphagia after primary antireflux surgery are treated successfully by reoperation in 70 per cent of patients. Identifying predictors of outcome could allow selection of patients likely to benefit from further surgery. The aim was to identify such predictors in patients reoperated on for recurrent GORD or troublesome dysphagia. METHODS: Between 1994 and 2005, 83 patients (mean(s.d.) age 47.2(14.4) years; 47 men) with recurrent GORD and 47 (aged 50.7(13.4) years; 18 men) with troublesome dysphagia had further surgery. The predictive values of demographic, anatomical and manometric variables, and 24-h pH monitoring were analysed with respect to symptomatic and objective outcomes in each group. RESULTS: None of the factors included in a multivariable analysis predicted outcome after surgery for recurrent GORD. Independent predictors of symptomatic outcome after reoperation for dysphagia were amplitude of distal oesophageal contractions (odds ratio (OR) 1.613 (95 per cent confidence interval (c.i.) 1.087 to 2.393); P = 0.017), intrathoracic wrap migration (OR 0.077 (0.003 to 1.755); P = 0.108) and an abdominal approach (OR 0.012 (0.001 to 0.337); P = 0.009). CONCLUSION: Low-amplitude distal oesophageal contractions, intrathoracic wrap migration and an abdominal approach were significant predictors of an unsuccessful symptomatic outcome after reoperation for troublesome dysphagia.

Cardiovascular events and all-cause mortality by albuminuria and decreased glomerular filtration rate in patients with vascular disease.

OBJECTIVES: Albuminuria and decreased estimated glomerular filtration rate (eGFR) are associated with increased cardiovascular risk, but do not necessarily coexist and have different pathophysiological mechanisms. This study aims to evaluate separate and combined effects of decreased eGFR and albuminuria on the occurrence of vascular diseases and mortality in patients with vascular disease. DESIGN: Prospective cohort study. SETTING: University Medical Center Utrecht, the Netherlands. SUBJECTS AND MAIN OUTCOME MEASURES: 2600 patients with vascular disease were followed for vascular events, vascular and all-cause mortality. Cox regression analysis was used to calculate hazard ratios (HRs) according to eGFR (MDRD) and albuminuria (albumin-to-creatinine ratio >3 mg mmol(-1)). RESULTS: In this population, 14.0% had albuminuria, 15.6% had eGFR <60 ml min(-1) 1.73 m(-2) and 5.2% had both. Nonalbuminuric decreased eGFR and albuminuria with normal eGFR generated moderately increased risks on all outcomes. eGFR <60 ml min(-1) 1.73 m(-2) without albuminuria mainly influenced the risk of vascular events (HR 1.50; 1.05-2.15) whilst albuminuria with eGFR >or=60 ml min(-1) 1.73 m(-2) principally affected all-cause mortality (HR 1.53; 1.04-2.26). The combination of eGFR <60 ml min(-1) 1.73 m(-2) and albuminuria was associated with an increased risk for vascular events (HR 2.27; 1.54-3.34), vascular mortality (HR 2.22; 1.40-3.52) and all-cause mortality (HR 1.84; 1.25-2.69). Comparable results were found in additional analyses amongst 759 diabetic patients. CONCLUSIONS: The combination of decreased eGFR with albuminuria is associated with the highest risks of vascular events, vascular and all-cause mortality in patients with vascular diseases. To adequately estimate vascular risk associated with impaired renal function, both eGFR and urinary albumin should be considered.

Effect of metabolic syndrome or type II diabetes mellitus on the occurrence of recurrent vascular events in hypertensive patients.

Patients with hypertension and manifest vascular disease are at high risk for recurrent cardiovascular diseases. It is unknown if the metabolic syndrome further increases the risk in these patients. This study aims to quantify the effect of metabolic syndrome and type II diabetes on cardiovascular events in hypertensive patients with vascular disease. A total of 2,196 hypertensive patients with vascular disease (cerebrovascular disease (34%), coronary heart disease (50%), peripheral arterial disease (28%), abdominal aortic aneurysm (13%)) from the Second Manifestations of Arterial Disease study were followed for up to 10 years (mean 3.9 years) for death, stroke and myocardial infarction. Age and sex adjusted hazard ratios (HR) were calculated for hypertensive patients with metabolic syndrome but without diabetes (n=775) and for hypertensive patients with type II diabetes (n=381), compared to merely hypertensive patients (n=1,040). Forty-nine percent had metabolic syndrome (NCEP ATPIII definition) and 17% had type II diabetes. Metabolic syndrome predicted vascular death (HR 1.41, 95% confidence interval (CI) 1.01-1.98), stroke (HR 1.36, 95% CI 0.85-2.16) and myocardial infarction (HR 1.40, 95% CI 0.97-2.01). Type II diabetes accounted for even higher risks of vascular end points (HR 1.41-1.64). The effect of metabolic syndrome on future events could not be explained by the presence of type II diabetes. Even in high-risk patients with hypertension and vascular disease, presence of metabolic syndrome or type II diabetes identifies patients at high risk for future cardiovascular events. Identifying metabolic syndrome patients may direct therapy focusing on treatment of insulin resistance by reducing weight and increasing physical activity.