Comparison of immunity against canine distemper, adenovirus and parvovirus af...Biogal
This study aimed at comparing the immunity of two multivalent vaccines in adult dogs in the city of Uberlândia, Minas Gerais state, Brazil.
VacciCheck was used in the study in order to determine the immunity levels of the dogs.
Whole Genome Sequencing (WGS) for food safety management: Perspectives from K...ExternalEvents
http://tiny.cc/faowgsworkshop
Use of genome sequencing technology on food safety management- Kenya's Perspectives. Presentation from the FAO expert workshop on practical applications of Whole Genome Sequencing (WGS) for food safety management - 7-8 December 2015, Rome, Italy.
A serology testing clinical review by Dr Jean Dodds. Updated scientific data created to better understand the recommended protocols for canine and feline vaccination.
What next for prevention of pneumococcal disease in light of serotype replacement? Is there a pathway to licensure for novel pneumococcal vaccines?
https://www.meningitis.org/mrf-conference-2017
Immunogenicity and Safety of HepatitisB Injection in the Dermis Using VAX-IDNovosanis
Although intramuscular injection is still the most preferred method for vaccination, intradermal delivery has several advantages over intramuscular, including an improved immune response. Its use is currently limited due to the difficulty in standardizing the injections using the Mantoux technique. VAX-ID is a newly developed intradermal injection device, allowing accurate and standardized drug delivery in the dermis with a high ease of use. To evaluate the device effectiveness, a Phase 1 trial was performed to assess for immunogenicity of a commercial available hepatitis B vaccine (HBVAXPRO, Sanofi Pasteur
MSD) administered via intramuscular and different intradermal routes in healthy HBV primed subjects.
Comparison of immunity against canine distemper, adenovirus and parvovirus af...Biogal
This study aimed at comparing the immunity of two multivalent vaccines in adult dogs in the city of Uberlândia, Minas Gerais state, Brazil.
VacciCheck was used in the study in order to determine the immunity levels of the dogs.
Whole Genome Sequencing (WGS) for food safety management: Perspectives from K...ExternalEvents
http://tiny.cc/faowgsworkshop
Use of genome sequencing technology on food safety management- Kenya's Perspectives. Presentation from the FAO expert workshop on practical applications of Whole Genome Sequencing (WGS) for food safety management - 7-8 December 2015, Rome, Italy.
A serology testing clinical review by Dr Jean Dodds. Updated scientific data created to better understand the recommended protocols for canine and feline vaccination.
What next for prevention of pneumococcal disease in light of serotype replacement? Is there a pathway to licensure for novel pneumococcal vaccines?
https://www.meningitis.org/mrf-conference-2017
Immunogenicity and Safety of HepatitisB Injection in the Dermis Using VAX-IDNovosanis
Although intramuscular injection is still the most preferred method for vaccination, intradermal delivery has several advantages over intramuscular, including an improved immune response. Its use is currently limited due to the difficulty in standardizing the injections using the Mantoux technique. VAX-ID is a newly developed intradermal injection device, allowing accurate and standardized drug delivery in the dermis with a high ease of use. To evaluate the device effectiveness, a Phase 1 trial was performed to assess for immunogenicity of a commercial available hepatitis B vaccine (HBVAXPRO, Sanofi Pasteur
MSD) administered via intramuscular and different intradermal routes in healthy HBV primed subjects.
Vaccination in adults - Slideset by Professor Paolo BonanniWAidid
The slideset by professor Paolo Bonanni on vaccination in adults makes an overview on influenza, streptococcus pneumoniae, diphtheria, tetanus, pertussis, Human Papilloma Virus (HPV), measles, mumps, rubella, varicella and tick borne encephalitis. Where we were and where we are.
It’s an example of how data analysis can contribute to effective COVID-19 policies. But it also presents challenges, from ensuring that individuals’ privacy is protected to the need to independently verify its accuracy.
Maternal healthcare providers need to review how to diagnose sepsis and septic shock among pregnant patients from various infections during pregnancy and postpartum, so that we can intervene within 1 hour from diagnosis to impact prognosis and maternal survival. This is a lecture for the 1st online postgraduate course of the Philippine Obstetrical and Gynecological Society Cebu chapter and the Vicente Sotto Memorial Medical Center Department of Obstetrics and Gynecology on February 10, 2021 based on the Surviving Sepsis Campaign and the PSMID Clinical Practice Guidelines on Sepsis and Septic Shock.
Etiologia de la celulitis y Predicción clínica de la enfermedad Estreptocócic...Alex Castañeda-Sabogal
Etiologia de la celulitis. Estudio prospectivo y predicción clínica de la infeccion por Estreptococcus basado en la frecuencia encontrada de las especies de estreptococo
In den meisten Projekten wird Apache mit mod_php zur Auslieferung der Webseiten eingesetzt. Doch wird der Funktionsumfang von Apache für die meisten Projekte nicht genutzt. In dieser Session geht es um die Vorteile, die sich durch den Umstieg auf den leichtgewichtigen nginx und die Einbindung von PHP als FastCGI-Service erzielen lassen.
Vaccination in adults - Slideset by Professor Paolo BonanniWAidid
The slideset by professor Paolo Bonanni on vaccination in adults makes an overview on influenza, streptococcus pneumoniae, diphtheria, tetanus, pertussis, Human Papilloma Virus (HPV), measles, mumps, rubella, varicella and tick borne encephalitis. Where we were and where we are.
It’s an example of how data analysis can contribute to effective COVID-19 policies. But it also presents challenges, from ensuring that individuals’ privacy is protected to the need to independently verify its accuracy.
Maternal healthcare providers need to review how to diagnose sepsis and septic shock among pregnant patients from various infections during pregnancy and postpartum, so that we can intervene within 1 hour from diagnosis to impact prognosis and maternal survival. This is a lecture for the 1st online postgraduate course of the Philippine Obstetrical and Gynecological Society Cebu chapter and the Vicente Sotto Memorial Medical Center Department of Obstetrics and Gynecology on February 10, 2021 based on the Surviving Sepsis Campaign and the PSMID Clinical Practice Guidelines on Sepsis and Septic Shock.
Etiologia de la celulitis y Predicción clínica de la enfermedad Estreptocócic...Alex Castañeda-Sabogal
Etiologia de la celulitis. Estudio prospectivo y predicción clínica de la infeccion por Estreptococcus basado en la frecuencia encontrada de las especies de estreptococo
In den meisten Projekten wird Apache mit mod_php zur Auslieferung der Webseiten eingesetzt. Doch wird der Funktionsumfang von Apache für die meisten Projekte nicht genutzt. In dieser Session geht es um die Vorteile, die sich durch den Umstieg auf den leichtgewichtigen nginx und die Einbindung von PHP als FastCGI-Service erzielen lassen.
Learn 12 plays your affiliate business needs to grow and thrive in 2012. These 12 plays will give you an unfair traffic advantage, skyrocket your conversions, and leave your competition in the dust.
Experience level: Beginner, Intermediate
Target audience: Affiliates/Publishers
Niche/vertical: Traffic generation
Jeremy Palmer, President, Optimize My Site (Twitter @jeremypalmer)
The biggest challenges facing the rich world today are persistent unemployment, widening income inequality, and accelerating climate change. Until now, most of the solutions to these problems have been politically unacceptable, in a world marked by short-termism and a desire for continuous economic growth.
In Reinventing Prosperity, Graeme Maxton and Jorgen Randers take a radically different approach and offer thirteen politically feasible proposals to improve our world. From shortening the work year and raising the retirement age to boosting welfare and redefining what we mean by work, the authors’ suggestions challenge many long-standing economic ideas and explain how it is possible to reduce unemployment, inequality, and the pace of climate change—and still have economic growth, if society wishes.
There has been a divorce between users and organisations and today's UX practice risks to miss some key points. We are not designing anymore for needs, but for values and meanings which can only be revealed through participative activities where users, designers and stakeholders have the opportunity to collaboratively construct and shape innovation.
Co-creation can be extremely beneficial to UX as can complete its approach by giving vision, engaging users in conversations - because "markets are conversations".
Presented on July 15th at LadiesThatUX - London
PERTUSSIS PROTECTION - CURRENT SCHEDULES IN EUROPEWAidid
Slide set by Professor Susanna Esposito, president WAidid, presented at the 3rd ESCMID Conference on Vaccines, held in Lisbon (Portugal), 6- 8 March 2015. Learn more: http://goo.gl/8GUwwL
Background: There is a global resolve among Clinicians towards adoption of imaging modalities in the evaluation of appendicitis because clinical algorithms have been disappointing. We sought to determine the authenticity of interobserver variability in ultrasound scan interpretation in a resourceconstrained mission hospital settings, northwestern region of Cameroon. Methods: In this study, we reviewed the standardized diagnostic approach in acute appendicitis and also performed prospective cross observational qualitative testing using sensitivity, specifi city, positive predictive value, negative predictive value, and accuracy to determine the interobserver variability of ultrasonography using the medical database of the two Mission Hospitals, northwestern region of Cameroon from January 2012 to December 2016. A sequential non-randomized convenient sampling was used and data was analyzed using the Statistical Package for the Social Sciences version 22.
ABSTRACT- Aim: The present study was to know the seroprevalence of Hepatitis C virus among indoor and outdoor patients of a teaching ter-tiary care hospital in North India. Study design: Place and duration of study: Department of Microbiology, Pt. B. D. Sharma PGIMS Rohtak, Haryana, India, between August 2013 to July 2014. Methodology: This is a retrospective study performed on blood samples collected from patients of all ages and both sexes. Commercially available Erba Lisa Hepatitis C ELISA kits were used which detects anti-HCV IgG antibodies. Statistical analysis was performed when two or more variables were needed to compare. SPSS version 17 was used to calculate P value. Results: The prevalence of HCV was 3.74% in our study. 72.7% were from males and 27.3% were from females. Highest number of positive sam-ples was from 11-20 years age group (5.6%). The positivity for anti-HCV antibodies was higher in indoor samples (7.8%) as compared to outdoor samples (2.3%). Conclusion: Strict need to follow universal precautions for HCV control and education of public so that high risk activities should be controlled. KEYWORDS: Hepatitis C virus, Seroprevalence, anti-HCV antibodies, Indoor, HCV control
Background: Cervical screening through conventional cervical cytology is most commonly used throughout the world. The Cervical cancer is the second most common cancer worldwide and in developing countries, the leading cause of death. It is one of the most preventable and curable of all cancers.
Objective: To Study the role of Pap smear in detecting neoplastic and non-neoplastic lesions of cervix and to determine the occurrence of various lesions in remote area of Bagalkot.
Methods: This is prospective study of 240 women with age group 20 to 60 years was carried out from May 2015 to June 2016 cytology section of pathology department, S. Nijalingappa Medical College & H.S.K Hospital & Research Centre, Bagalkot, India. Pap smears were prepared, fixed, stained and carefully examined.
Results: In this study, Reactive cellular changes associated with inflammation was the most common with 182 cases (75.8%) followed by Low-grade squamous intraepithelial lesions (SIL) with 11 cases (4.5%), then atypical squamous epithelial cells of undetermined significance 8 cases (3.3%), High-grade squamous intraepithelial lesions with 5 cases (2.1%), Atrophy with 3 cases (1.3%) and Atypical Glandular Cell in 3 cases (1.3%). The average age of women for all the epithelial abnormalities was 40 years.
Conclusion: This study will increase awareness of the Pap test and cervical cancer, thereby paving a way for the prevention of cervical cancer.
Key-words- Pap smear, Cervical cancer, The Bethesda System, Squamous intraepithelial lesions (SIL)
Современное лечение ВИЧ.Объединенные данные с конференции IAS 2019 / Contemp...hivlifeinfo
Review key HIV data from IAS 2019 on the updated NTD risk in women receiving ART at conception, PrEP, first-line and switch options, and early-phase investigational strategies.
26th International Papillomavirus Conference: Satellite Symposium
Enhancing HPV Prevention among Indigenous Populations: International Perspectives on Health and Well-Being
Montreal, Quebec
July 5, 2010
Panel 1 , Researching the Burden of HPV Disease, Immunization, and Cervical Screening among Indigenous Populations.
The STUDY of the DISTRIBUTION & DETERMINANTS of HEALTH-RELATED STATES in specified POPULATIONS, and the application of this study to CONTROL of health problems.
A "con" presentation of something I am really very much "pro". Still, this were the barriers I had to overcome why implementing S. aureus decolonization
Presentation "Give up on VRE" as part of a debate at HIS 2014 (Lyon, France). Clearly not everything in here is my true opinion, but was part of "playing my part".
More from Radboudumc REshape Center for Innovation (20)
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
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5cl-adba precursor (semi finished )
5cl-adba raw materials
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ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
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Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Top Papers 2014
1. 07-‐09-‐14
1
Andreas
Voss,
MD,PhD
Victoria
J.
Fraser,
MD
Radboud
University
Medical
Centre
Washington
University
School
of
Medicine
Nijmegen,
Netherlands
St.
Louis,
Missouri
Lets get
started !
¤ Central
concept
of
efforts
to
prevent
C.
difficile:
“Symptoma3c
pa3ents
in
hospitals
are
the
major
source
of
transmission”
¤
Are
we
missing
sources?
² …
novel
routes
of
disseminaQon
not
addressed
by
current
control
strategies
²
…
cases
acquired
outside
the
hospital
² …
important
sources
of
transmission?
² AsymptomaQc
carriers
of
toxin-‐producing
strains
of
C.
difficile
outnumber
infected
paQents
!
² InfecQons
were
as
frequently
linked
to
asymptomaQc
carriers
as
to
symptomaQc
paQents
(30%
and
29%,
respecQvely)
Dubberke
ICHE
2008;29:Suppl
1:S81-‐S92,
Loo
NEJM
2011;365:1693,
Curry
CID
2013
2. 07-‐09-‐14
2
¤ 3.6-‐year
study
using
WGS-‐typing
to
study
the
epidemiology
of
CDAD
in
Oxfordshire,
UK
Only
38%
and
54%
of
geneQcally
linked
cases
shared
ward-‐based
and
hospital-‐wide
contacts
Eyre
et
al.
NEJM
2013;369:1105-‐205
five
diarrhea
pa3ents,
one
line
up,
a
coincidence
Donskey
CJ.
NEJM
2013;369:1263-‐4
SymptomaQc
CDAD-‐paQents
no
longer
the
main
source
of
C.
difficile
in
hospitals
?
¤
Generalizability?
Study
done
in
a
non-‐outbreak
segng
with
good
infecQon
control
measures
²
isolaQon
of
suspected
paQents
²
daily
(audited)
hypo-‐chloride
disinfecQon
¤
DetecQon
methods?
How
good
was
the
detecQon
in
symptomaQc
paQents
(test
sensiQvity)
¤ Point
of
acquisiQon
not
examined.
No
cultures
on
admission.
Donskey
CJ.
NEJM
2013;369:1263-‐4
Gastmeier
et
al.
JAC
2014;6:1660
Data
from
German
naQonal
nosocomial
surveillance
system
(KISS)
Gastmeier
et
al.
JAC
2014;6:1660
Gastmeier
et
al.
JAC
2014;6:1660
BSI
UTI
SSI
3. 07-‐09-‐14
3
The
high
overall
VRE
proporQon
in
Germany
is
mainly
due
to
the
situaQon
in
four
states
(Rhine-‐Westphalia,
Hesse,
Thuringia
and
Saxony
).
There
is
an
urgent
need
to
analyse
the
epidemiology
of
VRE
in
detail
to
develop
appropriate
infecQon
control
strategies
Gastmeier
et
al.
JAC
2014;6:1660
Den
Heijer
et
al.
Lancet
Infect
Dis
2013;13:409-‐15
¤
About
20
family
doctors
per
country
¤
Countries:
Austria,
Belgium,
CroaQa,
France,
Hungary,
Spain,
Sweden,
the
Netherlands,
UK
(2010/11)
¤
Nasal
swabs
from
200
paQents,
aged
4
years
or
older
(or
≥18
years
in
the
UK),
who
visited
their
pracQce
for
a
non-‐
infecQous
disorder.
¤ Exclusion:
paQents
who
had
anQmicrobials
or
who
had
been
admiled
to
hospital
in
the
previous
3
months,
who
were
immunocompromised
(eg
those
with
diabetes
mellitus)
and
nursing
home
residents
Den
Heijer
et
al.
Lancet
Infect
Dis
2013;13:409-‐15
Den
Heijer
et
al.
Lancet
Infect
Dis
2013;13:409-‐15
MRSA
CC
008
Den
Heijer
et
al.
Lancet
Infect
Dis
2013;13:409-‐15
Den
Heijer
et
al.
Lancet
Infect
Dis
2013;13:409-‐15
CC
011
CC
011
4. 07-‐09-‐14
4
Jurke
et
al.
Euro
Surveill.
2013;18(36):pii=20579
¤ In
2007,
all
hospitals
started
to
systemaQcally
screen
defined
paQents
associated
with
any
one
of
the
known
risk
factors,
prior
to
or
upon
admission
to
a
hospital.
¤ From
2007
to
2011,
the
MRSA
admission
incidence
(0.51
vs
1.09
MRSA
cases/100
paQents
admiled),
the
MRSA
incidence
density
(0.87
vs
1.54
MRSA
cases/
1,000
paQent
days)
as
well
as
the
mean
daily
MRSA-‐
burden
(1.30
vs
1.82
MRSA-‐in-‐hospital
days/100
paQent
days)
increased
significantly
(p<0.0001)
Jurke
et
al.
Euro
Surveill.
2013;18(36):pii=20579
Jurke
et
al.
Euro
Surveill.
2013;18(36):pii=20579
¤ IniQally,
more
MRSA
carriers
are
found
when
more
paQents
are
screened.
² This
may
make
some
hospitals
reluctant
to
establish
such
a
screening
policy
due
to
increasing
and
costly
efforts
to
isolate
paQents
in
single
rooms.
¤ However,
only
aper
few
years,
the
nosocomial
MRSA
burden
decreases,
which
finally
may
encourage
the
hospitals
to
accept
this
burden
of
prevenQon.
Jurke
et
al.
Euro
Surveill.
2013;18(36):pii=20579
¤ Guidance
outlines
a
more
focused,
cost-‐effecQve
approach
to
MRSA
screening.
¤ RecommendaQon
for
Trusts
to
move
to
focussed
screening
programmes
has
been
designed
to
promote
a
more
efficient
and
effecQve
method
for
idenQfying
and
managing
high
risk
MRSA
posiQve
paQents.
¤ Focussed
screening
should
be
adopted
in
line
with
local
risk
assessments
to
ensure
that
Trusts
concentrate
on
reducing
negaQve
paQent
outcomes
for
their
own
populaQons.
Change
the
MRSA
screening
policy
from
mandatory
universal
screening
to
focused
screening
5. 07-‐09-‐14
5
Fätkenheuer
et
al
Lancet
2014,
published
online
Aug
21st
Fätkenheuer
et
al
Lancet
2014,
published
online
Aug
21st
…
okay,
but
what
did
we
do
in
the
NL
–
screen
&
isolate
and
20%
HH
compliance
Fätkenheuer
et
al
Lancet
2014,
published
online
Aug
21st
Hand hygiene +++
Screening ?
Isolation
Decolonization +
“the
strategy
of
screening
and
isola:on
cannot
be
regarded
as
a
gold
standard
to
prevent
the
spread
of
MRSA”
Sarah
Zhang
Nature
doi:10.1038/nature.2013.13752
Casey
et
al.
JAMA
2013;
September
16th
(published
online)
6. 07-‐09-‐14
6
¤ Proximity
to
swine
manure
applicaQon,
to
crop
fileds,
and
livestock
operaQons
each
was
associated
with
MRSA
and
skin
and
sop-‐Qssue
infecQon
Could
it
be
that
occupaQonal
hazards
¤ No
MRSA
belonging
to
CC398
(LA-‐&
lifestyle
are
more
important
MRSA)
than
!?
us?
Casey
et
al.
JAMA
2013;
September
16th
(published
online)
Hetem
et
al.
Emerging
Infect
Dis
2013;19:1797
Transmissibility
of
LA-‐MRSA
is
(sQll)
4.4
Qmes
lower
than
that
of
other
MRSA
(not
associated
with
livestock)
Hetem
et
al.
Emerging
Infect
Dis
2013;19:1797
Bourigault
et
al.
PLOS
Current
Outbreaks,
March
7,
2014
IN THE MRSA EPIDEMIOLOGY
¤
sequence
type
(ST)
8
community-‐associated
geneQc
lineage,
SCCmec
type
IVa,
spa
type
t292
related
to
MRSA
lineage
USA300
Rossi
et
al.
NEJM
2014,370:1524
7. 07-‐09-‐14
7
creeps … .. back to
Rossi
et
al.
NEJM
2014,370:1524
IN THE MRSA EPIDEMIOLOGY
Hearing CA-MRSA
USA300 & vanco-resistance
in one
strain gives me the
science …
Palerned
Progression
of
Bacterial
PopulaQons
in
the
Premature
Infant
Gut
• ProspecQve
stool
58
premies,
922
specimens,
SLCH
NICU,
16S
rNA
pyrosequencing,
• Microbiota
→
Bacilli,
Gammaproteobacteria
to
Clostridia
(abrupt
Δes)
• 33-‐36
wks
postconceptual,
3-‐12
wks
life
=
well
colonized
by
anaerobes
• AnQbioQcs,
birth
type,
diet
&
age
influence
pace
-‐not
sequence
La
Rosa
PS,
et
al.
PNAS
Early
EdiQon
2014;
[Epub
ahead
of
print].
Palerned
Progression
of
Bacterial
PopulaQons
in
the
Premature
Infant
Gut
La
Rosa
PS,
et
al.
PNAS
Early
EdiQon
2014;
[Epub
ahead
of
print].
Sepsis
from
the
Gut
• Methods:
ProspecQve
stool,
premies
with
sepsis,
Culture
&
genome
sequencing
• Results:
11
babies
with
late
onset
BSI;
7
had
stool
with
GBS,
S.
marcescens
or
E.
coli
which
matched
BSI,
4/96
overlap
non-‐
sepsis
babies
colonized
with
matching
GBS
or
S.
marcescens
• Impact:
Highlights
“microclusters”,
study
stool
surveillance,
DecolonizaQon
and
á
hygiene?
Carl
MA,
et
al.
CID
2014;58
(1
May):
1211-‐18.
MulQstate
Point-‐Prevalence
Survey
of
Health
Care-‐Associated
InfecQons
• Methods
– NHSN
definiQons,
1
day
surveys
of
183
hospitals
• Results
–
HAI
in
4%
(452/11,282)
(95%
CI,
3.7%-‐
4.4%)
– Pneumonia
(21.8%),
SSI
(21.8%),
GI
(17.1%)
– Device-‐associated
(25.6%),
CAUTI;
CLABSI,
VAP
– ~648,000
pts
with
721,800
HAIs
in
2011
Magill
SS,
et
al.
N
Engl
J
Med
2014;370:1198-‐208.
8. 07-‐09-‐14
8
MulQstate
Point-‐Prevalence
Survey
of
Health
Care-‐Associated
InfecQons
12.1%
10.7%
9.3%
9.9%
Organisms
C
diff
S.
aureus
Klebsiella
E.
coli
Magill
SS,
et
al.
N
Engl
J
Med
2014;370:1198-‐208.
MulQstate
Point-‐Prevalence
Survey
of
Health
Care-‐Associated
InfecQons
Different
paQents,
methods,
definiQons
Magill
SS,
et
al.
N
Engl
J
Med
2014;370:1198-‐208.
MulQstate
Point-‐Prevalence
Survey
of
Health
Care-‐Associated
InfecQons
Magill
SS,
et
al.
N
Engl
J
Med
2014;370:1198-‐208.
BSI
in
Community
Hospitals
in
21st
Century
• 9
comm
hospitals,
SE
US,
2003-‐2006,
1,470
pts
• 56%
COHA,
29%
CABSI,
15%
HOHA
• 23%
MDRO,
SA
(28%),
E.
coli
(24%),
CNS
(10%)
• 38%
inappropriate
AB
(33%
med,
range
21
–
71%)
• MV
predictors
of
inappropriate
AB:
hospital
(p<0.001),
assistance
≥3
ADLs
(p=0.005),
Charlson
score
(p=0.05),
COHA
(p=0.01),
HOHA
(p=0.02)
Anderson
DJ,
et
al.
PLoS
ONE
2014;9(3):e91713.
• Retro
cohort
in
CA;
1
THA/TKA,
2006
–
2009;
ICD-‐9-‐CM
codes,
within
365
days
of
surgery
• THA
SSI
(2.3%),
TKA
SSI
(2.0%)
• 17%
missed
by
opera:ve
hospital
surveillance
alone
• ProporQon
SSI
detected
at
nonop
hospital
(0-‐100%)
• Including
SSIs
at
nonop
hospitals
improved
rankings
for
6%
THA
&
61%
TKA
• 90
day
surveillance
detected
81%
THA
&
74%
TKA
SSI
Yokoe
DS,
et
al.
CID
2013;57
(1
Nov):1282-‐88.
ReporQng
SSI
Following
THA
&
TKA
Yokoe
DS,
et
al.
CID
2013;57
(1
Nov):1282-‐88.
9. 07-‐09-‐14
9
• 80,461
invasive
MRSA
(95%
CI,
69,515
–
93,414)
• 48,353
HACO
(95%
CI,
40,195
–
58,642)
• 14,156
HO
MRSA
(95%
CI,
10,096
–
20,440)
• 16,560
CA-‐MRSA(95%
CI,
12,806
–
21,811)
• Since
2005,
Na:onal
es:mated
incidence
!
in
HACO
by
27.7%,
!
in
HO
by
54.2%,
!
In
CA-‐MRSA
by
only
5%
Dantes
R,
et
al.
JAMA
Intern
Med
2013;173(21):1970-‐78.
QuanQfying
Sources
of
Bias
in
NHSN
CDI
Rates
• Sensi:vity
analysis,
124
NY
hospitals,
2010
• NY
NHSN
CDI
reports
compared
to
DC
billing
records
• Corrected
for
inaccurate
repor:ng,
OSH
lab
results,
excluding
pt
days
not
@
risk,
adjus:ng
for
pt
age
• Including
pt
days
“not
at
risk”
in
denominator
↓
HO
CDI
rate
43%,
8%
misclassifica:on
• Age
adjustment
(7%
misclassifica:on)
&
repor:ng
errors
(6%
misclassifica:on)
Haley
VB,
et
al.
ICHE
2014;35(1):1-‐7.
QuanQfying
Sources
of
Bias
in
NHSN
Haley
VB,
et
al.
ICHE
2014;35(1):1-‐7.
CDI
Rates
QuanQfying
Sources
of
Bias
in
NHSN
CDI
Rates
Haley
VB,
et
al.
ICHE
2014;35(1):1-‐7.
Development
&
ValidaQon
of
Recurrent
C
diff.
Risk-‐PredicQon
Model
• Retro
cohort,
large
urban
AMC,
2003
–
2009,
all
adults
with
inpt
CDI
• 10%
(425/4196)
pts
→
recurrent
CDI
• CO-‐HA,
≥
2
prior
hospitalizaQons
in
past
60
days,
new
gasQc
acid
suppression,
FQ
&
high
risk
AB
use
at
onset
&
age
predicted
recurrence
(C
stat
0.643)
discriminaQon;
calibraQon
(Brier
score
.089),
NPV
90%
or
>
• ICU
stay
protecQve
Zilberberg
MD,
et
al.
J
Hosp
Medicine
2014;9:418-‐423.
• 21
RCTs
8,735
pts;
18
(7,593)
used
for
meta-‐analysis
• Pooled
risk
of
all
serious
infecQons:
restricQve
vs
liberal
group
11.8%
(95%
CI,
7
–
16.7%)
vs
16.9%
(95%
CI,
8.9
–
25.4%)
• Risk
RaQo
RR
=
0.82
(95%
CI,
0.72
-‐
0.95)
• RestricQve
NNT
to
prevent
serious
infecQon
38
(95%
CI,
24
–
122)
• RR
0.80
(95%
CI,
0.70
–
0.97)
NNT
20
(95%
CI,
12
–
133)
even
with
Rohde
JM,
et
al.
JAMA
2014;311(13):1317-‐26.
leukocyte
reducQon
• RR
0.70
(95%
CI,
0.54
–
0.91)
Ortho,
RR
0.51
(95%
CI,
0.28
–
0.95)
Sepsis
• No
difference
for
cardiac,
criQcally
ill,
UGI
bleed,
LBWT
infants
10. 07-‐09-‐14
10
MDRO
• Hospital
analyses
of
MRSA
admit
prevalence,
acquisiQon
rates
&
incident
nosocomial
clinical
culture
(INCC)
• 112
VAs
2007
–
2010
aper
MRSA
bundle,
GL
mixed
models
• MRSA
admit
prev
11.4%,
acquis
5.2/1,000
pt
days
at
risk
• 10%
↑
in
ave
admit
prev
assoc
with
9.7%
↑
wkly
acquisiQon
rates
(p<.001),
9.8%
↑
wkly
INCC
rates
(p<.001)
• ↓
acquisiQon
→
↓
importaQon
→
↓
acquisiQon
• ↓
INCC
in
pts
with
neg
admit
→
↓
transmission
→
↓
infecQon
Jones
M,
et
al.
CID
2014;58
(1
Jan):32-‐39.
• 15,700
invasive
MRSA
infecQons
in
US
dialysis
pts
in
2010
Pop
data
9
US
metro
areas
2005
–
2011,
USRDS
• 7,489
infecQons
85.7%
HACO,
93.2%
BSI
• Incidence
↓
6.5
to
4.2/100
dialysis
pts
(annual
↓7.3%),
↓
6.7
%
HACO,
10.5%
HO
• 60.4%
dialyzed
through
CVC;
Fistula
First
IniQaQve
↓
CVC
use
in
HD
from
27.8%
in
2009
to
18.8%
in
2011
Nguyen
DB,
et
al.
CID
2013;57(10):1393-‐1400.
Invasive
MRSA
in
Chronic
Dialysis
in
US
2005
–
2011
Nguyen
DB,
et
al.
CID
2013;57(10):1393-‐1400.
Statewide
Surveillance
of
CRE
in
Michigan
• 9/2012
–
2/2013,
21
faciliQes
(17
ACH,
4
LTAC);102/957,220,
IR
1.07/10,000
pt
days
• 89
KP,
13
E
coli;
61%
urine
cultures
• 35%
HO,
65%
CO;
75%
of
CO
had
HC
exposure
in
past
90
days
• CVD,
ESRD,
DM
most
common
comorbidiQes
• Surgery
in
90
days,
recent
infecQon,
MDRO
colonizaQon,
AB
exp
-‐esp
3rd
or
4th
gen
CS
Brennan
BM,
et
al.
ICHE
2014;35(4):342-‐349.
State
Surveillance
of
CRE
in
Michigan
Brennan
BM,
et
al.
ICHE
2014;35(4):342-‐349.
11. 07-‐09-‐14
11
• Chicago
1
day
pt
prev
survey;
24/25
short-‐stay
ACH
ICU
,
7/7
LTACHs
• Rectal,
inguinal,
urine
sites
à
Enterobacteriaceae
blaKPC
• 30.4%
LTACH
pts
colonized
with
KPC
(119/391)
• 3.3%
ACH
pts
colonized
with
KPC
(30/910);
prev
raQo
9.2%;
(95%
CI,
6.3-‐13.5)
• LTACH
prev
range
(10-‐54%);
100%
⊕
vs
15/24
ACH
(0-‐29%)
• LTACH
type,
mech
vent
&
LOS
=
independent
risk
factors
Lin
MY,
et
al.
CID
2013;57
(1
Nov):1246-‐52.
Rising
Rates
of
CRE
in
Community
Hospitals
• CRE
evaluated
from
25
com
hospitals
‘08
–
12;
305
CRE
isolates
&
16
hospitals,
59%
symptomaQc
• KP
(91%),
HCA
(94%),
CRE
detecQon
rate
↑
5x
(0.26
to
1.4/100,000
pt
days),
IRR=
5.3
(95%
CI,
1.22
–
22.7)
p=0.01
• Only
5
hospitals
adopted
lower
CRE
break
pts
(4.1
vs
0.5/100,000
pt
days,
p<.001)
IRR,
8.1
(95%
CI,
2.7
–
24.6)
before
&
aper
Δ
• DetecQon
rate
(3.3
vs
1.1/100,000,
p=.01)
in
hospitals
with
lower
break
pt
Thaden
JT,
et
al.
ICHE
2014;35(8):978-‐983.
Rising
Rates
of
CRE
in
Community
Hospitals
Thaden
JT,
et
al.
ICHE
2014;35(8):978-‐983.
Ongoing
NaQonal
IntervenQon
to
Contain
CRE
• 2006
Israel
outbreak
CRE,
KP
ST-‐258
(from
US
in
2005)
• 3/2007
new
acquisiQon
55/100,000
pt
days
(clinical
Cx)
• Crude
mortality
44-‐70%,
BSI
mortality
50%
• MOH
ACH
guidelines:
1)
all
CRE
→
isolaQon
or
“carrier”
cohorts,
physical
separaQon;
2)
dedicated
staff
for
carriers
–
leveled
off
but
ongoing
spread
• >YR1,
acQve
surveillance
for
high
risk
(ward
contacts,
new
cases,
OSH
Tx,
wards
with
hi
CRE
prevalence)
• LTCF
–
PACH
surveillance
then
LTCF
guidelines
• Lab
guidelines
for
CPE
detecQon
&
D/C
isolaQon
Schwaber
MJ
and
Carmeli
Y.
Clin
Infect
Dis
2014;58(5):697-‐703.
Schwaber
MJ
and
Carmeli
Y.
Clin
Infect
Dis
2014;58(5):697-‐703.
Schwaber
MJ
and
Carmeli
Y.
Clin
Infect
Dis
2014;58(5):697-‐703.
12. 07-‐09-‐14
12
Schwaber
MJ
and
Carmeli
Y.
CID
2014;58(5):697-‐703.
• Cross-‐secQonal
study,
HUG,
Switzerland
• Cultured
food
&
food
handlers,
PCR
&
sequencing
blaCTX-‐M,
blaSHV,
blaTEM
genes,
MLST
• 92%
raw
chicken
ESBL-‐PE⊕;
86%
of
hospital
&
100%
of
community
• No
egg,
beef,
rabbit
or
cooked
chicken
ESBL-‐PE⊕
• No
an:bio:c
residues,
6.5%
HUG
food
handlers
ESBL-‐PE⊕
carriers
• Chicken
common
blaCTX-‐M1,
blaCTX-‐M2;
blaCTX-‐M14,
blaCTX-‐M15,
mostly
human
• Good
news
→
minimal
risk
to
food
handers,
hospital
staff,
pa:ents
• Hospital
food
bejer
in
Europe
than
US
☺
• AB
free
period
prior
to
animal
slaughter
in
EU
vs
US
hospital
pts
where
no
one
dies
without
5
an:bio:cs
☺
Stewardson
AJ,
et
al.
ICHE
2014;35(4):375-‐383.
Wastewater
Treatment
Plants
Release
Large
Amounts
of
ESBL
E.
coli
into
Environment
• Weekly
samples
x10
wks
from
11
sites,
waste
H2O
network
of
Bréchet
C,
et
al.
CID
2014;58(12):1658-‐65.
Besanҫon
City,
France
• Total
E.
coli
&
ESBL
E.
coli
determined
for
each
sample
• PFGE,
MLST,
blaESBL
genes
by
sequencing
• EC
load
>
in
urban
vs
hosp
waste
H2O
(7.5x105
vs
3.5x105
CFU
/ml)
• ESBL
E
coli
recovered
from
almost
all
samples
(0.3%
of
total
EC
in
untreated
H2O
upstream)
• ESBL
E
coli
higher
in
hospital
waste
H2O
vs
community
(27x103
vs
0.8x103
CFU
/ml)
• WWTP
eliminated
98%
of
E.
coli
&
94%
ESBL
EC
• WWTP
“enriched”
ESBL
E
coli,
>600
billion
ESBL
EC
released
into
river
daily;
ferQlizer
sludge
~
2.6x105
ESBL
EC/gram
NEW
TECHNOLOGIES
Emerging
Technologies
for
Rapid
IdenQficaQon
of
Bloodstream
Pathogens
• Timing
&
appropriateness
of
anQbioQc
Rx
influences
outcome
• 7.6%
↓
survival/Hour
aper
hypotension
unQl
effecQve
Rx
• 5x
↑
mortality
for
inappropriate
anQbioQcs
in
6%
of
sepQc
shock
• Broad
spectrum
AB
Rx
iniQally
• Pathogen
ID
from
Kothari
A,
et
al.
CID
2014;59(2):272-‐278.
⊕
blood
Cx
• PepQde
nucleic
acid
fluorescent
in
situ
hybridizaQon
molecular
strains
(PNA-‐FISH)
• PNA-‐FISH,
differenQate
SA
&
CoNS,
E.
faecalis
&
E.
species
E.
coli,
KP,
PA
&
Candida,
TAT=90”,
sensiQviQes
&
specificity
96-‐100%
• Quick
FISH
(AdvanDx)
2013,
TAT=20”
• Quasi-‐exp
before-‐
aper
of
MALDI-‐TOF
with
AST,
Uof
MI
• 245
intervenQon
&
256
pre-‐intervenQon
pts
• MALDI-‐TOF
with
AST
=
â
organism
ID
Qme
(84
vs
55.9
Hrs,
p
<
.001),
â
Qme
to
effecQve
AB
(90.3
vs
47.3
hrs,
p
<
.001)
• Mortality
(20.3%
vs
14.5%),
LOS
ICU
(14.9
vs
8.3
d),
recurrent
BSI
(5.9
vs
2.0%)
MALDI-‐TOF
(univariate)
• Accept
AST
rec
trend
â
mortality
OR
0.55
(p
=
0.75)
Huang
AM,
et
al.
CID
2013;57
(1
Nov):1237-‐45.
13. 07-‐09-‐14
13
Huang
AM,
et
al.
CID
2013;57
(1
Nov):1237-‐45.
MALDI-‐TOF
Cost
EffecQveness
&
Impact
• MALDI-‐TOF
with
ASP
↓
Qme
to
adjust
AB
by
46
Hrs
in
BSI,
↓
LOS
ICU
1.2
days
,
↓
LOS
1.8,
↓
cost
$19,547
• Gram
(-‐)
BSI,
42%
improvement
in
Rx
with
MALDI-‐TOF
• 501
pts
BSI
&
Fungemia,
ASP
&
MALDI-‐TOF
↓
Qme
to
effecQve
AB
by
9.7
Hrs
&
Qme
to
opQmal
Rx
by
43
hrs,
↓
ICU
LOS
6.6
days,
↓
mortality
20.3
to
12.7%
Perez
KK,
et
al.
Arch
Pathol
Lab
Med
2013;137:1247-‐54
Huang
AM,
et
al.
Clin
Infec
Dis
2013;57:1237-‐45
Clerc
O,
et
al.
Clin
Infect
Dis
2013;56:1101-‐7
Kothari
A,
et
al.
Clin
Infect
Dis
2014;59(2):272-‐278
… where is
my coffee…
… jawn …
¤
MSDS
Poly
spray
(silicone
quaternary
amine)
¤
8
surfaces
²
sink,
call
bulon,
bedside
table,
monitor,
telephone,
supply
cart,
door
handle,
floor
¤
Results:
² No
significant
effect
on
environmental
contaminaQon
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-‐62
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-‐62
14. 07-‐09-‐14
14
¤
Problem
adherence?
¤
Love
the
concept
of
changing
the
surface
¤
Studies
with
copper,
silver
silica,
Biosafe
HM
4100
(polymer)
embedded
in
polyurethane,
light-‐acQvated
anQmicrobials,
…
have
worked
before
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-‐62
Freeman
et
al.
AnQmicrob
Resistance
Infect
Control
2014;3:5
¤
We
systemaQcally
sampled
8
surfaces
in
the
rooms
and
bathrooms
of
adult
paQents
colonized
or
infected
with
ESBL-‐EC
or
ESBL-‐KP
throughout
their
hospital
stay.
¤
Environmental
contaminaQon
was
defined
as
recovery
of
an
ESBL-‐producing
organism
matching
the
source
paQent’s
isolate
Freeman
et
al.
AnQmicrobial
Resistance
and
InfecQon
Control
2014,
3:5
¤
Freeman
et
al.
AnQmicrobial
Resistance
and
InfecQon
Control
2014,
3:5
Rooms
of
paQents
with
ESBL-‐KP
have
substanQally
higher
contaminaQon
rates
than
those
with
ESBL-‐EC.
This
finding
may
help
explain
the
apparently
higher
transmissibility
of
ESBL-‐KP
in
the
hospital
segng
Freeman
et
al.
AnQmicrobial
Resistance
and
InfecQon
Control
2014,
3:5
Kramer
et
al.
BMC
Infect
Dis
2006;6:130
15. 07-‐09-‐14
15
E.
coli
1.5h
to
6
months
Klebsiella
spp.
2.0h
to
>30
months
Kramer
et
al.
BMC
Infect
Dis
2006;6:130
Kampf
et
al.
BMC
Infect
Dis
2014;14:37
¤ Reusable
Qssue
dispensers
with
different
surface
disinfectants
were
randomly
collected
from
healthcare
…
it
faciliis
not
Qes.
about
the
details
of
this
66
dispensers
paper,
but
the
point
¤ “helpful
containing
parts
of
the
disinfectant
that
even
environment”
soluQons
with
surface-‐may
acbe
Qve
a
source
ingredients
for
infecQwere
ons
collected
in
15
healthcare
faciliQes.
28
dispensers
from
nine
healthcare
faciliQes
were
contaminated
¤ In
none
of
the
hospitals
dispenser
processing
had
been
adequately
performed
Kampf
et
al.
BMC
Infect
Dis
2014;14:37
¤
NIH
program
to
encourage
handwashing
in
hospitals
and
day
care
centers
¤
Program
promotes
a
symbolic
teddy
bear
(T.
Bear)
with
slogans/reminders
to
pracQce
HH.
¤
Stuffed
T.
Bear
was
dispensed
to
the
hospitalized
child.
¤
Could
T.
Bear
serve
as
a
"fomite”?
Hughes
et
al.
Infect
Control.
1986
Oct;7(10):495-‐500
¤ ProspecQve
study
of
39
sterilized
T.
Bears,
one
week
aper
use:
² S.aureus,
K.pneumoniae,
P.aeruginosa,
E.coli,
Candida
spp,
Cryptococcus,
Aspergillus
and
others.
² Although
the
T.
Bear
handwashing
campaign
should
not
be
discredited,
the
promoQonal
toy
may
pose
an
unnecessary
expense
and
hazard
and
should
not
be
used
in
hospitals.
Hughes
et
al.
Infect
Control.
1986
Oct;7(10):495-‐500
hlp://www.dailymail.co.uk/femail/arQcle-‐2019527/Will-‐dishwasher-‐food-‐poisoning.html#ixzz3A00xnnOQ
16. 07-‐09-‐14
16
¤ Three
weeks
ago,
I
arranged
for
a
scienQst
to
take
swabs
from
ten
sites
around
my
home
...
¤ According
to
his
report,
I’ve
got
E.coli
in
the
dishwasher,
toxic
fungus
on
the
bath
mat
and
goodness
knows
what
festering
in
the
toy
box.
As
for
the
baby’s
car
seat,
you
don’t
even
want
to
go
there...
hlp://www.dailymail.co.uk/femail/arQcle-‐2019527/Will-‐dishwasher-‐food-‐poisoning.html#ixzz3A00xnnOQ
Angelakis
et
al.
Future
Microbiol
2014;9:249
By
country
By
type
of
currency
Angelakis
et
al.
Future
Microbiol
2014;9:249
Angelakis
et
al.
Future
Microbiol
2014;9:249
…
and
I
always
thought
that
it
gets
contaminated
during
use
…
Angelakis
et
al.
Future
Microbiol
2014;9:249
…
and
I
always
thought
that
it
gets
contaminated
during
use
…
Only
46%
of
the
HCWs
washed
their
hands
Aper
“visiQng”
the
toilets
17. 07-‐09-‐14
17
Kellog
et
al.
Am
J
Infect
Control
2012;40:893
¤ 1/3
of
the
hikers
has
fecal
contaminaQon
on
their
hands
¤ The
quesQon
is:
Who’s
fecal
flora
is
it?
…
but
the
snow
wasn’t
yellow
…
Kellog
et
al.
Am
J
Infect
Control
2012;40:893
Mermel
LA.
Clin
Infect
2013;56:123-‐130
Mermel
LA.
Clin
Infect
2013;56:123-‐130
Mermel
LA.
Clin
Infect
2013;56:123-‐130
18. 07-‐09-‐14
18
hlp://haicontroversies.blogspot.nl
Not
of
the
same
quality,
but
…
… finally
INTERVENTIONS
• Poster-‐sized
commitment
lelers
in
exam
rooms
x12
wks
in
cold
&
flu
season,
14
clinicians,
5
clinics
• Posters
=
photographs,
signatures,
commitment
to
avoid
inappropriate
AB
prescribing
for
acute
URI
• Inappropriate
RX
42.8%
&
43.5%
intervenQon
&
control
baseline
vs
33.7%
&
52.7%
with
intervenQon
(10%
↓)
• Commitment
lelers
19.7%
↓
in
inapprop
RX
(p=0.02)
• ~
NaQonal
impact
↓
2.6m
unnecessary
Scripts,
&
save
$70.4m/yr
Meeker
D,
et
al.
JAMA
Intern
Med
2014;174(3):425-‐431.
19. 07-‐09-‐14
19
Enriched
Enteral
NutriQon
DID
NOT
↓
InfecQons
in
Mechanically
VenQlated
PaQents
• DB
RCT,
301
pts
in
14
ICUs,
MV
&
tube
feeds
22
hrs,
Hi-‐protein
enteral
nutriQon
with
immune
modulaQng
nutrients
(152)
vs
std
Hi-‐
protein
enteral
nutriQon
(149)
• No
difference
in
infecQons,
53%
vs
52%
• Higher
mortality
with
enriched
nutriQon,
54%
vs
35%
vanZanten
ARH,
et
al.
JAMA
2014;312(5):514-‐524.
NaQonal
IntervenQon
to
Prevent
Spread
of
CRE
in
Israel
PACH
• ProspecQve
cohort
intervenQonal
study
• 13
Israeli
PACHs,
MulQfaceted
intervenQon
2008
–
2011
1) Periodic
on-‐site
assessment
of
IC
policies
&
resources
(16
pt
score)
2) Assessment
of
CRE
risk
factors
3) NaQonal
guidelines
for
CRE
control
in
PACHs,
acQve
surveillance
&
CP
for
CRE
carriers
4) Cross-‐secQonal
rectal
carriage
surveys
• IC
score
↑
from
6.8
–
14
(p<.001)
• Carriage
↓
from
12.1%
to
7.9%
(p=.008)
• Overall
carrier
prevalence
↓
from
16.8%
to
12.5%
(p=.013)
Ben-‐David
D,
et
al.
ICHE
2014;35(7):802-‐809.
Ben-‐David
D,
et
al.
ICHE
2014;35(7):802-‐809.
Daily
CHG
Bathing
&
SA
PrevenQon
• MICU
&
SICU;
BJH
1250
beds,
Qme-‐series
methods
• CHG
in
SICU
20.68%
↓
MRSA
acquisiQon
(12.64
vs
10.03/1,000
pt
days)
β
-‐2.62
(95
CI
-‐5.19
to
-‐0.04,
p=.
Viray
MA,
et
al.
ICHE
2014;35(3):243-‐250.
046)
• No
Δ
in
MICU
(No
CHG)
(10.97
vs
11.3/1,000
pt
days
β
-‐11.10
(95%
CI
-‐37.40
to
15.19,
p=.40)
• 20.77%
↓
in
all
SA
in
SICU
(2002-‐2007)
19.73/1,000
vs
15.63/1,000
pt
days
(95%
CI
-‐7.25
to
0.95,
p=.012)
• ICU-‐acquired
MRSA
↓
by
41%
in
SICU
(1.96
vs
1.15/1,000
pt
days,
p=.001)
• Strengths:
Qme-‐series
methods,
control
unit,
accounted
for
secular
trends
in
colonizaQon
pressure,
pt
mix
Figure
1.
Unadjusted
rates
of
methicillin-‐resistant
Staphylococcus
aureus
(MRSA)
acquisiQon
per
1,000
paQent-‐days
at
risk
for
the
intervenQon
care
unit.
Viray
MA,
et
al.
ICHE
2014;35(3):243-‐250.
• ADV
Source
Control
(CHG
bathing
&
QID
CHG
oral
care)
&
thorough
Env
cleaning
for
XDR
A.
baumanni,
Thai
MICU
• 3
phases;
12
mo
base;
CP,
Act
Surv,
cohorQng
XDR
A.
baumanni,
BID
Env
detergent
cleaning
&
ASP
• P2:
Bleach
cleaning
+
ADV
source
control
• P3:
2
mo
flood
closure;
same
as
P2
except
no
bleach
Apisarnthanarak
A,
et
al.
AJIC
2014;42:116-‐121.
20. 07-‐09-‐14
20
Apisarnthanarak
A,
et
al.
AJIC
2014;42:116-‐121.
QUALITY
IMPROVEMENT
• Methods:
CMS
Admin
Data,
2008-‐2009,
11
infec:ons
– Cohorts
with
and
without
ID,
propensity
score
matched,
demographics,
comorbidi:es,
hospital
type
– Regression
modes
ID
vs
non-‐ID
&
early
vs
late
ID
consult
• Results:
ID
↓readmissions
OR
0.96
(95%
CI
.93
-‐
.99)
– ↓LOS
3.7%
(95%
CI
-‐5.5%
to
-‐1.9%)
– ID
–
no
difference
in
charges
or
payments
– Early
ID
consult
had
↓
30
day
mortality,
readmission,
hospital
&
ICU
LOS,
&
charges
&
payments
than
late
ID
consult
Schmil
S,
et
al.
CID
2014;58
(1
Jan):22-‐28.
PosiQve
Impact
of
ID
Consults
• SAB:
9
matched
prs
–
excess
cost
per
life
saved
$18,000
• Pts
seen
by
ID
longer
course
anQbioQcs
(Lundberg)
• Mandatory
ID
consult
for
SAB
↑
use
of
echo
(P<.04),
detecQon
of
BE
(P<.04),
adherence
to
EBM
(P<.04)
(Jenkins)
• 2
Yr
prospecQve
study
SAB
56%
↓
in
28
day
mortality
with
ID
consult
(P=.022)
• 6
yr
cohort
study,
ID
↓
mortality
OR
0.6
(CI
.4
–
1.0)
• 600
SAB
cases,
ID
↓
7
day,
30
day
&
1
yr
mortality
(P<.0001)
(effecQve
iniQal
Rx)
Lundberg
J,
et
al.
Clin
Perform
Qual
Health
Care
1998;6:9-‐11.
Honda
H,
et
al.
Am
J
Med
2010;123:631-‐7.
Rieg
S,
et
al.
J
InfecQon
2009;59:232-‐9.
Robinson
JO,
et
al.
Eur
J
Clin
Microbiol
Infect
Dis
2012;31:2421-‐8.
Lahey
T,
et
al.
Medicine
2009;88:263.
Jenkins
TC,
et
al.
Clin
Infect
Dis
2008;46:1000-‐8.
Impact
of
an
Evidence-‐Based
Bundle
in
the
Quality
Management
and
Outcome
of
SAB
• SystemaQc
review,
quasi-‐exp
intervenQon,
12
Spanish
hospitals,
6
structured
wrilen
recommendaQons
(EBM)
• á
Adherence
to
f/u
blood
Cx
OR
2.83
(95%
CI,
1.78
–
4.49)
Lopez-‐Cortes
LE,
et
al.
CID
2013;57
(1
Nov):1225-‐33.
• á
Early
source
control
OR
4.56
(95%
CI,
2.12
–
9.79)
• á
Early
cloxacillin
for
MSSA
OR
1.79
(95%
CI,
1.15
–
2.78)
• á
Appropriate
duraQon
of
Rx
OR
2.13
(95%
CI,
1.24
–
3.64)
• â14
&
30
day
mortality
OR
0.47
(95%
CI,
0.26
–
0.85)
&
0.56
(95%
CI,
0.34
–
0.93)
HAND
HYGIENE
&
CONTACT
PRECAUTIONS
21. 07-‐09-‐14
21
Accuracy
of
RFID
Badge
to
Monitor
HH
• Comparison
of
direct
observaQon
with
RFID
data,
2
hospitals
• 1,554
HH
events,
accuracy
high
in
simulaQon
(88.5%),
low
in
real
life
(52.4)%,
p<0.01
• Accuracy
for
detecQng
HCW
movement
in
&
out
of
rooms
(100%)
simulaQon
vs
54.3%
in
&
49.5%
out
in
real
life
(p<0.01)
Pineles
LL,
et
al.
AJIC
2014;42(2):144-‐147.
Fig 2 RFID hand hygiene system accuracy in simulated validation phase versus real-life clinical practice.
Pineles
LL,
et
al.
AJIC
2014;42(2):144-‐147.
Fig 3 RFID badge detection system
used in a hospital unit with fields
detecting HCP in a pt room (blue) and
when using a HH dispenser (yellow).
Multiple sample HCPs are depicted with
a badge in place...
Pineles
LL,
et
al.
AJIC
2014;42(2):144-‐147.
Contact
PrecauQons:
More
is
Not
Necessarily
Beler
• Prosp
cohort,
2/2009
–
10/2009,
11
teaching
hospitals
• Compliance
HH
before
gowns/gloves
37.2%,
gowns
74.3%,
gloves
80%,
doffing
gowns/gloves
80%,
HH
aper
gloves
61%
• Compliance
all
components
28.9%
• ↑
burden
of
isolaQon
(≤20%
to
>60%)
↓
HH
compliance
(43.6%
-‐
4.9%)
&
all
5
components(31.5%
-‐
6.5%)
• MV
analysis
↑
noncompliance
all
5
bundle
OR
=
6.6
(95%
CI,
1.15
–
37.49)
(p=.03)
&
HH
before
gloves
• OR
=
10.1
(95%
CI,
1.84
–
55.54)
(p=.008)
• HH
compliance
↓
by
team
leader
vs
alone
(26.3%
vs
38.7%,
p<.05)
Dhar
S,
et
al.
ICHE
2014;35(3):213-‐221.
ZOONOSIS
• 43-‐yo
Saudi
man,
8
days
fever,
rhinorrhea,
cough,
malaise,
↑
SOB
• Owned
9
camels;
visited
them
daily
unQl
3
days
before
admission
• 4
camels
sick
–
rhinorrhea
• Pt
applied
nasal
medicine
to
camel
7
days
before
his
illness
• Pt’s
nasal
swabs
+
for
MERS-‐CoV
upE,
ORF1a,
ORF1b
on
RT-‐PCR
• MERS
CoV
cultured
from
pt
&
camel,
idenQcal
full
genome
sequencing
• Pt’s
AB
Qter
↑
from
0
to
1:280
Azhar
EI,
et
al.
NEJM
2014;370(26):2499-‐2505.
22. 07-‐09-‐14
22
Evidence
for
Camel
to
Human
MERS
Transmission
• EgypQan
tomb
bat
(Taphozous
perforatus)
in
Saudi
Arabia,
RNA
• Cross-‐reacQng
MERS-‐CoV
anQbodies
in
dromedary
camels
in
Oman,
Canary
Islands
&
Egypt
• MERS
Co-‐V
RNA
→
RT-‐PCR,
parQal
genome
sequencing
of
viral
RNA
in
3/4
nasal
samples
of
14
camels
&
2
pts
nasal
swabs
in
Qatar
Haagmans
BL,
et
al.
Lancet
Infect
Dis
2014;14:140-‐5.
Memish
ZA,
et
al.
Emerg
Infect
Dis
2013;19:1819-‐23.
Azhar
EI,
et
al.
NEJM
2014;370(26):2499-‐2505.
Bridget
&
Kuehn
JAMA
2014;13
Aug.
doi:10.1001/jama.2014.9916
OUTBREAKS
Hajj
Pilgrimage
&
AcquisiQon,
Spread
of
Respiratory
InfecQons
• >2
million
parQcipate
annually
• RetrospecQve
cohort
study
129
French
residents
• Pretravel
nose
&
throat
Cx,
quesQonnaire
2013
&
pre-‐return
tesQng
Flu
A,
Flu
B,
Flu
C,
Flu
(H1N1),
adenovirus,
metapneumovirus,
paraflu,
RSV,
rhinovirus,
S.
pneumo,
N.
meningiQdis,
B.
pertussis,
&
M.
pneumoniae
• 21.5%
pre
&
38.8%
post
Hajj
viruses+ (p=.003)
• 1/3
acquired
virus
in
Saudi
Arabia
(rhino
14%,
corona
12.4%,
flu
(H3N2)
6.2%)
No
MERS
• 50%
pre
&
62%
post
Hajj
acquired
S.
pneumo
• Flu
vaccine
&
HH
↓
prevalence
of
resp
infecQons
Benkouiten
S,
et
al.
Emerg
Infect
Dis
2014;20(11);
ahead
of
print
hlp://dx.doi.org/10.3201/eid2011.140600.
23. 07-‐09-‐14
23
Transplant-‐Associated
LCMV
InfecQon
• LCMV
–
lymphocyQc
choriomeningiQs
virus
endemic
in
rodents
(mice
=
fatal
meningiQs,
hamsters
=
asymptomaQc)
• Humans
=
mild-‐moderate
flu-‐like
illness
or
asepQc
meningiQs
with
few
sequelae
• 4
ill
organ
recipients
in
Iowa,
donor
49yo
♂
unresponsive
post
HA
&
vomiQng,
ICH
• Tx
recipients
fever,
abd
pain,
diarrhea,
SOB,
AMS
• LCMVC
RT-‐PCR
from
blood
&
liver
in
2
sickest
pts
&
aorQc
Qssue
from
donor
• 3/4
recipients
got
LCMVC
IgM
(not
cornea
recipient)
• Rx
=
↓
immunosuppression
with
PO
or
IV
ribavirin
&
IgG
• 5
clusters
reported
post
Tx
Hocevar
SN,
et
al.
Ann
Intern
Med
2014;160(4):213-‐220.
Schafer
IJ,
et
al.
CDC
MMWR
2014;63(Mar
21):249.
MulQstate
Outbreak
of
Salmonella
InfecQons
Linked
to
Organic
Sprouted
Chia
Powder
• 8/2014;
25
cases,
Salmonella
Newport
(20),
S.
HarŒord
(7),
S.
Oranienburg
(4)
from
16
states
• 3
hospitalized,
no
deaths,
ages
1
–
81yrs,
median
45,
65%
female
• Recall:
Navitas
Naturals
&
Omega
Blend
Sprouted
Smoothie
Mix
&
Williams-‐Sonoma
Omega
3
Smoothie
Mixer
• Pulse
Net
–
Pan
sensiQve
hlp://www.cdc.gov/salmonella/newport-‐05-‐14/
hjp://www.cdc.gov/salmonella/newport-‐05-‐14/
Persons
infected
with
the
outbreak
strains
of
Salmonella
Newport,
Harnord,
or
Oranienburg,
by
state*
MulQstate
Outbreak
of
Salmonella
Cotham
&
Kisarawe
Linked
to
Pet
Bearded
Dragon
• 150
persons,
35
states
since
2012,
57%,
<5
yrs
of
age,
43%
hospitalized,
8%
resistant
to
cerriaxone
• Don’t
let
children
or
immunosuppressed
adults
handle
rep:les
or
amphibians
• Don’t
keep
in
day
care,
schools
for
kids
<5
or
those
who
act
<5,
don’t
keep
in
kitchen
• Don’t
touch
your
mouth
arer
handling
rep:les/amphibians
• Don’t
let
them
loose
in
house,
don’t
bathe
them
in
kitchen
sink,
bathroom
sink
or
bathtub
hlp://www.cdc.gov/salmonella/cotham-‐04-‐14/
Outbreak
of
SM
BSI
in
Pts
with
TPN
from
Compounding
Pharmacy
• 19
pts
with
S
marcescens,
9
died,
alack
rate
35%
• Compounding
pharmacy;
filter
sterilizing
AA
soluQon,
using
nonsterile
AA
due
to
naQonal
shortage
• Breaches
in
mixing,
filtraQon
&
sterility
tesQng
• S
marcescens
from
pharmacy
H20
faucet,
mixing
container
&
AA
powder,
idenQcal
to
cases
Gupta
N,
et
al.
CID
2014;24
Apr
[Epub
ahead
of
print].
Gupta
N,
et
al.
CID
2014;24
Apr
[Epub
ahead
of
print].
24. 07-‐09-‐14
24
OTHER
RANDOM
THINGS
Efficacy
of
High-‐Dose
vs
Std-‐Dose
Influenza
Vaccine
in
Older
Adults
• Phase
IIIb-‐IV
mulQcenter,
RCT
DB
;
IIV3-‐HD
(60
μg
hemaggluQnin)
vs
std
trivalent
IIV3-‐SD
(15
μg
per
strain)
in
pts
≥65
yrs,
2011-‐12
&
2012-‐13
N
hemisphere
season
• 31,989
pts,
126
centers,
US
&
Canada
• ITT
228
(1.4%)
IIV3-‐HD
vs
301
(1.9%)
IIVS-‐SD
lab
confirmed
FLU
• RelaQve
efficacy
24.2%
(95%
CI,
9.7
–
36.5)
• HAI
Qters
&
seroprotecQon
rates
≥1:40
sig
higher
in
IIV3-‐HD
• Serious
AE
8.3%
IIV3-‐HD
vs
9.0%
RR
0.92
(95%
CI,
0.85
–
0.99)
DiazGranados
CA,
et
al.
NEJM
2014;371(7):635-‐645.
Impact
of
Postpartum
Influenza
Vaccine
• 3
hospitals
2012-‐2013,
flu
vaccine
offered
to
moms
&
household
members
in
Athens;
moms
contacted
every
2
weeks
re:
fever,
symptoms,
HC
use,
anQbioQcs
• 553
moms,
573
babies
• Vaccine
841/1844
(45.6%)
household
contacts
• 41.9%
siblings
→
49%
moms
vaccinated
• PP
vaccine
↓
37.7%
ILI,
↓
41.8%
HC
seeking,
↓
45%
AB
• MV
analysis
=
mom
vaccine
vs
siblings
(NS)
Maltezou
HC,
et
al.
Clin
Infect
Dis
2013;57(11):1520-‐1526.
• Healthy
vol
donors,
screened,
frozen
fecal
suspension
• Relapsing
CDI
pts
got
frozen
FMT
by
NG
or
colonoscopy,
20
pts,
10
each
arm
• Median
4
relapses
(range
2-‐16
prior
to
study)
• 14
(70%)
resolved
p
FMT
(8/10
colonoscopy,
6/10
NG)
• 5
retreated,
4
cured,
overall
cure
90%
• Daily
stools
↓
from
7
(IQR
5-‐10)
to
2
(IQR
1-‐2)
• Self-‐ranked
health
score
↑
4
(IQR
2-‐6)
to
8
(IQR
5-‐9)
Youngster
I,
et
al.
CID
2014;58(11):1515-‐1522.
Youngster
I,
et
al.
Clin
Infect
Dis
2014;58(11):1515-‐1522.
… no worries
– just a few
more minutes
25. 07-‐09-‐14
25
¤ “Zero”
infecQons
guaranteed!
Kaier
et
al.
Clin
Microbiol
Infect
2012;18:941
SystemaQc
review
BO-‐rates
and
understaffing
directly
influence
HAI-‐rate
Kaier
et
al.
Clin
Microbiol
Infect
2012;18:941
No
pa:ent
=
no
harm
Hollis
&
Ahmed
NEJM
2013;369:2474
¤
Approximately
80%
of
anQbioQcs
in
the
United
States
are
consumed
in
agriculture
and
aquaculture
¤ Non–pharmaceuQcal-‐
grade
anQbioQcs
are
typically
priced
at
approximately
$25
per
kilogram
Hollis
&
Ahmed
NEJM
2013;369:2474
¤ 2005:
FDA
banned
the
use
of
fluoro-‐
quinolones
in
poultry
¤ 2012:
FDA
issued
Hollis
&
Ahmed
NEJM
2013;369:2474
nonbinding
guidance
to
farmers
recommending
that
they
avoid
using
anQbioQcs
as
animal
growth
promoters
(banned
in
Europe)
¤ Do
the
same?
26. 07-‐09-‐14
26
Bernieret
al.
AAC
2014;58:71-‐77
Weekly
anQbioQc
consumpQon
per
1,000
inhabitants
(solid)
and
flu-‐like
syndrome
incidence
(dojed)
Bernier
et
al.
AnQmicrob
Agents
Chemother
2014;58:71-‐77
The
numbers
of
weekly
anQbioQc
prescripQons
per
1,000
inhabitants
during
campaign
periods
decreased
unQl
winter
2006
to
2007
(30%
[95%
confidence
interval
{CI},36.3
to23.8%];
P<0.001)
and
then
stabilized
except
for
individuals>60
years
of
age
Bernier
et
al.
AnQmicrob
Agents
Chemother
2014;58:71-‐77
No
explana:on
bejer
understanding
of
an:bio:c
use
by
senior
outpa:ents
is
urgently
needed!
Bernier
et
al.
AnQmicrob
Agents
Chemother
2014;58:71-‐77
chlorhexidine
alcohol
Povidone-‐iodine
Maiwald
&
Chan
J
AnQmicrob
Chemother
2014;69:2017
Maiwald
&
Chan
J
AnQmicrob
Chemother
2014;69:2017
27. 07-‐09-‐14
27
Charehbili
Surg
Infect
2014;15:DOI:
10.1089/sur.2012.185
¤
Single
center,
non-‐randomized,
non-‐blinded,
retrospecQve
study
¤
2010
and
prior:
1%
iodine
in
70%
alcohol
¤
2011
and
aper
a
preparaQon
of
0.5%
chlorhexidine
in
70%
alcohol
¤
SSI
according
to
naQonal
surveillance
definiQon
¤
Protocol
for
prevenQng
SSI
did
not
differ
during
the
two
years
in
which
the
study
was
conducted
(?)
Charehbili
Surg
Infect
2014;15:DOI:
10.1089/sur.2012.185
Charehbili
et
al.
Surg
Infect
2014;15:DOI:
10.1089/sur.2012.185
Steed
et
al.
Am
J
Infect
Control
2014
Steed
et
al.
Am
J
Infect
Control
2014
Steed
et
al.
Am
J
Infect
Control
2014
28. 07-‐09-‐14
28
¤
Very
effecQve
in
reducing
the
bacterial
load,
but
…
¤
…
2
hours
aper
last
applicaQon:
what
is
the
bacterial
load
in
the
next
morning?
¤
…
no
informaQon
about
effect
aper
mulQple
day
use
(load
reducQon?,
side
effects?)
¤
…
no
informaQon
on
the
percentage
of
HCWs
that
became
MRSA-‐free
Steed
et
al.
Am
J
Infect
Control
2014
Bryce
et
al.
J
Hosp
Infect
2014;
doi:
10.1016/j.jhin.2014.06.017.
[Epub
ahead
of
print]
Leape
NEJM
2014;
370:1063-‐64
Leape
NEJM
2014;
370:1063-‐64
…
only
this
one
isn’t
funny
!
29. 07-‐09-‐14
29
Urbach
et
al.
NEJM
2014;
370:1029-‐38
¤
InformaQon
on
the
use
of
surgical
safety
checklists
from
130
of
133
hospitals
¤
200,000
surgical
procedures
¤
Inclusion
of
3
months
before
the
introducQon
of
a
surgical
checklist,
and
one
starQng
3
months
aper
the
introducQon
of
the
checklist
Urbach
et
al.
NEJM
2014;
370:1029-‐38
Urbach
et
al.
NEJM
2014;
370:1029-‐38
¤ It
is
not
the
act
of
Qcking
off
a
checklist
that
reduces
complicaQons,
but
performance
of
the
acQons
it
calls
for
¤ Implement
the
behavioral
change
² demonstrate
the
need
for
change,
engage
leadership,
provide
training
in
teamwork,
make
HCW
accountable
“The
likely
reason
for
the
failure
of
the
surgical
checklist
in
Ontario
is
that
it
was
not
actually
used”
¤ Provide
local
teams
with
direcQon,
coaching,
training,
data
management,
opportunity
to
learn
from
others
¤ “Gaming”
¤
Full
implementaQon
needs
Qme
Leape
NEJM
2014;
370:1063-‐64
Start
of
a
series
in
ARIC
journal
…
Willemsen
et
al
(provisional
PDF
online,
ARIC
2014
30. 07-‐09-‐14
30
A. Local
guidelines
not
available
B. Shortcomings
in
constraints
C. HAIs
D. Use
of
medical
devices
E. Environmental
contaminaQon
F. AnQmicrobial
use
G. ESBL
carriage
Willemsen
et
al
(provisional
PDF
online,
ARIC
2014
Willemsen
et
al
(provisional
PDF
online)
ARIC
2014
LongQn
et
al.
Mayo
Clin
Proc
2014;89:291-‐299