Containing the burden of infectious diseases is everyone’s responsibility.:A call for an integrated strategy for developing and promoting hygiene behaviour change in home and everyday life

Across the world, health agencies recognize the profound impact of infectious disease on health and prosperity. Equally, they recognize that prevention is central to fighting infection, and that hygiene in home and everyday life (HEDL) is a key part of this. A current driver is the part that hygienei plays in tackling antibiotic resistance, but it also reflects growing numbers of people at greater risk of infection being cared for in the community. Sustaining the quality of state-funded healthcare requires that the public take greater responsibility for their own health, including protecting themselves and their families against infection. Hygiene must be must be everyone’s responsibility. However, if we are to be successful in promoting hygiene as part of public health, there are barriers which need to be overcome. A key issue is the need to balance evidence of the health benefits of hygiene against possible risks, such as environmental impacts and toxicity issues. Another issue is the role of microbes in human health and whether we have become “too clean”. Lack of a unified voice advocating for hygiene means these issues have tended to take precedence. Another barrier to change is public confusion about the need for hygiene and the difference between hygiene and cleanliness. To address this, we must work together to provide the public with a clear, consistent restatement of the importance of hygiene, and to change public perceptions about hygiene and good hygiene practice. This paper is unique because it examines these issues in an integrated manner and focuses on making achievable, constructive recommendations for developing an effective and sustainable approach. The paper lays out a risk management strategy for hygiene in home and everyday life which gives hygiene appropriate priority within the context of environmental and other health concerns. This “targeted hygiene” approach needs to be placed at the heart of a multimodal prevention strategy, alongside vaccination and other interventions. Based on the findings of this paper, we issue a call to action to national and international policy makers, health agencies and health professionals to recognize the need for an integrated, family-centredii approach to hygiene, and provide effective leadership to achieve this. This paper shows that many of the components of a behaviour change strategy are already in place, but need to be integrated rather than developed independently. We also issue a call to scientists, health professionals, environmental and regulatory agencies, immunologists, microbiomists, the private sector (hygiene appliance and product manufacturers) and the media to work together, through innovative research and communication policies. A collaborative effort is vital if we are to overcome barriers to change and action integrated behaviour change programmes that really work. The report represents the consensus views of an international, interdisciplinary group of experts in the field of infection prevention and hygiene. We recognise that this paper leaves many questions unanswered and would welcome further dialogue with stakeholders on how to develop policy. The aim of this paper is to provide a sound basis for such dialogue. At the 2016 launch of the European Human Biomonitoring Initiative, the EU commissioner for food safety said the followingiii which encapsulates the aim of this report. “We must collectively recognise that risk and uncertainty are part and parcel of every decision we take. We need to engage people in a serious and rational debate. But in this world of information overload – from old media and new – information, misinformation, opinions, prejudices, truths, half-truths and un-truths all compete for public attention. We need better communication of science so that people can be better informed about risk assessment and management decisions

Ketamine augmentation of electroconvulsive therapy to improve neuropsychological and clinical outcomes in depression (Ketamine-ECT):A multicentre, double-blind, randomised, parallel-group, superiority trial

Summary Background The use of electroconvulsive therapy (ECT) is limited by concerns about its cognitive adverse effects. Preliminary evidence suggests that administering the glutamate antagonist ketamine with ECT might alleviate cognitive adverse effects and accelerate symptomatic improvement; we tested this in a randomised trial of low-dose ketamine. Methods In this multicentre, randomised, parallel-group study in 11 ECT suites serving inpatient and outpatient care settings in seven National Health Service trusts in the North of England, we recruited severely depressed patients, who were diagnosed as having unipolar or bipolar depressive episodes defined as moderate or severe by DSM-IV criteria, aged at least 18 years, and were able and willing to provide written consent to participate in the study. Patients were randomly assigned (1:1) to ketamine (0·5 mg/kg intravenous bolus) or saline adjunctive to the anaesthetic for the duration of their ECT course. Patients and assessment and ECT treatment teams were masked to treatment allocation, although anaesthetists administering the study medication were not. We analysed the primary outcome, Hopkins Verbal Learning Test-Revised delayed verbal recall (HVLT-R-DR) after four ECT treatments, using a Gaussian repeated measures model in all patients receiving the first ECT treatment. In the same population, safety was assessed by adverse effect monitoring. This trial was registered with International Standard Randomised Controlled Trial Number, number ISRCTN14689382. Findings Between early December, 2012, and mid-June, 2015, 628 patients were screened for eligibility, of whom 79 were randomly assigned to treatment (40 in the ketamine group vs 39 in the saline group). Ketamine (mean 5·17, SD 2·92), when compared with saline (5·54, 3·42), had no benefit on the primary outcome (HVLT-R-DR; difference in means −0·43 [95% CI −1·73 to 0·87]). 15 (45%) of 33 ketamine-treated patients compared with 10 (27%) of 37 patients receiving saline experienced at least one adverse event which included two (6%) of 33 patients who had ketamine-attributable transient psychological effects. Psychiatric adverse events were the most common in both groups (six [27%] of 22 adverse events in the ketamine group vs seven [54%] of 13 in the saline group). Interpretation No evidence of benefit for ketamine was found although the sample size used was small; however, the results excluded greater than a small to moderate benefit with 95% confidence. The results do not support the use of adjunctive low-dose ketamine in routine ECT treatment

Study protocol for the randomised controlled trial: Ketamine augmentation of ECT to improve outcomes in depression (Ketamine-ECT study)

Background: There is a robust empirical evidence base supporting the acute efficacy of electroconvulsive therapy (ECT) for severe and treatment resistant depression. However, a major limitation, probably contributing to its declining use, is that ECT is associated with impairment in cognition, notably in anterograde and retrograde memory and executive function. Preclinical and preliminary human data suggests that ketamine, used either as the sole anaesthetic agent or in addition to other anaesthetics, may reduce or prevent cognitive impairment following ECT. A putative hypothesis is that ketamine, through antagonising glutamate receptors, protects from excess excitatory neurotransmitter stimulation during ECT. The primary aim of the ketamine-ECT study is to investigate whether adjunctive ketamine can attenuate the cognitive impairment caused by ECT. Its secondary aim is to examine if ketamine increases the speed of clinical improvement with ECT. Methods/Design: The ketamine ECT study is a multi-site randomised, placebo-controlled, double blind trial. It was originally planned to recruit 160 moderately to severely depressed patients who had been clinically prescribed ECT. This recruitment target was subsequently revised to 100 patients due to recruitment difficulties. Patients will be randomly allocated on a 1:1 basis to receive either adjunctive ketamine or saline in addition to standard anaesthesia for ECT. The primary neuropsychological outcome measure is anterograde verbal memory (Hopkins Verbal Learning Test-Revised delayed recall task) after 4 ECT treatments. Secondary cognitive outcomes include verbal fluency, autobiographical memory, visuospatial memory and digit span. Efficacy is assessed using observer and self-report efficacy measures of depressive symptomatology. The effects of ECT and ketamine on cortical activity during cognitive tasks will be studied in a sub-sample using functional near-infrared spectroscopy (fNIRS). Discussion: The ketamine-ECT study aims to establish whether or not adjunctive ketamine used together with standard anaesthesia for ECT will significantly reduce the adverse cognitive effects observed after ECT. Potential efficacy benefits of increased speed of symptom improvement and a reduction in the number of ECT treatments required will also be assessed, as will safety and tolerability of adjunctive ketamine. This study will provide important evidence as to whether adjunctive ketamine is routinely indicated for ECT given for depression in routine NHS clinical practice