A Nurse Led Heart Failure Education for Self-Care Symptom Monitoring and Management

Title Nurse-led education heart failure education for symptom monitoring and management Abstract Problem Statement: Over six million adults in the United States have heart failure (CDC.gov,2020). According to the Agency for Healthcare Research and Quality (AHRQ), almost 20% of heart failure patients hospitalized are readmitted under 30 days (AHRQ, 2013). The American Heart Association (AHA) (2022) recommends a visual symptom tracking tool for self-care symptom monitoring to increase patient adherence and reduce readmissions. Despite this recommendation, the AHA tool for symptom monitoring is not fully incorporated into the discharge of every heart failure patient often because of nursing management time constraints, and limited resources for designated discharge nurses. Purpose: The purpose of this DNP Project is to evaluate the feasibility of the utilization of the AHA symptom tracking tool and to determine the effect of nurse-led education for heart failure patients that incorporates the AHA symptom tracking tool into discharge education regarding self-care behaviors and symptom monitoring. Measurements of the effects include patient adherence to self-care behaviors and 30-day readmission rates. Methods: In this pilot study, patient education was provided to participants by the nurse researcher before discharge incorporating the AHA tool for symptom monitoring and management, daily weight, medication adherence, sodium restriction, and follow-up with primary appointments. A follow-up phone call 7-10 days after discharge was made to participants to determine adherence to self-care behaviors, symptom monitoring, and again at approximately 21 days post discharge. Analysis: In comparing hospital readmission rates to heart failure patients who received only standard discharge teaching, the analysis revealed a there was not a significant statistical difference in readmission rate between the groups. However, the use of the AHA tool was found to be effective with a small sample when combined with follow up phone calls. Further research is indicated on a larger scale to demonstrate the correlation between the education intervention, adherence to self-care behaviors and readmission rates

Molecular characterization of the serotype-associated plasmids of Salmonella enterica

The clinical importance of Salmonella has been known for more than a century. The control of salmonellosis requires detailed understanding of both pathogenicity and epidemiology. Certain plasmids are involved in the virulence of the salmonellae and their analysis often contributes to epidemiological investigation. Molecular characterization of the serotype associated plasmids of the salmonellae was undertaken. A predefined strategy of restriction endonuclease fragmentation pattern (REFP) analysis revealed plasmids previously defined as "serotype specific" were present in different serotypes. Plasmids indistinguishable from of molecular variants of established serotype associated plasmids (SAP's) were detected in other serotypes of serogroup Dl. The results showed that related or identical plasmids were present in both strains which varied only slightly in their H antigens e.g. Enteritidis (gm), Moscow (gq) and Blegdam (gmq) as well as a strain of Antarctica which possessed the H antigens gz63,. In addition to plasmid similarity within a serogroup, plasmids were identified in strains of Wangata which although a member of serogroup D are outwith the g-complex of flagellar antigens (H = Z4Z23). Unexpectedly, these plasmids were closely related to Typhimurium which belongs to serogroup B. The incompatibility of the plasmids was tested with a cointegrate plasmid pOG669 (a cointegrate of pOG660, the Typhimurium plasmid and pOG670, an IncX R-plasmid) and confirmation of incompatibility to the Typhimiuium component of this plasmid was shown by introduction and compatibility with pOG670. Plasmid incompatibility analysis of these plasmids revealed all the SAP's, Except Dublin, were incompatible with Typhimurium and confirmed a family of related plasmids common to but not restricted in their distribution to individual serotypes. Co-resident plasmids of intermediate size (30 - 40 kb) were observed relatively frequently in certain serotypes of GpD1- notably Dublin, Enteritidis, Moscow, Blegdam and Antarctica. With the exception of Antarctica these plasmids exhibited IncX properties - and although the possibility of dual incompatibility was not investigated, these properties, by inference were impossible as it would have resulted in incompatibility to pOG669 also. Restriction endonuclease fragmentation pattern analysis of the serotype associated plasmids of the salmonellae revealed a high degree of relatedness between plasmids of Typhimurium, Wangata, Gallinarum and Pullorum and a low degree of REFP similarity with the plasmids of Dublin and Abortusovis and the other SAP's. The presence of a plasinid thought to be an evolutionary intermediate in the development of Typhimurium and Enteritidis has been suggested. This study demonstrated the presence of plasmid in Dublin which showed more REFP similarity to the plasmid of Gallinarum than to Dublin itself and may be an intermediate in the development of the Dublin plasmid. This was strengthened by the incompatibility analysis of the plasmids. All the SAP's except Dublin were incompatible with the Typhimurium plasmid only; the plasmid of Dublin exhibited dual incompatibility properties with both pOG660 and IncX. The intermediate Dublin plasmid pOG683 showed incompatibility to the Typhimurium plasmid only. The presence of other co-resident plasmids in this serotype which exhibit IncX properties as well as the identification of large cointegrate plasmids which were unstable, suggests that the SAP of Dublin has arisen via a cointegration event with an IncX plasmid. Molecular variation within serotypes was observed at a higher incidence in host adapted serotypes (23%-Dublin, 47%-Pullorum) than those of broad host range (5% for both Enteritidis and Typhimurium). This was contradictory to the hypothesis that the narrow range of ecological conditions encountered by these serotypes would reduce the possibility of genetic diversity. Chromosomal analysis of these serotypes has previously shown that they were relatively stable and consisted of a single world-wide clone and minor sub-clones. The location of restriction sites for PstI and SmaI were determined for the plasmid of Typhimurium and fragment similarity toother SAP's in relation to existing maps suggested. A 2.3 kb PstI fragment was demonstrated to be present in the plasmids of Typhimurium, Wangata, Gallinarum, Pullorum, Bovismorbificans, Dublin and the Dublin variant pOG683. Smaller fragments of Abortusovis and Choleraesuis hybridized and indicated partial sequence homology. No homology was detected in the plasmid of Enteritidis. Not only do these results confirm a family of related plasmids within the salmonellae, they indicate much more of the plasmid is conserved. These analyses suggest molecular divergence of the plasmids from a common ancestor (Typhimurium) has arisen by loss of DNA. The population genetics of the SAP's of the salmonellae parallel the findings of chromosomal analysis in as much as they demonstrate the presence of a common worldwide clone. However, they also demonstrate that the rate of evolution of the plasmid is much higher than previously thought

Shiga toxin-producing Escherichia coli clonal complex 32, including serotype O145:H28, in the UK and Ireland

Introduction. Shiga toxin-producing Escherichia coli (STEC) O157:H7 has been the most clinically significant STEC serotype in the UK for over four decades. Over the last 10 years we have observed a decrease in STEC O157:H7 and an increase in non-O157 STEC serotypes, such as O145:H28. Gap Statement. Little is known about the microbiology and epidemiology of STEC belonging to CC32 (including O145:H28) in the UK. The aim of this study was to integrate genomic data with patient information to gain a better understanding of the virulence, disease severity, epidemic risk assessment and population structure of this clinically significant clonal complex. Methodology. Isolates of E. coli belonging to CC32 (n=309) in the archives of public health agencies in the UK and Ireland were whole-genome-sequenced, virulence-profiled and integrated with enhanced surveillance questionnaire (ESQ) data, including exposures and disease severity. Results. Overall, diagnoses of STEC belonging to CC32 (290/309, 94 %) in the UK have increased every year since 2014. Most cases were female (61 %), and the highest proportion of cases belonged to the 0–4 age group (53/211,25 %). The frequency of symptoms of diarrhoea (92 %), abdominal pain (84 %), blood in stool (71 %) and nausea (51 %) was similar to that reported in cases of STEC O157:H7, although cases of STEC CC32 were more frequently admitted to hospital (STEC CC32 48 % vs O157:H7  34 %) and/or developed haemolytic uraemic syndrome (HUS) (STEC CC32 9 % vs O157:H7 4 %). The majority of STEC isolates (268/290, 92 %) had the stx2a/eae virulence gene combination, most commonly associated with progression to STEC HUS. There was evidence of person-to-person transmission and small, temporally related, geographically dispersed outbreaks, characteristic of foodborne outbreaks linked to nationally distributed products. Conclusion. We recommend more widespread use of polymerase chain reaction (PCR) for the detection of all STEC serogroups, the development of consistent strategies for the follow-up testing of PCR-positive faecal specimens, the implementation of more comprehensive and standardized collection of epidemiological data, and routine sharing of sequencing data between public health agencies worldwide

Epidemiology and genomic analysis of Shiga toxin-producing Escherichia coli clonal complex 165 in the UK

Introduction. Shiga toxin-producing Escherichia coli (STEC) is a zoonotic, foodborne gastrointestinal pathogen that has the potential to cause severe clinical outcomes, including haemolytic uraemic syndrome (HUS). STEC-HUS is the leading cause of renal failure in children and can be fatal. Over the last decade, STEC clonal complex 165 (CC165) has emerged as a cause of STEC-HUS. Gap Statement. There is a need to understand the pathogenicity and prevalence of this emerging STEC clonal complex in the UK, to facilitate early diagnosis, improve clinical management, and prevent and control outbreaks. Aim. The aim of this study was to characterize CC165 through identification of virulence factors (VFs) and antimicrobial resistance (AMR) determinants in the genome and to integrate the genome data with the available epidemiological data to better understand the incidence and pathogenicity of this clonal complex in the UK. Methodology. All isolates belonging to CC165 in the archives at the UK public health agencies were sequenced and serotyped, and the virulence gene and AMR profiles were derived from the genome using PHE bioinformatics pipelines and the Centre for Genomic Epidemiology virulence database. Results. There were 48 CC165 isolates, of which 43 were STEC, four were enteropathogenic E. coli (EPEC) and one E. coli. STEC serotypes were predominately O80:H2 (n=28), and other serotypes included O45:H2 (n=9), O55:H9 (n=4), O132:H2 (n=1) and O180:H2 (n=1). All but one STEC isolate had Shiga toxin (stx) subtype stx2a or stx2d and 47/48 isolates had the eae gene encoding intimin involved in the intimate attachment of the bacteria to the human gut mucosa. We detected extra-intestinal virulence genes including those associated with iron acquisition (iro) and serum resistance (iss), indicating that this pathogen has the potential to translocate to extra-intestinal sites. Unlike other STEC clonal complexes, a high proportion of isolates (93%, 40/43) were multidrug-resistant, including resistance to aminoglycosides, beta-lactams, chloramphenicol, sulphonamides, tetracyclines and trimethoprim. Conclusion. The clinical significance of this clonal complex should not be underestimated. Exhibiting high levels of AMR and a combination of STEC and extra-intestinal pathogenic E. coli (ExPEC) virulence profiles, this clonal complex is an emerging threat to public health

Maternal and infant renal safety following tenofovir disoproxil fumarate exposure during pregnancy in a randomized control trial

Background Tenofovir disoproxil fumarate (TDF) in combination with other antiretroviral (ARV) drugs has been in clinical use for HIV treatment since its approval in 2001. Although the effectiveness of TDF in preventing perinatal HIV infection is well established, information about renal safety during pregnancy is still limited. Trial design The IMPAACT PROMISE study was an open-label, strategy trial that randomized pregnant women to one of three arms: TDF based antiretroviral therapy (ART), zidovudine (ZDV) based ART, and ZDV alone (standard of care at start of enrollment). The P1084s substudy was a nested, comparative study of renal outcomes in women and their infants. Methods PROMISE participants (n = 3543) were assessed for renal dysfunction using calculated creatinine clearance (CrCl) at study entry (> 14 weeks gestation), delivery, and postpartum weeks 6, 26, and 74. Of these women, 479 were enrolled in the P1084s substudy that also assessed maternal calcium and phosphate as well as infant calculated CrCl, calcium, and phosphate at birth. Results Among the 1338 women who could be randomized to TDF, less than 1% had a baseline calculated CrCl below 80 mL/min. The mean (standard deviation) maternal calculated CrCl at delivery in the TDF-ART arm [147.0 mL/min (51.4)] was lower than the ZDV-ART [155.0 mL/min (43.3); primary comparison] and the ZDV Alone [158.5 mL/min (45.0)] arms; the mean differences (95% confidence interval) were − 8.0 mL/min (− 14.5, − 1.5) and − 11.5 mL/min (− 18.0, − 4.9), respectively. The TDF-ART arm had lower mean maternal phosphate at delivery compared with the ZDV-ART [− 0.14 mg/dL (− 0.28, − 0.01)] and the ZDV Alone [− 0.17 mg/dL (− 0.31, − 0.02)] arms, and a greater percentage of maternal hypophosphatemia at delivery (4.23%) compared with the ZDV-ART (1.38%) and the ZDV Alone (1.46%) arms. Maternal calcium was similar between arms. In infants, mean calculated CrCl, calcium, and phosphate at birth were similar between arms (all CIs included 0). Conclusions Although mean maternal calculated CrCl at Delivery was lower in the TDF-ART arm, the difference between arms is unlikely to be clinically significant. During pregnancy, the TDF-ART regimen had no observed safety concerns for maternal or infant renal function. Trial Registration: NCT01061151 on 10/02/2010 for PROMISE (1077BF). NCT01066858 on 10/02/2010 for P1084s

Preliminary investigation of a significant national Cryptosporidium exceedance in the United Kingdom, August 2023 and ongoing

Routine laboratory surveillance has identified an unprecedented and ongoing exceedance of Cryptosporidium spp. across the United Kingdom, notably driven by C. hominis transmission, since 14 August 2023. Information from 477 reported cases in England and Wales, followed up with a standardised exposure questionnaire as of 25 September 2023, identified foreign travel in 250 (54%) of 463 respondents and swimming in 234 (66%) of 353 cases. A significant, common exposure has not yet been identified in first analyses

Gibberellins in seedlings and flowering trees of Prunus avium L.

Extracts of acids from mature seeds, germinating seeds, first, second and third year seedlings as well as mature, flowering trees of sweet cherry (Prunus avium L. cv. Stella) were analysed by gas chromatography-mass spectrometry. The presence of the known gibberellins (GAs) GA1 (1), GA3 (4), GA5 (7), GA8 (11), GA19 (14), GA20 (12), GA29 (13), GA32 (5), GA85 (2), GA86 (3) and GA87 (6) was confirmed by comparison of their mass spectra and Kovats retention indices with those of standards or literature values. In addition, 16α,17-dihydrodihydroxy GA25 (16) was identified and its stereochemistry confirmed by rational synthesis. The 12α,13-dihydroxy GAs, GA32 (5), GA85 (2), GA86 (3) and GA87 (6), were detected in mature seeds, germinating seeds and young seedlings, but not in flowering plants. The 13-hydroxy GAs, GA1 (1) and GA3 (4), were present in germinating seeds and, in addition to these, GA5 (7), GA8 (11), GA19 (14), GA20 (12) and GA29 (13) were detected in seedlings and mature flowering plants. In germinating seeds and seedlings (while the plants were growing actively), concentrations of the 12α,13-dihydroxy GAs, measured by bioassay, declined and those of the 13-hydroxy GAs increased. The results are discussed with reference to the known and predicted effects of the GAs on the vegetative growth and flowering of P. avium plants. (C) 2000 Elsevier Science Ltd

Epidemiology and genomic analysis of Shiga toxin-producing Escherichia coli clonal complex 165 in the UK

Introduction. Shiga toxin-producing Escherichia coli (STEC) is a zoonotic, foodborne gastrointestinal pathogen that has the potential to cause severe clinical outcomes, including haemolytic uraemic syndrome (HUS). STEC-HUS is the leading cause of renal failure in children and can be fatal. Over the last decade, STEC clonal complex 165 (CC165) has emerged as a cause of STEC-HUS.Gap Statement. There is a need to understand the pathogenicity and prevalence of this emerging STEC clonal complex in the UK, to facilitate early diagnosis, improve clinical management, and prevent and control outbreaks.Aim. The aim of this study was to characterize CC165 through identification of virulence factors (VFs) and antimicrobial resistance (AMR) determinants in the genome and to integrate the genome data with the available epidemiological data to better understand the incidence and pathogenicity of this clonal complex in the UK.Methodology. All isolates belonging to CC165 in the archives at the UK public health agencies were sequenced and serotyped, and the virulence gene and AMR profiles were derived from the genome using PHE bioinformatics pipelines and the Centre for Genomic Epidemiology virulence database.Results. There were 48 CC165 isolates, of which 43 were STEC, four were enteropathogenic E. coli (EPEC) and one E. coli. STEC serotypes were predominately O80:H2 (n=28), and other serotypes included O45:H2 (n=9), O55:H9 (n=4), O132:H2 (n=1) and O180:H2 (n=1). All but one STEC isolate had Shiga toxin (stx) subtype stx2a or stx2d and 47/48 isolates had the eae gene encoding intimin involved in the intimate attachment of the bacteria to the human gut mucosa. We detected extra-intestinal virulence genes including those associated with iron acquisition (iro) and serum resistance (iss), indicating that this pathogen has the potential to translocate to extra-intestinal sites. Unlike other STEC clonal complexes, a high proportion of isolates (93%, 40/43) were multidrug-resistant, including resistance to aminoglycosides, beta-lactams, chloramphenicol, sulphonamides, tetracyclines and trimethoprim.Conclusion. The clinical significance of this clonal complex should not be underestimated. Exhibiting high levels of AMR and a combination of STEC and extra-intestinal pathogenic E. coli (ExPEC) virulence profiles, this clonal complex is an emerging threat to public health