Microbial contamination of domiciliary nebulisers and clinical implications in chronic obstructive pulmonary disease.

BACKGROUND AND PURPOSE: Domiciliary nebulisers are widely used in chronic obstructive pulmonary disease (COPD) but nebuliser cleaning practice has not been assessed in patients with COPD who are often elderly and may have severe disease and multiple comorbidities. We aimed to evaluate microbial contamination of home nebulisers used by patients with COPD. METHODS: Random microbiological assessment of domiciliary nebulisers was undertaken together with an enquiry into cleaning practices. We also examined the effectiveness of the trust-wide cleaning instructions in eradicating isolated microorganisms in a laboratory setting. RESULTS: The mean age of patients in this study was 71 (range 40-93) years, and in 68% of patients a large number of significant comorbidities were present. Forty-four nebuliser sets were obtained and 73% were contaminated with microorganisms at >100 colony forming units/plate. Potentially pathogenic bacteria colonised 13 of the 44 nebulisers (30%) and organisms isolated included Pseudomonas aeroginosa, Staphylococcus aureus, multidrug resistant Serratia marcesans, Escherichia coli and multiresistant Klebsiella spp, Enterobacteriaceae and fungus Fusarium oxysporum. Washing of nebuliser masks, chambers and mouthpieces achieved complete eradication of Gram-positive bacterial and fungal flora. Gram-negative organisms were incompletely eradicated, which may be attributed to the presence of biofilms. We also found that in patients with pathogenic organisms cultured on the nebuliser sets, there was a higher probability of occurrence of a COPD exacerbation with a mean number of exacerbations of 3.3 (SD=1) per year in the group in whom pathogens were isolated compared with 1.7 (SD=1.2) exacerbations per year in those whose sets grew non-pathogenic flora (p=0.02). CONCLUSIONS: Nebulisers contaminated with microorganisms are potential reservoirs delivering serious pathogens to the lung. Relationships between nebuliser contamination, clinical infection and exacerbations require further examination, but is a potential concern in elderly patients with COPD with comorbidities who fail to effectively maintain reasonable standards of nebuliser cleanliness

Wellsprings of a 'World War': An early English attempt to conquer Canada during King William's war, 1688-97

This is the author's PDF version of an article published in Journal of Imperial and Commonwealth History© 2006. The definitive version is available at www.tandf.co.uk/journals/FICHThis article discusses the military history of the early years of King William's War, 1688-97, including an early attempt to conquer French Canada in 1690 by Sir William Phips. The article places this within differeing interpretations of the military historiography of early modern colonial America.This article was submitted to the RAE2008 for the University of Chester - History

Perceptual judgment and saccadic behavior in a spatial distortion with briefly presented stimuli.

When observers are asked to localize the peripheral position of a small probe with respect to the mid-position of a spatially extended comparison stimulus, they tend to judge the probe as being more peripheral than the mid-position of the comparison stimulus. This relative mislocalization seems to emerge from differences in absolute localization, that is the comparison stimulus is localized more towards the fovea than the probe. The present study compared saccadic behaviour and relative localization judgements in three experiments and determined the quantitative relationship between both measures. The results showed corresponding effects in localization errors and saccadic behaviour. Moreover, it was possible to estimate the amount of the relative mislocalization by means of the saccadic amplitude

Naturalizing action theory

The aim of this paper is to give a new argument for naturalized action theory. The sketch of the argument is the following: the immediate mental antecedents of actions, that is, the mental states that makes actions actions, are not normally accessible to introspection. But then we have no other option but to turn to the empirical sciences if we want to characterize and analyze them

Comparison of immunoglobulin and complement deposition in multiple biopsies from the uninvolved skin in dermatitis herpetiformis.

The distribution of immunoglobulins and C3 component of complement (C3) in the skin of twenty-four patients with dermatitis herpetiformis was studied. Skin biopsies were taken from three sites, the extensor surface of the elbow, the flexor surface of the forearm and from the thigh. Twenty-two (90%) patients showed variation in deposits of immunoglobulins and C3 at the three sites. IgA was present in all patients, but differed in quantities deposited at the three sites in nineteen (80%) patients. Similar variation between sites was observed with IgG, IgM and C3. There was variation within three biopsies, IgA being absent from some sections and present in others. Three patients had a continuous pattern of IgA deposition. One had both continuous and papillary deposits within a single section. There was no difference in the incidence or quantity of immunoglobulin and C3 between the elbow, forearm and thigh. There was observed to be a diminution in quantity of IgA and incidence of C3 in patients taking a gluten-free diet. Deposition of IgA, IgM, IgG and C3 is not uniform throughout the skin and conclusions drawn from the quantity of immunoglobulin and C3 in a single biopsy may not be reliable

The potassium iodide patch test in the dermatitis herpetiformis in relation to treatment with a gluten-free diet and dapsone.

The potassium iodide patch test was studied in twenty-six patients with dermatitis herpetiformis. Histological assessment was found more sensitive than clinical. All of five patients with active disease and not on treatment had a positive test, whereas only two of six patients taking a gluten-free diet (GFD) and one of eight taking dapsone were positive. In another two patients taking a GFD, but in whom the diet had not been strict, the test was positive. All three patients in remission and both patients with the linear pattern of IgA (but with active disease) were negative. Immunofluorescence studies showed no difference in the presence, quantity, or distribution of immunoglobulin, complement or fibrinogen between the patch test site and uninvolved skin, or in the uninvolved skin between patients with and without active lesions