Impact of recurrent Clostridium difficile infection: hospitalization and patient quality of life

Objectives: Data quantifying outcomes of recurrent Clostridium difficile infection (rCDI) are lacking. We sought to determine the UK hospital resource use and health-related quality of life (HrQoL) associated with rCDI hospitalisations. Patients and methods: A non-interventional study in 6 UK acute hospitals collected retrospective clinical and resource use data from medical records of 64 adults hospitalised for rCDI and 64 matched inpatient controls with a first episode only (f)CDI. Patients were observed from the index event (date rCDI/fCDI confirmed) for 28-days (or death, if sooner); UK-specific reference costs were applied. HrQoL was assessed prospectively in a separate cohort of 30 patients hospitalised with CDI, who completed the EQ-5D-3L questionnaire during their illness. Results: The median total management cost (post-index) was £7,539 and £6,294 for rCDI and fCDI, respectively (cost difference, p=0.075); median length of stay (LOS) was 21 days and 15.5 days, respectively (p=0.269). The median cost difference between matched rCDI and fCDI cases was £689 (IQR=£-1,873-£3,954). Subgroup analysis demonstrated the highest median costs (£8,542/patient) in severe rCDI cases. CDI management costs were driven primarily by hospital LOS, which accounted for >85% of costs in both groups. Mean EQ-5D index values were 46% lower in CDI patients compared with UK population values (0.42 and 0.78, respectively); EQ-VAS scores were 38% lower (47.82 and 77.3, respectively). Conclusions: CDI has considerable impact on patients and healthcare resources. This multicentre study provides a contemporaneous estimate of the real-world UK costs associated with rCDI management, which are substantial and comparable to fCDI costs

Vector Positronium States in QED3

The homogeneous Bethe-Salpeter equation is solved in the quenched ladder approximation for the vector positronium states of 4-component quantum electrodynamics in 2 space and 1 time dimensions. Fermion propagator input is from a Rainbow approximation Dyson-Schwinger solution, with a broad range of fermion masses considered. This work is an extension of earlier work on the scalar spectrum of the same model. The non-relativistic limit is also considered via the large fermion mass limit. Classification of states via their transformation properties under discrete parity transformations allows analogies to be drawn with the meson spectrum of QCD.Comment: 24 pages, 2 encapsulated postscript figure

Dental treatment and risk of variant CJD - a case control study

Abstract Objective: Knowledge of risk factors for variant CJD (vCJD) remains limited, but transmission of prion proteins via re-useable medical devices, including dental instruments, or enhanced susceptibility following trauma to the oral cavity is a concern. This study aimed to identify whether previous dental treatment is a risk factor for development of vCJD. Design: Case control study Methods: Risk factor questionnaires completed by interview with relatives of 130 vCJD patients and with relatives of 66 community and 53 hospital controls were examined by a dental surgeon. Responses regarding dental treatments were analysed. Results: We did not find a statistically significant excess of risk of vCJD associated with dental treatments with the exception of extractions in an unmatched analysis of vCJD cases with community controls (p=0.02). However, this result may be explained by multiple testing. Conclusions: This is the first published study to date to examine potential links between vCJD and dental treatment. There was no convincing evidence found of an increased risk of variant CJD associated with reported dental treatment. However, the power of the study is restricted by the number of vCJD cases to date and does not preclude the possibility that some cases have resulted from secondary transmission via dental procedures. Due to the limitations of the data available, more detailed analyses of dental records are required to fully exclude the possibility of transmission via dental treatment

Description of inclusive scattering of 4.045 GeV electrons from D

We exploit a relationship between the Structure Functions of nucleons, the physical deuteron and of a deuteron, composed of point-nucleons to compute angular distributions of inclusive cross sections of 4.05 GeV electrons. We report general agreement with data and interpret the remaining discrepancies. We discuss the potential of the data for information on neutron structure functions $F_k^n(x,Q^2)$ and the static form factor $G_M^n(Q^2)$.Comment: 9 pages,1 Fig., PS fil

Predictions for the 4 GeV TJNAF inclusive electron scattering experiment and for FSI effects in EMC ratios

We express nuclear structure functions $F_i^A$ as generalized convolutions of the structure function of a nucleon and of a nucleus, composed of point-nucleons. In computations of the latter we include Final State Interactions and results for $F_2^A$ are compared with a few directly measured data on C and Fe. The above $F_i^A$ are primarily used for predictions of the TJNAF 89-008 inclusive scattering experiment of 4 GeV electrons on various targets. Those cover a broad angular, and correspondingly wide $x,Q^2$ range, where the nucleon-inelastic part dominates large sections of the covered kinematics. The same model has been applied to the study of hitherto neglected Final State Interaction effects in the nuclear component in EMC ratios in the region $0.85\lesssim x\lesssim 0.25$.Comment: 12 page

Group cognitive analytic therapy for female survivors of childhood sexual abuse

Objectives: The effectiveness of cognitive analytic therapy delivered in groups has been under-researched considering the popularity of the approach. This study sought to investigate the effectiveness of 24 sessions of group cognitive analytic therapy (GCAT) delivered in routine practice for female survivors of childhood sexual abuse (CSA). Methods: In a longitudinal cohort design, N = 157 patients were treated with 24 sessions of GCAT. Validated outcome measures were administered at assessment, pre-GCAT, and post-GCAT. This enabled rates of reliable and clinically significant change to be compared between wait time and active group treatment. The uncontrolled treatment effect size was then benchmarked against outcomes from matched studies. Results: On the primary outcome measure, GCAT facilitated a moderate effect size of 0.34 with 11% of patients completing treatment meeting ‘recovery’ criteria. The dropout rate was 19%. Significant improvements in interpersonal functioning, anxiety, and well-being occurred during GCAT in comparison with wait time on secondary outcome measures. Conclusions: Group cognitive analytic therapy appears a promising intervention for adult female CSA survivors, with further controlled evaluation indicated

Sepsis-related deaths in the at-risk population on the wards: attributable fraction of mortality in a large point-prevalence study

Objective Sepsis mortality is reported to be high worldwide, however recently the attributable fraction of mortality due to sepsis (AFsepsis) has been questioned. If improvements in treatment options are to be evaluated, it is important to know what proportion of deaths are potentially preventable or modifiable after a sepsis episode. The aim of the study was to establish the fraction of deaths directly related to the sepsis episode on the general wards and emergency departments. Results 839 patients were recruited over the two 24-h periods in 2016 and 2017. 521 patients fulfilled SEPSIS-3 criteria. 166 patients (32.4%) with sepsis and 56 patients (17.6%) without sepsis died within 90 days. Out of the 166 sepsis deaths 12 (7.2%) could have been directly related to sepsis, 28 (16.9%) possibly related and 96 (57.8%) were not related to sepsis. Overall AFsepsis was 24.1%. Upon analysis of the 40 deaths likely to be attributable to sepsis, we found that 31 patients (77.5%) had the Clinical Frailty Score ≥ 6, 28 (70%) had existing DNA-CPR order and 17 had limitations of care orders (42.5%)

Bioassay studies support the potential for latrogenic transmission of variant Creutzfeldt Jakob disease through dental procedures

Background: Evidence is required to quantify the potential risks of transmission of variant Creutzfeldt Jakob (vCJD) through dental procedures. Studies, using animal models relevant to vCJD, were performed to address two questions. Firstly, whether oral tissues could become infectious following dietary exposure to BSE? Secondly, would a vCJD-contaminated dental instrument be able to transmit disease to another patient? Methods: BSE-301V was used as a clinically relevant model for vCJD. VM-mice were challenged by injection of infected brain homogenate into the small intestine (Q1) or by five minute contact between a deliberately-contaminated dental file and the gingival margin (Q2). Ten tissues were collected from groups of challenged mice at three or four weekly intervals, respectively. Each tissue was pooled, homogenised and bioassayed in indicator mice. Findings: Challenge via the small intestine gave a transmission rate of 100% (mean incubation 157±17 days). Infectivity was found in both dental pulp and the gingival margin within 3 weeks of challenge and was observed in all tissues tested within the oral cavity before the appearance of clinical symptoms. Following exposure to deliberately contaminated dental files, 97% of mice developed clinical disease (mean incubation 234±33 days). Interpretation: Infectivity was higher than expected, in a wider range of oral tissues, than was allowed for in previous risk assessments. Disease was transmitted following transient exposure of the gingiva to a contaminated dental file. These observations provide evidence that dental procedures could be a route of cross-infection for vCJD and support the enforcement of single-use for certain dental instruments

All clinically-relevant blood components transmit prion disease following a single blood transfusion: a sheep model of vCJD

Variant CJD (vCJD) is an incurable, infectious human disease, likely arising from the consumption of BSE-contaminated meat products. Whilst the epidemic appears to be waning, there is much concern that vCJD infection may be perpetuated in humans by the transfusion of contaminated blood products. Since 2004, several cases of transfusion-associated vCJD transmission have been reported and linked to blood collected from pre-clinically affected donors. Using an animal model in which the disease manifested resembles that of humans affected with vCJD, we examined which blood components used in human medicine are likely to pose the greatest risk of transmitting vCJD via transfusion. We collected two full units of blood from BSE-infected donor animals during the pre-clinical phase of infection. Using methods employed by transfusion services we prepared red cell concentrates, plasma and platelets units (including leucoreduced equivalents). Following transfusion, we showed that all components contain sufficient levels of infectivity to cause disease following only a single transfusion and also that leucoreduction did not prevent disease transmission. These data suggest that all blood components are vectors for prion disease transmission, and highlight the importance of multiple control measures to minimise the risk of human to human transmission of vCJD by blood transfusion

Red-flag sepsis and SOFA identifies different patient population at risk of sepsis-related deaths on the general ward

Controversy exists regarding the best diagnostic and screening tool for sepsis outside the intensive care unit (ICU). Sequential organ failure assessment (SOFA) score has been shown to be superior to systemic inflammatory response syndrome (SIRS) criteria, however, the performance of “Red Flag sepsis criteria” has not been tested formally. The aim of the study was to investigate the ability of Red Flag sepsis criteria to identify the patients at high risk of sepsis-related death in comparison to SOFA based sepsis criteria. We also investigated the comparison of Red Flag sepsis to quick SOFA (qSOFA), SIRS, and national early warning score (NEWS) scores and factors influencing patient mortality. Patients were recruited into a 24-hour point-prevalence study on the general wards and emergency departments across all Welsh acute hospitals. Inclusion criteria were: clinical suspicion of infection and NEWS 3 or above in-line with established escalation criteria in Wales. Data on Red Flag sepsis and SOFA criteria was collected together with qSOFA and SIRS scores and 90-day mortality. 459 patients were recruited over a 24-hour period. 246 were positive for Red Flag sepsis, mortality 33.7% (83/246); 241 for SOFA based sepsis criteria, mortality 39.4% (95/241); 54 for qSOFA, mortality 57.4% (31/54), and 268 for SIRS, mortality 33.6% (90/268). 55 patients were not picked up by any criteria. We found that older age was associated with death with OR (95% CI) of 1.03 (1.02–1.04); higher frailty score 1.24 (1.11–1.40); DNA-CPR order 1.74 (1.14–2.65); ceiling of care 1.55 (1.02–2.33); and SOFA score of 2 and above 1.69 (1.16–2.47). The different clinical tools captured different subsets of the at-risk population, with similar sensitivity. SOFA score 2 or above was independently associated with increased risk of death at 90 days. The sequalae of infection-related organ dysfunction cannot be reliably captured based on routine clinical and physiological parameters alone