An outbreak of Streptococcus pyogenes in a mental health facility : advantage of well-timed whole-genome sequencing over emm typing

Financial support: The outbreak investigation was supported by Institute of Mental Health.OBJECTIVE:  We report the utility of whole-genome sequencing (WGS) conducted in a clinically relevant time frame (ie, sufficient for guiding management decision), in managing a Streptococcus pyogenes outbreak, and present a comparison of its performance with emm typing. SETTING:  A 2,000-bed tertiary-care psychiatric hospital. METHODS:  Active surveillance was conducted to identify new cases of S. pyogenes. WGS guided targeted epidemiological investigations, and infection control measures were implemented. Single-nucleotide polymorphism (SNP)-based genome phylogeny, emm typing, and multilocus sequence typing (MLST) were performed. We compared the ability of WGS and emm typing to correctly identify person-to-person transmission and to guide the management of the outbreak. RESULTS:  The study included 204 patients and 152 staff. We identified 35 patients and 2 staff members with S. pyogenes. WGS revealed polyclonal S. pyogenes infections with 3 genetically distinct phylogenetic clusters (C1-C3). Cluster C1 isolates were all emm type 4, sequence type 915 and had pairwise SNP differences of 0-5, which suggested recent person-to-person transmissions. Epidemiological investigation revealed that cluster C1 was mediated by dermal colonization and transmission of S. pyogenes in a male residential ward. Clusters C2 and C3 were genomically diverse, with pairwise SNP differences of 21-45 and 26-58, and emm 11 and mostly emm120, respectively. Clusters C2 and C3, which may have been considered person-to-person transmissions by emm typing, were shown by WGS to be unlikely by integrating pairwise SNP differences with epidemiology. CONCLUSIONS:  WGS had higher resolution than emm typing in identifying clusters with recent and ongoing person-to-person transmissions, which allowed implementation of targeted intervention to control the outbreak.PostprintPeer reviewe

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Investigation of new materials and methods of construction of personnel armor

There has been a considerable amount of research done over the years on personnel and vehicle armor. However, much of this work has focused on finding materials that were very 'strong' to resist penetration of objects moving at high velocity. It is proposed here to study new armor concepts that are constructed using fundamental shock physics methods. The goal of this research is to develop materials concepts through an understanding of shock physics that will lead to new armor concepts for personnel, or for vehicles. It is envisioned that initial concepts will be developed from theoretical arguments, but with the aid of computational tools, such as hydrocodes. Our approach is to define materials theoretically that have desirable properties, and put these materials together into a computer model. It is also envisioned that at a minimum a four-layered approach is required. Currently, our concept is composed of an initial high impedance layer, which will serve to minimize the shock transmitted from an incoming blast wave. Additional layers are then optimized to stop projectile penetration. The second layer is envisioned to be able to quickly spread the energy from impact laterally coupled with a slow throughthickness sound speed for slowing down the shock wave. The third layer is then used to absorb energy much more effectively and transform kinetic energy into heat. If a fragment is still able to penetrate through layers 1, 2 and 3, it is essential to have a fourth layer with very high strength to provide a final attempt at stopping any penetrator.http://archive.org/details/investigationofn109453784Singapore Army author.Approved for public release; distribution is unlimited

Empowering the community and profession through collaborative digital learning

The global pandemic situation has shifted physical learning to online professional development to be challenging. This is particularly difficult to ensure effective psychomotor learning when learners are disconnected from the conventional peer interaction and physical hardware. This promoted the importance of resilience for both educators and learners to reconnect psychomotor learning through virtual/hybrid setting. A staff-student collaborative inspiration emerged with the collaboration across Malaysia and Edinburgh campuses in engaging multiple learning styles through remote digital learning. Aligned to the rising call of building innovation-entrepreneurship ecosystem, this student-led project focused on remote development of programming skills, translating ideas into tangible solution, and pitching among Malaysia and international students to address a selected Sustainable Development Goal. This inter-disciplinary initiative connects the field of engineering and psychology in studying the resilience context of learning. A resilience theme focuses on enhancing skills through digital platforms in building resilient communities. A total of 45 local and international students were engaged through an online prototype and idea pitching competition that supported by industrial workshops. A survey and thematic analysis were launched to gather the feedback from students upon completion of the project. The outcomes highlight the positive response from students’ perspective as participants and judges, and their learning growth. The studied themes indicate the effectiveness of learning through hardware/physical aspect on cognitive, psychomotor, and affective learning domains. This project remarks a cross academic fields (engineering and psychology), sectors (academy and industry), countries (Malaysia and Edinburgh), and roles (educators and learners) inter-disciplinary team effort

Empowering the community and profession through collaborative digital learning

The global pandemic situation has shifted physical learning to online professional development to be challenging. This is particularly difficult to ensure effective psychomotor learning when learners are disconnected from the conventional peer interaction and physical hardware. This promoted the importance of resilience for both educators and learners to reconnect psychomotor learning through virtual/hybrid setting. A staff-student collaborative inspiration emerged with the collaboration across Malaysia and Edinburgh campuses in engaging multiple learning styles through remote digital learning. Aligned to the rising call of building innovation-entrepreneurship ecosystem, this student-led project focused on remote development of programming skills, translating ideas into tangible solution, and pitching among Malaysia and international students to address a selected Sustainable Development Goal. This inter-disciplinary initiative connects the field of engineering and psychology in studying the resilience context of learning. A resilience theme focuses on enhancing skills through digital platforms in building resilient communities. A total of 45 local and international students were engaged through an online prototype and idea pitching competition that supported by industrial workshops. A survey and thematic analysis were launched to gather the feedback from students upon completion of the project. The outcomes highlight the positive response from students’ perspective as participants and judges, and their learning growth. The studied themes indicate the effectiveness of learning through hardware/physical aspect on cognitive, psychomotor, and affective learning domains. This project remarks a cross academic fields (engineering and psychology), sectors (academy and industry), countries (Malaysia and Edinburgh), and roles (educators and learners) inter-disciplinary team effort

Empowering the community and professional development through collaborative digital learning

The global pandemic situation has shifted physical learning to online professional development to be challenging. This is particularly difficult to ensure effective psychomotor learning when learners are disconnected from the conventional peer interaction and physical hardware. This promoted the importance of resilience for both educators and learners to reconnect psychomotor learning through virtual/hybrid setting. A staff-student collaborative inspiration emerged with the collaboration across Malaysia and Edinburgh campuses in engaging multiple learning styles through remote digital learning. Aligned to the rising call of building innovation-entrepreneurship ecosystem, this student-led project focused on remote development of programming skills, translating ideas into tangible solution, and pitching among Malaysia and international students to address a selected Sustainable Development Goal. This inter-disciplinary initiative connects the field of engineering and psychology in studying the resilience context of learning. A resilience theme focuses on enhancing skills through digital platforms in building resilient communities. A total of 45 local and international students were engaged through an online prototype and idea pitching competition that supported by industrial workshops. A survey and thematic analysis were launched to gather the feedback from students upon completion of the project. The outcomes highlight the positive response from students’ perspective as participants and judges, and their learning growth. The studied themes indicate the effectiveness of learning through hardware/physical aspect on cognitive, psychomotor, and affective learning domains. This project remarks a cross academic fields (engineering and psychology), sectors (academy and industry), countries (Malaysia and Edinburgh), and roles (educators and learners) inter-disciplinary team effort

A randomized controlled trial of a brain-computer interface based attention training program for ADHD

Objective : The use of brain-computer interface in neurofeedback therapy for attention deficit hyperactivity disorder (ADHD) is a relatively new approach. We conducted a randomized controlled trial (RCT) to determine whether an 8-week brain computer interface (BCI)-based attention training program improved inattentive symptoms in children with ADHD compared to a waitlist-control group, and the effects of a subsequent 12-week lower-intensity training. Study design : We randomized 172 children aged 6–12 attending an outpatient child psychiatry clinic diagnosed with inattentive or combined subtypes of ADHD and not receiving concurrent pharmacotherapy or behavioral intervention to either the intervention or waitlist-control group. Intervention involved 3 sessions of BCI-based training for 8 weeks, followed by 3 training sessions per month over the subsequent 12 weeks. The waitlist-control group received similar 20-week intervention after a wait-time of 8 weeks. Results : The participants’ mean age was 8.6 years (SD = 1.51), with 147 males (85.5%) and 25 females (14.5%). Modified intention to treat analyzes conducted on 163 participants with at least one follow-up rating showed that at 8 weeks, clinician-rated inattentive symptoms on the ADHD-Rating Scale (ADHD-RS) was reduced by 3.5 (SD 3.97) in the intervention group compared to 1.9 (SD 4.42) in the waitlist-control group (between-group difference of 1.6; 95% CI 0.3 to 2.9 p = 0.0177). At the end of the full 20-week treatment, the mean reduction (pre-post BCI) of the pooled group was 3.2 (95% CI 2.4 to 4.1). Conclusion : The results suggest that the BCI-based attention training program can improve ADHD symptoms after a minimum of 24 sessions and maintenance training may sustain this improvement. This intervention may be an option for treating milder cases or as an adjunctive treatment.NMRC (Natl Medical Research Council, S’pore)Published versio