Hospital Networks and the Dispersal of Hospital-Acquired Pathogens by Patient Transfer

Hospital-acquired infections (HAI) are often seen as preventable incidents that result from unsafe practices or poor hospital hygiene. This however ignores the fact that transmissibility is not only a property of the causative organisms but also of the hosts who can translocate bacteria when moving between hospitals. In an epidemiological sense, hospitals become connected through the patients they share. We here postulate that the degree of hospital connectedness crucially influences the rates of infections caused by hospital-acquired bacteria. To test this hypothesis, we mapped the movement of patients based on the UK-NHS Hospital Episode Statistics and observed that the proportion of patients admitted to a hospital after a recent episode in another hospital correlates with the hospital-specific incidence rate of MRSA bacteraemia as recorded by mandatory reporting. We observed a positive correlation between hospital connectedness and MRSA bacteraemia incidence rate that is significant for all financial years since 2001 except for 2008–09. All years combined, this correlation is positive and significantly different from zero (partial correlation coefficient r = 0.33 (0.28 to 0.38)). When comparing the referral pattern for English hospitals with referral patterns observed in the Netherlands, we predict that English hospitals more likely see a swifter and more sustained spread of HAIs. Our results indicate that hospitals cannot be viewed as individual units but rather should be viewed as connected elements of larger modular networks. Our findings stress the importance of cooperative effects that will have a bearing on the planning of health care systems, patient management and hospital infection control

The Microbiota Mediates Pathogen Clearance from the Gut Lumen after Non-Typhoidal Salmonella Diarrhea

Many enteropathogenic bacteria target the mammalian gut. The mechanisms protecting the host from infection are poorly understood. We have studied the protective functions of secretory antibodies (sIgA) and the microbiota, using a mouse model for S. typhimurium diarrhea. This pathogen is a common cause of diarrhea in humans world-wide. S. typhimurium (S. tmatt, sseD) causes a self-limiting gut infection in streptomycin-treated mice. After 40 days, all animals had overcome the disease, developed a sIgA response, and most had cleared the pathogen from the gut lumen. sIgA limited pathogen access to the mucosal surface and protected from gut inflammation in challenge infections. This protection was O-antigen specific, as demonstrated with pathogens lacking the S. typhimurium O-antigen (wbaP, S. enteritidis) and sIgA-deficient mice (TCRβ−/−δ−/−, JH−/−, IgA−/−, pIgR−/−). Surprisingly, sIgA-deficiency did not affect the kinetics of pathogen clearance from the gut lumen. Instead, this was mediated by the microbiota. This was confirmed using ‘L-mice’ which harbor a low complexity gut flora, lack colonization resistance and develop a normal sIgA response, but fail to clear S. tmatt from the gut lumen. In these mice, pathogen clearance was achieved by transferring a normal complex microbiota. Thus, besides colonization resistance ( = pathogen blockage by an intact microbiota), the microbiota mediates a second, novel protective function, i.e. pathogen clearance. Here, the normal microbiota re-grows from a state of depletion and disturbed composition and gradually clears even very high pathogen loads from the gut lumen, a site inaccessible to most “classical” immune effector mechanisms. In conclusion, sIgA and microbiota serve complementary protective functions. The microbiota confers colonization resistance and mediates pathogen clearance in primary infections, while sIgA protects from disease if the host re-encounters the same pathogen. This has implications for curing S. typhimurium diarrhea and for preventing transmission

Web-based tools can be used reliably to detect patients with major depressive disorder and subsyndromal depressive symptoms

BACKGROUND: Although depression has been regarded as a major public health problem, many individuals with depression still remain undetected or untreated. Despite the potential for Internet-based tools to greatly improve the success rate of screening for depression, their reliability and validity has not been well studied. Therefore the aim of this study was to evaluate the test-retest reliability and criterion validity of a Web-based system, the Internet-based Self-assessment Program for Depression (ISP-D). METHODS: The ISP-D to screen for major depressive disorder (MDD), minor depressive disorder (MinD), and subsyndromal depressive symptoms (SSD) was developed in traditional Chinese. Volunteers, 18 years and older, were recruited via the Internet and then assessed twice on the online ISP-D system to investigate the test-retest reliability of the test. They were subsequently prompted to schedule face-to-face interviews. The interviews were performed by the research psychiatrists using the Mini-International Neuropsychiatric Interview and the diagnoses made according to DSM-IV diagnostic criteria were used for the statistics of criterion validity. Kappa (κ) values were calculated to assess test-retest reliability. RESULTS: A total of 579 volunteer subjects were administered the test. Most of the subjects were young (mean age: 26.2 ± 6.6 years), female (77.7%), single (81.6%), and well educated (61.9% college or higher). The distributions of MDD, MinD, SSD and no depression specified were 30.9%, 7.4%, 15.2%, and 46.5%, respectively. The mean time to complete the ISP-D was 8.89 ± 6.77 min. One hundred and eighty-four of the respondents completed the retest (response rate: 31.8%). Our analysis revealed that the 2-week test-retest reliability for ISP-D was excellent (weighted κ = 0.801). Fifty-five participants completed the face-to-face interview for the validity study. The sensitivity, specificity, positive, and negative predictive values for major depressive disorder were 81.8% and 72.7%, 66.7%, and 85.7% respectively. The overall accuracy was 76.4%. CONCLUSION: The evidence indicates the ISP-D is a reliable and valid online tool for assessing depression. Further studies should test the ISP-D in clinical settings to increase its applications in clinical environments with different populations and in a larger sample size

Elastogenic Protein Expression of a Highly Elastic Murine Spinal Ligament: The Ligamentum Flavum

Spinal ligaments, such as the ligamentum flavum (LF), are prone to degeneration and iatrogenic injury that can lead to back pain and nerve dysfunction. Repair and regeneration strategies for these tissues are lacking, perhaps due to limited understanding of spinal ligament formation, the elaboration of its elastic fibers, maturation and homeostasis. Using immunohistochemistry and histology, we investigated murine LF elastogenesis and tissue formation from embryonic to mature postnatal stages. We characterized the spatiotemporal distribution of the key elastogenic proteins tropoelastin, fibrillin-1, fibulin-4 and lysyl oxidase. We found that elastogenesis begins in utero with the microfibril constituent fibrillin-1 staining intensely just before birth. Elastic fibers were first detected histologically at postnatal day (P) 7, the earliest stage at which tropoelastin and fibulin-4 stained intensely. From P7 to P28, elastic fibers grew in diameter and became straighter along the axis. The growth of elastic fibers coincided with intense staining of tropoelastin and fibulin-4 staining, possibly supporting a chaperone role for fibulin-4. These expression patterns correlated with reported skeletal and behavioral changes during murine development. This immunohistochemical characterization of elastogenesis of the LF will be useful for future studies investigating mechanisms for elastogenesis and developing new strategies for treatment or regeneration of spinal ligaments and other highly elastic tissues

Private Entry and Emerging Partnerships in Container Terminal Operations: Evidence from Asia

This paper seeks to expand understanding of inter-firm partnerships in the maritime sector. The paper recognises ocean carriers and global terminal operators as leading agents of change in the container port industry. While useful, the extant literature's focus on strategic alliances among mega-carriers neglects the role of terminals in defining firms' global strategies in logistical expansion. Meanwhile, rapidly expanding port-operating transnational corporations (TNC) are forcing fundamental shifts in partnership dynamics, defining port–carrier interaction. A multilayered network framework is introduced to build a conceptual link between private entry and emerging partnerships in the container terminal industry. Evidence from Asian ports and Asian TNCs are provided in support of this. The paper concludes by stressing the need to recognise heterogeneity among strategic entry paths available to private entrants in their stake over container terminal operation and finance. Maritime Economics & Logistics (2005) 7, 87–115. doi:10.1057/palgrave.mel.9100131