Investigation of a Q fever outbreak in a Scottish co-located slaughterhouse and cutting plant

Outbreaks of Q fever are rare in the UK. In 2006, the largest outbreak of Q fever in Scotland occurred at a co-located slaughterhouse and cutting plant with 110 cases. Preliminary investigations pointed to the sheep lairage being the potential source of exposure to the infective agent. A retrospective cohort study was carried out among workers along with environmental sampling to guide public health interventions. A total of 179 individuals were interviewed of whom 66 (37%) were migrant workers. Seventy-five (41.9%) were serologically confirmed cases. Passing through a walkway situated next to the sheep lairage, a nearby stores area, and being male were independently associated with being serologically positive for Q fever. The large proportion of migrant workers infected presented a significant logistical problem during outbreak investigation and follow up. The topic of vaccination against Q fever for slaughterhouse workers is contentious out with Australasia, but this outbreak highlights important occupational health issues

Effect of improved home ventilation on asthma control and house dust mite allergen levels

The warm, humid environment in modern homes favours the dust mite population, but the effect of improved home ventilation on asthma control has not been established. We tested the hypothesis that a domestic mechanical heat recovery ventilation system (MHRV), in addition to allergen avoidance measures, can improve asthma control by attenuating re-colonization rates. We conducted a randomized double-blind placebo-controlled parallel group trial of the installation of MHRV activated in half the homes of 120 adults with asthma, allergic to Dermatophagoides pteronyssinus. All homes had carpets steam cleaned and new bedding and mattress covers at baseline. The primary outcome was morning peak expiratory flow (PEF) at 12 months. At 12 months, the primary end-point; change in mean morning PEF as compared with baseline, did not differ between the MHRV group and the control group (mean difference 13.5 l/min, 95% CI: −2.6 to 29.8, P = 0.10). However, a secondary end-point; evening mean PEF, was significantly improved in the MHRV group (mean difference 24.5 l/min, 95% CI: 8.9-40.1, P = 0.002). Indoor relative humidity was reduced in MHRV homes, but there was no difference between the groups in Der p 1 levels, compared with baseline. The addition of MHRV to house dust mite eradication strategies did not achieve a reduction in mite allergen levels, but did improve evening PEF

Sequential Bilateral Lung Resection in a Patient with Mycobacterium Abscessus Lung Disease Refractory to Medical Treatment

Mycobacterium abscessus (M. abscessus) is the second most common nontuberculous mycobacteria (NTM) in South Korea. Nevertheless, the diagnosis and treatment of M. abscessus lung disease can be problematic. Surgical resection has been tried for patients with localized M. abscessus lung disease refractory to medical treatment. Here, we report on a 25-year-old woman with M. abscessus lung disease who had been diagnosed and treated three times for pulmonary tuberculosis. She was initially diagnosed as having M. intracellulare lung disease; however, M. abscessus was isolated after several months of medication. She had multiple bronchiectatic and cavitary lesions bilaterally, and M. abscessus was repeatedly isolated from her sputa despite prolonged treatment with clarithromycin, ethambutol, moxifloxacin, and amikacin. She improved only after sequential bilateral lung resection. Based on the experience with this patient, we suggest that, if medical treatment fails, surgical resection of a diseased lung should be considered even in patients with bilateral lesions

Practice development plans to improve the primary care management of acute asthma: randomised controlled trial

Background: Our professional development plan aimed to improve the primary care management of acute asthma, which is known to be suboptimal. Methods: We invited 59 general practices in Grampian, Scotland to participate. Consenting practices were randomised to early and delayed intervention groups. Practices undertook audits of their management of all acute attacks (excluding children under 5 years) occurring in the 3 months preceding baseline, 6-months and 12-months study time-points. The educational programme [including feedback of audit results, attendance at a multidisciplinary interactive workshop, and formulation of development plan by practice teams] was delivered to the early group at baseline and to the delayed group at 6 months. Primary outcome measure was recording of peak flow compared to best/predicted at 6 months. Analyses are presented both with, and without adjustment for clustering. Results: 23 consenting practices were randomised: 11 to early intervention. Baseline practice demography was similar. Six early intervention practices withdraw before completing the baseline audit. There was no significant improvement in our primary outcome measure (the proportion with peak flow compared to best/predicted) at either the 6 or 12 month time points after adjustment for baseline and practice effects. However, the between group difference in the adjusted combined assessment score, whilst non-significant at 6 months (Early: 2.48 (SE 0.43) vs. Delayed 2.26 (SE 0.33) p = 0.69) reached significance at 12 m (Early:3.60 (SE 0.35) vs. Delayed 2.30 (SE 0.28) p = 0.02). Conclusion: We demonstrated no significant benefit at the a priori 6-month assessment point, though improvement in the objective assessment of attacks was shown after 12 months. Our practice development programme, incorporating audit, feedback and a workshop, successfully engaged the healthcare team of participating practices, though future randomised trials of educational interventions need to recognise that effecting change in primary care practices takes time. Monitoring of the assessment of acute attacks proved to be a feasible and responsive indicator of quality care

Serum 25-hydroxyvitamin D levels in hospitalized adults with community-acquired pneumonia

Introduction: Community‐acquired pneumonia (CAP) is the infectious disease with the highest number of deaths worldwide. Several studies have shown an association between vitamin D deficiency and increases susceptibility to respiratory tract infections. Objective: The aim of this study was to evaluate the serum 25‐hydroxyvitamin D (25OHD) levels in hospitalized adults in general room with CAP. Materials and methods: An observational study was carried out in 207 hospitalized adults of both sex with CAP (>18 years) from Rosario city, Argentina (32° 52′ 18″S) between July 2015 and June 2016. Results: In total, 167 patients were included in the data analysis [59% women (57.4 ± 19.6 years), body mass index 27.2 ± 7.8 kg/m2]. In brief, 63% showed unilobar infiltrate and 37% were multilobar. The CURB‐65 index was 66.5% low risk, 16.0% intermediate risk and 17.5% high risk. According to Charlson comorbidity index (CCI) 53.5% had not comorbidity (CCI = 0) and 46.5% showed CCI ≥ 1. The 25OHD level was: 11.92 ± 7.6 ng/mL (51.5%: 30 ng/mL). Higher 25OHD were found in male (female: 10.8 ± 6.7 ng/mL, male: 13.5 ± 8.5 ng/mL, P = .02) and 25OHD correlated with age (r = –.17; P = .02). 25‐Hydroxyvitamin D was also correlated with CURB65 index (r = –.13; P = .049), CCI (r = –.20, P = .007) and with the 10 years of life expectative (%) (r = .19; P = .008). In addition, higher 25OHD were found with lower CCI (CCI 0 = 13.0 ± 8.2 ng/mL, CCI ≥ 1= 10.5 ± 6.7 ng/mL; P = .0093). Conclusions: Hospitalized adults with CAP have lower 25OHD levels and would be associated with the severity of CAP.Fil: Brance, María Lorena. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas. Laboratorio de Biología Ósea; ArgentinaFil: Miljevic, Julio Norberto. Provincia de Santa Fe. Municipalidad de Rosario; Argentina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; ArgentinaFil: Tizziani, Raquel. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Provincia de Santa Fe. Municipalidad de Rosario; ArgentinaFil: Taberna, María E.. Provincia de Santa Fe. Municipalidad de Rosario; Argentina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; ArgentinaFil: Grossi, Georgina P.. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Provincia de Santa Fe. Municipalidad de Rosario; ArgentinaFil: Toni, Pablo. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Provincia de Santa Fe. Municipalidad de Rosario; ArgentinaFil: Valentini, Elina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Sanatorio de la Mujer; ArgentinaFil: Trepat, Andrea. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Sanatorio de la Mujer; ArgentinaFil: Zaccardi, Julia. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Hospital Español de Rosario; ArgentinaFil: Moro, Juan. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Hospital Español de Rosario; ArgentinaFil: Finuci Curi, Baltasar. Provincia de Santa Fe. Ministerio de Salud. Hospital Provincial de Rosario; Argentina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; ArgentinaFil: Tamagnone, Norberto. Provincia de Santa Fe. Ministerio de Salud. Hospital Provincial de Rosario; Argentina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; ArgentinaFil: Ramirez, Mariano. Sanatorio Plaza de Rosario; Argentina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; ArgentinaFil: Severini, Javier. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Provincia de Santa Fe. Municipalidad de Rosario; ArgentinaFil: Chiarotti, Pablo Ignacio. Provincia de Santa Fe. Municipalidad de Rosario; Argentina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; ArgentinaFil: Consiglio, Francisco. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Sanatorio Laprida de Rosario; ArgentinaFil: Piñeski, Raúl. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Sanatorio Laprida de Rosario; ArgentinaFil: Ghelfi, Albertina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Provincia de Santa Fe. Ministerio de Salud. Hospital Escuela "Eva Perón"; ArgentinaFil: Kilstein, Jorge Guillermo. Provincia de Santa Fe. Ministerio de Salud. Hospital Escuela "Eva Perón"; Argentina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; ArgentinaFil: Street, Eduardo. Hospital Rosendo García de Rosario; Argentina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; ArgentinaFil: Moretti, Dino. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Sanatorio Delta de Rosario; ArgentinaFil: Oliveto, Viviana. Sanatorio Nuestra Señora del Rosario; Argentina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; ArgentinaFil: Mariño, Marcelo. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Sanatorio Británico de Rosario; ArgentinaFil: Manera, Jorge. Sanatorio Británico de Rosario; Argentina. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; ArgentinaFil: Brun, Lucas Ricardo Martín. Universidad Nacional de Rosario. Facultad de Ciencias Médicas; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentin

Physiological-social score (PMEWS) vs. CURB-65 to triage pandemic influenza: a comparative validation study using community-acquired pneumonia as a proxy

BACKGROUND: An influenza pandemic may increase Emergency Department attendance 7-fold. In the absence of a validated "flu score" to assess severity and assist triage decisions from primary into secondary care, current UK draft management recommendations have suggested the use of CURB-65 and chest X-ray as a proxy. We developed the Pandemic Medical Early Warning Score (PMEWS) to track and triage flu patients, taking into account physiological and social factors and without requiring laboratory or radiology services. METHODS: Validation of the PMEWS score against an unselected group of patients presenting and admitted to an urban UK teaching hospital with community acquired pneumonia. Comparison of PMEWS performance against CURB-65 for three outcome measures: need for admission, admission to high dependency or intensive care, and inpatient mortality using area under ROC curve (AUROC) and the Hanley-McNeil method of comparison. RESULTS: PMEWS was a better predictor of need for admission (AUROC 0.944) and need of higher level of care (AUROC 0.83) compared with CURB-65 (AUROCs 0.881 and 0.640 respectively) but was not as good a predictor of subsequent inpatient mortality (AUROC 0.663). CONCLUSION: Although further validation against other disease datasets as a proxy for pandemic flu is required, we show that PMEWS is rapidly applicable for triage of large numbers of flu patients to self-care, hospital admission or HDU/ICU care. It is scalable to reflect changing admission thresholds that will occur during a pandemic

Tailored second line therapy in asthmatic children with the arginine-16 genotype

The arginine-16 beta-2 receptor genotype confers increased susceptibility to exacerbations in asthmatic children taking regular long acting beta-2 agonists. We therefore evaluated using montelukast as an alternative to salmeterol as tailored second line asthma controller therapy in children expressing this susceptible genotype. 62 persistent asthmatic children with the homozygous arginine-16 genotype were randomized to receive salmeterol 50ug bid or montelukast 5/10mg od as add on to inhaled fluticasone for 1 year. School absences (the primary outcome) were reduced with montelukast arm compared to salmeterol: difference in score = 0.40 (95%CI 0.07-0.87) p=0.005. Albuterol use was also reduced with montelukast compared with salmeterol: difference in score = 0.47 (95%CI 0.16-0.79) p<0.0001. Greater improvements occurred in both symptom and quality of life scores with montelukast vs salmeterol, while there was no difference in FEV1. Montelukast may be suitable as tailored second line controller therapy instead of salmeterol in asthmatic children expressing the susceptible arginine-16 genotype - moving towards a personalised medicine approach to management