<i>Pseudomonas aeruginosa</i> intensive care unit outbreak:winnowing of transmissions with molecular and genomic typing

Bioinformatics and computational biology analyses were supported by the University of St Andrews Bioinformatics Unit which is funded by a Wellcome Trust ISSF award [grant 097831/Z/11/Z]. BJP, KO, MP, MTGH, GP and SHG are funded by the Chief Scientist Office through the Scottish Infection Research Network, a part of the SHAIPI consortium grant reference number SIRN/10.Background: Pseudomonas aeruginosa healthcare outbreaks can be time consuming and difficult to investigate. Guidance does not specify which typing technique is most practical to base decisions on. Aim: We explore the usefulness of whole genome sequencing (WGS) in the investigation of a Pseudomonas aeruginosa outbreak describing how it compares with pulsed-field gel electrophoresis (PFGE) and variable number tandem repeat (VNTR) analysis. Methods: Six patient isolates and six environmental samples from an Intensive Care Unit (ICU) positive for P. aeruginosa over two years underwent VNTR, PFGE and WGS. Findings:  VNTR and PFGE were required to fully determine the potential source of infection and rule out others. WGS results unambiguously distinguished linked isolates giving greater assurance of the transmission route between wash hand basin (WHB) water and two patients supporting control measures employed. Conclusion:  WGS provided detailed information without need for further typing. When allied to epidemiological information it can be used to understand outbreak situations rapidly and with certainty. Implementation of WGS in real-time would be a major advance in day-to-day practice. It could become a standard of care as it becomes more widespread due to its reproducibility and reduction in costs.Publisher PDFPeer reviewe

Psychometric assessment of the short-form Child Perceptions Questionnaire: an international collaborative study.

OBJECTIVE: To examine the factor structure and other psychometric characteristics of the most commonly used child oral-health-related quality-of-life (OHRQoL) measure (the 16-item short-form CPQ11-14 ) in a large number of children (N = 5804) from different settings and who had a range of caries experience and associated impacts. METHODS: Secondary data analyses used subnational epidemiological samples of 11- to 14-year-olds in Australia (N = 372), New Zealand (three samples: 352, 202, 429), Brunei (423), Cambodia (244), Hong Kong (542), Malaysia (439), Thailand (220, 325), England (88, 374), Germany (1055), Mexico (335) and Brazil (404). Confirmatory factor analysis (CFA) was used to examine the factor structure of the CPQ11-14 across the combined sample and within four regions (Australia/NZ, Asia, UK/Europe and Latin America). Item impact and internal reliability analysis were also conducted. RESULTS: Caries experience varied, with mean DMFT scores ranging from 0.5 in the Malaysian sample to 3.4 in one New Zealand sample. Even more variation was noted in the proportion reporting only fair or poor oral health; this was highest in the Cambodian and Mexican samples and lowest in the German sample and one New Zealand sample. One in 10 reported that their oral health had a marked impact on their life overall. The CFA across all samples revealed two factors with eigenvalues greater than 1. The first involved all items in the oral symptoms and functional limitations subscales; the second involved all emotional well-being and social well-being items. The first was designated the 'symptoms/function' subscale, and the second was designated the 'well-being' subscale. Cronbach's alpha scores were 0.72 and 0.84, respectively. The symptoms/function subscale contained more of the items with greater impact, with the item 'Food stuck in between your teeth' having greatest impact; in the well-being subscale, the 'Felt shy or embarrassed' item had the greatest impact. Repeating the analyses by world region gave similar findings. CONCLUSION: The CPQ11-14 performed well cross-sectionally in the largest analysis of the scale in the literature to date, with robust and mostly consistent psychometric characteristics, albeit with two underlying factors (rather than the originally hypothesized four-factor structure). It appears to be a sound, robust measure which should be useful for research, practice and policy

Structural Determinants and Children's Oral Health: A Cross-National Study

Much research on children's oral health has focused on proximal determinants at the expense of distal (upstream) factors. Yet, such upstream factors-the so-called structural determinants of health-play a crucial role. Children's lives, and in turn their health, are shaped by politics, economic forces, and social and public policies. The aim of this study was to examine the relationship between children's clinical (number of decayed, missing, and filled teeth) and self-reported oral health (oral health-related quality of life) and 4 key structural determinants (governance, macroeconomic policy, public policy, and social policy) as outlined in the World Health Organization's Commission for Social Determinants of Health framework. Secondary data analyses were carried out using subnational epidemiological samples of 8- to 15-y-olds in 11 countries ( N = 6,648): Australia (372), New Zealand (three samples; 352, 202, 429), Brunei (423), Cambodia (423), Hong Kong (542), Malaysia (439), Thailand (261, 506), United Kingdom (88, 374), Germany (1498), Mexico (335), and Brazil (404). The results indicated that the type of political regime, amount of governance (e.g., rule of law, accountability), gross domestic product per capita, employment ratio, income inequality, type of welfare regime, human development index, government expenditure on health, and out-of-pocket (private) health expenditure by citizens were all associated with children's oral health. The structural determinants accounted for between 5% and 21% of the variance in children's oral health quality-of-life scores. These findings bring attention to the upstream or structural determinants as an understudied area but one that could reap huge rewards for public health dentistry research and the oral health inequalities policy agenda

Rasch model of the child perceptions questionnaire in multi-country data

Objective To be fit-for-purpose, oral health-related quality of life instruments must possess a range of psychometric properties which had not been fully examined in the 16-item Short Form Child Perceptions Questionnaire for children aged 11 to 14 years (CPQ11-14 ISF-16). We used advanced statistical approaches to determine the CPQ’s measurement accuracy, precision, invariance and dimensionality and analyzed whether age range could be extended from 8 to 15 years. Methods Fit to the Rasch model was examined in 6648 8-to-15-year-olds from Australia, New Zealand, Brunei, Cambodia, Hong Kong, Malaysia, Thailand, Germany, United Kingdom, Brazil and Mexico. Results In all but two items, the initial five answer options were reduced to three or four, to increase precision of the children’s selection. Items 10 (Shy/embarrassed) and 11 (Concerned what others think) showed an ‘extra’ dependency between item scores beyond the relationship related to the underlying latent construct represented by the instrument, and so were deleted. Without these two items, the CPQ was unidimensional. The three oral symptoms items (4 Food stuck in teeth, 3 Bad breath and 1 Pain) were required for a sufficient person-item coverage. In three out of 14 items (21 %), Europe and South America showed regional differences in the patterns of how the answer options were selected. No differential item functioning was detected for age. Conclusion Except for a few modifications, the present analysis supports the combination of items, the cross-cultural validity of the CPQ with 14 items and the extension of the age range from 8 to 15 years. Clinical significance The valid, reliable, shortened and age-extended version of the CPQ resulting from this study should be used in routine care and clinical research. Less items and a wider age range increase its usability. Symptoms items are needed to precisely differentiate between children with higher and lower quality of life

An intervention to promote self-management, independence and self-efficacy in people with early-stage dementia : the Journeying through Dementia RCT

Background There are few effective interventions for dementia. Aim To determine the clinical effectiveness and cost-effectiveness of an intervention to promote self-management, independence and self-efficacy in people with early-stage dementia. Objectives To undertake a randomised controlled trial of the Journeying through Dementia intervention compared with usual care, conduct an internal pilot testing feasibility, assess intervention delivery fidelity and undertake a qualitative exploration of participants’ experiences. Design A pragmatic two-arm individually randomised trial analysed by intention to treat. Participants A total of 480 people diagnosed with mild dementia, with capacity to make informed decisions, living in the community and not participating in other studies, and 350 supporters whom they identified, from 13 locations in England, took part. Intervention Those randomised to the Journeying through Dementia intervention (n = 241) were invited to take part in 12 weekly facilitated groups and four one-to-one sessions delivered in the community by secondary care staff, in addition to their usual care. The control group (n = 239) received usual care. Usual care included drug treatment, needs assessment and referral to appropriate services. Usual care at each site was recorded. Main outcome measures The primary outcome was Dementia-Related Quality of Life score at 8 months post randomisation, with higher scores representing higher quality of life. Secondary outcomes included resource use, psychological well-being, self-management, instrumental activities of daily living and health-related quality of life. Randomisation and blinding Participants were randomised in a 1 : 1 ratio. Staff conducting outcome assessments were blinded. Data sources Outcome measures were administered in participants’ homes at baseline and at 8 and 12 months post randomisation. Interviews were conducted with participants, participating carers and interventionalists. Results The mean Dementia-Related Quality of Life score at 8 months was 93.3 (standard deviation 13.0) in the intervention arm (n = 191) and 91.9 (standard deviation 14.6) in the control arm (n = 197), with a difference in means of 0.9 (95% confidence interval –1.2 to 3.0; p = 0.380) after adjustment for covariates. This effect size (0.9) was less than the 4 points defined as clinically meaningful. For other outcomes, a difference was found only for Diener’s Flourishing Scale (adjusted mean difference 1.2, 95% confidence interval 0.1 to 2.3), in favour of the intervention (i.e. in a positive direction). The Journeying through Dementia intervention cost £608 more than usual care (95% confidence interval £105 to £1179) and had negligible difference in quality-adjusted life-years (–0.003, 95% confidence interval –0.044 to 0.038). Therefore, the Journeying through Dementia intervention had a mean incremental cost per quality-adjusted life-year of –£202,857 (95% confidence interval –£534,733 to £483,739); however, there is considerable uncertainty around this. Assessed fidelity was good. Interviewed participants described receiving some benefit and a minority benefited greatly. However, negative aspects were also raised by a minority. Seventeen per cent of participants in the intervention arm and 15% of participants in the control arm experienced at least one serious adverse event. None of the serious adverse events were classified as related to the intervention. Limitations Study limitations include recruitment of an active population, delivery challenges and limitations of existing outcome measures. Conclusions The Journeying through Dementia programme is not clinically effective, is unlikely to be cost-effective and cannot be recommended in its existing format. Future work Research should focus on the creation of new outcome measures to assess well-being in dementia and on using elements of the intervention, such as enabling enactment in the community. Trial registration This trial is registered as ISRCTN17993825

SARS-CoV-2-specific nasal IgA wanes 9 months after hospitalisation with COVID-19 and is not induced by subsequent vaccination

BACKGROUND: Most studies of immunity to SARS-CoV-2 focus on circulating antibody, giving limited insights into mucosal defences that prevent viral replication and onward transmission. We studied nasal and plasma antibody responses one year after hospitalisation for COVID-19, including a period when SARS-CoV-2 vaccination was introduced. METHODS: In this follow up study, plasma and nasosorption samples were prospectively collected from 446 adults hospitalised for COVID-19 between February 2020 and March 2021 via the ISARIC4C and PHOSP-COVID consortia. IgA and IgG responses to NP and S of ancestral SARS-CoV-2, Delta and Omicron (BA.1) variants were measured by electrochemiluminescence and compared with plasma neutralisation data. FINDINGS: Strong and consistent nasal anti-NP and anti-S IgA responses were demonstrated, which remained elevated for nine months (p < 0.0001). Nasal and plasma anti-S IgG remained elevated for at least 12 months (p < 0.0001) with plasma neutralising titres that were raised against all variants compared to controls (p < 0.0001). Of 323 with complete data, 307 were vaccinated between 6 and 12 months; coinciding with rises in nasal and plasma IgA and IgG anti-S titres for all SARS-CoV-2 variants, although the change in nasal IgA was minimal (1.46-fold change after 10 months, p = 0.011) and the median remained below the positive threshold determined by pre-pandemic controls. Samples 12 months after admission showed no association between nasal IgA and plasma IgG anti-S responses (R = 0.05, p = 0.18), indicating that nasal IgA responses are distinct from those in plasma and minimally boosted by vaccination. INTERPRETATION: The decline in nasal IgA responses 9 months after infection and minimal impact of subsequent vaccination may explain the lack of long-lasting nasal defence against reinfection and the limited effects of vaccination on transmission. These findings highlight the need to develop vaccines that enhance nasal immunity. FUNDING: This study has been supported by ISARIC4C and PHOSP-COVID consortia. ISARIC4C is supported by grants from the National Institute for Health and Care Research and the Medical Research Council. Liverpool Experimental Cancer Medicine Centre provided infrastructure support for this research. The PHOSP-COVD study is jointly funded by UK Research and Innovation and National Institute of Health and Care Research. The funders were not involved in the study design, interpretation of data or the writing of this manuscript

Neighbourhoods for health service administration

Health and social service administrators are increasingly realising the importance of adopting a community or neighbourhood scale for the organisation and delivery of many different services. The concept of neighbourhood is an elusive one, yet it has been used for a number of planning purposes. This paper reviews the nature and utility of neighbourhoods and demonstrates the variety of territorial units used by different statutory agencies. The results of an empirical exercise in North Staffordshire are reported as an example of the practical issues involved. Neighbourhoods are identified with a view to being used for data collection, the delivery of health care services and the possible implementation of health forums.neighbourhood community location service delivery

Responsiveness of the child perceptions questionnaire (11-14) for Cambodian children undergoing basic dental care

BackgroundOral-Health-Related Quality of Life (OHRQoL) instruments are useful outcome measures in dental health services research; however, there are no reports of the use OHRQoL measures in evaluating the outcome of basic dental care in children anywhere. AimThe aims of this study are to evaluate the responsiveness of the Khmer version of the Child Perceptions Questionnaire(11-14) (CPQ(11-14)) and to describe changes in OHRQoL associated with the provision of basic dental care. DesignA pre-test/post-test design, with a clinical convenience sample of children aged from 8 to 14 years of age who received basic dental care from a local nongovernmental organisation (NGO). ResultsOf the 140 children in the baseline sample, 116 (82.9%) were followed up. The mean change in CPQ(11-14) overall score for those with caries was 1.7, representing a small improvement in OHRQoL. There was a moderate (one in three) statistically significant reduction in the prevalence of impacts across the whole sample (P<0.001; McNemar test), and one in five improved by the minimally important difference (MID) of five-scale points. ConclusionsThe Khmer version of the CPQ(11-14) appears to be a valid and responsive measure for assessing treatment-associated changes in OHRQoL in children with dental caries in Cambodia

Validation of an Oral Health–Related Quality of Life Measure for Cambodian Children

This study aimed to determine the impact of dental caries in terms of Oral Health-Related Quality of Life (OHRQoL) for Cambodian children. The Child Perceptions Questionnaires (CPQ) were cross-culturally adapted and validated for the Cambodian population using a sample of 430 Cambodian children. The participants had a high caries burden, with a mean number of decayed-missing-and-filled deciduous tooth surfaces (dmfs) of 8.8 (SD = 11.1) and a mean DMFS of 3.7 (SD = 5.5) for the permanent dentition. Two in 5 children had at least one pulpally involved tooth. There was a significant difference in mean CPQ8-10 and CPQ11-14 scores by caries experience and by global item response for the respective age-groups, with those in the more severe caries categories scoring higher. Similar gradients were apparent with the CPQ11-14 in the 8- to 10-year age-group. The differences in OHRQoL scores by caries experience demonstrate the construct validity of the CPQ11-14 for the 8- to 14-year age-group