Recent Submissions

  • Short-term COVID-19 vaccine adverse effects among adults in Ekiti State, Nigeria

    Adesokan, Adedapo
    Background: The safety of the COVID-19 vaccines has been a topic of concern globally. This issue of safety is associated with vaccine hesitancy due to concerns about the adverse effects of the vaccines. Consequently, this study determined the short-term safety profile of the Oxford/AstraZeneca COVID-19 vaccine in Ekiti State, Nigeria. Methods: Descriptive cross-sectional study conducted between May and July 2021 among individuals who had received the first dose of the first batch of the Oxford/AstraZeneca COVID-19 vaccine at Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti, Nigeria. A Google form was used to collect data on the adverse effects of the vaccine. Results: Out of over 1,000 individuals who were approached, 758 respondents completed the study. A large percentage (57.4%) of those who received the vaccines were healthcare workers. Adverse effects were reported in 70.8% of the participants with most manifesting on the first day of the vaccination. The predominant adverse effects were injection site soreness (28.5%), followed by fatigue (18.7%) and muscle pain (8.6%). There was no report of severe adverse effects such as anaphylactic reactions, thrombosis, myocarditis, transient myelitis, or Guillen-Barre syndrome. Conclusion: This study found that self-reported adverse effects of the Oxford/AstraZeneca COVID-19 vaccine were mild and short in duration. This outcome has promising implications for improving COVID-19 vaccine uptake in the immediate environment and Nigeria.
  • The Molecular Epidemiology of Clostridioides difficile Infection in Central India: A Prospective Observational Cohort Study.

    Ambalkar, Shrikant (Microbiology Research, 2023-09)
    This prospective observational cohort study aimed to establish and compare baseline rates of Clostridioides difficile infection (CDI) in community and hospitalized patients in Nagpur and rural Melghat Maharashtra, including adults aged ≥18 years with a diagnosis of diarrhoea as defined as 3 or more loose stools in a 24 h period. All diarrhoeal samples were tested for CDI using the C. diff Quik Chek Complete enzyme immunoassay. C. difficile-positive stool samples were characterised by toxigenic culture, antimicrobial susceptibility testing and PCR ribotyping. C. difficile testing was performed on 1683 patients with acute diarrhoea. A total of 54 patients (3.21%; 95% CI: 2.42–4.17) tested positive for both the GDH antigen and free toxin. The risk factors for CDI included the presence of co-morbidities, antibiotic usage, and immunosuppression. The detected PCR ribotypes included 053-16, 017, 313, 001, 107, and 216. Our findings show that toxigenic C. difficile is an important but neglected aetiologic agent of infective diarrhoea in Central India. These results underscore the need to enhance the awareness and testing of patients with diarrhoea in India regarding the presence of toxigenic C. difficile, particularly in high-risk individuals with multiple co-morbidities, immunosuppression, and recent or ongoing antibiotic exposure or hospitalization.
  • A surgeon's trial success of curing pedal eumycetoma

    Mitchell, James (BMJ Case Reports, 2023-07)
    Mycetoma is a chronic infection of underlying fungal (eumycetoma) or bacterial (actinomycetoma) origin. It is characterised by a clinical triad of tumour-like swelling, actively draining sinuses and macroscopic grains of characteristic colours. We the case of a 66-year-old woman on immunosuppressive therapy presenting with eumycetoma of the foot (Madura foot). The fungal organism cultured was Acrophialophora fusispora. This case was managed with a combination of extensive surgical debridement, and packing with calcium sulfate (Stimulan) beads impregnated with vancomycin and voriconazole. As far as the authors are aware, this is a novel adjunct to the surgical treatment of deep fungal infection in the foot. Eumycetoma treated with surgery and oral antifungal therapy leads to cure rates of 25%–35%. This novel treatment seems to bear further investigation for the potential to improve cure rates. At 8 months follow-up, our patient appears to be making good progress with no current signs of recurrence.
  • Waterborne infections in haemato-oncology units - a narrative review.

    Weinbren, Michael
    Bone marrow transplant and haemato-oncology patients are at risk of healthcare associated infections due to waterborne pathogens. We undertook a narrative review of waterborne outbreaks in haemato-oncology patients from 2000-2022. Databases searched included Pubmed, DARE and CDSR and were undertaken by two authors. We analysed the organisms implicated, sources identified and infection prevention and control strategies implemented. The most commonly implicated pathogens were Pseudomonas aeruginosa, non-tuberculous mycobacteria and Legionella pneumophila. Bloodstream infection was the most common clinical presentation. The majority of incidents employed multimodal strategies to achieve control, addressing both the water source and routes of transmission. This review highlights the risk to haemato-oncology patients from waterborne pathogens and discusses future preventative strategies and the requirement for new UK guidance for haemato-oncology units.
  • Implementing changes to reduce infections in ICU patients. Water services and waste systems.

    Weinbren, Michael
    Evidence linking the role of water services in transmission of infection to patients in ICUs has increased in recent years.This research based commentary set out to identify potential solutions for water and wastewater systems in ICU settings.Databases and open source information was used to obtain data on approaches to water and wastewater-related issues in ICU settings. This and the authors experiences have been used to describe approaches to these problems.The lack of updated guidance has required some ICUs to develop unique responses, including ‘water free’ patient care combined with reduction in water services. The options consider guidance, compliance, training and education as key factors to successful outcomes and protecting vulnerable patients in ICU.The authors found a number of problems with water and wastewater systems in ICU to which there has not been a cohesive response in terms of guidance to support users and designers. The resultant void permits new projects to proceed with suboptimal and designs which place patients and staff at risk. As an interim measure a series of solutions suitable for existing units and new builds need to be considered.
  • Factors to consider in the safe design of intensive care units - Part 1: historical aspects and ventilation systems.

    Weinbren, Michael
    Evidence linking the role of ventilation systems in transmission of infection to patients in intensive care units has increased in recent years.This research-based commentary set out to identify the historical aspect of intensive care unit design, current problems and some potential solutions with respect to ventilation systems.Databases and open source information was used to obtain data on the historical aspects and current guidance in ICU, and the authors experiences have been used to suggest potential solutions to ventilation problems in ICU.The authors found a number of problems with ventilation in ICU to which there has not been a cohesive response in terms of guidance to support users and designers. The resultant void permits new projects to proceed with suboptimal and designs which place patients and staff at risk.The NHS is now at the start of major new investments in healthcare facilities in England and this together with the end of the antibiotic era mandates new guidance to address these major concerns. [ABSTRACT FROM AUTHOR]
  • Aspects and problems associated with the water services to be considered in intensive care units

    Weinbren, Michael
    Water is a product taken for granted and assumed to be a safe commodity in intensive care units (ICU). Biofilm readily becomes established in complex water services presenting a risk to vulnerable patients. Harboured within biofilms are opportunistic pathogens which can be transmitted via hand contact, splashing, aerosol and indirect contact through medical equipment. Evidence linking the role of water services in transmission of infection to patients in ICUs has increased in recent years.This research based commentary set out to identify current problems with water and wastewater systems in ICU settings.Databases and open source information was used to obtain data on current water and wastewater-related issues in ICU settings. This and the authors experiences have been used to describe current challenges.the authors found a number of problems with water systems in ICU to which there has not been a cohesive response in terms of guidance to support users and designers. The resultant void permits new projects to proceed with suboptimal and designs which place patients and staff at risk.Hand hygiene stations are frequently misused or close enough to patients such that splashing poses a transmission risk. The wastewater system (drain) also presents a risk, from where Gram-negative antibiotic resistant organisms may be dispersed resulting in untreatable patient infections. The water and wastewater system provide a superhighway for the movement of pathogenic microorganisms and these risks need to be addressed if we are to safeguard vulnerable users in ICU. [ABSTRACT FROM AUTHOR]
  • Presymptomatic, asymptomatic and post-symptomatic transmission of SARS-CoV-2: joint British Infection Association (BIA), Healthcare Infection Society (HIS), Infection Prevention Society (IPS) and Royal College of Pathologists (RCPath) guidance

    Weinbren, Michael (BMC Infectious Diseases, 2022-05)
    This is the second of two guidance articles produced by the British Infection Association (BIA), the Healthcare Infection Society (HIS), the Infection Prevention Society (IPS) and the Royal College of Pathologists (RCPath). Both articles refer to the pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Using evidence that emerged during the first wave of the pandemic, the articles summarise aspects of the transmission dynamics of SARS-CoV-2 and provide guidance on how to reduce the risk of transmission. This article focuses on the risks of presymptomatic, asymptomatic and post-symptomatic SARS-CoV-2 transmission, allowing healthcare workers and the public to understand how transmission occurs and to take action to protect themselves and others. The guidance recognises further waves of the pandemic, the possibility of reinfection, the emergence of new variants of the virus and ongoing immunisation programmes.
  • THE IMPACT OF USING INTRAOPERATIVE ULTRASOUND ON SURGICAL RESECTION OF HIGH-GRADE GLIOMA: A SYSTEMATIC REVIEW AND META-ANALYSIS

    Christou, A (Neuroncology, 2022-09)
    BACKGROUND: Despite operative and adjuvant therapies, high-grade glioma (HGG) remains incurable, with the extent of surgical resection being one of the modalities that can improve patient survival. Enabling maximal safe and minimising post-operative neurological morbidity is a key aim of surgical resection. Numerous intraoperative surgical adjuncts are used at surgery and intraoperative ultrasound (IoUS), is one such adjunct. IoUS is a cost-effective, easy to use, repeatable surgical adjunct, safe for the patient and potentially available in all centres. Although it's commonly used, no up to date systematic review exists collating and quantifying the level of evidence, delineating its impact on the extent of surgical resection. MATERIAL AND METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The study was registered with the PROSPERO data- base (CRD42022300034). Keywords across Medline/PubMed and Embase between 1996 and November 2021 were used. We included articles with adult supratentorial, histopathologically confirmed HGG patients aimed for resection, evaluating the correlation of IoUS use and gross-total resection (GTR). Meta-analyses were conducted according to the statistical heterogeneity between the studies using the Open Meta Analyst software. RESULT(S): 2942 articles were identified of which 16 were qualitative assessed and 10 used for quantitative meta-analysis. In qualitative assessment, a mean 4.63/8 Newcastle-Ottawa-Scale score was found for studies with no cohorts (no use of IoUS) and a mean score of 6/9, for studies including exposed versus non-exposed cohorts. The RCT was of moderate quality according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. A pooled analysis across 10 studies of HGG aimed for resection with the use of IoUS, led to GTR achieved in 168/365 cases, resulting in an overall GTR rate of 51.1% (95% CI, 33.9%-68.3%, p<0.001), with great heterogeneity across studies (93.02% p<0.001). In a subgroup meta-analysis of 3 studies of HGG aimed for complete resection only, GTR was achieved in 43/62 cases, yielding a 72.7% GTR rate (95% CI 41.6%-100%, p<0.001) with significant heterogeneity across studies (I2 92.1%, p<0.001). In 4 case-controlled studies, a total of 43.6% (48/110) GTR rate was achieved when IoUS was used versus 24.7% (65/263) when IoUS was not used, resulting in an odds ratio = 2.009 (95% CI 1.157-3.490, p <0.001) for achieving GTR. CONCLUSION(S): The meta-analysis showed a high GTR rate (72.7%) when HGG were aimed for complete resection and a two-fold probability of achieving GTR when IoUS is used than not used.
  • Therapist differences in a randomised trial of the outcome of cognitive behaviour therapy for health anxiety in medical patients

    Lisseman-Stones, Yvonne (International Journal of Nursing Studies, 2015-03)
    Background: Health anxiety is common in medical settings and can be treated successfully by cognitive behaviour therapy. However it is not clear who might be best placed to deliver this therapy. Objectives: In a planned secondary analysis of data from a randomised trial of adapted cognitive behaviour therapy for health anxiety we compared outcomes of therapy delivered by nurses and other professional groups. Design: A randomised controlled trial with two treatment arms, 5-10 sessions of cognitive behaviour therapy adapted health anxiety or standard care. Setting: Cardiology, endocrine, gastroenterology, neurological and respiratory clinics in six general hospitals in the UK covering urban, suburban and rural areas. Participants: Medical patients attending the clinics who had pathological health anxiety and also scored for a diagnosis of hypochondriasis. Methods: Patients were randomised to one of two treatment arms, 5-10 sessions of cognitive behaviour therapy adapted health anxiety or standard care delivered by naive therapists (not randomised) who were trained in advance before delivering the treatment. Independent assessment of outcomes by researchers masked to allocation status at 3m, 6m, 12m and 24m. Results: 444 patients were randomised in the trial, 219 to cognitive behaviour therapy adapted health anxiety and 225 to standard care. 373 (84%) completed assessments after two years. Those treated by nurses (n=66) had improvement in health anxiety, generalised anxiety and depression outcomes that were significantly better and twice as great as those of the professional groups of assistant psychologists (n=87) and graduate workers (n=66) (P<0.01 over all time points). The number needed to treat to show superiority of nurse-delivered treatment over other treatment delivery was 4 at 6 months and 6 at one year. Conclusion: General nurses, after suitable training, are very effective therapists for patients with health anxiety in medical clinics and should be the therapists of choice for patients in these settings.
  • Pseudomonas water testing and ISO standards in UK and Germany.

    Weinbren, Michael (Journal of Hospital Infection, 2018-11)
    In the UK, HTM 04-01 recommends microbiological testing of water for Pseudomonas aeruginosa (PA) as part of the strategy to control water supply-related risks in hospitals. The guidance states that ‘All microbiological measurements should be by approved methods and/or be carried out by United Kingdom Accreditation Service (UKAS)-accredited laboratories for the method being used.’
  • Water, Life and Death

    Weinbren, Michael (2019-02)
  • Mini-review: Clostridioides difficile epidemiology in India.

    Ambalkar, Shrikant
    Clostridioides difficile infection (CDI) continues to affect hospitalized patients and community populations worldwide. In contrast to the substantial resources invested in the diagnosis and prevention of CDI in high-income countries, this anaerobic toxigenic bacterium has been largely overlooked in low-and-middle-income countries (LMICs) such as India, where there remains a paucity of epidemiologic data evaluating the burden of CDI. Extensive multi-institutional studies describing C. difficile epidemiology in India have not yet been performed. Given recent economic growth in many Asian countries, with aging populations, increased access to healthcare and widespread inappropriate use of antimicrobials, C. difficile is likely to be highly prevalent and causing significant disease burden. Greater efforts are required to enhance awareness of this neglected pathogen, through educating healthcare practitioners to test for CDI. There is also an urgent need to strengthen laboratory capacity, and ideally establish a national reference laboratory, to help facilitate a greater understanding of the molecular epidemiology of CDI in India and other LMICs. This mini-review aims to summarize the existing research evaluating the burden of CDI in humans and the environment in India.
  • A two-centre study assessing the impact of the COVID-19 pandemic on orthodontic patients in secondary care.

    Flett, Andrew
    Objective: To evaluate the impact of the coronavirus pandemic on patients in active orthodontic treatment. Design: Digital online survey. Setting: Two secondary care orthodontic departments in the United Kingdom. Participants: A prospective convenience sample of 103 patients in active orthodontic treatment. Methods: A 12-item questionnaire developed using the platform SurveyMonkey was used to assess the following: (1) patient's feelings towards attending their orthodontic appointments; (2) their desire to continue with their treatment; (3) how many patients encountered problems with their appliance during the lockdown; (4) how patients sought help during the first national lockdown period; and (5) any other concerns regarding impact on their orthodontic treatment. Results: A total of 103 participants responses were collected over a four-week period across two departments. Of them, 45% required a face-to-face appointment to solve a problem with their appliance; 45% of patients who had problems with their orthodontic appliance were able to resolve the issue through digital means either via telephone/email advice from their provider or from accessing help via the Internet; and 99% of patients wanted to continue with their orthodontic treatment. Conclusion: Our study has shown that a significantly higher percentage of patients are more concerned regarding attending face-to-face appointments after the first national lockdown due to the coronavirus pandemic. Providers of orthodontic care should ensure they support their patients by providing digital support and adopt virtual means of managing emergency cases patients in the event of any further imposed national or local lockdowns. Furthermore, access and availability of emergency face-to-face orthodontic care is necessary for many patients in active orthodontic treatment.
  • Patients' experiences of occupational therapy within a multidisciplinary pain management programme: A qualitative study

    Goodall, Jacqueline
    Background Occupational problems are common for adults experiencing chronic pain, but occupational therapists are not always accessed as part of the multidisciplinary team. Despite evidence of benefit for work-focused interventions, there is limited evidence for broader benefit from occupational therapy interventions within the context of multidisciplinary pain management. The aim of this study was to explore the experiences of programme attendees who received structured intervention from an occupational therapist as part of a multidisciplinary pain management programme, and gain an understanding as to how they felt it influenced changes they made to occupational participation. Method A qualitative approach was undertaken with 9 individual patients recruited from a group pain management programme for adults with chronic low back pain. Semi-structured interviews were carried out, recorded and transcribed. Thematic analysis was used to identify themes in the data. Results Three key themes were identified: 1) the helpfulness of activity pacing techniques 2) the value of participating in a therapeutic activity-based session and 3) an increased understanding of the importance of leisure and creative activities in the context of their lives. Conclusion Participants perceived the specific occupational therapy content of the programme to be helpful in a number of different ways. The findings suggest that occupational therapy can be important in facilitating patients to apply theoretical techniques in the real world, thereby increasing the likelihood of long term benefit.
  • Drains and the periphery of the water system - what do you do when the guidance is outdated?.

    Weinbren, Michael
    Summary The periphery of the water system (defined as the last 2 m of pipework from an outlet and ensuing devices including drainage), is the juncture of multiple inherent risks: the necessity to use materials with higher risk of biofilm formation, difficulty in maintaining safe water temperatures, a human interface with drainage systems, poor design, poor layout and use by staff. Add to this risk a large new healthcare facility capital build programme in England, outdated guidance and bacteria emanating from drainage systems containing highly mobile genetic elements (threatening the end of the antibiotic era), and the scene is set for the perfect storm.There is an urgent need for the re-evaluation of the periphery of the water system and drainage systems. Consequently, in this article we examine the requirement and placement of hand wash stations (HWSs), design of showers, kitchens and the dirty utility with respect to water services. Lastly, we discuss the provision of safe water to high-risk patient groups. The purpose of this article is to stimulate debate and provide infection control and design teams with support in deviating from the outdated existing guidance and to challenge conventional thinking until new advice is forthcoming.
  • Prevalence of Clostridioides difficile infection in Central India: a prospective observational cohort study

    Ambalkar, Shrikant (GUT, 2021)
    ntroduction The true burden of Clostridioides difficile infection (CDI) in India remains poorly understood. Prolifigate, unregulated antibiotic use and inappropriate prescribing suggest that CDI could be widespread in India. Our aim was to establish and compare baselines rates of CDI in both in-and outpatient settings in Nagpur city district and rural Melghat, Central India. Methods We recruited adult participants aged ≥18 years of age who could provide written or thumb-print informed consent. A diagnosis of diarrhoea was defined as 3 or more loose stools in a 24-hour period. Immunosuppression was defined as those on prednisolone (>5mg/day), immunomodulators or biologics. Baseline characteristics were also collected and included: demographics, symptomatology, antibiotics exposure, duration of diarrhoea, hospitalisation status at recruitment, and duration, BMI, animal exposure, housing conditions, toilet access, and seasonality. All diarrhoeal samples were tested for CDI using the C. DIFF QUIK CHEK COMPLETE-enzyme immunoassay in accordance with the manufacturers’ instructions. Results C. difficile testing was performed on 1223 patients with acute diarrhoea. A total of 36 patients (2.9%) tested positive for both GDH antigen and toxin expression. A higher% of urban inpatient diarrheal samples tested positive for toxigenic C. difficile (26 cases; 8%) compared to that seen for urban outpatients (9 cases; 3%) and the rural diarrhoeal group (1 outpatient case). Of those testing positive for toxigenic C. difficile, 63.9% were immunosuppressed and almost all (94.4%) were on antibiotics at the time of recruitment. The majority of the toxigenic CDI cases were detected during the monsoon season, lived in very good or good housing conditions, had access to good toilet facilities and reported no co-habitation with animals. Non-toxigenic C. difficile was detected in 6.2%, 4.8%, and 0.5% in the urban inpatient, urban outpatient, and rural populations tested, respectively. Conclusions Toxigenic C. difficile is an important but neglected aetiologic cause of infective diarrhoea in Central India. The higher prevalence within the urban inpatient setting likely reflects greater exposure to antibiotics and hospitalisation. Our findings underscore the need to enhance awareness of and testing of patients with diarrhoea in India, particularly in high-risk individuals with recent or ongoing antibiotic exposure or hospitalisation.
  • Multiplex PCR for determining aetiology of infectious diarrhoea in rural and urban central Indian populations

    Ambalkar, Shrikant (Gut, 2021)
    Introduction Infectious diarrhoea is a major cause of morbidity and mortality in Central India. There is an urgent unmet need to implement rapid point-of-care tests to deliver effective and targeted treatment plans. The aim of this exploratory study was to assess the performance of the FilmArray Gastrointestinal Panel for the detection of enteric pathogens directly from stool specimens collected from diarrhoeal and non-diarrhoeal control populations in Central India. Methods Faecal samples were collected from participants with and without acute diarrhoea presenting to an inpatient or outpatient setting in Nagpur city district and rural Melghat. Each stool sample was stored at 4°C and preserved in Cary-Blair enteric transport medium for multiplex PCR using the FilmArray GI Panel according to the manufacturer’s instructions. This panel allows for the simultaneous detection of 22 common diarrhoeal agents, including bacteria, viruses and protozoa. Baseline characteristics were also recorded and included: demographics, symptomatology, antibiotics exposure, duration of diarrhoea, hospitalisation status at recruitment, and duration, BMI, animal exposure, housing conditions, toilet access, and seasonality. Results 179 participants provided stool samples for analysis on the FilmArray GI Panel. 70 and 109 participants were from rural Melghat and Nagpur urban district, respectively. Of these, 138 were from mainly non-hospitalised participants with acute diarrhoea from urban (n=89) and rural areas (n=49). In the urban cohort, 81% (88/109) of all diarrhoeal and non-diarrhoeal samples tested positive for one (27%) or more (54%) pathogens. In the rural cohort, a striking 97% (68/70) of samples yielded positivity to one (14%) or multiple organisms (83%). The most prevalent pathogen detected in both the diarrhoeal and control cohorts was Enterohaemorrhagic E. coli (51% vs 59%, respectively). However, other pathotypes of diarrhoeagenic E. coli were highly prevalent in both cohorts, including ETEC, EPEC, Shigella/EIEC, and STEC. A higher proportion of diarrhoeal samples tested positive to Campylobacter (12%) compared to the non-diarrhoeal control group (5%). Unlike the diarrhoeal samples, no control samples yielded positivity to Vibrio cholerae, Cyclospora cayetanensis, Astrovirus, Rotavirus A or Sapovirus Conclusions Detection of high levels of polymicrobial enteric infections are prevalent in Central Indian symptomatic and asymptomatic populations. E. coli pathotypes predominate in both urban and rural settings. Further studies are required to understand the clinical significance of these mixed infections, as well as how best to manage them.

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