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The purpose of this study was to identify the patient, injury, and treatment factors associated with infection of bicondylar plateau fractures and to evaluate whether center variation exists.Retrospective review.Eighteen academic trauma centers.A total of 1,287 patients with 1,297 OTA type 41-C bicondylar tibia plateau fractures who underwent open reduction and internal fixation were included. Exclusion criteria were follow-up less than 120 days, insufficient documentation, and definitive treatment only with external fixation.Open reduction and internal fixation.Superficial and deep infection.One hundred one patients (7.8%) developed an infection. In multivariate regression analysis, diabetes (DM) (OR [odds ratio] 3.24; P ≤ 0.001), alcohol abuse (EtOH) (OR 1.8; P = 0.040), dual plating (OR 1.8; P ≤ 0.001), and temporary external fixation (OR 2.07; P = 0.013) were associated with infection. In a risk-adjusted model, we found center variation in infection rates (P = 0.030).In a large series of patients undergoing open reduction and internal fixation of bicondylar plateau fractures, the infection rate was 7.8%. Infection was associated with DM, EtOH, combined dual plating, and temporary external fixation. Center expertise may also play a role because one center had a statistically lower rate and two trended toward higher rates after adjusting for confounders.Level IV-Therapeutic retrospective cohort study.

Hypoxia-inducible factor-1α (HIF-1α) is an important regulator of glucose metabolism and inflammatory cytokine production in innate immune responses. Viruses modulate HIF-1α to support viral replication and the survival of infected cells, but it is unclear if this transcription factor also plays an important role in regulating antiviral immune responses. In this study, we found that short and long dsRNA differentially engage TLR3, inducing distinct levels of proinflammatory cytokine production (TNF-α and IL-6) in bone marrow–derived macrophages from C57BL/6 mice. These responses are associated with differential accumulation of HIF-1α, which augments NF-κB activation. Unlike TLR4 responses, increased HIF-1α following TLR3 engagement is not associated with significant alterations in glycolytic activity and was more pronounced in low glucose conditions. We also show that the mechanisms supporting HIF-1α stabilization may differ following stimulation with short versus long dsRNA and that pyruvate kinase M2 and mitochondrial reactive oxygen species play a central role in these processes. Collectively, this work suggests that HIF-1α may fine-tune proinflammatory cytokine production during early antiviral immune responses, particularly when there is limited glucose availability or under other conditions of stress. Our findings also suggest we may be able to regulate the magnitude of proinflammatory cytokine production during antiviral responses by targeting proteins or molecules that contribute to HIF-1α stabilization.

Strategies to reduce antibiotic overuse in hospitals depend on prescribers taking decisions to stop unnecessary antibiotic use. There is scarce evidence for how to support these decisions. We evaluated a multifaceted behaviour change intervention (ie, the antibiotic review kit) designed to reduce antibiotic use among adult acute general medical inpatients by increasing appropriate decisions to stop antibiotics at clinical review.We performed a stepped-wedge, cluster (hospital)-randomised controlled trial using computer-generated sequence randomisation of eligible hospitals in seven calendar-time blocks in the UK. Hospitals were eligible for inclusion if they admitted adult non-elective general or medical inpatients, had a local representative to champion the intervention, and could provide the required study data. Hospital clusters were randomised to an implementation date occurring at 1-2 week intervals, and the date was concealed until 12 weeks before implementation, when local preparations were designed to start. The intervention effect was assessed using data from pseudonymised routine electronic health records, ward-level antibiotic dispensing, Clostridioides difficile tests, prescription audits, and an implementation process evaluation. Co-primary outcomes were monthly antibiotic defined daily doses per adult acute general medical admission (hospital-level, superiority) and all-cause mortality within 30 days of admission (patient level, non-inferiority margin of 5%). Outcomes were assessed in the modified intention-to-treat population (ie, excluding sites that withdrew before implementation). Intervention effects were assessed by use of interrupted time series analyses within each site, estimating overall effects through random-effects meta-analysis, with heterogeneity across prespecified potential modifiers assessed by use of meta-regression. This trial is completed and is registered with ISRCTN, ISRCTN12674243.58 hospital organisations expressed an interest in participating. Three pilot sites implemented the intervention between Sept 25 and Nov 20, 2017. 43 further sites were randomised to implement the intervention between Feb 12, 2018, and July 1, 2019, and seven sites withdrew before implementation. 39 sites were followed up for at least 14 months. Adjusted estimates showed reductions in total antibiotic defined daily doses per acute general medical admission (-4·8% per year, 95% CI -9·1 to -0·2) following the intervention. Among 7 160 421 acute general medical admissions, the ARK intervention was associated with an immediate change of -2·7% (95% CI -5·7 to 0·3) and sustained change of 3·0% (-0·1 to 6·2) in adjusted 30-day mortality.The antibiotic review kit intervention resulted in sustained reductions in antibiotic use among adult acute general medical inpatients. The weak, inconsistent intervention effects on mortality are probably explained by the onset of the COVID-19 pandemic. Hospitals should use the antibiotic review kit to reduce antibiotic overuse.UK National Institute for Health and Care Research.

We sought to improve the referral process to a community paramedicine (CP) program following a 9-1-1 encounter.An electronic health record (EHR) for CP records with the ability to link to emergency EHR was identified and implemented with a single-click referral to the CP program. Referrals were tracked for 15 months before and after implementation.Referral capacity increased from an average of 14.2 referrals per month to 44.9 referrals per month.The results of this study suggest an EHR is a useful investment for CP programs and may be integral to efficient program operations.

BACKGROUND: Getting effective fall prevention into the homes of medically and physically vulnerable individuals is a critical public health challenge. Community paramedicine is emerging globally as a new model of care that allows emergency medical service units to evaluate and treat patients in non-emergency contexts for prevention efforts and chronic care management. The promise of community paramedicine as a delivery system for fall prevention that scales to community-level improvements in outcomes is compelling but untested. OBJECTIVE: To study the impact of a community paramedic program’s optimization of a fall prevention system entailing a clinical pathway and learning health system (called Community-FIT) on community-level fall-related emergency medical service utilization rates. METHODS: We used an implementation science framework and quality improvement methods to design and optimize a fall prevention model of care that can be embedded within community paramedic operations. The model was implemented and optimized in an emergency medical service agency servicing a Midwestern city in the United States (~35,000 residents). Primary outcome measures included relative risk reduction in the number of community-level fall-related 9-1-1 calls and fall-related hospital transports. Interrupted time series analysis was used to evaluate relative risk reduction from a 12-month baseline period (September 2016 - August 2017) to a 12-month post-implementation period (September 2018 – August 2019). RESULTS: Community paramedic home visits increased from 25 in 2017, to 236 in 2018, to 517 in 2019, indicating a large increase in the number of households that benefitted from the efforts. A relative risk reduction of 0.66 (95% [CI] 0.53, 0.76) in the number of fall calls and 0.63 (95% [CI] 0.46, 0.75) in the number of fall-related calls resulting in transports to the hospital were observed. CONCLUSIONS: Community-FIT may offer a powerful mechanism for community paramedics to reduce fall-related 9-1-1 calls and transports to hospitals that can be implemented in emergency medical agencies across the country.

Colistin is a last resort antibiotic for the treatment of carbapenemase producing Klebsiella pneumoniae. The disruption of the mgrB gene by insertion sequences (ISs) is a mechanism mediating colistin resistance. Plasmids encode mobilizable IS elements which integrate into the mgrB gene in K. pneumoniae causing gene inactivation and colistin resistance. The species prevalence of mgrB‐gene disrupting insertion elements ISL3 (ISKpn25), IS5 (ISKpn26), ISKpn14, and IS903B present on plasmids were assessed. IS containing plasmids were also scanned for antimicrobial resistance genes, including carbapenem resistant genes. Plasmids encoding ISs are abundant in K. pneumoniae. IS903B was found in 28 unique Inc groups, while ISKpn25 was largely carried by IncFIB(pQil) plasmids. ISKpn26 and ISKpn14 were most often found associated with IncFII(pHN7A8) plasmids. Of the 34 unique countries which contained any of the IS elements, ISKpn25 was identified from 26. ISKpn26, ISKpn14, and IS903B ISs were identified from 89.3%, 44.9%, and 23.9% plasmid samples from China. Plasmids carrying ISKpn25, ISKpn14, and ISKpn26 IS have a 4.6‐, 6.0‐, and 6.6‐fold higher carbapenemase gene count, respectively, relative to IS903B‐carrying plasmids. IS903B bearing plasmids have a 20‐, 5‐, and 5‐fold higher environmental source isolation count relative to ISKpn25, ISKpn14, and ISKpn26 bearing plasmids. ISKpn25 present on IncFIB(pQil) sourced from clinical settings is established across multiple countries, while ISKpn26, ISKpn14, and IS903B appear most often in China. Carbapenemase presence in tandem with IS elements may help promote an extensively drug resistant profile in K. pneumoniae limiting already narrow treatment options., Klebsiella pneumoniae is the dominant species carrying colistin‐resistance inducing insertion sequence elements ISKpn25, ISKpn26, ISKpn14, and IS903B on plasmids. ISKpn25, ISKpn26, ISKpn14 bearing plasmids have a high carriage of carbapenemase genes and are associated with clinical source isolation relative to IS903B. Clinically derived plasmids that harbor both carbapenemases and IS elements may engender an extensively drug‐resistant phenotype during colistin therapy in hospitals, limiting already narrow treatment options.

Importance Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. Objective To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. Design, Setting, and Participants This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. Interventions A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. Main Outcomes and Measures The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. Results The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, –3.4%; 95% CI, –6.9% to 0.1%;P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, –3.7%; 95% CI, –6.7% to –0.8%;P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, –1.6% to 2.1%;P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. Conclusions and Relevance Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. Trial Registration ClinicalTrials.gov Identifier:NCT02227446

Introduction: Home modifications are associated with decreased risk for falls and facilitate safe aging in place. The purpose of this study was to identify barriers to procurement of home modifications for older adults. Materials and Methods: Cross-sectional interviews by 2 separate (1 male and 1 female) researchers in a Midwestern city of home repair (“handyman”) and construction businesses within 15 miles of the areas of interest (neighborhood with a high socioeconomic status and neighborhood with low socioeconomic status) with a publicly listed phone number (n = 98). Estimated cost, earliest date of installation, and duration for a home modification project (installation of 3 grab bars) were collected. Results: At least 1 response was attained only 43% of the time (n = 42), and residential grab bar installations were not provided by most businesses (n = 24). The average quote for materials and labor was $394.31 (range $125-$1300). Five of the 7 businesses that responded to both researchers with the same representative differed in cost estimates, generally offering a reduced quote for the low socioeconomic status neighborhood by as much as $300. Quotes provided to the female researcher were also higher than those obtained by the male researcher by about $30 regardless of socioeconomic status. The average wait for home modifications was 23 days and the average anticipated duration of the project was 2.6 hours. Discussion: There are financial and procedural barriers to accessing home modifications for older adults who independently attempt to acquire them. There is a need for pathways in clinical and community settings to reduce barriers to home modifications to reduce the risk of falls. Conclusion: Home modifications are a promising tool to reduce falls and fall-related injuries in older adults. However, further work to identify cost-effective and timely options to reduce acquisition barriers is necessary to leverage the preventive power of home modifications.

BackgroundLyme disease is endemic in the UK with a high incidence in southwest England. Neurological involvement occurs in approximately 5% of infected individuals. Previous reviews in southwest England have shown a consistent phenotype in most cases, however anecdotal review suggests a small number of atypical cases, with diverse presentations, which provide a diagnostic challenge, even to experienced neurologists.MethodsWe performed a retrospective, observational study of all identified cases (positive screening ELISA confirmed by immunoblot and neurological symptoms) of neuroborreliosis from six hospitals between January 2015 and December 2017. In addition, we reviewed atypical cases seen over the last decade in the regional neurosciences centre in depth.Results72 patients were included in the observational study. 83% had characteristics of Bannwarth’s syndrome (cranial neuropathy, radiculopathy and CSF pleocytosis). Unusual cases included mononeu- ritis multiplex.Central nervous system involvement was rare. We saw cases presenting with cerebrovascular events, meningitis and encephalitis. Complete resolution of symptoms was reported in 72% of patients. 28% of patients reported residual symptoms, most commonly fatigue and memory problems.ConclusionsThis is the largest UK review of neuroborreliosis. The presentation is usually typical, but atypical presentations vary and can be challenging. The majority of patients recover fully.amyrossrussell@gmail.com

Group B streptococcus is the leading cause of infection in infants. Currently, intrapartum antibiotic prophylaxis is the major strategy to prevent invasive group B streptococcus disease. However, intrapartum antibiotic prophylaxis does not prevent maternal sepsis, premature births, stillbirths or late-onset disease. Maternal vaccination may offer an alternative strategy. Multivalent polysaccharide protein conjugate vaccine development is under way and a serocorrelate of protection is needed to expedite vaccine licensure.The ultimate aim of this work is to determine the correlate of protection against the major group B streptococcus disease-causing serotypes in infants in the UK. The aim of this feasibility study is to test key operational aspects of the study design.Prospective cohort study of pregnant women and their infants in a 6-month period (1 July to 31 December 2018).Five secondary and tertiary hospitals from London and South England. National iGBS disease surveillance was conducted in all trusts in England and Wales.Pregnant women aged ≥ 18 years who were delivering at one of the selected hospitals and who provided consent during the study period. There were no exclusion criteria.No interventions were performed.(1) To test the feasibility of collecting serum at delivery from a large cohort of pregnant women. (2) To test the key operational aspects for a proposed large serocorrelates study. (3) To test the feasibility of collecting samples from those with invasive group B streptococcus.A total of 1823 women were recruited during the study period. Overall, 85% of serum samples were collected at three sites collecting only cord blood. At the two sites collecting maternal, cord and infant blood samples, the collection rate was 60%. A total of 614 women were screened for group B streptococcus with a colonisation rate of 22% (serotype distribution: 30% III, 25% Ia, 16% II, 14% Ib, 14% V and 1% IV). A blood sample was collected from 34 infants who were born to colonised women. Maternal and infant blood and the bacterial isolates for 15 newborns who developed invasive group B streptococcal disease during the study period were collected (serotype distribution: 29% III, 29% II, 21% Ia, 7% Ib, 7% IV and 7% V).Recruitment and sample collection were dependent on the presence of research midwives rather than the whole clinical team. In addition, individualised consent limited the number of women who could be approached each day, and site set-up for the national surveillance study and the limited time period of this feasibility study limited recruitment of all eligible participants.We have verified the feasibility of collecting and processing rectovaginal swabs and blood samples in pregnant women, as well as samples from those with invasive group B streptococcal disease. We have made recommendations for the recruitment of cases within the proposed GBS3 study and for controls both within GBS3 and as an extension of this feasibility study.A large case-control study comparing specific immunoglobulin G levels in mothers whose infants develop invasive group B streptococcal disease with those in colonised mothers whose infants do not develop invasive group B streptococcal disease is recommended.Current Controlled Trials ISRCTN49326091; IRAS project identification number 246149/REC reference number 18/WM/0147.This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inGroup B streptococcus is often carried by healthy women and usually causes no problems. Group B streptococcus may be passed from mother to child, primarily through the birth canal, and, in rare cases, can cause serious disease (i.e. pneumonia, sepsis or meningitis) and even death in babies. It may be possible to prevent group B streptococcus disease in babies by giving a vaccine to pregnant women. The reason for vaccinating the mother is so that she can pass on protection (antibodies) during the pregnancy to her baby. A vaccine is currently being developed against group B streptococcus that aims to boost this protection. To help vaccine development progress faster, we need to find out how much antibody is actually needed to protect babies from group B streptococcus disease. A large study is needed to address this question; therefore, we have performed a feasibility study to assess the practicalities of performing this large study. Specifically, we will assess (1) women’s willingness to participate in a swabbing and cord blood study, (2) the ability to collect swabs and cord blood once recruited, (3) the ability to identify group B streptococcus disease in this population and (4) the laboratory processing of samples. We recruited 1823 pregnant women from five maternity units in England in a 6-month period: 22% of all women delivering at all sites and 74% of those women who were approached. In three hospitals, cord blood samples from 85% of 1201 women were collected. In two hospitals, we collected 60% of maternal blood samples, 53% of cord blood samples and 99% of swabs from the vagina and rectum from 622 women. A total of 22% of these women carried group B streptococcus in their vagina or gut and we collected blood samples from 34 healthy babies born to these women. During the study, we collected samples from 15 babies who had developed severe group B streptococcus disease; four babies were born to women participating in the study and the rest were identified through national surveillance. In conclusion, we have verified the feasibility of collecting and processing swabs from the vagina and rectum and blood samples in pregnant women, as well as samples from babies who developed group B streptococcus disease. In addition, we have identified a number of strategies that could be adopted in a future study in order to increase recruitment and sample collection.

Introduction We sought to determine the effects of sociodemographic factors on the occurrence of orthopaedic injuries in an adult population presenting to a level 1 trauma center. Materials and methods We conducted a retrospective chart review of patients who received orthopaedic trauma care at a level 1 academic trauma center. Results 20,919 orthopaedic trauma injury cases were treated at an academic level 1 trauma center between 01 January 1993 and 27 August 2017. Following application of inclusion/exclusion criteria, a total of 14,654 patients were retrieved for analysis. Out of 14,654 patients, 4602 (31.4%) belonged to low socioeconomic status (SES), 4961 (32.0%) to middle SES and 5361 (36.6%) to high SES. Following adjustment for age, sex, race, insurance status and injury severity score (ISS), patients belonging to middle SES vs. low SES (OR 0.77 [95% CI 0.63-0.94]; p = 0.009) or high SES vs. low SES (OR 0.77 [95% CI 0.62-0.95]; p = 0.016) had lower odds of receiving a penetrating injury as compared to a blunt injury. Conclusion The results from this study indicate that a link exists between sociodemographic factors and the occurrence of orthopaedic injuries presenting to a level 1 trauma center. The most common cause of injury varied within age groups, by sex, and within the different socioeconomic groups.

Importance Postoperative delirium in older adults is a common and costly complication after surgery. Cognitive reserve affects the risk of postoperative delirium, and thus preoperative augmentation of reserve as a preventive technique is of vital interest. Objective To determine whether cognitive prehabilitation reduces the incidence of postoperative delirium among older adults. Design, setting, and participants This was a prospective, single-blinded randomized clinical trial conducted from March 2015 to August 2019 at the Ohio State University Wexner Medical Center in Columbus. Patients 60 years and older undergoing major, noncardiac, nonneurological surgery under general anesthesia, with an expected hospital stay of at least 72 hours, were eligible for trial inclusion. Patients were excluded for preoperative cognitive dysfunction and active depression. Interventions Participation in electronic, tablet-based preoperative cognitive exercise targeting memory, speed, attention, flexibility, and problem-solving functions. Main outcomes and measures The primary outcome was incidence of delirium between postoperative day 0 to day 7 or discharge, as measured by a brief Confusion Assessment Method, Memorial Delirium Assessment Scale, or a structured medical record review. Secondary outcomes compared delirium characteristics between patients in the intervention and control groups. Results Of the 699 patients approached for trial participation, 322 completed consent and 268 were randomized. Subsequently, 17 patients were excluded, leaving 251 patients in the primary outcome analysis. A total of 125 patients in the intervention group and 126 control patients were included in the final analysis (median [interquartile range] age, 67 [63-71] years; 163 women [64.9%]). Ninety-seven percent of the patients in the intervention group completed some brain exercise (median, 4.6 [interquartile range, 1.31-7.4] hours). The delirium rate among control participants was 23.0% (29 of 126). With intention-to-treat analysis, the delirium rate in the intervention group was 14.4% (18 of 125; P = .08). Post hoc analysis removed 4 patients who did not attempt any cognitive exercise from the intervention group, yielding a delirium rate of 13.2% (16 of 121; P = .04). Secondary analyses among patients with delirium showed no differences in postoperative delirium onset day or duration or total delirium-positive days across study groups. Conclusions and relevance The intervention lowered delirium risk in patients who were at least minimally compliant. The ideal activities, timing, and effective dosage for cognitive exercise-based interventions to decrease postoperative delirium risk and burden need further study. Trial registration ClinicalTrials.gov Identifier: NCT02230605.

Objective To estimate the economic burden to the health service of surgical site infection following caesarean section and to identify potential savings achievable through implementation of a surveillance programme.\ud Design Economic model to evaluate the costs and benefits of surveillance from community and hospital healthcare providers’ perspective.\ud Setting England.\ud Participants Women undergoing caesarean section in National Health Service\ud hospitals.\ud Main outcome measure Costs attributable to treatment and management of surgical site infection following caesarean section.\ud Results The costs (2010) for a hospital carrying out 800 caesarean sections a year based on infection risk of 9.6% were estimated at £18,914 (95% CI 11,521 to 29,499) with 28% accounted for by community care (£5,370). With inflation to 2019 prices, this equates to an estimated cost of £5.0m for all caesarean sections performed annually in England 2018-19, approximately £1,866 and £93 per infection managed in hospital and community respectively. The cost of surveillance for a hospital for one calendar quarter was estimated as £3,747 (2010 costs).\ud Modelling a decrease in risk of infection of 30, 20 or 10% between successive surveillance periods indicated that a variable intermittent surveillance strategy achieved higher or similar net savings than continuous surveillance. Breakeven was reached sooner with the variable surveillance strategy than continuous surveillance\ud when the baseline risk of infection was 10 or 15% and smaller loses with a baseline risk of 5%.\ud Conclusion Surveillance of surgical site infections after caesarean section with feedback of data to surgical teams offers a potentially effective means to reduce infection risk, improve patient experience and save money for the health service.\ud Strengths and limitations\ud • The model estimated both community (28%) and hospital costs (72%), providing a more representative estimate of overall economic burden to the health service.\ud • Time-matching of patients with and without infection according to length of post-operative stay provided a more accurate assessment of excess bed-days attributable to surgical site infection (2.6 days) than average excess length of stay (median difference 5 days) comparison by disentangling the impact of prolonged length of stay on increased chance of detecting an infection.\ud • Through capture and assessment of the costs and impact of surveillance, our model demonstrated the potential for savings through reductions in incidence of surgical site infections.\ud • Costs were obtained from NHS National Schedule Reference Costs and other sources rather than observed expenditure and assumptions made about the number of extra midwife and general practitioner appointments resulting from infection.\ud • The study was based on healthcare utilisation and did not assess direct and indirect costs borne by the patients or their carers.

OBJECTIVES/GOALS: Healthcare costs for falls are expected to reach nearly 55 billion dollars annually in the US by 2020. Leveraging 911 calls as trigger events to activate fall prevention solutions could transform our ability to identify high-risk individuals and significantly improve fall prevention strategies globally. METHODS/STUDY POPULATION: An innovative pilot program entitled Community-centered Fall Intervention Team (Community FIT). Community FIT that leverages 911 calls, implementation science approaches, community partnerships, and collaboration among multiple healthcare disciplines including physical therapists, community paramedics, physicians, and social service coordinators was used to design and implement a community paramedicine fall intervention program. 911 call reports from February 2016 – August 2019 were analyzed using time series analyses to measure community level outcomes in fall-related calls and transports. RESULTS/ANTICIPATED RESULTS: 224 grab bars were installed free of charge to local residents (averaging approximately $125 per home for modifications).Over an 18-month period, time series analysis indicated an approximate demonstrated a consistent drop in the average fall-related 911 calls per month from 11.6 to 4.5 calls (a change of 61.21%) and a decrease of 58% in the transport rates to the hospital for fall-related 911 calls. 911 referrals to the community paramedicine program have also increased by 83%, demonstrating increased activation of fall prevention strategies with Community FIT. DISCUSSION/SIGNIFICANCE OF IMPACT: Collectively, these pilot study results provide preliminary support for individual and system level improvements in fall prevention by leveraging 911 calls to activate a community medicine fall prevention program. Future studies are needed to determine reach, long-term effectiveness, and sustainability of the program. CONFLICT OF INTEREST DESCRIPTION: Johnson & Johnson Hip Fracture Advisory Board (not related to project submission)

The precautions described by Emma have only been put into place after it became evident that certain strains of the Burkholderia cepaciacomplex (Bcc) not only cause life-threatening lung damage in Cystic Fibrosis (CF), but may be transmissible between patients. CF is a multisystem, inherited genetic disorder caused by an abnormality in sodium and chloride ion transport across cell membranes. The Bcc consists of Gram-negative, oxidase-positive bacilli and currently comprises some closely related species, formerly known as genomovars. It is thought that most Bcc infections in CF patients are acquired independently from the environment, although siblings typically share the same strain, and certain strains have been associated with a more widespread cross-infection risk. Transient infections with these organisms occur rarely, with the majority of patients becoming chronically infected. Lung transplant is a potential treatment for some patients with CF lung disease but is associated with a poor outcome in patients infected with Bcc.

After decades of decreasing scarlet fever incidence, a dramatic increase was seen in England beginning in 2014. Investigations were launched to assess clinical and epidemiological patterns and identify potential causes.In this population-based surveillance study, we analysed statutory scarlet fever notifications held by Public Health England from 1911 to 2016 in England and Wales to identify periods of sudden escalation of scarlet fever. Characteristics of cases and outbreaks in England including frequency of complications and hospital admissions were assessed and compared with the pre-upsurge period. Isolates from throat swabs were obtained and were emm typed.Data were retrieved for our analysis between Jan 1, 1911, and Dec 31, 2016. Population rates of scarlet fever increased by a factor of three between 2013 and 2014 from 8·2 to 27·2 per 100 000 (rate ratio [RR] 3·34, 95% CI 3·23-3·45; p0·0001); further increases were observed in 2015 (30·6 per 100 000) and in 2016 (33·2 per 100 000), which reached the highest number of cases (19 206) and rate of scarlet fever notifcation since 1967. The median age of cases in 2014 was 4 years (IQR 3-7) with an incidence of 186 per 100 000 children under age 10 years. All parts of England saw an increase in incidence, with 620 outbreaks reported in 2016. Hospital admissions for scarlet fever increased by 97% between 2013 and 2016; one in 40 cases were admitted for management of the condition or potential complications. Analysis of strains (n=303) identified a diversity of emm types with emm3 (43%), emm12 (15%), emm1 (11%), and emm4 (9%) being the most common. Longitudinal analysis identified 4-yearly periodicity in population incidence of scarlet fever but of consistently lower magnitude than the current escalation.England is experiencing an unprecedented rise in scarlet fever with the highest incidence for nearly 50 years. Reasons for this escalation are unclear and identifying these remains a public health priority.None.

The majority of political science research on religion and politics examines how religious variables influence political outcomes. Either implicitly or explicitly, this literature posits a one-way causal arrow from religion to politics. This dissertation argues that in many developing countries, however, religious and political change have been endogenous (interrelated). This is particularly true in weak states, where established religious groups mobilized to promote third wave democratization. In such contexts, politicians simultaneously faced heightened political competition and established religious groups mobilized to demand accountable democratic governance after the Cold War. Under these conditions, I argue that politicians faced incentives to intervene in the religious sphere, and to actively propagate conversionary religious movements. In doing so, politicians sought to cultivate both moral authority and new constituencies that would compete with the established "watch dog" religious groups. I term this strategy "politicized propagation," and argue that it is an important mechanism undergirding the endogenous relationship between religious and political change in the region. Although the theoretical argument advanced in this dissertation is general, I assess the argument empirically by focusing on the explosive rise of pentecostal (born again) Christianity as a politically salient identity in some, but not all, sub-Saharan states in recent decades. I begin by evaluating the dissertation’s broadest claim — that religion and politics are endogenous — at the cross-national level. Specifically, I assess the degree to which a country’s pentecostal population share in 2010 is predicted by that country’s (i) level of political competition in the 1990s and 2000s, and (ii) prior mobilization by established religions for democratization. The evidence reveals a strong, and significant positive correlation between these political context variables and pentecostal population shares in the region. Moreover, through a controlled comparison of born again movements (i.e., charismatics and pentecostals), I am able to adjudicate between the appeal of born again doctrine, and the organizational features of pentecostal churches (such as decentralized network structures, and relative freedom from transnational oversight and rigid training requirements for leaders), which make pentecostal churches accessible and malleable political allies. The dissertation’s cross-national findings therefore refute alternative explanations for cross-national variation in the rise of pentecostalism, as well as the null hypothesis that political and religious change were not endogenous in sub-Saharan states. The latter half of the dissertation proceeds to evaluate causal process mechanisms by examining church-state relations in a single case over time. Specifically, I focus on Zambia, a predominantly Christian nation, where I collected quantitative and qualitative data in 2011 and 2013. My analyses of these data reveal that Zambia's ruling party systematically targeted local pentecostal churches with cash grants, media permits, urban land plots, and political appointments between 1991 and 2011. Moreover, I find that the government was significantly more likely to allocate perks, such as lucrative tax breaks or church business licenses, in the lead up to national elections. This evidence provides strong suggestive support for the theory of politicized propagation. Zambians' subjective perceptions of the relationship between different religious groups and the state are consistent with the theory of politicized propagation, but also belie the wide-ranging motivations of pentecostal converts. I conclude with reflections on the impact of politicized propagation, as well as the ability of this argument to illuminate political dynamics of born again Christian movements in Latin America, and Islamic movements in sub-Saharan Africa.

Background. Few cross-population studies examining the epidemiology of invasive group B streptococcal (GBS) disease have been undertaken. To identify longitudinal trends in the burden and characteristics of infections, national surveillance data on diagnoses in England and Wales from 1991 to 2010 were analyzed. Methods. A parallel review of laboratory-confirmed invasive GBS infection surveillance reports and isolates submitted to the national reference laboratory was undertaken. Cases were defined as GBS isolated from a normally sterile site. Results. A total of 21 386 reports of invasive GBS infection were made between 1991 and 2010. The annual rate of reports doubled over the 20 years from 1.48 to 2.99 per 100 000 population. Significant increases were seen in all age groups but most pronounced in adults. Rates of early-onset (0–6 days) infant disease fluctuated but showed a general rise between 2000 and 2010 from 0.28 to 0.41 per 1000 live births. Rates of late-onset (7–90 days) disease increased steadily between 1991 and 2010 from 0.11 to 0.29 per 1000 live births. Resistance to erythromycin increased markedly from 2.5% in 1991 to 15% in 2010. The distribution of serotypes varied according to patient age and over time with type III increasing among early-onset cases and decreasing in adults. Conclusions. Although risk of invasive GBS infection remains highest within the first few days of life, the relative burden of disease is shifting toward adults. The rise in incidence and antibiotic resistance makes development of an effective and safe vaccine all the more pressing.

After an increase in the number of reported cases of Pneumocystis jirovecii pneumonia in England, we investigated data from 2000-2010 to verify the increase. We analyzed national databases for microbiological and clinical diagnoses of P. jirovecii pneumonia and associated deaths. We found that laboratory-confirmed cases in England had increased an average of 7% per year and that death certifications and hospital admissions also increased. Hospital admissions indicated increased P. jirovecii pneumonia diagnoses among patients not infected with HIV, particularly among those who had received a transplant or had a hematologic malignancy. A new risk was identified: preexisting lung disease. Infection rates among HIV-positive adults decreased. The results confirm that diagnoses of potentially preventable P. jirovecii pneumonia among persons outside the known risk group of persons with HIV infection have increased. This finding warrants further characterization of risk groups and a review of P. jirovecii pneumonia prevention strategies.

SUMMARYOur study aimed to evaluate changes in the epidemiology of pathogens causing surgical site infections (SSIs) in England between 2000 and 2013 in the context of intensified national interventions to reduce healthcare-associated infections introduced since 2006. National prospective surveillance data on target surgical procedures were used for this study. Data on causative organism were available for 72% of inpatient-detected SSIs meeting the standard case definitions for superficial, deep and organ-space infections (9767/13 531) which were analysed for trends. A multivariable logistic linear mixed model with hospital random effects was fitted to evaluate trends by pathogen. Staphylococcus aureus was the predominant cause of SSI between 2000 (41%) and 2009 (24%), decreasing from 2006 onwards reaching 16% in 2013. Data for 2005–2013 showed that the odds of SSI caused by S. aureus decreased significantly by 14% per year [adjusted odds ratio (aOR) 0·86, 95% confidence interval (CI) 0·83–0·89] driven by significant decreases in methicillin-resistant S. aureus (MRSA) (aOR 0·71, 95% CI 0·68–0·75). However a small significant increase in methicillin-sensitive S. aureus was identified (aOR 1·06, 95% CI 1·02–1·10). Enterobacteriaceae were stable during 2000–2007 (12% of cases overall), increasing from 2008 (18%) onwards, being present in 25% of cases in 2013; the model supported these increasing trends during 2007–2013 (aOR 1·12, 95% CI 1·07–1·18). The decreasing trends in S. aureus SSIs from 2006 and the increases in Enterobacteriaceae SSIs from 2008 may be related to intensified national efforts targeted at reducing MRSA bacteraemia combined with changes in antibiotic use aimed at controlling C. difficile infections.

We determined the incidence, risk factors and antimicrobial susceptibility associated with Escherichia coli bacteraemia in England over a 24 month period. Case data were obtained from the national mandatory surveillance database, with susceptibility data linked from LabBase2, a voluntary national microbiology database. Between April 2012 and March 2014, 66,512 E. coli bacteraemia cases were reported. Disease incidence increased by 6% from 60.4 per 100,000 population in 2012–13 to 63.5 per 100,000 population in 2013–14 (p E. coli bacteraemia varied with patient age and sex, with 70.5% (46,883/66,512) of cases seen in patients aged ≥ 65 years and 52.4% (33,969/64,846) of cases in females. The most common underlying cause of bacteraemia was infection of the genital/urinary tract (41.1%; 27,328/66,512), of which 98.4% (26,891/27,328) were urinary tract infections (UTIs). The majority of cases (76.1%; 50,617/66,512) had positive blood cultures before or within two days of admission and were classified as community onset cases, however 15.7% (10,468/66,512) occurred in patients who had been hospitalised for over a week. Non-susceptibility to ciprofloxacin, third-generation cephalosporins, piperacillin–tazobactam, gentamicin and carbapenems were 18.4% (8,439/45,829), 10.4% (4,256/40,734), 10.2% (4,694/46,186), 9.7% (4,770/49,114) and 0.2% (91/42,986), respectively. Antibiotic non-susceptibility was higher in hospital-onset cases than for those presenting from the community (e.g. ciprofloxacin non-susceptibility was 22.1% (2,234/10,105) for hospital-onset vs 17.4% (5,920/34,069) for community-onset cases). Interventions to reduce the incidence of E. coli bacteraemia will have to target the community setting and UTIs if substantial reductions are to be realised.

Micro-Abstract We analyzed 115 iliac crest bone marrow biopsy specimens from 101 patients with metastatic castration-resistant prostate cancer, divided into a test (n = 57) and a validation (n = 58) set. We developed a score based on computed tomography Hounsfield units and lactate dehydrogenase levels, which were associated with a positive biopsy result. The score can be used to select patients for whom a bone marrow biopsy will provide tissue for molecular characterization., Background The urgent need for castration-resistant prostate cancer molecular characterization to guide treatment has been constrained by the disease's predilection to metastasize primarily to bone. We hypothesized that the use of clinical and imaging criteria could maximize tissue acquisition from bone marrow biopsies (BMBs). We aimed to develop a score for the selection of patients undergoing BMB. Materials and Methods A total of 115 BMBs were performed in 101 patients: 57 were included in a derivation set and 58 were used as the validation set. The clinical and laboratory data and prebiopsy computed tomography parameters (Hounsfield units [HUs]) were determined. A score for the prediction of biopsy positivity was developed from logistic regression analysis of the derivation set and tested in the validation set. Results Of the 115 biopsy specimens, 75 (62.5%) were positive; 35 (61.4%) in the test set and 40 (69%) in the validation set. On univariable analysis, hemoglobin (P = .019), lactate dehydrogenase (P = .003), prostate-specific antigen (P = .005), and mean HUs (P = .004) were selected. A score based on the LDH level (≥ 225 IU/L) and mean HUs (≥ 125) was developed in multivariate analysis and was associated with BMB positivity in the validation set (odds ratio, 5.1; 95% confidence interval, 1.9%-13.4%; P = .001). The area under the curve of the score was 0.79 in the test set and 0.77 in the validation set. Conclusion BMB of the iliac crest is a feasible technique for obtaining tumor tissue for genomic analysis in patients with castration-resistant prostate cancer metastatic to the bone. A signature based on the mean HUs and LDH level can predict a positive yield with acceptable internal validity. Prospective studies of independent cohorts are needed to establish the external validity of the score.

Please cite this paper as: Wloch C, Wilson J, Lamagni T, Harrington P, Charlett A, Sheridan E. Risk factors for surgical site infection following caesarean section in England: results from a multicentre cohort study. BJOG 2012;119:1324–1333. Objective To assess the frequency and risk factors for surgical site infection following caesarean section. Design Prospective multicentre cohort study. Setting Fourteen NHS hospitals in England, April to September 2009. Population Women who underwent caesarean section at participating hospitals during designated study periods. Methods Infections that met standard case definitions were identified through active follow up by healthcare staff during the hospital stay, on return to hospital, during midwife home visits and through self-completed patient questionnaires. Main outcome measure Surgical site infection within 30 days of operation. Results Altogether, 9.6% (394/4107) of women in the study developed a postsurgical infection following caesarean section with 0.6% (23/4107) readmitted for treatment of the infection. Being overweight (body mass index [BMI] 25–30 kg/m2 odds ratio [OR] 1.6, 95% confidence interval [95% CI] 1.2–2.2) or obese (BMI 30–35 kg/m2 OR 2.4, 95% CI 1.7–3.4; BMI > 35 kg/m2 OR 3.7, 95% CI 2.6–5.2) were major independent risk factors for infection (compared with BMI 18.5–25 kg/m2). There was a suggestion that younger women, and operations performed by associate specialist and staff grade surgeons had a greater odds of developing surgical site infection with OR 1.9, 95% CI 1.1–3.4 (

Since 2001 it has been mandatory for acute hospital Trusts (groups of hospitals under the same management) in England to report all cases of bacteraemia due to Staphylococcus aureus together with information on their susceptibility or resistance to methicillin. This allowed the incidence of methicillin-resistant S. aureus (MRSA) bacteraemia (expressed as the number of cases per 1000 occupied bed days) to be determined for each Trust. In late 2005, the scheme was enhanced to collect demographic, clinical and epidemiological information on each case using a web-based data collection system. Analysis of this mandatory dataset has provided important information on the trends in MRSA bacteraemia in England and has documented a year-on-year decrease in incidence since 2006, following a government initiative in which Trusts were tasked with halving their MRSA bacteraemia rates over a 3 year period. In addition, the enhanced mandatory surveillance scheme has captured a wealth of data that have helped to further define the epidemiology of MRSA bacteraemia. It is to be hoped that based on the English experience of mandatory surveillance, other countries will consider the implementation of similar schemes, not only for MRSA but for other pathogens of public health importance.

The national mandatory surveillance system for reporting meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia in England has captured data on the source of reported bacteraemias since 2006. This study analysed episodes of MRSA bacteraemia (N = 4404) where a probable source of infection was reported between 2006 and 2009. In 2009, this information was available for one-third of reported episodes of MRSA bacteraemia. Of these, 20% were attributed to intravascular devices and 28% were attributed to skin and soft tissue infection. Sixty-four percent of the patients were male, and urinary tract infection was a significantly more common source of MRSA bacteraemia in males compared with females (12% vs 3%). Detection of bacteraemia within two days of hospital admission does not reliably discriminate between community- and hospital-associated MRSA bacteraemia as community cases are frequently associated with an invasive procedure/device. Between 2006 and 2009, there was a significant decline in the proportion of episodes of MRSA bacteraemia associated with central vascular catheters [incidence rate ratio (IRR) 0.42, 95% confidence interval (CI) 0.29–0.61; P < 0.001], peripheral vascular catheters (IRR 0.69, 95% CI 0.48–0.99; P = 0.042) and surgical site infection (IRR 0.42, 95% CI 0.25–0.72; P = 0.001), and a significant increase in the proportion of episodes of MRSA bacteraemia associated with skin and soft tissue infection (IRR 1.33, 95% CI 1.05–1.69; P = 0.017) and attributed to contamination of the specimen (IRR 1.96, 95% CI 1.25–3.06; P = 0.003). Since data were not available for all cases, the generalizability of these trends depends on the assumption that records with source data reflect a reasonably random sample of cases in each year. These changes have occurred in the context of a general decline in the rate of MRSA bacteraemia in England since 2006.

OBJECTIVES: To determine the susceptibility of lower respiratory tract (LRT) isolates of Streptococcus pneumoniae, Staphylococcus aureus and Haemophilus influenzae to antimicrobial agents recommended by UK guidelines for treatment of pneumonia associated with influenza-like illness. METHODS: Analysis of antimicrobial susceptibility data from sentinel microbiology laboratories in England, Wales and Northern Ireland was carried out. Subjects comprised patients who had an LRT specimen taken in a general practitioner surgery or hospital outpatient setting between January 2007 and March 2010. The main outcome measurements were antimicrobial susceptibility trends of LRT isolates over time, between patient age groups and in different geographical regions. RESULTS: Susceptibility to tetracyclines or co-amoxiclav was high. Of the 70,288 and 45,288 isolates with susceptibility results for tetracyclines or co-amoxiclav, 96% and 92%, respectively, were susceptible. Overall susceptibility to ciprofloxacin, ampicillin/amoxicillin and macrolides was lower than for tetracyclines or co-amoxiclav and varied markedly by organism. There were few clinically relevant variations in susceptibility to doxycycline or co-amoxiclav over time, geographically or between age groups. CONCLUSIONS: The data support the use of doxycycline or co-amoxiclav as appropriate empiric treatment for LRT infection caused by the pathogens investigated, for patients in primary care.