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  • Epidemiologic Characteristics of ESBL-Producing ST131 E. coli Identified Through the Emerging Infections Program, 2017

  • Nadezhda Duffy, Davina Campbell, Hannah E. Reses, Elizabeth Basiliere, Chris Bower, Ghinwa Dumyati, Marion Kainer, Daniel Muleta, Benji Byrd-Warner, Richard Stanton, Jonathan Daniels, Alison Halpin, Joseph Lutgring, Isaac See
  • Journal:
    Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
    Published online by Cambridge University Press:
    02 November 2020, pp. s214-s215
    Print publication:
    October 2020
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  • Background: Extended-spectrum β-lactamase–producing (ESBL) Escherichia coli infection incidence is increasing in the United States. This increase may be due to the rapid expansion of ST131, which is now the predominant ESBL strain globally, often multidrug resistant, and has been shown to establish longer-term human colonization than other E. coli strains. We assessed potential risk factors that distinguish ST131 from other ESBL E. coli. Methods: From October 1 through December 31, 2017, 5 CDC Emerging Infections Program (EIP) sites pilot tested active, laboratory-based surveillance in selected counties in Colorado, Georgia, New Mexico, New York, and Tennessee. An E. coli case was defined as the first isolation from a normally sterile body site or urine in a surveillance area resident in a 30-day period resistant to 1 extended-spectrum cephalosporin antibiotic and susceptible or intermediate to all carbapenem antibiotics tested. Epidemiologic data were collected from case patients’ medical records. A convenience sample of 117 E. coli isolates from case patients was collected. All isolates underwent whole-genome sequencing to determine sequence type and the presence of ESBL genes. We compared ST131 E. coli epidemiology to other ESBL E. coli. Results: Among 117 E. coli isolates, 97 (83%) were ESBL producers. Of the 97 ESBL E. coli, 52 (54%) were ST131 (range, for 4 EIP sites submitting >10 isolates: 25%–88%; P < .001). Other common STs were ST38 (12%) and ST10 (5%). ST131 infections were more likely to be healthcare-associated than non-ST131 (56% vs 36%; P = .05) (Table 1). Among specific prior healthcare exposures, only residence in long-term care facilities (LTCFs) in the year before culture was more common among ST131 case patients (29% vs 11%; P = .03). Notably, 85% of ESBL E. coli collected from LTCF residents were ST131. ST131 E. coli were more common among patients with underlying medical conditions (81% vs 60%; P = .02). No statistically significant difference by sex, race, age, culture source, location of culture collection, and frequency of antibiotic use in the prior 30 days was observed. Conclusions:The prevalence of ST131 E. coli varies regionally. The association between ST131 and LTCFs suggests that these may be particularly important settings for ST131 acquisition. Improving infection control measures that limit ESBL transmission in these settings and preventing dissemination in facilities receiving patients from LTCFs may be necessary to contain ST131 spread.

    Funding: None

    Disclosures: None

  • Telephone-supported computerised cognitive–behavioural therapy: REEACT-2 large-scale pragmatic randomised controlled trial

  • Simon Gilbody, Sally Brabyn, Karina Lovell, David Kessler, Thomas Devlin, Lucy Smith, Ricardo Araya, Michael Barkham, Peter Bower, Cindy Cooper, Sarah Knowles, Elizabeth Littlewood, David A. Richards, Debbie Tallon, David White, Gillian Worthy, on behalf of the REEACT collaborative
  • Journal:
    The British Journal of Psychiatry / Volume 210 / Issue 5 / May 2017
    Published online by Cambridge University Press:
    02 January 2018, pp. 362-367
    Print publication:
    May 2017
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  • Background

    Computerised cognitive–behavioural therapy (cCBT) for depression has the potential to be efficient therapy but engagement is poor in primary care trials.

    Aims

    We tested the benefits of adding telephone support to cCBT.

    Method

    We compared telephone-facilitated cCBT (MoodGYM) (n = 187) to minimally supported cCBT (MoodGYM) (n = 182) in a pragmatic randomised trial (trial registration: ISRCTN55310481). Outcomes were depression severity (Patient Health Questionnaire (PHQ)-9), anxiety (Generalized Anxiety Disorder Questionnaire (GAD)-7) and somatoform complaints (PHQ-15) at 4 and 12 months.

    Results

    Use of cCBT increased by a factor of between 1.5 and 2 with telephone facilitation. At 4 months PHQ-9 scores were 1.9 points lower (95% CI 0.5–3.3) for telephone-supported cCBT. At 12 months, the results were no longer statistically significant (0.9 PHQ-9 points, 95% CI −0.5 to 2.3). There was improvement in anxiety scores and for somatic complaints.

    Conclusions

    Telephone facilitation of cCBT improves engagement and expedites depression improvement. The effect was small to moderate and comparable with other low-intensity psychological interventions.

  • Case 90 - Elevatedintracranial pressure

  • from Section II - Neurocritical care
  • Edited by George A. Mashour, Ehab Farag
  • Book:
    Case Studies in Neuroanesthesia and Neurocritical Care
    Published online:
    03 May 2011
    Print publication:
    03 February 2011, pp 304-308

  • Summary

    Intracranial pressure (ICP) is an important parameter guiding the management of patients in the intensive care unit (ICU) with intracranial pathology. The subdural hemorrhage was evacuated and a right frontal intraventricular ICP catheter was inserted under general anesthetic. ICP has become central to the critical care management of neurologic patients. There are also direct risks associated with the use of monitoring catheters including infection and hemorrhage. Control of ICP in the ICU depends on the manipulation of a variety of factors with the aim of minimizing secondary insults. The management of intracranial hypertension in the ICU requires a multifaceted stepwise approach, with particular care and attention to avoidable complications such as hypoxia, hypercarbia, and hypotension that may dramatically worsen outcome. Rapid control of ICP and resumption of adequate cerebral perfusion pressure (CPP) are the focus of a management strategy, which requires a systematic approach.

  • Case 16 - Patientwith coronary artery stent

  • from Section I - Neuroanesthesia
  • Edited by George A. Mashour, Ehab Farag
  • Book:
    Case Studies in Neuroanesthesia and Neurocritical Care
    Published online:
    03 May 2011
    Print publication:
    03 February 2011, pp 51-54

  • Summary

    Immediate emergence after neurosurgery is desirable to facilitate neurologic examination and early identification of complications. Awakening is determined by many factors including preoperative status, type of surgery, and intraoperative events. This chapter presents a case study of a 58-year-old female with a body mass index of 32 who complained about gradual hearing loss, increasing frequency of headaches and vertigo and subsequently was diagnosed with an acoustic neuroma. In order to facilitate early detection of neurologic complications, anesthesiologists usually aim for an early emergence following intracranial surgery. The most common causes of delayed postoperative emergence include residual drug effects, respiratory failure, metabolic derangements, and neurologic complications. Cerebral swelling can occur intraoperatively or preexist. In the context of posterior fossa surgery this is of particular concern. Multiple factors contribute to a delayed emergence from anesthesia and a systematic approach to rule out all possible causes is necessary.

  • Equity of access to psychological therapies

  • David A. Richards, Peter Bower
  • Journal:
    The British Journal of Psychiatry / Volume 198 / Issue 2 / February 2011
    Published online by Cambridge University Press:
    02 January 2018, pp. 91-92
    Print publication:
    February 2011
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  • Improving access to psychological treatments for common mental disorders is a priority in a number of countries worldwide. We consider the evidence presented by Harris et al on the Australian Better Access initiative, and discuss the challenges of delivering such intitiatives and evaluating their impact.

  • One good thing leads to another: Cascades of positive youth development among American adolescents

  • Selva Lewin-Bizan, Edmond P. Bowers, Richard M. Lerner
  • Journal:
    Development and Psychopathology / Volume 22 / Issue 4 / November 2010
    Published online by Cambridge University Press:
    01 October 2010, pp. 759-770

  • Developmental cascades are links across the life span among heterotypic (qualitatively distinct) variables associated with one or more levels of organization within the ecology of human development. Using data from the longitudinal, 4-H Study of Positive Youth Development (PYD), we illustrate a developmental systems theory predicated model of cascades in the relations between individuals and contexts that promote positive development among adolescents. Consistent with expectations about the bases of PYD and the role in such development on person and context, ecological resources associated with parenting are linked to individual self-regulatory behaviors that in turn impact PYD, which is then associated with youth community contributions. We discuss the limitations and future directions of this research and the implications of developmental cascades for applications to policies and programs.

  • 27 - Collaborative care and stepped care: innovations for common mental disorders

  • from Part III - Policy and practice
    • By David Richards, Professor of Mental Health Services Research, University of Exeter, UK, Peter Bower, Reader in Health Services Research at the Primary Care Research Group, University of Manchester, Simon Gilbody, Professor of Psychological Medicine and Health Services Research at the University of York
  • Edited by Linda Gask, Helen Lester, Tony Kendrick, Robert Peveler
  • Book:
    Primary Care Mental Health
    Published online:
    02 January 2018
    Print publication:
    01 October 2009, pp 395-408

  • Summary

    Competing demands in the management of common mental health problems

    The individual and public health burden of mental ill health is dominated by ‘common mental health problems’ such as depression and anxiety. Prevalence estimates from around the globe suggest that around 16% of the adult population experience depression and anxiety in any one year, with common or ‘high prevalence’ mental health problems constituting 97% of the total population prevalence (Singleton et al, 2001; Andrews & Tolkein II Team, 2006). These problems cause such significant disability (World Health Organization, 2001) that in Australia it is estimated that at least 50% of days lost to disability through all types of mental illness are caused by the experience of depression or anxiety (Andrews et al, 2001). Many patients do not present for help; of those who do, as many as 50% will report purely physical symptoms and not be recognised as suffering from anxiety and depression. Even so, somewhere between 1% and 3.5% of the adult population are likely to be diagnosed with a common mental health problem annually (National Institute for Health and Clinical Excellence, 2004a,b, 2005).

    In the UK, the prevalence of these problems and the lack of effective services to deal with them have been blamed for a multi-billion pound cross-subsidy from the welfare budget. It has been estimated that the UK spends £7–£10 billion per year on benefit payments to support people with anxiety and depression through the payment of incapacity benefit to the long-term sick (Centre for Economic Performance, 2006). With more people on incapacity benefits owing to mental illness than unemployment benefit, mental health problems were cited as ‘the biggest causes of misery’ in Britain (Centre for Economic Performance, 2006).

    Ameliorating the burden of common mental health problems presents a major challenge for primary care. The challenge is particularly significant because primary care services are expected to meet a number of goals:

  • • Access. Service provision should meet the need for services in the community. The right to obtain treatment should depend on need for services, not ability to pay or geographic location.

  • • Effectiveness. Mental health services should do what they are intended to do: improve health. Health may be defined in terms of health status, or broader definitions may involve wider function and quality of life.

  • The ultrastructure of the daughter sporocyst of Cercaria bucephalopsis haimaena Lacaze-Duthiers, 1854 (Digenea: Bucephalidae) from the edible cockle, Cardium edule L.

  • B. L. James, E. A. Bowers, J. G. Richards
  • Journal:
    Parasitology / Volume 56 / Issue 4 / November 1966
    Published online by Cambridge University Press:
    06 April 2009, pp. 753-762

  • The body wall of the daughter sporocyst of Cercaria bucephalopsis haimaena Lacaze-Duthiers, 1854, is shown by the electron-microscope to consist of an external syncytial tegument, lying on a basement membrane, and an internal cellular subtegument, which surrounds a body cavity containing developing cercariae.

    The syncytial tegument has areas of dense cytoplasm alternating with sparse reticulate cytoplasm. The dense cytoplasm contains nuclei, a few mitochondria and secretory products which probably include a neutral mucopolysaccharide. This may be the precursor of the acid mucopolysaccharide in the sparse reticulate cytoplasm and on the surface of the daughter sporocyst.

    Nutrients are probably absorbed through the outer plasma membrane of the tegument, pass through the sparse reticulate cytoplasm in the middle region of the tegument, the inner plasma membrane and basement membrane into the subtegument.

    The ultrastructure of the tegument of adult and larval Digenea are compared.

    We would like to thank Dr Gwendolen Rees for allowing us to examine the electron-micrographs of Parorchis acanthus. We are also grateful to Professor E. W. Knight-Jones for the provision of excellent working facilities and to the Science Research Council, for a grant to one of us (E.A.B.) which made the work possible.

  • Relationship between service ecology, special observation and self-harm during acute in-patient care: City-128 study

  • Len Bowers, Richard Whittington, Peter Nolan, David Parkin, Sarah Curtis, Kamaldeep Bhui, Diane Hackney, Teresa Allan, Alan Simpson
  • Journal:
    The British Journal of Psychiatry / Volume 193 / Issue 5 / November 2008
    Published online by Cambridge University Press:
    02 January 2018, pp. 395-401
    Print publication:
    November 2008
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  • Background

    Special observation (the allocation of nurses to watch over nominated patients) is one means by which psychiatric services endeavour to keep in-patients safe from harm. The practice is both contentious and of unknown efficacy.

    Aims

    To assess the relationship between special observation and self-harm rates, by ward, while controlling for potential confounding variables.

    Method

    A multivariate cross-sectional study collecting data on self-harm, special observation, other conflict and containment, physical environment, patient and staff factors for a 6-month period on 136 acute-admission psychiatric wards.

    Results

    Constant special observation was not associated with self-harm rates, but intermittent observation was associated with reduced self-harm, as were levels of qualified nursing staff and more intense programmes of patient activities.

    Conclusions

    Certain features of nursing deployment and activity may serve to protect patients. The efficacy of constant special observation remains open to question.

  • Collaborative care for depression in UK primary care: a randomized controlled trial

  • D. A. Richards, K. Lovell, S. Gilbody, L. Gask, D. Torgerson, M. Barkham, M. Bland, P. Bower, A. J. Lankshear, A. Simpson, J. Fletcher, D. Escott, S. Hennessy, R. Richardson
  • Journal:
    Psychological Medicine / Volume 38 / Issue 2 / February 2008
    Published online by Cambridge University Press:
    06 September 2007, pp. 279-287
  • Background

    Collaborative care is an effective intervention for depression which includes both organizational and patient-level intervention components. The effect in the UK is unknown, as is whether cluster- or patient-randomization would be the most appropriate design for a Phase III clinical trial.

    Method

    We undertook a Phase II patient-level randomized controlled trial in primary care, nested within a cluster-randomized trial. Depressed participants were randomized to ‘collaborative care’ – case manager-coordinated medication support and brief psychological treatment, enhanced specialist and GP communication – or a usual care control. The primary outcome was symptoms of depression (PHQ-9).

    Results

    We recruited 114 participants, 41 to the intervention group, 38 to the patient randomized control group and 35 to the cluster-randomized control group. For the intervention compared to the cluster control the PHQ-9 effect size was 0.63 (95% CI 0.18–1.07). There was evidence of substantial contamination between intervention and patient-randomized control participants with less difference between the intervention group and patient-randomized control group (−2.99, 95% CI −7.56 to 1.58, p=0.186) than between the intervention and cluster-randomized control group (−4.64, 95% CI −7.93 to −1.35, p=0.008). The intra-class correlation coefficient for our primary outcome was 0.06 (95% CI 0.00–0.32).

    Conclusions

    Collaborative care is a potentially powerful organizational intervention for improving depression treatment in UK primary care, the effect of which is probably partly mediated through the organizational aspects of the intervention. A large Phase III cluster-randomized trial is required to provide the most methodologically accurate test of these initial encouraging findings.

  • Teaching psychiatrists to teach: qualifications in clinical education for psychiatrists

  • Stephen Dinniss, Richard Bowers, Antony Christopher
  • Journal:
    Psychiatric Bulletin / Volume 31 / Issue 3 / March 2007
    Published online by Cambridge University Press:
    02 January 2018, pp. 107-109
    Print publication:
    March 2007
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  • The education and training of medical students and trainees is a key role of senior clinicians, and the General Medical Council states we ‘must develop the skills, attitudes and practices of a competent teacher’ (General Medical Council, 2005). The Royal College of Psychiatrists places the role of educator as a core competency for psychiatrists (Bhugra, 2005) and believes we should understand ‘the principles of education and use teaching methods appropriate to educational objectives' (Royal College of Psychiatrists, 2004).

  • What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression

  • JUDITH GELLATLY, PETER BOWER, SUE HENNESSY, DAVID RICHARDS, SIMON GILBODY, KARINA LOVELL
  • Journal:
    Psychological Medicine / Volume 37 / Issue 9 / September 2007
    Published online by Cambridge University Press:
    19 February 2007, pp. 1217-1228
  • Background

    Although self-help interventions are effective in treating depression, less is known about the factors that determine effectiveness (i.e. moderators of effect). This study sought to determine whether the content of self-help interventions, the study populations or aspects of study design were the most important moderators.

    Method

    Randomized trials of the effectiveness of self-help interventions versus controls in the treatment of depressive symptoms were identified using previous reviews and electronic database searches. Data on moderators (i.e. patient populations, study design, intervention content) and outcomes were extracted and analysed using meta-regression.

    Results

    Thirty-four studies were identified with 39 comparisons. Study design factors associated with greater effectiveness were unclear allocation concealment, observer-rated outcome measures and waiting-list control groups. Greater effectiveness was also associated with recruitment in non-clinical settings, patients with existing depression (rather than those ‘at risk’), contact with a therapist (i.e. guided self-help) and the use of cognitive behavioural therapy (CBT) techniques. However, only guided self-help remained significant in the multivariate analysis [regression coefficient 0·36, 95% confidence interval (CI) 0·05–0·68, p=0·03]. In the subset of guided studies, there were no significant associations between outcomes and the session length, content, delivery mode or therapist background.

    Conclusions

    The results provide some insights into moderators of self-help interventions, which might assist in the design of future interventions. However, the present study did not provide a comprehensive description, and other research methods might be required to identify factors associated with the effectiveness of self-help.

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