The diagnosis of sarcoidosis requires compatible clinical and radiographic manifestations treatment for sciatica purchase 15 mg flexeril fast delivery, exclusion of other diseases that may present similarly xanax medications for anxiety purchase cheap flexeril on-line, and histopathologic detection of noncaseating granulomas medications in mexico buy genuine flexeril line. Patients who present with asymptomatic bilateral hilar adenopathy or a classical Lofgren syndrome of fever medicine to stop runny nose buy genuine flexeril online, erythema nodosum medicine garden discount flexeril uk, arthralgias medicine engineering flexeril 15mg on line, and bilateral hilar lymphadenopathy or Heerfordt syndrome (uveitis treatment croup cheap flexeril 15mg free shipping, parotid gland enlargement symptoms 5dpiui purchase online flexeril, facial nerve palsy and fever) do not require biopsy. If U/S-guided endoscopy or flexible bronchoscopy cannot be performed or is nondiagnostic, the next step is usually surgical mediastinal lymph node biopsy, followed by surgical lung biopsy via thoracoscopy or thoracotomy. For patients with bothersome symptoms, worsening radiographic opacities, and increasing pulmonary function impairment, initiate oral glucocorticoids rather than continued observation. Final Diagnosis Sarcoidosis 198 Case 4 Chief Complaint Purified protein derivative skin test results History and Physical Examination A 39-year-old man comes to your office as part of a routine screening examination for a new job. The reading is based on the diameter of the induration/swollen area (not the red area). Most cases (>90%) occur within the first 2 years after a negative test converts to a positive test. He has bitemporal wasting, poor dentition, and multiple 1 to 2-cm mobile cervical lymph nodes. Given the recent emergence of multi-drug-resistant strains, the current recommendation is to begin therapy with 4 drugs until the specific drug sensitivities become available. Surgical management was therefore directed at closing open cavities in order to encourage healing. Plombage involved inserting porcelain balls into the thoracic cavity to collapse the lung underneath and thus reduced the need for a disfiguring operation. He describes a dry, nonproductive cough that began about 1 month before the onset of his shortness of breath. The radiographic finding of calcified pleural plaques is classic for asbestos exposure. It will also help in the evaluation of pulmonary hypertension secondary to hypoxia. Other industries associated with asbestos exposure include automobile repair, insulation, textiles, mining, milling, and shipbuilding. Because poorly conditioned persons ventilate more, they are more likely to have a higher exposure and subsequent disease. Chest x-ray reveals the formation of pleural plaques, which are not associated with pulmonary compromise. This risk increases dramatically with concomitant asbestos exposure and cigarette smoking (to 70 when compared to the risk of the normal population). Finally, there is a strong association between asbestos and mesothelioma, although the risk is less than that of developing bronchogenic carcinoma. He was recently treated for an episode of infectious bronchitis characterized by fever and a productive cough. He notes a 10-lb weight loss over the last year and has increasingly restricted his activities because of respiratory compromise. He has a history of smoking 2 packs per day for 50 years but denies alcohol intake. His cardiac impulse is visible in the sub-xiphoid area; there is a regular rhythm, distant heart sounds, and an increased S2. This is not a clinical picture consistent with asthma, even though poorly controlled asthma can result in an obstructive process; it is less likely given the age of the patient and significant smoking history. Bronchogenic tumors such as squamous cell carcinoma and small cell carcinoma would be the most likely tumors seen in smokers and both can invade the bronchus resulting in a post obstructive pneumonia. Home O2 if the patient has PaO2 55 or saturation <88%, or patient has cor pulmonale 218 and PaO2 >55 to 59. The first dose of medication can be given in the office (such as bronchodilator and steroid) before the transfer. Pneumococcal vaccine should be given every 5 years and influenza vaccine yearly to all patients with chronic obstructive pulmonary disease. It is subdivided into pathologic patterns in which either the respiratory bronchioles alone (centroacinar) or more distal portions (panacinar) are involved. Cigarette smoking causes the following changes, all contributing to the generation of emphysematous changes. Abnormalities in ciliary movement Hyperplasia of mucous-secreting glands Inhibition of the alveolar macrophages Release of proteolytic enzymes from neutrophils Inhibition of antiproteolytic enzymes Antitrypsin is an enzyme responsible for the inhibition of trypsinase and elastinase in the lung, and patients deficient in this enzyme experience severe panacinar emphysema. Always consider alpha-1 antitrypsin deficiency in patients with emphysema involving the base of the lung and liver abnormalities. Emphysema is characterized by a loss of airway elastic recoil and caliber resulting in collapse during forced expiration (referred to as the loss of radial traction). This leads to a prolonged expiratory phase, an increase in residual capacity, and air trapping with increases in lung 220 volumes. Neck circumference is 18 inches, with notable macroglossia, micrognathia and a high arched hard palate. Additional symptoms and signs include restless sleep, periods of silence terminated by loud snorts or snoring, nocturnal angina, poor concentration, and awakening with a sensation of choking, gasping, or smothering. The physical exam can be normal, although obesity, elevated blood pressure, a narrow airway, and a large neck circumference are common. She has a 5-pack-year history of cigarette smoking but stopped smoking 15 years ago. Nodules with smooth borders are usually benign; nodules with 227 spiculated borders have a high likelihood of being malignant. The lung is a common site of metastasis from various tumors, but this patient does not have a history of cancer, and metastases are usually multiple, peripheral and not calcified. Examination of the head, eyes, ears, nose, and throat shows poor dentition, a supple neck, and intact cranial nerves. There is no clubbing, cyanosis, or edema of the extremities, although there is a resting tremor of the hands. Acute confusion and fever are suggestive of meningitis and this can be excluded with a lumbar puncture if the diagnosis is not certain. It is a diagnosis of exclusion, along with a history of high-volume alcohol consumption. Discussion Abstinence or withdrawal syndrome refers to a constellation of symptoms that develop only after a period of relative or absolute abstinence from alcohol. It should not be confused with the more mild signs and symptoms of alcohol withdrawal such as tremulousness. There are also2 derangements in the serum electrolytes that are most often related to dehydration. Patients frequently fall before they arrive for medical attention, are in a poor state of health, and often suffer from malnutrition. The alcoholic patient generally lives on a diet high in carbohydrates (alcohol) and low in thiamine, and tends to have no vitamin B reserves. There is no definitive proof, however, that giving the thiamine just before or after the dextrose really makes any difference because they are given so closely together. This is best achieved with benzodiazepines or chlordiazepoxide; however, the specific agent used is not as important as using a sufficiently high amount of the medication. If the patient has liver failure, lorazepam and oxazepam are the only safe agents. If the patient is refractory to benzodiazepines, barbiturates or propofol can be effective. This leads to increases in cardiac output because of the decrease in resistance (low afterload) and an increase in venous return. The chronically elevated venous return overworks the heart and leads to eccentric hypertrophy (dilated cardiomyopathy). While playing, he sustained head trauma and had a brief period of loss of consciousness from which he awoke and was his normal self. Setting: emergency department Assessment Rapidly evolving and often lethal, acute epidural hematomas are formed by laceration of a dural vessel, which produces a clot between the skull and the dura. The increased pressure results in headache, vomiting, and weakness of contralateral limbs. Stress ulcer prophylaxis with proton pump inhibitors, H blockers, or sucralfate2 6. Earliest possible evacuation of the hematoma before transtentorial herniation can occur is essential for a 239 favorable outcome. The 2 essential components of a successful procedure are (a) removing the clot to relieve brain compression, and (b) securing the source of bleeding to prevent recurrence. As the clot is removed, hemostasis is achieved by electrocoagulation and ligation of the main trunks of the middle meningeal vessels as they appear on the dura. The acute management of increased intracranial pressure involves hyperventilation and mannitol injection. Their best indication is to decrease swelling around brain tumors, such as neoplasms and infection, which lead to increased intracranial pressure from edema. Her roommate states that she has been depressed lately and is sleeping more than usual. Assessment 243 the presentation of an acute change in mental status in a depressed patient should lead you to suspect a possible drug overdose. A respiratory alkalosis and metabolic acidosis should prompt you to suspect salicylate intoxication. It causes an acute respiratory alkalosis at first by central brainstem stimulation. Aspirin is directly toxic to the kidney tubules and lung parenchyma and may give acute tubular necrosis and acute respiratory distress syndrome. Acute ingestion of >100 mg/kg leads to an initial respiratory alkalosis and later may cause a mixed respiratory alkalosis and metabolic acidosis. Activated charcoal is administered to absorb the ingested toxin, 245 thereby blocking further systemic absorption. Following these initial measures, alkalinization of the urine should be performed to promote ionization of the salicylate and to thus reduce further reabsorption. The patient states he had 2 similar episodes 7 months ago but did not seek medical attention. Rectal exam shows no hemorrhoids or stool, but there is bright red blood in rectum. Assessment Large volume bleeding from the colon in adults is usually caused by diverticular disease, angiodysplasia, or ulcerative colitis. When active hemorrhage is occurring, radionuclide scintigraphy or angiography can be performed to identify the site of hemorrhage. Colonoscopy will show lesions in the colon also, but they are harder to see during large volume bleeding. Blood transfusion if patient symptomatic from anemia or if active ongoing bleed 4. Brisk colonic hemorrhage due to angiodysplasia responds to endoscopic electrocoagulation. Vasopressin is rarely necessary and should be avoided in a patient with cardiac disease because it causes vasospasm. It should be thought of first when seeing a diabetic patient with change in mental status. Giving glucose to a disoriented person is more important than waiting for specific diagnostics. Urine cultures: no growth Discussion In diabetic patients, the most common causes of hypoglycemia are as follows: Change in dietary habits without an appropriate change in medication Increase in metabolic demands. Insulinoma also causes elevated insulin levels and elevated c-peptide, but is rare. It is due to an excess of insulin released after glucose stimulation often after gastric resection. The most important factor in a case of acute allergic reaction is evidence of instability, such as dyspnea, hypotension, or signs of airway obstruction, such as stridor. Discussion Anaphylaxis is an acute systemic reaction resulting from the interaction of a foreign antigen with surface immunoglobulin E located on mast cells and basophils in a previously sensitized person. This results in the release of histamine, leukotrienes, and other factors that lead to smooth-muscle contraction causing bronchoconstriction, and smooth-muscle relaxation leading to vasodilation. Vasodilation results in the leakage of plasma into the extravascular space, which may result in urticaria and angioedema, hypovolemia and shock, pulmonary edema, obstruction of the upper 259 airway, and cardiac arrhythmias. Following an initial assessment, epinephrine should be administered as the first-line agent. Then, antihistamines (such as diphenhydramine or hydroxyzine), H2 blockers, and steroids may be added. All patients with an episode of severe anaphylaxis should be observed for at least 6 to 8 hrs, due to the possibility of a late second reaction. Beta-blockers are contraindicated in those at risk for anaphylaxis because they can make it worse. He suffers extensive burns on his right arm and anterior chest, and is brought by ambulance to the emergency department. He is currently awake and alert with a patent airway and moving air without difficulty. Heart and lung examinations are normal except for tachycardia; there is no wheezing. That makes 100% oxygen administration the most important initial therapy for burns. Assessment Diagnosing skin burns in this case is not difficult; the challenge is to determine the exact extent of the burns. Second-degree burns are often associated with blistering and a white or fibrinous exudate. Patients often lack sensation in these areas because of loss of both epidermal and dermal elements, including 265 hair follicles and pain receptors. The most common causes of death in the initial period following second and third-degree burns are hypovolemic shock, infection, and airway injury. Even without a direct burn of the airway, inhalation injury can lead to serious illness because of the elevation of carboxyhemoglobin levels. The airway and lung may appear normal at first, but life-threatening abnormalities may appear later. The decision to use intubation is based on the degree of airway inflammation and level of oxygenation. The patient should be started on 100% supplemental oxygen, as oxygen therapy decreases the half-life of the carboxyhemoglobin. Operative debridement of deep partial-thickness burns and skin grafting should be done as soon as feasible. He has had hypertension for 20 years, which is well controlled with enalapril, and he takes albuterol for asthma. Physical examination shows a supple neck and no jugular venous distention or thyromegaly. Cardiovascular exam shows an irregularly irregular rhythm with no rubs or gallops. Initial Management Setting: emergency room Diagnostic/Therapeutic Plan Electrocardiogram Test Results Irregular tachycardia with absent P waves Ventricular response 140/min Pulse irregularly irregular Assessment the presentation of palpitations and a rapid pulse is suggestive of a cardiac arrhythmia. Atrial flutter and supraventricular tachycardia will generally not give an irregularly irregular heart rhythm. The differential diagnosis includes multifocal atrial tachycardia, which most often can be distinguished by the presence of 3 distinct P-wave morphologies on the electrocardiogram. Once rate control is achieved, the next step is to decide whether to continue with rate control or to proceed with rhythm control. Anticoagulation should be given for 3 wks before elective cardioversion if the arrhythmia has been present for several days or if the patient is at increased risk for stroke (cardiomyopathy, rheumatic mitral valve disease, prosthetic valves, left atrial enlargement, or a previous stroke). Another option before elective cardioversion is to perform a trans-esophageal echocardiogram to exclude the presence of a thrombus. Verapamil produces a rapid effect but because of its profoundly negative inotropic/dromotropic activity, it must not be used when there is evidence of ventricular dysfunction or conduction block.
Every day at 8 am for six 44 months treatment ketoacidosis cheap flexeril 15mg free shipping, prepupa that had fallen into the attached buckets were collected and weighed per attractant and recorded for later analysis medicine 4 you pharma pvt ltd buy flexeril 15mg with amex. The company is based at Yellow Springs medicine x ed discount 15mg flexeril mastercard, Ohio and uses frass tea treatment quietus tinnitus discount flexeril 15mg mastercard, as bait attractant for oviposting females symptoms throat cancer cheap flexeril 15 mg with mastercard. Frass tea is prepared by soaking frass (remnant of larvae feed) in water for 2-3 nights treatment 3rd nerve palsy purchase flexeril line. The company however was in need to diversify baiting attractants as the frass lacked consistency in egg production medications in canada buy generic flexeril online. This coupled with the need to compare performance of different strains on attractant substrates that were available and had been used in Kenya formed the basis of the study severe withdrawal symptoms buy flexeril 15 mg with mastercard. Five attractants namely cow manure, fruits mix (pineapples, bananas, watermelon and avocado), a commercial, rotten fish, frass tea and sweet scenting commercial liquid were selected for the trial. All the fresh fruits and commercial scent were bought from a fruit market at Yellow Springs town. The frass tea was made by overnight soaking frass from previous feeding remnants in water. The selected compartments were those not adjacent to each other in order to avoid interference of putrescence of baiting attractants. Each of the baiting attractant was put into a separate 50ml plastic container to the half mark level (Figure 8). The containers were then covered with a nylon net that allows the spread of odour but prevent the insects from seeing or touching the trapping material within as per the method of Sripontan and Chiu (2017). A lid with twenty equidistantly perforated holes was then used to secure the nylon material to the plastic container (Figure 8). A block of wooden pieces stuck together by rubber bands was put on top of the container containing the attractant substrate and each day at 4pm, a pair of containers containing different attractants and the block of wood was separately put inside the selected compartments of a cage (Figure 9). Figure 8: Rubber bound wooden blocks used to trap eggs oviposted by the black soldier fly After 24 hours, the attractant and the block of wood with laid eggs were removed, and the eggs scratched from the woods with a pen knife. This was repeated until all the attractant pairs had been tried to give a total of eight replicates per attractant. Care was taken to ensure uniform distribution of the attractants within the compartments of the cages. Sanergy Ltd located about 45 km, south east of Nairobi City, within Machakos County, in an area that is dry most times of the year, sunny, and sparsely populated. The company takes an innovative system-based approach to build out an entire sustainable sanitation value chain cycle that has three main components namely: 1. Collecting the waste from the toilets in sealed 30 litre capacity cartridges on a regular basis from the operators and exchanging them with clean empty ones. This way, the waste is safely removed from the community and between November 2011 and May, 2014, 6,200 metric tonnes of waste had been collected and safely removed from the 47 community. This facilitates hygienic sanitation for approximately 33,000 residents (Sanergy, 2014). However, low productivity, high mortality and longer development periods on the substrate have been witnessed. The study therefore compared the performance of this substrate with that of other locally available substrates with an aim of blending them with the primary substrate to boost production. Banana peels and food remains were also obtained free of charge from the nearby Kinanie market as garbage collections, with the only costs related to their acquisition being transport costs. The substrates were packed in air tight gunny bags and transported to the production facility at Kinanie. The performance of the substrates was evaluated in terms of the effect on growth rate, development period and nutrient composition of the larvae in larvae feeding experiments. Corrugated plastic pipes were put in the adult colony and stale food remains was used as an attractant medium as per the standard operating procedure at Sanergy (Sanergy, 2014). Eggs laid within two days were collected and transferred to a cylindrical plastic vessel containing a 15% protein chick mash thoroughly mixed with water to moisture content of 60% (Figure 10). The container with eggs was transferred to a nursery section with controlled conditions 0 (temperature, 30 C, relative humidity, 70%) for hatching. To accelerate their growth, newly hatched neonates were allowed to feed on the commercial chick mash until they th were 5 days old (Tschirner and Simon, 2015). Sampling was done from among these by initially counting the larvae into five groups each containing 2,000 larvae, using a pair of forceps to handle the delicate larvae. Each group was then weighed on an electronic weighing scale to determine the average collective weight of 2,000 larvae, and consequently the mean initial weight per larvae. The average weight of a cohort was then used to divide the rest of the larvae into 12 cohorts to ensure triplicate treatment per substrate. For control, an extra container with substrate but no larvae was included for each substrate. The feeding containers were randomly placed on a floor surface and covered with a mosquito netting to keep off other fly species from ovipositing on the substrates (Figure 11). The sampled larvae from each substrate treatment were pooled together and sun dried and stored in airtight zip lock bags for nutrient analysis as per the method described by (Intl, 1995). The feeding was continued for a total of 16 days, by which time most larvae (white/cream in colour) had changed into black/brown prepupae (Tomberlin et al. All the prepupa and any larvae were then harvested by sieving them through a 5-mm diameter mesh screen and the residue material o dried at 105 C for 24 hours to determine its dry mass. The final prepupa weight was taken to be the average weight of the biomass recorded on the day of harvest. The chosen substrates were also available in Kenya albeit in waste form and therefore results obtained could be compared and equivalent substrates utilized. All the sieved larvae from three bins were separately weighed to determine their collective weight. The sum of the total weight of larvae from the three bins was averaged to determine the average weight of a bin and thereafter the average larvae weight before feeding was started. Though the study intended to utilize organic waste forms of the substrates, legal restrictions prohibited the usage of these materials, necessitating purchase of the above substrates. The purchased substrates were separately chopped into small pieces using a knife in different feeding basins (Figure 12). Then six feeding basins were selected and clearly labelled according to the intended respective feeding composition. Using a feed rate of 150mg/l/d, and the number of larvae per group (approximately 33,000), 4. Thereafter, 1000 ml of water was added and a small hand rake used to mix it with the components. During feeding management practices included frequent monitoring of water content and feeding behaviour of larvae. Daily, the feedstocks in all the treatments were agitated by a rake to ensure uniform aeration and feeding within the substrates. The total weight obtained was divided by the number of larvae to obtain an 52 average weight of each larva. After sampling, fresh food rations were provided and this was continued until the first turned prepupa was noticed within a bin and at this point, addition of fresh food was stopped and larva allowed feed for four more days and for the feed to dry up to facilitate easy sieving during larvae and frass separation. Harvested Black Soldier Fly larvae were sun dried for 4 days in a greenhouse and then ground into powder using a kitchen blender. Fifteen millitres of concentrated sulphuric acid was then added and the mixture transferred into an acid hydrolyser for 3 h. Seventy percent pure diethyl ether was added to each sample and then transferred to an ether extractor machine. After extraction, the ether o extract was then dried in an oven at 110 C for 30 min before weighing to determine the net weight of the extract. Black Soldier Fly larvae were obtained and prepared for feeding experiments as previously described in section 3. Larvae sampling 54 th th th th and weighing was done as previously described on the 4, 8, 12 and 16 days respectively. The total amount of substrate required before the next feeding was calculated on the basis of the feeding rate and total amount of larvae and thereafter weighed and distributed to the respective feeding containers. The feeding was done for 16 days but harvesting was delayed until prepupa (recognized by a change of colour of the integument from white/cream for larvae to dark/brown for prepupa) were observed (Tomberlin et al. The effect of the different treatments was analyzed quantitatively in terms of weight gain, larvae growth rate and duration of development, and qualitatively in terms of protein/lipid ratio of the produced larvae. The total amount of food distributed into each basin was calculated on the basis of number of larvae, feeding rate of 200mg/l/d and number of days to the next feeding period. After food distribution, each larval cohort was evenly spread on the allocated feedstock ration. In all the feeding regimes, feeding was done for 16 days followed by harvesting when prepupa (recognized by a change of colour of the integument from white/cream for larvae to dark/brown for prepupa) were observed (Tomberlin et al. An earlier study by Fritzi (2015) at Sanergy had combined faecal sludge with the co substrates at a ratio of 50:50. Therefore ratios close but in either side of this reference ratio were selected for comparison and compared to the control diet (100% faecal sludge). The two were then thoroughly mixed in large plastic bowls to obtain homogeneity before distribution into the feeding basins (Figure 13). In all the mixing treatments, feeding was done for 16 days but harvesting was delayed until prepupal (recognized by a change of colour of the integument from white/cream for larvae to dark/brown for prepupa) were observed (Tomberlin et al. Each larval cohort was spread 56 evenly on its allocated substrate for feeding in triplicates. The feeding containers were then randomly placed on a floor surface and covered with a mosquito netting to keep off other fly species from laying on the substrates (Figure 14). The sampled larvae were collectively weighed on an electronic scale and thereafter, returned to their respective feeding containers. The total weight obtained was divided by the number of larvae to obtain an average weight of each larva. The weight gain after every 4 days was calculated by comparing the obtained average larval weight with the previous mean larval weight. The final prepupa weight was taken to be the average weight recorded on the day of harvest. On the last day of sampling, all the prepupa and any remaining larvae in a treatment were separately harvested by sieving through a 5mm dimeter mesh screen and supplemented by manual picking of small sized larvae that may have passed through the sieve together with the residue, to minimize losses. Thereafter, the weight of total feed provided and that of total residues obtained were used to calculate the reduction effect of a treatment. The performance of the different treatments was evaluated using the recorded parameters of periodical larval weights, total prepupal/larval harvests in grams and calculation of feed conversion and reduction efficiency. The selection of the ingredients was done on the basis of their local availability in sufficient amounts, cost, need for disposal and nutrient profile. Preference was given to those that are byproducts or waste products, whose incorporation in feeds could also enhance good sanitation (Madu et al. Cassava flour and ethoxyquin were added at a rate of 150 mg per kg of diet as a binder and preservative respectively (Pandey, 2013). The ingredients were manually mixed thoroughly to form a homogenous mixture followed by addition of warm water to form dough. To ensure pellet floatability on water, cooking liquid oil was added using a handheld sprayer (Pandey, 2013). The pellets were then sundried to a final moisture content of 6-10%, and 59 then cut into 1 cm sized pieces using a sterile scalpel and stored in in a cool dry place at room temperature for fish feeding (Pandey, 2013). At the end of the two week period, a random sample of 30 fish were individually weighed using an electronic scale according to Khan et al. Thereafter the feeding ration was adjusted weekly on the basis of the previous obtained weekly mean weights. The experimental cages were inspected daily to remove any dead fish (usually found floating). The parameters used to evaluate the performance and feed characteristics included periodical fish weights, final fish mean weight, feed floatability time and duration of feed stability on water, feed shelf life, colour of the feeds and effect on water parameters (Mustapha et al. All the statistical analyses were conducted in the R studio (Team, 2015; Team, 2016). These included the common housefly, green bottle fly, blowflies and sandflies among others. A mass of eggs oviposited inside the corrugation th grooves were also observed on the same day. However wide variability within and between the substrates was evident as indicated by the standard deviations. Table 9: Substrate reduction, bioconversion rate and feed conversion rate of Hermetia illucens larvae fed on different organic waste substrates. The fat content was highest on avocado diet followed by banana diet and lowest on kales diet. The dry matter content was significantly high in the avocado and banana diets respectively and low on pineapple, watermelon and kales diets in that order. The fibre content was however highest on banana raised prepupa and lowest on those raised on avocado diet (Table 10). Table 10: Proximate analysis of the nutrient content of prepupa harvested from different vegetable and fruit substrates. Among the plant substrates, bananas produced the heaviest prepupa followed by watermelon, pineapples, avocados and lastly kales. Prepupa harvested from kales had both the least average mass and total biomass yield (Table 11). There was a significant difference in terms of days taken to mature across the treatments 4. Among the fruits category, the greatest amount of residue was obtained on pineapple treatment while avocados yielded the least amount of remnant wastes. During early days, there was little consumption of kales but this improved with time as the kales underwent decomposition. Kales yielded the lowest bioconversion rate while the control diet had the highest. Among the fruits, bananas and watermelons had higher bioconversion rates compared to pineapples and avocados. The feed conversion ratio on the other hand was lowest for the control diet followed by banana diet and was highest on the kales diet. Ass from day eight to day 16, the performance of 100mg/l/d and 150mg/l/d was significantly below that of 200 and 250mg/l/d with the performance at 200mg/l/d and 250 mg/larva/day not being significantly different (Figure 21). Increase of feeding rate from 100 to 200 mg/larva/day resulted in increase in the prepupal weight and prepupal yield (Table 12 and Table 13). Across the other homogeneous substrates, the prepupal biomass yield increased with increase in feeding rate with higher biomass being obtained from larvae fed at 200mg/l/d and 250mg/l/d feed rates compared to 100 and 150 mg/l/d feed rates (Tables 12 and 13). However the effect of 200 and 250 mg/l/d was not different across the substrates especially in terms of days to maturity, substrate reduction and bioconversion rate as shown in Table 12; and prepupal weight and yield (Table 13; Figure 22). The amount of food provided also had an effect on the time taken by larvae to mature. For example at 250mg/l/d and 200mg/l/d, a significant proportion of the th th population had turned into prepupa by the 15 and 16 days respectively compared to th th 18 and 20 for those fed on 150mg/l/d and 100mg/l/d respectively. As shown in Table 14 below, feeding regimes had significant effects in terms of maturation period, substrate reduction, feed conversion ratio and bioconversion rates. The figure shows that there was no significant effect of feeding regime on the larvae growth rate between day zero and day four with differences becoming discernible as from day four onwards. The performance of the 30:70 and 50:50 combinations were not significantly different across the different substrate treatments. The prepupa crude protein and crude fat content, the most important nutrients in animal feeds were 38. Though differences were noted between water parameters of the two feed types, these were insignificant at 95% confidence interval. The parameter that showed the biggest variation in the two feed treatments occurred in the nitrite (15. During this time, the commonly observed flies in the attractant medium were the common housefly, blowflies and the green bottle fly. Consequently, only a handful of prepupa was moving into the harvesting buckets across the attractant substrates. This could be attributed to initial low numbers of female adults within the locality, or due to incomplete rotting of attractants to produce a strong putrescent smell to attract the females in large numbers. Furthermore, the initial competition with the other fly species in the vicinity could also account for the low numbers of self-harvesting prepupa. It is possible that the initially hatched larvae sent out species specific chemicals that attracted more females to the attractant. This in turn led to more egg production and consequently the boost in the prepupa harvest. Stankus (2013) observed the housefly to be the primary colonizer of a new food source. The variation in the amount of larvae harvested could be due to the differences in the intensity and quality of oduors produced by the decomposing food, as well as the nutritional quality of the substrate materials. The attraction of wild Black Soldier Flies by Bonso (2013) using rat meat, fresh fish, fresh human faeces and wet chicken feed found that rat meat carcass was the best attractant among these though Tomberlin and Sheppard (2002) and (Diener et al. However the stench was a public nuisance that necessitated the location of the production facility away from human habitats and wearing of nose masks (Bonso, 2013).
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Importantly treatment viral pneumonia cheap flexeril 15 mg without a prescription, this study is limited in that children were often receiving intensive levels of intervention outside of the intervention setting 97140 treatment code buy flexeril pills in toronto, making impact of prescribed intervention hard to determine treatment 5th toe fracture buy flexeril 15mg on-line. In a report also including a population reported in a retrospective cohort symptoms zinc overdose purchase generic flexeril canada, parental stress was not associated with any outcomes medications buy genuine flexeril on-line. One study comparing an 8-week caregiver-delivered joint attention approach with a waitlist control assessed intensity of total hours of intervention (external to the study) treatment glaucoma cheap 15 mg flexeril, investigator-rated quality of caregiver participation medications hypertension purchase flexeril 15 mg on-line, and parent-rated 150 adherence as predictors of outcomes at the 12-month followup treatment hiccups 15 mg flexeril with visa. Greater caregiver quality of involvement predicted increased joint engagement (p<. Investigators also explored relationships among maternal synchronization (responsiveness to child communications) and long-term (12 months post-intervention) child language outcomes. The link between short-term gain in maternal synchronization and long-term language (12 months post treatment) gains was not moderated by maternal insightfulness, nor did initial language skills moderate the link between gains in maternal synchronization after 12 weeks and long term gains 156 in expressive language. Intervention-Related Factors Several studies of early intensive behavioral and developmental approaches evaluated potential effects associated with characteristics of the interventions themselves. In a retrospective cohort study, outcomes were related to age at enrollment, treatment duration, and higher baseline adaptive scores, with duration becoming nonsignificant after accounting for group membership (correlation of duration, group=. A significant interaction emerged between age at enrollment and group membership, 86 with younger starting age influencing outcomes for the treatment group but not control. Finally, in a 77 prospective cohort study, hours of intervention did not correlate with outcomes. Treatment Phase Changes That Predict Outcomes No studies were identified that provided data on changes early in treatment that predicted outcomes. Treatment Effects That Predict Long-Term Outcomes Few studies assess end-of-treatment effects that may predict long-term outcomes. Several early intensive behavioral and developmental interventions change measures over the course of very lengthy treatments, but such outcomes usually have not been assessed beyond treatment 140, 141, 148, 149 windows. One family of studies attempted to follow young children receiving early joint attention intervention until they were school-aged, but it failed to include adequate followup of the control group. Overview of the Literature Twelve studies (reported in multiple publications) reporting on different interventions measured generalization of effects seen in treatment. However, several studies incorporated parent or teacher-delivered components, which may promote generalization of skills to the 93, 101-104, 126, 129, 151-153, 155, 157, 158, 161, 166, 178, 196 home and classroom. Detailed Analysis Few studies measured generalization of effects seen in treatment; however, several studies incorporated parent or teacher-delivered components, which may promote generalization of skills to the home and classroom. Among play/interaction-focused studies, one study of imitation training reported that gains in elicited imitation skills in the treatment group were also reflected in improvements in motor imitation skills, suggesting transfer of skills learned in the 152, 153 intervention. In a prospective cohort study assessing an intervention targeting pretend play, treatment group participants maintained their level of play dialog with novel toys when scripted 161 dialog (a component of the initial intervention) was not provided. Four interventions targeting 75 joint attention skills based in preschools reported generalization: in one, increases in joint attention initiations with preschool teachers generalized to longer duration of joint engagement 155 with mothers (10% increase from baseline compared with 2% decrease for control group). Two other studies 157 suggested that joint attention skills training transferred to the classroom with treatment group participants spending less unengaged time and/or initiating more gestures. In a final study, children receiving either a joint attention or symbolic play interventions were able to generalize 158 increases in responding to joint attention to a novel individual. Studies of early intervention approaches reported greater socially engaged imitation that 103, 104 generalized across settings and context in the treatment group, increased frequency of joint 93 attention acts with an unfamiliar examiner, and maintenance of skills over time and in the home 101, 102 and center-based setting. One study of a social skills intervention reported increases in participant social skills on intervention staff-rated but not parent-rated measures for either a 129 Skillstreaming group or comparison group receiving a sociodramatic relational intervention. For the current review, we identified three studies addressing treatment approaches for very young children. Mean ages were all under three years, and all studies address interventions that can be used with children under age 2. Two poor quality studies compared parent training to lower intensity supportive interventions. The lower intensity treatment model, Autism-1-2-3, compared two groups that received the same series of ten thirty-minute child and parent-training sessions, with one group having a lagged start date and serving as a control. Compared with the control group, children in the treatment group showed improved adaptive, imitation, and communication skills, based only upon parent report. Mothers in the treatment group also reported improved health but did not report decreases in parenting stress. In summary, young children who received behavioral interventions seemed to improve regardless of intervention type. It is important to note that none of the fair or better quality studies of young children compared children getting treatment to a no treatment control group. Potential modifiers of treatment efficacy include baseline 93 levels of object interest. Most outcome measures of adaptive functioning were based upon parent report, and the effect of parental perception of treatment efficacy on perception of child functioning was generally not explored. We provide an overview of the state of the literature by intervention type, detail the strength of evidence for the impact of each major intervention on relevant outcomes, and describe major issues and gaps in the current body of evidence. Assessing the literature requires consideration of two main components, namely the observed effectiveness of interventions and our confidence that those effects will remain stable in the face of future research. Our confidence that the observed effect is the true effect and that perceived effectiveness is unlikely to change with future research is presented as strength of evidence, and can be insufficient, low, moderate or high. Once we established the maximum strength of evidence possible based upon these criteria, we assessed the number of studies and range of study designs for a given intervention-outcome pair, and downgraded the strength of evidence rating when the cumulative evidence was not sufficient to justify the higher rating. As such, this category includes defined manualized approaches that vary substantially in terms of their structure, approach and setting. We located 37 papers comprising 25 unique studies addressing early intensive behavioral and developmental interventions for this review update. Our strength of the evidence assessment considers studies from both the 2011 and current reviews. However, the magnitude of these effects varies across studies and this variation may describe subgroups showing different responses to particular interventions. Intervention response is likely moderated by both treatment and child factors, but exactly how these moderators function is not entirely clear. Sample sizes of studies in the current review are typically small (total Ns ranging from 11-284, median=40), and some studies may be considered pilots for larger studies that may better elucidate questions about interventions intensity and moderators of effects. In fact, almost equal numbers of studies report treatment impact versus null treatment effects. Since our previous review, there have been substantially more studies of well-controlled low intensity interventions that provide parent training in bolstering social communication skills. Children receiving low-intensity interventions have not demonstrated the same substantial gains as seen in the early intensive intervention paradigms regarding cognitive and adaptive skills. Strength of the Evidence A growing evidence base suggests that some children receiving early intensive behavioral and developmental interventions. At present it is challenging to understand which approaches to high intensity intervention have the greatest effects for specific children (Table 12). Data are not yet sufficient in this literature base to understand impact on adaptive behavior skills. Available studies indicate variable responses, with modest improvement for some children in some approaches, but limited improvement in other parent training paradigms (Table 13). Not all of these improvements were Retrospective maintained at long-term followups. Across studies where positive effects were seen, the actual treatment impact on skills may vary based on child and intervention factors. A key limitation is that approaches across studies vary substantially, and it is hard to determine the effects of these unique studies on specific groups of children. However, children in high Low for Prospective intensity early intensive intervention improved positive effect cohort: 7 fair, 2 more than children receiving other types of poor (616) services. Retrospective There was variability within domains, such that cohort: 1 fair, 2 some studies found improvement whereas poor (182) others found declines in domain standard scores. For example, one study found a decrease in the motor skills domain for both treatment and control groups. An important limitation is that adaptive behavior was always measured by parent report (Vineland) rather than objective observation. Prospective cohort: 4 fair, 2 Most control groups were also receiving poor (470) treatment and also showed improvement, making it difficult to tease apart the effect of Retrospective early intensive intervention specifically vs. Evidence emerged that (142) baseline symptom severity predicts response to treatment, although the direction is inconsistent. A limitation is that some studies measured language using direct testing, whereas others only used the Vineland Communication domain. Prospective cohort: 2 good, Of studies that assessed language 2 poor (176) outcomes, two possible child variables influencing treatment efficacy emerged. The first is that younger child age was associated with greater language improvements at followup in two studies. Second, another study found that higher baseline levels of object interest in children were associated with attenuated growth in communication skills. The overall quality of studies improved compared with the previous review with two good quality and 10 fair quality studies, and one of poor quality. Other studies incorporated peer-mediated and/or group-based approaches, and still others described interventions that focused on emotion identification and theory of mind training. The studies also varied in intensity, with most interventions consisting of 1-2 hour sessions/week lasting for approximately 4-5 weeks. Most studies reported some short term gains in either parent-rated social skills or directly tested emotion recognition. While we now have higher quality investigations of social skills interventions demonstrating positive effects, our ability to determine the effectiveness of these interventions continues to be limited by the diversity of the intervention protocols and measurement tools. Maintenance and generalization of these skills beyond the intervention setting is also inconsistent, with parent and clinician-raters noting variability in performance across settings. All studies demonstrated benefit on at least one outcome measure, but a lack of consistency in the interventions or measures used makes it difficult to assess consistency or precision. Most studies relied on parent or teacher report of intermediate outcomes, although some studies have attempted to included ratings and outcomes (peer/teacher nominations, social networks/maps) with potential for assessment of generalization (Table 14). Low for (117) positive effect Maintenance and generalization of these skills beyond the treatment context had variable results. Regarding joint attention skills, interventions were delivered by parents, teachers, and interventionists over typically short durations ( 12 weeks). As with other studies reported in this review, participants in play/interaction studies often received other early intervention services in addition to the targeted intervention, making disentangling effects of the intervention difficult. Specific and focal training regarding imitation skills utilizing naturalistic approaches to promote imitation. Additionally, parent training in a variety of play-based interventions is associated with positive outcomes for encouraging early social communication skills. Strength of the Evidence A growing evidence base reports on effects in children receiving early joint attention-related intervention in combination with other interventions show substantial improvements in joint attention and language skills over time. Within this growing literature, our confidence (strength of evidence) in this effect is moderate, based on the need for additional research that identifies which groups of children benefit the most from this approach and how this intervention relates to other ongoing concurrent offered interventions. Results from a variety of play-based interventions also suggest that young children often display short-term improvements in early play, imitation, language, and social interaction skills. However, our confidence in these estimates is low, and substantial evidence that these short-term improvements are linked to broader indices of change over time is lacking (Table 15). Six of these studies reported significantly greater improvements in anxiety symptoms in the intervention group compared with controls. All studies provided followup data reflecting treatment effects that lasted beyond the period of direct intervention. Specifically, one fair quality study combined a parent training approach with risperidone. This combination significantly reduced irritability, stereotypic behaviors, and hyperactivity, and improved socialization and communication skills. Within this population our confidence (strength of evidence) in this effect is high. With regard to parent training paradigms to address challenging behavior, results of parent training studies and parent training in addition to 90 treatment with risperidone have demonstrated short-term improvements in terms of the frequency and intensity of challenging behavior. With few higher quality studies in this area, we considered the strength of the evidence to be insufficient (Table 17). The clinical implications of changes in brainwave patterns reported in the studies are unclear, and the studies were small and short 192, 194, 195 term. One poor quality study of 191 parent education to mitigate feeding problems reported no significant effects. Table 17 outlines interventions/outcomes for which we considered the strength of the evidence to be insufficient. Modifiers of Treatment Effects Understanding the degree to which child characteristics. However, as was reported in the 2011 review, few studies were clearly designed or powered to allow for analysis of heterogeneous effects. Primarily studies in this section are those in which potential correlates were identified that may be moderators, but have not been studied as such. Higher cognitive skills and higher adaptive behavior scores at baseline also were often associated with better outcomes across behavioral interventions, but the associations were not consistent. Regarding intervention-related factors, duration of treatment had an inconsistent effect, with some studies reporting improved outcomes with greater intervention time and others reporting no association. Studies have often not been adequately designed or controlled in order to help identify true moderators of treatment. Treatment Phase Changes That Predict Outcomes the reviewed literature offers little information about what specific early changes from baseline measurements of child characteristics might predict long-term outcome and response. Some evidence suggests that the best predictor of long-term outcome is not baseline characteristics at all, but rather the magnitude of change seen over the course of treatment. Treatment Effects That Predict Long-Term Outcomes Few studies assess end-of-treatment effects that may predict outcomes. Several early intensive behavioral and developmental intervention paradigms change measures over the course of very lengthy treatments, but such outcomes usually have not been assessed beyond treatment 140, 141, 148, 149 windows. It also involved children were receiving many hours of uncontrolled interventions during the course of study. Generalization of Treatment Effects Few studies included in this review explicitly measured generalization of treatment effects to different conditions or locations. Presumably, changes measured on these instruments document important skills with potential impact in other areas. However, some caution is warranted: In some instances, the interventions themselves may actually target component skills of these assessments, particularly in the case of cognitive and language assessments. The majority of the social skills and behavioral intervention studies targeting associated conditions attempted to index outcomes based on parent, self, teacher, and peer report of targeted symptoms. While such ratings outside of the clinical setting may be suggestive of generalization in that they improve outcomes in the daily context/life of the child, in most cases, these outcomes are parent reported and not confirmed with direct observation. Behavioral intervention studies rarely measured outcomes beyond the intervention period, and therefore we cannot assume that effects are maintained over time. Treatment Components That Drive Outcomes We again did not identify any studies meeting our inclusion criteria that addressed this question. None of the fair or good quality studies compared treatment groups to a no treatment control group. One poor 97 quality study found positive differential effects of treatment, but the level of intervention intensity varied significantly between groups, making it difficult to differentiate the effects of treatment intensity vs. Potential modifiers of treatment efficacy include baseline levels of 93 object interest. Most outcome measures of adaptive functioning were based upon parent report, and the effect of parental perception of treatment efficacy on perception (and report) of child functioning was generally not explored. Findings in Relation to What Is Already Known Other reviewers have also synthesized the impact of early intensive behavioral interventions. We also summarize two overview meta 198, 199 analyses (not quality rated) addressing early intervention. Specifically, other reviews have demonstrated consistent impact on cognitive and language skills with fairly large effect sizes across these somewhat overlapping syntheses. These same investigations have also noted much less consistent changes in adaptive behavior skills. Further, these reviews have highlighted similar methodological concerns as 95 noted in our current review: relatively small sample sizes, inclusion of nonrandomized studies, lack of standardized control groups, errors in interpretation of studies, and wide variations in the early intervention approaches assessed. The investigators rated all studies as having high risk of bias (low overall quality) and found positive effects for early intervention on all outcomes. Tests of heterogeneity and small sample sizes precluded assessment of moderators of effects. Results restricted to studies with control groups were consistent with results for all studies across outcomes. Across outcomes, effect sizes were generally slightly better for clinic-based approaches vs.
Recommended Best Practice #12: Rates of procedure-specific surgical site infections should be stratified by wound class symptoms 11 dpo discount flexeril online visa. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 59 B treatment ulcerative colitis discount 15mg flexeril. A risk index is only useful if the risk index is correlated with the actual risk of infection in a health 151 care setting medications qd buy flexeril toronto. There are medications during pregnancy order flexeril once a day, however medicine ubrania discount flexeril online amex, limitations to this method and risk index does not accurately predict risk for some surgical procedures medications hypothyroidism best flexeril 15 mg, such as cardiovascular surgery and spinal 151 surgery medications related to the blood generic flexeril 15 mg with mastercard. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 61 Box 15: Application of Risk Stratification Methodology (acute care example) the Infection Control Team at City General Hospital stratifies its rates of surgical site infections for cholecystectomy and colectomy by wound class medicine and health flexeril 15 mg. Surgical Site Surgical site infections undergoing surgical infections per 100 Infections following surgery procedure over quarter procedures) Colectomy 10 250 = 10 x 100 250 = 4. If changes are made to the way data is stratified in a facility, the date of the change must be noted and future data can only be compared to data generated after the change. The recommended steps in interpretation of surveillance rates are summarized in Figure 8. A hospital or long-term care home should use the following questions to guide the interpretation of a surveillance rate: A. If discrepancies in the rates are found, then identification of the area of miscalculation can serve to reinforce methods and provide additional practice in calculation of rates. The Infection Control Team could seek the assistance of a biostatistician/epidemiologist in calculating the mean rate and standard deviation to assist them in interpreting whether a difference is substantial, especially when numbers are small, data are not normally distributed or to evaluate changes in processes. This can be used to determine, on a month-to-month or quarterly basis, whether a particular infection rate is acceptable or is abnormally high. Process control charts are used in some facilities to determine when infection rates are too high and require action. Process control charts were initially developed in industry in 1931 to provide information about a 159 process behaviour and they have been successfully used for quality control initiatives in hospitals and in 160, 161 syndromic surveillance. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 66 ii. These differences could indicate: changes in hospital practices changes in surveillance methodology changes to case definitions. First, surgeons had begun to treat potentially infected wounds based solely on signs and symptoms. Second, the hospital laboratory began screening wound specimens and selected a limited set, meeting specific criteria, for culture. Recommended Best Practice #14: the possibility that differences in rates of infection in your facility from previous surveillance periods may be the result of changes in institutional practices or surveillance practices should be explored. Temporal variations impacting on data Rates of infection may vary from previous surveillance periods due to changes related to time: seasonal variations for example, respiratory infections have a low frequency in the summer months but may increase over the winter months weekly variations for example, onset of infection over the weekend may not be recognized or confirmed until Monday when patient/resident care and laboratory staffing levels increase, which may result in a higher number of infections being recorded on that day. These contextual factors should also be considered in interpretation of a surveillance rate. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 68 C. Recognized standards or benchmarks A hospital or long-term care home can evaluate their rates of infection relative to an established benchmark. For other infections where there are no well established benchmarks, a group of similar health care settings may choose to benchmark against each other. Benchmark is not available If an appropriate benchmark is not available for a specific indication and one is required. This review can assist in identifying whether differences in the rates of infection can be attributed to surveillance methods, such as different approaches to case finding, or to the use of different case definitions. Upon review of the surveillance methods of several other facilities, a health care setting should be able to identify those that use the same case definitions and similar approaches to case finding. This set of peer facilities can provide an ongoing comparison group of surveillance rates. Some facilities may have this expertise available, while others may have to seek out someone with this training. Another source of assistance in interpretation of surveillance rates is the Department of Epidemiology/Biostatistics of a nearby university. Pearl of Wisdom: Comparisons over time or across health care settings are only appropriate if the same case finding methods have similar sensitivities and specificities, the same case definitions are applied to establish infection and the same methods are used to calculate rates of infection and to adjust for risk factors. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 69 Recommended Best Practice #15: A set of peer institutions should be identified that use the same case definitions and similar case finding methods, to serve as a comparison group. An epidemiologist/biostatistician can assist in confirming whether there are too few infection events for clinically meaningful differences to be detected. Differences in the rate of infection arise from many factors, including: factors relating to the infectious agent, such as increased frequency of the microorganism in the hospital or community setting factors relating to the host, including an increasingly acutely ill and susceptible patient population in health care settings. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 71 E. This communication, often in the form of a quarterly report, should outline any changes to the risk of infection across all patient/resident care areas that are covered by the surveillance system. These reports offer a more detailed analysis of the specific types of infections affecting patients/residents served by these particular care areas. The dissemination of surveillance information should take place on a systematic, ongoing basis so that health care providers and administrators can use it in the evaluation and planning patient care practices. All information provided in surveillance reports must be clear, easy to follow and provide only the information required. Information should be presented using a standardized format, as managers and/or health care providers often have little time available for an in-depth review of the data. Whenever possible, the Infection Control Team should employ visual aids, such as bar or pie charts, graphs and tables, in order to display surveillance data. Refer to Appendix I for information regarding tools for the visual display of surveillance data. Recommended Best Practice #17: Communication of surveillance data should take place on an ongoing, systematic basis and be targeted to those with the ability to change infection control practice. As with surveillance reports, alerts should present only key information with the use of graphs or charts whenever possible to communicate the main messages quickly and effectively. Examples of how an Infection Control Team can undertake the dissemination of information generated through a surveillance system are provided in Boxes 18 and 19. The following key features help to ensure that surveillance graphs are easy to interpret: the graph has a clear title with date and a subtitle that summarizes the data being presented. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 74 the denominator is clearly indicated. Unlabelled or improperly labelled axes and graphs without legends are common pitfalls impeding communication made by those presenting data that are easily rectified. The number of resident catheter days has, however, increased from previous periods. The graphs demonstrate a substantial decline in the rates of respiratory tract infection over the last two influenza seasons at Forest Manor, coinciding with the highest rates of vaccine uptake among health care providers. At Forest Manor, the percentage of immunized health care providers increased modestly from 2001 to 2003 following an active education campaign to increase compliance with vaccine recommendations. It was only in 2005, when vaccination coverage was at its highest, that the most substantial impact on lowering the rates of lower respiratory tract infections was achieved. These data clearly demonstrated the impact that health care provider immunization had on respiratory tract infections in residents, and they were used to form the institutional policies necessary to achieve vaccine coverage in staff. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 75 Lower Respiratory Tract Infections for Influenza Seasons 2000-2006 7 6 5 4 Rate of lower respiratory tract 3 infections per 1,000 resident days 2 1 0 April-Nov April-Nov April-Nov April-Nov April-Nov April-Nov 2001 2002 2003 2004 2005 2006 Influenza Seasons Staff immunization for influenza seasons 2000-2006 90 80 70 60 50 Percentage of 40 staff influenza vaccine uptake 30 20 10 0 2000 2001 2002 2003 2004 2005 2006 Year Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 76 9. Evaluate the Surveillance System A final recommended practice is evaluation of the surveillance system, which entails a review of: 166 how efficiently and effectively the surveillance system works (process evaluation) how the information produced by a surveillance system is used to reduce the risk of health care 167 associated infection (outcome evaluation). Periodic review of surveillance methods should be incorporated as part of regular Infection Control Committee meetings. These review sessions will provide an opportunity for the Infection Control Team to review case definitions, case finding methods (including number of potential cases missed) and other surveillance procedures to ensure consistency in application. An example of a peer review session to evaluate surveillance definitions may be found in Box 20. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 77 Where surveillance data are not used as effectively as they could be to effect changes to practice, the Infection Control Team should examine the underlying reasons for this and if necessary make changes to its surveillance system. Modifications to a surveillance system might include: re-assessment of the infections monitored changes to the approach to case finding ways in which information generated by the system is communicated to other health care providers and decision-makers. Recommended Best Practice #18: the surveillance process implemented in a facility. Summary of Best Practices this summary table is intended to assist with self-assessment internal to the health care setting for quality improvement purposes. As a first step in the planning of a surveillance system, a health care setting should assess: the types of patients/residents that it serves; the key medical interventions and procedures that they undergo; the types of infections for which they are most at risk. Syndromic surveillance of respiratory infections and gastroenteritis should be undertaken in all hospitals and long term care homes. Where hospitals and long-term care homes select outcomes for surveillance in addition to the infections listed above, the following should be considered: the frequency of the infection; the impacts of the infection (including per cent case fatality and excess costs associated with the infection); and the preventability of the infection. In both hospitals and long-term care homes, the outcomes selected for surveillance should be re-evaluated at least annually. Hospitals should use standardized, validated case definitions for surveillance (Appendix C) and apply the definitions consistently. Long-term care homes should use standardized, validated definitions for health care-associated infections in long-term care as provided in Appendix D. Steps should be taken in hospitals and long-term care homes to ensure that case definitions are consistently and accurately applied. Active surveillance should be used for surveillance programs in hospitals and long-term care homes because of the higher sensitivity associated with this approach to case finding. Rates of health care-associated infection for patient/resident length of stay should be adjusted by using the number of patient/resident days as the denominator, rather than number of admissions or number of beds. Rates of surgical site infection in patients undergoing the same surgical procedure should be calculated. Strategies should also be developed to detect surgical site infections post-discharge. There is no generally accepted method for conducting post-discharge surveillance outside the hospital setting. Rates of device-associated infection that are adjusted for duration of exposure to the device should be calculated. When collecting data for the denominator for device-associated infection rates, data should be collected on the length of time that each patient/resident was exposed to a particular device, rather than the total number of days that all patients were exposed to the device. Rates of procedure-specific surgical site infections should be stratified by wound class. The possibility that differences in rates of infection in your facility from previous surveillance periods may be the result of changes in institutional practices or surveillance practices should be explored. A set of peer institutions should be identified that use the same case definitions and similar case finding methods to serve as a comparison group. Communication of surveillance data should take place on an ongoing, systematic basis and be targeted to those with the ability to change infection control practice. All surveillance reports should be clear and easy to follow, including the use of visual aids including pie charts, bar charts and graphs. C Insufficient evidence to support a recommendation for or against use D Moderate evidence to support a recommendation against use. Search Terms Used to Identify Studies for Subsequent Review Nosocomial infection. The design, populations examined, results and evaluation of each of the 15 studies are summarized in the table below. Although none of the studies examined the impact of surveillance systems in long-term care, there is no reason to suggest that similar effects would not be observed in that setting. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 83 Summary of Studies Associating Change in Rates of Health Care-associated Infection with Establishment of a Surveillance System Study Summary study design Key results Adjustment for case mix Identifiable impact of factors surveillance 1980, Examined changes in the rates of Rates declined from 5. The frequency of infection was compared to a group of hospitals in which no intervention took place. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 85 Study Summary study design Key results Adjustment for case mix Identifiable impact of factors surveillance 2006, Examined changes in the rates Surgical site infections were Analysis adjusted for several No changes to infection control Brandt et of surgical site infections in the reduced by 25% following patient and procedural-related practices are discussed. Procedures associated with a significant predict surgical site infections, 11 surgical subgroups. Criterion elements must occur within a timeframe that does not exceed a gap of one calendar day between two adjacent elements. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 89 B. Elements of the criterion must occur within a timeframe that does not exceed a gap of one calendar day between elements two adjacent elements. Elements of the criterion must occur within a timeframe that does not exceed a gap of one calendar day between two adjacent elements. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 93 D. Common Cold Syndromes/Pharyngitis the resident must have at least two of the following signs or symptoms: 1. Symptoms must be new, and care must be taken to ensure that they are not caused by allergies. The resident must have at least three of the following signs or symptoms: a) chills b) new headache or eye pain c) myalgias or body aches d) malaise or loss of appetite e) sore throat f) new or increased dry cough. Comments: If criteria for influenza-like illness and another upper or lower respiratory tract infection are met at the same time, only the diagnosis of influenza-like illness should be recorded. Interpretation of a chest radiograph as demonstrating pneumonia, or the presence of a new infiltrate. At least one of the following constitutional criteria (see box): a) fever b) leukocytosis c) acute change in mental status from baseline d) acute functional decline Comments: Non-infectious causes of symptoms must be ruled out. Constitutional Criteria: Fever: Leukocytosis: Acute functional decline: A new 3 single oral temperature >37. In particular, congestive heart failure or interstitial lung disease may produce symptoms and signs similar to those of respiratory infections. Surveillance for asymptomatic bacteriuria (defined as the presence of a positive urine culture in the absence of new signs and symptoms of urinary tract infection) is not recommended, as this represents baseline status for many residents. The resident has at least one of the following signs or symptoms: a) Fever, rigors, or new onset hypotension, with no alternate site of infection b) Either acute change in mental status or acute functional decline, with no alternate diagnosis, and Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 99 leukocytosis (see box, Section A. However, evidence suggests that most of these epidsodes are likely not due to infection of a urinary source. Urine specimens for culture should be processed as soon as possible, preferably within one to two hours after collection. If urine specimens cannot be processed within 30 minutes of collection, they should be refrigerated. Urinary catheter specimens for culture should be collected following replacement of the catheter if the current catheter has been in place for more than 14 days. New drainage from one or both ears (non-purulent drainage must be accompanied by additional symptoms, such as ear pain or redness). In some homes, it may be appropriate also to accept a diagnosis made by other qualified clinicians. Mouth and Perioral Infection Oral and perioral infections, including oral candidiasis (manifest by the presence of raised white patches on inflamed mucosa or plaques on oral mucosa), must be diagnosed by a physician or a dentist. Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations | July 2014 100 Comments: Mucocutaneous Candida infections are usually due to underlying clinical conditions, such as poorly controlled diabetes or severe immunosuppression. Although they are not transmissible infections in the health care setting, they can be a marker for increased antibiotic exposure. Cellulitis/Soft Tissue/Wound Infection One of the following criteria must be met: 1. The resident must have at least four of the following signs or symptoms: a) heat at the affected site b) redness at the affected site c) swelling at the affected site d) tenderness or pain at the affected site e) serous drainage at the affected site f) one constitutional criterion (see box, Section A. More than one resident with streptococcal skin infection from the same serogroup in a long-term care home may indicate an outbreak. Either physician diagnosis or laboratory confirmation from a scraping or a medical biopsy (see Comments) Comments: Dermatophytes have been known to cause occasional infections and rare outbreaks in the long-term care setting. Herpesvirus For a diagnosis of cold sores (herpes simplex) or shingles (herpes zoster), the resident must have both: 1. For herpetic infections, laboratory confirmation includes positive electron microscopy or culture of scraping or swab. At least one of the following: a) physician diagnosis b) laboratory confirmation (scraping or biopsy) c) epidemiologic linkage to a case of scabies with laboratory confirmation Comments: Care must be taken to rule out rashes due to skin irritation, allergic reactions, eczema and other non-infectious skin conditions. An epidemiologic linkage to a case can be considered if there is evidence of geographic proximity in the facility, temporal relationalship to the onset of symptoms, or evidence of common source of exposure. For instance, new medication may cause both diarrhea and vomiting; nausea and vomiting may be associated with gallbladder disease; initiation of new enteral feeding may be associated with diarrhea. In the presence of an outbreak, stool specimens should be sent to confirm the presence of norovirus or other pathogens.
