Central line bundle implementation in US intensive care units and impact on bloodstream infections

Background

Central line-associated bloodstream infections (CLABSI) represent a serious patient safety issue. To prevent these infections, bundled interventions are increasingly recommended. We examine the extent of adoption of Central Line (CL) Bundle elements throughout US intensive care units (ICU) and determine their effectiveness in preventing CLABSIs.

Methodology/Principal Findings

In this cross-sectional study, National Healthcare Safety Network (NHSN) hospitals provided the following: ICU-specific NHSN-reported rates of CLABSI/1,000 central line days; policies and compliance rates regarding bundle components; and other setting characteristics. In 250 hospitals the mean CLABSI rate was 2.1 per 1000 central line days and 49% reported having a written CL Bundle policy. However, of those that monitored compliance, only 38% reported very high compliance with the CL Bundle. Only when an ICU had a policy, monitored compliance, and had ≥95% compliance did CLABSI rates decrease. Complying with any one of three CL Bundle elements resulted in decreased CLABSI rates (β = -1.029, p = 0.015). If an ICU without good bundle compliance achieved high compliance with any one bundle element, we estimated that its CLABSI rate would decrease by 38%.

Conclusions/Significance

In NHSN hospitals across the US, the CL Bundle is associated with lower infection rates only when compliance is high. Hospitals must target improving bundle implementation and compliance as opposed to simply instituting policies.     

Assessing the Necessity of the Standardized Infection Ratio for Reporting Central Line-Associated Bloodstream Infections

This brief article presents results that support the contention that risk adjustment via the standardized infection ratio (SIR) for the reporting of central line-associated bloodstream infections (CLABSIs) may be no more predictive than standard rate adjustments utilizing CLABSIs per central line days (i.e., CLABSI rates). Recent data posted on the U.S. Department of Health and Human Services’ Hospital Compare website showed that nearly 70% of 1721 reporting hospitals with at least 1000 central line days had five or fewer infections during 2011. These hospitals had 39.3% of the total central line days and a significantly lower SIR than poorer performing hospitals with six or more CLABSIs (p<0.0001). In addition, 19 hospitals are presented which had central line days between 9000 to over 22,000 that also had zero to three CLABSIs. Some of these hospitals were university referral centers and inner city facilities. There was great variation of CLABSI cases among US hospitals. Evidence is mounting that all hospitals should be able to achieve a near zero incidence of CLABSIs and that these infections may in fact be near ‘never events’, which begs whether risk adjustment with the SIR is needed and whether it adds more information than does rate adjustment using CLABSI rates.     

A Simulation Study to Assess Indicators of Antimicrobial Use as Predictors of Resistance: Does It Matter Which Indicator Is Used?

Objective

Indicators of antimicrobial use have been described previously, but few studies have compared their accuracy in prediction of antimicrobial resistance in hospital settings. This study aimed to identify conditions under which significant differences would be observed in the predictive accuracy of indicators in the context of surveillance of intensive care units (ICUs).

Methods

Ten resistance / antimicrobial use combinations were studied. We used simulation to determine if Québec’s network of 81 ICUs or the National Healthcare Safety Network (NHSN) of 2952 ICUs are large enough to allow the detection of predetermined differences between the most accurate and 1) the second most accurate indicator, and 2) the least accurate indicator, in more than 80% of simulations. For each indicator, we simulated absolute errors in prediction for each ICU and each 4-week period, for surveillance lasting up to 5 years. Absolute errors were generated following a binomial distribution, using mean absolute errors (MAEs) observed in 9 ICUs as the average proportion; simulated MAEs were compared using t-tests. This was repeated 1000 times per scenario.

Results

When comparing the two most accurate indicators, 80% power was reached less often with the Québec network versus the NHSN (0/20 versus 2/20 scenarios, with 5 years of surveillance data), a finding reinforced when comparing the most and least accurate indicators (3/20 versus 20/20 scenarios). When simulating 1 year of data, scenarios reaching an 80% power dropped to 0/20, comparing the two most accurate indicators with the larger network, and to 1/20, comparing the most and least accurate indicators with the smaller network.

Conclusion

Most of the time (72%), identifying an indicator of antimicrobial use predicting antimicrobial resistance with a better accuracy was not possible. The choice of an indicator for an eventual surveillance system should rely on criteria other that predictive accuracy.     

Hospital-Wide Multidisciplinary,Multimodal Intervention Programme to Reduce Central Venous Catheter-Associated Bloodstream Infection

Central line-associated bloodstream infection (CLABSI) is the major complication of central venous catheters (CVC). The aim of the study was to test the effectiveness of a hospital-wide strategy on CLABSI reduction. Between 2008 and 2011, all CVCs were observed individually and hospital-wide at a large university-affiliated, tertiary care hospital. CVC insertion training started from the 3^rd quarter and a total of 146 physicians employed or newly entering the hospital were trained in simulator workshops. CVC care started from quarter 7 and a total of 1274 nurses were trained by their supervisors using a web-based, modular, e-learning programme. The study included 3952 patients with 6353 CVCs accumulating 61,366 catheter-days. Hospital-wide, 106 patients had 114 CLABSIs with a cumulative incidence of 1.79 infections per 100 catheters. We observed a significant quarterly reduction of the incidence density (incidence rate ratios [95% confidence interval]: 0.92 [0.88–0.96]; P<0.001) after adjusting for multiple confounders. The incidence densities (n/1000 catheter-days) in the first and last study year were 2.3/1000 and 0.7/1000 hospital-wide, 1.7/1000 and 0.4/1000 in the intensive care units, and 2.7/1000 and 0.9/1000 in non-intensive care settings, respectively. Median time-to-infection was 15 days (Interquartile range, 8-22). Our findings suggest that clinically relevant reduction of hospital-wide CLABSI was reached with a comprehensive, multidisciplinary and multimodal quality improvement programme including aspects of behavioural change and key principles of good implementation practice. This is one of the first multimodal, multidisciplinary, hospital-wide training strategies successfully reducing CLABSI.     

The underlying inflammatory chronic disease influences infliximab pharmacokinetics

Infliximab is an anti-tumor necrosis factor monoclonal antibody approved in chronic inflammatory diseases such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), Crohn's disease (CD) and ulcerative colitis (UC). Infliximab pharmacokinetics is variable between patients, but influence of the underlying disease was never assessed. This study aimed at assessing this influence using a cohort of patients monitored in a single center and with the same assay. Infliximab trough concentrations were determined on samples collected between weeks 0 and 22 after treatment initiation in 218 patients treated for RA, PsA, AS, CD or UC. Infliximab pharmacokinetics was analyzed by a one-compartment population model with first-order elimination rate constant. In AS patients, volume of distribution (V) and elimination clearance (CL) were 5.4 L and 0.24 L/day, respectively. In CD and UC patients, V was 49% and 52% higher than in AS, respectively, and CL was 47% and 60% higher than in AS, respectively. In RA patients, CL was 49% higher than in AS patients. Simulations showed that without methotrexate, a 3 mg/kg dosing regimen would lead only 16% of RA patients to reach the target concentration (2.5 mg/L) at week 22, whereas target concentrations would be reached in approximately half of RA patients cotreated with methotrexate, as well as half of CD (3.5 mg/L) and UC (3.7 mg/L) patients. The suboptimality of approved dosing regimens supports the development of dosing optimization based on concentration measurements.     

重症监护病房的病原调查及耐药性监测研究

目的调查浙江中医药大学附属第一医院重症监护病房（ICU）临床分离株的病原分布及细菌耐药状况,并与非ICU相比较,观察二者的区别,为临床用药提供有效的参考价值。方法收集该院2010年1月至2011年6月临床送检的各类标本,采用VITEK-2 compact全自动微生物鉴定仪,用GPI、GNI、ANC、YST鉴定卡、AST—GN13、AST—GP67药敏卡进行菌株的鉴定和药敏,根据美国临床实验室标准化协会（CLSI2010）制定的指导原则,判断细菌的耐药率。结果共计分离到2341株细菌,其中ICU有505株占21．6％,非ICU有1836株占78．4％。在ICU分离到的细菌中,革兰阳性菌占23．2％（117／505）;非发酵菌占47．3％（239／505）。在非ICU中,革兰阳性菌占34．4％（632／1836）;非发酵菌20．2％（371／1836）。ICU前3位细菌分别为鲍曼不动杆菌、肺炎克雷伯杆菌、洋葱伯克霍尔德菌。非ICU前3位依次为大肠埃希菌、金黄色葡萄球菌、铜绿假单胞菌。非发酵菌中,铜绿假单胞菌和鲍曼不动杆菌对哌拉西林／他唑巴坦、头孢他啶、头孢吡肟、亚胺培南、美洛培南的耐药率,ICU和非ICU差异有统计学意义（P〈0．05）。亚胺培南对ICU铜绿假单胞中的MIC50是非ICU的8倍,MIC。值相当。ICU与非ICU分离的葡萄球菌属细菌对头孢唑啉、环丙沙星、左旋氧氟沙星的耐药率差异有统计学意义（P〈0．05）。ICU和非ICU葡萄球菌对利奈唑胺、万古霉素、替考拉宁全部敏感。结论ICU患者分离的细菌以革兰阴性菌为主,其中又以非发酵菌占大多数。非ICU患者分离的革兰阳性菌比例明显要比ICU高。在主要的致病菌中,ICU的耐药率明显高于非ICU。     

Evaluation of prenatal diagnosis of cleft lip/palate by foetal ultrasonographic examination

Ultrasound scans in the midtrimester of pregnancy are now a routine part of antenatal care in many countries. This type of screening procedure can detect serious foetal anomalies. Thanks to our registry of congenital anomalies a study was undertaken. The objective of the study was to evaluate prenatal detection of cleft lip (palate)(CL/P) by routine ultrasonographic examination of the foetus in 265679 consecutive pregnancies from 1979 to 1998. The percentage of prenatal detection of CL/P was low. For isolated malformation (foetuses with only CL/P) the detection rate was low: 17.8%; however, this detection rate increased from 5.3% during the period 1979-1988 to 26.5% during the period 1989-1998, for foetuses with associated malformations (foetuses with CL/P and one or more additional major malformations) these detection rates were 34.6, 13. 3 and 50.0%, respectively. In foetuses with associated malformations with CL/P this detection rate was higher for chromosomal abnormalities with CL/P and for non-syndromic, non-chromosomal multiply malformed children with CL/P than for non-chromosomal recognized syndromes with CL/P.     

梅州市两次麻疹疫苗强化免疫效果分析

目的综合评估分析梅州市两次麻疹疫苗强化免疫效果,为消除麻疹提供科学依据。方法综合分析麻疹疫苗强化免疫现场调查资料、评估法定传染病报告系统中麻疹发病率的变化;随机对辖区内1～12岁健康儿童216名,采用酶联免疫吸附试验(ELISA)进行强化免疫前及完成二次强化免疫后麻疹lgG抗体水平监测。结果监测人群完成二次强化免疫后麻疹IgG抗体阳性率达100.00%(216/216),2009年强化组、2010年强化组麻疹IgG抗体保护率和几何平均滴度(GMT)分别为82.08%、87.62%和1958.83、2050.26,均显著高于强化免疫前;2009年强化免疫后麻疹年发病率由强化免疫前五年平均发病率1.71/10万下降至0.22/10万,下降率87.13%,2010年强化后麻疹年发病率再次下降(0.039/10万),下降率82.27%。结论梅州市两次麻疹疫苗强化免疫效果显著,均大幅度降低了麻疹发病率、提高了人群麻疹抗体水平。     

Epidemiological,socio-demographic and clinical features of the early phase of the COVID-19 epidemic in Ecuador

The SARS-CoV-2 virus has spread rapidly around the globe. Nevertheless, there is limited information describing the characteristics and outcomes of COVID-19 patients in Latin America. We conducted a cross-sectional analysis of 9,468 confirmed COVID-19 cases reported in Ecuador. We calculated overall incidence, mortality, case fatality rates, disability adjusted life years, attack and crude mortality rates, as well as relative risk and relative odds of death, adjusted for age, sex and presence of comorbidities. A total of 9,468 positive COVID-19 cases and 474 deaths were included in the analysis. Men accounted for 55.4% (n = 5, 247) of cases and women for 44.6% (n = 4, 221). We found the presence of comorbidities, being male and older than 65 years were important determinants of mortality. Coastal regions were most affected by COVID-19, with higher mortality rates than the highlands. Fatigue was reported in 53.2% of the patients, followed by headache (43%), dry cough (41.7%), ageusia (37.1%) and anosmia (36.1%). We present an analysis of the burden of COVID-19 in Ecuador. Our findings show that men are at higher risk of dying from COVID-19 than women, and risk increases with age and the presence of comorbidities. We also found that blue-collar workers and the unemployed are at greater risk of dying. These early observations offer clinical insights for the medical community to help improve patient care and for public health officials to strengthen Ecuador’s response to the outbreak.     

Mycobacterium tuberculosis CDC1551 induces a more vigorous host response in vivo and in vitro, but is not more virulent than other clinical isolates.

Mycobacterium tuberculosis CDC1551, a clinical isolate reported to be hypervirulent and to grow faster than other isolates, was compared with two other clinical isolates (HN60 and HN878) and two laboratory strains (H37Rv and Erdman). The initial (1-14 days) growth of CDC1551, HN60, HN878, and H37Rv was similar in the lungs of aerosol-infected mice, but growth of Erdman was slower. Thereafter, the growth rate of CDC1551 decreased relative to the other strains which continued to grow at comparable rates up to day 21. In the lungs of CDC1551-infected mice, small well-organized granulomas with high levels of TNF-alpha, IL-6, IL-10, IL-12, and IFN-gamma mRNA were apparent sooner than in lungs of mice infected with the other strains. CDC1551-infected mice survived significantly longer. These findings were confirmed in vitro. The growth rates of H37Rv and CDC1551 in human monocytes were the same, but higher levels of TNF-alpha, IL-10, IL-6, and IL-12 were induced in monocytes after infection with CDC1551 or by exposure of monocytes to lipid fractions from CDC1551. CD14 expression on the surface of the monocytes was up-regulated to a greater extent by exposure to the lipids of CDC1551. Thus, CDC1551 is not more virulent than other M. tuberculosis isolates in terms of growth in vivo and in vitro, but it induces a more rapid and robust host response.     

Effect of transfer of one or two in vitro-produced embryos and post-transfer administration of gonadotropin releasing hormone on pregnancy rates of heat-stressed dairy cattle

Pregnancy rates following transfer of an in vitro-produced (IVP) embryo are often lower than those obtained following transfer of an embryo produced by superovulation. The purpose of the current pair of experiments was to examine two strategies for increasing pregnancy rates in heat stressed, dairy recipients receiving an IVP embryo. One method was to transfer two embryos into the uterine horn ipsilateral to the CL, whereas the other method involved injection of GnRH at Day 11 after the anticipated day of ovulation. In Experiment 1, 32 virgin crossbred heifers and 26 lactating crossbred cows were prepared for timed embryo transfer by being subjected to a timed ovulation protocol. Those having a palpable CL were randomly selected to receive one (n = 31 recipients) or two (n = 27 recipients) embryos on Day 7 after anticipated ovulation. At Day 64 of gestation, the pregnancy rate tended to be higher (P = 0.07) for cows than for heifers. Heifers that received one embryo tended to have a higher pregnancy rate than those that received two embryos (41% versus 20%, respectively) while there was no difference in pregnancy rate for cows that received one or two embryos (57% versus 50%, respectively). Pregnancy loss between Day 64 and 127 only occurred for cows that received two embryos (pregnancy rate at Day 127=17%). Between Day 127 and term, one animal (a cow with a single embryo) lost its pregnancy. There was no difference in pregnancy rates at Day 127 or calving rates between cows and heifers, but females that received two embryos had lower Day-127 pregnancy rates and calving rates than females that received one embryo (P < 0.03). Of the females receiving two embryos that calved, 2 of 5 gave birth to twins. For Experiment 2, 87 multiparous, late lactation, nonpregnant Holstein cows were synchronized for timed embryo transfer as in Experiment 1. Cows received a single embryo in the uterine horn ipsilateral to the ovary containing the CL and received either 100 microg GnRH or vehicle at Day 11 after anticipated ovulation (i.e. 4 days after embryo transfer). There was no difference in pregnancy rate for cows that received the GnRH or vehicle treatment (18% versus 17%, respectively). In conclusion, neither unilateral transfer of two embryos nor administration of GnRH at Day 11 after anticipated ovulation improved pregnancy rates of dairy cattle exposed to heat stress.     

Effect of superovulation induction on embryonic development on day 5 and subsequent development and survival after nonsurgical embryo transfer in pigs

To evaluate the effects of eCG dosage on recovery and quality of Day 5 embryos and on subsequent development and survival after embryo transfer, batches of 5 to 10 donor sows were treated with 1000 or 1500 IU eCG. Recipients from the same batch were synchronously treated with 800 IU eCG. Ovulation was induced with 750 IU hCG (72 h after eCG) in donors and recipients. Donors were inseminated and embryos were collected at 162 h after hCG (120 h after ovulation). Ovulation rate was lower using 1000 IU eCG (28.5+/-11.7; n=48) than 1500 IU eCG (45.7+/-20.3; n=32; P<0.0001). Embryo recovery rate (82.9+/-16.9%) and percentage expanded blastocysts (56.2+/-31.4%) were similar (P>0.05). Expanded blastocysts from each group of sows were pooled into 2 groups within eCG treatment, containing embryos from normally ovulating sows (< or = 25 corpora lutea [CL]) or from superovulated sows (> 25 CL). Average diameter and number of cells of a random sample of the expanded blastocysts per pool were recorded. The average diameter of blastocysts (160.5+/-11.5 microm) was not affected by eCG dosage or ovulation rate (P>0.10). The average number of cells per embryo was higher in the 1000 IU eCG group (84.3+/-15.3) than in the 1500 IU eCG group (70.2+/-1.9; P<0.05) but was similar for normal and superovulated donors within each eCG group (P>0.10). Of the 4 groups, litters of 28 to 30 blastocysts were nonsurgically transferred to 27 synchronous recipients. Pregnant recipients were slaughtered on Day 37 after hCG treatment to evaluate embryonic development and survival. Pregnancy rate for the 1000 and 1500 IU eCG donor groups was 71% (10/14) and 46% (6/13; P>0.10), respectively. The number of implantations and fetuses for the 1000 IU eCG groups was 12.9+/-3.0 and 11.1+/-2.7, and 14.2+/-7.0 and 10.5+/-4.6, respectively, for the 1500 IU eCG groups (P>0.10). After post-priory categorizing the litters of blastocysts to below or above the average diameter (158 microm) of the transferred embryos, irrespective of eCG dosage or ovulation rate, the pregnancy rate was 43% (6/14) and 77% (10/13; P<0.10), respectively. Post-priory categorizing the transferred litters to below or above the average number of cells per embryo litter, irrespective of eCG dosage or ovulation rate, showed no differences in pregnancy rates or number of implantations and fetuses (P>0.10). It was concluded that eCG dosage affects embryonic development at Day 7 after hCG, and this effect was not due to ovulation rate. Embryonic survival after nonsurgical transfer was not related to eCG dosage but tended to be related to the diameter of the blastocysts.     

Effect of an abrupt change in sexual and reproductive health policy on teen birth rates in Ecuador, 2008–2017

Several countries have implemented “family-centered” abstinence-only policies for teenagers, as opposed to encouraging utilization and expansion of reproductive health services and education. Little is known, however, about the effects of these more restrictive policies on adolescent birth rates at the national level or their differential effects by race and ethnicity. The extant literature is even scarcer in low- and middle-income countries. We analyze an unexpected policy change in Ecuador that abruptly reversed course and restricted reproductive health services for teenage women in 2014. We use a canton- and time-fixed effects difference-in-differences analysis of Ecuador’s 221 cantons with time-varying controls to analyze the impact of the abrupt policy change on the difference of teen (15−19 years) minus young adult (20−24 years) birth rates. In a difference-in-difference-in-differences analysis, the policy change increases birth rates by 8.5 births per 1000 women in cantons with higher indigenous concentration. Results are robust to changes in the comparison population (young adults vs. women in their late 20 s or in their early 30 s), pre-intervention control periods, population weighting, serial correlation, logarithmic model specification, adjustments for intervention year, definition of indigenous concentration, and potential delays in policy implementation.     

Hospital admissions for asthma in east London: associations with characteristics of local general practices,prescribing, and population.

OBJECTIVE: To determine the relative importance of appropriate prescribing for asthma in explaining high rates of hospital admission for asthma among east London general practices. DESIGN: Poisson regression analysis describing relation of each general practice''s admission rates for asthma with prescribing for asthma and characteristics of general practitioners, practices, and practice populations. SETTING: East London, a deprived inner city area with high admission rates for asthma. SUBJECTS: All 163 general practices in East London and the City Health Authority (complete data available for 124 practices). MAIN OUTCOME MEASURES: Admission rates for asthma, excluding readmissions, for ages 5-64 years; ratio of asthma prophylaxis to bronchodilator prescribing; selected characteristics of general practitioners, practices, and practice populations. RESULTS: Median admission rate for asthma was 0.9 (range 0-3.6) per 1000 patients per year. Higher admission rates were most strongly associated with small size of practice partnership: admission rates of singlehanded and two partner practices were higher than those of practices with three or more principals by 1.7 times (95% confidence interval 1.4 to 2.0, P < 0.001) and 1.3 times (1.1 to 1.6, P = 0.001) respectively. Practices with higher rates of night visits also had significantly higher admission rates: an increase in night visiting rate by 10 visits per 1000 patients over two years was associated with an increase in admission rates for asthma by 4% (1% to 7%). These associations were independent of asthma prescribing ratios, measures of practice resources, and characteristics of practice populations. CONCLUSIONS: Higher asthma admission rates in east London practices were most strongly associated with smaller partnership size and higher rates of night visiting. Evaluating ways of helping smaller partnerships develop structured proactive care for asthma patients at high risk of admission is a priority.     

Estrus synchronization in cattle using estradiol, melengestrol acetate and PGF

In Experiment 1, all cattle were fed MGA (0.5 mg/head/d) for 7 d (designated Days 0 to 6) and given PGF on Day 6. One-half were administered estradiol valerate (EV; 5 mg, im) on Day 0. At Location 1, a higher proportion (P < 0.005) of EV-treated heifers were detected in estrus and bred by AI between Days 7 and 13 than control heifers not receiving EV (27 of 33 versus 15 of 32), but the number of pregnancies (12 vs 10) was not significantly different. Eighty-three of 104 EV-treated and 89 of 106 control cows were inseminated, resulting in 50 and 45 pregnancies, respectively (not significant). At Location 2, cattle were similarly treated and exposed to bulls on Days 7 to 49. Fall pregnancy rate was higher (P < 0.015) for EV-treated than control heifers (44 of 48 vs 33 of 46), but was not significantly different for cows (22 of 26 vs 19 of 23). In Experiment 2, estradiol 17beta (E17beta; 5 mg, im) and progesterone (100 mg, im) were administered on Day 0 (instead of EV). In a third group (designated the PGF group), cattle were bred on Days 0 to 6, and PGF was administered on Day 6 to those not yet bred. For 213 cows, the percentage pregnant to a synchronized estrus was greater in the PGF group (72%) than in either the control group treated with MGA (49%; P = 0.005) or the group receiving MGA and E17beta (54%; P < 0.025). Fall pregnancy rates were 91, 89, and 96% for the 213 cows (not significant) and 89, 93, and 98% for 131 heifers (not significant) in the PGF, MGA and E17beta groups, respectively. In cattle without a functional CL, the average diameter of the largest follicle at Day 6 was 1 to 2 mm smaller in the E17beta + MGA group than in the MGA group (difference significant only in cows at Location 1). Combined for both locations, the synchronized pregnancy rate in heifers without a functional CL on Day 6 was higher (P < 0.05) in the E17beta + MGA group than in the MGA group (11 of 21, 52% versus 4 of 20, 20%). Estrogen treatment caused regression of ovarian follicles with emergence of a new follicular wave. Including estrogen in an estrus synchronization program utilizing MGA and PGF significantly increased fall pregnancy rate in heifers (at 1 location) and the synchronized pregnancy rate of heifers without a functional CL at the time of PGF treatment (combined for both locations).     

Abundance of Lutzomyia ovallesi but not Lu. gomezi (Diptera: Psychodidae) correlated with cutaneous leishmaniasis incidence in north-central Venezuela

In north-central Venezuela Lutzomyia gomezi and Lu. ovallesi are the main endophilic/anthropophilic species of phlebotomine sandflies implicated as vectors of cutaneous leishmaniasis (CL). Lutzomyia ovallesi has been found infected with Leishmania braziliensis (1.2%) and less often with Le. mexicana (0.07%), while Le. braziliensis infections have also been found in Lu. gomezi (0.47%). We investigated population densities of these sandflies using two sampling methods with four series of collections between January 1991 and March 1995 at El Ingenio, Miranda State. All-night outdoor collections from a Shannon trap were correlated with indoor collections from CDC light–traps by linear regression, which proved to be statistically significant for both species. Estimated numbers of female sandflies per house per night were found to be proportional to monthly precipitation (i.e. rainfall), with a lag time of seven months for Lu. ovallesi and of six months for Lu. gomezi . Predominance of Lu. ovallesi over Lu. gomezi ( c. 10 :1 ) was observed throughout the year, with the number of infected females estimated as 0.043 ± 0.047 Lu. ovallesi and 0.0085 ± 0.0124 Lu. gomezi per CDC trap per house per night (ratio ∼ 5:1). The mean rate of new CL cases per house per year and sandfly abundance were correlated by linear regression, showing a statistically significant relationship for Lu. ovallesi but not for Lu. gomezi . The negative intercept indicated that, on average, the CDC trap density exceeds 800 Lu. ovallesi females/house/year before new CL cases occur at El Ingenio.     

Seasonal variation of livebirths, stillbirths, extramarital births and twin maternities in Switzerland.

A study was made of the seasonal variation in all births, and births according to marital status, multiplicity and birth status (live and still) in Switzerland recorded between 1876 and 1990. To obtain seasonal variation in as pure as possible form, our analyses are based on rates. When comparing the seasonality in data sets showing markedly different levels, standardised indices were used. Assuming the length of pregnancies with twins to be about one month shorter than for pregnancies with singletons, lagged twinning rates were calculated but, in comparison with actual twinning rates, the general seasonal variation remained. Therefore, this study was based on actual twinning rates. A monotonic increase in the amplitude of the seasonal variation in general births was noted for the period 1876-1930, with strong seasonal variation holding for 1921-1980. After that, a marked decline in the amplitude can be observed. Seasonality of both all births and twin maternities showed very similar pattern for the periods 1876-1930 and 1969-1990, with maxima in the spring (March-May) and troughs in late autumn (October-December). Twin maternities showed a strong seasonality for the period 1876-1930, being about 20% higher in March than in October. The twinning rate in the period 1876-1930 was about 2.6 per thousand units higher than in the period 1969-90. For twin maternities there was also a stronger seasonal variation during the earlier period than during the later one. The pattern of the seasonal variation for extramarital births, showing a maximum in February (conceptions in May-June) and a minimum in August (conceptions in November-December) with a difference of no less than 24% was more marked than for the marital births. It seems likely that this seasonality of extra-marital maternities was due mainly to seasonal variation of coital rates and multiple ovulation in the early summer months coinciding with optima of light, temperature and food supply. A strong reduction in the rate of stillbirths (gestational age more than 29 weeks) was observed during the twentieth century. The stillbirth rate declined from about 40 per 1000 in the 1870s to fewer than 5 per 1000 in the 1980s. Irrespective of this strong decline in the stillbirth rate, the same seasonal rhythm was noticed throughout the period with high stillbirth rates among births around March and low rates during the summer and autumn.     

Time trends in twin perinatal mortality in northern England, 1982-94. Northern Region Perinatal Mortality Survey Steering Group.

The dynamics of perinatal mortality rates (PNMR) and causes of death in twin pregnancies over 13 years in the Northern Region of the National Health Service in England is described. All twin perinatal deaths occurring between 1982-1994 were identified from the Northern Region Perinatal Mortality Survey. The twinning rate increased from 9.9 per 1000 maternities in 1982 to 12.0 in 1994. There was a total of 10,734 twin pregnancies and of these 421 resulted in 530 perinatal deaths. The perinatal mortality rate in twins significantly decreased over time (1982-87, 55.4 per 1000; 1988-94, 44.4 per 1000; P = 0.01). The PNMR was significantly higher for twins from like-sexed than from unlike-sexed pairs (53.5 and 34.4 per 1000 respectively, P < 0.001). Despite no improvement in birthweight distribution in the twin population, birthweight-specific perinatal mortality rates for both like and unlike-sexed twins decreased for each birthweight category in 1988-94 compared with 1982-87. Twins with very low birthweight (< 1500 g) comprised 69%, and preterm twins (< 37 completed weeks of gestation) 74.9% of all twin perinatal deaths. The major immediate cause of early neonatal death was pulmonary immaturity (63%); antepartum anoxia caused 76.9% of antenatal deaths. Unexplained preterm labour and intrauterine death were the leading obstetric factors underlying death in twins. Despite a decrease over the 13 years, the perinatal mortality rate in twins in the Northern Region remains high. Continued monitoring of trends in twinning and mortality rates is needed to inform health care planning.     

潍坊市儿童11种国家免疫规划疫苗接种率抽样调查

目的了解潍坊市11种国家免疫规划疫苗的接种状况,比较常住儿童与流动儿童的接种率水平。方法采用分层随机抽样方法对2005年1月1日—2010年12月31日出生的儿童进行抽样调查。结果调查的常住和流动儿童2 160名,建卡、建证、卡证相符率均>95%,差异无统计学意义(P>0.05);BCG、HepB、OPV123、DPT123、MV或MR、MenA、JE-I 1、MMR、DPT4、HepA-I、JE-I 2、OPV4、MenAC1的接种率,常住儿童为95.63%～99.44%,流动儿童为93.89%～98.89%,差异无统计学意义(P>0.05);HepB首针、MV初种及时率常住和流动儿童均>95%,差异无统计学意义(P>0.05);6岁年龄组MenAC2、DT、MV3常住儿童分别为92.15%、91.11%、93.33%;流动儿童分别为86.25%、85.00%、87.08%,差异有统计学意义(χ2=18.89、18.42、23.48,P<0.01)。结论潍坊市4岁以下常住和流动儿童疫苗各剂次接种率差异无统计学意义,6岁年龄组MenAC2、DT、MV3疫苗接种率常住儿童高于流动儿童,差异有统计学意义(P<0.01)。     

食管鳞癌组织中CDC2、CLDN5蛋白表达及其临床病理意义的研究

目的探讨CDC2及CLDN5在食管鳞癌中表达及其临床病理特征的关系。方法应用免疫组化Elivision法检测90例食管鳞癌组织、28例正常食管黏膜组织及16例重度不典型增生组织中CDC2和CLDN5的蛋白表达情况。结果在食管鳞癌和正常食管黏膜组织中CDC2和CI。DN5的阳性表达率分别为88．89％（80／90）、85．56％（77／90）和48．86％（12／28）、25．00％（7／28）,两者差异有统计学意义（P〈O．05）。CDC2蛋白表达在低分化食管鳞癌中明显高于高分化食管鳞癌;临床分期Ⅲ＋Ⅳ期组的CDC2蛋白的表达显著高于I期、Ⅱ期组（P〈O．05）。CDC2和CLDN5在食管鳞癌中表达呈正相关（r=0．537,P〈o．05）。结论CDC2和CLDN5在食管鳞癌的发生、发展过程中可能发挥重要作用,可能作为食管癌临床早期诊断的重要指标。