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Water-jet nozzles in electric toilets--commonly used in Japan and other parts of Asia--may be reservoirs for multidrug-resistant Pseudomonas aeruginosa (MDRP) in hospitals, increasing the risk of dangerous germ transmission among patients, according to new research being presented at the European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) held online this year.

"This is the first report of hospital transmissions associated with electric toilets and could have major implications for infection control," says Dr Itaru Nakamura from Tokyo Medical University Hospital in Japan who led the research. "If water-jet nozzles are a source of hospital superbug cross-contamination, additional interventions - such as modified hand hygiene practices and toilet disinfection protocols - may be needed to stem the risk of transmission among healthcare providers and patients alike."

More than 80% Japanese households use electric toilets with an integrated bidet, which flush automatically [2]. The main feature is a nozzle the size of a pencil that comes out from underneath the toilet seat and squirts water to wash the bottom and clean the toilet. The nozzle is also self-cleaning and cleans itself before and after every operation.

P. aeruginosa naturally occurs in soil and freshwater, but it can also thrive on the moist surfaces in hospitals, leading to opportunistic infections in weakened and ill patients that could develop into life-threatening conditions like pneumonia or sepsis.

Because of the overuse of antibiotics, these bacteria have evolved the ability to withstand attempts to treat infections with drugs that once killed them. And infections caused by MDRP bacteria are becoming more common in both the community and hospitals. Mortality rates among people infected with these superbug strains are double those of people infected with strains that are susceptible to treatment [1].

In this study, researchers investigated the presence of multidrug-resistant bacteria recovered from the waterjet-nozzles of electric toilets in a haematology ward of Tokyo Medical University Hospital between September 2020 and January 2021.

The team made more than 10 visits to take samples from water-jet nozzles in electric toilets used by three patients with MDRP infections, including two patients with severe sepsis. MDRP strains were defined as those with resistance to at least two antibiotics such as imipenem, meropenem, amikacin and ciprofloxacin.

Using genetic fingerprinting techniques, they looked to see whether the strains of MDRP from the three infected patients were the same as the environmental MDRP strain sampled from the toilet nozzles. They found the samples matched, with strain 'ST235' dominating in all the samples--suggesting that transfers to and from patients were happening.

"In short, our findings imply that multidrug-resistant P. aeruginosa bacteria were being transmitted within the patient community, and critically that the infection may be spread within hospitals via contaminated electric toilet nozzles", says Dr Nakamura. "With good hospital hygiene, which includes handwashing and environmental cleaning, we can control the spread of these pathogens, especially within in settings where patients' immune systems are compromised."

The authors point out that this was only a small study in a single hospital ward. They also highlighted several limitations including that the genetic analysis was not able to distinguish the direction of transfer, whether it is from the patient to the water-jet nozzles, or from those nozzles to the patients.

New research presented at this year's European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) taking place online (9-12 July) shows that covering high-touch (the most regularly touched) surfaces in hospitals with silver-impregnated foil could significantly reduce levels of contamination by clinically important bacterial pathogens.

The study by Professor Andreas Widmer and colleagues at the University Hospital Basel, Basel, Switzerland, evaluated the antimicrobial effectiveness of a polyvinyl chloride (PVC) foil containing an integrated silver-based agent containing 2% silver ions.

The hospital environment has increasingly been recognised as having critical importance when formulating infection control measures as evidence has increased of the role it plays as a source of bacterial transmission and subsequent hospital-acquired infections. Regular cleaning and disinfection have been proposed as an option for lowering infection risk, however performing this to the required standard is a time and resource-intensive process.

An alternative approach is to use auto-disinfecting surfaces which would make it difficult for pathogens to survive and would require less thorough cleaning to achieve a safe environment in patient rooms. In this study a silver-impregnated PVC foil was applied to high-touch surfaces in patient rooms where contamination levels of bacterial pathogens were anticipated to be high.

The researchers found that contamination levels on foil-covered surfaces were significantly lower than on those without the covering. Overall, mean germ numbers were reduced by more than 60 times, while the median bioburden on untreated control surfaces was more than 3 times higher than on the antimicrobial foil. The large difference between mean and median relates to the large biological variability of germ density on the different types of surfaces.

The team also discovered that clinically important bacteria - in particular Enterococci - were significantly less likely to be present on foil-covered surfaces, and the antimicrobial effects were still present 6 months later.

The authors conclude: "A foil containing an integrated silver-based agent effectively decreases the load of clinically important disease-causing bacteria over a 6-month study period."

They add: "Auto-disinfectant foils or similar antimicrobially equipped surfaces might help prevent transmission, in particular of Gram-positive pathogens from the environment. Many studies confirm rapid recolonization (reinfection) of hospital surfaces even after vigorous disinfection. Therefore, such auto-disinfectant foils could be desirable in certain healthcare areas such as transplant units or also during outbreaks such as the SARS-CoV-2 pandemic we are currently experiencing. Further research should be extended to the antiviral activity of such surfaces, as this silver-impregnated PVC foil has been found to work in experiments against another type of coronavirus: human coronavirus HCov-229E."

Nashville, Tenn. (1:35 p.m. EDT--July 10, 2021) -- Use of a biodegradable balloon spacer during massive rotator cuff tear surgery produced similar outcomes when compared to partial rotator cuff repair for patients with massive rotator cuff tears (MRCTs) at 24-month follow up, with potential for early improvement, according to research presented today at the American Orthopedic Society of Sports Medicine - Arthroscopy Association of North America Combined 2021 Annual Meeting.

Despite various treatment options, the successful management of irreparable, MRCTs remains challenging. Implantation of a biodegradable subacromial balloon spacer has gained considerable interest for the treatment of MCRTs due to its potential to recenter the humeral head within the glenoid.

"However, few studies have been completed that compare the balloon spacer implant with other surgical procedures, over a longer period of time with a significant number of patients," said Nikhil Verma, MD, an orthopedic surgeon at Rush University Medical Center in Chicago, and the Principal Investigator for the clinical study.

Dr. Verma and his colleagues completed a non-inferiority, prospective, single-blinded, multicenter, randomized, controlled, pivotal study for surgical treatment of MRCTs. Patients were 40 years of age or older with symptomatic full thickness MRCTs (tears ? 5 cm, ? 2 tendons) that had failed non-operative management. The study included follow up at day 10, week 6, months 3, 6, 12 and 24.

The safety and effectiveness of the subacromial balloon spacer were evaluated by patient reported and physician-assessed outcomes, including the American Shoulder and Elbow Society (ASES), Western Ontario rotator cuff index (WORC), Constant Shoulder Outcome Score (CS), and Range of Motion (ROM), in addition to safety observations. A total of 20 sites were included in the investigation. One hundred, eighty-four patients were randomized into the clinical study (n= 93 balloon spacer; n= 91 partial repair).

According to data presented today, patients in the balloon spacer group demonstrated similar results to patients in the partial repair group for ASES substantial clinical benefit (SCB) threshold improvement. ASES SCB has been previously defined as a change of 17.5 points. At 24-month follow up, 82% (n=76/93) of patients in the balloon spacer group, and 79% (n=72/91) in the partial repair group, had reached the SCB change from baseline threshold. Significant improvement over time relative to baseline was observed in ASES (Fig. 1) and WORC (Fig. 2) scores in both groups. Early improvements were noted in the balloon spacer group for WORC, CS, and ROM outcomes. Mean procedure duration was approximately 44 minutes for the balloon spacer group and 71 minutes for the partial repair group.

Subsequent secondary surgeries to the treated shoulder occurred in 6 patients (n=3 balloon spacer; n=3 partial repair), with two patients in each group requiring reverse shoulder arthroplasty and one patient in each group undergoing shoulder arthroscopy. One additional patient in the balloon spacer group required a subsequent reverse shoulder arthroplasty due to fracture non-union following a fall.

"Use of the balloon spacer was found to produce similar outcomes when compared to partial rotator cuff repair for patients with MRCTs at 24-month follow up," said Dr. Verma. "Early improvement was also noted in the balloon spacer group with shortened operative time compared to partial repair."

Obese patients with a form of advanced prostate cancer survive longer than overweight and normal weight patients, new research has found.

The study, presented today at the European Association of Urology congress, EAU21, followed more than 1500 patients over three years. Patients classed as obese - with a BMI over 30 - had a ten percent higher survival rate than thinner patients over 36 months.

Although obesity is usually associated with an increased risk of death from many cancers and some other chronic diseases, there is some evidence in a few cancers of a survival advantage for patients with high body mass index. This phenomenon is known as the 'obesity paradox'.

Nicola Fossati, Alberto Martini and colleagues at San Raffaele University in Italy wanted to test whether the 'obesity paradox' held true for patients with metastatic castration resistant prostate cancer - an advanced form of the disease that no longer responds to testosterone lowering treatments.

They looked at survival rates in 1,577 patients involved in three different clinical trials, with an average age of 69 and average BMI of 28. They found that BMI was a protective factor in both overall and cancer-specific survival, with 4% higher overall survival probability and 29% cancer-specific survival probability. Even when they adjusted for higher doses of chemotherapy given to larger patients, the team found the protective effect remained. Over 36 months, around 30% of obese patients survived compared to 20% of overweight and normal weight individuals.

Dr Nicola Fossati, a urologist at San Raffaele University says: "Looking at patients with metastasis of prostate cancer, we found that obese patients are living longer. This means that BMI could be used to predict survival in these patients.

"This obesity paradox has been seen in some other cancers, possibly due to the relationship between tissue fat and cancer genomes, and more research is needed in this area. It's also possible that improved survival may be due to the interaction of chemotherapy with other drugs. Obese patients in this older age group tend to be taking medication for other conditions and we do not fully understand how these medicines interconnect.

"Nevertheless, we would not recommend weight gain to anyone with this or another disease. Obesity is a risk factor for many cancers and other diseases and patients should always aim for a healthy BMI of 18 to 24."

Professor Peter Albers, from Düsseldorf University, who chairs the EAU Scientific Congress Office, said: "There are many possible explanations for the association of body weight with positive outcome in metastatic cancers. It might be that patients with higher BMI are able to tolerate the toxicity of the treatments and their side effects better; in prostate cancer it might be due to the protective impact of hormones found in tissue fat; and it is known that healthy men with slightly higher BMI have a higher overall life expectancy compared to very slim ones.

"However, at the moment, these are just hypotheses. Further research is needed to identify the biological mechanism behind these different outcomes. Until that mechanism is proven, we can't recommend any change to treatment for patients with advanced prostate cancer."

Using an existing drug for late-stage kidney cancer at an earlier stage of the disease could reduce the risk of cancer recurring by a third, according to new research.

The findings from the Phase III trial are presented today at the European Association of Urology congress (EAU21).
There is a high risk of kidney cancer returning, following surgery to remove tumours, but there is currently no treatment to help prevent this.

The KEYNOTE study involved just under 1000 patients with kidney cancer who had undergone surgery. Half of them were given the immunotherapy drug pembrolizumab, or pembro, and the other half a placebo.

Pembro is used to treat a number of cancers, including late-stage kidney cancer, where the disease has spread to other organs. The international trial across 20 countries was the first time the drug had been used with patients at an early stage of the disease.

The team found that over two years, patients on pembro were a third less likely to see their disease return than those on the placebo. Follow-up with patients is continuing, to determine the impact of the treatment on survival rates over a five-year period.

The study also showed that the side effects from the drug were similar to those normally expected with a cancer treatment.

Co-investigator on the study, Professor Thomas Powles of Barts Cancer Institute at Queen Mary University of London, said: "This early data from the trial is very promising, with a clear reduction in the disease recurring in patients on pembro. There are signs as well that the drug may improve survival rates, but we can't be sure of that for another few years. We're hopeful that this trial, when complete, will provide a strong case for this drug to be approved for use by the medicines regulator."

Combination immunotherapy promising for advanced bladder cancer

Professor Powles is presenting further findings at EAU21 today from another trial, which also involves a new use for an existing cancer immunotherapy drug. The DANUBE study looked at durvalumab in patients with late-stage bladder cancer, where the disease had already spread to other parts of the body. Durvalumab is used widely as a lung cancer treatment, particularly in the USA.

Over 1000 patients were recruited to the trial, with a third of them receiving durvalumab, a third receiving durvalumab combined with a new immunotherapy drug, tremelimumab, and a third receiving standard chemotherapy.

They found that overall, the immunotherapy drugs did not increase survival more than standard chemotherapy.

However, in exploratory analysis, in a subset of patients (those who had a raised level of a specific biomarker (PD-L1) and who weren't eligible for the chemotherapy drug cisplatin) the activity of durvalumab was increased by the addition of tremilimumab.

Professor Powles said: "While we weren't comparing durvalumab against other licensed immune therapies in this clinical situation, we could see the new combination of immunotherapies did show some additional promise that warranted a more detailed look."

Two large randomised controlled trials are now underway, testing durvalumab and tremelimumab against the existing immunotherapy treatments, both in late-stage and early-stage bladder cancer, in patients with high levels of the LD-P1 biomarker who can't be given cisplatin. The results from the first trial should be reported later this year, while the other is still recruiting.

Researchers in Belgium report on the case of a 90-year-old woman who was simultaneously infected with two different variants of concern (VOCs) of COVID-19, in a Case Report being presented at the European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) held online this year.

On March 3 2021, the woman, whose medical history was unremarkable, was admitted to the OLV Hospital in the Belgian city of Aalst after a spate of falls. She tested positive for COVID-19 on the same day. She lived alone and received nursing care at home, and had not been vaccinated against COVID-19.

Initially, there were no signs of respiratory distress and the patient had good oxygen saturation. However, she developed rapidly worsening respiratory symptoms, and died five days later.

When the patient's respiratory sample was tested for VOCs with PCR, they discovered that she had been infected by two different strains of the virus--one which originated in the UK, known as B.1.1.7 (Alpha), and another that was first detected in South Africa (B.1.351; Beta).

The presence of both strains was confirmed by PCR on a second respiratory sample, by sequencing of the S-gene and by whole genome sequencing.

"This is one of the first documented cases of co-infection with two SARS-CoV-2 variants of concern", says lead author and molecular biologist Dr Anne Vankeerberghen from the OLV Hospital in Aalst, Belgium. "Both these variants were circulating in Belgium at the time, so it is likely that the lady was co-infected with different viruses from two different people. Unfortunately, we don't know how she became infected."

On December 14, 2020, the UK authorities informed WHO that a variant (B.1.1.7; Alpha) had been detected in the south east of England (Kent). Within a few weeks, this variant took over from the viral strains circulating in this region, and has since spread to more than 50 countries, including Belgium. On December 18, 2020, the South African authorities reported that a variant (B.1.351; Beta) had been detected and was spreading rapidly throughout three provinces of South Africa, and has now been identified in at least 40 countries, including Belgium.

In January 2021, scientists in Brazil reported that two people had been simultaneously infected with two different strains of the coronavirus--the Brazilian variant known as B.1.1.28 (E484K) and a novel variant VUI-NP13L, which had previously been discovered in Rio Grande do Sul. But the study has yet to be published in a scientific journal [1]. Previous research has reported people infected with different influenza strains [2].

"Whether the co-infection of the two variants of concern played a role in the fast deterioration of the patient is difficult to say", says Vankeerberghen. "Up to now, there have been no other published cases. However, the global occurrence of this phenomenon is probably underestimated due to limited testing for variants of concern and the lack of a simple way to identify co-infections with whole genome sequencing."

She continues, "Since co-infections with variants of concern can only be detected by VOC-analysis of positive samples, we would encourage scientists to perform fast, easy and cheap VOC-analysis by PCR on a large proportion of their positive samples, rather than just whole genome sequencing on a small proportion. Independent of the technique used, being alert to co-infections remains crucial."

Most countries have not introduced nationwide prostate-cancer screening, as current methods result in overdiagnoses and excessive and unnecessary biopsies. A new study by researchers at Karolinska Institutet in Sweden, which is published in The New England Journal of Medicine, indicates that screening by magnetic resonance imaging (MRI) and targeted biopsies could potentially cut overdiagnoses by half. The results are presented today at the European Association of Urology Congress.

"Our results from a large, randomised study show that modern methods for prostate cancer screening maintain the benefits of screening, while decreasing the harms substantially. This addresses the greatest barrier to the introduction of nationwide screening," explains Tobias Nordström, associate professor of Urology at the Department of Clinical Sciences, Danderyd Hospital at Karolinska Institutet, who is in charge of the STHLM3MRI study.

Yearly, approximately 1,4 million men get a prostate cancer diagnosis and 375,000 men die from the disease. Previous studies have shown that organised screening can result in earlier detection and thereby reduce the risk of prostate-cancer deaths.

Current screening methods - PSA (prostate-specific antigen) tests combined with traditional biopsies - result in unnecessary biopsies, and the detection of numerous minor low-risk tumours. Consequently, no country except Lithuania has chosen to introduce a nationwide prostate-cancer screening programme, as the benefits do not exceed the disadvantages.

"Refined screening methods are required to reduce overdiagnosis and overtreatment of low-risk tumours, and prevent unnecessary biopsies and biopsy-related side-effects," explains Martin Eklund, associate professor at the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, with joint responsibility for the STHLM3MRI study.

The results of the STHLM3MRI study indicate that overdiagnoses can be halved by substituting traditional prostate biopsies with magnetic resonance imaging (MRI) and targeted biopsies. The number of unnecessary biopsies and the identification of minor low-risk tumours is reduced, while the new method can detect just as many clinically significant tumours.

STHLM3MRI is a randomised study conducted between 2018 and 2021 with participants from Stockholm County, which included 12,750 men. The participants first provided a blood sample for PSA analysis, as well as analysis by the new Stockholm3 test, developed by researchers at Karolinska Institutet. Men whose tests showed elevated levels were then randomly selected for traditional biopsies or MRI. In the MRI group, biopsies were conducted strictly on suspected tumours identified by MRI.

The study proceeded thereafter by investigating how the Stockholm3 test could be combined with MRI to further improve the method for prostate-cancer screening.

"We will soon present the second of the two main reports from the STHLM3MRI trial where we assess the role of a novel blood test as adjunct to MRI in prostate cancer screening. The future of prostate cancer diagnostics probably includes both improved blood tests and MRI. Nationwide screening for breast and cervical cancer among women has been available in the Western world for some time. We are finally able to show that men can also reduce their risk of malignant cancer through nationwide prostate-cancer screening that utilises modern methods," Tobias Nordström concludes.

Professor Hendrik Van Poppel, Adjunct Secretary General of the European Association of Urology (EAU) said: "It is exciting to see breakthroughs such as this in the field of early detection of prostate cancer. An innovation such as STHLM3MRI makes an even more compelling case for the European Commission to ensure a risk stratified approach to early detection of prostate cancer is adopted across the whole of Europe. The EAU is working hard to ensure that early detection of prostate cancer is addressed in the implementation of Europe's Beating Cancer Plan in order to reduce mortality of Europe's most common male cancer while also dealing with the challenges of overdiagnosis and overtreatment. We are really looking forward to seeing how STHLM3MRI can continue to contribute to this aim".

INDIANAPOLIS - A new study from U.S. Department of Veterans Affairs, Regenstrief Institute, IUPUI and Icahn School of Medicine at Mount Sinai researchers reports that primary care physicians recognize the need for better coordination and welcome health information exchange (HIE) event notifications as a means of improving the flow of information to enable provision of better patient care.

Individuals often receive medical care from more than one healthcare system. Care coordination among providers, for example after discharge from an emergency department or hospital in one system, with the patient's primary care physician in another, is challenging and frequently doesn't occur. This siloed approach to medical care with incomplete sharing of clinical information, may adversely affect health outcomes.

"While our study focused on patients whose primary care was provided in the VA system, this is an issue faced by patients and their providers in many, if not most, healthcare systems in the United States," said study senior author Brian Dixon, PhD, MPA, the Regenstrief and Indiana University Richard M. Fairbanks School of Public Health at IUPUI director of public health informatics.

Dr. Dixon and colleagues reported that primary care doctors in the VA system typically are not notified when their patients were seen at a non-VA emergency department or hospitalized at a non-VA facility, so physicians are unaware of the need for follow up and often have to wait months before learning of the event from a patient themselves - months during which the patient was not receiving care from the doctor responsible for overseeing their overall health.

"The majority of Americans rely on their primary care physician to coordinate care of medical specialists and hospitalizations. They expect their doctor to know about their care, but most of the time that's not happening," said Dr. Dixon. "Our study is unique because we investigated primary care teams' perspectives on utilization of an electronic foundation -- health information exchange -- to enable automatic notifications -- for example, a primary care physician's patient has been hospitalized for a heart attack -- to remediate this problem and found positive reception."

Primary care team members interviewed by the study authors viewed electronic alerts (for example, notification that a patient was seen in the ED for chest pains and sent home when it was determined not to be a cardiac event) as both necessary and effective in supporting timely follow-up care, especially for older adults at higher risk of such medical events.

The study, "Perceptions of event notification following discharge to improve geriatric care: qualitative interviews of care team members from a 2-site cluster randomized trial" appears online ahead of print in Journal of the American Medical Informatics Association (JAMIA). Authors, in addition to Dr. Dixon, are Emily Franzosa, Morgan Traylor, Kimberly Judon, Vivian Guerrero Aquino, Ashley L. Schwartzkopf and Kenneth S. Boockvar, all of the VA. Dr. Boockvar is also with Icahn School of Medicine at Mount Sinai.

Now that this qualitative study has demonstrated the perceived benefits and acceptability of electronic event notification by primary care physicians and their teams, Dr. Dixon and colleagues are working on a quantitative analysis, measuring the actual impact of these notifications on follow-up care as well as preventing repeat emergency department visits and rehospitalizations.

Nashville, Tenn., (3:40 EDT--July 9, 2021)--An analysis of MRI images of the tissue grafts used for patients who underwent surgery to repair the anterior cruciate knee ligament suggests grafts used from the quadriceps may be superior to tissue grafts from the hamstring. The research was presented today at the American Orthopaedic Society for Sports Medicine - Arthroscopy Association of North America Combined 2021 Annual Meeting.

Younger patients who required ACL reconstruction surgery have historically been treated with a hamstring graft to replace the injured ACL, but preliminary evidence suggests a graft from the quadriceps may be superior. Researchers from the Hospital for Special Surgery in New York City evaluated graft maturity by comparing MRI signal intensity of quadriceps tendon autografts and hamstring tendon autografts used in primary ACL reconstruction.

Dr. Daniel W. Green and Dr. Frank A. Cordasco, Hospital for Special Surgery, New York, reported that the researchers analyzed 71 patients (38 in the HTA group and 33 in the QTA group) under the age of 18 who underwent a primary ACL reconstruction between 2011 and 2018 at the Hospital for Special Surgery, using either a HTA or QTA with available MRIs at 6 and 12 months post-operatively. Age, sex, and type of surgery were not different between groups.

Signal intensity ratio (SIR) was measured on sagittal MRI by averaging the signal at three regions of interest (ROIs) along the ACL graft and dividing each by the signal of the tibial footprint of the PCL. Statistical analysis was performed to determine interrater reliability and differences between time points and groups.

Green and Cordasco found no significant difference in SIR between groups on the 6-month MRI. But, at 12 months, SIR of the QTA group was significantly less than that in the HTA group (p=.029). Within the HTA group, there was no significant difference in SIR between time points. In the QTA group, there was a significant decrease in SIR between the 6 month and 12-month post-operative MRI (p=.045) (Figure 2).

"The decrease in signal between six and 12 months post-operatively suggests quicker graft maturation and improved structural integrity of QTA as compared to HTA," said Green. "This provides evidence that one year postoperatively, QTA may have a superior rate of incorporation and synovialization as compared to the HTA."

What The Study Did: Researchers characterized clinical content of ambulatory care among office-based compared with telemedicine visits in the United States before and during the COVID-19 pandemic.

Authors: G. Caleb Alexander, M.D., M.S., of the Johns Hopkins Bloomberg School of Public Health in Baltimore, is the corresponding author.

To access the embargoed study: Visit our For The Media website at this link https://media.jamanetwork.com/

(doi:10.1001/jamahealthforum.2021.1529)

Editor's Note: The article includes conflicts of interest disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, conflict of interest and financial disclosures, and funding and support.

Supplementing testosterone significantly reduces heart attacks and strokes in men with unnaturally low levels of the hormone, according to new research presented at the European Association of Urology congress today.

The ten-year study involved over 800 men from Germany and Qatar with testosterone deficiency, whose family history, blood pressure, cholesterol levels, diabetes or weight put them at high risk of heart attack or stroke.

Only men with testosterone levels below normal, who also displayed symptoms of low testosterone, such as low mood, decreased appetite, depression, erectile dysfunction, loss of libido or weight gain, were included in the research.

Just over half of the men opted for long-term testosterone replacement therapy, enabling the researchers to compare this group to those whose condition was left untreated. All the men were encouraged to make lifestyle changes, in terms of diet, alcohol, smoking and exercise, to improve their cardiovascular health.

Of 412 men on testosterone therapy, 16 died and none suffered a heart attack or stroke. Of the 393 men who chose not to take testosterone supplements, 74 died, 70 had a heart attack and 59 suffered a stroke. Even when discrepancy in age was taken into account - the group taking testosterone was on average five years younger than the other group - these differences remained clear cut. For the men under 55, the risk of heart attack and stroke was reduced by 25 percent; for men over 60, the risk was reduced by 15 percent.

The health of the men on testosterone therapy also improved by other measures. They lost weight, had more lean muscle mass, their cholesterol level and liver function improved, their diabetes was better controlled and their blood pressure dropped.

Professor Omar Aboumarzouk, from the Hamad Medical Corporation in Qatar, explains: "Given that all these men would normally have been expected to suffer a heart attack or stroke in the next five to ten years, with no other intervention, it was a real surprise to see no cardiovascular events at all in the group on testosterone therapy. It's clear that this treatment can significantly reduce the risks in this particular group."

However, the team are keen to stress that testosterone therapy is not a silver bullet and should only be considered for patients who meet certain criteria.

"Testosterone can be seriously harmful if taken by men with normal levels, or who function perfectly well with reduced levels of the hormone," says Professor Aboumarzouk. "While men need testosterone for certain psychological and biological functions, only those with low levels who display other symptoms are likely to benefit from testosterone therapy.

"For those at high risk of heart attack and stroke, who are deficient in testosterone, it's likely that bringing the hormone back to normal levels helps them to maximise the benefits of other steps necessary to improve their overall health. This includes increasing exercise levels, eating healthier food, giving up smoking and reducing alcohol consumption.

"We believe that physicians treating patients with low testosterone, who are at high risk of heart attack or stroke, should consider testosterone therapy as one aspect of their treatment."

The study, which involved researchers from Dresden, Bremen and Muenster in Germany and Doha in Qatar, is still continuing.

Dr Maarten Albersen, Member of the EAU Scientific Office, from Leuven University in Belgium says: "The long-term cardiovascular risks or benefits of testosterone therapy are still unclear, because of conflicting results from previous research. This new study has shown a reduction in major cardiovascular events and mortality in men who received testosterone therapy, compared to men who opted not to receive this treatment.

"However, these were men with a medium risk of heart attack or stroke, and those receiving testosterone were younger and had a slightly lower risk at the start of the study. The study was long enough to see differences in the rate of cardiovascular events. However, the numbers involved and the fact that the trial was not randomised mean it's still difficult to draw any hard conclusions. A new trial is now underway, aiming to recruit 6000 participants, and this should provide definitive answers on the cardiovascular risks or even benefits of hormone therapy in men with low testosterone."

Outpatient antibiotic prescribing fell by almost 4% a year between 2011 and 2018, according to a study of prescribing patterns in the largest integrated health care system in the USA, being presented at the European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) held online this year.

Veterans Affairs (VA) facilities play a large role in the provision of outpatient care across the USA, providing care to over 9 million Veterans at more than 1,200 outpatient clinics.

The researchers speculate that the downward trend may be related to the antibiotic stewardship programmes widely implemented across the Veterans Health Administration (VHA) health-system since 2014.

"We have seen positive steps taken to reduce antibiotic use in VA outpatient clinics, community-based outpatient clinics, emergency departments, and other outpatient settings, and healthcare teams should be congratulated for their ongoing work to reduce unnecessary antibiotic use", says lead author Dr Haley Appaneal from Providence VA Medical Center, Rhode Island, USA.

"But over 8 years, prescriptions for three of the most commonly prescribed outpatient antibiotics--have changed little. And even with that drop in overall prescriptions, the threat of antibiotic resistance is increasing, so there is much more to be done."

In the USA, more than 2.8 million antibiotic-resistant infections occur every year, causing at least 35,000 deaths and $20 billion in health-care costs [1]. According to WHO, infections such as pneumonia, tuberculosis, sepsis, gonorrhoea, and foodborne diseases, are becoming harder, and sometimes impossible, to treat as antibiotics become less effective [2].

Bacteria have long been thought to develop antibiotic resistance largely due to repeated exposure through over-prescribing. Each year, 266 million courses of antibiotics are dispensed to outpatients in the USA [3].

In 2011, the VHA established the National Antimicrobial Stewardship Task Force (ASTF) to help guide implementation and development of antibiotic stewardship programmes in the VA and in 2014, the VHA required all of its hospitals to introduce antibiotic stewardship programmes. Between 2008 and 2015, inpatient antibiotic use decreased substantially by 12% [4].

However, 80-90% of antibiotic use occurs in the outpatient setting, and the US Centers for Disease Control and Prevention (CDC) estimates that at least 30% of outpatient antibiotics are unnecessary (no antibiotic was needed), and up to 50% inappropriate prescribing (unnecessary use and inappropriate selection, dosing and duration) [5].

To provide more evidence on prescribing patterns, researchers analysed data from VA pharmacy datasets to examine trends in antibiotic prescriptions dispensed in VA outpatient clinics across the USA between 2011-2018.

They calculated annual number of days of therapy (DOT) per 100 outpatient visits for all antibiotics and then individually for the 5 most common antibiotics (doxycycline, azithromycin, amoxicillin/clavulanate, ciprofloxacin, and sulfamethoxazole/trimethoprim).
Over 8 years, total antibiotic prescriptions dispensed in the community went down by an average of 3.9% a year, falling from 39.6 DOT/100 visits in 2011 to 29.4 DOT/100 visits in 2018.

The largest decline was in the use of the broad-spectrum antibiotic ciprofloxacin, which decreased by an estimated 12.6% on average per year. The authors point out that here has been a national movement away from the use of fluroquinolones, such as ciprofloxacin, if alternative agents are available due to the harms associated with their use, including Clostridium difficile infection, adverse drug events, and selection of resistance. The VA and the Food and Drug Administration both have issued safety warnings related to fluroquinolones and recommend restricting their use for uncomplicated infections which generally have other safer treatment options, such as acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections (UTI).

The use of sulfamethoxazole/trimethoprim (commonly used for UTIs) also decreased substantially (by around 7% a year).

However, outpatient prescriptions remained unchanged and were high for doxycycline (commonly used to treat skin infections and sexually transmitted infections), azithromycin (widely used for chest, nose, and throat infections), and amoxicillin/clavulanate (used for wide range infections, particularly respiratory) between 2011 and 2018.

"Use of these three commonly prescribed antibiotics remain high and may be an appropriate target for antibiotic stewardship programmes in the VA to further reduce inappropriate outpatient prescribing", says Dr Appaneal. "It might also help combat resistance if national guidelines took stewardship principles into account when making disease-specific recommendations for antibiotic use."

She continues, "Antibiotics are essential for treating serious bacterial infections, such as sepsis, pneumonia and meningitis. But they should not be used to treat acute respiratory conditions such as asthma, coughs, earache and sore throats, which do not respond to these drugs. Antibiotic resistance is not just a matter for clinicians--the public also have a crucial role to play in helping to preserve these vital medicines."

The authors point out several limitations of their study including that it does not take into account prescriptions filled outside the VA system (such as community pharmacies) and may not be complete in all outpatient settings such as the emergency department or outpatient surgery settings. They also note that the study was based on a largely older white male population so the generalisability of the findings to the general US population is limited.

New research presented at this year's European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) taking place online (9-12 July), suggests that three commonly prescribed classes of drugs that are not themselves antibiotics--proton pump inhibitors (PPIs), beta-blockers and antimetabolites--could lead to antibiotic resistant infections caused by bacteria from the Enterobacteriaceae family. These antibiotic resistant infections are in turn linked to longer hospital stays and potentially greater risk of death.

The observational study underscores the importance of commonly used non-antimicrobial drugs (NAMDs) as a risk factor for antibiotic resistance, researchers say.

Bacteria are thought to develop antibiotic resistance largely due to repeated exposure through over-prescribing, making recent antibiotic use a key risk factor for drug resistance. But in up to half of patients harbouring drug resistant bacteria when they are admitted to hospital, there is no identifiable risk factor.

Commonly used NAMDs help to treat diseases and manage symptoms of chronic conditions, but they can cause unwanted side effects. A few commonly used NAMDs have recently been found to have a significant impact on the bacterial composition of the gut microbiome [1]. However, the role of NAMD use as a risk factor for infection with antibiotic-resistant bacteria has not been systematically studied.

To address this, researchers examined data from 1,807 adults admitted to a tertiary-level academic hospital in Tel Aviv, Israel between January 1, 2017 and April 18, 2019, with a diagnosis of upper urinary tract infection, and a positive urine or blood culture growing Enterobacteriaceae. Use of 19 non-antimicrobial drug classes prior to hospital admission was retrieved from electronic medical records.

Antimicrobial drug-resistant organisms were identified in over half of patient samples (944/1,807). And multidrug-resistant organisms (resistant to 3 or more classes of antibiotics) were identified in around a quarter of episodes (431/1,807).

Analyses found that use of seven common drug categories was associated with increased resistance to antimicrobial drugs--SSRIs which help people manage symptoms of depression; typical antipsychotics used to treat mental health conditions such as schizophrenia; Anti 10A inhibitors for stroke prevention in patients with atrial fibrillation; PPIs which reduce the production of stomach acid; beta-blockers which help treat heart problems; and antimetabolites (chemotherapy drugs) commonly used to treat cancers and inflammatory diseases.

The researchers also found that three drug classes (PPI, beta-blockers and antimetabolites) were significantly associated with resistance to third-generation cephalosporins, trimethoprim-sulfamethoxazole, and fluoroquinolones. Antimetabolites appeared to have the strongest impact on antibiotic resistance.

"Our findings highlight the importance of non-antimicrobial drug exposure as a risk factor for antibiotic resistance, says lead author Dr Meital Elbaz from Tel Aviv Medical Center in Israel. "We urgently need larger studies with more drug classes to confirm the discovery and to clarify the biological link between common prescription drugs and antibiotic resistance."

The authors point out several limitations of their study including that exposure to NAMD was based on medical records, and information about dosage and duration of use was lacking. In addition, for some drugs, the number of patients was too small to achieve statistical significance.

*Note: this paper is being presented at the European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) and is being published in The Lancet Public Health. Please credit both the congress and the journal in your stories*

New research from Switzerland presented at this year's European Congress of Clinical Microbiology & Infectious Diseases (ECCMID), held online this year, shows that people living in poorer neighbourhoods were less likely to be tested for COVID-19 but more likely to test positive, be hospitalised, or die, compared with those in more wealthy areas. The study is by Professor Matthias Egger and Dr Julien Riou, Institute of Social and Preventive Medicine, Bern, Switzerland.

For the study, the authors analysed surveillance data reported to the Swiss Federal Office of Public Health from March 1, 2020, to April 16, 2021. They assigned a rating to each residence included in the study, using the Swiss neighbourhood index of socioeconomic position (Swiss-SEP). The index describes 1.27 million small neighbourhoods of approximately 50 households each on the basis of rent per m², education and occupation of household heads, and crowding, rating each residence from 1 (poorest) to 10 (wealthiest). Models were adjusted for sex, age, canton (administrative area), and wave of the epidemic (before or after June 8, 2020).

Analyses were based on 4,129,636 tests, 609 782 positive tests, 26143 hospitalisations, 2432 ICU admissions, 9383 deaths, and 8,221,406 residents. Comparing the highest with the lowest Swiss-SEP group and using the general population as the denominator, those in the wealthiest SEP neighbourhoods were 18% more likely to be tested for SARS-CoV-2 than those in the poorest. And, compared with the poorest neighbourhoods, those in the wealthiest neighbourhoods were 25% less likely to test positive, 32% less likely to be hospitalised, 46% less likely to be admitted to the ICU, and 14% less likely to die.

The authors also found these associations between neighbourhood SEP and outcomes were stronger in younger age groups, probably because frail people, who are over-represented in the socioeconomically disadvantaged groups, die at younger ages; therefore, the survivors at older ages are a select group of healthier people.

The authors say: "In this whole-population study of the COVID-19 epidemic in Switzerland in 2020-21, we found that people living in wealthier areas were more likely to get tested for SARS-CoV-2 but less likely to test positive and be admitted to hospital or the ICU, and less likely to die, compared with those in poorer areas."

They explain: "The higher incidence of SARS-CoV-2 infections, combined with a higher prevalence of comorbidities in poorer compared with wealthier neighbourhoods is likely to have contributed to worse outcomes, including the higher risk of hospitalisation and death. By June 2021, vaccination coverage had increased considerably, with over 40% of the Swiss population having received at least one dose of SARS-CoV-2 vaccine, and the Government is gradually easing preventive measures. It is essential to continue to monitor testing for SARS-CoV-2, access and uptake of COVID-19 vaccination, and outcomes of COVID-19. Governments and health-care systems should address this pandemic of inequality by taking measures to reduce health inequalities in their response to the SARS-CoV-2 pandemic."

The authors also highlight that this study illustrates the "inverse care law" in the unique setting of a pandemic in Switzerland, one of the world's wealthiest countries. The inverse care law was formulated 50 years ago and states that disadvantaged populations need more health care than advantaged populations but in reality receive less.

Primary care clinicians face a heavy administrative burden, spending significantly more time using the electronic health record (EHR) than their counterparts in other specialties. With studies demonstrating high rates of burnout among primary care clinicians, researchers from Brigham and Women's Hospital and collaborators set out to examine how different types of primary care clinicians interface with the EHR. They found that general internal medicine and family medicine clinicians spent an average of two hours actively using the EHR each day, while general pediatric clinicians actively used the system for about an hour and a half. These findings, across all primary care specialties, included about 30 minutes of EHR usage after working hours. Results are published as a research letter in JAMA Network Open.

"How primary care clinicians spend time with the record affects care in several ways," said corresponding author Lisa Rotenstein, MD, MBA, of the Department of Medicine at the Brigham. "If physicians can be more efficient, there will likely be less burnout; and if less time is spent on the EHR, there is more time to interact with patients, and to ensure that the truly important things get done."

In their study, the researchers analyzed data from 349 ambulatory health care organizations in the U.S. that used the EHR vendor Epic Systems in 2019. The authors broke down their analysis of time spent using the EHR according to activity: clinical review, notes, exchanging messages, and placing orders. They explain that because their analysis only captures time actively spent interfacing with the EHR, it is likely an underestimate of clinicians' total engagement with the EHR, and the time spent is likely even higher.

The researchers' analysis revealed that pediatricians spent half as long on messages from patients or their families and two-thirds as much time reviewing charts and orders compared to their primary care counterparts; however, they spent the same amount of time on notes. While some differences in EHR usage could be driven by patient complexity, consistent findings on note-taking burdens across primary care specialties indicate that the documentation functions in the EHR could be improved.

Virtual or AI-powered scribes could reduce the burden of notetaking across primary care specialties and can be evaluated in future studies, the authors state. Interventions that streamline messaging and placing orders are also research priorities.

"The physician and patient experience are inextricably linked, as we know that burnout has consequences for quality of care and patient outcomes in addition to its important consequences for individual physicians," said co-author David Bates, MD, MSc, chief of the Division of General Internal Medicine and Primary Care. "Future studies should help us better understand why pediatric clinicians are spending less time on the EHR than other primary care clinicians, and whether there are any lessons about how pediatric EHRs are designed that could be applied to other specialties."