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Background:Burkholderia multivorans are gram-negative bacteria typically found in water and soil. B. multivorans outbreaks among patients without cystic fibrosis have been associated with exposure to contaminated medical devices or nonsterile aqueous products. Acquisition can also occur from exposure to environmental reservoirs like sinks or other hospital water sources. We describe an outbreak of B. multivorans among hospitalized patients without cystic fibrosis at 2 hospitals within the same healthcare system in California (hospitals A and B) between August 2021 and July 2022. Methods: We defined confirmed case patients as patients without cystic fibrosis hospitalized at hospital A or hospital B between January 2020 to July 2022 with B. multivorans isolated from any body site matching the outbreak strain. We reviewed medical records to describe case patients and to identify common exposures. We evaluated infection control practices and interviewed staff to detect exposures to nonsterile water. Select samples from water, ice, drains, and sink splash zone surfaces were collected and cultured for B. multivorans in March 2022 and July 2022 from both hospitals. Common aqueous products used among case patients were tested for B. multivorans. Genetic relatedness between clinical and environmental samples was determined using random amplified polymorphic DNA (RAPD) and repetitive extragenic palindromic polymerase chain reaction (Rep-PCR). Results: We identified 23 confirmed case patients; 20 (87%) of these were identified at an intensive care unit (ICU) in hospital A. B. multivorans was isolated from respiratory sources in 18 cases (78%). We observed medication preparation items, gloves, and patient care items stored within sink splash zones in ICU medication preparation rooms and patient rooms. Nonsterile water and ice were used for bed baths, swallow evaluations, and ice packs. B. multivorans was cultured from ice and water dispensed from an 11-year-old ice machine in the ICU at hospital A in March 2022 but no other water sources. Additional testing in July 2022 yielded B. multivorans from ice and a drain pan from a new ice machine in the same ICU location at hospital A. All products were negative. Clinical and environmental isolates were the same strain by RAPD and Rep-PCR. Conclusions: The use of nonsterile water and ice from a contaminated ice machine contributed to this outbreak. Water-related fixtures can serve as reservoirs for Burkholderia, posing infection risk to hospitalized and immunocompromised patients. During outbreaks of water-related organisms, such as B. multivorans , nonsterile water and ice use should be investigated as potential sources of transmission and other options should be considered, especially for critically ill patients.
The COVID-19 pandemic increased food insufficiency: a severe form of food insecurity. Drawing on an ecological framework, we aimed to understand factors that contributed to changes in food insufficiency from April to December 2020, in a large urban population hard hit by the pandemic.
We conducted internet surveys every 2 weeks in April–December 2020, including a subset of items from the Food Insecurity Experience Scale. Longitudinal analysis identified predictors of food insufficiency, using fixed effects models.
Los Angeles County, which has a diverse population of 10 million residents.
A representative sample of 1535 adults in Los Angeles County who are participants in the Understanding Coronavirus in America tracking survey.
Rates of food insufficiency spiked in the first year of the pandemic, especially among participants living in poverty, in middle adulthood and with larger households. Government food assistance from the Supplemental Nutrition Assistance Program was significantly associated with reduced food insufficiency over time, while other forms of assistance such as help from family and friends or stimulus funds were not.
The findings highlight that during a crisis, there is value in rapidly monitoring food insufficiency and investing in government food benefits.
Among nursing home outbreaks of coronavirus disease 2019 (COVID-19) with ≥3 breakthrough infections when the predominant severe acute respiratory coronavirus virus 2 (SARS-CoV-2) variant circulating was the SARS-CoV-2 δ (delta) variant, fully vaccinated residents were 28% less likely to be infected than were unvaccinated residents. Once infected, they had approximately half the risk for all-cause hospitalization and all-cause death compared with unvaccinated infected residents.
Various global-scale proposals exist to reduce the loss of biological diversity. These include the Half-Earth and Whole-Earth visions that respectively seek to set aside half the planet for wildlife conservation or to diversify conservation practices fundamentally and change the economic systems that determine environmental harm. Here we assess these visions in the specific context of Bornean orangutans Pongo pygmaeus and their conservation. Using an expert-led process we explored three scenarios over a 10-year time frame: continuation of Current Conditions, a Half-Earth approach and a Whole-Earth approach. In addition, we examined a 100-year population recovery scenario assuming 0% offtake of Bornean orangutans. Current Conditions were predicted to result in a population c. 73% of its current size by 2032. Half-Earth was judged comparatively easy to achieve and predicted to result in an orangutan population of c. 87% of its current size by 2032. Whole-Earth was anticipated to lead to greater forest loss and ape killing, resulting in a prediction of c. 44% of the current orangutan population for 2032. Finally, under the recovery scenario, populations could be c. 148% of their current size by 2122. Although we acknowledge uncertainties in all of these predictions, we conclude that the Half-Earth and Whole-Earth visions operate along different timelines, with the implementation of Whole-Earth requiring too much time to benefit orangutans. None of the theorized proposals provided a complete solution, so drawing elements from each will be required. We provide recommendations for equitable outcomes.
Health and Physical Education provides readers with the knowledge, understanding and skills required to successfully teach health and physical education in Australia. With emphasis on the development of movement competence and health literacy from the early years to secondary, this book brings together research, theory, curriculum and pedagogy in an engaging introduction for pre-service teachers. Now in its fourth edition, Health and Physical Education has been thoroughly updated, and features a new chapter covering ethics, morals the and duty of care and their practical application in school health and physical education. Maintaining strong connections to learners of all ages, the text links closely to the Early Years Learning Framework and the recently updated Australian Curriculum: Health and Physical Education. Each chapter is framed by the five propositions of the Australian Curriculum: Health and Physical Education, and includes vignettes, activities and discussion and review questions to encourage reflection and group work.
Service user involvement (SUI) in recovery-oriented care planning (ROCP) warrants more sophisticated theorisation and explanation to support practice improvement. This study investigated which changes to practice work best, in what circumstances, and to what extent, to embed an active role for service users’ involvement in ROCP during the acute inpatient mental health care pathway.
A realist synthesis, combined with qualitative methods, was conducted to theoretically explore the causal mechanisms that underlie SUI in ROCP and how contextual factors influence the link between these causal mechanisms and outcomes. The study was conducted in three stages: theory-gleaning, theory-refinement and theory-consolidation. Initial programme theories were developed in the theory-gleaning stage. Theories were refined iteratively in the theory-refinement stage, using evidence from a realist review and interview data. With stakeholder involvement, refined programme theories were finely tuned using ‘if-then’ statements in the consolidation stage.
Five programme theories relating to the acute care pathway were identified following the realist synthesis:
1)‘Provider-controlled care transition’ (admission to acute inpatient mental health units), referring to limitations to service users’ active involvement. The focus of care and access to acute inpatients units should be needs-led, rather than resource-led or demand-driven;
2)‘Care plan as a recovery tool?’ – addressing infrastructural and organisational limitations to active SUI in care-plan formulation. The use of multidisciplinary meetings as a forum for care-plan formulation can create a cohesive approach and facilitate shared ownership;
3) ‘Ward rounds as a non-inclusive arena for shared decision making’, highlighting their unfulfilled potential for shared decision making about treatment. Professionals should focus on preparing service users for the ward-round process. Opportunities and access for service users to build therapeutic relationships with treating doctors are vital components;
4)‘Peer support worker intervention' as a key factor in service users’ recovery’, concerning their positive impact. Their presence in ward rounds and care-planning meetings might create a more user-friendly atmosphere for service users; and
5)‘Provider-controlled care transition’ (discharge from acute inpatient mental health units), increasing focus on preparing service users for transition into the community, and constraints on resources should not dictate or anticipate decisions on discharging service users.
The study identified practices required to embed an active role for service users to be involved in ROCP, namely multi-contextual interventions at various levels (macro, meso and micro) of the mental health system. The study uncovered barriers that restrain SUI in ROCP, impacting desirable outcomes.
To describe the genomic analysis and epidemiologic response related to a slow and prolonged methicillin-resistant Staphylococcus aureus (MRSA) outbreak.
Prospective observational study.
Neonatal intensive care unit (NICU).
We conducted an epidemiologic investigation of a NICU MRSA outbreak involving serial baby and staff screening to identify opportunities for decolonization. Whole-genome sequencing was performed on MRSA isolates.
A NICU with excellent hand hygiene compliance and longstanding minimal healthcare-associated infections experienced an MRSA outbreak involving 15 babies and 6 healthcare personnel (HCP). In total, 12 cases occurred slowly over a 1-year period (mean, 30.7 days apart) followed by 3 additional cases 7 months later. Multiple progressive infection prevention interventions were implemented, including contact precautions and cohorting of MRSA-positive babies, hand hygiene observers, enhanced environmental cleaning, screening of babies and staff, and decolonization of carriers. Only decolonization of HCP found to be persistent carriers of MRSA was successful in stopping transmission and ending the outbreak. Genomic analyses identified bidirectional transmission between babies and HCP during the outbreak.
In comparison to fast outbreaks, outbreaks that are “slow and sustained” may be more common to units with strong existing infection prevention practices such that a series of breaches have to align to result in a case. We identified a slow outbreak that persisted among staff and babies and was only stopped by identifying and decolonizing persistent MRSA carriage among staff. A repeated decolonization regimen was successful in allowing previously persistent carriers to safely continue work duties.
Research has shown that 20–30% of prisoners meet the diagnostic criteria for attention-deficit hyperactivity disorder (ADHD). Methylphenidate reduces ADHD symptoms, but effects in prisoners are uncertain because of comorbid mental health and substance use disorders.
To estimate the efficacy of an osmotic-release oral system methylphenidate (OROS-methylphenidate) in reducing ADHD symptoms in young adult prisoners with ADHD.
We conducted an 8-week parallel-arm, double-blind, randomised placebo-controlled trial of OROS-methylphenidate versus placebo in male prisoners (aged 16–25 years) meeting the DSM-5 criteria for ADHD. Primary outcome was ADHD symptoms at 8 weeks, using the investigator-rated Connors Adult ADHD Rating Scale (CAARS-O). Thirteen secondary outcomes were measured, including emotional dysregulation, mind wandering, violent attitudes, mental health symptoms, and prison officer and educational staff ratings of behaviour and aggression.
In the OROS-methylphenidate arm, mean CAARS-O score at 8 weeks was estimated to be reduced by 0.57 points relative to the placebo arm (95% CI −2.41 to 3.56), and non-significant. The responder rate, defined as a 20% reduction in CAARS-O score, was 48.3% for the OROS-methylphenidate arm and 47.9% for the placebo arm. No statistically significant trial arm differences were detected for any of the secondary outcomes. Mean final titrated dose was 53.8 mg in the OROS-methylphenidate arm.
ADHD symptoms did not respond to OROS-methylphenidate in young adult prisoners. The findings do not support routine treatment with OROS-methylphenidate in this population. Further research is needed to evaluate effects of higher average dosing and adherence to treatment, multi-modal treatments and preventative interventions in the community.
One in six nursing home residents and staff with positive SARS-CoV-2 tests ≥90 days after initial infection had specimen cycle thresholds (Ct) <30. Individuals with specimen Ct<30 were more likely to report symptoms but were not different from individuals with high Ct value specimens by other clinical and testing data.
Despite evidence favoring perioperative antibiotic prophylaxis (ABP) use in patients undergoing craniotomy to reduce rates of surgical site infections (SSIs), standardized protocols are lacking. We describe demographic characteristics, risk factors, and ABP choice in patients with craniotomy complicated with SSI.
Retrospective case series from January 1, 2017, through December 31, 2020.
Tertiary-care referral center.
Adults who underwent craniotomy and were diagnosed with an SSI.
Logistic regression to estimate odds ratios and 95% confidence intervals to identify factors associated with SSIs.
In total, 5,328 patients undergoing craniotomy were identified during the study period; 59 (1.1%) suffered an SSI. Compared with non-SSI cases, patients with SSI had a significantly higher frequency of emergency procedures: 13.5% versus 5.8% (P = .02; odds ratio [OR], 2.52; 95% confidene interval [CI], 1.10–5.06; P = .031). Patients with SSI had a higher rate of a dirty (5.1% vs 0.9%) and lower rate of clean-contaminated (3.3% vs 14.5%) wound class than those without infection (P = .002). Nearly all patients received ABP before craniotomy (98.3% in the SSI group vs 99.6% in the non-SSI group; P = .10). Combination of vancomycin and cefazolin as dual therapy was more prevalent in the group of patients without infection (n = 1,761, 34.1%) than those with SSI (n = 4, 6.8%) (P < .001), associated with decreased odds for SSI (OR, 0.17; 95% CI, 0.005–0.42; P ≤ .001).
SSI are frequently seen after an emergent neurosurgical procedure and a dirty wound classification. Combination of prophylactic cefazolin and vancomycin is associated with decreased risk for SSI.