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Refugee and migrant populations have increased vulnerability to antimicrobial resistance, yet stewardship guidance is lacking. We addressed this gap through a cross-sectional survey, finding that these populations and immigrants from low and middle-income countries had lower health literacy on the issue compared to native-born Americans and those from high-income countries.
Background: Antimicrobial resistance (AMR) is a global health threat, particularly in refugee populations, due to challenges posed by migration. Little guidance has been provided by public health agencies regarding antimicrobial stewardship specific to this demographic. Studies have primarily focused on encampment areas abroad. We sought to better understand health literacy and beliefs regarding AMR in local refugee and immigrant populations in southeastern Michigan. Methods: From November 1, 2022 to March 10, 2023, we distributed an anonymous questionnaire to adult patients at four primary care clinics in Southeastern Michigan and made it available online. The questionnaire collected demographic information and used 5-point Likert scale responses regarding antibiotic use in children with symptoms of respiratory infection. We binarized the questions and responses to determine whether respondents provided the preferred response and added these to create an overall health literacy score, then used simple linear and multivariable linear regression modeling to identify demographic variables independently associated with the health literacy score. Chi-squared and Mann-Whitney tests were also performed where appropriate. Results: Immigrants and refugees/asylum-seekers from low or middle-income countries (group A, n = 109) were compared to native-born Americans and immigrants from high-income countries (group B, n = 171) with participants from 40 countries (Figure 1). Age distribution did not differ between groups, while group B had generally longer duration of living in the United States (Figure 2). Differences were found in other demographic categories except female gender, with group B reporting higher income, educational levels, and English ability (Figure 3). Simple linear regression revealed that all demographic variables except age significantly correlated with responses (Figure 4). Multivariable linear regression showed that female gender, educational level, and age correlated with greater health literacy, while being in group A trended towards significance with respect to correlating with lesser health literacy (Figure 5). Conclusions: Immigrants and refugees/asylum-seekers from LMICs demonstrated beliefs suggesting deficits in knowledge of AMR compared to native-born Americans and those from high-income countries, independent of other potentially confounding demographic characteristics. Female gender, educational level, and age independently correlated with greater health literacy. These results could inform future patient-centered antimicrobial stewardship educational interventions in certain target populations such as immigrants and refugees/asylum-seekers in the United States.
In this systematic review and dose–response meta-analysis, we aimed to assess whether coffee and tea consumption is related to the risk of glioma. We performed a systematic literature search using PubMed, Embase, Scopus and the EuropePMC from the inception of database up until 1 October 2020. Exposures in the present study were coffee and tea consumption, the main outcome was the incidence of glioma. The present study compares the association between the exposure of coffee and tea with the incidence of glioma, and the results are reported in relative risks (RR). There are 12 unique studies comprising of 1 960 731 participants with 2987 glioma cases. Higher coffee consumption was associated with a statistically non-significant trend towards lower risk of glioma (RR 0·77 (95 % CI 0·55, 1·03), P= 0·11; I2:75·27 %). Meta-regression showed that the association between coffee and glioma was reduced by smoking (P= 0·029). Higher tea consumption was associated with a lower risk of glioma (RR 0·84 (95 % CI 0·71, 0·98), P= 0·030; I2:16·42 %). Sensitivity analysis by removal of case–control studies showed that higher coffee consumption (RR 0·85 (95 % CI 0·72, 1·00), P= 0·046; I2:0 %) and higher tea consumption (RR 0·81 (95 % CI 0·70, 0·93), P= 0·004; I2:0 %, Pnon-linearity = 0·140) were associated with lower risk of glioma. Dose–response meta-analysis showed that every one cup of coffee per day decreases the risk of glioma by 3 % (RR 0·97 (95 % CI 0·94, 0·99), P= 0·016, Pnon-linearity = 0·054) and every one cup of tea per day decreases the risk of glioma by 3 % (RR 0·97 (95 % CI 0·94, 1·00), P= 0·048). This meta-analysis showed apparent association between coffee and tea intake and risk of glioma.
Background:Candida auris prevalence in Illinois, particularly in the metropolitan Chicago area, is high. The Illinois Department of Public Health recommends empiric contact precautions for patients with a tracheostomy or requiring mechanical ventilation from skilled nursing facilities (vSNFs) or long-term acute-care hospitals (LTACHs) who are admitted to an acute-care hospital. Cases of C. auris infection and colonization are reportable to the Illinois Extensively Drug Resistant Organism Registry (XDRO Registry). NorthShore University HealthSystem (NSUHS) actively screens adult intensive care unit (ICU) admissions from LTACHs and vSNFs for CA. Methods: NSUHS is a 4-hospital system located north of Chicago with 750 beds, 4 ICUs and ∼64,000 annual admissions. Beginning in April 2019, a composite axilla–groin swab was collected from all ICU LTACH or vSNF admissions. Composite swabs are cultured on Inhibitory Mold Agar. In July 2019, an ICU clinical case of C. auris was identified from a ventilated patient admitted from an outside hospital prompting the expansion of screening to include acute-care hospital transfers. To evaluate the value of screening criteria, a medical record review and retrospective query of the XDRO Registry was performed for all screened patients. Because cocolonization with carbapenemase-producing organisms (CPO) has been reported, CPO status was also queried. Results: Between April 1 and October 31, 2019, 70 patients were screened. Two screened patients did not meet the screening criteria (Fig. 1). No patients, with the exception of the clinical case, were found to be colonized with CA. The XDRO Registry query identified no patients with C. auris. Of the 70 patients, 9 (13%) had a CPO. Of those screened, 14 (20%) had a tracheostomy and/or mechanical ventilation (Table 1). Conclusions: Querying the XDRO registry at admission in combination with a medical record review appears adequate to identify patients admitted to a NSUHS ICU with C. auris and CPOs. Targeting patients admitted with a tracheostomy and/or mechanical ventilation may further reduce the number of screening cultures performed.
Background: Catheter-associated urinary tract infections (CAUTIs) account for >15% of hospital-acquired infections, resulting in increased length of stay and costs. Consequently, methods to improve indwelling urinary catheter (IUC) care and maintenance are warranted to reduce the risk of hospital-acquired CAUTIs. This study was a prospective quality improvement (QI) project to reduce CAUTIs using prepackaged cloths (ReadyCleanse by Medline Industries) and a simple, standardized cleaning process for care and maintenance of IUCs. Methods: This study is an ongoing QI project at NorthShore University HealthSystem, a 4-hospital system located north of Chicago, Illinois, with 750 beds and ∼64,000 annual admissions. The study consists of a 1.5-month staff training on proper product use (phase 1), followed by an intervention using the cloths for IUC care (phase 2). Each package contains 5 individual cloths corresponding to a simple, 5-step, cleansing protocol. IUC care and maintenance are performed twice daily on a routine basis and after each incontinent episode. Beginning July 2018, current practice (soap and wash cloth) was replaced with the ReadyCleanse cloths, and on August 1, 2018, data collection began. Adult patients admitted at all 4 NorthShore Hospitals with an IUC for >24 hours are enrolled in the study. From patient electronic health records, we collected patient demographics, reason for IUC insertion, days of catheter use, and development of CAUTI (according to the NHSN definition). During the intervention, observations of compliance and performance of catheter care were also performed. For the analysis described here, results for the first 14 months of the study were compared to CAUTI numbers from the 14-month period prior to the start of the study (February 2017–March 2018); the data presented represent ∼50% of the planned data collection. Results: As of September 30, 2019, 4,969 patients were prospectively enrolled in the study: 1,491 patients from hospital A, 1,451 from hospital B, 1,091 from hospital C, and 936 from hospital D. Patient demographics for the study cohort were 47% female, with a median age of 77 years and an average of 3.9 catheter days per patient. Systemwide, observational audits for compliance using the cloths averaged 95%. Upon completion of study month 14, 22 CAUTIs had been identified, compared to 26 CAUTIs for the comparison period, indicating a 15% reduction. Conclusion: Implementation of this simple, standardized alternative for IUC care is feasible on a large scale and may have potential for reducing CAUTI rates.
To determine the source of a healthcare-associated outbreak of Pantoea agglomerans bloodstream infections.
Epidemiologic investigation of the outbreak.
Oncology clinic (clinic A).
Cases were defined as Pantoea isolation from blood or catheter tip cultures of clinic A patients during July 2012–May 2013. Clinic A medical charts and laboratory records were reviewed; infection prevention practices and the facility’s water system were evaluated. Environmental samples were collected for culture. Clinical and environmental P. agglomerans isolates were compared using pulsed-field gel electrophoresis.
Twelve cases were identified; median (range) age was 65 (41–78) years. All patients had malignant tumors and had received infusions at clinic A. Deficiencies in parenteral medication preparation and handling were identified (eg, placing infusates near sinks with potential for splash-back contamination). Facility inspection revealed substantial dead-end water piping and inadequate chlorine residual in tap water from multiple sinks, including the pharmacy clean room sink. P. agglomerans was isolated from composite surface swabs of 7 sinks and an ice machine; the pharmacy clean room sink isolate was indistinguishable by pulsed-field gel electrophoresis from 7 of 9 available patient isolates.
Exposure of locally prepared infusates to a contaminated pharmacy sink caused the outbreak. Improvements in parenteral medication preparation, including moving chemotherapy preparation offsite, along with terminal sink cleaning and water system remediation ended the outbreak. Greater awareness of recommended medication preparation and handling practices as well as further efforts to better define the contribution of contaminated sinks and plumbing deficiencies to healthcare-associated infections are needed.
The subsurface exploration of other planetary bodies can be used to unravel their geological history and assess their habitability. On Mars in particular, present-day habitable conditions may be restricted to the subsurface. Using a deep subsurface mine, we carried out a program of extraterrestrial analog research – MINe Analog Research (MINAR). MINAR aims to carry out the scientific study of the deep subsurface and test instrumentation designed for planetary surface exploration by investigating deep subsurface geology, whilst establishing the potential this technology has to be transferred into the mining industry. An integrated multi-instrument suite was used to investigate samples of representative evaporite minerals from a subsurface Permian evaporite sequence, in particular to assess mineral and elemental variations which provide small-scale regions of enhanced habitability. The instruments used were the Panoramic Camera emulator, Close-Up Imager, Raman spectrometer, Small Planetary Linear Impulse Tool, Ultrasonic drill and handheld X-ray diffraction (XRD). We present science results from the analog research and show that these instruments can be used to investigate in situ the geological context and mineralogical variations of a deep subsurface environment, and thus habitability, from millimetre to metre scales. We also show that these instruments are complementary. For example, the identification of primary evaporite minerals such as NaCl and KCl, which are difficult to detect by portable Raman spectrometers, can be accomplished with XRD. By contrast, Raman is highly effective at locating and detecting mineral inclusions in primary evaporite minerals. MINAR demonstrates the effective use of a deep subsurface environment for planetary instrument development, understanding the habitability of extreme deep subsurface environments on Earth and other planetary bodies, and advancing the use of space technology in economic mining.
Shell artefacts in Island Southeast Asia have often been considered local variants of ground-stone implements, introduced in the Late Pleistocene from Mainland Southeast Asia. The discovery of a well-preserved Tridacna shell adze from Ilin Island in the Philippines, suggests, however, a different interpretation. Using radiocarbon dating, X-ray diffraction and stratigraphic and chronological placement within the archaeological record, the authors place the ‘old shell’ effect into context, and suggest that shell technology was in fact a local innovation that emerged in the early Middle Holocene. The chronology and distribution of these artefacts has significant implications for the antiquity of early human interaction between the Philippines and Melanesia. It may have occurred long before the migrations of Austronesian-speaking peoples and the emergence of the Lapita Cultural Complex that are traditionally thought to mark the first contact.
Objectives: Endobronchial ultrasound (EBUS), encompassing endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) and Endobronchial ultrasound transbronchial lung biopsy (EBUS-TBLB) has been proven to be a useful modality in the staging and diagnosis of lung cancer. However, there are limited publications on the cost-effectiveness of EBUS and no economic evaluations relevant to the Singapore setting. An economic evaluation using our hospital's data was used to assess the cost implications of EBUS substituting where clinically appropriate: transthoracic needle aspiration; (TTNA), fluoroscopy-guided transbronchial lung biopsy (TBLB), and mediastinoscopy in the diagnosis and staging of lung cancer.
Methods: Relationship between the clinical and economic implications of alternative modalities was modeled using data inputs that were relevant to the Singapore setting. Two decision analytic models were constructed to evaluate the cost of EBUS compared with TTNA, TBLB, and staging mediastinoscopy. Only direct costs were imputed.
Results: In the base–case analysis, TTNA was the most economical strategy (SGD3,335 = US$2,403) where clinically suitable for the diagnosis of lung cancer as compared to the other options: TBLB (SGD4,499) and EBUS-TBLB (SGD4,857). On the other hand, EBUS-TBNA resulted in expected cost savings of SGD1,214 per positive staging of lung cancer as compared to mediastinoscopy.
Conclusions: The use of EBUS-TBNA could result in cost savings of SGD1,214 per positive staging of lung cancer as compared to mediastinoscopy. Whereas TTNA was the most economical intervention for the diagnosis of lung cancer as compared to the other options, its main limitation lies in its suitability only for peripheral lung lesions and high complication rate.
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