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Using statewide surveillance, we describe candidemia in Connecticut during 1998–2000 and 2019. In 2019, candidemia was more frequently associated with community-onset and non-albicans Candida species and less frequently associated with central vascular catheters, recent surgery, and in-hospital mortality. Understanding changes in candidemia can optimize clinical management and prevention strategies.
Background: Healthcare facilities have experienced many challenges during the COVID-19 pandemic, including limited personal protective equipment (PPE) supplies. Healthcare personnel (HCP) rely on PPE, vaccines, and other infection control measures to prevent SARS-CoV-2 infections. We describe PPE concerns reported by HCP who had close contact with COVID-19 patients in the workplace and tested positive for SARS-CoV-2. Method: The CDC collaborated with Emerging Infections Program (EIP) sites in 10 states to conduct surveillance for SARS-CoV-2 infections in HCP. EIP staff interviewed HCP with positive SARS-CoV-2 viral tests (ie, cases) to collect data on demographics, healthcare roles, exposures, PPE use, and concerns about their PPE use during COVID-19 patient care in the 14 days before the HCP’s SARS-CoV-2 positive test. PPE concerns were qualitatively coded as being related to supply (eg, low quality, shortages); use (eg, extended use, reuse, lack of fit test); or facility policy (eg, lack of guidance). We calculated and compared the percentages of cases reporting each concern type during the initial phase of the pandemic (April–May 2020), during the first US peak of daily COVID-19 cases (June–August 2020), and during the second US peak (September 2020–January 2021). We compared percentages using mid-P or Fisher exact tests (α = 0.05). Results: Among 1,998 HCP cases occurring during April 2020–January 2021 who had close contact with COVID-19 patients, 613 (30.7%) reported ≥1 PPE concern (Table 1). The percentage of cases reporting supply or use concerns was higher during the first peak period than the second peak period (supply concerns: 12.5% vs 7.5%; use concerns: 25.5% vs 18.2%; p Conclusions: Although lower percentages of HCP cases overall reported PPE concerns after the first US peak, our results highlight the importance of developing capacity to produce and distribute PPE during times of increased demand. The difference we observed among selected groups of cases may indicate that PPE access and use were more challenging for some, such as nonphysicians and nursing home HCP. These findings underscore the need to ensure that PPE is accessible and used correctly by HCP for whom use is recommended.
From 2014 to 2020, we compiled radiocarbon ages from the lower 48 states, creating a database of more than 100,000 archaeological, geological, and paleontological ages that will be freely available to researchers through the Canadian Archaeological Radiocarbon Database. Here, we discuss the process used to compile ages, general characteristics of the database, and lessons learned from this exercise in “big data” compilation.
To estimate population-based rates and to describe clinical characteristics of hospital-acquired (HA) influenza.
US Influenza Hospitalization Surveillance Network (FluSurv-NET) during 2011–2012 through 2018–2019 seasons.
Patients were identified through provider-initiated or facility-based testing. HA influenza was defined as a positive influenza test date and respiratory symptom onset >3 days after admission. Patients with positive test date >3 days after admission but missing respiratory symptom onset date were classified as possible HA influenza.
Among 94,158 influenza-associated hospitalizations, 353 (0.4%) had HA influenza. The overall adjusted rate of HA influenza was 0.4 per 100,000 persons. Among HA influenza cases, 50.7% were 65 years of age or older, and 52.0% of children and 95.7% of adults had underlying conditions; 44.9% overall had received influenza vaccine prior to hospitalization. Overall, 34.5% of HA cases received ICU care during hospitalization, 19.8% required mechanical ventilation, and 6.7% died. After including possible HA cases, prevalence among all influenza-associated hospitalizations increased to 1.3% and the adjusted rate increased to 1.5 per 100,000 persons.
Over 8 seasons, rates of HA influenza were low but were likely underestimated because testing was not systematic. A high proportion of patients with HA influenza were unvaccinated and had severe outcomes. Annual influenza vaccination and implementation of robust hospital infection control measures may help to prevent HA influenza and its impacts on patient outcomes and the healthcare system.
Background: Candidemia is the fourth most common bloodstream infection in hospitalized patients in the United States, with an attributable mortality rate between 30% and 50%. Understanding the epidemiology of candidemia is critical due to its prevalence and association with extended hospital stays, high treatment cost, and significant morbidity and mortality. In 2019 the Connecticut Department of Public Health deemed candidemia a mandatory reportable condition and began state-wide surveillance in conjunction with the CDC’s Emerging Infections Program (EIP). Previously, the EIP had conducted population-based statewide surveillance of candidemia in Connecticut from 1998 to 2000, allowing an opportunity to assess how the epidemiology of candidemia has evolved. The goal of this study is to compare state-wide Connecticut EIP candidemia data from 2 periods (1998–2000 and 2019) to identify trends in infections and incidence, providing insight for potential improvements to current prevention measures and treatments. Methods: The sample population included all Connecticut residents aged ≥20 who tested positive for a candidemia infection during 1998–2000 and 2019. Patients who had positive blood cultures for Candida spp but were < 20 years old or were not Connecticut residents were excluded. Connecticut EIP candidemia case report forms from each time period were compared and matching fields were chosen as variables for univariate analysis to search for statistically significant differences. Selected variables include: Candida species present in blood culture, patient demographics, previous exposures to healthcare settings, length of stay, presence of central venous catheter (CVC), and location of the patient at diagnosis (community vs. hospital onset). De-identified patient-level information was provided by the EIP. Results: In total, 381 candidemia episodes from 1998–2000 were compared to 247 episodes in 2019. The proportion of C. albicans species in 1998–2000 was 49.9% and declined to 40.5% of cases in 2019 (P = .02). Outcomes improved as well, with 65.2% of patients in 2019 having survived compared to 51.4% in 1998–2000 (P = .001). Other findings indicate that patients with candidemia in 2019 were less likely to have a central venous catheter, less likely to have undergone a recent surgery, and were more likely to have community-onset infection (all p < 0.05). Conclusions: The epidemiology of candidemia has changed over the past 20 years, with significant improvements in patient survival and a shift toward community-onset infections and non-Albicans spp. These findings have important implications in designing prevention strategies and optimizing candidemia management, particularly in the community setting where increased intravenous drug use and the availability of home healthcare may be important factors.
Healthcare personnel with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection were interviewed to describe activities and practices in and outside the workplace. Among 2,625 healthcare personnel, workplace-related factors that may increase infection risk were more common among nursing-home personnel than hospital personnel, whereas selected factors outside the workplace were more common among hospital personnel.
Pharmacogenomic testing has emerged to aid medication selection for patients with major depressive disorder (MDD) by identifying potential gene-drug interactions (GDI). Many pharmacogenomic tests are available with varying levels of supporting evidence, including direct-to-consumer and physician-ordered tests. We retrospectively evaluated the safety of using a physician-ordered combinatorial pharmacogenomic test (GeneSight) to guide medication selection for patients with MDD in a large, randomized, controlled trial (GUIDED).
Materials and Methods
Patients diagnosed with MDD who had an inadequate response to ≥1 psychotropic medication were randomized to treatment as usual (TAU) or combinatorial pharmacogenomic test-guided care (guided-care). All received combinatorial pharmacogenomic testing and medications were categorized by predicted GDI (no, moderate, or significant GDI). Patients and raters were blinded to study arm, and physicians were blinded to test results for patients in TAU, through week 8. Measures included adverse events (AEs, present/absent), worsening suicidal ideation (increase of ≥1 on the corresponding HAM-D17 question), or symptom worsening (HAM-D17 increase of ≥1). These measures were evaluated based on medication changes [add only, drop only, switch (add and drop), any, and none] and study arm, as well as baseline medication GDI.
Most patients had a medication change between baseline and week 8 (938/1,166; 80.5%), including 269 (23.1%) who added only, 80 (6.9%) who dropped only, and 589 (50.5%) who switched medications. In the full cohort, changing medications resulted in an increased relative risk (RR) of experiencing AEs at both week 4 and 8 [RR 2.00 (95% CI 1.41–2.83) and RR 2.25 (95% CI 1.39–3.65), respectively]. This was true regardless of arm, with no significant difference observed between guided-care and TAU, though the RRs for guided-care were lower than for TAU. Medication change was not associated with increased suicidal ideation or symptom worsening, regardless of study arm or type of medication change. Special attention was focused on patients who entered the study taking medications identified by pharmacogenomic testing as likely having significant GDI; those who were only taking medications subject to no or moderate GDI at week 8 were significantly less likely to experience AEs than those who were still taking at least one medication subject to significant GDI (RR 0.39, 95% CI 0.15–0.99, p=0.048). No other significant differences in risk were observed at week 8.
These data indicate that patient safety in the combinatorial pharmacogenomic test-guided care arm was no worse than TAU in the GUIDED trial. Moreover, combinatorial pharmacogenomic-guided medication selection may reduce some safety concerns. Collectively, these data demonstrate that combinatorial pharmacogenomic testing can be adopted safely into clinical practice without risking symptom degradation among patients.
Plastic entering the archaeological and geological record may be the defining signature of the Anthropocene. Amidst the growing awareness of the role of plastic in marine pollution, this study demonstrates its terrestrial ubiquity. The excavation of two experimentally reconstructed roundhouses built on their original sites at Castell Henllys Iron Age fort, Wales, reveals evidence of 30 years of heritage interpretation and visitor activity. The nature and extent of the cultural material recovered accurately reflects known activities at this heritage site, but also reveals an unexpected amount of plastic debris in archaeological contexts, indicating how, even in well-managed contexts, plastic is entering terrestrial deposits.
Background: Recognition of bioterrorism-related infections by hospital and emergency department clinicians may be the first line of defense in a bioterrorist attack.
Methods: We identified unexplained infectious deaths consistent with the clinical presentation of anthrax, tularemia, smallpox, and botulism using Connecticut death certificates and hospital chart information. Minimum work-up criteria were established to assess the completeness of diagnostic testing.
Results: Of 4558 unexplained infectious deaths, 133 were consistent with anthrax (2.9%) and 6 (0.13%) with tularemia. None were consistent with smallpox or botulism. No deaths had anthrax or tularemia listed in the differential diagnosis or had disease-specific serology performed. Minimum work-up criteria were met for only 53% of cases.
Conclusions: Except for anthrax, few unexplained deaths in Connecticut could possibly be the result of the bioterrorism agents studied. In 47% of deaths from illnesses that could be anthrax, the diagnosis would likely have been missed. As of 2004, Connecticut physicians were not well prepared to intentionally or incidentally diagnose initial cases of anthrax or tularemia. More effective clinician education and surveillance strategies are needed to minimize the potential to miss initial cases in a bioterrorism attack. (Disaster Med Public Health Preparedness. 2008;2:87–94)
Recent efforts to implement prepaid legal services plans have raised antitrust questions, and the objective of this article is a systematic analysis of those questions and the problems to which they lead. After an introduction to prepaid legal services plans that sets the factual background, a number of specific antitrust problems will be examined: jurisdictional
issues, the exemption for state action, minimum price fixing, joint ventures, maximum price fixing, discrimination against certain types of plans, and exclusive dealing problems. Finally, prepaid legal services plans will be examined in light of the McCarran-Ferguson Act exemption of the “business of insurance” from antitrust coverage which, in turn, will necessitate a look at existing and potential state regulatory control over prepaid legal services plans.
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