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Women carrying a fetus diagnosed with congenital heart disease often experience significant distress because of their medical diagnosis. Given the well-documented impact associated with elevated prenatal stress and critical importance of developing targeted interventions, this study aims to examine stressors, coping and resilience resources, and mental health treatment preferences in pregnant women receiving a congenital heart disease diagnosis to inform the development of a psychological intervention to reduce maternal distress prenatally.
Three groups of participants were included consisting of two pregnant women carrying a fetus with congenital heart disease, five women of children (4−16 months) with congenital heart disease, and five paediatric cardiology medical providers. Responses were gathered via semi-structured interviews and analysed using qualitative thematic analysis.
Information regarding four broad areas were analysed of emotional distress during pregnancy; experience of initial diagnosis; coping and resilience; and perspectives on a mental health intervention in pregnancy. Anxiety regarding baby’s future, guilt following diagnosis, and various coping strategies emerged as primary themes among the participant sample. Medical staff corroborated mothers’ heightened anxiety and viewed a psychotherapeutic intervention during the prenatal period as essential and complimentary to standard of care.
We identified salient themes and preferred components for a future psychological intervention delivered prenatally.
Patients’ and providers’ perspectives regarding the nature of maternal distress, resilience and treatment preferences can inform the development of interventions to support the emotional well-being of pregnant women carrying a fetus with congenital heart disease to optimise care and potentially improve outcomes for fetal brain development.
Our population-based study objectives were to describe characteristics and outcomes of Escherichia coli bloodstream infections (BSIs), and to evaluate factors associated with outcomes. We included incident E. coli BSIs from western interior residents (British Columbia, Canada; 04/2010–03/2020). We obtained data including patient demographics, location of onset, infection focus, Charlson comorbidity index (CCI), antimicrobial resistance, 30-day all-cause mortality and length of hospital stay (LOS). Using multivariable logistic regression models fitted with generalised estimating equations, we estimated factors associated with 30-day mortality and long post-infection LOS (>75th percentile). We identified 1080 incident E. coli BSIs in 1009 patients. The crude incidence and 30-day mortality rates were 59.1 BSIs and 6.8 deaths/100 000 person-years, respectively. The 30-day case fatality risk was 11.5%. Compared to community-acquired E. coli BSIs, either healthcare-associated or nosocomial cases had higher odds of 30-day mortality. Older cases, non-urogenital BSI foci and CCI ⩾ 3 had higher odds of 30-day mortality compared to younger cases, urogenital foci and CCI < 3. In patients that survived to discharge, those with extended-spectrum β-lactamase (ESBL)-producing E. coli BSIs, nosocomial BSIs, and CCI ⩾ 3 had higher odds of long post-infection LOS compared to those with non-ESBL-producing, community-acquired and healthcare-associated, and CCI < 3. There is a substantial disease burden from E. coli BSIs.
To stop transmission of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in association with myocardial perfusion imaging (MPI) at a cardiology clinic.
Outbreak investigation and quasispecies analysis of HCV hypervariable region 1 genome.
Outpatient cardiology clinic.
Patients undergoing MPI.
Case patients met definitions for HBV or HCV infection. Cases were identified through surveillance registry cross-matching against clinic records and serological screening. Observations of clinic practices were performed.
During 2012–2014, 7 cases of HCV and 4 cases of HBV occurred in 4 distinct clusters among patients at a cardiology clinic. Among 3 case patients with HCV infection who had MPI on June 25, 2014, 2 had 98.48% genetic identity of HCV RNA. Among 4 case patients with HCV infection who had MPI on March 13, 2014, 3 had 96.96%–99.24% molecular identity of HCV RNA. Also, 2 clusters of 2 patients each with HBV infection had MPI on March 7, 2012, and December 4, 2014. Clinic staff reused saline vials for >1 patient. No infection control breaches were identified at the compounding pharmacy that supplied the clinic. Patients seen in clinic through March 27, 2015, were encouraged to seek testing for HBV, HCV, and human immunodeficiency virus. The clinic switched to all single-dose medications and single-use intravenous flushes on March 27, 2015, and no further cases were identified.
This prolonged healthcare-associated outbreak of HBV and HCV was most likely related to breaches in injection safety. Providers should follow injection safety guidelines in all practice settings.
We assessed the magnitude of unidentified coronavirus disease 2019 (COVID-19) in our healthcare personnel (HCP) early in the COVID-19 pandemic, and we evaluated risk factors for infection to identify areas for improvement in infection control practice in a northern California academic medical center.
We reviewed anti–severe acute respiratory coronavirus virus 2 (SARS-CoV-2) receptor-binding domain (RBD) IgG serologic test results and self-reported risk factors for seropositivity among 10,449 asymptomatic HCP who underwent voluntary serology testing between April 20 and May 20, 2020.
In total, 136 employees (1.3%) tested positive for SARS-CoV-2 IgG. This included 41 individuals (30.1%) who had previously tested positive for SARS-CoV-2 by nasopharyngeal reverse-transcription polymerase chain reaction (RT-PCR) between March 13 and April 16, 2020. In multivariable analysis, employees of Hispanic ethnicity (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.22–3.46) and those working in environmental services, food services, or patient transport (OR, 4.81; 95% CI, 2.08–10.30) were at increased risk for seropositivity compared to other groups. Employees reporting a household contact with COVID-19 were also at higher risk for seropositivity (OR, 3.25; 95% CI, 1.47–6.44), but those with a work, exposure alone were not (OR, 1.27; 95% CI, 0.58–2.47). Importantly, one-third of seropositive individuals reported no prior symptoms, no suspected exposures, and no prior positive RT-PCR test.
In this study, SARS-CoV-2 seropositivity among HCP early in the northern California epidemic appeared to be quite low and was more likely attributable to community rather than occupational exposure.
Antimicrobial resistance is an urgent public health threat. Identifying trends in antimicrobial susceptibility can inform public health policy at the state and local levels.
To determine the ability of statewide antibiogram aggregation for public health surveillance to identify changes in antimicrobial resistance trends.
Facility-level trend analysis.
Crude and adjusted trend analyses of the susceptibility of Escherichia coli and Klebsiella pneumoniae to particular antibiotics, as reported by aggregated antibiograms, were examined from 2008 through 2018. Multivariable regression analyses via generalized linear mixed models were used to examine associations between hospital characteristics and trends of E. coli and K. pneumoniae susceptibility to ciprofloxacin and ceftriaxone.
E. coli and K. pneumoniae showed inverse trends in drug susceptibility over time. K. pneumoniae susceptibility to fluoroquinolones increased by 5% between 2008 and 2018 (P < .05). In contrast, E. coli susceptibility declined during the same period to ceftriaxone (6%), gentamicin (4%), and fluoroquinolones (4%) (P < .05). When compared to Boston hospitals, E. coli isolates from hospitals in other regions had a >4% higher proportion of susceptibility to ciprofloxacin and a >3% higher proportion of susceptibility to ceftriaxone (P < .05). Isolates of K. pneumoniae had higher susceptibility to ciprofloxacin (>3%) and ceftriaxone (>1.5%) in all regions when compared to Boston hospitals (P < .05).
Cumulative antibiograms can be used to monitor antimicrobial resistance, to discern regional and facility differences, and to detect changes in trends. Furthermore, because the number of years that hospitals contributed reports to the state-level aggregate had no significant influence on susceptibility trends, other states should not be discouraged by incomplete hospital compliance.
Drawing on a landscape analysis of existing data-sharing initiatives, in-depth interviews with expert stakeholders, and public deliberations with community advisory panels across the U.S., we describe features of the evolving medical information commons (MIC). We identify participant-centricity and trustworthiness as the most important features of an MIC and discuss the implications for those seeking to create a sustainable, useful, and widely available collection of linked resources for research and other purposes.
Mobile phones can replace traditional self-monitoring tools through cell phone-based ecological momentary assessment (CEMA) of lifestyle behaviours and camera phone-based images of meals, i.e. photographic food records (PFR). Adherence to mobile self-monitoring needs to be evaluated in real-world treatment settings. Towards this goal, we examine CEMA and PFR adherence to the use of a mobile app designed to help mothers self-monitor lifestyle behaviours and stress.
In 2012, forty-two mothers recorded CEMA of diet quality, exercise, sleep, stress and mood four times daily and PFR during meals over 6 months in Los Angeles, California, USA.
A purposive sample of mothers from mixed ethnicities.
Adherence to recording CEMA at least once daily was higher compared with recording PFR at least once daily over the study period (74 v. 11 %); adherence to both types of reports decreased over time. Participants who recorded PFR for more than a day (n 31) were more likely to be obese v. normal- to overweight and to have higher blood pressure, on average (all P<0·05). Based on random-effects regression, CEMA and PFR adherence was highest during weekdays (both P<0·01). Additionally, PFR adherence was associated with older age (P=0·04). CEMA adherence was highest in the morning (P<0·01). PFR recordings occurred throughout the day.
Variations in population and temporal characteristics should be considered for mobile assessment schedules. Neither CEMA nor PFR alone is ideal over extended periods.
Alzheimer’s disease (AD) has long been recognized as a heterogeneous illness, with a common clinical presentation of progressive amnesia and less common “atypical” clinical presentations, including syndromes dominated by visual, aphasic, “frontal,” or apraxic symptoms. Our knowledge of atypical clinical phenotypes of AD comes from clinicopathologic studies, but with the growing use of in vivo molecular biomarkers of amyloid and tau pathology, we are beginning to recognize that these syndromes may not be as rare as once thought. When a clinician is evaluating a patient whose clinical phenotype is dominated by progressive aphasia, complex visual impairment, or other neuropsychiatric symptoms with relative sparing of memory, the differential diagnosis may be broader and a confident diagnosis of an atypical form of AD may require the use of molecular biomarkers. Despite the evolving sophistication in our diagnostic tools, and the acknowledgment of atypical AD syndromes in the 2011 revised diagnostic criteria for AD, the assessment of such patients still poses substantial challenges. We use a case-based approach to review the clinical and imaging phenotypes of a series of patients with typical and atypical AD, and discuss our current approach to their evaluation. One day, we hope that regardless of whether a patient exhibits typical or atypical symptoms of AD pathology, we will be able to identify the condition at a prodromal phase and institute a combination of symptomatic and disease-modifying therapies to support cognitive processes, function, and behavior, and slow or halt progression to dementia.
Our objective was to estimate the per-infection and cumulative mortality and cost burden of multidrug-resistant (MDR) Acinetobacter healthcare-associated infections (HAIs) in the United States using data from published studies.
We identified studies that estimated the excess cost, length of stay (LOS), or mortality attributable to MDR Acinetobacter HAIs. We generated estimates of the cost per HAI using 3 methods: (1) overall cost estimates, (2) multiplying LOS estimates by a cost per inpatient-day ($4,350) from the payer perspective, and (3) multiplying LOS estimates by a cost per inpatient-day from the hospital ($2,030) perspective. We deflated our estimates for time-dependent bias using an adjustment factor derived from studies that estimated attributable LOS using both time-fixed methods and either multistate models (70.4% decrease) or matching patients with and without HAIs using the timing of infection (47.4% decrease). Finally, we used the incidence rate of MDR Acinetobacter HAIs to generate cumulative incidence, cost, and mortality associated with these infections.
Our estimates of the cost per infection were $129,917 (method 1), $72,025 (method 2), and $33,510 (method 3). The pooled relative risk of mortality was 4.51 (95% CI, 1.10–32.65), which yielded a mortality rate of 10.6% (95% CI, 2.5%–29.4%). With an incidence rate of 0.141 (95% CI, 0.136–0.161) per 1,000 patient-days at risk, we estimated an annual cumulative incidence of 12,524 (95% CI, 11,509–13,625) in the United States.
The estimates presented here are relevant to understanding the expenditures and lives that could be saved by preventing MDR Acinetobacter HAIs.
We have been interested in the plasmonic properties of alternative conducting materials to metals, such as conducting oxides, and we have recently expanded our studies to include highly correlated oxides, such as vanadium dioxide (VO2) thin films. VO2 exhibits a metal-insulator transition (MIT) just above ambient temperature at ∼ 340K. Interestingly, this transition can be induced thermally, optically or applying electric fields. Across the MIT, the optical properties are completely modified over a broad frequency range. We will present our recent optical investigations on the photon induced transition studies on such films, as well as the surface plasmon resonance (SPR) modulation in nanopatterned Au gratings by the thermally induced MIT in VO2 thin films, addressing possibilities of ultrafast SPR modulation with VO2.
Ceremonial architecture of late precontact (A.D. 600-1500) societies of Puerto Rico consists of stone-lined plazas and ball courts (bateys,). Archaeologists use these structures to signify the onset of hierarchical “chiefly” polities and to interpret their regional organization. Problematically, little consideration is given to the costs of their physical construction and the associated organizational implications at local and regional scales. In this paper, we use data gathered through geoarchaeological field investigations to develop labor estimates for the plaza and bateys at the site of Tibes—one of the largest precolumbian ceremonial centers in Puerto Rico. The estimates provide a basis for addressing how these features were constructed at the site and are considered within the broader organizational contexts of incipient polities in the island's south-central region between A.D. 600 and A.D. 1200.
A method to remove the effects of elastic and thermal diffuse scattering (TDS) of the incident electron probe from electron energy-loss and energy-dispersive X-ray spectroscopy data for atomically resolved spectrum images of single crystals of known thickness is presented. By calculating the distribution of the probe within a specimen of known structure, it is possible to deconvolve the channeling of the probe and TDS from experimental data by reformulating the inelastic cross-section as an inverse problem. In electron energy-loss spectroscopy this allows valid comparisons with first principles fine-structure calculations to be made. In energy-dispersive X-ray spectroscopy, direct compositional analyses such as ζ-factor and Cliff–Lorimer k-factor analysis can be performed without the complications of channeling and TDS. We explore in detail how this method can be incorporated into existing multislice programs, and demonstrate practical considerations in implementing this method using a simulated test specimen. We show the importance of taking into account the scattering of the probe in k-factor analysis in a zone axis orientation. The applicability and limitations of the method are discussed.
To determine the source and identify control measures of an outbreak of Tsukamurella species bloodstream infections at an outpatient oncology facility.
Epidemiologic investigation of the outbreak with a case-control study.
A case was an infection in which Tsukamurella species was isolated from a blood or catheter tip culture during the period January 2011 through June 2012 from a patient of the oncology clinic. Laboratory records of area hospitals and patient charts were reviewed. A case-control study was conducted among clinic patients to identify risk factors for Tsukamurella species bloodstream infection. Clinic staff were interviewed, and infection control practices were assessed.
Fifteen cases of Tsukamurella (Tsukamurella pulmonis or Tsukamurella tyrosinosolvens) bloodstream infection were identified, all in patients with underlying malignancy and indwelling central lines. The median age of case patients was 68 years; 47% were male. The only significant risk factor for infection was receipt of saline flush from the clinic during the period September–October 2011 (P = .03), when the clinic had been preparing saline flush from a common-source bag of saline. Other infection control deficiencies that were identified at the clinic included suboptimal procedures for central line access and preparation of chemotherapy.
Although multiple infection control lapses were identified, the outbreak was likely caused by improper preparation of saline flush syringes by the clinic. The outbreak demonstrates that bloodstream infections among oncology patients can result from improper infection control practices and highlights the critical need for increased attention to and oversight of infection control in outpatient oncology settings.
The role of explosions and patient transport vehicles as sources and vectors of Gram-negative, multidrug-resistant organisms (MDROs) that predominate infections following lengthy evacuations after disasters due to natural hazards and in current war-trauma patients is unknown.
Damaged or heavily-used vehicles could be sources of the MDROs subsequently linked to nosocomial infections.
From January through May 2008 in Iraq, inside surfaces of heavily-used, tactical vehicles (Experimental Group) were sampled with sterile, pre-moistened swabs. Swabs, along with positive and negative controls, were shipped to the reference laboratory in Washington, DC, where they underwent culture, identification and susceptibility testing, and pulsed-field gel electrophoresis. Multidrug-resistant organisms were defined according to the standard Centers for Disease Control and Prevention definitions. High risk organisms (HROs) were defined as susceptible E. coli, A. baumannii, P. aeruginosa, Enterobacter spp, or Klebsiella spp. Concurrently, new counterparts (Control Group) were similarly surveyed in a storage lot in Georgia, USA. Groups were compared using the Chi-squared test.
One hundred thirty-nine consecutive vehicles including all available ambulances were sampled, yielding 153 swabs. Nineteen were lost or damaged during shipping. Seventy-nine swabs yielded growth of one or more Gram-negative bacteria. The amount and genotype of MDROs in heavily-used vehicles, including those involved in roadside bombings, were compared to control vehicles and to strains isolated from wounds and environmental surfaces at the base hospital. Predominant organisms included P. agglomerans (34%), S. flexneri (8%), E. vulneris (6%), Pseudomonas sp. (6%), and K. pneumonia (6%). No MDROs were isolated. Thirteen vehicles (eight of 94 experimental and five of 45 control) yielded HRO. There was no difference in contamination rates (P = .63). No HROs were isolated from ambulances. No clonal association existed between vehicle and hospital strains.
Given the implications that this knowledge gap has on military and civilian prehospital reservoirs of infection, further study is warranted to confirm these findings and identify targets for preventive intervention throughout civilian disaster and military casualty evacuation chains.
LeshoE, AkeJ, HuangX, CashDM, NikolichM, BarberM, RobensK, GarnettE, LindlerL, ScottP. Amount of Usage and Involvement in Explosions Not Associated with Increased Contamination of Prehospital Vehicles with Multi-drug-resistant Organisms. Prehosp Disaster Med. 2013;28(2):1-3..
This study explored whether remote blast-related MTBI and/or current Axis I psychopathology contribute to neuropsychological outcomes among OEF/OIF veterans with varied combat histories. OEF/OIF veterans underwent structured interviews to evaluate history of blast-related MTBI and psychopathology and were assigned to MTBI (n = 18), Axis I (n = 24), Co-morbid MTBI/Axis I (n = 34), or post-deployment control (n = 28) groups. A main effect for Axis I diagnosis on overall neuropsychological performance was identified (F(3,100) = 4.81; p = .004), with large effect sizes noted for the Axis I only (d = .98) and Co-morbid MTBI/Axis I (d = .95) groups relative to the control group. The latter groups demonstrated primary limitations on measures of learning/memory and processing speed. The MTBI only group demonstrated performances that were not significantly different from the remaining three groups. These findings suggest that a remote history of blast-related MTBI does not contribute to objective cognitive impairment in the late stage of injury. Impairments, when present, are subtle and most likely attributable to PTSD and other psychological conditions. Implications for clinical neuropsychologists and future research are discussed. (JINS, 2012, 18, 1–11)