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Spontaneous cerebrospinal fluid leak of the temporal bone is an emerging clinical entity for which prompt and accurate diagnosis is difficult given the subtle signs and symptoms that patients present with. This study sought to describe the key temporal bone abnormalities in patients with spontaneous cerebrospinal fluid leak.
A retrospective cohort study was conducted of adult patients with biochemically confirmed spontaneous cerebrospinal fluid leak. Demographics and radiological features identified on computed tomography imaging of the temporal bones and/or magnetic resonance imaging were analysed.
Sixty-one patients with spontaneous cerebrospinal fluid leak were identified. Fifty-four patients (88.5 per cent) underwent both temporal bone computed tomography and magnetic resonance imaging. Despite imaging revealing bilateral defects in over 75 per cent of the cohort, only two patients presented with bilateral spontaneous cerebrospinal fluid leaks. Anterior tegmen mastoideum defects were most common, with an average size of 2.5 mm (range, 1–10 mm).
Temporal bone computed tomography is sensitive for the identification of defects when suspicion exists. In the setting of an opacified middle ear and/or mastoid, close examination of the skull base is crucial given that this fluid is potentially cerebrospinal fluid.
Regular physical activity is safe and effective therapy for adults with CHD and is recommended by European Society of Cardiology guidelines. The COVID-19 pandemic poses enormous challenges to healthcare teams and patients when ensuring guideline compliance. We explored the implications of COVID-19 on physical activity levels in adult CHD patients.
Materials and methods:
A data-based questionnaire was distributed to adult CHD patients at a regional tertiary centre from October to November 2020.
Prior to the COVID-19 pandemic, 96 (79.3%) of 125 respondents reported participating in regular physical activity, with 66 (52.8%) meeting target levels (moderate physical activity for at least 150 minutes per week). Commonest motivations for physical activity were general fitness (53.6%), weight loss (36.0%), and mental health benefits (30.4%). During the pandemic, the proportion that met target levels significantly decreased from 52.8% to 40.8% (p = 0.03). The commonest reason was fear of COVID-19 (28.0%), followed by loss of motivation (23.2%) and gym/fitness centre closure (15.2%).
The COVID-19 pandemic has negatively impacted exercise levels of adult CHD patients. Most do not meet recommended physical activity levels, mainly attributable to fear of COVID-19. Even before the pandemic, only half of respondents met physical activity guidelines. Availability of online classes can positively impact exercise levels so could enhance guideline compliance. This insight into health perceptions and behaviours of adult CHD patients may help develop quality improvement initiatives to improve physical activity levels in this population.
The extent to which obsessive–compulsive and related disorders (OCRDs) are impulsive, compulsive, or both requires further investigation. We investigated the existence of different clusters in an online nonclinical sample and in which groups DSM-5 OCRDs and other related psychopathological symptoms are best placed.
Seven hundred and seventy-four adult participants completed online questionnaires including the Cambridge–Chicago Compulsivity Trait Scale (CHI-T), the Barratt Impulsiveness Scale (BIS-15), and a series of DSM-5 OCRDs symptom severity and other psychopathological measures. We used K-means cluster analysis using CHI-T and BIS responses to test three and four factor solutions. Next, we investigated whether different OCRDs symptoms predicted cluster membership using a multinomial regression model.
The best solution identified one “healthy” and three “clinical” clusters (ie, one predominantly “compulsive” group, one predominantly “impulsive” group, and one “mixed”—“compulsive and impulsive group”). A multinomial regression model found obsessive–compulsive, body dysmorphic, and schizotypal symptoms to be associated with the “mixed” and the “compulsive” clusters, and hoarding and emotional symptoms to be related, on a trend level, to the “impulsive” cluster. Additional analysis showed cognitive-perceptual schizotypal symptoms to be associated with the “mixed” but not the “compulsive” group.
Our findings suggest that obsessive–compulsive disorder; body dysmorphic disorder and schizotypal symptoms can be mapped across the “compulsive” and “mixed” clusters of the compulsive–impulsive spectrum. Although there was a trend toward hoarding being associated with the “impulsive” group, trichotillomania, and skin picking disorder symptoms did not clearly fit to the demarcated clusters.
The Cincinnatian (Katian) of the Cincinnati Tri-State area is widely regarded as one of the most fossiliferous sections known (Meyer and Davis, 2009). Echinoderms from these strata include well-described asteroids, crinoids, cyclocystoids, edrioasteroids, glyptocystoids, mitrates, and ophiuroids. John Pope discovered a partially articulated echinoderm in float from the Fairview Formation that does not correspond to any known Cincinnatian echinoderm. Although mentioned in Ubaghs (1966, as a presumable personal communication from Pope, 1960), Haude and Langenstrassen (1976), Reich (2001), and Reich and Haude (2004), this specimen at the Cincinnati Museum Center (CMCPIP 51316) has neither been described nor illustrated; yet, these authors attributed it to Volchovia Hecker, 1938 in the Class Ophiocistioidea. Questions swirl around this fossil: what is its complete morphology; does it belong to Volchovia; whether or not it can be assigned to Volchovia, is it an ophiocistioid? The first step to understand this enigmatic echinoderm is to illustrate and describe the specimen, which is the objective of this note.
To assess extent of a healthcare-associated outbreak of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) and to evaluate the effectiveness of infection control measures, including universal masking.
Outbreak investigation including 4 large-scale point-prevalence surveys.
Integrated VA healthcare system with 2 facilities and 330 beds.
Index patient and 250 exposed patients and staff.
We identified exposed patients and staff and classified them as probable and confirmed cases based on symptoms and testing. We performed a field investigation and an assessment of patient and staff interactions to develop probable transmission routes. Infection prevention interventions included droplet and contact precautions, employee quarantine, and universal masking with medical and cloth face masks. We conducted 4 point-prevalence surveys of patient and staff subsets using real-time reverse-transcriptase polymerase chain reaction for SARS-CoV-2.
Among 250 potentially exposed patients and staff, 14 confirmed cases of coronavirus disease 2019 (COVID-19) were identified. Patient roommates and staff with prolonged patient contact were most likely to be infected. The last potential date of transmission from staff to patient was day 22, the day universal masking was implemented. Subsequent point-prevalence surveys in 126 patients and 234 staff identified 0 patient cases and 5 staff cases of COVID-19, without evidence of healthcare-associated transmission.
Universal masking with medical face masks was effective in preventing further spread of SARS-CoV-2 in our facility in conjunction with other traditional infection prevention measures.
The concept of, and link between, the heart and mind has been postulated for centuries and there is now a growing recognition of the connection between mental and cardiovascular health: that cardiovascular disease (CVD) and mental health problems are not only common companions, but that each can lead to the other (Chaddha et al., 2016; Cohen et al., 2015). For example, depression and anxiety are common in people with CVD and are consistently associated with lower quality of life, poorer somatic symptoms, higher mortality, and higher healthcare costs, with between 1 in 2 (Westermair et al., 2018) to 1 in 3 (Norlund et al., 2018) people with CVD meeting the criteria for an anxiety and/or depressive disorder and 1 in 5 (Westermair et al., 2018) receiving mental health care.
Among 1,770 healthcare workers serving in high-risk care areas for coronavirus disease 2019 (COVID-19), 39 (2.2%) were seropositive. Exposure to severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in the community was associated with being seropositive. Job or unit type and percentage of time working with COVID-19 patients were not associated with positive antibody tests.
Rock debris covers ~30% of glacier ablation areas in the Central Himalaya and modifies the impact of atmospheric conditions on mass balance. The thermal properties of supraglacial debris are diurnally variable but remain poorly constrained for monsoon-influenced glaciers over the timescale of the ablation season. We measured vertical debris profile temperatures at 12 sites on four glaciers in the Everest region with debris thickness ranging from 0.08 to 2.8 m. Typically, the length of the ice ablation season beneath supraglacial debris was 160 days (15 May to 22 October)—a month longer than the monsoon season. Debris temperature gradients were approximately linear (r2 > 0.83), measured as −40°C m–1 where debris was up to 0.1 m thick, −20°C m–1 for debris 0.1–0.5 m thick, and −4°C m–1 for debris greater than 0.5 m thick. Our results demonstrate that the influence of supraglacial debris on the temperature of the underlying ice surface, and therefore melt, is stable at a seasonal timescale and can be estimated from near-surface temperature. These results have the potential to greatly improve the representation of ablation in calculations of debris-covered glacier mass balance and projections of their response to climate change.
Understanding risk factors for death from Covid-19 is key to providing good quality clinical care. We assessed the presenting characteristics of the ‘first wave’ of patients with Covid-19 at Royal Oldham Hospital, UK and undertook logistic regression modelling to investigate factors associated with death. Of 470 patients admitted, 169 (36%) died. The median age was 71 years (interquartile range 57–82), and 255 (54.3%) were men. The most common comorbidities were hypertension (n = 218, 46.4%), diabetes (n = 143, 30.4%) and chronic neurological disease (n = 123, 26.1%). The most frequent complications were acute kidney injury (AKI) (n = 157, 33.4%) and myocardial injury (n = 21, 4.5%). Forty-three (9.1%) patients required intubation and ventilation, and 39 (8.3%) received non-invasive ventilation. Independent risk factors for death were increasing age (odds ratio (OR) per 10 year increase above 40 years 1.87, 95% confidence interval (CI) 1.57–2.27), hypertension (OR 1.72, 95% CI 1.10–2.70), cancer (OR 2.20, 95% CI 1.27–3.81), platelets <150 × 103/μl (OR 1.93, 95% CI 1.13–3.30), C-reactive protein ≥100 μg/ml (OR 1.68, 95% CI 1.05–2.68), >50% chest radiograph infiltrates (OR 2.09, 95% CI 1.16–3.77) and AKI (OR 2.60, 95% CI 1.64–4.13). There was no independent association between death and gender, ethnicity, deprivation level, fever, SpO2/FiO2, lymphopoenia or other comorbidities. These findings will inform clinical and shared decision making, including use of respiratory support and therapeutic agents.
Background: With the emergence of antibiotic resistant threats and the need for appropriate antibiotic use, laboratory microbiology information is important to guide clinical decision making in nursing homes, where access to such data can be limited. Susceptibility data are necessary to inform antibiotic selection and to monitor changes in resistance patterns over time. To contribute to existing data that describe antibiotic resistance among nursing home residents, we summarized antibiotic susceptibility data from organisms commonly isolated from urine cultures collected as part of the CDC multistate, Emerging Infections Program (EIP) nursing home prevalence survey. Methods: In 2017, urine culture and antibiotic susceptibility data for selected organisms were retrospectively collected from nursing home residents’ medical records by trained EIP staff. Urine culture results reported as negative (no growth) or contaminated were excluded. Susceptibility results were recorded as susceptible, non-susceptible (resistant or intermediate), or not tested. The pooled mean percentage tested and percentage non-susceptible were calculated for selected antibiotic agents and classes using available data. Susceptibility data were analyzed for organisms with ≥20 isolates. The definition for multidrug-resistance (MDR) was based on the CDC and European Centre for Disease Prevention and Control’s interim standard definitions. Data were analyzed using SAS v 9.4 software. Results: Among 161 participating nursing homes and 15,276 residents, 300 residents (2.0%) had documentation of a urine culture at the time of the survey, and 229 (76.3%) were positive. Escherichia coli, Proteus mirabilis, Klebsiella spp, and Enterococcus spp represented 73.0% of all urine isolates (N = 278). There were 215 (77.3%) isolates with reported susceptibility data (Fig. 1). Of these, data were analyzed for 187 (87.0%) (Fig. 2). All isolates tested for carbapenems were susceptible. Fluoroquinolone non-susceptibility was most prevalent among E. coli (42.9%) and P. mirabilis (55.9%). Among Klebsiella spp, the highest percentages of non-susceptibility were observed for extended-spectrum cephalosporins and folate pathway inhibitors (25.0% each). Glycopeptide non-susceptibility was 10.0% for Enterococcus spp. The percentage of isolates classified as MDR ranged from 10.1% for E. coli to 14.7% for P. mirabilis. Conclusions: Substantial levels of non-susceptibility were observed for nursing home residents’ urine isolates, with 10% to 56% reported as non-susceptible to the antibiotics assessed. Non-susceptibility was highest for fluoroquinolones, an antibiotic class commonly used in nursing homes, and ≥ 10% of selected isolates were MDR. Our findings reinforce the importance of nursing homes using susceptibility data from laboratory service providers to guide antibiotic prescribing and to monitor levels of resistance.
Background: Antibiotics are among the most commonly prescribed drugs in nursing homes; urinary tract infections (UTIs) are a frequent indication. Although there is no gold standard for the diagnosis of UTIs, various criteria have been developed to inform and standardize nursing home prescribing decisions, with the goal of reducing unnecessary antibiotic prescribing. Using different published criteria designed to guide decisions on initiating treatment of UTIs (ie, symptomatic, catheter-associated, and uncomplicated cystitis), our objective was to assess the appropriateness of antibiotic prescribing among NH residents. Methods: In 2017, the CDC Emerging Infections Program (EIP) performed a prevalence survey of healthcare-associated infections and antibiotic use in 161 nursing homes from 10 states: California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. EIP staff reviewed resident medical records to collect demographic and clinical information, infection signs, symptoms, and diagnostic testing documented on the day an antibiotic was initiated and 6 days prior. We applied 4 criteria to determine whether initiation of treatment for UTI was supported: (1) the Loeb minimum clinical criteria (Loeb); (2) the Suspected UTI Situation, Background, Assessment, and Recommendation tool (UTI SBAR tool); (3) adaptation of Infectious Diseases Society of America UTI treatment guidelines for nursing home residents (Crnich & Drinka); and (4) diagnostic criteria for uncomplicated cystitis (cystitis consensus) (Fig. 1). We calculated the percentage of residents for whom initiating UTI treatment was appropriate by these criteria. Results: Of 248 residents for whom UTI treatment was initiated in the nursing home, the median age was 79 years [IQR, 19], 63% were female, and 35% were admitted for postacute care. There was substantial variability in the percentage of residents with antibiotic initiation classified as appropriate by each of the criteria, ranging from 8% for the cystitis consensus, to 27% for Loeb, to 33% for the UTI SBAR tool, to 51% for Crnich and Drinka (Fig. 2). Conclusions: Appropriate initiation of UTI treatment among nursing home residents remained low regardless of criteria used. At best only half of antibiotic treatment met published prescribing criteria. Although insufficient documentation of infection signs, symptoms and testing may have contributed to the low percentages observed, adequate documentation in the medical record to support prescribing should be standard practice, as outlined in the CDC Core Elements of Antibiotic Stewardship for nursing homes. Standardized UTI prescribing criteria should be incorporated into nursing home stewardship activities to improve the assessment and documentation of symptomatic UTI and to reduce inappropriate antibiotic use.
Antibiotic resistance (AR) is a growing and highly prevalent problem in nursing homes. We describe selected AR phenotypes from pathogens causing urinary tract infections (UTIs) reported by nursing homes to the National Healthcare Safety Network (NHSN).
Pathogens and antibiotic susceptibility testing results for UTI events in nursing homes between January 2013 and December 2017 were analyzed. The pathogen distribution and pooled mean proportion of isolates that tested resistant to select antibiotic agents are reported.
Setting and Participants:
US nursing homes voluntarily participating in the Long-Term Care Facility component of the NHSN.
Overall, 243 nursing homes reported 1 or more UTIs: 121 (50%) were nonprofit facilities, median bed size was 91 (range: 9–801), and average occupancy was 87%. In total, 6,157 pathogens were reported for 5,485 UTI events. Moreover, 9 pathogens accounted for 90% of all reported UTIs; the 3 most frequently identified were Escherichia coli (41%), Proteus species (14%), and Klebsiella pneumoniae/oxytoca (13%). Among E. coli, fluoroquinolone, and extended-spectrum cephalosporin resistance were most prevalent (50% and 20%, respectively). Although Staphylococcus aureus and Enterococcus faecium represented <5% of pathogens reported, they had the highest rates of resistance (67% methicillin resistant and 60% vancomycin resistant, respectively). Multidrug resistance was most common in Pseudomonas aeruginosa (11%). For the resistant phenotypes we assessed, 36% of all UTIs reported were associated with a resistant pathogen.
This is the first summary of AR among common pathogens causing UTIs reported to NHSN by nursing homes. Improved understanding of the resistance burden among common infections helps inform facility infection prevention and antibiotic stewardship efforts.
Bayesian analysis of radiocarbon (14C) dates in North American archaeology is increasing, especially among archaeologists working in deeper time. However, historical archaeologists have been slow to embrace these new techniques, and there have been only a few examples of the incorporation of calendar dates as informative priors in Bayesian models in such work in the United States. To illustrate the value of Bayesian approaches to sites with both substantial earlier Native American occupations as well as a historic era European presence, we present the results of our Bayesian analysis of 14C dates from the earlier Guale village and the Mission period contexts from the Sapelo Shell Ring Complex (9MC23) in southern Georgia. Jefferies and Moore have explored the Spanish Mission period deposits at this site to better understand the Native American interactions with the Spanish during the 16th and 17th centuries along the Georgia Coast. Given the results of our Bayesian modeling, we can say with some degree of confidence that the deposits thus far excavated and sampled contain important information dating to the 17th-century mission on Sapelo Island. In addition, our modeling of new dates suggests the range of the pre-Mission era Guale village. Based on these new dates, we can now say with some degree of certainty which of the deposits sampled likely contain information that dates to one of the critical periods of Mission period research, the AD 1660–1684 period that ushered in the close of mission efforts on the Georgia Coast.
To describe the pattern of transmission of SARS-CoV-2 during 2 nosocomial outbreaks of COVID-19 with regard to the possibility of airborne transmission.
Contact investigations with active case finding were used to assess the pattern of spread from 2 COVID-19 index patients.
A community hospital and university medical center in the United States, in February and March, 2020, early in the COVID-19 pandemic.
Two index patients and 421 exposed health care workers.
Exposed staff were identified by analyzing the EMR and conducting active case finding in combination with structured interviews. Staff were tested for COVID-19 by obtaining oropharyngeal/nasopharyngeal specimens, with RT-PCR testing to detect SARS-CoV-2.
Two separate index patients were admitted in February and March 2020, without initial suspicion for COVID-19 and without contact or droplet precautions in place; both patients underwent several aerosol generating procedures in this context. A total of 421 health care workers were exposed in total, and the results of the case contact investigations identified 8 secondary infections in health care workers. In all 8 cases, the staff had close contact with the index patients without sufficient personal protective equipment. Importantly, despite multiple aerosol generating procedures, there was no evidence of airborne transmission.
These observations suggest that, at least in a healthcare setting, a majority of SARS-CoV-2 transmission is likely to take place during close contact with infected patients through respiratory droplets, rather than by long-distance airborne transmission.
Older adults’ mental health problems are a growing public health concern, especially because their rate of mental health service use is particularly low. Decades of mental health service utilisation models have been developed, yet key assumptions from these models focus primarily on factors that facilitate or inhibit access into the treatment system without taking into considering the dynamics of how individuals respond to their mental health problems and engage in service utilisation. More recently, dynamic models like the Network Episode Model (NEM-II) have been developed to challenge the underlying, rational choice assumption of traditional utilisation models. Given the multifaceted and complex nature of older adults’ mental health problems, the objective of this study was to examine whether the NEM-II is a helpful and appropriate model for understanding the dynamic process of how older adults navigate the mental health system, including factors that advanced and delayed help-seeking. Our qualitative analyses from 15 interviews with older adults revealed that their backgrounds, social supports and treatment systems influence, and are influenced by, their illness careers. Factors that delayed help-seeking included: a lack of support, ‘inappropriate’ referrals/advice from treatment professionals and poor mental health literacy. This research suggests the NEM-II is a helpful and appropriate theory for understanding older adults’ pathways to treatment, and has implications to enhance older adults’ access to psychological services.
The evolution of resistance to multiple herbicides in Palmer amaranth is a major challenge for its management. In this study, a Palmer amaranth population from Hutchinson, Kansas (HMR), was characterized for resistance to inhibitors of photosystem II (PSII) (e.g., atrazine), acetolactate synthase (ALS) (e.g., chlorsulfuron), and EPSP synthase (EPSPS) (e.g., glyphosate), and this resistance was investigated. About 100 HMR plants were treated with field-recommended doses (1×) of atrazine, chlorsulfuron, and glyphosate, separately along with Hutchinson multiple-herbicide (atrazine, chlorsulfuron, and glyphosate)–susceptible (HMS) Palmer amaranth as control. The mechanism of resistance to these herbicides was investigated by sequencing or amplifying the psbA, ALS, and EPSPS genes, the molecular targets of atrazine, chlorsulfuron, and glyphosate, respectively. Fifty-two percent of plants survived a 1× (2,240 g ai ha−1) atrazine application with no known psbA gene mutation, indicating the predominance of a non–target site resistance mechanism to this herbicide. Forty-two percent of plants survived a 1× (18 g ai ha−1) dose of chlorsulfuron with proline197serine, proline197threonine, proline197alanine, and proline197asparagine, or tryptophan574leucine mutations in the ALS gene. About 40% of the plants survived a 1× (840 g ae ha−1) dose of glyphosate with no known mutations in the EPSPS gene. Quantitative PCR results revealed increased EPSPS copy number (50 to 140) as the mechanism of glyphosate resistance in the survivors. The most important finding of this study was the evolution of resistance to at least two sites of action (SOAs) (~50% of plants) and to all three herbicides due to target site as well as non–target site mechanisms. The high incidence of individual plants with resistance to multiple SOAs poses a challenge for effective management of this weed.
OBJECTIVES/GOALS: This study’s goal is to examine the feasibility and acceptability of using VRM to impact the APP of adults in the inpatient setting. Aims include examining the: 1) feasibility of VRM for APP management; 2) acceptability of using VRM for APP management; and 3) experience of VRM for APP management. METHODS/STUDY POPULATION: To comprehensively examine participants’ experience of using VRM for APP, this study will employ a convergent mixed-methods design in which living kidney donors (N = 45) will be recruited to serially use VRM during their hospital stay. Feasibility and acceptability will be evaluated using descriptive and inferential statistics evaluating patient-reported outcome (PRO) measures taken pre-, post- and 1-hour post-VRM, PRO measures extracted from the participant’s electronic health record and data on VRM use. Semi-structured interviews will allow formulation of inferences based on participants’ experience of VRM for APP management and their insights on content, deployment, and clinical use of VRM. RESULTS/ANTICIPATED RESULTS: This in-process study expects: 1) an adequate sample of participants undergoing living kidney donor surgery who agree to enroll with retention of >90% of participants (Aim 1); 2) participants to report VRM as an acceptable and suitable treatment, feel “present” and interested in the VR environment, and feel comfortable using VRM in the hospital (Aim 2); and 3) to provide insight into participants’ experience of VRM for APP, understanding of extended VRM use for APP analgesia, examination of key variables affecting participants’ experience of VRM for APP and feedback about VRM procedures and protocol to inform future VRM use for APP management (Aim 3). DISCUSSION/SIGNIFICANCE OF IMPACT: Results of the proposed study will inform future clinical testing and deployment of VRM, guide future use of VRM as an adjunct for inpatient APP management, and provide insight into inpatients’ experience of VRM for APP analgesia.