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Background: Group B Streptococcus (GBS) can cause life-threating invasive infections, yet GBS is also a normal component of the intestinal and genitourinary tract. Although it is regarded as a potential urinary pathogen, the morbidity and mortality associated with recovery of GBS from urine cultures of nonpregnant adults is not well understood. We evaluated characteristics and mortality among nonpregnant adults with urine cultures that grew GBS. Methods: Using administrative data from the Veterans’ Healthcare Administration (VHA), we conducted a retrospective cohort study of VA healthcare system users from January 1, 2008, through December 31, 2017, with monomicrobial urine cultures growing ≥100,000 colony-forming units of GBS. Urinary tract infection (UTI) cases were defined as urinalysis positive for leukocyte esterase and pyuria (≥10 white blood cells), an International Classification of Diseases (ICD) code for UTI, and an antibiotic prescription. Cases with colonization were defined as negative for leukocyte esterase and pyuria, no ICD code for UTI, and no antibiotic prescription. Cases not meeting either definition were deemed unclassifiable. We compared demographics, comorbidities, and all-cause mortality among these 3 groups. Results: Over the 10-year study period, 26,848 veterans had 30,740 urine cultures positive for GBS. Applying the definitions above, there were 2,807 cases of infection, 8,789 cases of colonization, and 15,252 cases that were unclassifiable. Patients with a GBS UTI were slightly older compared to those who were colonized, with a higher Charlson comorbidity index and greater burden of chronic renal disease (Table 1). Individuals with infection versus colonization had 30-day mortality rates of 1% and 0%, respectively, and 1-year mortality rates of 9% and 4%, respectively (Figure 1). Conclusions: The association of a greater burden of illness among veterans who met our definition of UTI compared to colonization might be more reflective of providers’ responses to patients with chronic medical conditions rather than a difference in GBS as a cause of UTI. Overall, the prospect of a urine culture that grows GBS does not appear to be associated with adverse long-term outcomes.
Background: The influence of increased use of telehealth during the emergence of COVID-19 on antibiotic prescriptions in outpatient settings is unknown. The VA Northeast Ohio Healthcare System has 13 community-based outpatient clinics (CBOCs) that provide primary and preventive care. We assessed changes in antibiotic prescriptions that occurred as care shifted from in-person to telehealth visits. Methods: Using VHA administrative databases, we identified all primary care CBOC visits between January 1, 2019, and December 31, 2020, that included a diagnosis for an acute respiratory infection (ARI), a urinary tract infection (UTI), or a skin or soft-tissue infection (SSTI), excluding visits with >1 of these diagnoses or with additional infectious diagnoses (eg, pneumonia, influenza). We summarized the proportion of telehealth visits and the proportion of patients prescribed antibiotics at quarterly intervals. We specifically assessed outpatient visits from April to December 2019 compared to the same months in 2020 to account for seasonality while analyzing diagnosis and antibiotic trends in the emergence of the COVID-19 pandemic. Results: The patients receiving care in April–December 2019 compared to April–December 2020 were similar (Table 1). From April through December 2019, 90% of CBOC primary care visits with a diagnosis for ARI, UTI, or SSTI were in-person, and antibiotics were prescribed at 63%, 46%, and 65% of visits in either modality, respectively (Figure 1). From April through December 2020, only 33% of CBOC primary care visits for ARI, UTI, and SSTI were in person, and antibiotics were prescribed at 46%, 38%, and 47% of visits in either modality, respectively. Comparing April–December in 2019 and 2020, the number of CBOC visits for ARI fell by 76% (2,152 visits to 509 visits), with a more modest decline of 20% and 35% observed for UTI and SSTI visits. In-person visits for ARIs and SSTIs were more likely than telehealth visits to result in an antibiotic prescription (Figure 2). Conclusions: Among the CBOCs at our healthcare system, an increase in the proportion of telehealth visits and a reduction in ARI diagnoses occurred after the emergence of COVID-19. In this setting, we observed a reduction in the proportion of visits for ARIs, UTIs, and SSTIs that included an antibiotic prescription.
Background: Outcomes among nursing home residents with asymptomatic compared to symptomatic COVID-19 are not well characterized. We assessed all-cause mortality among Veterans’ Affairs (VA) community living center (CLC) residents; we compared those residents with a negative SARS-CoV-2 test to residents with symptomatic, presymptomatic, and asymptomatic SARS-CoV-2 infections. Methods: We conducted a national retrospective cohort study of CLC residents tested for COVID-19 between March 1 and July 31, 2020, based on data compiled through the VA COVID-19 shared data resource. Among those with a positive SARS-CoV-2 test, residents were considered symptomatic if they had experienced COVID-19 symptoms in the 30 days prior to the test. Residents were considered presymptomatic if they did not experience symptoms in the 30 days prior to testing and developed a fever (>38°C) or required supplemental oxygen within 14 and 60 days, respectively, following the test. Residents were considered asymptomatic in the absence of these pre- and posttest symptoms. Results: From March 1 to July 31, 2020, of 9,052 CLC residents screened for COVID-19, 8,325 (92%) tested negative (Table 1). Among 727 residents with positive tests, 467 (64%) were symptomatic, 88 (12%) were presymptomatic, and 172 (24%) remained asymptomatic. We observed significant differences in the racial makeup of these disease groups. Among CLC residents who were symptomatic or presymptomatic, 176 (32%) of 555 were black compared to 39 (23%) of 172 who were asymptomatic and 1,810 (22%) of 8,325 who tested negative for SAR-CoV-2. All-cause 30-day mortality rates for symptomatic and presymptomatic residents were 25% and 34%, respectively, which exceeded the all-cause 30-day mortality of asymptomatic residents (12%) and residents with a negative test (6%) (Figure 1). Conclusions: More than one-third of CLC residents with COVID-19 were asymptomatic at the time of testing. This finding highlights the importance of vigilant infection prevention and control measures. Our finding that mortality among presymptomatic residents exceeded that of symptomatic residents raises consideration for enhancing supportive care measures, such as supplemental oxygen and mitigation of inflammatory reactions, as a means to reduce mortality among nursing home residents with presymptomatic SARS-CoV-2 infections.
Background: Rates of invasive infections caused by caused group B Streptococcus (GBS) are increasing among adults. The burden of noninvasive GBS infections, including pneumonia, has not been well characterized. Here, we compare comorbidities and mortality associated with invasive and noninvasive pneumonia caused by GBS. Methods: Using the Veterans’ Health Administration national data warehouse, we studied a retrospective cohort review of veterans diagnosed with GBS pneumonia between 2008 and 2017. Invasive pneumonia was defined as blood cultures positive for GBS associated with an order for a chest x-ray and an International Classification of Disease (ICD) code for pneumonia. Noninvasive pneumonia was defined as a respiratory culture positive for GBS associated with both an order for a chest x-ray and an ICD code for pneumonia among patients with negative or without blood cultures. Patients with respiratory cultures positive for GBS without either an associated chest x-ray or ICD code for pneumonia were considered colonized. We compared demographics, comorbid conditions, and mortality among patients with invasive and noninvasive GBS pneumonia. Results: Between 2008 and 2017, we detected 706 cases of invasive GBS pneumonia, 1,244 cases of noninvasive GBS pneumonia, and 1,470 cases of respiratory colonization with GBS. Most patients were male (97%), with an average age of 69.0 years (SD, 12.0 years). The prevalence of several comorbid conditions differed between those with invasive and noninvasive disease: diabetes mellitus (61% and 46%, respectively); chronic pulmonary diseases (53% and 65%, respectively); chronic heart disease (58% and 44%, respectively), chronic kidney disease (43% and 27%, respectively). Mortality was similar among those with invasive and noninvasive GBS pneumonia at 30 days (17% and 18%, respectively) and at 1 year (38% and 43%, respectively) (Fig. 1). Conclusions: We identified important differences in underlying comorbid conditions between patients with invasive and noninvasive GBS pneumonia, which may give rise to differences in their clinical presentation. Overall mortality, however, was similar: more than one-third of patients with GBS pneumonia died within 1 year. These findings indicate that noninvasive GBS pneumonia is an important clinical entity.
Background: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) is a frequent cause of healthcare-associated infections (HAIs). The CDC Emerging Infections Program (EIP) conducted population and laboratory-based surveillance of CRPA in selected areas in 8 states from August 1, 2016, through July 31, 2018. We aimed to describe the molecular epidemiology and mechanisms of resistance of CRPA isolates collected through this surveillance. Methods: We defined a case as the first isolate of P. aeruginosa resistant to imipenem, meropenem, or doripenem from the lower respiratory tract, urine, wounds, or normally sterile sites identified from a resident of the EIP catchment area in a 30-day period; EIP sites submitted a systematic random sample of isolates to CDC for further characterization. Of 1,021 CRPA clinical isolates submitted, 707 have been sequenced to date using an Illumina MiSeq. Sequenced genomes were classified using the 7-gene multilocus sequence typing (MLST) scheme, and a core genome MLST (cgMLST) scheme was used to determine phylogeny. Antimicrobial resistance genes were identified using publicly available databases, and chromosomal mechanisms of carbapenem resistance were determined using previously validated genetic markers. Results: There were 189 sequence types (STs) among the 707 sequenced genomes (Fig. 1). The most frequently occurring were high-risk clones ST235 (8.5%) and ST298 (4.7%), which were found across all EIP sites. Carbapenemase genes were identified in 5 (<1%) isolates. Overall, 95.6% of the isolates had chromosomal mutations associated with carbapenem resistance: 93.2% had porinD-associated mutations that decrease membrane permeability to the drugs; 24.8% had mutations associated with overexpression of the multidrug efflux pump MexAB-OprM; and 22.9% had mutations associated with overexpression of the endogenous β-lactamase ampC. More than 1 such chromosomal resistance mutation type was present in 37.8% of the isolates. Conclusions: The diversity of the sequence types demonstrates that HAIs caused by CRPA can arise from a variety of strains and that high-risk clones are broadly disseminated across the EIP sites but are a minority of CRPA strains overall. Carbapenem resistance in P. aeruginosa was predominantly driven by chromosomal mutations rather than acquired mechanisms (ie, carbapenemases). The diversity of the CRPA isolates and the lack of carbapenemase genes suggest that this ubiquitous pathogen can readily evolve chromosomal resistance mechanisms, but unlike carbapenemases, these cannot be easily spread through horizontal transfer.
Over the past decade, a growing interest has developed on the archaeology, palaeontology, and palaeoenvironments of the Arabian Peninsula. It is now clear that hominins repeatedly dispersed into Arabia, notably during pluvial interglacial periods when much of the peninsula was characterised by a semiarid grassland environment. During the intervening glacial phases, however, grasslands were replaced with arid and hyperarid deserts. These millennial-scale climatic fluctuations have subjected bones and fossils to a dramatic suite of environmental conditions, affecting their fossilisation and preservation. Yet, as relatively few palaeontological assemblages have been reported from the Pleistocene of Arabia, our understanding of the preservational pathways that skeletal elements can take in these types of environments is lacking. Here, we report the first widespread taxonomic and taphonomic assessment of Arabian fossil deposits. Novel fossil fauna are described and overall the fauna are consistent with a well-watered semiarid grassland environment. Likewise, the taphonomic results suggest that bones were deposited under more humid conditions than present in the region today. However, fossils often exhibit significant attrition, obscuring and fragmenting most finds. These are likely tied to wind abrasion, insolation, and salt weathering following fossilisation and exhumation, processes particularly prevalent in desert environments.
Over the past decade, the World Health Summit (WHS) has provided a global platform for policy-makers and decision-makers to interact with academics and practitioners on global health. Recently the WHS adopted health security into their agenda for transnational disease risks (eg, Ebola and antimicrobial resistance) that increasingly threaten multiple sectors. Global health engagement (GHE) focuses efforts across interdisciplinary and interorganizational lines to identify critical threats and provide rapid deployment of key resources at the right time for addressing health security risks. As a product of subject matter experts convening at the WHS, a special side-group has organically risen with leadership and coordination from the German Institute for Defense and Strategic Studies in support of GHE activities across governmental, academic, and industry partners. Through novel approaches and targeted methodology that maximize outcomes and streamline global health operational process, the Global Health Security Alliance (GloHSA) was born. This short conference report describes in more detail the GloHSA.
Carbonate glasses can be formed routinely in the system K2CO3–MgCO3. The enthalpy of formation for one such 0.55K2CO3–0.45MgCO3 glass was determined at 298 K to be 115.00 ± 1.21 kJ/mol by drop solution calorimetry in molten sodium molybdate (3Na2O·MoO3) at 975 K. The corresponding heat of formation from oxides at 298 K was −261.12 ± 3.02 kJ/mol. This ternary glass is shown to be slightly metastable with respect to binary crystalline components (K2CO3 and MgCO3) and may be further stabilized by entropy terms arising from cation disorder and carbonate group distortions. This high degree of disorder is confirmed by 13C MAS NMR measurement of the average chemical shift tensor values, which show asymmetry of the carbonate anion to be significantly larger than previously reported values. Molecular dynamics simulations show that the structure of this carbonate glass reflects the strong interaction between the oxygen atoms in distorted carbonate anions and potassium cations.
Schmidt-hammer exposure-age dating (SHD) of boulders on cryoplanation terrace treads and associated bedrock cliff faces revealed Holocene ages ranging from 0 ± 825 to 8890 ± 1185 yr. The cliffs were significantly younger than the inner treads, which tended to be younger than the outer treads. Radiocarbon dates from the regolith of 3854 to 4821 cal yr BP (2σ range) indicated maximum rates of cliff recession of ~0.1 mm/yr, which suggests the onset of terrace formation before the last glacial maximum. Age, angularity, and size of clasts, together with planation across bedrock structures and the seepage of groundwater from the cliff foot, all support a process-based conceptual model of cryoplanation terrace development in which frost weathering leads to parallel cliff recession and, hence, terrace extension. The availability of groundwater during autumn freezeback is viewed as critical for frost wedging and/or the growth of segregation ice during prolonged winter frost penetration. Permafrost promotes cryoplanation by providing an impermeable frost table beneath the active layer, focusing groundwater flow, and supplying water for sediment transport by solifluction across the tread. Snow beds are considered an effect rather than a cause of cryoplanation terraces, and cryoplanation is seen as distinct from nivation.
Starting in 2016, we initiated a pilot tele-antibiotic stewardship program at 2 rural Veterans Affairs medical centers (VAMCs). Antibiotic days of therapy decreased significantly (P < .05) in the acute and long-term care units at both intervention sites, suggesting that tele-stewardship can effectively support antibiotic stewardship practices in rural VAMCs.
The prehospital disaster and emergency medical services community stands on the front-line in the response to events such as novel influenza, multi-drug resistant tuberculosis, and other high consequence diseases such as the Ebola Virus Disease.
To address provider and community safety, we developed an online educational program utilizing a Multi-Pathogen Approach to infectious disease personal protective equipment (PPE) deployment by prehospital providers. Such vigilance starts with syndromic recognition and quickly transcends to include operational issues, clinical interventions, and public health integration.
The University of Maryland, Baltimore County (Maryland, USA), Department of Emergency Health Services partnered with the Maryland State Department of Health (USA), to develop an online educational curriculum. The curriculum was developed through an expert panel consensus group including prehospital providers and is hybrid in design and includes awareness level training and procedural guidance.
Currently deployed online, this educational content demonstrating the use of the Multi-Pathogen Approach is accessible open-access via YouTube worldwide on computers, tablets, and smartphones. This curriculum is also accessible for continuing medical education to over 50,000 prehospital, hospital, and clinic personnel throughout Maryland and the National Capital Region of the United States. The curriculum consists of twelve modules of didactic and live videotaped demonstrations.
The development of the Multi-Pathogen Approach for the deployment of PPE and the use of online education modules has given prehospital providers an easily accessible open-access tool for high consequence disease management. The development of educational efforts such as these can help ensure better patient care and prehospital EMS system readiness.
Bentonite clay is often included as a buffer, backfill and/or sealing material in designs for deep geological repositories for radioactive wastes. It is expected that bentonite materials may undergo some mineralogical alteration as they interact with in situ groundwaters over long timescales on the order of thousands to millions of years. Long-term modelling of these materials is therefore important in order to demonstrate confidence that the engineered designs will continue to perform as required over their intended lifetimes (required assessment timescales can be up to 1 million years). The key geochemical processes that must be considered in such modelling are mineral dissolution and precipitation and cation exchange. These processes are expected to occur simultaneously and so modelling of their coupled effects and their rates (kinetics) is necessary. Illustrative reactive-transport models of the geochemical alteration of montmorillonite (the primary mineral in bentonite exhibiting cation exchange) are presented which demonstrate that one possible approach to fully coupling cation exchange and clay mineral dissolution kinetics, referred to here as the ‘all-component coupling’ approach, may lead to unrealistic behaviour due to feedback that may occur in the formulation. This feedback can be avoided if a ‘common-component’ conceptual model for the dissolution of exchanger end members is adopted, where only the saturation of the exchanger ‘structural unit’ is considered when evaluating the potential for dissolution of the mineral. Such considerations have been proposed historically in stability analyses for montmorillonite, but have not been explored widely in the modelling literature.
The United States relies on uncompensated family caregivers to provide most of the long-term care required by older adults as they age. But such care comes at a significant financial cost to these caregivers in the form of lower lifetime earnings and diminished (or even no) Social Security retirement benefits, ineligibility for Medicare coverage of their healthcare costs, and minimal retirement savings. To reduce the impact of uncompensated caregiving on the intergenerational transmission of poverty, this paper discusses three possible mechanisms of compensating family caregivers: public payments, deemed wage credits under Social Security, and income tax incentives.
To test the feasibility of using telehealth to support antimicrobial stewardship at Veterans Affairs medical centers (VAMCs) that have limited access to infectious disease-trained specialists.
A prospective quasi-experimental pilot study.
Two rural VAMCs with acute-care and long-term care units.
At each intervention site, medical providers, pharmacists, infection preventionists, staff nurses, and off-site infectious disease physicians formed a videoconference antimicrobial stewardship team (VAST) that met weekly to discuss cases and antimicrobial stewardship-related education.
Descriptive measures included fidelity of implementation, number of cases discussed, infectious syndromes, types of recommendations, and acceptance rate of recommendations made by the VAST. Qualitative results stemmed from semi-structured interviews with VAST participants at the intervention sites.
Each site adapted the VAST to suit their local needs. On average, sites A and B discussed 3.5 and 3.1 cases per session, respectively. At site A, 98 of 140 cases (70%) were from the acute-care units; at site B, 59 of 119 cases (50%) were from the acute-care units. The most common clinical syndrome discussed was pneumonia or respiratory syndrome (41% and 35% for sites A and B, respectively). Providers implemented most VAST recommendations, with an acceptance rate of 73% (186 of 256 recommendations) and 65% (99 of 153 recommendations) at sites A and B, respectively. Qualitative results based on 24 interviews revealed that participants valued the multidisciplinary aspects of the VAST sessions and felt that it improved their antimicrobial stewardship efforts and patient care.
This pilot study has successfully demonstrated the feasibility of using telehealth to support antimicrobial stewardship at rural VAMCs with limited access to local infectious disease expertise.
OBJECTIVES/SPECIFIC AIMS: Background: Delirium is a well described form of acute brain organ dysfunction characterized by decreased or increased movement, changes in attention and concentration as well as perceptual disturbances (i.e., hallucinations) and delusions. Catatonia, a neuropsychiatric syndrome traditionally described in patients with severe psychiatric illness, can present as phenotypically similar to delirium and is characterized by increased, decreased and/or abnormal movements, staring, rigidity, and mutism. Delirium and catatonia can co-occur in the setting of medical illness, but no studies have explored this relationship by age. Our objective was to assess whether advancing age and the presence of catatonia are associated with delirium. METHODS/STUDY POPULATION: Methods: We prospectively enrolled critically ill patients at a single institution who were on a ventilator or in shock and evaluated them daily for delirium using the Confusion Assessment for the ICU and for catatonia using the Bush Francis Catatonia Rating Scale. Measures of association (OR) were assessed with a simple logistic regression model with catatonia as the independent variable and delirium as the dependent variable. Effect measure modification by age was assessed using a Likelihood ratio test. RESULTS/ANTICIPATED RESULTS: Results: We enrolled 136 medical and surgical critically ill patients with 452 matched (concomitant) delirium and catatonia assessments. Median age was 59 years (IQR: 52–68). In our cohort of 136 patients, 58 patients (43%) had delirium only, 4 (3%) had catatonia only, 42 (31%) had both delirium and catatonia, and 32 (24%) had neither. Age was significantly associated with prevalent delirium (i.e., increasing age associated with decreased risk for delirium) (p=0.04) after adjusting for catatonia severity. Catatonia was significantly associated with prevalent delirium (p<0.0001) after adjusting for age. Peak delirium risk was for patients aged 55 years with 3 or more catatonic signs, who had 53.4 times the odds of delirium (95% CI: 16.06, 176.75) than those with no catatonic signs. Patients 70 years and older with 3 or more catatonia features had half this risk. DISCUSSION/SIGNIFICANCE OF IMPACT: Conclusions: Catatonia is significantly associated with prevalent delirium even after controlling for age. These data support an inverted U-shape risk of delirium after adjusting for catatonia. This relationship and its clinical ramifications need to be examined in a larger sample, including patients with dementia. Additionally, we need to assess which acute brain syndrome (delirium or catatonia) develops first.
Antineuronal antibodies are associated with psychosis, although their clinical significance in first episode of psychosis (FEP) is undetermined.
To examine all patients admitted for treatment of FEP for antineuronal antibodies and describe clinical presentations and treatment outcomes in those who were antibody positive.
Individuals admitted for FEP to six mental health units in Queensland, Australia, were prospectively tested for serum antineuronal antibodies. Antibody-positive patients were referred for neurological and immunological assessment and therapy.
Of 113 consenting participants, six had antineuronal antibodies (anti-N-methyl-D-aspartate receptor antibodies [n = 4], voltage-gated potassium channel antibodies [n = 1] and antibodies against uncharacterised antigen [n = 1]). Five received immunotherapy, which prompted resolution of psychosis in four.
A small subgroup of patients admitted to hospital with FEP have antineuronal antibodies detectable in serum and are responsive to immunotherapy. Early diagnosis and treatment is critical to optimise recovery.