Identifying patients at increased risk of non-ventilator-associated pneumonia on admission to hospital: a pragmatic prognostic screening tool to trigger preventative action.

BACKGROUND: Non-ventilator healthcare-associated pneumonia (NV-HAP) is an important healthcare-associated infection. This study tested the feasibility of using routine admission data to identify those patients at high risk of NV-HAP who could benefit from targeted, preventive interventions. METHODS: Patients aged ≥64 years who developed NV-HAP five days or more after admission to elderly-care wards, were identified by retrospective case note review together with matched controls. Data on potential predictors of NV-HAP were captured from admission records. Multi-variate analysis was used to build a prognostic screening tool (PRHAPs); acceptability and feasibility of the tool was evaluated. RESULTS: A total of 382 cases/381 control patients were included in the analysis. Ten predictors were included in the final model; nine increased the risk of NV-HAP (OR between 1.68 and 2.42) and one (independent mobility) was protective (OR 0.48; 95% CI 0.30-0.75). The model correctly predicted 68% of the patients with and without NV-HAP; sensitivity 77%; specificity 61%. The PRHAPs tool risk score was 60% or more if two predictors were present and over 70% if three were present. An expert consensus group supported incorporating the PRHAPs tool into electronic logic systems as an efficient mechanism to identify patients at risk of NV-HAP and target preventative strategies. CONCLUSIONS: This prognostic screening (PRHAPs) tool, applied to data routinely collected when a patient is admitted to hospital, could enable staff to identify patients at greatest risk of NV-HAP, target scarce resources in implementing a prevention care bundle, and reduce the use of antimicrobial agents.

Undue burden: Black faculty, COVID-19, and the racial justice movement.

A crucial reckoning was initiated when the COVID-19 pandemic began to expose and intensify long-standing racial/ethnic health inequities, all while various sectors of society pursued racial justice reform. As a result, there has been a contextual shift towards broader recognition of systemic racism, and not race, as the shared foundational driver of both societal maladies. This confluence of issues is of particular relevance to Black populations disproportionately affected by the pandemic and racial injustice. In response, institutions have initiated diversity, equity, and inclusion (DEI) efforts as a way forward. This article considers how the dual pandemic climate of COVID-19-related health inequities and the racial justice movement could exacerbate the "time and effort tax" on Black faculty to engage in DEI efforts in academia and biomedicine. We discuss the impact of this "tax" on career advancement and well-being, and introduce an operational framework for considering the interconnected influence of systemic racism, the dual pandemics, and DEI work on the experience of Black faculty. If not meaningfully addressed, the "time and effort tax" could contribute to Black and other underrepresented minority faculty leaving academia and biomedicine - consequently, the very diversity, equity, and inclusion work meant to increase representation could decrease it.

Cutaneous ulcerative lesions of unknown etiology affecting lionfish Pterois spp. in the Gulf of Mexico.

OBJECTIVE: Cutaneous ulcerative skin lesions in a complex of invasive Gulf of Mexico lionfish (Red Lionfish Pterois volitans, Devil Firefish P. miles, and the hybrid Red Lionfish × Devil Firefish) became epizootic beginning in mid-August 2017. Herein, we provide the first pathological descriptions of these lesions and summarize our analyses to elucidate the etiology of the disease. METHODS: We examined ulcerated and normal fish through gross pathology and histopathology, bacterial sampling, and unbiased metagenomic next-generation sequencing. We tracked prevalence of the disease, and we used biological health indicators (condition factor, splenosomatic and hepatosomatic index) to evaluate impacts to health, while considering sex and age as potential risk factors. RESULT: Typical ulcerative lesions were deep, exposing skeletal muscle, and were bordered by pale or reddened areas often with some degree of scale loss. Only incidental parasites were found in our examinations. Most fish (86%; n = 50) exhibited wound healing grossly and histologically, confirmed by the presence of granulation tissues. A primary bacterial pathogen was not evident through bacterial culture or histopathology. Metagenomic next-generation sequencing did not reveal a viral pathogen (DNA or RNA) but did provide information about the microbiome of some ulcerated specimens. Compared with clinically healthy fish, ulcerated fish had a significantly lower condition factor and a higher splenosomatic index. Disease prevalence at monitored sites through July 2021 indicated that ulcerated fish were still present but at substantially lower prevalence than observed in 2017. CONCLUSION: Although some common findings in a number of specimens suggest a potential role for opportunistic bacteria, collectively our suite of diagnostics and analyses did not reveal an intralesional infectious agent, and we must consider the possibility that there was no communicable pathogen.

COVID-19 in patients with and without cancer: Examining differences in patient characteristics and outcomes.

This study examines differences between patients with and without cancer in patient demographic and clinical characteristics and COVID-19 mortality and discusses the implications of these differences in relation to existing cancer disparities and COVID-19 vulnerabilities. Data was collected as a part of a retrospective study on a cohort of COVID-19 positive patients across Mount Sinai Health System from March 28, 2020 to April 26, 2020. Descriptive, comparative, and regression analyses were applied to examine differences between patients with and without cancer in demographic and clinical characteristics and COVID-19 mortality and whether cancer status predicts COVID-19 mortality controlling for these covariates using SAS 9.4. Results showed that, of 4641 patients who tested positive for COVID-19, 5.1% (N=236) had cancer. The median age of the total sample was 58 years (Q1-Q3: 41-71); 55.3% were male, 19.2% were current/former smokers, 6.1% were obese. The most commonly reported comorbidities were hypertension (22.6%) and diabetes (16.0%). Overall, the COVID-19 mortality rate was 8.3%. Examining differences between COVID-19 patients with and without cancer revealed significant differences (p<0.05) in COVID-19 mortality, hospitalization rates, age, gender, race, smoking status, obesity, and comorbidity indicators (e.g., diabetes) with cancer patients more likely to be older, male, black, obese, smokers, and with existing comorbidities. Controlling for these clinical, demographic, and behavioral characteristics, results of logistic regression analyses showed significant effects of older age and male gender on COVID-19 mortality (p<0.05). While cancer patients with COVID-19 were more likely to experience worse COVID-19 outcomes, these associations might be related to common cancer and COVID-19 vulnerability factors such as older age and gender. The coexistence of these vulnerability age and gender factors in both cancer and COVID-19 populations emphasizes the need for better understanding of their implications for cancer and COVID-19 disparities, both diseases prevention efforts, policies, and clinical management.

Dealing With the Unthinkable: Bladder and Colorectal Cancer Patients' and Informal Caregivers' Unmet Needs and Challenges in Life After Ostomies.

OBJECTIVES: We examined patient and informal caregiver unmet needs to identify areas for targeted supportive care interventions and programs to enhance both patient and informal caregiver experience. DATA SOURCES: A total of 30 patients who underwent ostomy surgeries for bladder or colorectal cancers and 13 informal caregivers participated in the study. Patients were enrolled at the Icahn School of Medicine at Mount Sinai between 2017 and 2018. Qualitative data were collected by individual interviews, audiotaped, and transcribed verbatim. Transcribed data were iteratively analyzed using Atlas.ti to explore patient and caregiver unmet needs. RESULTS: Patients and informal caregivers reported having insufficient psychological preparation for ostomy surgeries, and very limited hands-on training on stoma care and utility of stomal appliances. Unmet psychological needs related to depression, anxiety, and distress caused by changes in body image and sexual, urinary, and bowel function were reported. Patients and caregivers also reported significant patient medical needs in the acute postoperative period including pain, fatigue, sleep disturbance, inflammation, and complications resulting in hospital readmissions. Colorectal cancer patients specifically experienced significant challenges with changes in diet and nutrition that contributed to ostomy care burden. Both patients and caregivers recommended seeking psychological and social support to enhance both patient and caregiver emotional adjustment to life after ostomies. CONCLUSION: Meeting patient and informal caregiver unmet informational and supportive care needs is imperative to improve their quality of life and adjustment. IMPLICATIONS FOR NURSING PRACTICE: An effective supportive care plan should be designed and utilized in clinical care to improve ostomy patients' and caregivers' outcomes.

Identifying Distinct High Unmet-Need Phenotypes and Their Associated Bladder Cancer Patient Demographic, Clinical, Psychosocial, and Functional Characteristics: Results of Two Clustering Methods.

OBJECTIVES: We explored phenotypes of high unmet need of patients with bladder cancer and their associated patient demographic, clinical, psychosocial, and functional characteristics. DATA SOURCES: Patients (N=159) were recruited from the Bladder Cancer Advocacy Network and completed an online survey measuring unmet needs (BCNAS-32), quality of life (FACT-Bl), anxiety and depression (HADS), coping (BRIEF Cope), social support (SPS), and self-efficacy beliefs (GSE). Hierarchical agglomerative (HA) and partitioning clustering (PC) analyses were used to identify and confirm high unmet-need phenotypes and their associated patient characteristics. Results showed a two-cluster solution; a cluster of patients with high unmet needs (17% and 34%, respectively) and a cluster of patients with low-moderate unmet needs (83% and 66%, respectively). These two methods showed moderate agreement (κ=0.57) and no significant differences in patient demographic and clinical characteristics between the two groups. However, the high-need group identified by the HA clustering method had significantly higher psychological (81 vs 66, p < .05), health system (93 vs 74, p < .001), daily living (93 vs 74, P < .001), sexuality (97 vs 69, P < .001), logistics (84 vs 69, P < .001), and communication (90 vs 76, P < .001) needs. This group also had worse quality of life and emotional adjustment and lower personal and social resources (P < .001) compared with the group identified by the PC method. CONCLUSION: A significant proportion of patients with bladder cancer continues to have high unique but inter-related phenotypes of needs based on the HA clustering method. IMPLICATIONS FOR NURSING PRACTICE: Identifying characteristics of the most vulnerable patients will help tailor support programs to assist these patients with their unmet needs.

Testing the efficacy of lionfish traps in the northern Gulf of Mexico.

Spearfishing is currently the primary approach for removing invasive lionfish (Pterois volitans/miles) to mitigate their impacts on western Atlantic marine ecosystems, but a substantial portion of lionfish spawning biomass is beyond the depth limits of SCUBA divers. Innovative technologies may offer a means to target deepwater populations and allow for the development of a lionfish trap fishery, but the removal efficiency and potential environmental impacts of lionfish traps have not been evaluated. We tested a collapsible, non-containment trap (the 'Gittings trap') near artificial reefs in the northern Gulf of Mexico. A total of 327 lionfish and 28 native fish (four were species protected with regulations) recruited (i.e., were observed within the trap footprint at the time of retrieval) to traps during 82 trap sets, catching 144 lionfish and 29 native fish (one more than recruited, indicating detection error). Lionfish recruitment was highest for single (versus paired) traps deployed <15 m from reefs with a 1-day soak time, for which mean lionfish and native fish recruitment per trap were approximately 5 and 0.1, respectively. Lionfish from traps were an average of 19 mm or 62 grams larger than those caught spearfishing. Community impacts from Gittings traps appeared minimal given that recruitment rates were >10X higher for lionfish than native fishes and that traps did not move on the bottom during two major storm events, although further testing will be necessary to test trap movement with surface floats. Additional research should also focus on design and operational modifications to improve Gittings trap deployment success (68% successfully opened on the seabed) and reduce lionfish escapement (56% escaped from traps upon retrieval). While removal efficiency for lionfish demonstrated by traps (12-24%) was far below that of spearfishing, Gittings traps appear suitable for future development and testing on deepwater natural reefs, which constitute >90% of the region's reef habitat.

Precipitous Declines in Northern Gulf of Mexico Invasive Lionfish Populations Following the Emergence of an Ulcerative Skin Disease.

Invasive Indo-Pacific lionfish Pterois volitans/miles have become well-established in many western Atlantic marine habitats and regions. However, high densities and low genetic diversity could make their populations susceptible to disease. We examined changes in northern Gulf of Mexico (nGOM) lionfish populations following the emergence of an ulcerative skin disease in August 2017, when estimated disease prevalence was as high as 40%. Ulcerated female lionfish had 9% lower relative condition compared to non-ulcerated females. Changes in lionfish size composition indicated a potential recruitment failure in early summer 2018, when the proportion of new recruits declined by >80%. Remotely operated vehicle surveys during 2016-2018 indicated lionfish population density declined in 2018 by 75% on natural reefs. The strongest declines (77-79%) in lionfish density were on high-density (>25 lionfish per 100 m2) artificial reefs, which declined to similar levels as low-density (<15 lionfish per 100 m2) artificial reefs that had prior lionfish removals. Fisheries-dependent sampling indicated lionfish commercial spearfishing landings, commercial catch per unit effort (CPUE), and lionfish tournament CPUE also declined approximately 50% in 2018. Collectively, these results provide correlative evidence for density-dependent epizootic population control, have implications for managing lionfish and impacted native species, and improve our understanding of biological invasions.

Cellular Uptake and Efflux of Palbociclib In Vitro in Single Cell and Spheroid Models.

Adequate drug distribution through tumors is essential for treatment to be effective. Palbociclib is a cyclin-dependent kinase 4/6 inhibitor approved for use in patients with hormone receptor positive, human epidermal growth factor receptor 2 negative metastatic breast cancer. It has unusual physicochemical properties, which may significantly influence its distribution in tumor tissue. We studied the penetration and distribution of palbociclib in vitro, including the use of multicellular three-dimensional models and mathematical modeling. MCF-7 and DLD-1 cell lines were grown as single cell suspensions (SCS) and spheroids; palbociclib uptake and efflux were studied using liquid chromatography-tandem mass spectrometry. Intracellular concentrations of palbociclib for MCF-7 SCS (C max 3.22 µM) and spheroids (C max 2.91 µM) were 32- and 29-fold higher and in DLD-1, 13- and 7-fold higher, respectively, than the media concentration (0.1 µM). Total palbociclib uptake was lower in DLD-1 cells than MCF-7 cells in both SCS and spheroids. Both uptake and efflux of palbociclib were slower in spheroids than SCS. These data were used to develop a mathematical model of palbociclib transport that quantifies key parameters determining drug penetration and distribution. The model reproduced qualitatively most features of the experimental data and distinguished between SCS and spheroids, providing additional support for hypotheses derived from the experimental data. Mathematical modeling has the potential for translating in vitro data into clinically relevant estimates of tumor drug concentrations. SIGNIFICANCE STATEMENT: This study explores palbociclib uptake and efflux in single cell suspension and spheroid models of cancer. Large intracellular concentrations of palbociclib are found after drug exposure. The data from this study may aid understanding of the intratumoural pharmacokinetics of palbociclib, which is useful in understanding how drug distributes within tumor tissue and optimizing drug efficacy. Biomathematical modelling has the potential to derive intratumoural drug concentrations from plasma pharmacokinetics in patients.

Effect of using fidaxomicin on recurrent Clostridium difficile infection.

Fidaxomicin is a macrocyclic antibiotic licensed for treating Clostridium difficile infection (CDI). In the UK, fidaxomicin is often reserved for severe CDI or recurrences. At Queen Elizabeth Hospital Birmingham, all courses of fidaxomicin during 2017/2018 were reviewed. Thirty-eight patients received fidaxomicin, of which 64% responded to treatment when fidaxomicin was given during the first episode of mild CDI. Conversely, all patients with recurrent CDI failed treatment with fidaxomicin. There were mixed results for the use of fidaxomicin for severe CDI, with only 42% of patients responding. These results suggest that fidaxomicin is best suited as a treatment for mild CDI during a patient's first episode.

Tap out: reducing waterborne Pseudomonas aeruginosa transmission in an intensive care unit.

BACKGROUND: Pseudomonas aeruginosa is a ubiquitous and important opportunistic pathogen in immunocompromised or critically ill patients. Nosocomial P. aeruginosa outbreaks have been associated with hospital water sources. AIM: To describe engineering interventions to minimize contamination of water outlets and the subsequent clinical impact. METHODS: New tap outlets were fitted at selected outlets across the intensive care unit (ICU). Laboratory testing demonstrated that, following artificial contamination with P. aeruginosa, these taps could be effectively decontaminated using a thermal washer-disinfector. Water samples were collected weekly from new outlets on the ICU over an eight-month period and tested for the enumeration of P. aeruginosa via membrane filtration. Surveillance of P. aeruginosa from clinical specimens was routinely undertaken. FINDINGS: Prior to the interventions, water sampling on ICU indicated that 30% of the outlets were positive for P. aeruginosa at any one time, and whole genome sequencing data suggested at least 30% transmission from water to patient. Since their installation, weekly sampling of the new tap outlets has been negative for P. aeruginosa, and the number of P. aeruginosa clinical isolates has fallen by 50%. CONCLUSION: Installation and maintenance of tap outlets free of P. aeruginosa can substantially reduce the number of P. aeruginosa clinical isolates in an ICU.

Unmasking leading to a healthcare worker Mycobacterium tuberculosis transmission.

BACKGROUND: Mycobacterium tuberculosis is a major health burden worldwide. The disease may present as an individual case, community outbreak, or more rarely as a nosocomial outbreak. Even in countries with a low prevalence such as the UK, tuberculosis (TB) presents a risk to healthcare workers (HCWs). AIM: To report an outbreak which manifested 12 months after a patient with pulmonary tuberculosis was admitted to Queen Elizabeth Hospital Birmingham. METHODS: We present the epidemiological and outbreak investigations; the role of whole genome sequencing (WGS) in identifying the outbreak and control measures to prevent further outbreaks. FINDINGS: Subsequent to a diagnosis of open TB in a patient, transmission was confirmed in one HCW who had active TB; HCWs with latent TB infection (LTBI) were also identified among seven HCW contacts of the index patient. Of note, all the LBTI patients had other risk factors for TB. Routine use of WGS identified the outbreak link between the index patient and the HCW with active TB disease, and informed our investigations. CONCLUSION: Exposure most likely occurred during an aerosol-generating procedure (AGP) which was done in accordance with national guidance at that time without using respiratory protection. Enhanced control measures were implemented following the outbreak.

Zika and Public Health: Understanding the Epidemiology and Information Environment.

Because Zika is a newly emerging infectious disease with little previous information known about it, there are many epidemiologic and clinical questions. The complexity of providing care to those who are at risk for infection or are already infected with Zika in this evidence-scarce environment cannot be understated. In this article, we provide an overview of the Zika virus (ZIKV) in the context of public health and pediatric health care. A broad public health focus is used to provide relevant information for addressing important questions about the epidemic and to facilitate communication with patients, parents, and caregivers within the current information environment. We explore issues regarding the epidemiology of the virus (including why ZIKV outbreaks are occurring), what has changed since the sporadic case reports before the outbreaks, why the true incidence is difficult to estimate, why attack rates vary by population and geography, and why the association between Zika and congenital Zika syndrome and Guillain-Barré syndrome have only come to light recently. Additionally, challenges related to the current information environment, traditional and informal information sources about the ZIKV, and examples of Zika public health communication campaigns are discussed. Importantly, we review the existing findings regarding the US population's Zika-related knowledge, attitudes, beliefs, and behavior by highlighting variations and gaps. We conclude by identifying related research questions that remain critical.