Antimicrobial resistance in food-borne pathogens at the human-animal interface: Results from a large surveillance study in India.

Background: The burden of foodborne diseases and antimicrobial resistance carried by key foodborne pathogens in India is unknown due to a lack of an integrated surveillance system at the human-animal interface. Methods: We present data from the WHO-AGISAR (Advisory Group on Integrated Surveillance of Antimicrobial Resistance), India project. Concurrent human and animal sampling was done across a large area across north India. Community-acquired diarrhea cases (n = 1968) of all age groups were included. Cross-sectional sampling of stool/ intestinal contents (n = 487) and meat samples (n = 419) from food-producing animals was done at farms, retail shops, and slaughterhouses. Pathogens were cultured and identified, and antimicrobial susceptibility was performed. Results: Over 80% of diarrhoeal samples were obtained from moderate to severe diarrhea patients, which yielded EAEC (5%), ETEC (4.84%), EPEC (4.32%), and Campylobacter spp. (2%). A high carriage of EPEC (32.11%) and Campylobacter spp. (24.72%) was noted in food animals, but the prevalence of ETEC (2%) and EAEC (1%) was low. Atypical EPEC (aEPEC, 84.52%, p ≤0.0001) were predominant and caused milder diarrhea. All EPEC from animal/poultry were aEPEC. Overall, a very high level of resistance was observed, and the MDR rate ranged from 29.2% in Campylobacter spp., 53.6% in EPEC, and 59.8% in ETEC. Resistance to piperacillin-tazobactam, cefepime, ceftriaxone, and co-trimoxazole was significantly higher in human strains. In contrast, resistance to ciprofloxacin, aminoglycosides, and tetracycline was higher in animal strains, reflecting the corresponding usage in human and animal sectors. ESBL production was commoner in animal isolates than in humans, indicating high use of third-generation cephalosporins in the animal sector. C. hyointestinalis is an emerging zoonotic pathogen, first time reported from India. Conclusion: In one of the most extensive studies from India, a high burden of key foodborne pathogens with MDR and ESBL phenotypes was found in livestock, poultry, and retail meat.

Comparative analysis of virulence determinants, phylogroups, and antibiotic susceptibility patterns of typical versus atypical Enteroaggregative E. coli in India.

Enteroaggregative Escherichia coli (EAEC) is an evolving enteric pathogen that causes acute and chronic diarrhea in developed and industrialized nations in children. EAEC epidemiology and the importance of atypical EAEC (aEAEC) isolation in childhood diarrhea are not well documented in the Indian setting. A comparative analysis was undertaken to evaluate virulence, phylogeny, and antibiotic sensitivity among typical tEAEC versus aEAEC. A total of 171 EAEC isolates were extracted from a broad surveillance sample of diarrheal (N = 1210) and healthy children (N = 550) across North India. Polymerase chain reaction (PCR) for the aggR gene (master regulator gene) was conducted to differentiate tEAEC and aEAEC. For 21 virulence genes, we used multiplex PCR to classify possible virulence factors among these strains. Phylogenetic classes were identified by a multiplex PCR for chuA, yjaA, and a cryptic DNA fragment, TspE4C2. Antibiotic susceptibility was conducted by the disc diffusion method as per CLSI guidelines. EAEC was associated with moderate to severe diarrhea in children. The prevalence of EAEC infection (11.4%) was higher than any other DEC group (p = 0.002). tEAEC occurrence in the diarrheal group was higher than in the control group (p = 0.0001). tEAEC strain harbored more virulence genes than aEAEC. astA, aap, and aggR genes were most frequently found in the EAEC from the diarrheal population. Within tEAEC, this gene combination was present in more than 50% of strains. Also, 75.8% of EAEC strains were multidrug-resistant (MDR). Phylogroup D (43.9%) and B1 (39.4%) were most prevalent in the diarrheal and control group, respectively. Genetic analysis revealed EAEC variability; the comparison of tEAEC and aEAEC allowed us to better understand the EAEC virulence repertoire. Further microbiological and epidemiological research is required to examine the pathogenicity of not only typical but also atypical EAEC.

Prospective case series on the use of peripheral nerve stimulation for focal mononeuropathy treatment.

Aim: This case series looks at outcomes in 39 patients implanted using the Bioness Stimrouter system on various isolated mononeuropathies. Patients & methods: A case series of 39 patients with a total of 42 implants were enrolled starting August 2017 at various pain management centers. Results: Of 39 patients studied, 78% of the participants noticed an improvement in their pain. There was a 71% reduction in pain scores with the average preprocedure score of 8 improving to 2 post-implant. Participants noted on average a 72% improvement in activity with the greatest observed in the brachial plexus (80%) and suprascapular nerve (80%) and smallest in the intercostal nerve (40%). Approximately 89% of those implanted with a peripheral nerve stimulator experienced a greater than 50% reduction in opioid consumption. Conclusion: Peripheral nerve stimulators are a new, minimally invasive neuromodulation modality that shows promising early results in our 39-patient case series.

First Year Medical Student Peer Nominations of Professionalism: A Methodological Detective Story about Making Sense of Non-Sense.

This article explores the assessment of professionalism within a cohort of medical students during a sequential 13-week medical school histology and anatomy course. Across seven data points, students were asked to identify a professionalism role model from amongst their peers and to score Likert-structured rationales for their decision. Based on density scores, an initial social network analysis identified six peer-nomination "stars." However, analysis of these stars revealed considerable variability and random-like "noise" in both the nomination and explanation data sets. Subsequent analyses of both data sets explored the possibility of underlying patterns in this noise using tests of reliability, principal components factor analysis, and fixed-effects regression analysis. These explorations revealed the presence of two dimensions (professional vs. supportive) in how students sought to explain their nomination decisions. Although data variability remained quite high, significantly less variability was present in the professional than in the supportive dimension, suggesting that academic helpfulness rationales are both empirically distinct and more mutable than rationales grounded in professionalism-related factors. In addition, data showed that the greater the stability in one's choice of a professionalism role model nomination over the T1-T7 data periods, the more stable one's reasons for that nomination-both for professionalism and supportive dimensions. Results indicate that while peer assessment of professionalism by first-year medical students may not be very reliable, students can differentiate between more personal and professional factors, even at this early stage in their professional development. Formal instruction within the pre-clinical curriculum should recognize and address this distinction. Anat Sci Educ. © 2018 American Association of Anatomists.

Using Serial Hemoglobin Levels to Detect Occult Blood Loss in the Early Evaluation of Blunt Trauma Patients.

BACKGROUND: Serial hemoglobin measurement (ΔHgb) is intended to aid in the early identification of blunt trauma patients who have significant blood loss requiring intervention. However, the utility of ΔHgb has yet to be rigorously studied. OBJECTIVE: We sought to determine if ΔHgb is a reliable diagnostic tool in assessing blood loss in blunt trauma patients. METHODS: We enrolled consecutive blunt trauma patients ≥18 years of age who presented to a level I trauma center. We measured 2 hemoglobin levels spaced 5 min apart and calculated the difference (ΔHgb) for each patient. We also recorded whether each patient required any of the following interventions to treat their injuries: 1) operation or procedure to control hemorrhage; 2) radiographic embolization; 3) administration of blood and blood products; 4) administration of ≥3 liters of intravenous fluids; and 5) exsanguination. Our primary outcome was the area under the receiver operating characteristic (ROC) curve. RESULTS: We enrolled 251 patients, including 192 males and 59 females with a mean age of 40 years. Interventions occurred in 56 patients and were withheld in 195. The median ΔHgb was -0.1 gm/dL (interquartile range -0.5 to 0.1 gm/dL) for patients requiring intervention and 0.0 gm/dL (interquartile range -0.6 to 0.3 gm/dL) for patients not requiring intervention. We found the area under the ROC curve to be 0.53 (95% confidence interval 0.44-0.62). CONCLUSIONS: Our results indicated that ΔHgb does not reliably distinguish between blunt trauma patients who require intervention and those who do not.

Safety of Uninterrupted Warfarin Therapy in Patients Undergoing Cardiovascular Endovascular Procedures: A Systematic Review and Meta-Analysis.

PURPOSE: To conduct a systematic review and meta-analysis of complication rates and outcomes in patients undergoing endovascular procedures who receive uninterrupted versus interrupted warfarin therapy. MATERIALS AND METHODS: Literature published between 1990 and 2014 was searched for reports of comparative studies of vascular procedures. Information on periprocedural complications and patient deaths less than 30 days after the procedure was extracted. A random effects model was used and odds ratios (ORs) were reported. An OR of less than 1 was considered to indicate lower risk of the outcome with uninterrupted warfarin therapy. Meta-analysis was conducted by using meta-analysis software. RESULTS: A total of 27 studies of 20,376 patients were included. For arterial procedures, there were no significant differences between the uninterrupted and interrupted warfarin therapy groups in access site hematoma (OR, 0.59; 95% confidence interval [CI]: 0.33, 1.03; P = .06), any bleeding complications (OR, 0.56; 95% CI: 0.30, 1.06; P = .07), mortality (OR, 1.40; 95% CI: 0.37, 5.25; P = .62), intracranial hemorrhage (OR, 0.55; 95% CI: 0.03, 8.91; P = .68), ischemic stroke (OR, 0.85; 95% CI: 0.12, 5.84; P = .87), and major bleeding (OR, 0.56; 95% CI: 0.21, 1.51; P = .25). For venous procedures, uninterrupted warfarin was associated with lower odds of access site hematoma (OR, 0.70; 95% CI: 0.50, 0.99; P = .04), any bleeding complications (OR, 0.61; 95% CI: 0.48, 0.77; P < .01), ischemic stroke (OR, 0.21; 95% CI: 0.10, 0.45; P < .01), and major bleeding (OR, 0.64; 95% CI: 0.51, 0.80; P < .01). For arterial and venous procedures combined, uninterrupted warfarin was associated with lower odds of access site hematoma (OR, 0.68; 95% CI: 0.51, 0.91; P = .01), bleeding complications (OR, 0.59; 95% CI: 0.48, 0.74; P < .01), ischemic stroke (OR, 0.25; 95% CI: 0.12, 0.50; P < .01), and major bleeding (OR, 0.61; 95% CI: 0.49, 0.77; P < .01). Heterogeneity in most analyses was low, and confidence in the estimates was moderate. CONCLUSION: Uninterrupted perioperative warfarin therapy is safe for patients undergoing arterial procedures, but interrupted warfarin may be preferred for those undergoing venous procedures; no differences in outcome rates were found in the randomized controlled trials. Future studies should be performed to validate these results.

Cancer caregiver quality of life: need for targeted intervention.

OBJECTIVES: Caregiving can negatively impact well-being. Cancer caregivers face unique challenges given the intense nature of cancer and treatment, which increases their risk for burden, poor quality of life (QOL), and burnout. Studies to reduce caregiver burden demonstrate QOL improvement and distress reduction in the short term. However, few studies exist to address long-term benefits. We assessed changes in various QOL domains after participation in a QOL intervention for caregivers of patients having newly diagnosed advanced cancer. METHODS: Our institutional review board-approved study randomized patient-caregiver dyads to either usual care or an in-person group intervention composed of six 90-min sessions of structured multidisciplinary QOL components delivered over 4 weeks, with 10 follow-up phone calls within 20 weeks. Caregivers attended four of the six sessions attended by patients. Sessions included physical therapy, coping and communication strategies, mental health education, spirituality, and social needs. Caregiver QOL (Caregiver Quality of Life Index-Cancer Scale [CQOLC] and Linear Analogue Self-Assessment [LASA]) and mood (Profile of Mood States-Brief [POMS-B]) were measured at baseline and 4, 27, and 52 weeks. Wilcoxon tests and effect sizes were used to compare the caregiver groups. RESULTS: Of the 131 caregivers (65 intervention and 66 usual care), 116 completed the study. Caregivers post-intervention (at 4 weeks) had improved scores on LASA Spiritual Well-being; POMS-B total score, Vigor/Activity, and Fatigue/Inertia; and CQOLC Adaptation. At long term (at 27 weeks), caregivers retained improvement in POMS-B Fatigue/Inertia and gained improvements in CQOLC Disruptiveness and Financial Concerns. CONCLUSIONS: Caregivers who received the intervention had higher QOL ratings for specific QOL domains but not for overall QOL. Although a comprehensive intervention was helpful, more specific, targeted interventions tailored for individual needs are recommended. Copyright © 2015 John Wiley & Sons, Ltd.

Vasospasm Is a Consistent Finding in Pernio (Chilblains) and a Possible Clue to Pathogenesis.

BACKGROUND/AIMS: Pernio (chilblains) is an inflammatory condition classically characterized by localized erythema and swelling of acral sites upon exposure to cool and damp conditions. We sought to determine whether cold-induced vasospasm has a role in the development of pernio. METHODS: We retrospectively reviewed 5 patients with pernio who were seen at our institution between January 1, 2000 and December 31, 2011, and had undergone a noninvasive arterial vascular study of the upper extremities that corresponded to a site of clinical involvement of pernio and who had also undergone vasospastic testing and ice water immersion as part of the noninvasive arterial vascular study protocol. RESULTS: Vascular testing in all patients (mean age 37.8 years; 4 women) demonstrated vasospasm with ice water immersion. CONCLUSION: Our findings suggest that vasospasm likely has a role in the pathophysiology of pernio and may also provide a rationale for the pharmacological treatment of vasospasm in patients with pernio.

Trends in CT Utilization for Pediatric Fall Patients in US Emergency Departments.

RATIONALE AND OBJECTIVES: Falls are a common cause of emergency department (ED) visits in the United States. We evaluated trends in computed tomography (CT) utilization for pediatric fall victims in the United States from 2001 to 2010. MATERIALS AND METHODS: Using the National Hospital Ambulatory Medical Care Survey from 2001 to 2010, we identified all visits of pediatric (aged <18 years) patients presenting to EDs after falls. This database surveys approximately 500 EDs per year for 4 weeks providing national estimates on ED resource utilization and outcomes. We studied trends in CT utilization and proportion of visits with life-threatening conditions after falls. We also studied the association between CT utilization rates and demographic characteristics and admission status. RESULTS: A total of 9763 unweighted observations for a total of 32,432,686 pediatric fall patients were seen in US EDs from 2001 to 2010. The proportion of pediatric fall patients receiving CT increased from 5.3% in 2001 to a peak of 16.6% in 2009 and decreased to 11.3% in 2010, whereas the proportion of pediatric fall patients with life-threatening conditions fluctuated between 1.2% and 3.3% during this period. In multivariate logistic regression analysis, each increasing year was independently associated with CT utilization (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.14-1.16). Patients aged 0-1 years had higher odds of CT utilization than patients aged 13-17 years (OR, 2.27; 95% CI, 2.26-2.27). CONCLUSIONS: There was a twofold increase in CT utilization among pediatric fall visits from 2001 to 2010. When controlling for demographic and clinical variables, increasing year was independently associated with CT utilization. These findings suggest that CT may be overutilized among pediatric fall patients.

Pyoderma gangrenosum associated with solid organ malignancies.

BACKGROUND: Pyoderma gangrenosum (PG) can be associated with systemic diseases, including inflammatory bowel disease, inflammatory arthritis, and hematologic malignancy. Previous literature exploring the rare association between PG and solid organ malignancy is predominantly limited to single case reports. METHODS: We retrospectively reviewed the cases of five patients with PG and solid organ malignancies at our institution between 1996 and 2013. RESULTS: For the five patients identified, PG and solid organ malignancy occurred within three months of each other. Mean age at onset of PG was 55.6 years, and four patients were women. Three patients had breast carcinoma (one was recurrent), and two had gastrointestinal carcinoma. PG occurred before (n = 2), after (n = 2), or synchronously with (n = 1) the malignancy. In one patient with a history of PG and quiescent inflammatory bowel disease, recurrent PG developed synchronously with a new diagnosis of metastatic rectosigmoid carcinoma. Three patients had partial or complete response of PG with treatment of PG alone. CONCLUSIONS: To our knowledge, our study is the first to report that the onset of PG can herald a recurrence of a solid organ malignancy and that recurrent PG can be associated with solid organ malignancy. A possible association of solid organ malignancy and PG should be considered in patients with PG of unknown etiology or with a history of malignancy.

Prevalence of hidradenitis suppurativa: a population-based study in Olmsted County, Minnesota.

BACKGROUND: Hidradenitis suppurativa (HS) is a follicular occlusion disorder occurring in apocrine-rich regions of the skin. Estimates of the prevalence of this disorder have not been population-based. OBJECTIVE: We sought to provide population-based information on the prevalence of HS in Olmsted County, Minnesota, as of January 1, 2009. METHODS: The Rochester Epidemiology Project, a unique infrastructure that combines and makes accessible all medical records in Olmsted County since the 1960s, was used to collect population-based data on the prevalence of HS. RESULTS: We identified 178 confirmed cases of HS that included 135 females and 43 males, and estimated the total sex- and age-adjusted prevalence in Olmsted County to be 127.8 per 100,000 or 0.13%. The total prevalence was significantly higher among women than men. CONCLUSION: This study represents the first population-based investigation on the prevalence of HS. In this population-based cohort, HS was less prevalent than suggested by previous reports.

Do age and quality of life of patients with cancer influence quality of life of the caregiver?

OBJECTIVE: There are significant burdens associated with providing care for loved ones with cancer. However, caregiver quality of life (QOL) is often overlooked. With the increasing number of older adults with cancer, it is important to determine whether a patient's age and QOL have any association with the caregiver's QOL. The objective of our study was to describe caregiver QOL and explore whether patient age and other psychosocial factors impact caregiver QOL. MATERIALS AND METHODS: Baseline information from patients with advanced cancer undergoing radiation and their caregivers, who were enrolled in a randomized, controlled clinical trial to test the effectiveness of a structured, multidisciplinary QOL intervention, was analyzed for this study. Caregivers completed the Caregiver Quality of Life Index-Cancer (CQOLC) Scale. Both patients and caregivers completed the Linear Analogue Self-Assessment (LASA) to measure QOL, and Profile of Mood States (POMS) to measure mood states. RESULTS: Overall, 131 patient-caregiver pairs participated in the study. At baseline, caregivers of older adults (≥65years) had higher mental (P=0.01), emotional (P=0.003), spiritual (P<0.01), and social support (P=0.03) LASA QOL scores. Caregivers of older adults also had higher baseline QOL (CQOLC, P=0.003) and mood (POMS, P=0.04) than caregivers of younger adults. Caregivers of patients with higher LASA QOL scores had higher overall (P=0.02), mental (P=0.006), physical (P=0.02), emotional (P=0.002), and spiritual LASA QOL scores (P=0.047). CONCLUSIONS: Caregivers of older adults with advanced cancer demonstrated better QOL and fewer mood disturbances compared to caregivers of younger patients. When patients have good QOL, caregivers also had good QOL.