Mycobacterium abscessus Meningitis Associated with Stem Cell Treatment During Medical Tourism.

Mycobacterium abscessus infections have been reported as adverse events related to medical tourism. We report M. abscessus meningitis in a patient who traveled from Colorado, USA, to Mexico to receive intrathecal stem cell injections as treatment for multiple sclerosis. We also review the management of this challenging central nervous system infection.

Remembering and Enhancing the Impact of Women in Infectious Diseases.

Following the establishment of the Infectious Diseases Society of America (IDSA), women played a minor role as IDSA leaders, awards recipients, and presenters at the national meeting. Since the formation of the IDSA Women's Committee in 1992, women have played an increasing role in all of these domains of the Society. Two subsequent IDSA task forces have emphasized the importance of women, and other unrepresented minorities, to the success of the core missions of the Society. Ongoing efforts to maintain the presence of women and their unique talents, experiences, and understandings in the Society will sustain the strengths of IDSA.

A Program to Support Scholarship During Internal Medicine Residency Training: Impact on Academic Productivity and Resident Experiences.

Problem: Although scholarship during residency training is an important requirement from the Accreditation Council for Graduate Medical Education, efforts to support resident scholarship have demonstrated inconsistent effects and have not comprehensively evaluated resident experiences. Intervention: We developed the Leadership and Discovery Program (LEAD) to facilitate scholarship among all non-research-track categorical internal medicine (IM) residents. This multifaceted program set expectations for all residents to participate in a scholarly project, supported faculty to manage the program, facilitated access to faculty mentors, established a local resident research day to highlight scholarship, and developed a didactic lecture series. Context: We implemented LEAD at a large university training program. We assessed resident scholarship before and after LEAD implementation using objective metrics of academic productivity (i.e., scientific presentations, peer-reviewed publications, and both presentations and publications). We compared these metrics in LEAD participants and a similar historical group of pre-LEAD controls. We also assessed these outcomes over the same two periods in research track residents who participated in research training independent from and predating LEAD (research track controls and pre-LEAD research track controls). We conducted focus groups to qualitatively assess resident experiences with LEAD. Outcome: Compared to 63 pre-LEAD controls, greater proportions of 52 LEAD participants completed scientific presentations (48.1% vs. 28.6%, p = .03) and scientific presentations and peer-reviewed publications (23.1% vs. 9.5%, p = .05). No significant differences existed for any academic productivity metrics among research track controls and pre-LEAD research track controls (p > .23, all comparisons). Perceived facilitators of participation in LEAD included residents' desire for research experiences and opportunities to publish prior to fellowship training; the main barrier to participation was feeling overwhelmed due to the time constraints imposed by clinical training. Suggestions for improvement included establishing clearer programmatic expectations and providing lists of potential mentors and projects. Lessons Learned: Implementation of a multifaceted program to support scholarship during residency was associated with significant increases in academic productivity among IM residents. Residents perceived that programs to support scholarship during residency training should outline clear expectations and identify available mentors and projects for residents who are challenged by the time constraints of clinical training.

The 50/50 Block Schedule: Impact on Residents' and Preceptors' Perceptions, Patient Outcomes, and Continuity of Care.

PROBLEM: Traditionally, internal medicine continuity clinic consists of a half day per week, regardless of rotation, which may create conflict with ongoing inpatient responsibilities. A 50/50 block schedule, which alternates inpatient and outpatient rotations and concentrates continuity clinic during outpatient rotations, minimizes conflicting responsibilities. However, its impact on patient care has not been widely studied. Continuity is a concern, and intervisit continuity in particular has not been evaluated. INTERVENTION: We implemented a 50/50 block model with "clinic buddy" system to optimize continuity and assessed outcomes pre- and postintervention. Residents alternated inpatient and elective blocks, with clinic 1 full day per week on elective blocks only. Resident and preceptor perceptions were measured using 5-point Likert surveys to evaluate impact on clinic experience and workload. The authors calculated visit and intervisit continuity using a Usual Provider of Care index and measured blood pressure and hemoglobin A1c as quality markers to evaluate the impact on continuity and quality of care. CONTEXT: Participants were 208 medicine residents and 39 core faculty members at 3 University of Pittsburgh Medical Center clinics. The intervention was implemented in June 2014. OUTCOME: In the 50/50 system, inpatient distractions decreased (3.59 vs. 1.71, p < .001). Residents more strongly agreed that there was adequate time for conferences (3.33 vs. 4.05), they worked well within the system to achieve best patient care (3.13 vs. 3.61), and multidisciplinary teams worked well together (3.51 vs. 4.08) (all p < .001). Intervisit continuity was unchanged (73%, both models, p = .79). Visit continuity decreased (67.2% vs. 63.7%, p < .001). Blood pressure and hemoglobin A1c were unchanged. LESSONS LEARNED: This 50/50 model minimized inpatient distractions in clinic and increased perceived time for learning. Residents reported improved sense of patient ownership, relations within the multidisciplinary team, and integration into the clinic system. Intervisit continuity was preserved, visit continuity was slightly decreased, and patient outcomes were not impacted in this model.

Hold-over admissions: are they educational for residents?

PURPOSE: Since implementation of resident duty-hour restrictions, many academic medical centers utilize night-float teams to admit patients during off hours. Patients are transferred to other resident physicians the subsequent morning as "hold-over admissions." Despite the increase of hold-over admissions, there are limited data on resident perceptions of their educational value. This study investigated resident perceptions of hold-over admissions, and whether they approach hold-over admissions differently than new admissions. METHOD: Survey of internal medicine residents at an academic medical center. RESULTS: A total of 111 residents responded with a response rate of 71 %. Residents reported spending 56.2 min (standard deviation [SD] 18.9) compared to 80.0 min (SD 25.8) admitting new patients (p < 0.01). Residents reported spending significantly (p < 0.01) less time reviewing the medical record, performing histories, examining patients, devising care plans and writing orders in hold-over admissions compared to new admissions. Residents had neutral views on the educational value of hold-over admissions. Features that significantly (p < 0.01) increased the educational value of admissions included severe illness, patient complexity, and being able to write the initial patient care orders. Residents estimated 42.5 % (SD 14) of their admissions were hold-over patients. CONCLUSIONS: Residents spend less time in all aspects of admitting hold-over patients. Despite less time spent admitting hold-over patients, residents had neutral views on the educational value of such admissions.

Cost-effectiveness of adjuvanted versus nonadjuvanted influenza vaccine in adult hemodialysis patients.

BACKGROUND: Currently more than 340,000 individuals are receiving long-term hemodialysis (HD) therapy for end-stage renal disease and therefore are particularly vulnerable to influenza, prone to more severe influenza outcomes, and less likely to achieve seroprotection from standard influenza vaccines. Influenza vaccine adjuvants, chemical or biologic compounds added to a vaccine to boost the elicited immunologic response, may help overcome this problem. STUDY DESIGN: Economic stochastic decision analytic simulation model. SETTING & PARTICIPANTS: US adult HD population. MODEL, PERSPECTIVE, & TIMEFRAME: The model simulated the decision to use either an adjuvanted or nonadjuvanted vaccine, assumed the societal perspective, and represented a single influenza season, or 1 year. INTERVENTION: Adjuvanted influenza vaccine at different adjuvant costs and efficacies. Sensitivity analyses explored the impact of varying influenza clinical attack rate, influenza hospitalization rate, and influenza-related mortality. OUTCOMES: Incremental cost-effectiveness ratio of adjuvanted influenza vaccine (vs nonadjuvanted) with effectiveness measured in quality-adjusted life-years. RESULTS: Adjuvanted influenza vaccine would be cost-effective (incremental cost-effectiveness ratio <$50,000/quality-adjusted life-year) at a $1 adjuvant cost (on top of the standard vaccine cost) when adjuvant efficacy (in overcoming the difference between influenza vaccine response in HD patients and healthy adults) ≥60% and economically dominant (provides both cost savings and health benefits) when the $1 adjuvant's efficacy is 100%. A $2 adjuvant would be cost-effective if adjuvant efficacy was 100%. LIMITATIONS: All models are simplifications of real life and cannot capture all possible factors and outcomes. CONCLUSIONS: Adjuvanted influenza vaccine with adjuvant cost ≤$2 could be a cost-effective strategy in a standard influenza season depending on the potency of the adjuvant.

Simulating school closure strategies to mitigate an influenza epidemic.

BACKGROUND: There remains substantial debate over the impact of school closure as a mitigation strategy during an influenza pandemic. The ongoing 2009 H1N1 influenza pandemic has provided an unparalleled opportunity to test interventions with the most up-to-date simulations. METHODS: To assist the Allegheny County Health Department during the 2009 H1N1 influenza pandemic, the University of Pittsburgh Models of Infectious Disease Agents Study group employed an agent-based computer simulation model (ABM) of Allegheny County, Pennsylvania, to explore the effects of various school closure strategies on mitigating influenza epidemics of different reproductive rates (R0). RESULTS: Entire school system closures were not more effective than individual school closures. Any type of school closure may need to be maintained throughout most of the epidemic (ie, at least 8 weeks) to have any significant effect on the overall serologic attack rate. In fact, relatively short school closures (ie, 2 weeks or less) may actually slightly increase the overall attack rate by returning susceptible students back into schools in the middle of the epidemic. Varying the illness threshold at which school closures are triggered did not seem to have substantial impact on the effectiveness of school closures, suggesting that short delays in closing schools should not cause concern. CONCLUSIONS: School closures alone may not be able to quell an epidemic but, when maintained for at least 8 weeks, could delay the epidemic peak for up to a week, providing additional time to implement a second more effective intervention such as vaccination.

Structural Vulnerability in the U.S. Revealed in Three Waves of COVID-19.

The novel coronavirus disease (COVID-19) pandemic has unveiled underlying health inequities throughout the United States. The pandemic has spread across U.S. states, affecting different vulnerable populations, including both inner-city and rural populations, and those living in congregate settings such as nursing homes and assisted-living facilities. In addition, since early April, there has been an increasing number of outbreaks of COVID-19 in jails and prisons. We describe three overlapping epidemiologic waves of spread of COVID-19 linked to three different kinds of structural vulnerabilities.

Integrating host genomics with surveillance for invasive bacterial diseases.

We tested the feasibility of linking Active Bacterial Core surveillance, a prospective, population-based surveillance system for invasive bacterial disease, to a newborn dried blood spot (nDBS) repository. Using nDBS specimens, we resequenced CD46, putative host gene receptor for Neisseria meningitidis, and identified variants associated with susceptibility to this disease.

Serogroup B meningococcal vaccines.

Neisseria meningitidis causes severe, often fatal septicemia and meningitis. Polysaccharide vaccines that offer protection against infection with meningococcal serogroups A, C, Y and W-135 are effective in older children and adults, and have been widely used. New polysaccharide-conjugate vaccines against one or more of these serogroups are now in use or under accelerated development; however, a broadly protective vaccine against infection by serogroup B N meningitidis is not yet available. Serogroup B contributes significantly to the burden of meningococcal disease in many industrialized countries where both epidemic and endemic serogroup B infections occur. Vaccines effective against specific strains responsible for serogroup B epidemic disease have been developed, but the development of a safe serogroup B vaccine that is cross protective against multiple strains and is effective in infants and young children is a challenge. In spite of these difficulties, promising approaches stemming from a better understanding of meningococcal pathogenesis and of the genetics of serogroup B N meningitidis continue to evolve. Progress toward an effective serogroup B vaccine, an important addition for meningococcal disease prevention, is the focus of this review. The epidemiology and pathogenesis of meningococcal disease are detailed, along with discussion of the challenges faced in the development of efficacious serogroup B vaccines.

Social Contact Networks and Mixing among Students in K-12 Schools in Pittsburgh, PA.

Students attending schools play an important role in the transmission of influenza. In this study, we present a social network analysis of contacts among 1,828 students in eight different schools in urban and suburban areas in and near Pittsburgh, Pennsylvania, United States of America, including elementary, elementary-middle, middle, and high schools. We collected social contact information of students who wore wireless sensor devices that regularly recorded other devices if they are within a distance of 3 meters. We analyzed these networks to identify patterns of proximal student interactions in different classes and grades, to describe community structure within the schools, and to assess the impact of the physical environment of schools on proximal contacts. In the elementary and middle schools, we observed a high number of intra-grade and intra-classroom contacts and a relatively low number of inter-grade contacts. However, in high schools, contact networks were well connected and mixed across grades. High modularity of lower grades suggests that assumptions of homogeneous mixing in epidemic models may be inappropriate; whereas lower modularity in high schools suggests that homogenous mixing assumptions may be more acceptable in these settings. The results suggest that interventions targeting subsets of classrooms may work better in elementary schools than high schools. Our work presents quantitative measures of age-specific, school-based contacts that can be used as the basis for constructing models of the transmission of infections in schools.

Comparison of mortality associated with vancomycin-resistant and vancomycin-susceptible enterococcal bloodstream infections: a meta-analysis.

BACKGROUND: Whether vancomycin resistance is independently associated with mortality among patients with enterococcal bloodstream infection (BSI) is controversial. To address this issue, we performed a systematic literature review with meta-analysis. METHODS: Data sources were studies identified using the MEDLINE database (for articles from 1988 through March 2003), the Cochrane Library (for articles published up to March 2003), and bibliographies of identified articles. Inclusion criteria were that the study assessed mortality after enterococcal BSI, compared mortality after vancomycin-resistant enterococci (VRE) BSI with that after vancomycin-susceptible enterococci (VSE) BSI, and adjusted for severity of illness. Study exclusion criteria were as follows: no report of the adjusted measure of effect (adjusted odds ratio [OR], adjusted hazard ratio, or adjusted relative risk) of vancomycin resistance on mortality available and/or its adjusted 95% confidence interval (95% CI). Data in the tables, figures, or text were independently extracted by 2 of the authors. Individual weights were calculated using the 95% CI of the adjusted measures of effect performing both fixed-effect and random-effects models. RESULTS: Nine studies were eligible (11 studies met the inclusion criteria, and 2 were excluded), with a total of 1614 enterococcal BSI episodes (683 VRE episodes and 931 VSE episodes). Patients with bacteremia caused by VRE were more likely to die than were those with VSE bacteremia (summary OR, 2.52; 95% CI, 1.9-3.4). CONCLUSIONS: Vancomycin resistance is independently associated with increased mortality among patients with enterococcal bloodstream infection.

Peripheral neuropathy associated with prolonged use of linezolid.

We present a case of a woman who developed severe, painful peripheral neuropathy while receiving linezolid therapy for 6 months. Nerve conduction studies indicated a sensory-motor axonal neuropathy. Extensive assessment did not show alternative explanations for her neuropathy. At the time of death 1 month after discontinuing linezolid, the neuropathy had not resolved. A review of published material shows a growing body of evidence that long-term use of linezolid may be associated with severe peripheral and optic neuropathy. 21 cases have been reported. In most cases, optic neuropathies resolved after stopping linezolid but peripheral neuropathies did not. The duration of therapy rather than indication for treatment seems to be the most important factor. The mechanism of toxicity is unknown but certain pharmacological properties of linezolid that may play a part are proposed. This report highlights the importance of post-approval surveillance and reporting of serious adverse drug effects, and potential consequences of off-label use of pharmaceuticals. It further demonstrates the critical role clinicians have in communicating awareness of emerging drug toxicities.

Meningococcal conjugate vaccines.

Neisseria meningitidis is a leading cause of bacterial meningitis and sepsis in the US, Europe and in many other parts of the world, including parts of sub-Saharan Africa (known as the African 'meningitis belt'). There are > 500000 cases of meningococcal disease annually with an estimated death toll of 135000 worldwide. Approximately 10 - 15 % of survivors experience significant morbidity in the form of neurological sequelae, including hearing loss, speech disorders, loss of limbs, mental retardation and paralysis. Disease is usually caused by N. meningitidis serogroups A, B, C, Y or W-135. Prevention of meningococcal disease includes isolation, chemoprophylaxis and vaccination with available polysaccharide vaccines. However, the polysaccharide meningococcal vaccines (i.e., A and C; A, C and W-135; or A, C, Y and W-135) initially developed in the 1970s are generally poorly immunogenic in children or require repeated doses and do not produce long-lasting immunity. Conjugate vaccine technology has been very successfully used in childhood vaccines for the prevention of other bacterial meningitis pathogens, including vaccines against Haemophilus influenzae serotype b (Hib) and more recently, the seven- and nine-valent conjugate pneumococcal vaccines. Newly released meningococcal conjugate vaccines against N. meningitidis serogroup C have been highly efficacious in young children and adolescents, with minimal side effects. Conjugate vaccines targeting other important meningococcal serogroups (e.g., N. meningitidis serogroup A, responsible for the large pandemic outbreaks and the majority of disease in sub-Saharan Africa and serogroups Y and W-135) are under development and together with the serogroup C conjugates, have the potential to significantly impact worldwide sporadic and epidemic meningococcal disease. The search for an effective serogroup B meningococcal vaccine remains elusive. This manuscript reviews the conjugate meningococcal vaccines and their potential for meningococcal disease prevention.

Overcoming patient barriers to discussing physician hand hygiene: do patients prefer electronic reminders to other methods?

BACKGROUND: Despite agreement that handwashing decreases hospital-acquired infections (HAIs), physician hand hygiene remains suboptimal. Interventions to empower patients to discuss handwashing have had variable success. OBJECTIVE: To understand patient perceived barriers to discussing physician hand hygiene and to determine whether patients prefer electronic alerts over printed information as an intervention to discuss physician handwashing. DESIGN: Cross-sectional study of 250 medical/surgical patients at an academic medical center. RESULTS: Ninety-six percent of patients had heard of HAIs. Ninety-six percent of patients thought it was important for physicians to clean their hands before touching anything in a patient's room. The majority of patients (78%) believed patients should remind physicians to clean their hands. Thirty-two percent of patients observed physician hand hygiene noncompliance. In multivariate analysis, predictors of not speaking up regarding physician hand hygiene included never having worked in health care (odds ratio [OR], 2.8 [95% confidence interval (CI), 1.5-5.1]), not observing a physician clean hands before touching the patient (OR, 2.4 [95% CI, 1.3-4.4]), and not thinking patients should have to remind physicians to clean hands (OR, 5.5 [95% CI, 2.4-12.7]). Ninety-three percent of patients favored electronic device reminders over printed information as an intervention to encourage patients to discuss hand hygiene with their doctors. CONCLUSIONS: The strongest predictor of not challenging a doctor to clean their hands was not believing it was the patient's role to do so. Patients prefer electronic device reminders to printed information as an aid in overcoming barriers to discussing hand hygiene with physicians.

The potential economic value of a 'universal' (multi-year) influenza vaccine.

BACKGROUND: Limitations of the current annual influenza vaccine have led to ongoing efforts to develop a 'universal' influenza vaccine, i.e., one that targets a ubiquitous portion of the influenza virus so that the coverage of a single vaccination can persist for multiple years. OBJECTIVES: To estimate the economic value of a 'universal' influenza vaccine compared to the standard annual influenza vaccine, starting vaccination in the pediatric population (2-18 year olds), over the course of their lifetime. PATIENT/METHODS: Monte Carlo decision analytic computer simulation model. RESULTS: Universal vaccine dominates (i.e., less costly and more effective) the annual vaccine when the universal vaccine cost ≤ $100/dose and efficacy ≥ 75% for both the 5- and 10-year duration. The universal vaccine is also dominant when efficacy is ≥ 50% and protects for 10 years. A $200 universal vaccine was only cost-effective when ≥ 75% efficacious for a 5-year duration when annual compliance was 25% and for a 10-year duration for all annual compliance rates. A universal vaccine is not cost-effective when it cost $200 and when its efficacy is ≤ 50%. The cost-effectiveness of the universal vaccine increases with the duration of protection. CONCLUSIONS: Although development of a universal vaccine requires surmounting scientific hurdles, our results delineate the circumstances under which such a vaccine would be a cost-effective alternative to the annual influenza vaccine.