Coronavirus Disease 2019 (COVID-19) Re-infection by a Phylogenetically Distinct Severe Acute Respiratory Syndrome Coronavirus 2 Strain Confirmed by Whole Genome Sequencing.

BACKGROUND: Waning immunity occurs in patients who have recovered from Coronavirus Disease 2019 (COVID-19). However, it remains unclear whether true re-infection occurs. METHODS: Whole genome sequencing was performed directly on respiratory specimens collected during 2 episodes of COVID-19 in a patient. Comparative genome analysis was conducted to differentiate re-infection from persistent viral shedding. Laboratory results, including RT-PCR Ct values and serum Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) IgG, were analyzed. RESULTS: The second episode of asymptomatic infection occurred 142 days after the first symptomatic episode in an apparently immunocompetent patient. During the second episode, there was evidence of acute infection including elevated C-reactive protein and SARS-CoV-2 IgG seroconversion. Viral genomes from first and second episodes belong to different clades/lineages. The virus genome from the first episode contained a a stop codon at position 64 of ORF8, leading to a truncation of 58 amino acids. Another 23 nucleotide and 13 amino acid differences located in 9 different proteins, including positions of B and T cell epitopes, were found between viruses from the first and second episodes. Compared to viral genomes in GISAID, the first virus genome was phylogenetically closely related to strains collected in March/April 2020, while the second virus genome was closely related to strains collected in July/August 2020. CONCLUSIONS: Epidemiological, clinical, serological, and genomic analyses confirmed that the patient had re-infection instead of persistent viral shedding from first infection. Our results suggest SARS-CoV-2 may continue to circulate among humans despite herd immunity due to natural infection. Further studies of patients with re-infection will shed light on protective immunological correlates for guiding vaccine design.

Methodology for Addressing Infectious Aerosol Persistence in Real-Time Using Sensor Network.

Human exposure to infectious aerosols results in the transmission of diseases such as influenza, tuberculosis, and COVID-19. Most dental procedures generate a significant number of aerosolized particles, increasing transmission risk in dental settings. Since the generation of aerosols in dentistry is unavoidable, many clinics have started using intervention strategies such as area-filtration units and extraoral evacuation equipment, especially under the relatively recent constraints of the pandemic. However, the effectiveness of these devices in dental operatories has not been studied. Therefore, the ability of dental personnel to efficiently position and operate such instruments is also limited. To address these challenges, we utilized a real-time sensor network for assessment of aerosol dynamics during dental restoration and cleaning producers with and without intervention. The strategies tested during the procedures were (i) local area High-Efficiency Particle Air (HEPA) filters and (ii) Extra-Oral Suction Device (EOSD). The study was conducted at the University of Washington School of Dentistry using a network of 13 fixed sensors positioned within the operatory and one wearable sensor worn by the dental operator. The sensor network provides time and space-resolved particulate matter (PM) data. Three-dimensional (3D) visualization informed aerosol persistence in the operatory. It was found that area filters did not improve the overall aerosol concentration in dental offices in a significant way. A decrease in PM concentration by an average of 16% was observed when EOSD equipment was used during the procedures. The combination of real-time sensors and 3D visualization can provide dental personnel and facility managers with actionable feedback to effectively assess aerosol transmission in medical settings and develop evidence-based intervention strategies.

Paraplegic patients: how to measure balance and what is normal or functional?

PURPOSE: To review the current understanding and data of sagittal balance and alignment considerations in paraplegic patients. METHODS: A PubMed literature search was conducted to identify all relevant articles relating to sagittal alignment and sagittal balance considerations in paraplegic and spinal cord injury patients. RESULTS: While there are numerous studies and publications on sagittal balance in the ambulatory patient with spinal deformity or complex spine disorders, there is paucity of the literature on "normal" sagittal balance in the paraplegic patients. Studies have reported significantly alterations of the sagittal alignment parameters in the non-ambulatory paraplegic patients compared to ambulatory patients. The variability of the alignment changes is related to the differences in the level of the spinal cord injury and their differences in the activations of truncal muscles to allow functional movements in those patients, particularly in optimizing sitting and transferring. Surgical goal in treating paraplegic patients with complex pathologies should not be solely directed to achieve the "normal" radiographic parameters of sagittal alignment in the ambulatory patients. The goal should be to maintain good coronal balance to allow ideal sitting position and to preserve motion segment to optimize functions of paraplegia patients. CONCLUSION: Current available literature data have not defined normal sagittal parameters for paraplegic patients. There are significant differences in postural sagittal parameters and muscle activations in paraplegic and non-spinal cord injury patients that can lead to differences in sagittal alignment and balance. Treatment goal in spine surgery for paraplegic patients should address their global function, sitting balance, and ability to perform self-care rather than the accepted radiographic parameters for adult spinal deformity in ambulatory patients.

Respirable size-selective sampler for end-of-shift quartz measurement: Development and performance.

Aims of this study were to develop a respirable size-selective sampler for direct-on-filter (DoF) quartz measurement at the end-of-shift (EoS) using a portable Fourier transform infrared (FTIR) spectrometer and to determine its size-selective sampling performance. A new miniaturized sampler has been designed to have an effective particle deposition diameter close to the portable FTIR beam diameter (6 mm). The new sampler (named the EoS cyclone) was constructed using a 3D printer. The sampling efficiency of the EoS cyclone was determined using polydisperse glass sphere particles and a time-of-flight direct reading instrument. Respirable dust mass concentration and quartz absorbance levels of samples collected with the EoS cyclone were compared to those collected with the 10-mm nylon cyclone. The EoS cyclone operated at a flow rate of 1.2 l min-1 showed minimum bias compared to the international standard respirable convention. The use of the EoS cyclone induced respirable dust mass concentration results similar but significantly larger (5%) than those obtained from samples collected with 10-mm nylon cyclones. The sensitivity of the DoF-FTIR analysis in estimating quartz was found increased more than 10 times when the samples were collected with the EoS cyclone. The average particle deposition diameter was 8.8 mm in 60 samples. The newly developed user friendly EoS cyclone may provide a better sampling strategy in quartz exposure assessment with faster feedback.

Silica Measurement with High Flow Rate Respirable Size Selective Samplers: A Field Study.

High and low flow rate respirable size selective samplers including the CIP10-R (10 l min(-1)), FSP10 (11.2 l min(-1)), GK2.69 (4.4 l min(-1)), 10-mm nylon (1.7 l min(-1)), and Higgins-Dewell type (2.2 l min(-1)) were compared via side-by-side sampling in workplaces for respirable crystalline silica measurement. Sampling was conducted at eight different occupational sites in the USA and five different stonemasonry sites in Ireland. A total of 536 (268 pairs) personal samples and 55 area samples were collected. Gravimetric analysis was used to determine respirable dust mass and X-ray diffraction analysis was used to determine quartz mass. Ratios of respirable dust mass concentration, quartz mass concentration, respirable dust mass, and quartz mass from high and low flow rate samplers were compared. In general, samplers did not show significant differences greater than 30% in respirable dust mass concentration and quartz mass concentration when outliers (ratio <0.3 or >3.0) were removed from the analysis. The frequency of samples above the limit of detection and limit of quantification of quartz was significantly higher for the CIP10-R and FSP10 samplers compared to low flow rate samplers, while the GK2.69 cyclone did not show significant difference from low flow rate samplers. High flow rate samplers collected significantly more respirable dust and quartz than low flow rate samplers as expected indicating that utilizing high flow rate samplers might improve precision in quartz measurement. Although the samplers did not show significant differences in respirable dust and quartz concentrations, other practical attributes might make them more or less suitable for personal sampling.

Evaluation of pump pulsation in respirable size-selective sampling: Part III. Investigation of European standard methods.

Lee et al. (Evaluation of pump pulsation in respirable size-selective sampling: part I. Pulsation measurements. Ann Occup Hyg 2014a;58:60-73) introduced an approach to measure pump pulsation (PP) using a real-world sampling train, while the European Standards (EN) (EN 1232-1997 and EN 12919-1999) suggest measuring PP using a resistor in place of the sampler. The goal of this study is to characterize PP according to both EN methods and to determine the relationship of PP between the published method (Lee et al., 2014a) and the EN methods. Additional test parameters were investigated to determine whether the test conditions suggested by the EN methods were appropriate for measuring pulsations. Experiments were conducted using a factorial combination of personal sampling pumps (six medium- and two high-volumetric flow rate pumps), back pressures (six medium- and seven high-flow rate pumps), resistors (two types), tubing lengths between a pump and resistor (60 and 90 cm), and different flow rates (2 and 2.5 l min(-1) for the medium- and 4.4, 10, and 11.2 l min(-1) for the high-flow rate pumps). The selection of sampling pumps and the ranges of back pressure were based on measurements obtained in the previous study (Lee et al., 2014a). Among six medium-flow rate pumps, only the Gilian5000 and the Apex IS conformed to the 10% criterion specified in EN 1232-1997. Although the AirChek XR5000 exceeded the 10% limit, the average PP (10.9%) was close to the criterion. One high-flow rate pump, the Legacy (PP=8.1%), conformed to the 10% criterion in EN 12919-1999, while the Elite12 did not (PP=18.3%). Conducting supplemental tests with additional test parameters beyond those used in the two subject EN standards did not strengthen the characterization of PPs. For the selected test conditions, a linear regression model [PPEN=0.014+0.375×PPNIOSH (adjusted R2=0.871)] was developed to determine the PP relationship between the published method (Lee et al., 2014a) and the EN methods. The 25% PP criterion recommended by Lee et al. (2014a), average value derived from repetitive measurements, corresponds to 11% PPEN. The 10% pass/fail criterion in the EN Standards is not based on extensive laboratory evaluation and would unreasonably exclude at least one pump (i.e. AirChek XR5000 in this study) and, therefore, the more accurate criterion of average 11% from repetitive measurements should be substituted. This study suggests that users can measure PP using either a real-world sampling train or a resistor setup and obtain equivalent findings by applying the model herein derived. The findings of this study will be delivered to the consensus committees to be considered when those standards, including the EN 1232-1997, EN 12919-1999, and ISO 13137-2013, are revised.

Evaluation of pump pulsation in respirable size-selective sampling: part I. Pulsation measurements.

Pulsations generated by personal sampling pumps modulate the airflow through the sampling trains, thereby varying sampling efficiencies, and possibly invalidating collection or monitoring. The purpose of this study was to characterize pulsations generated by personal sampling pumps relative to a nominal flow rate at the inlet of different respirable cyclones. Experiments were conducted using a factorial combination of 13 widely used sampling pumps (11 medium and 2 high volumetric flow rate pumps having a diaphragm mechanism) and 7 cyclones [10-mm nylon also known as Dorr-Oliver (DO), Higgins-Dewell (HD), GS-1, GS-3, Aluminum, GK2.69, and FSP-10]. A hot-wire anemometer probe cemented to the inlet of each cyclone type was used to obtain pulsation readings. The three medium flow rate pump models showing the highest, a midrange, and the lowest pulsations and two high flow rate pump models for each cyclone type were tested with dust-loaded filters (0.05, 0.21, and 1.25mg) to determine the effects of filter loading on pulsations. The effects of different tubing materials and lengths on pulsations were also investigated. The fundamental frequency range was 22-110 Hz and the magnitude of pulsation as a proportion of the mean flow rate ranged from 4.4 to 73.1%. Most pump/cyclone combinations generated pulse magnitudes ≥10% (48 out of 59 combinations), while pulse shapes varied considerably. Pulsation magnitudes were not considerably different for the clean and dust-loaded filters for the DO, HD, and Aluminum cyclones, but no consistent pattern was observed for the other cyclone types. Tubing material had less effect on pulsations than tubing length; when the tubing length was 183cm, pronounced damping was observed for a pump with high pulsation (>60%) for all tested tubing materials except for the Tygon Inert tubing. The findings in this study prompted a further study to determine the possibility of shifts in cyclone sampling efficiency due to sampling pump pulsations, and those results are reported subsequently.

Evaluation of pump pulsation in respirable size-selective sampling: part II. Changes in sampling efficiency.

This second, and concluding, part of this study evaluated changes in sampling efficiency of respirable size-selective samplers due to air pulsations generated by the selected personal sampling pumps characterized in Part I (Lee E, Lee L, Möhlmann C et al. Evaluation of pump pulsation in respirable size-selective sampling: Part I. Pulsation measurements. Ann Occup Hyg 2013). Nine particle sizes of monodisperse ammonium fluorescein (from 1 to 9 µm mass median aerodynamic diameter) were generated individually by a vibrating orifice aerosol generator from dilute solutions of fluorescein in aqueous ammonia and then injected into an environmental chamber. To collect these particles, 10-mm nylon cyclones, also known as Dorr-Oliver (DO) cyclones, were used with five medium volumetric flow rate pumps. Those were the Apex IS, HFS513, GilAir5, Elite5, and Basic5 pumps, which were found in Part I to generate pulsations of 5% (the lowest), 25%, 30%, 56%, and 70% (the highest), respectively. GK2.69 cyclones were used with the Legacy [pump pulsation (PP) = 15%] and Elite12 (PP = 41%) pumps for collection at high flows. The DO cyclone was also used to evaluate changes in sampling efficiency due to pulse shape. The HFS513 pump, which generates a more complex pulse shape, was compared to a single sine wave fluctuation generated by a piston. The luminescent intensity of the fluorescein extracted from each sample was measured with a luminescence spectrometer. Sampling efficiencies were obtained by dividing the intensity of the fluorescein extracted from the filter placed in a cyclone with the intensity obtained from the filter used with a sharp-edged reference sampler. Then, sampling efficiency curves were generated using a sigmoid function with three parameters and each sampling efficiency curve was compared to that of the reference cyclone by constructing bias maps. In general, no change in sampling efficiency (bias under ±10%) was observed until pulsations exceeded 25% for the DO cyclone. However, for three models of pumps producing 30%, 56%, and 70% pulsations, substantial changes were confirmed. The GK2.69 cyclone showed a similar pattern to that of the DO cyclone, i.e. no change in sampling efficiency for the Legacy producing 15% pulsation and a substantial change for the Elite12 producing 41% pulsation. Pulse shape did not cause any change in sampling efficiency when compared to the single sine wave. The findings suggest that 25% pulsation at the inlet of the cyclone as measured by this test can be acceptable for the respirable particle collection. If this test is used in place of that currently in European standards (EN 1232-1997 and EN 12919-1999) or is used in any International Organization for Standardization standard, then a 25% pulsation criterion could be adopted. This work suggests that a 10% criterion as currently specified in the European standards for testing may be overly restrictive and not able to be met by many pumps on the market. Further work is recommended to determine which criterion would be applicable to this test if it is to be retained in its current form.

Exposure to chlorpyrifos in gaseous and particulate form in greenhouses: a pilot study.

Phase distribution of airborne chemicals is important because intake and uptake mechanisms of each phase are different. The phase distribution and concentrations are needed to determine strategies of exposure assessment, hazard control, and worker protection. However, procedures for establishing phase distribution and concentration have not been standardized. The objective of this study was to compare measurements of an airborne semivolatile pesticide (chlorpyrifos) by phase using two different procedures. Six pesticide applications in two facilities were studied and at each site, samples were collected for three time slots: T1, the first 1 or 2 hr after the commencement of application; T2, a 6-hr period immediately following T1; and T3, a 6-hr period after the required re-entry interval (24 hr for chlorpyrifos).Two phase-separating devices were co-located at the center of each greenhouse: semivolatile aerosol dichotomous sampler (SADS) using flow rates of 1.8 l x min(-1) and 0.2 l x min(-1), corresponding to a total inlet flow rate of 2.0 l x min(-1) with a vapor phase flow fraction of 0.1; and an electrostatic precipitator (ESP), along with a standard OVS XAD-2 tube. Chlorpyrifos in vapor and particulate form in a SADS sampling train and that in vapor form in an ESP sampling train were collected in OVS tubes. Chlorpyrifos in particulate form in the ESP setting would have been collected on aluminum substrate. However, no chlorpyrifos in particulate form was recovered from the ESP. Overall (vapor plus particle) concentrations measured by OVS ranged 11.7-186.6 µg/m(3) at T1 and decreased on average 77.1% and 98.9% at T2 and T3, respectively. Overall concentrations measured by SADS were 66.6%, 72.7%, and 102% of those measured by OVS on average at T1, T2, and T3, respectively. Particle fractions from the overall concentrations measured by SADS were 60.0%, 49.2%, and 13.8%, respectively, for T1, T2, and T3. SADS gives better guidance on the distribution of chlorpyrifos than does the ESP, although the accuracy of the concentration distribution cannot be verified in the absence of a standardized procedure for determining phase division.

Geriatric consultation service in emergency department: how does it work?

BACKGROUND: Hong Kong is having a significant prevalence of geriatric patients who usually require admission after presentation to the hospital through emergency departments. The geriatric consultation programme 'We Care' aims at lowering acute geriatric medical admission. OBJECTIVES: The study aims at analysing the impact of the geriatric consultation service on the acute medical admission, and to study the characteristics and outcome of geriatric patients. METHODS: Retrospective study. Patients who received geriatric consultations during 1 January 2009 to 1 March 2011 were enrolled. The demographic information, diseases case mix, venue of discharge, clinical severity, community nursing service referrals and adverse outcomes were retrieved and analysed. The incidence of adverse outcomes under the presence of each factor was studied. RESULTS: 2202 geriatric patients were referred. Their age ranged from 45 to 99 (mean 79.91, SD 7.45, median 80). These cases were categorised into: (1) chronic pulmonary disease (n=673; 30.6%), (2) debilitating cardiac disease (n=526; 23.9%), (3) geriatric syndromes (n=147; 6.7%), (4) neurological problems (n=416; 18.9%), (5) diabetes-related problems (n=146; 6.6%), (6) terminal malignancy (n=39; 1.8%), (7) electrolyte or input/output disturbance (n=137; 6.2%), (8) non-respiratory infections (n=36, 1.6%) and (9) others (n=82; 3.7%). Acute medical admission was evaded in 84.7% of all consultations with 1039 (47.2%) patients discharged home and 825 patients (37.5%) admitted to convalescent hospital. The incidence rate of adverse outcomes was 1.6%. CONCLUSION: Programme 'We Care' provided comprehensive geriatric assessment to suitable geriatric patients, resulting in an effective reduction of acute geriatric hospital admission.

Effect of calibration and environmental condition on the performance of direct-reading organic vapor monitors.

The performance of three MIRAN SapphIRe Portable Infrared Ambient Air Analyzers and three Century Portable Toxic Vapor Analyzers equipped with photoionization (PID) and flame ionization (FID) detectors was compared with charcoal tube sampling. Relationships were investigated using two different calibration methods at four cyclohexane concentrations, three temperatures, and four relative humidities. For the first method, the TVA monitors were calibrated with a single concentration of methane for the FID, and isobutylene for the PID. The SapphIRe monitors were zeroed and the monitor's manufacturer-supplied library was used. For the second method, a five-point cyclohexane calibration curve was created for each monitor. Comparison of the monitor results of each calibration method (pooled data) indicated a significant difference between methods (t-test, p < 0.001), The SapphIRe group had results closer to the charcoal tubes with the second calibration method, while the PID and FID monitor groups performed better using the first calibration method. The PID monitor group's performance was affected only at the 90% relative humidity (RH) condition. Using the first method, the monitor readings were compared with the charcoal tube average using mixed linear model analyses of variance (ANOVAs) and regression. The ANOVA results showed there was a statistically significant difference among readings from all monitor types (p <0.0001). The regression results demonstrated that the SapphIRe (r² = 0.97) and FID (r² = 0.92) monitor groups correlated well with the charcoal tubes. The PID monitor group had a similar correlation when 90% RH was excluded (r² = 0.94) but had a weaker correlation when it was included (r² = 0.58). The operator should take care when using these monitors at high concentrations and the PID monitors at high humidities, consider the variability between units of the same monitor, and conduct performance verification of the monitor being used.

Multipronged infection control strategy to achieve zero nosocomial coronavirus disease 2019 (COVID-19) cases among Hong Kong healthcare workers in the first 300 days of the pandemic.

BACKGROUND: Nosocomial outbreaks leading to healthcare worker (HCW) infection and death have been increasingly reported during the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: We implemented a strategy to reduce nosocomial acquisition. METHODS: We summarized our experience in implementing a multipronged infection control strategy in the first 300 days (December 31, 2019, to October 25, 2020) of the COVID-19 pandemic under the governance of Hospital Authority in Hong Kong. RESULTS: Of 5,296 COVID-19 patients, 4,808 (90.8%) were diagnosed in the first pandemic wave (142 cases), second wave (896 cases), and third wave (3,770 cases) in Hong Kong. With the exception of 1 patient who died before admission, all COVID-19 patients were admitted to the public healthcare system for a total of 78,834 COVID-19 patient days. The median length of stay was 13 days (range, 1-128). Of 81,955 HCWs, 38 HCWs (0.05%; 2 doctors and 11 nurses and 25 nonprofessional staff) acquired COVID-19. With the exception of 5 of 38 HCWs (13.2%) infected by HCW-to-HCW transmission in the nonclinical settings, no HCW had documented transmission from COVID-19 patients in the hospitals. The incidence of COVID-19 among HCWs was significantly lower than that of our general population (0.46 per 1,000 HCWs vs 0.71 per 1,000 population; P = .008). The incidence of COVID-19 among professional staff was significantly lower than that of nonprofessional staff (0.30 vs 0.66 per 1,000 full-time equivalent; P = .022). CONCLUSIONS: A hospital-based approach spared our healthcare service from being overloaded. With our multipronged infection control strategy, no nosocomial COVID-19 in was identified among HCWs in the first 300 days of the COVID-19 pandemic in Hong Kong.

Size-selective sampling of particulates using a physiologic sampling pump.

Recent laboratory research indicates physiologic sampling of gas and vapor may provide more representative estimates of personal exposures than traditional methods. Modifications to the physiologic sampling pump (PSP) used in that research are described which extend its usefulness to size-selective sampling of particulates. PSPs used in previous research varied motor speed to keep sampling proportional to the subject's inhalation. This caused airflow and particle velocities through the collection device to continually change making those pumps unsuitable for sampling particulates. The modified implementation of the PSP pulls a constant airflow into and through a cyclone, then uses valves to either direct the airflow through, or divert the airflow around, the sampling filter. By using physiologic inputs to regulate the fraction of each second that air flows through the sampling filter, samples may be collected in proportion to inhalation rate. To evaluate the performance of a functional prototype 5 different sizes of monodisperse aerosols of ammonium fluorescein were generated by a vibrating orifice aerosol generator and introduced into a calm air chamber. To simulate different inhalation rates the valves of the PSP were energized using 9 different duty cycles. Efficiency curves are presented and compared to a standard respirable convention by bias mapping. The performance of the modified cyclone used in the PSP sampling head compared favorably with a commercially available cyclone of the same model, operating at a constant airflow (± 10% over almost all the size distributions of concern). The new method makes physiologic sampling of the respirable fraction of particulates feasible.

Infection control challenges in setting up community isolation and treatment facilities for patients with coronavirus disease 2019 (COVID-19): Implementation of directly observed environmental disinfection.

BACKGROUND: Extensive environmental contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been reported in hospitals during the coronavirus disease 2019 (COVID-19) pandemic. We report our experience with the practice of directly observed environmental disinfection (DOED) in a community isolation facility (CIF) and a community treatment facility (CTF) in Hong Kong. METHODS: The CIF, with 250 single-room bungalows in a holiday camp, opened on July 24, 2020, to receive step-down patients from hospitals. The CTF, with 500 beds in open cubicles inside a convention hall, was activated on August 1, 2020, to admit newly diagnosed COVID-19 patients from the community. Healthcare workers (HCWs) and cleaning staff received infection control training to reinforce donning and doffing of personal protective equipment and to understand the practice of DOED, in which the cleaning staff observed patient and staff activities and then performed environmental disinfection immediately thereafter. Supervisors also observed cleaning staff to ensure the quality of work. In the CTF, air and environmental samples were collected on days 7, 14, 21, and 28 for SARS-CoV-2 detection by RT-PCR. Patient compliance with mask wearing was also recorded. RESULTS: Of 291 HCWs and 54 cleaning staff who managed 243 patients in the CIF and 674 patients in the CTF from July 24 to August 29, 2020, no one acquired COVID-19. All 24 air samples and 520 environmental samples collected in the patient area of the CTF were negative for SARS-CoV-2. Patient compliance with mask wearing was 100%. CONCLUSION: With appropriate infection control measures, zero environmental contamination and nosocomial transmission of SARS-CoV-2 to HCWs and cleaning staff was achieved.

The impact of spike N501Y mutation on neutralizing activity and RBD binding of SARS-CoV-2 convalescent serum.

BACKGROUND: Several SARS-CoV-2 lineages with spike receptor binding domain (RBD) N501Y mutation have spread globally. We evaluated the impact of N501Y on neutralizing activity of COVID-19 convalescent sera and on anti-RBD IgG assays. METHODS: The susceptibility to neutralization by COVID-19 patients' convalescent sera from Hong Kong were compared between two SARS-CoV-2 isolates (B117-1/B117-2) from the α variant with N501Y and 4 non-N501Y isolates. The effect of N501Y on antibody binding was assessed. The performance of commercially-available IgG assays was determined for patients infected with N501Y variants. FINDINGS: The microneutralization antibody (MN) titers of convalescent sera from 9 recovered COVID-19 patients against B117-1 (geometric mean titer[GMT],80; 95% CI, 47-136) were similar to those against the non-N501Y viruses. However, MN titer of these serum against B117-2 (GMT, 20; 95% CI, 11-36) was statistically significantly reduced when compared with non-N501Y viruses (P < 0.01; one-way ANOVA). The difference between B117-1 and B117-2 was confirmed by testing 60 additional convalescent sera. B117-1 and B117-2 differ by only 3 amino acids (nsp2-S512Y, nsp13-K460R, spike-A1056V). Enzyme immunoassay using 272 convalescent sera showed reduced binding of anti-RBD IgG to N501Y or N501Y-E484K-K417N when compared with that of wild-type RBD (mean difference: 0.1116 and 0.5613, respectively; one-way ANOVA). Of 7 anti-N-IgG positive sera from patients infected with N501Y variants (collected 9-14 days post symptom onset), 6 (85.7%) tested negative for a commercially-available anti-S1-IgG assay. FUNDING: Richard and Carol Yu, Michael Tong, and the Government Consultancy Service (see acknowledgments for full list). INTERPRETATION: We highlighted the importance of using a panel of viruses within the same lineage to determine the impact of virus variants on neutralization. Furthermore, clinicians should be aware of the potential reduced sensitivity of anti-RBD IgG assays.

Laboratory evaluation of a physiologic sampling pump (PSP).

Recently, physiologic sampling pumps (PSPs), which can adjust their sampling rates in proportion to wearers' minute ventilation (V[combining dot above](E)), have been proposed to better estimate exposure to airborne contaminants in the workplace. A laboratory evaluation was conducted to compare the performance of a new PSP with a traditional sampling pump (TSP) in an exposure chamber. Fifteen subjects (aged 19-36 years) performed two replicate sessions of step-tests for correlated and uncorrelated exposure scenarios on four separate days. When exposed to a scenario in which subject V[combining dot above](E) is highly correlated with m-xylene concentration over the sampling period (r = 0.93), the PSP-measured time-weighted average (TWA) concentrations are higher than TSP-measured concentrations (average ratio of PSP to TSP = 1.18). The ratio of PSP- and TSP-measured TWA concentrations for the uncorrelated scenario (r = 0.02) is closer to one, as expected, with an average value of 0.94. The test results of the linear mixed model further indicate that the performance of the PSP is unaffected by the anthropometric and physiological characteristics of the wearer. Potential differences in exposure estimates resulting from the use of the two instruments were examined in light of various schemes which can potentially occur in the field. With the capability of estimating the total volume of air inhaled over the sampling period with improved accuracy, PSPs show promise in reducing the inherent uncertainty in current risk assessment approaches that entail constant-flow (TSP) sampling approaches.

Source of Social Support and Caregiving Self-Efficacy on Caregiver Burden and Patient's Quality of Life: A Path Analysis on Patients with Palliative Care Needs and Their Caregivers.

Few studies have explored the inter-relationships of sources of social support and caregiving self-efficacy with caregiver burden and patient's quality of life among patients with palliative care needs and their caregivers. This study tested the associations of two sources of social support (family and friends) and the mediating role of caregiving self-efficacy on caregiver burden and patient's quality of life. A convenience sample of 225 patient-caregiver dyads recruited between September 2016 and May 2017 from three hospitals in Hong Kong was included in the current analysis. Results showed that the final model provided a satisfactory fit (SRMR = 0.070, R-RMSEA = 0.055 and R-CFI = 0.926) with the data, as good as the hypothesized model did (p = 0.326). Significant associations were detected. Family support had a significant negative indirect effect on caregiver burden and a significant positive indirect effect on patient's quality of life through caregiving self-efficacy, whereas friend support had a significant positive direct effect on caregiver burden but a minimal effect, if any, on patient's quality of life. These findings emphasized (1) the importance of caregiving self-efficacy in improving caregiver burden and patient's quality of life and that (2) sources of social support may be an important dimension moderating the associations of caregiving self-efficacy with caregiver burden and patient's quality of life.

A novel physiologic sampling pump capable of rapid response to breathing.

The merits of using physiologic sampling pumps (PSPs) instead of using constant-flow sampling pumps, i.e., "traditional sampling pumps" (TSPs), are discussed. A novel PSP that overcomes shortcomings of previous PSP designs is presented. Calibrated valves are used to obviate pump inertia that has limited the system response and accuracy of prior work. Technologies that provide minute ventilation (V[combining dot above](E)) of subjects in real time may therefore be used to the limit of their own accuracies to sample inhalation exposures. Analysis of the design and data from a prototype are presented to show how air sampling can be modulated to follow breathing.

Depression Increases the Rates of Neurological Complications and Failed Back Surgery Syndrome in Patients Undergoing Lumbar Spine Surgery.

STUDY DESIGN: This was a retrospective database study. OBJECTIVE: The aim of this study was to use a large sample to accurately determine risk factors and rates of neurological complications in patients undergoing commonly performed lumbar spine surgeries. SUMMARY OF BACKGROUND DATA: Damage to neurological structures and failed back surgery syndrome (FBSS) are among the most feared complications of lumbar spine surgery. Despite the large impact on quality of life these complications have, reported rates of neurological complications vary immensely, ranging from 0.46% to 24%. MATERIALS AND METHODS: Data were obtained for patients undergoing initial posterior lumbar interbody fusion, transforaminal lumbar interbody fusion, anterior lumbar interbody fusion, posterolateral fusion, discectomy, and laminectomy procedures from January 2007 to June 2015 covered by the nationwide insurance carrier Humana. Patient records were analyzed to determine rates of dural tear, damage to nervous tissue, cauda equina syndrome, neurogenic bowel/bladder, and FBSS following each procedure. Rates were determined for patients undergoing single/multilevel procedures, by age, and for patients with a previous diagnosis of depression to determine the influence these factors had on the risk of neurologic complications. RESULTS: Analysis of 70,581 patient records revealed a dural tear rate of 2.87%, damage to the nervous tissue of 1.47%, cauda equina syndrome of 0.75%, neurogenic bowel or bladder of 0.45%, and FBSS of 15.05% following lumbar spine surgery. The incidence of complications was highest for patients undergoing multilevel procedures and posterior fusion. Depression was a significant risk factor for FBSS (risk ratio, 1.74; P<0.0001), damage to nervous tissue (1.41; P<0.0001), and dural tear (1.15; P<0.0001), but had no impact on risk of cauda equina syndrome or neurogenic bowel or bladder. Increased age was associated with higher rates of dural tear and damage to nervous tissue. CONCLUSIONS: Patients with a history of depression are at significantly increased risk for neurologic complications following lumbar spine surgery and should be managed accordingly.

The DOWN Questionnaire: A Novel Screening Tool for Cervical Spondylotic Myelopathy.

STUDY DESIGN: Case-control study. OBJECTIVES: Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord injury in adults aged over 55 years. However, since the onset is typically insidious, accurately diagnosing CSM can be challenging, often requiring referral to a subspecialist and advanced imaging. To help identify patients at risk for CSM, this case-control study compared responses to a series of 4 questions (DOWN questionnaire) in myelopathic and non-myelopathic patients. METHODS: Ninety-two patients, 46 with and 46 without myelopathy, were recruited for the study. Each patient answered 4 questions encompassing common symptoms associated with CSM. Responses between patient groups were compared, and Cohen's κ was used to assess for agreement between responses and the diagnosis of myelopathy. RESULTS: We found a sensitivity of 91% and a κ of 0.54 to 3 positive responses and a sensitivity of 72% and a κ of 0.61 to 4 positive responses. CONCLUSIONS: Positive responses to 3 or more DOWN questions has high sensitivity and moderate agreement with the diagnosis of myelopathy based on history, physical exam, and review of advanced imaging by an orthopedic or neurological surgeon. The DOWN questionnaire is a potentially useful screening tool to identify patients at risk for CSM.