Case Series of Jamestown Canyon Virus Infections with Neurologic Outcomes, Canada, 2011-2016.

Jamestown Canyon virus (JCV) is a mosquitoborne orthobunyavirus in the California serogroup that circulates throughout Canada and the United States. Most JCV exposures result in asymptomatic infection or a mild febrile illness, but JCV can also cause neurologic diseases, such as meningitis and encephalitis. We describe a case series of confirmed JCV-mediated neuroinvasive disease among persons from the provinces of British Columbia, Alberta, Quebec, and Nova Scotia, Canada, during 2011-2016. We highlight the case definitions, epidemiology, unique features and clinical manifestations, disease seasonality, and outcomes for those cases. Two of the patients (from Quebec and Nova Scotia) might have acquired JCV infections during travel to the northeastern region of the United States. This case series collectively demonstrates JCV's wide distribution and indicates the need for increased awareness of JCV as the underlying cause of meningitis/meningoencephalitis during mosquito season.

Improving access to HIV care among people who inject drugs through tele-harm reduction: a qualitative analysis of perceived discrimination and stigma.

BACKGROUND: Tele-harm reduction (THR) is a telehealth-enhanced, peer-led, harm reduction intervention delivered within a trusted syringe services program (SSP) venue. The primary goal of THR is to facilitate linkage to care and rapid, enduring virologic suppression among people who inject drugs (PWID) with HIV. An SSP in Miami, Florida, developed THR to circumvent pervasive stigma within the traditional healthcare system. METHODS: During intervention development, we conducted in-depth interviews with PWID with HIV (n = 25) to identify barriers and facilitators to care via THR. We employed a general inductive approach to transcripts guided by iterative readings of the raw data to derive the concepts, themes, and interpretations of the THR intervention. RESULTS: Of the 25 PWID interviewed, 15 were in HIV care and adherent to medication; 4 were in HIV care but non-adherent; and 6 were not in care. Themes that emerged from the qualitative analysis included the trust and confidence PWID have with SSP clinicians as opposed to professionals within the traditional healthcare system. Several barriers to treatment were reported among PWID, including perceived and actual discrimination by friends and family, negative internalized behaviors, denial of HIV status, and fear of engaging in care. Facilitators to HIV care included empathy and respect by SSP staff, flexibility of telehealth location, and an overall destigmatizing approach. CONCLUSION: PWID identified barriers and facilitators to receipt of HIV care through the THR intervention. Interviews helped inform THR intervention development, centered on PWID in the destigmatizing environment of an SSP.

The Dependence of Online Gambling Businesses on High-Spending Customers: Quantification and Implications.

Online gambling has grown to be a significant industry but it faces regulatory threats because of perception that it is heavily dependent on a small segment of its customers who gamble heavily and at a level carrying elevated risk of harm. Employing a large multi-operator data set from Britain, which records individual transactions by some 140,000 individuals observed over one year, we are enabled to provide more precise estimates of the degree of concentration of revenue, compared with previous studies. High dependence on a relatively small number of customers is shown though there is variation from product to product in how small the group of account-holders of potential concern is. We conclude with a discussion of prospects for the industry in light of heightened awareness of gambling harm and resulting restrictions on online gambling spending introduced or proposed by governments or regulators in several jurisdictions.

An unexpected abundance of bidirectional promoters within Salmonella Typhimurium plasmids.

Transcription of the DNA template, to generate an RNA message, is the first step in gene expression. The process initiates at DNA sequences called promoters. Conventionally, promoters have been considered to drive transcription in a specific direction. However, in recent work, we showed that many prokaryotic promoters can drive divergent transcription. This is a consequence of key DNA sequences for transcription initiation being inherently symmetrical. Here, we used global transcription start site mapping to determine the prevalence of such bidirectional promoters in Salmonella Typhimurium. Surprisingly, bidirectional promoters occur three times more frequently in plasmid components of the genome compared to chromosomal DNA. Implications for the evolution of promoter sequences are discussed.

Examining the Psychometrics of the National HIV Behavioral Surveillance Measure for Community HIV-Related Stigma.

The research tested the psychometrics of the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS) community HIV-related stigma scale. Data was from men who have sex with men (MSM) NHBS cycles conducted 2011-2017 in Miami-Dade, Florida among n = 1455 participants. MSM were cis-gender male, 18+ years old, reported lifetime oral/anal sex with a male, and lived in Miami-Dade County. We assessed reliability using Cronbach's alpha and McDonald's omega, determined factors using principal factor analysis, and assessed construct validity using five a priori hypotheses. The scale was unidimensional, had questionable internal reliability (α = 0.68, ω = 0.69), and met four of five a priori hypotheses in the expected direction. Correlations were medium-weak in strength and only one was consistently met. Future iterations of the NHBS survey should consider replacing the 4-item community HIV-related stigma scale with an instrument that has superior internal reliability, measures multiple HIV-related stigma dimensions, and demonstrates stronger evidence of validity.

RESUMEN: La investigación evaluó la psicometrías de la escala comunitaria de estigma relacionada con el VIH de La Vigilancia del Comportamiento Nacional del VIH de los Centros de Control y la Prevención de Enfermedades (National HIV Behavioral Surveillance, NHBS por sus siglas en Ingles). Los datos fueron de hombres que tienen sexo con hombres (HSH) ciclos NHBS realizados 2011­2027 en Miami-Dade, Florida entre n = 1455 participantes. Los HSH eran hombres cisgénero, mayores de 18 años, reportando haber tenido sexo oral/anal de toda la vida con un hombre y vivían en el condado de Miami-Dale. Evaluamos la confiabilidad usando el alfa de Cronbach y el omega de McDonald, determinamos los factores usando el análisis de factores principales y evaluamos la validez de constructo usando cinco hipótesis a priori. La escala era unidimensional, tenía una fiabilidad interna cuestionable (α = 0.68, ω = 0.69), y cumplía cuatro de cinco hipótesis a priori en la dirección esperada. Las correlaciones fueron de intensidad media-débil y solo una se cumplió de manera consistente. Las iteraciones futuras de la encuesta NHBS debería considerar reemplazar la escala comunitaria de estigma relacionada con el VIH de 4 ítems por un instrumento que tenga una confiabilidad interna superior, mida múltiples dimensiones del estigma relacionado con el VIH y demuestre una evidencia mas solida de validez.

"We want everything in a one-stop shop": acceptability and feasibility of PrEP and buprenorphine implementation with mobile syringe services for Black people who inject drugs.

INTRODUCTION: A recent surge in HIV outbreaks, driven by the opioid and stimulant use crises, has destabilized our progress toward targets set forth by Ending the HIV Epidemic: A Plan for America for the high-priority community of people who inject drugs (PWID), particularly Black PWID. METHODS: In order to ascertain the acceptability and feasibility of using a mobile syringe services program (SSP) for comprehensive HIV prevention via PrEP and medications for opioid use disorder (MOUD), our mixed methods approach included a quantitative assessment and semi-structured qualitative interviews with Black PWID (n = 30) in Miami-Dade County who were actively engaged in mobile syringe services. RESULTS: Participants felt that delivery of MOUD and PrEP at a mobile SSP would be both feasible and acceptable, helping to address transportation, cost, and stigma barriers common within traditional healthcare settings. Participants preferred staff who are compassionate and nonjudgmental and have lived experience. CONCLUSIONS: A mobile harm reduction setting could be an effective venue for delivering comprehensive HIV prevention services to Black PWID, a community that experiences significant barriers to care via marginalization and racism in a fragmented healthcare system.

Transmission of Problem Gambling Between Adjacent Generations.

We investigate the extent to which gambling problems at age 20 are linked to parental gambling behaviour during childhood, employing data from a longitudinal study (ALSPAC) which has followed parents and children from Avon, England since pregnancy. 1058 children completed a problem gambling screen at age 20. When those children had been age 6, each of their parents was asked about their own gambling. We used regression to estimate the effect of parental gambling behaviour at child age 6 on the child's problem gambling risk at age 20. Parental gambling participation at child age 6 was not a predictor of offspring problem gambling; but problem gambling by parents was a predictor of offspring problem gambling. However, this latter result was found only cross-gender (fathers' behaviour influencing daughters and mothers' behaviour influencing sons). This pattern was robust to models including measures of parental education and variables capturing family attitudes to health choices and the degree of domestic harmony. The sample illustrates high problem gambling prevalence amongst young adults. Although there is transmission of 'problem gambling' between generations, it appears to happen only cross-gender. This limits the importance of parental problem gambling as a source of the high prevalence because relatively few mothers exhibit problem gambling and risks to daughters from fathers are in the context of initially low baseline risks. Preventative policies might therefore be more appropriately targeted at young adults rather than rely on influencing parental gambling behaviour earlier in the child's life.

A Study of Adaptive Gambling Behavior of Casino Employees in Macau.

Two hypotheses have been advanced to explain gambling prevalence and addiction among various populations-the exposure hypothesis and the adaptation hypothesis. This study tests these hypotheses in the context of casino employees in Macau. In the etiology of gambling, casino employees have been considered a unique segment of the population. Employees working in casinos are probably more exposed to gambling stimuli than any other group. The findings suggest that indicators of heavy involvement in casino gambling among casino employees were no higher than among other residents of Macau. In terms of gambling frequency, casino employees actually gambled less often than the general adult population in Macau. These results are in contrast to results from studies of gaming venue employees in Australia and Canada. The differing findings are probably attributable to particularities of Macau discussed in the article.

Rapid Identification and Investigation of an HIV Risk Network Among People Who Inject Drugs -Miami, FL, 2018.

Prevention of HIV outbreaks among people who inject drugs remains a challenge to ending the HIV epidemic in the United States. The first legal syringe services program (SSP) in Florida implemented routine screening in 2018 leading to the identification of ten anonymous HIV seroconversions. The SSP collaborated with the Department of Health to conduct an epidemiologic investigation. All seven acute HIV seroconversions were linked to care (86% within 30 days) and achieved viral suppression (mean 70 days). Six of the seven individuals are epidemiologically and/or socially linked to at least two other seroconversions. Analysis of the HIV genotypes revealed that two individuals are connected molecularly at 0.5% genetic distance. We identified a risk network with complex transmission dynamics that could not be explained by epidemiological methods or molecular analyses alone. Providing wrap-around services through the SSP, including routine screening, intensive linkage and patient navigation, could be an effective model for achieving viral suppression for people who inject drugs.

Ensemble modeling informs hypoxia management in the northern Gulf of Mexico.

A large region of low-dissolved-oxygen bottom waters (hypoxia) forms nearly every summer in the northern Gulf of Mexico because of nutrient inputs from the Mississippi River Basin and water column stratification. Policymakers developed goals to reduce the area of hypoxic extent because of its ecological, economic, and commercial fisheries impacts. However, the goals remain elusive after 30 y of research and monitoring and 15 y of goal-setting and assessment because there has been little change in river nitrogen concentrations. An intergovernmental Task Force recently extended to 2035 the deadline for achieving the goal of a 5,000-km2 5-y average hypoxic zone and set an interim load target of a 20% reduction of the spring nitrogen loading from the Mississippi River by 2025 as part of their adaptive management process. The Task Force has asked modelers to reassess the loading reduction required to achieve the 2035 goal and to determine the effect of the 20% interim load reduction. Here, we address both questions using a probabilistic ensemble of four substantially different hypoxia models. Our results indicate that, under typical weather conditions, a 59% reduction in Mississippi River nitrogen load is required to reduce hypoxic area to 5,000 km2 The interim goal of a 20% load reduction is expected to produce an 18% reduction in hypoxic area over the long term. However, due to substantial interannual variability, a 25% load reduction is required before there is 95% certainty of observing any hypoxic area reduction between consecutive 5-y assessment periods.

Recurrent sterile abscesses in a case of X-linked neutropenia.

Cutaneous manifestations are common in monogenic immune disorders, including both infectious and non-infectious etiologies. We report follow-up of a case initially published in Pediatric Dermatology in 2001 of a 13-year-old boy with a history of inflammatory skin lesions and neutropenia who developed neutrophilic dermatoses precipitated by G-CSF. Whole exome sequencing performed at 36 years of age revealed a gain-of-function mutation in the WAS gene, leading to a diagnosis of X-linked neutropenia. This case report provides closure on a decades-long diagnostic odyssey and underscores the importance of genetic sequencing in patients who present with unusual dermatologic findings.

When is an abscess more than an abscess? Syringe services programs and the harm reduction safety-net: a case report.

BACKGROUND: Syringe services programs (SSPs) are able to offer wrap-around services for people who inject drugs (PWID) and improve health outcomes. CASE PRESENTATION: A 47-year-old man screened positive for a skin and soft tissue infection (SSTI) at an SSP and was referred to a weekly on-site student-run wound care clinic. He was evaluated by first- and third-year medical students, and volunteer attending physicians determined that the infection was too severe to be managed on site. Students escorted the patient to the emergency department, where he was diagnosed with a methicillin-resistant Staphylococcus aureus arm abscess as well as acute HIV infection. CONCLUSION: Student-run wound care clinics at SSPs, in conjunction with ongoing harm reduction measures, screenings, and treatment services, provide a safety-net of care for PWID and help mitigate the harms of injection drug use.

Baseline prevalence and correlates of HIV and HCV infection among people who inject drugs accessing a syringe services program; Miami, FL.

BACKGROUND: Blood-borne viral infections, such as HIV and hepatitis C (HCV), are common infections among people who inject drugs (PWID). This study aims to determine the prevalence of HIV and HCV infection among PWID accessing the first legal syringe services program (SSP) in the state of Florida, along with examining baseline correlates of HIV and HCV infection. METHODS: Baseline behavioral enrollment assessments of 837 participants accessing an SSP for the first time were analyzed. Patients self-reporting or testing HIV or HCV positive at the enrollment visit were included. Socio-demographic, drug use, and injection-related risk behaviors in the last 30 days were compared across groups defined by all combinations of HIV and HCV serostatus. Bivariate and multivariable logistic regression models were used to assess correlates of baseline HCV and HIV infection independently. RESULTS: Overall prevalence for HCV and HIV infection were 44.4% and 10.2%, respectively. After adjusting for confounders, the most significant correlates of baseline HCV infection were age (aOR = 1.01), lower education level (aOR = 1.13), currently homeless (aOR = 1.16), injecting more than seven times a day (aOR = 1.14), reusing syringes (aOR = 1.18), and sharing injection equipment (aOR = 1.13). The most significant predictors of baseline HIV infection were age (aOR = 1.01), non-Hispanic Black race (aOR = 1.28), Hispanic ethnicity (aOR = 1.12), gay or bisexual orientation (aOR = 1.22), and methamphetamine injection (aOR = 1.22). In addition, heroin injection (aOR = 0.92) was significantly associated with a lower odds of HIV infection. DISCUSSION/CONCLUSION: Baseline behavioral predictors differed between HIV infection and HCV infection among participants accessing syringe services. Understanding the risk factors associated with each infection should be considered when developing additional harm reduction interventions tailored for diverse PWID populations served at SSPs.

Correction to: When is an abscess more than an abscess? Syringe services programs and the harm reduction safety-net: a case report.

An amendment to this paper has been published and can be accessed via the original article.

Implementation of a medical student-run telemedicine program for medications for opioid use disorder during the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic led to the closure of the IDEA syringe services program medical student-run free clinic in Miami, Florida. In an effort to continue to serve the community of people who inject drugs and practice compassionate and non-judgmental care, the students transitioned the clinic to a model of TeleMOUD (medications for opioid use disorder). We describe development and implementation of a medical student-run telemedicine clinic through an academic medical center-operated syringe services program. METHODS: Students advertised TeleMOUD services at the syringe service program on social media and created an online sign-up form. They coordinated appointments and interviewed patients by phone or videoconference where they assessed patients for opioid use disorder. Supervising attending physicians also interviewed patients and prescribed buprenorphine when appropriate. Students assisted patients in obtaining medication from the pharmacy and provided support and guidance during home buprenorphine induction. RESULTS: Over the first 9 weeks in operation, 31 appointments were requested, and 22 initial telehealth appointments were completed by a team of students and attending physicians. Fifteen appointments were for MOUD and 7 for other health issues. All patients seeking MOUD were prescribed buprenorphine and 12/15 successfully picked up medications from the pharmacy. The mean time between appointment request and prescription pick-up was 9.5 days. CONCLUSIONS: TeleMOUD is feasible and successful in providing people who inject drugs with low barrier access to life-saving MOUD during the COVID-19 pandemic. This model also provided medical students with experience treating addiction during a time when they were restricted from most clinical activities.

Unusual relatives of the multisubunit RNA polymerase.

Transcription, the first step of gene expression, is accomplished in all domains of life by the multisubunit RNA polymerase (msRNAP). Accordingly, the msRNAP is an ancient enzyme that is ubiquitous across all cellular organisms. Conserved in absolutely all msRNAPs is the catalytic magnesium-binding aspartate triad and the structural fold it is present on, the double ψ ß barrel (DPBB). In-depth bioinformatics has begun to reveal a wealth of unusual proteins distantly related to msRNAP, identified due to their possession of the aspartate triad and DPBB folds. Three examples of these novel RNAPs are YonO of the Bacillus subtilis SPß prophage, non-virion RNAP (nvRNAP) of the B. subtilis AR9 bacteriophage and ORF6 RNAP of the Kluyveromyces lactis cytoplasmic killer system. While YonO and AR9 nvRNAP are both bacteriophage enzymes, they drastically contrast. YonO is an incredibly minimal single-subunit RNAP, while AR9 nvRNAP is multisubunit bearing much more resemblance to the canonical msRNAP. ORF6 RNAP is an intermediate, given it is a single-subunit enzyme with substantial conservation with the msRNAP. Recent findings have begun to shed light on these polymerases, which have the potential to update our understanding of the mechanisms used for transcription and give new insights into the canonical msRNAP and its evolution. This mini-review serves to introduce and outline our current understanding of these three examples of novel, unusual RNAPs.

Baseline differences in characteristics and risk behaviors among people who inject drugs by syringe exchange program modality: an analysis of the Miami IDEA syringe exchange.

BACKGROUND: In March of 2016, Florida passed the Infection Disease Elimination Act (IDEA), legalizing the formation of the first syringe exchange program in Florida, which opened in December of 2016 at a fixed site in Overtown, Miami. Since that time, the exchange expanded in April of 2017 to include a mobile van unit that provides the same services at different locations throughout Miami-Dade County. METHODS: Trained interviewers conducted face-to-face interviews from all first-time participants at the IDEA Exchange, both at the fixed site and the mobile van unit. RESULTS: Among 718 first-time enrollees, 74.8% were male, 52.1% were non-Hispanic White, 85.9% completed high school, 59.8% were unemployed, 42.1% were homeless, 54.2% reported an annual income of less than $15,000, and the mean age was 38 years. Participants at the fixed site and mobile van unit reported differences in socioeconomic status, injection drug-related behaviors, and pre-existing hepatitis C virus (HCV) infection status. CONCLUSIONS: Taken together, these results suggest that the mobile unit is capturing a subset of PWID in Miami that the fixed site is not, and vice-versa. As the opioid crisis extends into all demographics, such multimodal efforts to target various populations of PWID should be kept in mind, especially when unveiling future syringe exchanges in Florida and other late-adopting states.

New Price, New Hope? An Examination of the Effects of Doubling the Ticket Price in UK Lotto.

The UK Lotto game was introduced in November 1994 with a standard 6/49 format and an entry fee of £1 per ticket. After several years, revenue began to fall despite extensive publicity and a variety of inducements. By 2013, nominal weekly revenue was less than half the 1995 level. In October 2013, the operator doubled the price of a ticket to £2 and made a number of changes to the pay-out structure of smaller prizes. The intent of the changes was to reverse the long downward trend in game revenue by encouraging higher jackpots and offering more pay-out opportunities for each ticket. We use draw by draw revenue and other data to evaluate how players responded to these changes and find that, while ticket sales fell dramatically, total revenue rose following the changes. Primarily this appears to have been the consequence of increased frequency of rollovers (and therefore of more frequent high jackpot draws) rather than ticket price inelasticity. However, although there was a short-term gain in revenue, the changes did not arrest, and indeed seem to have accentuated, the long-run trend decrease in the revenue generated by the game.

StormSense: A New Integrated Network of IoT Water Level Sensors in the Smart Cities of Hampton Roads, VA.

Propagation of cost-effective water level sensors powered through the Internet of Things (IoT) has expanded the available offerings of ingestible data streams at the disposal of modern smart cities. StormSense is an IoT-enabled inundation forecasting research initiative and an active participant in the Global City Teams Challenge seeking to enhance flood preparedness in the smart cities of Hampton Roads, VA for flooding resulting from storm surge, rain, and tides. In this study, we present the results of the new StormSense water level sensors to help establish the "regional resilience monitoring network" noted as a key recommendation from the Intergovernmental Pilot Project. To accomplish this, the Commonwealth Center for Recurrent Flooding Resiliency's Tidewatch tidal forecast system is being used as a starting point to integrate the extant (NOAA) and new (USGS and StormSense) water level sensors throughout the region, and demonstrate replicability of the solution across the cities of Newport News, Norfolk, and Virginia Beach within Hampton Roads, VA. StormSense's network employs a mix of ultrasonic and radar remote sensing technologies to record water levels during 2017 Hurricanes Jose and Maria. These data were used to validate the inundation predictions of a street-level hydrodynamic model (5-m resolution), while the water levels from the sensors and the model were concomitantly validated by a temporary water level sensor deployed by the USGS in the Hague, and crowd-sourced GPS maximum flooding extent observations from the Sea Level Rise app, developed in Norfolk, VA.

Longitudinal clinical findings and outcome among patients with Cryptococcus gattii infection in British Columbia.

BACKGROUND: Cryptococcus gattii (Cg) infection emerged in British Columbia in 1999. A longitudinal, clinical description of patients has not been reported. METHODS: Medical records were reviewed for Cg patients identified through surveillance (1999-2007). Risk factors for Cg mortality were explored using multivariate Cox regression; longitudinal patterns in serum cryptococcal antigen (SCrAg) titers and the probability of chest cryptococcomas over time were estimated using cubic B-splines in mixed-effects regression models. RESULTS: Among 152 patients, 111 (73.0%) were culture confirmed. Isolated lung infection was present in 105 (69.1%) patients; 47 (30.9%) had central nervous system infection, with or without lung involvement. Malignancy was the provisional diagnosis in 64 (42.1%) patients. Underlying diseases were present in 91 (59.9%) patients; 23 (15.1%) were immunocompromised, and 23 (15.1%) had asymptomatic disease. There were only 2 (1.8%) culture positive relapses, both within 12 months of follow-up. The estimated median time to resolution of lung cryptococcomas and decline in SCrAg titer to <1:8 was 2.8 and 2.9 years, respectively. Cg-related and all-cause mortality among culture-confirmed cases at 12 months' follow-up was 23.3% and 27.2%, respectively. Cg-related mortality was associated with age >50 years (hazard ratio [HR], 15.6; 95% confidence interval [CI], 1.9-130.5) and immunocompromise (HR, 5.8; CI, 1.5-21.6). All Cg-related mortality occurred among culture-positive cases within 1 year of diagnosis. CONCLUSIONS: Cryptococcomas and serum antigenemia were slow to resolve. However, late onset of failed therapy or relapse was uncommon, suggesting that delayed resolution of these findings does not require prolongation of treatment beyond that recommended by guidelines.