Respiratory Microbiome Disruption and Risk for Ventilator-Associated Lower Respiratory Tract Infection.

BACKGROUND: Ventilator-associated lower respiratory tract infection (VA-LRTI) is common among critically ill patients and has been associated with increased morbidity and mortality. In acute critical illness, respiratory microbiome disruption indices (MDIs) have been shown to predict risk for VA-LRTI, but their utility beyond the first days of critical illness is unknown. We sought to characterize how MDIs previously shown to predict VA-LRTI at initiation of mechanical ventilation change with prolonged mechanical ventilation, and if they remain associated with VA-LRTI risk. METHODS: We developed a cohort of 83 subjects admitted to a long-term acute care hospital due to their prolonged dependence on mechanical ventilation; performed dense, longitudinal sampling of the lower respiratory tract, collecting 1066 specimens; and characterized the lower respiratory microbiome by 16S rRNA sequencing as well as total bacterial abundance by 16S rRNA quantitative polymerase chain reaction. RESULTS: Cross-sectional MDIs, including low Shannon diversity and high total bacterial abundance, were associated with risk for VA-LRTI, but associations had wide posterior credible intervals. Persistent lower respiratory microbiome disruption showed a more robust association with VA-LRTI risk, with each day of (base e) Shannon diversity <2.0 associated with a VA-LRTI odds ratio of 1.36 (95% credible interval, 1.10-1.72). The observed association was consistent across multiple clinical definitions of VA-LRTI. CONCLUSIONS: Cross-sectional MDIs have limited ability to discriminate VA-LRTI risk during prolonged mechanical ventilation, but persistent lower respiratory tract microbiome disruption, best characterized by consecutive days with low Shannon diversity, may identify a population at high risk for infection and may help target infection-prevention interventions.

Before the Bullets Fly: The Physician's Role in Preventing Firearm Injury.

Firearm injury is a disease that is disproportionately prevalent in the United States. When a bullet hits a human being, it brings together multiple structural determinants of health into one acute, life-changing event. Firearm injury can lead to long-term mental and physical challenges for individuals, families, and communities. Despite the impact of this disease, physicians often underestimate their role in not only treating but also preventing firearm injury. Physicians can intervene through screening, counseling, community engagement, and advocacy, and can mobilize the health care systems they serve to engage with injury prevention. Physicians also play a key role in expanding the knowledge base on firearm injury through much-needed research on the epidemiology, context, and outcomes of firearm injury. When we treat firearm injury as a disease, we can develop and implement interventions from the clinic to the statehouse that can curb profound harms. This work and these opportunities belong not only to emergency physicians and trauma surgeons, but to all fields that evaluate and assess patients over the life course.

Characterization of Recurrences Following Second Breast-Conserving Surgery with Intraoperative Radiotherapy.

BACKGROUND: Breast-conserving surgery with breast re-irradiation is an emerging technique in the treatment of selected cases of locally recurrent breast cancer. Further information is needed to characterize factors that may select for an appropriate patient population for this treatment approach. METHODS: We report herein a single-institution retrospective analysis of patients with ipsilateral breast cancer recurrence treated with a second breast-conserving therapy with intraoperative radiotherapy. Patient records were reviewed to analyze toxicity, further recurrence, and characteristics of recurrent patients following this treatment approach. RESULTS: We included 57 patients in the analysis. At median follow-up of 24.5 months, ipsilateral breast tumor recurrence occurred in six patients (11%), four of which localized to the quadrant of the initial recurrent disease and two of which recurred elsewhere in the treated breast. Locoregional control was 89%, and disease-free survival was 81%. Only one patient was found to have grade 3 or greater toxicity. CONCLUSION: A second breast-conserving surgery with intraoperative radiotherapy is tolerable with acceptable toxicity for patients with locally recurrent disease refusing mastectomy. Prospective clinical trials are needed to define the subset of patients who may be appropriate for this treatment approach as an alternative to mastectomy.

Deep Learning Based on MR Imaging for Predicting Outcome of Uterine Fibroid Embolization.

PURPOSE: To develop and validate a deep learning model based on routine magnetic resonance (MR) imaging obtained before uterine fibroid embolization to predict procedure outcome. MATERIALS AND METHODS: Clinical data were collected on patients treated with uterine fibroid embolization at the Hospital of the University of Pennsylvania from 2007 to 2018. Fibroids for each patient were manually segmented by an abdominal radiologist on a T1-weighted contrast-enhanced (T1C) sequence and a T2-weighted sequence of MR imaging obtained before and after embolization. A residual convolutional neural network (ResNet) model to predict clinical outcome was trained using MR imaging obtained before the procedure. RESULTS: Inclusion criteria were met by 727 fibroids in 409 patients. At clinical follow-up, 85.6% (n = 350) of 409 patients (590 of 727 fibroids; 81.1%) experienced symptom resolution or improvement, and 14.4% (n = 59) of 409 patients (137 of 727 fibroids; 18.9%) had no improvement or worsening symptoms. The T1C trained model achieved a test accuracy of 0.847 (95% confidence interval [CI], 0.745-0.914), sensitivity of 0.932 (95% CI, 0.833-0.978), and specificity of 0.462 (95% CI, 0.232-0.709). In comparison, the average of 4 radiologists achieved a test accuracy of 0.722 (95% CI, 0.609-0.813), sensitivity of 0.852 (95% CI, 0.737-0.923), and specificity of 0.135 (95% CI, 0.021-0.415). CONCLUSIONS: This study demonstrates that deep learning based on a ResNet model achieves good accuracy in predicting outcome of uterine fibroid embolization. If further validated, the model may help clinicians better identify patients who can most benefit from this therapy and aid clinical decision making.

Association of TNF-α-308 Polymorphism with Susceptibility to Autoimmune Hepatitis in Tunisians.

Autoimmune hepatitis (AIH) is a chronic hepatitis of unknown etiology and several proinflammatory cytokines are implicated in its pathogenesis. The association of TNF-α gene polymorphism with AIH onset is not fully elucidated especially in the Tunisian population. The aim of this study was to determine the association of TNF-α (-308 G > A) polymorphism with AIH susceptibility and with TNF-α expression or clinical manifestations of AIH. A total of 50 AIH patients and 150 controls were included. Evaluation of TNF-α polymorphism was performed by ARMS PCR method. A significantly higher frequence of the AA genotype was found in AIH patients compared to controls (34 vs. 8%, p = 0.00002, OR 5.88). The frequency of the A-allele was significantly higher in patients with AIH compared to controls (55 vs. 37.3%, p = 0.002, OR 2.05). The G-allele was significantly more frequent in healthy controls compared to AIH patients [43 vs. 61.3%, p = 0.001, OR 0.47 (0.3-0.75)]. There was a positive correlation between the A/A genotype and a higher serum expression of TNF-α. The TNF*A allele confer susceptibility to AIH in the Tunisian patients and is associated with increased production of TNF-α. Anti-TNF antibodies could be an alternative to the use of corticotherapy and may avoid the exacerbated immune response in AIH.

Construction and Structure Determination of a Three-Dimensional DNA Crystal.

Structural DNA nanotechnology combines branched DNA junctions with sticky-ended cohesion to create self-assembling macromolecular architectures. One of the key goals of structural DNA nanotechnology is to construct three-dimensional (3D) crystalline lattices. Here we present a new DNA motif and a strategy that has led to the assembly of a 3D lattice. We have determined the X-ray crystal structures of two related constructs to 3.1 Å resolution using bromine-derivatized crystals. The motif we used employs a five-nucleotide repeating sequence that weaves through a series of two-turn DNA duplexes. The duplexes are tied into a layered structure that is organized and dictated by a concert of four-arm junctions; these in turn assemble into continuous arrays facilitated by sequence-specific sticky-ended cohesion. The 3D X-ray structure of these DNA crystals holds promise for the design of new structural motifs to create programmable 3D DNA lattices with atomic spatial resolution. The two arrays differ by the use of four or six repeats of the five-nucleotide units in the repeating but statistically disordered central strand. In addition, we report a 2D rhombuslike array formed from similar components.

Genome-wide association of IL-28B with response to pegylated interferon-alpha and ribavirin therapy for chronic hepatitis C in a Tunisian population.

BACKGROUND:   A polymorphism upstream of interleukin (IL)-28B was recently identified to be associated with a 2-fold difference in sustained virologic response (SVR) to pegylated interferon-alpha and ribavirin therapy in a large cohort of treatment-naive, adherent patients with chronic hepatitis C (CHC) virus genotype 1 (HCV-1) infection. AIM: We sought to confirm the polymorphism's clinical relevance by intention-to-treat analysis evaluating on-treatment virologic response and SVR. METHODS: We perform a prospective study in gastroenterology unitof tunis'military hospital in collaboration with immunology unit, military center of blood transfusion and laboratory of biochemistry of childrens' hospital of Tunis. HCV patients were genotyped as CC, CT or TT at the polymorphic site rs12979860 and TT, TG or GG at the polymorphic site rs8099917. Viral kinetics and rates of rapid virologic response (RVR, week 4) and SVR were compared by IL-28B type in a tunisian population. RESULTS: 154 patients including 80 healthy blood donors(sexratio: 1, mean age: 40.35 ±10.15 years) and 74 patients treated for CHC (39 men and 35 women; mean age = 51.7± 9.4 years) were enrolled. 35.6% of patients were genotyped as CC at the polymorphic site rs12979860 and 69.1% as TT at the polymorphic site rs8099917. The CC IL-28B type at rs12979860 was associated with a greater likelihood of SVR (77% vs 31.9%; p<0.001; OR: 7.11 [2.37-21.35]) compared with CT and TT. The CC IL-28B type at rs12979860 wasn't associated with improved of rapid virologic response (RVR). In a multivariate logistic regression model, the rs12979860 CC genotype predicted SVR (p<0.001; OR: 7.11 IC95% [2.37-21.35]). The TT IL-28B type at rs 8099917 wasn't associated with improved RVR and SVR compared with TG and GG. CONCLUSION: In treatment-naive HCV patients treated with pegylated interferon and ribavirin, a polymorphism upstream CC at the site rs12979860 of IL-28B is associated with increased sustained virologic response and effectively predicts treatment outcome.

Predictors of successful endoscopic colonic polypectomy.

BACKGROUND: Endoscopic polypectomy is the technique of choice for resection of colorectal polyps and has a major interest in the prevention of colorectal cancer. The aim of this study was to evaluate the technique, results and tolerance of colonic polypectomy. METHODS: We conducted a retrospective study including 200 consecutive patients with colorectal polyps and who underwent therapeutic endoscopic polypectomy, performed at the endoscopy unit of the Military Hospital in Tunis, between december 2008 and december 2012. RESULTS: Hundred and forty men and 60 women were included. The average age was 58.5 ± 14.5 years. The polyp was unique in more than half of cases. The most frequent location was the sigmoid colon (30.5%). Approximately, » of the polyps was larger than 10 mm. According to the Paris endoscopic classification, 78% of polyps were sessile (Is). Seventy-two percent of polyps were adenomas. Twentyfive per cent of them contained a villous component, 40 % were advanced adenomas and 3% malignant adenomas. Regarding polypectomy, 232 polyps (64%) were treated by the cold forceps, 68 polyps (18.5 %) by the diathermic snare and 63 (17.5 %) by a mucosal resection. Thirty-one percent of polypectomy were fragmented. The evaluation of the efficacy of treatment among adenomas and potentially malignant tumors, had identified 36% of treatment failure. The common independent predictive factor of fragmented resection and treatment failure were the size ≥ 10 mm (p <10-3). Among a total of 363 polypectomies, 23 (6.3%) were complicated, by 11 procedural bleeding, 11 micro-perforations and 1 delayed hemorrhage. The common independent predictive factor of these complications was the size ≥ 10 mm (p <10-3). During following, there were 12 residual polyps (6%), 36 new polyps (18%) and 6 colorectal cancers (3%). The only independent predictive factor of an unfavorable course was the multiplicity of polyps. The colorectal polyps-free survival was 90.2% at 12 months and 88.4% at 24 months. CONCLUSION: The evaluation of colorectal polypectomy in our series had confirmed the effectiveness and the low morbidity of this practice. The polyp size was the only independent predictive factor of both treatment failure and complications.

[Endoscopic treatment of Zenker's diverticulum with soft diverticuloscope: a first Tunisian experience]. / Traitement endoscopique du diverticule de Zenker par un diverticuloscope souple: Une première expérience Tunisienne.

INTRODUCTION: Zenker's diverticulum is an acquired hernia from the posterior pharyngeal mucosa developed in the pharyngo-esophageal junction. The gold standard for diagnosis is pharyngo-esophageal barium swallow study. Open surgery with cricopharyngeal myotomy has long been the conventional treatment. Actually, endoscopic treatment is an efficient alternative to resolve the problem with shorter surgery duration and less complication. AIM: We report 3 cases of patients with Zenker's diverticulum treated with endoscopic approach in our department between 2013 and 2014. CASE REPORT: There were three men aged 71, 79 and 62 years admitted to our department with symptomatic Zenker's diverticulum. Predominant symptoms were dysphagia and regurgitation. Diverticulotomy with a flexible endoscope was performed for all patients, using argon plasma coagulation in the first case and a needle-knife in the two others. Hemostatic clips were placed at the end of the procedure. There was no complication in the last two cases. Perforation at the left lateral side of the cervical diverticulum was observed in the first patient solved by diet and antibiotics. We performed a pharyngo-esophageal barium swallow study before and after the intervention in all patients showing significant regression of the diverticulum and we observed a complete regression of clinical symptoms. CONCLUSION: Treatment with endoscopic approach using a flexible endoscope and a diverticuloscope for good exposure of the diverticulum is a safe procedure offering a rapid improvement of symptoms with a lower risk of complications and a shorter duration of hospitalization compared to surgical treatment.

Argon plasma coagulation in the management of symptomatic gastrointestinal angiodysplasia: experience in 69 consecutive patients.

BACKGROUND: Gastrointestinal angiodysplasias are associated with a high bleeding risk. AIM: to evaluate the efficiency of argon plasma electrocoagulation in the treatment of gastrointestinal angiodysplasia and to identify predictive factors of success of this technique. METHODS: Retrospective study of patients with bleeding gastrointestinal angiodysplasia treated with argon plasma electrocoagulation in the digestive endoscopy unit of the military hospital in Tunis between January 2000 and December 2011. RESULTS: 69 patients with a mean age of 68.7 years were included.The endoscopic treatment resulted in a rise in hemoglobin value from 7.3 to 9.3 g/ dl (p = 0.0001) and a decrease of transfusion requirements from 2.5 to 0.1 units of packed red cells (p <0.0001). It allowed to avoid surgery for 93.6% of patients with complex medicalhistory. Recurrence of bleeding was observed in 33.3% of patients after a mean time of 12.3 months. In a multivariate analysis, no factors were independently associated with the recurrence of bleeding. The overall survival without rebleeding at 1 and 2 years were 50% and 42% respectively. CONCLUSION: Argon plasma coagulation is an easy, effective and safe treatment of bleeding angiodysplasia. This technique is particularly interesting for patients with multiple medical problems, where surgical treatment could be burdened by significant morbidity and mortality risk.

Screening for viral hepatitis C in a young Tunisian population (more than 175,000 recruits).

BACKGROUND: In front of the considerable impact of the viral hepatitis C, the prevention is more than ever a priority, based essentially on the screening. AIM: We realized an epidemiological study in a population of young recruits with the aim of considering prevalence of anti-hepatitis C Virus (anti-HCV) antibodies, describing its epidemiological evolution and establishing a cartography of the viral hepatitis C in Tunisia. METHODS: Epidemiological retrospective study of prevalence was realized from the data of the screening of anti-HCV antibodies from 2003 till 2012 of all the young recruits suggested to be incorporated for the national service or suggested to be recruited as career soldier. The study was exhaustive concerning 175 322 young and healthy male adults aged between 20 and 30 years old, originating from all parts of Tunisia. The screening was realized by third and fourth generation ELISA tests then validated by Immunoblot. RESULTS: The prevalence was 0.11% and the confirmed prevalence was 0.07%. The positive subjects were mainly between 20 and 25 years old (82.32%) and 91.05% were detected within the framework of their incorporations to the national service. The lowest prevalence was 0.07% in 2004, and the highest was 0.17% in 2011, without a significant tendency in the increase or in the decrease during the period of study (r = 0.857 ; p = 0.564). The screening of anti-VHC antibodies had an unequal geographical distribution according to a North-South decreasing gradient. The highest proportions were registered in the North-West (23.23%) and the District of Tunis (22.73%), contrary to the South-East which was weakly affected (3.54%). The governorates with the highest proportions were Tunis (19.19%), Bizerte (11.62%) and Jendouba (8.59%), the governorates of Monastir and Tataouine were weakly affected (0.51%). CONCLUSION: Prevalence of anti-HCV antibodies in the young and male Tunisian population was weak, stable without significant tendency in the increase or in the decrease from 2003 till 2012, characterized by an unequal geographical distribution according to a North-South decreasing gradient.

Clinical impact of multidrug-resistant bacterial infections in patients with cirrhosis.

Aim: Recently, the emergency of multidrug-resistant organisms (MDRO) has complicated the management of bacterial infections (BI) in cirrhosis. We aimed to assess their clinical impact on patients with decompensated cirrhosis. Methods: A retrospective study included consecutive cirrhotic patients hospitalized for acute decompensation (AD) between January 2010 and December 2019. Results: A total of 518 AD admissions in 219 patients were included, with 260 BI episodes (50.2%). MDRO prevalence was 38.2% of the total isolates. Recent antibiotic use (OR = 4.91), nosocomial infection (OR = 2.95), and healthcare-associated infection (OR = 3.45) were their main risk factors. MDROs were associated with empiric treatment failure (OR = 23.42), a higher prevalence of sepsis (OR = 4.93), ACLF (OR = 3.42) and mortality. Conclusion: The clinical impact of MDROs was pejorative, with an increased risk of empiric treatment failure, organ failure and death.

In recent years, an increasing spread of multidrug-resistant bacteria had been observed worldwide. The emergence of these strains could represent a major problem in fragile patients such as cirrhotic patients. Over 10 years, our study analyzed the bacteriological profile of cirrhotic patient infections. The multidrug-resistant bacteria prevalence was 38.2%. Exposure to healthcare facilities and recent antibiotic use, were their main risk factors. These strains had a negative impact with an increased risk of treatment failure and death.

New Study Alert! Significant prevalence and negative clinical impact of multidrug-resistant organism (MDRO) infections in patients with cirrhosis. Main risk factors: recent antibiotic use and exposure to healthcare facilities. #cirrhosis #bacterialinfection #antibiotherapy #resistance.

[Predictive factors of response to peginterferon and ribavirin in Tunisians patients with chronic hepatitis C: report of 141 cases]. / Facteurs prédictifs de réponse à la bithérapie pégylée au cours de l'hépatite chronique c dans une population tunisienne: à propos de 141 cas.

BACKGROUND: The current treatment recommendation for chronic hepatitis c is the combination of peginterferon and ribavirin. AIMS: To report our experience in the treatment of chronic hepatitis c and determine the predictive factors of sustained virologic response. METHODS: Analysis of consecutive patients treated with peginterferon and ribavirine from 1st January 2000 and 31st December 2009. results: 141 patients with an average age of 50 years were included. 75 % of the patients were infected by a VHc of genotype 1. 22.6 % of the patients were cirrhotics. 7 % of the patients (n=10) had to stop the treatment because of severe side-effects. A reduction of the dose was indicated for 16 % of the patients (n=23). Among the 117 patients with the end of treatment virologic response, 24 patients (20.5%) relapse during the 6 months after the end of therapy. The sustained virologic response in intention to treat was 66 % (57.9 % in case of genotype 1-4 and 91 % in case of genotype 2-3). In multivariate analysis, 4 independent factors of sustained virologic response were identified: the male gender, a viral genotype not 1, a pre-therapeutic viral load ≤ 600 000 UI / ml and a rapid virologic response. CONCLUSION: Approximately two thirds of the patients with chronic hepatitis c achieved a sustained virologic response with peginterferon and ribavirin. Our results are comparable to those of the literature. They will credibly be improved by the introduction of the new antiviral agents.

[Outcomes of endoscopic gluing with cyanoacrylate glue of bleeding gastric varices]. / Résultats de l'obturation endoscopique des varices gastriques hémorragiques par colle biologique.

BACKGROUND: Gastric variceal bleeding is associated with significant morbidity and mortality. Its optimal treatment is not yet standardized and glue injection is the most often proposed treatment. The longterm results of this technique are still controversial. AIM: To assess the safety and efficacy of gastric variceal glue injection. METHODS: Consecutive patients that underwent glue injection for gastric variceal bleeding in our endoscopy unit, from January 2000 to August 2011, were assessed. RESULTS: Sixteen patients (9 men, 7 women) underwent cyanoacrylate glue injections for gastric variceal bleeding. The median follow-up period of 13 patients was 33 months (three were lost to follow-up). The average age was 60 years (3 - 80 years). All patients had stigmata of recent bleeding at endoscopy. Patients underwent an average of 2 gluing sessions (1-3 sessions). N-butyl-2-cyanoacrylate (Histoacryl ®) was the most often product used. No significant complications from cyanoacrylate injection were observed. No patient had a recurrent variceal bleeding. During the median follow-up period, two patients died. CONCLUSION: Our data suggest that cyanoacrylate injection therapy is safe and effective for the prevention of short- and long-term bleeding from gastric varices.

[Non alcoholic fatty liver disease: a new risk factor for cardiovascular disease?]. / La stéatose hépatique non alcoolique : Un nouveau facteur de risque cardio-vasculaire?

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is frequently diagnosed in daily practice. This condition is represented by a large spectrum of chronic liver diseases going from pure hepatic steatosis to cirrhosis and its complications, including hepatocellular carcinoma. NAFLD is usually associated to glucose and lipoproteins metabolism increasing the cardiovascular risk. AIM: To review new advances in the knowledge of the pathophysiological links between NAFLD and cardiovascular risk, evaluation of cardiovascular risk in this special situation and the different therapeutics proposed. METHODS: Systematic review of the literature using medical data bases (Medline) with the following key words: non-alcoholic fatty liver disease, hepatic steatosis, cardiovascular risk, metabolic syndrome. RESULTS: We'll report pathophysiological links between NAFLD and cardiovascular risk, propose an evaluation of cardiovascular risk in this special situation and expose a therapeutic strategy. CONCLUSION: The discovery of a non alcoholic fatty liver disease should lead to a cardiovascular risk evaluation.

[Nocturnal gastroesophageal reflux and sleep apnea: what relationship?]. / Reflux gastro-oesophagien nocturne et syndrome d'apnées du sommeil : Quelles relations ?

BACKGROUND: Gastroesophageal reflux disease and nocturnal sleep disturbances are frequently encountered in clinical practice and are often associated. However, the combination of these two syndromes does not necessarily imply a cause and effect. In a more precise, the relationship between nocturnal gastroesophageal reflux and sleep apnea syndrome has been debated since even if their respective prevalences are high in the presence of one or the other syndrome, it is difficult to eliminate mutual induction. AIM: To determine the pathophysiological relations, the frequency of the association between nocturnal gastroesophageal reflux and sleep apnea syndrome and the impact of specific therapies to each of these two syndromes on the other. METHODS: Review of the literature. RESULTS: On the relationship between these two entities, it seems obvious that nocturnal gastroesophageal reflux affects the normal physiology of sleep and alters its quality and that the sleep apnea syndrome can aggravate reflux. On the frequency of their association, gastroesophageal reflux was observed in the presence of sleep apnea syndrome; in 27 to 75% of patients in studies that do not include pH-metric and polysomnographic recording simultaneously. Regarding treatment, continuous positive airway pressure seems to improve night time gastroesophageal reflux both in terms of symptoms that pH-metric results. Similarly, inhibitors of proton pump inhibitors have demonstrated their effectiveness in combination with specific treatment, in improving symptoms caused by sleep apnea syndrome. CONCLUSION: we can confirm that there is a strong link between nocturnal gastroesophageal reflux and sleep apnea syndrome but causality is hard to be confirmed. Moreover, it seems useful to look for sleep disorders in patients with nocturnal gastroesophageal reflux also to suggest the diagnosis of gastroesophageal reflux in patients with sleep apnea syndrome.

Subglottic suction frequency and adverse ventilator-associated events during critical illness.

OBJECTIVE: Tracheal intubation and mechanical ventilation provide essential support for patients with respiratory failure, but the course of mechanical ventilation may be complicated by adverse ventilator-associated events (VAEs), which may or may not be associated with infection. We sought to understand how the frequency of subglottic suction, an indicator of the quantity of sputum produced by ventilated patients, relates to the onset of all VAEs and infection-associated VAEs. DESIGN: We performed a case-crossover study including 87 patients with VAEs, and we evaluated 848 days in the pre-VAE period at risk for a VAE. SETTING AND PARTICIPANTS: Critically ill patients were recruited from the medical intensive care unit of an academic medical center. METHODS: We used the number of as-needed subglottic suctioning events performed per calendar day to quantify sputum production, and we compared the immediate pre-VAE period to the preceding period. We used CDC surveillance definitions for VAE and to categorize whether events were infection associated or not. RESULTS: Sputum quantity measured by subglottic suction frequency is greater in the period immediately prior to VAE than in the preceding period. However, it does not discriminate well between infection-associated VAEs and VAEs without associated infection. CONCLUSIONS: Subglottic suction frequency may serve as a valuable marker of sputum quantity, and it is associated with risk of a VAE. However, our results require validation in a broader population of mechanically ventilated patients and intensive care settings.

Quantifying the Impact of Nasopharyngeal Specimen Quality on Severe Acute Respiratory Syndrome Coronavirus 2 Test Performance.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse-transcription polymerase chain reaction (RT-PCR) cycle threshold (Ct) has been used to estimate quantitative viral load, with the goal of targeting isolation precautions for individuals with coronavirus disease 2019 (COVID-19) and guiding public health interventions. However, variability in specimen quality can alter the Ct values obtained from SARS-CoV-2 clinical assays. We sought to define how variable nasopharyngeal (NP) swab quality impacts clinical SARS-CoV-2 test sensitivity. METHODS: We performed amplification of a human gene target (ß-actin) in parallel with a clinical RT-PCR targeting the SARS-CoV-2 ORF1ab gene for 1282 NP specimens collected from patients with clinical concern for COVID-19. We evaluated the relationship between NP specimen quality, characterized by late Ct values for the human gene target ß-actin Ct, and the probability of SARS-CoV-2 detection via logistic regression, as well as the linear relationship between SARS-CoV-2 and ß-actin Ct. RESULTS: Low-quality NP swabs are less likely to detect SARS-CoV-2 (odds ratio, 0.607 [95% credible interval {CrI}, .487-.753]). We observed a positive linear relationship between SARS-CoV-2 and ß-actin Ct values (slope, 0.181 [95% CrI, .097-.264]), consistent with a reduction in detection of 0.181 cycles for each additional cycle of the ß-actin target. COVID-19 disease severity was not associated with ß-actin Ct values. CONCLUSIONS: Variability in NP specimen quality significantly impacts the performance of clinical SARS-CoV-2 assays, and caution should be taken when interpreting quantitative SARS-CoV-2 Ct results. If unrecognized, low-quality NP specimens, which are characterized by a low level of amplifiable human DNA target, may limit the successful application of SARS-CoV-2 Ct values to direct infection control and public health interventions.

Increased Firearm Injury During the COVID-19 Pandemic: A Hidden Urban Burden.

BACKGROUND: Public health measures were instituted to reduce COVID-19 spread. A decrease in total emergency department volume followed, but the impact on injury is unknown. With lockdown and social distancing potentially increasing domicile discord, we hypothesized that intentional injury increased during COVID-19, driven primarily by an increase in penetrating trauma. STUDY DESIGN: A retrospective review of acute adult patient care in an urban Level I trauma center assessed injury patterns. Presenting patient characteristics and diagnoses from 6 weeks pre to 10 weeks post statewide stay-at-home orders (March 16, 2020) were compared, as well as with 2015-2019. Subsets were defined by intentionality (intentional vs nonintentional) and mechanism of injury (blunt vs penetrating). Fisher exact and Wilcoxon tests were used to compare proportions and means. RESULTS: There were 357 trauma patients that presented pre stay-at-home order and 480 that presented post stay-at-home order. Pre and post groups demonstrated differences in sex (35.6% vs 27.9% female; p = 0.02), age (47.4 ± 22.1 years vs 42 ± 20.3 years; p = 0.009), and race (1.4% vs 2.3% Asian; 63.3% vs 68.3% Black; 30.5% vs 22.3% White; and 4.8% vs 7.1% other; p = 0.03). Post stay-at-home order mechanism of injury revealed more intentional injury (p = 0.0008). Decreases in nonintentional trauma after adoption of social isolation paralleled declines in daily emergency department visits. Compared with earlier years, 2020 demonstrated a significantly greater proportion of intentional violent injury during the peripandemic months, especially from firearms. CONCLUSIONS: Unprecedented social isolation policies to address COVID-19 were associated with increased intentional injury, especially gun violence. Meanwhile, emergency department and nonintentional trauma visits decreased. Pandemic-related public health measures should embrace intentional injury prevention and management strategies.