Outbreaks of mumps genotype G viruses in the Netherlands between October 2019 and March 2020: clusters associated with multiple introductions.

BACKGROUND: From October 2019-March 2020, several clusters of mumps cases were identified in the Netherlands. Our objective was to describe cluster-associated mumps virus transmission using epidemiological and molecular information in order to help future mumps outbreak investigation and control efforts. METHODS: An epidemiological cluster includes ≥ 2 mumps cases with at least an epidemiological-link to a laboratory-confirmed mumps case. A molecular group includes ≥ 2 mumps cases with identical mumps virus sequences. Cases with symptom onset date between 1 October 2019 and 31 March 2020 reported through the National Notifiable Diseases Surveillance System were included. We described epidemiological and clinical characteristics of mumps cases. Sequence data was obtained from selected regions of mumps virus genomes (2270 nucleotides). Associations between epidemiological and molecular information were investigated. RESULTS: In total, 102 mumps cases were notified (90% laboratory-confirmed, 10% epidemiologically-linked). 71 out of 102 cases were identified as part of an epidemiological cluster and/or molecular group. Twenty-one (30%) of 71 cases were identified solely from epidemiological information, 25 (35%) solely from molecular surveillance, and 25 (35%) using both. Fourteen epidemiological clusters were identified containing a total of 46 (range: 2-12, median: 3) cases. Complete sequence data was obtained from 50 mumps genotype G viruses. Twelve molecular groups were identified containing 43 (range: 2-13) cases, dispersed geographically and timewise. Combined information grouped seven epidemiological clusters into two distinct molecular groups. The first lasting for 14 weeks, the other for 6. Additionally, one molecular group was detected, linked by geography and time but without an epidemiological-link. CONCLUSIONS: Combined epidemiological and molecular information indicated ongoing mumps virus transmission from multiple introductions for extended time periods. Sequence analysis provided valuable insights into epidemiological clustering. If combined information is available in a timely manner, this would improve outbreak detection, generate further insight into mumps transmission, and guide necessary control measures.

Systems thinking for health emergencies: use of process mapping during outbreak response.

Process mapping is a systems thinking approach used to understand, analyse and optimise processes within complex systems. We aim to demonstrate how this methodology can be applied during disease outbreaks to strengthen response and health systems. Process mapping exercises were conducted during three unique emerging disease outbreak contexts with different: mode of transmission, size, and health system infrastructure. System functioning improved considerably in each country. In Sierra Leone, laboratory testing was accelerated from 6 days to within 24 hours. In the Democratic Republic of Congo, time to suspected case notification reduced from 7 to 3 days. In Nigeria, key data reached the national level in 48 hours instead of 5 days. Our research shows that despite the chaos and complexities associated with emerging pathogen outbreaks, the implementation of a process mapping exercise can address immediate response priorities while simultaneously strengthening components of a health system.

Bronchial arterial embolisation for massive haemoptysis in cavitary sarcoidosis.

A 48-year-old non-smoking man with a 6-year history of pulmonary cavitary sarcoidosis presented with acute onset of haemoptysis of approximately 600 ml. Prior episodes of haemoptysis had resolved only after serial upper lobe wedge resections bilaterally and steroids. A chest CT identified bilateral upper lobe cavitary lesions with extravasation of contrast from a large right upper lobe cavity. The patient underwent urgent bronchial angiography and subsequent bronchial artery embolisation of a left bronchial artery and three right bronchial arteries. He was started on methotrexate and steroids for refractory sarcoidosis. Two years after embolisation, the patient remained haemoptysis-free with his sarcoid well controlled on methotrexate monotherapy.

Eucapnic voluntary hyperventilation is superior to methacholine challenge testing for detecting airway hyperreactivity in nonathletes.

INTRODUCTION: Response to eucapnic voluntary hyperventilation (EVH) has not been compared with methacholine challenge testing (MCCT) in nonathletes being evaluated for dyspnea on exertion. OBJECTIVE: To determine the airway response to EVH and MCCT in a population of nonathletes who exercise regularly but have symptoms with exertion. METHODS: We reviewed records for all patients with exercise symptoms who underwent both EVH and MCCT. Presenting symptoms, comorbid diseases, and results of bronchoprovocation (BP) testing were recorded. This study was approved by the institutional review board at our hospital. RESULTS: A total of 131 patients (mean age 32.3 ± 11.6, body mass index (BMI) 27.1 ± 4.7 kg/m(2), 59.5% male) had an EVH, MCCT, and clinical evaluation performed. Overall, 37 (28.2%) patients had positive BP testing and met criteria for exercise-induced bronchoconstriction (EIB). There were 32 (24.4%) patients with a positive EVH, compared with only 11 patients with a positive MCCT (8.4%). There were 26 patients (19.8%) who had a positive EVH but a negative MCCT, and correlation between the two tests was poor to moderate (r = 0.11-0.57). A complaint of chest pain and younger age were independent predictors for a positive EVH, whereas a history of tobacco use and a decreased FEV(1)/FVC (forced expiratory volume in 1 s/forced vital capacity) predicted a positive MCCT. A previous diagnosis of asthma was an independent predictor for a response to either test. Discussion. In a population of nonathletes who exercise regularly and have symptoms with exertion, EIB is common. Correlation between EVH and MCCT in this population is poor, and although the tests are somewhat complementary, a large percentage of patients had a negative MCCT but a positive EVH. CONCLUSIONS: EIB is common in nonathletes with exercise-induced symptoms, and EVH is the preferred test for this population. CLINICAL IMPLICATIONS: EIB is common in nonathletes who exercise regularly. In this population, MCCT will miss most patients with EIB, and MCCT and EVH show only poor-to-moderate correlation. CAPSULE SUMMARY: EVH has not been compared with MCCT in nonathletes without a diagnosis of asthma. Our study shows that the two tests are complementary in this population, but EVH is positive more often.

Comparison of adjustable and fixed oral appliances for the treatment of obstructive sleep apnea.

STUDY OBJECTIVES: To compare the efficacy of adjustable and fixed oral appliances for the treatment of OSA. METHODS: Retrospective review of consecutive patients with OSA treated with either adjustable or fixed oral appliances. Polysomnography was conducted before and during therapy. Effective treatment was defined as an apnea-hypopnea index (AHI) < 5 events/h or < 10 events/h with resolution of sleepiness (Epworth < 10). We compared efficacy rates between fixed and adjustable appliances and sought to identify factors associated with greater success. RESULTS: We included 805 patients, 602 (74.8%) treated with an adjustable and 203 (25.2%) a fixed oral appliances. Among the cohort, 86.4% were men; mean age was 41.3 ± 9.2 years. Mean AHI was 30.7 ± 25.6, with 34.1% having mild (AHI 5-14.9), 29.2% moderate (AHI 15-29.9), and 36.8% severe (AHI ≥ 30) OSA. Successful therapy was significantly more common with adjustable appliances. Obstructive events were reduced to < 5/h in 56.8% with adjustable compared to 47.0% with fixed appliances (p = 0.02). Similarly, a reduction of events to < 10 with resolution of sleepiness occurred in 66.4% with adjustable appliances versus 44.9% with fixed appliances (p < 0.001). For both devices, success was more common in younger patients, with lower BMI and less severe disease. CONCLUSIONS: Adjustable devices produced greater reductions in obstructive events and were more likely to provide successful therapy, especially in moderate-severe OSA. Fixed appliances were effective in mild disease, but were less successful in those with higher AHIs. Given these findings, the baseline AHI should be considered when selecting the type of oral appliance.

Efficacy of an adjustable oral appliance and comparison with continuous positive airway pressure for the treatment of obstructive sleep apnea syndrome.

BACKGROUND: We sought to establish the efficacy of an adjustable oral appliance (aOA) in the largest patient population studied to date, to our knowledge, and to provide a comparison with continuous positive airway pressure (CPAP). METHODS: We conducted a retrospective analysis of patients using an aOA. Results of overnight polysomnography with aOA titration were evaluated and compared with CPAP. Predictors of a successful aOA titration were determined using a multivariate logistic regression model. RESULTS: A total of 497 patients were given an aOA during the specified time period. The aOA reduced the mean apnea-hypopnea index (AHI) to 8.4 ± 11.4, and 70.3%, 47.6%, and 41.4% of patients with mild, moderate, and severe disease achieved an AHI < 5, respectively. Patients using an aOA decreased their mean Epworth Sleepiness Score by 2.71 (95% CI, 2.3-3.2; P < .001) at follow-up. CPAP improved the AHI by -3.43 (95% CI, 1.88-4.99; P < .001) when compared with an aOA, but when adjusted for severity of disease, this difference only reached significance for patients with severe disease (-5.88 [95% CI, -8.95 to -2.82; P < .001]). However, 70.1% of all patients achieved an AHI < 5 using CPAP compared with 51.6% for the aOA (P < .001). On multivariate analysis, baseline AHI was a significant predictor of achieving an AHI < 5 on aOA titration, and age showed a trend toward significance. CONCLUSIONS: In comparison with past reports, more patients in our study achieved an AHI < 5 using an aOA. The aOA is comparable to CPAP for patients with mild disease, whereas CPAP is superior for patients with moderate to severe disease. A lower AHI was the only predictor of a successful aOA titration.

Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial.

BACKGROUND: Adherence to short-term continuous positive airway pressure (CPAP) may predict long-term use. Unfortunately, initial CPAP intolerance may lead to poor adherence or abandonment of therapy. OBJECTIVE: To determine whether a short course of eszopiclone at the onset of therapy improves long-term CPAP adherence more than placebo in adults with obstructive sleep apnea. DESIGN: Parallel randomized, placebo-controlled trial from March 2007 to December 2008. Randomization, maintained and concealed centrally by pharmacy personnel, was computer-generated using fixed blocks of 10. Referring physicians, investigators, and patients were blinded to the treatment assignment until after the final data were collected. (ClinicalTrials.gov registration number: NCT00612157). SETTING: Academic sleep disorder center. PATIENTS: 160 adults (mean age, 45.7 years [SD, 7.3]; mean apnea-hypopnea index, 36.9 events/h [SD, 23]) with newly diagnosed obstructive sleep apnea initiating CPAP. INTERVENTION: Eszopiclone, 3 mg (n = 76), or matching placebo (n = 78) for the first 14 nights of CPAP. MEASUREMENTS: Use of CPAP was measured weekly for 24 weeks. Adherence to CPAP (primary outcome) and the rate of CPAP discontinuation and improvements in symptoms (secondary outcomes) were compared. Follow-up at 1, 3, and 6 months was completed by 150, 136, and 120 patients, respectively. RESULTS: Patients in the eszopiclone group used CPAP for 20.8% more nights (95% CI, 7.2% to 34.4%; P = 0.003), 1.3 more hours per night for all nights (CI, 0.4 to 2.2 hours; P = 0.005), and 1.1 more hours per night of CPAP use (CI, 0.2 to 2.1 hours; P = 0.019). The hazard ratio for discontinuation of CPAP was 1.90 (CI, 1.1 to 3.4; P = 0.033) times higher in the placebo group. Side effects were reported in 7.1% of patients and did not differ between groups. LIMITATIONS: Patients had severe obstructive sleep apnea treated at a specialized sleep center with frequent follow-up; results may not be generalizable to different settings. Patients' tolerance to CPAP and their reasons for discontinuation were not assessed. CONCLUSION: Compared with placebo, a short course of eszopiclone during the first 2 weeks of CPAP improved adherence and led to fewer patients discontinuing therapy.

An intensivist-directed intensive care unit improves clinical outcomes in a combat zone.

OBJECTIVE: Intensivist-directed intensive care units (ICUs) have been shown to improve clinical outcomes. Numerous barriers exist that limit hospitals adopting this practice. We sought to show this staffing model can be implemented in an austere environment with limited resources resulting in improved outcomes. DESIGN: We conducted a retrospective observational cohort study of consecutive adult patients admitted to the ICU between March 2004 and January 2007. SETTING: This study was conducted in an ICU in a U.S. Army Combat Support Hospital deployed to Afghanistan. PATIENTS: North Atlantic Trade Organization members (U.S. military service members, American civilian contractors, members of the North Atlantic Trade Organization Coalition International Security Assistance Force), members of the Afghanistan National Army and National Police, and local Afghani nationals were included in the study. Both traumatic injuries and medical illnesses were treated. INTERVENTIONS: During the observation period, the ICU was converted from an open model to an intensivist-directed model. MEASUREMENTS AND MAIN RESULTS: Outcomes compared between the two models included ICU and hospital mortality, duration of mechanical ventilation, and ventilator-associated pneumonia rates. During the observation period, there were 2740 admissions, 965 of which were initially admitted to the ICU. We found significant reductions in ICU mortality (6.6% vs. 4.0%, p < 0.001), duration of mechanical ventilation (4.7 +/- 3.9 days vs. 3.1 +/- 2.7 days, p < 0.001), and rates of ventilator-associated pneumonia (42.5% vs. 8.0%; p < 0.001). CONCLUSIONS: Transition to an intensivist-directed ICU in an Army Combat Support Hospital improved outcomes among ICU patients. This study demonstrates the feasibility of using this model in an austere, combat environment.

Utility of split-night polysomnography in the diagnosis of upper airway resistance syndrome.

PURPOSE: Split-night polysomnography can both establish the diagnosis and titrate continuous positive airway pressure (CPAP) during a single study in patients with sleep-disordered breathing. We sought to determine if split-night polysomnography could be effectively used in upper airway resistance syndrome (UARS) without diminishing diagnostic accuracy or success of CPAP titration. METHODS: Consecutive patients diagnosed with UARS were included. Split-night studies were performed in patients meeting predefined criteria. We compared data between those undergoing traditional and split-night polysomnography. RESULTS: We included 100 consecutive patients (41.2 +/- 7.4 years, 54% men). Forty-six underwent split-night polysomnography. Groups were similar at baseline. There were no differences in polysomnography or success rate of CPAP titration. Among those not undergoing split-night studies, the mean time between diagnostic polysomnography and CPAP titration was 71.9 +/- 49.0 days. CONCLUSIONS: Split-night polysomnography can be effectively utilized to diagnose UARS and initiate CPAP therapy. This practice can reduce the number of studies needed and obviate the inherent delay in initiating CPAP therapy.

Ehrlichiosis: making the diagnosis in the acute setting.

Human monocytic ehrlichiosis (HME) is a tick-borne disease transmitted during the summer months in the mid-Atlantic, southeastern and south-central United States. A large proportion of patients presenting with ehrlichiosis must be hospitalized because of the severity of their presenting signs, symptoms and lab abnormalities. We report a case of HME presenting with negative serologies and positive DNA PCR for Ehrlichia chaffeensis during the acute illness. The patient was empirically treated with doxycycline before the availability of diagnostic test results and had a rapid recovery. This report summarizes the common findings of ehrlichiosis on presentation, diagnostic strategies, and treatment options. This case emphasizes the importance of considering tick-borne diseases in the differential diagnosis for patients presenting with nonspecific febrile syndromes in endemic areas and using the clinical scenario to determine whether empiric treatment for a tick-borne disease is necessary. Delaying treatment while awaiting confirmatory tests is unnecessary, and may result in a less favorable patient outcome.

Histopathologic changes related to fibrotic oviduct occlusion after genital tract infection of mice with Chlamydia muridarum.

OBJECTIVES: We sought to determine if intraluminal occluding fibrosis of the oviduct occurs after urogenital Chlamydia muridarum infection in mice. STUDY: Oviduct occlusion was assessed by infusing dye into the distal uterus and tracking the diffusion of the dye into the oviduct. We also conducted histologic assessment of the affected tissues using hematoxylin and eosin (H&E) and Masson trichrome stains. RESULTS: All previously infected susceptible mice had occluded oviducts compared with 17.5% of previously uninfected mice. Oviduct occlusion correlated with hydrosalpinx formation and infertility. Intraluminal oviduct fibrosis was observed in several sections of tissue displaying hydrosalpinx but not in tissues without hydrosalpinx. Fibrosis was localized to the oviduct isthmus and oviduct proper, proximal to the uterus. CONCLUSION: Intralumenal occluding fibrosis of the oviduct is a sequela of infection with C. muridarum in this model. These observations support the use of the murine model to study pathogenesis of chlamydial upper genital tract infection.