An Outbreak of Covid-19 on an Aircraft Carrier.

BACKGROUND: An outbreak of coronavirus disease 2019 (Covid-19) occurred on the U.S.S. Theodore Roosevelt, a nuclear-powered aircraft carrier with a crew of 4779 personnel. METHODS: We obtained clinical and demographic data for all crew members, including results of testing by real-time reverse-transcriptase polymerase chain reaction (rRT-PCR). All crew members were followed up for a minimum of 10 weeks, regardless of test results or the absence of symptoms. RESULTS: The crew was predominantly young (mean age, 27 years) and was in general good health, meeting U.S. Navy standards for sea duty. Over the course of the outbreak, 1271 crew members (26.6% of the crew) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by rRT-PCR testing, and more than 1000 infections were identified within 5 weeks after the first laboratory-confirmed infection. An additional 60 crew members had suspected Covid-19 (i.e., illness that met Council of State and Territorial Epidemiologists clinical criteria for Covid-19 without a positive test result). Among the crew members with laboratory-confirmed infection, 76.9% (978 of 1271) had no symptoms at the time that they tested positive and 55.0% had symptoms develop at any time during the clinical course. Among the 1331 crew members with suspected or confirmed Covid-19, 23 (1.7%) were hospitalized, 4 (0.3%) received intensive care, and 1 died. Crew members who worked in confined spaces appeared more likely to become infected. CONCLUSIONS: SARS-CoV-2 spread quickly among the crew of the U.S.S. Theodore Roosevelt. Transmission was facilitated by close-quarters conditions and by asymptomatic and presymptomatic infected crew members. Nearly half of those who tested positive for the virus never had symptoms.

SARS-CoV-2 Infections and Serologic Responses from a Sample of U.S. Navy Service Members - USS Theodore Roosevelt, April 2020.

Compared with the volume of data on coronavirus disease 2019 (COVID-19) outbreaks among older adults, relatively few data are available concerning COVID-19 in younger, healthy persons in the United States (1,2). In late March 2020, the aircraft carrier USS Theodore Roosevelt arrived at port in Guam after numerous U.S. service members onboard developed COVID-19. In April, the U.S. Navy and CDC investigated this outbreak, and the demographic, epidemiologic, and laboratory findings among a convenience sample of 382 service members serving aboard the aircraft carrier are reported in this study. The outbreak was characterized by widespread transmission with relatively mild symptoms and asymptomatic infection among this sample of mostly young, healthy adults with close, congregate exposures. Service members who reported taking preventive measures had a lower infection rate than did those who did not report taking these measures (e.g., wearing a face covering, 55.8% versus 80.8%; avoiding common areas, 53.8% versus 67.5%; and observing social distancing, 54.7% versus 70.0%, respectively). The presence of neutralizing antibodies, which represent antibodies that inhibit SARS-CoV-2, among the majority (59.2%) of those with antibody responses is a promising indicator of at least short-term immunity. This report improves the understanding of COVID-19 in the U.S. military and among young adults in congregate settings and reinforces the importance of preventive measures to lower risk for infection in similar environments.

Content validity testing of questions for a patient satisfaction with general anesthesia care instrument.

INTRODUCTION: Patient satisfaction with any health care experience is the result of a complex set of interactions between the patient and the health system in which care is received. Measuring patient satisfaction allows quantification of the congruence between the expectations of care and the care that is received. It is important to quantify satisfaction with care because it involves the patient in the care experience and decreases the potential gap between expected and actual care delivered over time. Despite the benefits of measuring satisfaction with anesthesia care, this outcome has been historically understudied possibly because of a lack of reliable tools that measure the construct. PURPOSE: The purpose of this study was to test the content validity of items derived from an integrated review of studies that measured patient satisfaction with anesthesia care. METHODS: The content validity of the questions was tested using an expert panel. A total of 13 nurse anesthetists consented to participate in the study as expert panel members. Each expert panel member evaluated the items for content validity on a 4-point scale. Both an Individual Content Validity Index (I-CVI) and a Scale Content Validity Index (S-CVI) were calculated. RESULTS: All I-CVI scores were greater than 0.8. The range of I-CVI was 0.833 to 1.0. The average scale Content Validity Index (S-CVI/ave) was 0.979. CONCLUSION: High content validity of all items was supported by an expert panel of anesthesia providers. The high level of agreement among raters related to the content of the general anesthesia statements supports progressing to the next step in instrument development.

Use of the Rasch model for initial testing of fit statistics and rating scale diagnosis for a general anesthesia satisfaction questionnaire.

BACKGROUND AND PURPOSE: The level of patient satisfaction is a result of a complex set of interactions between the patient and the health care provider. It is important to quantify satisfaction with care because it involves the patient in the care experience and decreases the potential gap between expected and actual care delivered. METHODS: We tested a preliminary 23-item instrument to measure patient satisfaction with general anesthesia care. The rating scale Rasch model was chosen as the framework. RESULTS: There were 10 items found to have sufficient evidence of stable fit statistics. Items included 2 questions related to information provided, 2 questions related to concern and kindness of the provider, and 1 question each for interpersonal skills of the provider, attention by the provider, feeling safe, well-being, privacy, and overall anesthesia satisfaction. CONCLUSION: Such actions as providing enough time to understand the anesthesia plan, answering questions related to the anesthetic, showing kindness and concern for the patient, displaying good interpersonal skills, providing adequate attention to the patient, providing a safe environment that maintains privacy and provides a sense of well-being are important actions that are well within the control of individual anesthesia providers and may lead to improved care from the perception of the patient.

Use of the Rasch Model for Fit Statistics and Rating Scale Diagnosis for the Student Perception Appraisal-Revised.

Background and Purpose: Nursing student retention is essential to meet workforce demands. Jeffrey's Nursing Student Retention Student Perception Appraisal-Revised (SPA-R1) has been used extensively to understand factors that impact retention. Psychometric testing of the SPA-R1 contributes to greater confidence in the instrument's reliability and validity. Methods: Item response theory and specifically, the single parameter polytomous Rasch model was used as a framework for fit statistic testing and rating scale diagnostics of the SPA-R1. This was a secondary analysis of a convenience sample of undergraduate prelicensure nursing students. The setting for the previous study was virtual, and the study period was 2022. Results: The model item characteristic curves for the 27 items of the SPA-R1 have similar shapes and are clustered in proximity. Overall, there are three clusters of items evident in the Rasch standardized residual contrast. The Rasch scale diagnostics indicated that the scale appropriately monotonically increases. However, there is a greater than 5 logit distance between does not apply and severely restricts, between severely restricts and moderately restricts, and between does not restrict or support and moderately supports. These large threshold distances indicate that additional steps in the scale may be warranted. The items cover the mid-range of the amount of retention perceptions; however, there are no items that represent the highest magnitude of the perceived amount of influence on retention. Conclusions: This study contributes further evidence to support the validity and reliability of the SPA-R1. We recommend adding steps to the scale, removing the does not apply response option, and considering scoring by three domains or clusters.

Genotypic distribution of a specialist model microorganism, Methanosaeta, along an estuarine gradient: does metabolic restriction limit niche differentiation potential?

A reductionist ecological approach of using a model genus was adopted in order to understand how microbial community structure is driven by metabolic properties. The distribution along an estuarine gradient of the highly specialised genus Methanosaeta was investigated and compared to the previously determined distribution of the more metabolically flexible Desulfobulbus. Methanosaeta genotypic distribution along the Colne estuary (Essex, UK) was determined by DNA- and RNA-based denaturing gradient gel electrophoresis and 16S rRNA gene sequence analyses. Methanosaeta distribution was monotonic, with a consistently diverse community and no apparent niche partitioning either in DNA or RNA analyses. This distribution pattern contrasts markedly with the previously described niche partitioning and sympatric differentiation of the model generalist, Desulfobulbus. To explain this difference, it is hypothesised that Methanosaeta's strict metabolic needs limit its adaptation potential, thus populations do not partition into spatially distinct groups and so do not appear to be constrained by gross environmental factors such as salinity. Thus, at least for these two model genera, it appears that metabolic flexibility may be an important factor in spatial distribution and this may be applicable to other microbes.

Genotypic distribution of an indigenous model microorganism along an estuarine gradient.

Using the genus Desulfobulbus as an indigenous model, microbial distribution along an estuarine gradient was investigated. Denaturing gradient gel electrophoresis analysis indicated a sequential change in Desulfobulbus genotypes along the estuary with marine, brackish and freshwater genotypes detected. This differential distribution was significantly correlated with porewater concentrations of chloride, sulphate and nitrate. Temporal analysis indicated that there was a shift in the whole Desulfobulbus community towards to marine end of the estuary by the end of the winter compared with the late summer. This distribution pattern is similar to those seen with other estuarine organisms and, given the correlation with chloride and sulphate, is indicative of classic niche separation within this genus driven by gross environmental factors such as salinity. These results will help in developing a truly ecological description of microbial biodiversity.

Non-clinical information obtained by dentists during initial examinations of older adult patients.

The authors sent a questionnaire to a random sample of general dentists in Ontario, Canada, to assess the types of non-clinical information (NCI) dentists usually obtain during initial examinations of older patients. From a list of 11 NCI questions, dentists indicated which questions they usually asked during new patient examinations. The adjusted response rate was 34% (n = 672). Respondents most often asked about pain and satisfaction with the appearance of teeth and/or dentures. About half the respondents asked about oral dryness and whether problems with chewing had limited food choices. Respondents were least likely to ask about problems with speaking and avoidance of eating with others because of chewing problems. Traits of those who asked the least common NCI questions typically including continuing education courses in geriatric dentistry, self-perceived competence in treating elderly adults living in institutional settings, exposure to geriatric outreach settings during dental school and greater dentist involvement in patient history taking.

Salivary sIgA and cortisol: markers for functional dependence in older adults.

Elderly persons with health problems and physical limitations have reduced independence. Since poor functional ability is a known risk factor for disease among older populations, including oral disease, this study was undertaken to assess whether salivary defense factors and the stress hormone cortisol are significant markers for functional dependence. Oral examinations; salivary and microbial analyses; and interviews using the Activities of Daily Living (ADD index, the Mini Nutritional Assessment (MNA) and the Perceived Life Stress Questionnaire (PLSQ) were conducted for 123 dentate subjects. Of the subjects, 80 lived independently in the community or in apartments at the Baycrest Centre for Geriatric Care in Toronto, Canada, and 43 resided in the Baycrest nursing home or the Baycrest Hospital. Whole saliva samples were assayed for total secretory immunoglobulin A (sIgA), sIgA1, sIgA2, total protein and cortisol using ELISA. Dependent residents in the nursing home/hospital scored significantly lower in the nutritional assessment, had higher mean PLSQ scores, increased total protein and cortisol concentrations, and reduced salivary flow rates in comparison to ambulatory residents in the community/apartments. In multivariable logistic regression, factors associated with functional dependence were: being male, perceiving income as inadequate, having low salivary flow rate and drinking less than 5 cups of water per day. These results indicate that salivary flow and cortisol may be useful markers of functional dependence; however, the ability of these markers to predict functional decline cannot be confirmed until longitudinal studies are conducted.

The use of nalmefene for intrathecal opioid-associated nausea in postpartum patients.

The aim of this study was to compare the severity of nausea and incidence of emesis in laboring parturients who received intravenous nalmefene or placebo following an intrathecal opioid (ITO). We randomly assigned 60 ASA class I or II multiparous women to receive nalmefene or placebo. Subjects received fentanyl, 25 micrograms, and morphine, 250 micrograms, intrathecally on request for analgesia. Thirty minutes after vaginal delivery, the experimental group received nalmefene, 20 micrograms, and the placebo group received an equivalent volume of normal saline intravenously. Visual analog scale nausea scores and data about episodes of emesis were obtained during labor and during the first 24 hours postpartum. There were no significant differences in age, weight, duration of labor, volume of intravenous fluids infused, time from last meal to delivery, or time from administration of the ITO to injection of the study drug. There were no significant differences in mean visual analog scale nausea scores or frequency of emesis for any time interval. Nalmefene, 20 micrograms, given intravenously within 30 minutes of vaginal delivery does not significantly reduce the nausea and vomiting associated with the use of ITOs for labor analgesia.

Use of the Rasch Model for Initial Testing of Fit Statistics and Rating Scale Diagnosis for a General Anesthesia Satisfaction Questionnaire.

BACKGROUND AND PURPOSE: The level of patient satisfaction is a result of a complex set of interactions between the patient and the health care provider. It is important to quantify satisfaction with care because it involves the patient in the care experience and decreases the potential gap between expected and actual care delivered. METHODS: We tested a preliminary 23-item instrument to measure patient satisfaction with general anesthesia care. The rating scale Rasch model was chosen as the framework. RESULTS: There were 10 items found to have sufficient evidence of stable fit statistics. Items included 2 questions related to information provided, 2 questions related to concern and kindness of the provider, and 1 question each for interpersonal skills of the provider, attention by the provider, feeling safe, well-being, privacy, and overall anesthesia satisfaction. CONCLUSION: Such actions as providing enough time to understand the anesthesia plan, answering questions related to the anesthetic, showing kindness and concern for the patient, displaying good interpersonal skills, providing adequate attention to the patient, providing a safe environment that maintains privacy and provides a sense of well-being are important actions that are well within the control of individual anesthesia providers and may lead to improved care from the perception of the patient.

An integrative review of factors related to patient satisfaction with general anesthesia care.

Surgery is typically performed using one or more types of anesthesia. An important patient outcome related to the anesthetic, and a measure of quality from the patient's perspective, is patient satisfaction with anesthesia care. Currently, no psychometrically validated instruments that measure patient satisfaction with general anesthesia care are available in the United States. This integrative review focuses on identifying factors related to adult patients' satisfaction with general anesthesia care. We found the most frequently mentioned modifiable factors related to patient satisfaction were information provided and pain or discomfort. The only nonmodifiable factor with sufficient evidence to include in future studies on instrument development is the patient's age. This review provides information that can help in the design and implementation of quality improvement initiatives and in the development of an instrument to measure patient satisfaction with general anesthesia care.

Contrasting patterns of niche partitioning between two anaerobic terminal oxidizers of organic matter.

Understanding the ecological principles underlying the structure and function of microbial communities remains an important goal for microbial ecology. We examined two biogeochemically important taxa, the sulfate-reducing bacterial genus, Desulfobulbus, and the methanogenic archaeal genus, Methanosaeta, to compare and contrast niche partitioning by these two taxa that are ecologically linked as anaerobic terminal oxidizers of organic material. An observational approach utilizing functional gene pyrosequencing was combined with a community-based reciprocal incubation experiment and characterization of a novel Desulfobulbus isolate. To analyze the pyrosequencing data, we constructed a data analysis pipeline, which we validated with several control data sets. For both taxa, particular genotypes were clearly associated with certain portions of an estuarine gradient, consistent with habitat or niche partitioning. Methanosaeta genotypes were generally divided between those found almost exclusively in the marine habitat (∼30% of operational taxonomic units (OTUs)), and those which were ubiquitously distributed across all or most of the estuary (∼70% of OTUs). In contrast to this relatively monotonic distribution, for Desulfobulbus, there were many more genotypes, and their distributions represented a wide range of inferred niche widths from specialist genotypes found only at a single site, to ubiquitous or generalist genotypes found in all 10 sites examined along the full estuarine gradient. Incubation experiments clearly showed that, for both taxa, communities from opposite ends of the estuary did not come to resemble one another, regardless of the chemical environment. Growth of a Desulfobulbus isolated into pure culture indicated that the potential niche of this organism is significantly larger than the realized niche. We concluded that niche partitioning can be an important force structuring microbial populations, with biotic and abiotic components having very different effects depending on the physiology and ecology of each taxon.

Evolutionary divergence and biogeography of sympatric niche-differentiated bacterial populations.

Using multiple lines of evidence from denaturing gradient gel electrophoresis, environmental sequences and TaqMan quantitative PCR assays targeting a functional gene for sulfate respiration (dsr) affiliated with the geochemically important genus Desulfobulbus, we revealed strongly restricted distributions of specific genotypes and populations correlated with sampling position along an estuarine gradient free of dispersal barriers. Evidence of evolutionary divergence of populations was provided by three complementary analyses. First, analysis of molecular variance rejected the null hypothesis that genetic diversity within each sampling site was not significantly different than that of all sites pooled together (P<0.0001). Second, UniFrac and Parsimony tests showed phylogenetic clustering of sampling sites was highly significant (P<0.001). Third, pairwise F(ST) statistics showed significant evolutionary divergence of populations based on the location in the estuary. To test the hypothesis that environmental niche-driven evolutionary divergence can create and maintain microbial biogeography, we used both statistical inference and an experimental manipulation to assess the independent effects of environment and geography. Significant effects of each on genotype distributions and population divergence supported the hypothesis. Our data are consistent with both sympatric and parapatric models of speciation, and suggest niche partitioning can contribute to evolutionary divergence and observable biogeographic patterns in microbial communities even among closely related taxa at limited spatial scales without significant barriers to dispersal.