Higher severe acute respiratory syndrome coronavirus 2 infection rate in pregnant patients.

BACKGROUND: During the early months of the coronavirus disease 2019 pandemic, risks associated with severe acute respiratory syndrome coronavirus 2 in pregnancy were uncertain. Pregnant patients can serve as a model for the success of clinical and public health responses during public health emergencies as they are typically in frequent contact with the medical system. Population-based estimates of severe acute respiratory syndrome coronavirus 2 infections in pregnancy are unknown because of incomplete ascertainment of pregnancy status or inclusion of only single centers or hospitalized cases. Whether pregnant women were protected by the public health response or through their interactions with obstetrical providers in the early months of pandemic is not clearly understood. OBJECTIVE: This study aimed to estimate the severe acute respiratory syndrome coronavirus 2 infection rate in pregnancy and to examine the disparities by race and ethnicity and English language proficiency in Washington State. STUDY DESIGN: Pregnant patients with a polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection diagnosed between March 1, 2020, and June 30, 2020 were identified within 35 hospitals and clinics, capturing 61% of annual deliveries in Washington State. Infection rates in pregnancy were estimated overall and by Washington State Accountable Community of Health region and cross-sectionally compared with severe acute respiratory syndrome coronavirus 2 infection rates in similarly aged adults in Washington State. Race and ethnicity and language used for medical care of pregnant patients were compared with recent data from Washington State. RESULTS: A total of 240 pregnant patients with severe acute respiratory syndrome coronavirus 2 infections were identified during the study period with 70.7% from minority racial and ethnic groups. The principal findings in our study were as follows: (1) the severe acute respiratory syndrome coronavirus 2 infection rate was 13.9 per 1000 deliveries in pregnant patients (95% confidence interval, 8.3-23.2) compared with 7.3 per 1000 (95% confidence interval, 7.2-7.4) in adults aged 20 to 39 years in Washington State (rate ratio, 1.7; 95% confidence interval, 1.3-2.3); (2) the severe acute respiratory syndrome coronavirus 2 infection rate reduced to 11.3 per 1000 deliveries (95% confidence interval, 6.3-20.3) when excluding 45 cases of severe acute respiratory syndrome coronavirus disease 2 detected through asymptomatic screening (rate ratio, 1.3; 95% confidence interval, 0.96-1.9); (3) the proportion of pregnant patients in non-White racial and ethnic groups with severe acute respiratory syndrome coronavirus disease 2 infection was 2- to 4-fold higher than the race and ethnicity distribution of women in Washington State who delivered live births in 2018; and (4) the proportion of pregnant patients with severe acute respiratory syndrome coronavirus 2 infection receiving medical care in a non-English language was higher than estimates of pregnant patients receiving care with limited English proficiency in Washington State (30.4% vs 7.6%). CONCLUSION: The severe acute respiratory syndrome coronavirus 2 infection rate in pregnant people was 70% higher than similarly aged adults in Washington State, which could not be completely explained by universal screening at delivery. Pregnant patients from nearly all racial and ethnic minority groups and patients receiving medical care in a non-English language were overrepresented. Pregnant women were not protected from severe acute respiratory syndrome coronavirus 2 infection in the early months of the pandemic. Moreover, the greatest burden of infections occurred in nearly all racial and ethnic minority groups. These data coupled with a broader recognition that pregnancy is a risk factor for severe illness and maternal mortality strongly suggested that pregnant people should be broadly prioritized for coronavirus disease 2019 vaccine allocation in the United States similar to some states.

Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State.

BACKGROUND: Evidence is accumulating that coronavirus disease 2019 increases the risk of hospitalization and mechanical ventilation in pregnant patients and for preterm delivery. However, the impact on maternal mortality and whether morbidity is differentially affected by disease severity at delivery and trimester of infection are unknown. OBJECTIVE: This study aimed to describe disease severity and outcomes of severe acute respiratory syndrome coronavirus 2 infections in pregnancy across the Washington State, including pregnancy complications and outcomes, hospitalization, and case fatality. STUDY DESIGN: Pregnant patients with a polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 1, 2020, and June 30, 2020, were identified in a multicenter retrospective cohort study from 35 sites in Washington State. Sites captured 61% of annual state deliveries. Case-fatality rates in pregnancy were compared with coronavirus disease 2019 fatality rates in similarly aged adults in Washington State using rate ratios and rate differences. Maternal and neonatal outcomes were compared by trimester of infection and disease severity at the time of delivery. RESULTS: The principal study findings were as follows: (1) among 240 pregnant patients in Washington State with severe acute respiratory syndrome coronavirus 2 infections, 1 in 11 developed severe or critical disease, 1 in 10 were hospitalized for coronavirus disease 2019, and 1 in 80 died; (2) the coronavirus disease 2019-associated hospitalization rate was 3.5-fold higher than in similarly aged adults in Washington State (10.0% vs 2.8%; rate ratio, 3.5; 95% confidence interval, 2.3-5.3); (3) pregnant patients hospitalized for a respiratory concern were more likely to have a comorbidity or underlying conditions including asthma, hypertension, type 2 diabetes mellitus, autoimmune disease, and class III obesity; (4) 3 maternal deaths (1.3%) were attributed to coronavirus disease 2019 for a maternal mortality rate of 1250 of 100,000 pregnancies (95% confidence interval, 257-3653); (5) the coronavirus disease 2019 case fatality in pregnancy was a significant 13.6-fold (95% confidence interval, 2.7-43.6) higher in pregnant patients than in similarly aged individuals in Washington State with an absolute difference in mortality rate of 1.2% (95% confidence interval, -0.3 to 2.6); and (6) preterm birth was significantly higher among women with severe or critical coronavirus disease 2019 at delivery than for women who had recovered from coronavirus disease 2019 (45.4% severe or critical coronavirus disease 2019 vs 5.2% mild coronavirus disease 2019; P<.001). CONCLUSION: Coronavirus disease 2019 hospitalization and case-fatality rates in pregnant patients were significantly higher than in similarly aged adults in Washington State. These data indicate that pregnant patients are at risk of severe or critical disease and mortality compared to nonpregnant adults, and also at risk for preterm birth.

Clinical characteristics of 46 pregnant women with a severe acute respiratory syndrome coronavirus 2 infection in Washington State.

BACKGROUND: The impact of coronavirus disease 2019 on pregnant women is incompletely understood, but early data from case series suggest a variable course of illness from asymptomatic or mild disease to maternal death. It is unclear whether pregnant women manifest enhanced disease similar to influenza viral infection or whether specific risk factors might predispose to severe disease. OBJECTIVE: To describe maternal disease and obstetrical outcomes associated with coronavirus disease 2019 in pregnancy to rapidly inform clinical care. STUDY DESIGN: This is a retrospective study of pregnant patients with a laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection from 6 hospital systems in Washington State between Jan. 21, 2020, and April 17, 2020. Demographics, medical and obstetrical history, and coronavirus disease 2019 encounter data were abstracted from medical records. RESULTS: A total of 46 pregnant patients with a severe acute respiratory syndrome coronavirus 2 infection were identified from hospital systems capturing 40% of births in Washington State. Nearly all pregnant individuals with a severe acute respiratory syndrome coronavirus 2 infection were symptomatic (93.5%, n=43) and the majority were in their second or third trimester (43.5% [n=20] and 50.0% [n=23], respectively). Symptoms resolved in a median of 24 days (interquartile range, 13-37). Notably, 7 women were hospitalized (16%) including 1 admitted to the intensive care unit. A total of 6 cases (15%) were categorized as severe coronavirus disease 2019 with nearly all patients being either overweight or obese before pregnancy or with asthma or other comorbidities. Of the 8 deliveries that occurred during the study period, there was 1 preterm birth at 33 weeks' gestation to improve pulmonary status in a woman with class III obesity, and 1 stillbirth of unknown etiology. CONCLUSION: Severe coronavirus disease 2019 developed in approximately 15% of pregnant patients and occurred primarily in overweight or obese women with underlying conditions. Obesity and coronavirus disease 2019 may synergistically increase risk for a medically indicated preterm birth to improve maternal pulmonary status in late pregnancy. These findings support categorizing pregnant patients as a higher-risk group, particularly those with chronic comorbidities.

Local Extreme Heat Planning: an Interactive Tool to Examine a Heat Vulnerability Index for Philadelphia, Pennsylvania.

Exposure to extreme heat contributes to high morbidity and mortality relative to other climate hazards. The city of Philadelphia, PA is particularly vulnerable to the impacts of extreme heat, due to the urban heat island effect and high prevalence of sensitive populations. We developed a heat vulnerability index, which identified priority areas that are most at-risk of experiencing adverse heat-related health outcomes and in need of preparedness and mitigation interventions. An interactive website was created to display the maps and allow the public to navigate the data with links to potential resources for relief from extreme heat days. Such methods can be adapted for other cities that wish to identify and target long-term priority areas.

Accountable Care Organizations and Health Disparities of Rural Latinos: A Longitudinal Analysis.

The purpose of this study was 2-fold: (1) to analyze the change in diabetes-related hospitalization rates of rural Latino older adult patients as compared with their White counterparts and (2) to determine what factors, including rural health clinic (RHC) participation in accountable care organizations (ACOs), are related to reduced disparities in diabetes-related hospitalization rates. Data for Latino Medicare beneficiaries who were served by RHCs over an 8-year period were analyzed. First, a difference-of-means test was conducted to determine whether there was a change in disparity from the pre-ACO period (2008-2011) to the post-ACO period (2012-2015). A statistically significant decrease in disparity over time was found (t = -7.6899, df = 115, P < 0.001.) Second, multiple regression analyses of 3 separate models were conducted to determine whether ACO participation contributed to reducing disparities in diabetes-related hospitalization rates between Latinos and Whites. The analyses indicated moderate evidence that consistent ACO participation is associated with lower health disparities (t = -1.947, P = 0.0525). However, this association is not significant after balancing covariates, and no causal relationship can be established. Latinos compose one of the fastest growing groups in rural as well as urban areas of the United States. It is critical that ACOs, with their emphasis on care coordination, health care quality, and value, monitor their provision of services to Latinos, rural, and other vulnerable populations.

Trends in Health Disparities of Rural Latinos Pre- and Post-Accountable Care Organization Implementation.

Purpose: We present findings from a longitudinal investigation, the purpose of which was to compare health disparities of rural Latino older adult patients diagnosed with diabetes to their non-Latino White counterparts. Methodology/Approach: A pre-post design was implemented treating Medicare Accountable Care Organization (ACO) participation by Rural Health Clinics (RHCs) as an intervention, and using diabetes-related hospitalizations to measure disparities. Data for a nationwide panel of 2,683 RHCs were analyzed for a study period of eight years: 2008 - 2015. In addition, data were analyzed for a subset of 116 RHCs located in Florida, Texas, and California that participated in a Medicare ACO in one or more years of the study period. Findings: Two broad findings resulted from this investigation. First, for both the nationwide panel of RHCs and the three-state sample of "ACO RHCs," there was a decrease in the mean disparities in diabetes-related hospitalization rates over the eight-year study period. Second, in comparing a three-year time period after Medicare ACO implementation in 2012 to a four-year period before the implementation, a statistically significant difference in mean disparities was found for the nationwide panel. Research limitations/implications: There are a number of factors that may contribute to the decrease in diabetes-related hospitalization rates for Latinos in more recent years. Future research will identify specific contributors to reducing diabetes-related hospitalization disparities between Latinos and the general population, including the possible influence of ACO participation by RHCs. Originality/Value of Paper: This paper presents original research conducted using data related to rural Latino older adults. The data represent multiple states and an eight-year time period. The U.S. Latino population is growing at a rapid pace. As a group, they are at a high risk for developing diabetes, the complications of which are serious and costly to the patient and the U.S. healthcare system. With the continued growth of the Latino population, it is critical that their health disparities be monitored, and that factors that contribute to their health and well-being be identified and promoted.

Healthcare Needs of U.S. Rural Latinos: A Growing, Multicultural Population.

PURPOSE: From 2000 to 2050, the Latino population in the United States (U.S.) is expected to grow by 273%. Health outcomes vary widely among Latino subgroups and health disparities more adversely affect rural residents. The commonly used "one-size-fits-all" approach assumes that the U.S. Latino population is homogeneous. SAMPLE METHOD: Rural Latinos in four study states: Arizona (AZ), California (CA), Florida (FL) and Texas (TX) were the focus of this study. This research describes changes in the Latino population in rural counties of the U.S. in two dimensions: 1) change in population by number, and 2) change in population by country of origin using data from 2000-2017. FINDINGS: The following themes emerged: 1) the overall Latino population grew in each state; 2) rural Latino populations in each state also increased but at a higher rate; 3) there is a variety of diversity in the countries of origin of rural Latinos based in each state; and 4) a considerable proportion of Latinos living in rural areas are of unknown Latino origins. CONCLUSIONS: As the largest racial or ethnic minority in rural populations and as the second largest group in the nation, Latino health has a significant influence on the U.S. healthcare system. For nurses, evidence-based strategies can be tailored to address diverse Latino subpopulations to reduce specific disparities for various ethnic populations.

Dimerization of the bacterial RsrI N6-adenine DNA methyltransferase.

Dimeric restriction endonucleases and monomeric modification methyltransferases were long accepted as the structural paradigm for Type II restriction systems. Recent studies, however, have revealed an increasing number of apparently dimeric DNA methyltransferases. Our initial characterization of RsrI methyltransferase (M.RsrI) was consistent with the enzyme functioning as a monomer, but, subsequently, the enzyme crystallized as a dimer with 1500 A2 of buried surface area. This result led us to re-examine the biochemical properties of M.RsrI. Gel-shift studies of M.RsrI binding to DNA suggested that binding cooperativity targets hemimethylated DNA preferentially over unmethylated DNA. Size-exclusion chromatography indicated that the M.RsrI-DNA complex had a size and stoichiometry consistent with a dimeric enzyme binding to the DNA. Kinetic measurements revealed a quadratic relationship between enzyme velocity and concentration. Site-directed mutagenesis at the dimer interface affected the kinetics and DNA-binding of the enzyme, providing support for a model proposing an active enzyme dimer. We also identified a conserved motif in the dimer interfaces of the beta-class methyltransferases M.RsrI, M.MboIIA and M2.DpnII. Taken together, these data suggest that M.RsrI may be part of a sub-class of MTases that function as dimers.

Soft tissue perineurioma of the finger: expanding the differential diagnosis of a soft tissue tumor presenting on a digit.

Peripheral nerves are surrounded by an external sheath, which contains concentric layers of thin perineurial cells. Perineuriomas are rare nerve sheath tumors composed of well-differentiated perineurial cells that have a distinct ultrastructural and immunochemical phenotype. We review the histologic characteristics and staining patterns, reported variants, and salient features that differentiate this entity from other soft tissue tumors that may present on a digit. Because of the nonspecific clinical appearance and varying histology on hematoxylin-eosin stain, perineuriomas are likely to be confused with more common tumors of the hand and, therefore, should be included in the differential diagnosis of a soft tissue tumor presenting on a digit.

Epidemic trichodinosis associated with severe epidermal hyperplasia in largemouth bass, Micropterus salmoides, from North Carolina, USA.

An epidemic of trichodinosis associated with severe epidermal hyperplasia occurred in adult largemouth bass (Micropterus salmoides) from the Chowan River drainage, North Carolina (USA) in late winter to early spring 2002. Initial reports by anglers of fish with a "jelly-like slime coat" on the skin prompted an electrofishing survey in which about 10% of sampled largemouth bass had a very thick, bluish-white "mucoid layer" on the body and fins. Moderate to heavy infestations of the ciliate Trichodina were detected in wet mounts of skin from five of five fish having the mucoid layer; these fish also had significant gill infestations. An additional two fish with only mild reddening and four asymptomatic fish (no skin lesions) had mild skin infestations but no gill infestations. Two asymptomatic fish had no skin parasites. Four fish with the mucoid layer were necropsied and had extremely severe epidermal hyperplasia on the body and fins. The hyperplasic epidermis had relatively few mucus cells and typically was about 5-10 times thicker than healthy epidermis. The upper four fifths of the epidermis consisted of finely vacuolated, highly flattened, somewhat disorganized epithelial cells. No other significant clinical or histopathologic abnormalities were detected. No systemic infection by pathogenic bacteria was noted. The environmental cause of the epidemic is uncertain but the lesions suggest that some chronic stressor was involved.

Locating and communicating with at-risk populations about emergency preparedness: the vulnerable populations outreach model.

Vulnerable populations tend to have the worst health outcomes during and after disasters; however, these populations are rarely included in the emergency planning process. In Philadelphia, the Department of Public Health and the Office of Emergency Management have reached out to community-based organizations that serve vulnerable populations to include these key stakeholders in emergency planning. In this article, we outline strategies for locating, engaging, and communicating with vulnerable populations about both organizational and personal emergency preparedness. Such strategies include creating a method for bidirectional communication via a free quarterly health newsletter that is distributed to community-based organizations serving vulnerable populations. We also note successes and next steps from engaging vulnerable populations in the planning process in Philadelphia.

A child with hypohidrotic ectodermal dysplasia with features of a collodion membrane.

Collodion membrane is a presenting phenotype common to several disorders, predominantly congenital ichthyoses. Seventy percent of infants born with hypohidrotic (anhidrotic) ectodermal dysplasia are noted by their parents to have significant scaling and peeling. Although dry skin is a frequently reported sign in children with hypohidrotic ectodermal dysplasia, only one French study has reported a true collodion membrane at birth. We suspect that scaling with features of collodion membrane is more common in infants than is reflected in the literature, and we describe another such infant, later diagnosed with hypohidrotic ectodermal dysplasia.

Structures of liganded and unliganded RsrI N6-adenine DNA methyltransferase: a distinct orientation for active cofactor binding.

The structures of RsrI DNA methyltransferase (M.RsrI) bound to the substrate S-adenosyl-l-methionine (AdoMet), the product S-adenosyl-l-homocysteine (AdoHcy), the inhibitor sinefungin, as well as a mutant apo-enzyme have been determined by x-ray crystallography. Two distinct binding configurations were observed for the three ligands. The substrate AdoMet adopts a bent shape that directs the activated methyl group toward the active site near the catalytic DPPY motif. The product AdoHcy and the competitive inhibitor sinefungin bind with a straight conformation in which the amino acid moiety occupies a position near the activated methyl group in the AdoMet complex. Analysis of ligand binding in comparison with other DNA methyltransferases reveals a small, common subset of available conformations for the ligand. The structures of M.RsrI with the non-substrate ligands contained a bound chloride ion in the AdoMet carboxylate-binding pocket, explaining its inhibition by chloride salts. The L72P mutant of M.RsrI is the first DNA methyltransferase structure without bound ligand. With respect to the wild-type protein, it had a larger ligand-binding pocket and displayed movement of a loop (223-227) that is responsible for binding the ligand, which may account for the weaker affinity of the L72P mutant for AdoMet. These studies show the subtle changes in the tight specific interactions of substrate, product, and an inhibitor with M.RsrI and help explain how each displays its unique effect on the activity of the enzyme.