Household Transmission of Carbapenemase-producing Enterobacterales in Ontario, Canada.

BACKGROUND: Data on household transmission of carbapenemase-producing Enterobacterales (CPE) remain limited. We studied risk of CPE household co-colonization and transmission in Ontario, Canada. METHODS: We enrolled CPE index cases (identified via population-based surveillance from January 2015 to October 2018) and their household contacts. At months 0, 3, 6, 9, and 12, participants provided rectal and groin swabs. Swabs were cultured for CPE until September 2017, when direct polymerase chain reaction (PCR; with culture of specimens if a carbapenemase gene was detected) replaced culture. CPE risk factor data were collected by interview and combined with isolate whole-genome sequencing to determine likelihood of household transmission. Risk factors for household contact colonization were explored using a multivariable logistic regression model with generalized estimating equations. RESULTS: Ninety-five households with 177 household contacts participated. Sixteen (9%) household contacts in 16 (17%) households were CPE-colonized. Household transmission was confirmed in 3/177 (2%) cases, probable in 2/177 (1%), possible in 9/177 (5%), and unlikely in 2/177 (1%). Household contacts were more likely to be colonized if they were the index case's spouse (odds ratio [OR], 6.17; 95% confidence interval [CI], 1.05-36.35), if their index case remained CPE-colonized at household enrollment (OR, 7.00; 95% CI, 1.92-25.49), or if they had at least 1 set of specimens processed after direct PCR was introduced (OR, 6.46; 95% CI, 1.52-27.40). CONCLUSIONS: Nine percent of household contacts were CPE-colonized; 3% were a result of household transmission. Hospitals may consider admission screening for patients known to have CPE-colonized household contacts.

A comparison of the self-report patterns of analog versus real-world malingerers of attention deficit hyperactivity disorder.

Much of what we know about malingering of attention deficit hyperactivity disorder (ADHD) has been learned from the performance of analog malingerers, typically first-year psychology students given credit for study participation. It is not clear, however, whether their performance is similar to that found in actual clinical settings. Indeed, past research suggests that analog malingerers may overexaggerate deficits relative to real-world malingerers, making them easier to identify in controlled studies. The purpose of the current study was, therefore, to compare the performance of analog malingers to post-secondary students strongly suspected of malingering ADHD on a self-report measure of ADHD symptoms. Their scores were, in turn, compared to those returned by students with genuine ADHD and clinical controls. Results demonstrated that, apart from analog subjects overexaggerating symptoms of hyperactivity, few differences exist between the scores returned by analog malingerers relative to clinical malingerers. While newly devised symptom validity measures show promise in identifying malingered ADHD, neither the analog nor the clinical malingers consistently failed these symptom validity scales. Furthermore, a good portion in both malingering groups failed to endorse high levels of ADHD symptoms in general. Clinical implications are discussed.

Emergence of Carbapenemase-Producing Enterobacteriaceae, South-Central Ontario, Canada1.

We analyzed population-based surveillance data from the Toronto Invasive Bacterial Diseases Network to describe carbapenemase-producing Enterobacteriaceae (CPE) infections during 2007-2015 in south-central Ontario, Canada. We reviewed patients' medical records and travel histories, analyzed microbiologic and clinical characteristics of CPE infections, and calculated incidence. Among 291 cases identified, New Delhi metallo-ß-lactamase was the predominant carbapenemase (51%). The proportion of CPE-positive patients with prior admission to a hospital in Canada who had not received healthcare abroad or traveled to high-risk areas was 13% for patients with oxacillinase-48, 24% for patients with New Delhi metallo-ß-lactamase, 55% for patients with Klebsiella pneumoniae carbapenemase, and 67% for patients with Verona integron-encoded metallo-ß-lactamase. Incidence of CPE infection increased, reaching 0.33 cases/100,000 population in 2015. For a substantial proportion of patients, no healthcare abroad or high-risk travel could be established, suggesting CPE acquisition in Canada. Policy and practice changes are needed to mitigate nosocomial CPE transmission in hospitals in Canada.

Group A Streptococcal Outbreak in a Geriatric Mental Health Unit.

We report a Group A streptococcal (GAS) outbreak in a geriatric mental health in-patient unit. Communication with cognitively impaired patients, limitations in adherence to hygiene practices and communal dining may have facilitated transmission. Settle plates aided in identifying a colonized patient. Rapid access to whole genome sequencing facilitated assessment and management.

Predictive value of performance validity testing and symptom validity testing in psychoeducational assessment.

Using archival data from 2463 psychoeducational assessments of postsecondary students we investigated whether failure on either symptom or performance validity tests (SVTs or PVTs) was associated with score differences on various cognitive, achievement, or executive functioning performance measures or on symptom report measures related to mental health or attention complaints. In total, 14.6% of students failed one or more PVT, 33.6% failed one or more SVT, and 41.6% failed at least one validity test. Individuals who failed SVTs tended to have the highest levels of self-reported symptoms relative to other groups but did not score worse on performance-based psychological tests. Those who failed PVTs scored worse on performance-based tests relative to other groups. Failure on at least one PVT and one SVT resulted in both performance and self-reported symptoms suggestive of greater impairment compared with those who passed all validity measures. Findings also highlight the need for domain-specific SVTs; failing ADHD SVTs was associated only with extreme reports of ADHD and executive functioning symptoms while failing mental health SVTs related only to extreme reports of mental health complaints. Results support using at least one PVT and one SVT in psychoeducational assessments to aid in diagnostic certainty, given the frequency of non-credible presentation in this population of postsecondary students.

Base rates of non-credible performance in a post-secondary student sample seeking accessibility accommodations.

Objective: Performance Validity Tests (PVTs) have been used to identify non-credible performance in clinical, medicolegal, forensic, and, more recently, academic settings. The inclusion of PVTs when administering psychoeducational assessments is essential given that specific accommodation such as flexible deadlines and increased writing time can provide an external incentive for students without disabilities to feign symptoms. Method: The present study used archival data to establish base rates of non-credible performance in a sample of post-secondary students (n = 1045) who underwent a comprehensive psychoeducational evaluation for the purposes of obtaining academic accommodations. In accordance with current guidelines, non-credible performance was determined by failure on two or more freestanding or embedded PVTs. Results: 9.4% of participants failed at least two of the PVTs they were administered, of which 8.5% failed two PVTs, and approximately 1% failed three PVTs. Base rates of failure for specific PVTs ranged from 25% (b Test) to 11.2% (TOVA). Conclusions: The present study found a lower base rate of non-credible performance than previously observed in comparable populations. This likely reflects the utilization of conservative criteria in detecting non-credible performance to avoid false positives. By contrast, inconsistent base rates previously found in the literature may reflect inconsistent methodologies. These results further emphasize the importance of administering multiple PVTs during psychoeducational assessments. The implications of these findings can further inform clinicians administering assessments in academic settings and aid in the appropriate utilization of PVTs in psychoeducational evaluation to determine accessibility accommodations.

Hospital outbreak of the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) delta variant in partially and fully vaccinated patients and healthcare workers in Toronto, Canada.

The severe acute respiratory coronavirus virus 2 (SARS-CoV-2) delta variant is highly transmissible, and current vaccines may have reduced effectiveness in preventing symptomatic infection. Using epidemiological and genomic analyses, we investigated an outbreak of the variant in an acute-care setting among partially and fully vaccinated individuals. Effective outbreak control was achieved using standard measures.

Burden of Severe Illness Associated With Laboratory-Confirmed Influenza in Adults Aged 50-64 Years, 2010-2011 to 2016-2017.

Background: Understanding the burden of influenza is necessary to optimize recommendations for influenza vaccination. We describe the epidemiology of severe influenza in 50- to 64-year-old residents of metropolitan Toronto and Peel region, Canada, over 7 influenza seasons. Methods: Prospective population-based surveillance for hospitalization associated with laboratory-confirmed influenza was conducted from September 2010 to August 2017. Conditions increasing risk of influenza complications were as defined by Canada's National Advisory Committee on Immunization. Age-specific prevalence of medical conditions was estimated using Ontario health administrative data. Population rates were estimated using Statistics Canada data. Results: Over 7 seasons, 1228 hospitalizations occurred in patients aged 50-64 years: 40% due to A(H3N2), 30% A(H1N1), and 22% influenza B. The average annual hospitalization rate was 15.6, 20.9, and 33.2 per 100 000 in patients aged 50-54, 55-59, and 60-64 years, respectively; average annual mortality was 0.9/100 000. Overall, 33% of patients had received current season influenza vaccine; 963 (86%) had ≥1 underlying condition increasing influenza complication risk. The most common underlying medical conditions were chronic lung disease (38%) and diabetes mellitus (31%); 25% of patients were immunocompromised. The average annual hospitalization rate was 6.1/100 000 in those without and 41/100 000 in those with any underlying condition, and highest in those with renal disease or immunocompromise (138 and 281 per 100 000, respectively). The case fatality rate in hospitalized patients was 4.4%; median length of stay was 4 days (interquartile range, 2-8 days). Conclusions: The burden of severe influenza in 50- to 64-year-olds remains significant despite our universal publicly funded vaccination program. These data may assist in improving estimates of the cost-effectiveness of new strategies to reduce this burden.

Accommodation Decision-Making for Postsecondary Students with ADHD: Treating the Able as Disabled.

Students with attention-deficit/hyperactivity disorder (ADHD) may be entitled to academic accommodations in postsecondary education. Disability Services Offices (DSOs) in Canada say that objective evidence of functional impairment is required prior to providing academic accommodations. This study set out to determine if postsecondary disability service providers use objective, third-party data when making accommodation decisions. Providers were asked if they would grant extra time accommodations to a fictitious prospective student. The student self-reported attention and academic problems that emerged during COVID restrictions, and that extra time helped her earn better grades and reduced her anxiety. While her neuropsychological report suggested superficial similarity to ADHD and contained accommodation recommendations, it lacked any objective evidence supporting either an ADHD diagnosis or functional impairments that would support extra time accommodation. Despite the lack of current or historical functional impairment, 100% of all DSO decision makers confirmed that they would grant extra time accommodations to this student. Results suggest that DSOs' accommodation decisions are not based on evidence of functional impairment but rely mainly on student self-report and the recommendations of a professional. As such, the current system of determining reasonable accommodations is flawed and inequitable, offering non-impaired individuals access to supports and services that may privilege them over their similarly abled peers. Postsecondary institutions must either develop more defensible methods of disability determination or provide all students with access to accommodations to create a more equitable learning environment.

The impact of depression and anxiety on speed of academic performance and retrieval fluency in postsecondary students.

Objective: This study evaluated the functional effects of severe mental health symptoms on speed of academic performance to assist clinicians and educators in determining whether extra time accommodations are evidence-based for students with such diagnoses. Method: Using archival data from 1476 post-secondary students, we examined the performance of students with existing mental health diagnoses who were also reporting extremely high levels of symptoms. Their performance on timed academic achievement and cognitive processing measures was compared with performance of students with learning disabilities, Attention Deficit Hyperactivity Disorder, and clinical controls. Students failing stand-alone performance validity and/or symptom validity measures were excluded from this investigation. Results: Students diagnosed with anxiety and/or depression did not differ from clinical controls on any timed performance measure, typically performing academic tasks within a normal amount of time. By contrast, those with reading disabilities were typically the slowest on all academic tasks. Conclusion: Across the range of timed tests, students with mental health diagnoses did not show functional impairments in tests with a speed component. As such, they would not typically require increased time to perform speeded academic tasks, but they might require alternative accommodations in their post-secondary programmes in order to participate equally.

Processing speed and timed academic skills in children with learning problems.

Information processing speed is commonly measured in intelligence and neuropsychological testing, and the scores from speed measures are considered in diagnostic and management recommendations for students with academic learning problems. However, this score usage often depends on assumptions about strong relationships between cognitive speed and the ability to perform actual academic tasks under time pressure. The primary purpose of the present study was to test the strength of these relationships empirically. In the present study, children with prior learning disability diagnoses (146 girls and 301 boys, ages 10-14 years old) completed diagnostic batteries that included measures of cognitive speed as well as timed academic skills. The relationships between the two types of measures were often modest (median r = 0.25), and the gap between processing speed and timed academic scores was typically approximately 1 standard deviation. The pattern of relationships suggested that superficial similarity in stimuli and task demands affected the strength of associations. These results suggest that timed academic skills cannot be reliably estimated based on processing speed scores, and there will often be significant gaps between the two. Therefore, making diagnostic judgments (e.g., learning disability diagnoses) or management recommendations (e.g., for extended time testing accommodations) should be based on more direct measures of relevant academic skills.

Discriminating malingered attention Deficit Hyperactivity Disorder from genuine symptom reporting using novel Personality Assessment Inventory validity measures.

It is now widely understood that ADHD can be feigned easily and convincingly. Despite this, almost no methods exist to assist clinicians in identifying when such behavior occurs. Recently, new validity indicators specific to feigned ADHD were reported for the Personality Assessment Inventory (PAI). Derived from a logistic regression, these algorithms are said to have excellent specificity and good sensitivity in identifying feigned ADHD. However, these authors compared those with genuine ADHD only to nonclinical undergraduate students (asked to respond honestly or asked to simulate ADHD); no criterion group of definite malingerers was included. We therefore investigated these new validity indicators with 331 postsecondary students who underwent assessment for possible ADHD and compared scores of those who were eventually diagnosed with ADHD (n = 111) to those who were not [Clinical controls (66), Definite malingerers (36); No diagnosis (117)]. The two proposed PAI algorithms were found to have poor positive predictive value (.19 and .17). Self-report validity measures from the Connors' Adult Attention Rating Scale, and the Negative Impression Management scale on the PAI returned more positive results. Overall, more research is needed to better identify noncredible ADHD presentation, as the PAI-based methods proposed by Aita et al. appear inadequate as symptom validity measures.

What can we learn about performance validity from TOVA response profiles?

Given the functional impairments associated with Attention Deficit/Hyperactivity Disorder (AD/HD), a valid diagnosis is important. However, particularly when carried out in adulthood, the diagnostic process can be challenging and is complicated by conclusive evidence that a proportion of individuals referred for evaluation of AD/HD exaggerate or feign their symptoms. Relatively few methods, however, exist to identify such feigning. While continuous performance tests (CPTs) may provide useful information regarding performance validity, the question remains as to whether there are consistent patterns of exaggeration demonstrated by those feigning AD/HD. Thus, this study used cluster analysis to determine whether valid and reliable performance clusters would emerge based on CPT performance. Using archival data from a university-based AD/HD screening clinic, we investigated the performance of 305 adults on the Test of Variables of Attention (TOVA). Three profiles emerged, including one cluster who demonstrated exceptionally low performance on the TOVA, exceptionally high reports of AD/HD symptomology, and higher rates of failure on symptom and performance validity tests. The implication from our analysis is that this group most likely represents individuals who were exaggerating or magnifying their difficulties. The results reaffirm previous research showing that performance profiles on a continuous performance test can be used as an indicator of credible performance.

Learning disability documentation submitted by osteopathic medical students.

An increasing number of individuals are requesting disability accommodations on high-stakes licensing examinations, and neuropsychological evaluation reports are a frequent component of disability documentation. This study reviewed 103 requests for accommodations based on a learning disability (LD), submitted to the National Board of Osteopathic Medical Examiners between 2013 and 2016 for accommodation on the licensure exams for osteopathic physicians. Depending on criteria employed, anywhere from 84 to 97% of applicants failed to meet recognized criteria for a LD diagnosis, with the vast majority demonstrating academic functioning that was average or better relative to most other individuals in the general population. Thus, although given a disability diagnosis, the majority lacked evidence of substantial impairment that would require accommodations under the Americans with Disabilities Act. Additionally, no significant differences were found between the academic achievement or fluency scores of those requesting 50% as compared to 100% extra time. Finally, many evaluators employed grade-based assessment measures to demonstrate academic impairment, even when candidates' functioning using age-based comparisons was unimpaired. Recommendations for future research and practice based on these and other findings are discussed.

The license plate test performance in Canadian adolescents with learning disabilities: A preliminary study.

Accurate identification of symptom exaggeration is essential when determining whether data obtained in pediatric evaluations are valid or interpretable. Performance validity measures identify performance patterns that are implausible if the test taker is investing full effort; however, it is unclear whether or not persons with preexisting cognitive difficulties such as Specific Learning Disabilities (SLD) might be falsely accused of poor test motivation due to actual but impaired reading, processing or memory skills. The purpose of this study was to evaluate the newly developed License Plate Test (LPT) performance in students with identified SLD providing good effort, to examine the influence of severe reading or learning problems on LPT performance. Participants were 29 students with SLDs aged 11-14 years (M = 12.1), who completed psycho-educational assessments as part of a transition program to secondary school. Results indicate that recognition memory measures on the LPT were insensitive to cognitive impairments in these children; all students achieved scores of 80% or higher on these tasks. Performance was more variable as test demands of the LPT increased, and the difference between performance on easy and hard subtests was related to greater difficulties with working memory. These results provide preliminary data regarding how children with SLD perform on the LPT, allowing for development of appropriate cut scores to maximize sensitivity and specificity of this test for use with child and adolescent populations.

Differences in performance on the test of variables of attention between credible vs. noncredible individuals being screened for attention deficit hyperactivity disorder.

Measuring performance validity in Attention Deficit Hyperactivity Disorder (ADHD) assessments is essential, with multiple studies identifying how easily young adults can feign symptoms on self-report measures. Few methods, however, exist to identify such feigning when it occurs. While some clinicians include computerized tests of attention (e.g., Test of Variables of Attention [TOVA]) when assessing for possible ADHD, it is unclear how symptom exaggerators perform, and whether the TOVA Symptom Exaggeration Index (SEI) adequately identifies performance-based exaggeration when it occurs. Using archival data from a university-based ADHD screening clinic we investigated the performance of 245 late adolescents/emerging adults. Three groups were created: (1) Good effort but not ADHD (n = 183); (2) Good effort and diagnosed ADHD (n = 13); and (3) suspect effort (n = 49), based on final diagnosis and performance on an existing validity measure. Results showed clearly that those with suspect effort performed more poorly than the other two groups on all but second-half commission errors on the TOVA. Similar to Nicholls et al., the suspect effort group showed significantly subaverage (i.e., greater than two standard deviations below the mean) scores in Omission errors; in this replication, however, this was true for both the first and second half of the test. Response time variability was similarly exaggerated, with the suspect effort group again returning extreme scores in both halves of the test. Suspect effort students were indistinguishable from those with genuine ADHD when looking solely at self-reported symptoms; however, embedded symptom validity measures on an ADHD rating scale discriminated well between groups. Overall, results support the use of the TOVA as an embedded performance validity measure in the assessment of late adolescents/emerging adults and support previous findings that symptom report alone cannot distinguish credible from noncredible ADHD presentation.

Dissemination of Verona Integron-encoded Metallo-ß-lactamase among clinical and environmental Enterobacteriaceae isolates in Ontario, Canada.

Surveillance data from Southern Ontario show that a majority of Verona Integron-encoded Metallo-ß-lactamase (VIM)-producing Enterobacteriaceae are locally acquired. To better understand the local epidemiology, we analysed clinical and environmental blaVIM-positive Enterobacteriaceae from the area. Clinical samples were collected within the Toronto Invasive Bacterial Diseases Network (2010-2016); environmental water samples were collected in 2015. We gathered patient information on place of residence and hospital admissions prior to the diagnosis. Patients with and without plausible source of acquisition were compared regarding risk exposures. Microbiological isolates underwent whole-genome sequencing (WGS); blaVIM carrying plasmids were characterized. We identified 15 patients, thereof 11 with blaVIM-1-positive Enterobacter hormaechei within two genetic clusters based on WGS. Whereas no obvious epidemiologic link was identified among cluster I patients, those in cluster II were connected to a hospital outbreak. Except for patients with probable acquisition abroad, we did not identify any further risk exposures. Two blaVIM-1-positive E. hormaechei from environmental waters matched with the clinical clusters; plasmid sequencing suggested a common ancestor plasmid for the two clusters. These data show that both clonal spread and horizontal gene transfer are drivers of the dissemination of blaVIM-1-carrying Enterobacter hormaechei in hospitals and the aquatic environment in Southern Ontario, Canada.

Comparing Age- and Grade-Based Norms on the Woodcock-Johnson III Normative Update.

There has been a marked increase in accommodation requests from students with disabilities at both the postsecondary education level and on high-stakes examinations. As such, accurate identification and quantification of normative impairment is essential for equitable provision of accommodations. Considerable diversity currently exists in methods used to diagnose learning disabilities, including whether an impairment is normative or relative. This study investigated the impact on impairment classification if grade-based norms were used to interpret identical raw scores compared with age-based norms. Fourteen raw scores distributed equally across the adult range of the Woodcock-Johnson III Normative Update subtests were scored using norms for either age (18-29 years) or grade (13-17). The results indicate that raw scores receive a significantly lower standardized score (and thus percentile ranking) when grade-based norms are used. Furthermore, the difference between age- and grade-based scores increases dramatically as raw scores decrease, and there is a significant interaction between age and grade in the standard scores obtained. This study provides evidence to suggest that using different norms may result in different decisions about diagnoses and appropriate accommodations.

Diagnostic Accuracy of the Conners' Adult ADHD Rating Scale in a Postsecondary Population.

Objective: Clinicians frequently rely upon the results of self-report rating scales when making the diagnosis of ADHD; however, little research exists regarding the ability of self-report measures to accurately differentiate ADHD from other disorders. Method: This present study investigated the ability of the Conners' Adult ADHD Rating Scale (CAARS) to discriminate between 249 postsecondary students with carefully diagnosed ADHD and 507 clinical controls. Results: The overall discriminant validity of the CAARS was 69%, and it had an unacceptably high false positive and false negative rate. At lower prevalence rates, a high score on the CAARS has only a 22% chance of accurately identifying individuals with ADHD. Conclusion: Although the CAARS is an adequate screening measure, it should not be the main method by which a diagnosis is made, as it frequently misidentifies individuals with other psychological complaints as having ADHD. Implications for clinical practice are discussed.

Development of a symptom validity index to assist in identifying ADHD symptom exaggeration or feigning.

OBJECTIVE: Concerns have been identified regarding the ease with which students and young adults can feign or exaggerate symptoms of ADHD, and no formal measures exist to identify such behavior when it occurs. This article describes the development and initial validation of a new symptom validity measure designed to detect feigned or exaggerated ADHD symptom reporting. METHOD: Employing items from a commonly used self-report measure of ADHD (Conners' Adult ADHD Rating Scale [CAARS]) and select items from a scale measuring symptoms of dissociation, we assessed students diagnosed with ADHD, students with other diagnoses, and student volunteers with no psychopathology. RESULTS: This new measure (Exaggeration Index or EI) demonstrated excellent specificity (.97) and adequate sensitivity (.24) in discriminating between those who are suspected of or instructed to feign or exaggerate symptoms of ADHD and all other clinical groups. CONCLUSION: The results strongly suggest that the EI may be a useful adjunct to existing validity measures when identifying exaggerated or implausible symptoms of ADHD.