Understanding the Relationship Between Antiviral Prescription Data and COVID-19 Incidence in New York City: A Retrospective Cohort Study.

The coronavirus disease 2019 (COVID-19) pandemic has caused more than 675 million confirmed cases and nearly 7 million deaths worldwide [1]. While testing for COVID-19 was initially centered in health care facilities, with required reporting to health departments, it is increasingly being performed in the home with rapid antigen testing [2]. Most at-home tests are self-interpreted and not reported to a provider or health department, which could lead to delayed reporting or underreporting of cases [3]. As such, there is a strong possibility that reported cases may become a less reliable indicator of transmission over time.

John Snow: Anesthesiologist, Epidemiologist, Scientist, and Hero.

A 19th century physician was crucial to the establishment of 2 medical specialties-anesthesiology and public health. Everyone whose interest in public health has increased in the last year will be amazed at Dr John Snow's career in anesthesiology. Those who recognize him as the first full-time physician anesthetist will be struck by his development of medical mapping during the Cholera Pandemic of 1848, resulting in one of the fundamental techniques of epidemiology and public health that has continued through today. Snow's accomplishments in anesthesiology and epidemiology reflected a concatenation of science, focus, and creativity. His training in the early 19th century integrated science, medicine, and his keen interest in respiratory physiology. His early clinical exposure to colliery workers in Newcastle was likely influenced by the earlier development of pneumatic medicine. He was committed to the notion that chemistry, especially the use of medicinal gases, would be transformative for medicine. Thus, he was "primed" when the news of the American anodyne ether reached London in 1846. When the third cholera pandemic reached London shortly thereafter, in the fall of 1848, his academic and practical understanding of gas chemistry and pharmacology, respiratory physiology, and anesthetic agents led him to question the popularly promulgated miasma-based theories of transmission. His methodical investigations, research, and perseverance were mirrored in his scholarly work, numerous presentations, and public advocacy. He articulated many scientific principles essential to the early practice of anesthesia-anesthetic potency, quantitative dosing of anesthetic agents, engineering principles required for conserving the latent heat of vaporization, and minimizing the contribution of anesthetic equipment to airway resistance. He moved easily and methodically between these worlds of physiology, chemistry, engineering, clinical medicine, and public health. In his role as the first medical epidemiologist, Snow understood the power of medical mapping and the graphic presentation of data. He was a pioneer in 2 nascent fields of medicine that were historically and remain contemporarily connected.

Prevalence of strongyloidiasis among cardiothoracic organ transplant candidates in a non-endemic region: A single-center experience with universal screening.

Disseminated strongyloidiasis and hyperinfection syndrome can cause significant morbidity and mortality after transplantation. Screening and treatment prior to transplantation can reduce or prevent this disease. Targeted screening of transplant candidates based on assessed risk, fails to identify all who would benefit. We implemented universal serology-based screening for Strongyloides at our transplant center, located in a non-endemic area. Of 200 transplant candidates who were evaluated for cardiothoracic transplant from January 2018 to June 2019, 169 were screened serologically and 21 (12.4%) were seropositive. Among seropositive patients, 57% reported travel to an endemic region, 38% were born outside the USA, 38% had eosinophilia, and 5% had history of gram-negative bacteremia. We estimate that universal screening for strongyloidiasis could identify an average of 17 additional candidates for preventive treatment for every 200 transplant candidates.

The renal transport of hippurate and protein-bound solutes.

Measurement of the concentration of hippurate in the inferior vena cava and renal blood samples performed in 13 subjects with normal or near-normal serum creatinine concentrations confirmed the prediction that endogenous hippurate was cleared on a single pass through the kidney with the same avidity as that reported for infused para-amino hippurate. This suggests that a timed urine collection without infusion would provide a measure of effective renal plasma flow. Comparison of the arteriovenous concentration differences for a panel of protein-bound solutes identified solutes that were secreted by the renal tubule and solutes that were subjected to tubular reabsorption.

Correction: The effect of isohydric hemodialysis on the binding and removal of uremic retention solutes.

[This corrects the article DOI: 10.1371/journal.pone.0192770.].

The effect of isohydric hemodialysis on the binding and removal of uremic retention solutes.

BACKGROUND: There is growing evidence that the accumulation of protein- bound uremic retention solutes, such as indoxyl sulfate, p-cresyl sulfate and kynurenic acid, play a role in the accelerated cardiovascular disease seen in patients undergoing chronic hemodialysis. Protein-binding, presumably to albumin, renders these solutes poor-dialyzable. We previously observed that the free fraction of indoxyl sulfate was markedly reduced at the end of hemodialysis. We hypothesized that solute binding might be pH-dependent and attributed the changes in free solute concentration to the higher serum pH observed at the end of standard hemodialysis with dialysis buffer bicarbonate concentration greater than 35 mmol/L. We observed that acidification of uremic plasma to pH 6 in vitro greatly increased the proportion of freeIS. METHODS: We tested our hypothesis by reducing the dialysate bicarbonate buffer concentration to 25 mmol/L for the initial half of the hemodialysis treatment ("isohydric dialysis"). Eight stable hemodialysis patients underwent "isohydric dialysis" for 90 minutes and then were switched to standard buffer (bicarbonate = 37mmol/L). A second dialysis, 2 days later, employed standard buffer throughout. RESULTS: We found a clearcut separation of blood pH and bicarbonate concentrations after 90 minutes of "isohydric dialysis" (pH = 7.37, bicarbonate = 22.4 mmol/L) and standard dialysis (pH = 7.49, bicarbonate = 29.0 mmol/L). Binding affinity varied widely among the 10 uremic retention solutes analyzed. Kynurenic acid (0.05 free), p-cresyl sulfate (0.12 free) and indoxyl sulfate (0.13 free) demonstrated the greatest degree of binding. Three solutes (indoxyl glucuronide, p-cresyl glucuronide, and phenyl glucuronide) were virtually unbound. Analysis of free and bound concentrations of uremic retention solutes confirmed our prediction that binding of solute is affected by pH. However, in a mixed models analysis, we found that the reduction in total uremic solute concentration during dialysis accounted for a greater proportion of the variation in free concentration, presumably an effect of saturation binding to albumin, than did the relatively small change in pH produced by isohydric dialysis. The effect of pH on binding appeared to be restricted to those solutes most highly protein-bound. The solutes most tightly bound exhibited the lowest dialyzer clearances. An increase in dialyzer clearance during isohydric and standard dialyses was statistically significant only for kynurenic acid. CONCLUSION: These findings provide evidence that the binding of uremic retention solutes is influenced by pH. The effect of reducing buffer bicarbonate concentration ("isohydric dialysis:"), though significant, was small but may be taken to suggest that further modification of dialysis technique that would expose blood to a greater decrease in pH would lead to a greater increase the free fraction of solute and enhance the efficacy of hemodialysis in the removal of highly protein-bound uremic retention solutes.

Perioperative considerations in infantile neuroaxonal dystrophy.

Infantile neuroaxonal dystrophy is a rare neurological disorder that is universally fatal with life expectancy under 10 years. A 10-year-old boy with infantile neuroaxonal dystrophy and severe neuromuscular scoliosis underwent posterior spinal fusion following halo traction. He was successfully extubated to bilevel positive airway pressure on postoperative day 3 and discharged home on postoperative day 11. Infantile neuroaxonal dystrophy presents several perioperative challenges including concerns for difficult intubation and respiratory dysfunction.

Anesthetic Management of Patients With Inborn Errors of Metabolism.

Inborn errors of metabolism (IEM) are characterized by the body's inability to convert food into energy. The pathogenetic mechanism is based on defects in a variety of cellular enzymes. In addition to impairment of energy generation, accumulation of substrates may occur, which can deposit in tissue and lead to organ dysfunction. IEM can have profound implications for perioperative management, including difficult airway management, cardiac dysfunction, aspiration risk, seizures, and metabolic dysregulation. For the anesthesiologist, comprehensive knowledge is difficult to attain because of the heterogeneity of this group and the low prevalence of specific diseases. The first part of this article reviews intermediary metabolism, whereas the second part aims to highlight important aspects in perioperative management of patients with IEM. Instead of reviewing each single disorder within the vast group of IEM, we provide a conceptual framework that will facilitate the understanding of main problems encountered in each of the disease subgroups.

Individualized remediation during fellowship training.

The Accreditation Council for Graduate Medical Education requires medical training programs to monitor, track, and formally document a fellow's performance. If deficiencies are found, programs are expected to prepare and implement an effective plan of action for improvement and to ensure that graduates acquire the personal and professional attributes of an independent physician. We revised our evaluation policy and instituted a remediation protocol in 2008. Since that time, 130 pediatric anesthesia fellows have graduated. Seven fellows (5%) underwent departmental formal consultation for deficient behavior or poor performance. Of these 7 fellows, 4 underwent an individualized remediation program (IRP). A formal performance review and written contract, with specifically identified problems and general themes, recommendations for time-based successful behaviors, and clearly identified consequences for unsuccessful behaviors, was initiated for each fellow undergoing an IRP. All fellows who participated in this program completed their subspecialty training in pediatric anesthesia, and all eligible fellows have successfully achieved their subspecialty board certification. Our approach has the advantage of multimodality, time-based daily evaluations, and group discussions in the context of a Clinical Competency Committee. Utilization of an IRP as a metric for progress has features similar to effective cognitive behavioral therapy contracts and has ensured that our graduates are held to clearly delineated and specified skills and behaviors that allow them to work independently in the field of pediatric anesthesiology.

Hepatitis C Screening of the "Birth Cohort" (Born 1945-1965) and Younger Inmates of New York City Jails.

OBJECTIVES: To examine uptake of screening for all individuals born between 1945 and 1965 (referred to by the Centers for Disease Control and Prevention as the "birth cohort") and outline preliminary HCV prevalence data in the New York City jail system. METHODS: Data were extracted from electronic health records for all individuals screened for HCV between June 13, 2013, and June 13, 2014, in New York City jails. We used the Abbott EIA 2.0 HCV antibody assay for testing. RESULTS: In the year of study, 56 590 individuals were incarcerated; 15.1% were born between 1945 and 1965, and 84.6% were born after 1965. HCV screening was completed for 64.1% of the birth cohort and for 11.1% born after 1965, with 55.1% and 43.8% of cases found in these groups, respectively. The overall seropositivity rate was 20.6%. CONCLUSIONS: Birth cohort screening in a large jail system identified many HCV cases, but HCV infection was common among younger age groups. PUBLIC HEALTH IMPLICATIONS: Universal screening may be warranted pending further study including cost-effectiveness analyses.

Cytotoxic Virulence Predicts Mortality in Nosocomial Pneumonia Due to Methicillin-Resistant Staphylococcus aureus.

The current study identified bacterial factors that may improve management of methicillin-resistant Staphylococcus aureus (MRSA) nosocomial pneumonia. Isolates were obtained from 386 patients enrolled in a randomized, controlled study of antibiotic efficacy. Isolates were screened for production of virulence factors and for vancomycin susceptibility. After adjustment for host factors such as severity of illness and treatment modality, cytotoxic activity was strongly and inversely associated with mortality; however, it had no effect on clinical cure. Isolates having low cytotoxicity, which were derived largely from healthcare-associated clones, exhibited a greater prevalence of vancomycin heteroresistance, and they were recovered more often from patients who were older and frailer. Additionally, a clone with low cytotoxic activity was associated with death and poor clinical improvement. Clone specificity and attenuated virulence appear to be associated with outcome. To our knowledge, these are the first correlations between MRSA virulence and mortality in nosocomial pneumonia.

Anesthetic considerations in Sheldon-Hall syndrome.

Arthrogryposis is characterized by multiple, nonprogressive joint contractures which may be caused by maternal disorders such as oligohydramnios as well as fetal akinesia resulting from primary disorders of muscle, connective tissue, or neurologic tissue. Its prevalence is about 1 : 3000. Distal arthrogryposis (DA) is a heterogenous group of genetic disorders with a characteristic flexion of the joints of the hands and feet divided into different types with additional features. Sheldon-Hall Syndrome (SHS), also known as distal arthrogryposis type 2A (DA2A), has some nonorthopedic features of specific importance to anesthetic care.

Genetic predictors of cervical dysplasia in African American HIV-infected women: ACTG DACS 268.

OBJECTIVE: To examine genome-wide associations in HIV-infected women with a history of cervical dysplasia compared with HIV-infected women with no history of abnormal Papanicolaou (Pap) tests. DESIGN: Case-control study using data from women analyzed for the HIV Controllers Study and enrolled in HIV treatment-naïve studies in the AIDS Clinical Trials Group (ACTG). METHODS: Genotyping utilized Illumina HumanHap 650 Y or 1MDuo platforms. After quality control and principal component analysis, ~610,000 significant single nucleotide polymorphisms (SNPs) were tested for association. Threshold for significance was P < 5 × 10(-8) for genome-wide associations. RESULTS: No significant genomic association was observed between women with low-grade dysplasia and controls. The genome-wide association study (GWAS) analysis between women with high-grade dysplasia or invasive cervical cancer and normal controls identified significant SNPs. In the analyses limited to African American women, 11 SNPs were significantly associated with the development of high-grade dysplasia or cancer after correcting for multiple comparisons. The model using significant SNPs alone had improved accuracy in predicting high-grade dysplasia in African American women compared to the use of clinical data (area under the receiver operating characteristic curve for genetic and clinical model = 0.9 and 0.747, respectively). CONCLUSIONS: These preliminary data serve as proof of concept that there may be a genetic predisposition to developing high-grade cervical dysplasia in African American HIV-infected women. Given the small sample size, the results need to be validated in a separate cohort.

Perioperative care of adolescents.

PURPOSE OF REVIEW: To describe adolescent development within the context of perioperative anesthetic management. RECENT FINDINGS: Most adolescent deaths are as a result of unintentional injury. Motor vehicle accidents are the most common cause, with homicide the second most common cause of intentional injury. Suicide is also a significant cause of adolescent death. The thinning of gray matter following preadolescence overtakes synaptogenesis, resulting in a more efficient, adult-like brain. Although adolescent substance use has declined over the last 30 years, cigarette smoking, alcohol and illicit drug use, sexual activity, and violent behavior remain significant concerns in perioperative care. The tremendous increase in physical working capacity and maximum oxygen consumption during adolescence commonly results in the pursuit of muscularity, substance use and abuse, dieting regimens, and muscle dysmorphia. Childhood obesity has risen by more than 50% in the last 10 years. Anorexics die at a rate of 10-20% from complications of starvation or from suicide. Up to 8% of adolescents are diagnosed with major depressive disorder. Poorly controlled perioperative pain is still common. Many adolescents have decision-making capacity and therefore assent to surgery becomes an important perioperative consideration. SUMMARY: Adolescents are a very healthy population subject to unintentional and intentional injury. Emotional and judgmental maturation is a cofactor in these injuries, better appreciated through improved understanding of developmental neurobiology. In addition, increases in muscle mass, requirements for nutrition and rest, maladaptive behavior, and health choices are important for optimal perioperative care.

United States anesthesiologists over 50: retirement decision making and workforce implications.

BACKGROUND: Anesthesiology is among the medical specialties expected to have physician shortage. With little known about older anesthesiologists' work effort and retirement decision making, the American Society of Anesthesiologists participated in a 2006 national survey of physicians aged 50-79 yr. METHODS: Samples of anesthesiologists and other specialists completed a survey of work activities, professional satisfaction, self-defined health and financial status, retirement plans and perspectives, and demographics. A complex survey design enabled adjustments for sampling and response-rate biases so that respondents' characteristics resembled those in the American Medical Association Physician Masterfile. Retirement decision making was modeled with multivariable ordinal logistic regression. Life-table analysis provided a forecast of likely clinical workforce trends over an ensuing 30 yr. RESULTS: Anesthesiologists (N = 3,222; response rate = 37%) reported a mean work week of 49.4 h and a mean retirement age of 62.7 yr, both values similar to those of other older physicians. Work week decreased with age, and part-time work increased. Women worked a shorter work week (mean, 47.9 vs. 49.7 h, P = 0.024), partly due to greater part-time work (20.2 vs. 13.1%, P value less than 0.001). Relative importance of factors reported among those leaving patient care differed by age cohort, subspecialty, and work status. Poor health was cited by 64% of anesthesiologists retiring in their 50s as compared with 43% of those retiring later (P = 0.039). CONCLUSIONS: This survey lends support for greater attention to potentially modifiable factors, such as workplace wellness and professional satisfaction, to prevent premature retirement. The growing trend in part-time work deserves further study.

Obesity prevention in young schoolchildren: results of a pilot study.

BACKGROUND: Overweight and obesity occur in 17% of children in the United States. Complications of excess weight in Americans cause 216,000 to 300,000 deaths yearly and cost $147 billion. METHODS: A convenience sample of 14 intervention and 15 control schools in the Catholic Diocese of Pittsburgh was used. A program to improve lifestyle (Values Initiative Teaching About Lifestyle [VITAL®]), was implemented in young children to encourage healthy eating and appropriate physical activity. Students had annual evaluations of height and weight over a 2-year period, and teachers participating in VITAL completed questionnaires regarding the program. Changes in age- and sex-adjusted body mass index (BMI) percentiles in control and intervention groups were compared using linear mixed models regression. RESULTS: VITAL was highly rated by teachers and was popular with children. Over the 2-year period, adjusted mean BMI percentiles declined from 66.1 to 65.0 in control children and from 62.8 to 58.9 in intervention children. The rates of change in the 2 groups were significantly different (p = .015). CONCLUSION: VITAL improves lifestyle of young schoolchildren, is inexpensive, easy to implement, and should be expanded to improve health and reduce healthcare's financial burden.

Nasal carriage as a source of agr-defective Staphylococcus aureus bacteremia.

Inactivating mutations in the Staphylococcus aureus virulence regulator agr are associated with worse outcomes in bacteremic patients. However, whether agr dysfunction is primarily a cause or a consequence of early bacteremia is unknown. Analysis of 158 paired S. aureus clones from blood and nasal carriage sites in individual patients revealed that recovery of an agr-defective mutant from blood was usually predicted by the agr functionality of carriage isolates. Many agr-positive blood isolates produced low levels of hemolytic toxins, but levels were similar to those of colonizing strains within patients, suggesting that introduction into the blood did not select for mutations with minor functional effects. Evidently, the transition from commensalism to opportunism in S. aureus does not require full virulence in hospitalized patients. Furthermore, agr-defective mutants were found in uninfected nasal carriers in the same proportion as in carriers who develop bacteremia, suggesting low correlation between virulence and infectivity.