Meeting the Consultation Surge: A Nationwide Survey of Consult Volume and Mitigation Strategies in Infectious Diseases Fellowship Programs.

High patient volume in fellowship programs can affect learning, wellness, and patient outcomes. Training programs must find ways to mitigate high consultation volume to protect the learning environment. This survey describes average new consults and average censuses for infectious diseases training programs and strategies implemented to mitigate high volume.

High-Volume, High-Acuity, and High-Impact Learning: Tips and Tricks for Infectious Diseases Training Programs.

The Infectious Diseases Society of America Training Program Directors Committee met in October 2022 and discussed an observed increase in clinical volume and acuity on infectious diseases (ID) services, and its impact on fellow education. Committee members sought to develop specific goals and strategies related to improving training program culture, preserving quality education on inpatient consult services and in the clinic, and negotiating change at the annual IDWeek Training Program Director meeting. This paper outlines a presentation of ideas brought forth at the meeting and is meant to serve as a reference document for infectious diseases training program directors seeking guidance in this area.

Inclusion, Diversity, Access, and Equity in Infectious Diseases Fellowship Training: Tools for Program Directors.

The Infectious Diseases Society of America (IDSA) has set clear priorities in recent years to promote inclusion, diversity, access, and equity (IDA&E) in infectious disease (ID) clinical practice, medical education, and research. The IDSA IDA&E Task Force was launched in 2018 to ensure implementation of these principles. The IDSA Training Program Directors Committee met in 2021 and discussed IDA&E best practices as they pertain to the education of ID fellows. Committee members sought to develop specific goals and strategies related to recruitment, clinical training, didactics, and faculty development. This article represents a presentation of ideas brought forth at the meeting in those spheres and is meant to serve as a reference document for ID training program directors seeking guidance in this area.

Guidelines for Diagnosis and Management of Infective Endocarditis in Adults: A WikiGuidelines Group Consensus Statement.

Importance: Practice guidelines often provide recommendations in which the strength of the recommendation is dissociated from the quality of the evidence. Objective: To create a clinical guideline for the diagnosis and management of adult bacterial infective endocarditis (IE) that addresses the gap between the evidence and recommendation strength. Evidence Review: This consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In April 2022 a call to new and existing members was released electronically (social media and email) for the next WikiGuidelines topic, and subsequently, topics and questions related to the diagnosis and management of adult bacterial IE were crowdsourced and prioritized by vote. For each topic, PubMed literature searches were conducted including all years and languages. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were crafted discussing the risks and benefits of different approaches. Findings: A total of 51 members from 10 countries reviewed 587 articles and submitted information relevant to 4 sections: establishing the diagnosis of IE (9 questions); multidisciplinary IE teams (1 question); prophylaxis (2 questions); and treatment (5 questions). Of 17 unique questions, a clear recommendation could only be provided for 1 question: 3 randomized clinical trials have established that oral transitional therapy is at least as effective as intravenous (IV)-only therapy for the treatment of IE. Clinical reviews were generated for the remaining questions. Conclusions and Relevance: In this consensus statement that applied the WikiGuideline method for clinical guideline development, oral transitional therapy was at least as effective as IV-only therapy for the treatment of IE. Several randomized clinical trials are underway to inform other areas of practice, and further research is needed.

The Infectious Diseases Specialist, At Risk of Extinction.

The results of the Infectious Diseases (ID) fellowship match over the past decade have raised concerns that the future of our specialty is in peril, despite the unprecedented demand for ID expertise as exemplified by the COVID-19 pandemic. While there was a modest increase in ID fellowships applicants attributable to the pandemic, the disappointing 2023 match results indicate that the increase was short-lived. Multiple factors contribute to low interest in ID including but not only low salaries relative to other specialties. Solutions to grow the ID workforce are urgently needed and are critical to the public health of this nation.

Exposure to Green and Historic Urban Environments and Mental Well-Being: Results from EEG and Psychometric Outcome Measures.

Previous studies have identified the benefits of exposure to green or historic environments using qualitative methods and psychometric measures, but studies using a combination of measures are lacking. This study builds on current literature by focusing specifically on green and historic urban environments and using both psychological and physiological measures to investigate the impact of virtual exposure on well-being. Results from the psychological measures showed that the presence of historic elements was associated with a significantly stronger recuperation of hedonic tone (p = 0.01) and reduction in stress (p = 0.04). However, the presence of greenness had no significant effect on hedonic tone or stress. In contrast, physiological measures (EEG) showed significantly lower levels of alpha activity (p < 0.001) in occipital regions of the brain when participants viewed green environments, reflecting increased engagement and visual attention. In conclusion, this study has added to the literature by showing the impact that historic environments can have on well-being, as well as highlighting a lack of concordance between psychological and physiological measures. This supports the use of a combination of subjective and direct objective measures in future research in this field.

Exploring the role of exposure to green and blue spaces in preventing anxiety and depression among young people aged 14-24 years living in urban settings: A systematic review and conceptual framework.

Despite the growing problem of anxiety and depression amongst young people aged 14-24 years living in urban settings, reviews about the role of exposure to green and blue spaces or nature in preventing anxiety and depression tend to focus on children, adults or sometimes adolescents. This review aims to explore whether exposure to green and blue spaces reduces the risk of anxiety and depression among young people aged 14-24 years living in urban settings and provide a conceptual framework. The academic databases CINAHL plus, Global Health, MEDLINE, ProQuest: Dissertations and Theses, PsycINFO, Scopus and OpenGrey were searched for research published in English between January 2000 and June 2020. All study designs were eligible. All included studies were assessed for quality. Searches identified 9208 sources with 48 meeting the inclusion criteria for the review. Experimental studies provided evidence that walking or being in a green space improves mood and state anxiety immediately following the intervention. Non-randomised evaluations and observational studies suggest that social interaction, physical activity, and mindfulness mediate the relationship between exposure to green space and mental health. We propose that the absence of noise and restorative qualities of green spaces promotes mindfulness and interrupt rumination, which in turn reduce the risk of anxiety disorders and depression. This review and the resulting conceptual framework provide evidence to healthcare professionals about the value of contact with nature and green social prescribing. For policymakers, it provides evidence about the value of bringing the benefits of forests, vegetation and nature into cities, and ensuring that these spaces are accessible and safe for young people to use.

Exposure to Green, Blue and Historic Environments and Mental Well-Being: A Comparison between Virtual Reality Head-Mounted Display and Flat Screen Exposure.

Improving the mental health of urban residents is a global public health priority. This study builds on existing work that demonstrates the ability of virtual exposure to restorative environments to improve population mental health. It compares the restorative effects of green, blue and historic environments delivered by both flat screen and immersive virtual reality technology, and triangulates data from psychological, physiological and qualitative sources. Results from the subjective measure analyses showed that exposures to all the experimental videos were associated with self-reported reduced anxiety and improved mood, although the historic environment was associated with a smaller reduction of anxiety (p < 0.01). These results were supported by the qualitative accounts. For two of the electroencephalography (EEG) frequency bands, higher levels of activity were observed for historic environments. In relation to the mode of delivery, the subjective measures did not suggest any effect, while for the EEG analyses there was evidence of a significant effect of technology across three out of four frequency bands. In conclusion, this study adds to the evidence that the benefits of restorative environments can be delivered through virtual exposure and suggests that virtual reality may provide greater levels of immersion than flat screen viewing.

Use of Novel Strategies to Develop Guidelines for Management of Pyogenic Osteomyelitis in Adults: A WikiGuidelines Group Consensus Statement.

Importance: Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence. Objective: To construct a clinical guideline for pyogenic osteomyelitis management, with a new standard of evidence to resolve the gap between strength of recommendation and quality of evidence, through the use of a novel open access approach utilizing social media tools. Evidence Review: This consensus statement and systematic review study used a novel approach from the WikiGuidelines Group, an open access collaborative research project, to construct clinical guidelines for pyogenic osteomyelitis. In June 2021 and February 2022, authors recruited via social media conducted multiple PubMed literature searches, including all years and languages, regarding osteomyelitis management; criteria for article quality and inclusion were specified in the group's charter. The GRADE system for evaluating evidence was not used based on previously published concerns regarding the potential dissociation between strength of recommendation and quality of evidence. Instead, the charter required that clear recommendations be made only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were drafted to discuss pros and cons of care choices. Both clear recommendations and clinical reviews were planned with the intention to be regularly updated as new data become available. Findings: Sixty-three participants with diverse expertise from 8 countries developed the group's charter and its first guideline on pyogenic osteomyelitis. These participants included both nonacademic and academic physicians and pharmacists specializing in general internal medicine or hospital medicine, infectious diseases, orthopedic surgery, pharmacology, and medical microbiology. Of the 7 questions addressed in the guideline, 2 clear recommendations were offered for the use of oral antibiotic therapy and the duration of therapy. In addition, 5 clinical reviews were authored addressing diagnosis, approaches to osteomyelitis underlying a pressure ulcer, timing for the administration of empirical therapy, specific antimicrobial options (including empirical regimens, use of antimicrobials targeting resistant pathogens, the role of bone penetration, and the use of rifampin as adjunctive therapy), and the role of biomarkers and imaging to assess responses to therapy. Conclusions and Relevance: The WikiGuidelines approach offers a novel methodology for clinical guideline development that precludes recommendations based on low-quality data or opinion. The primary limitation is the need for more rigorous clinical investigations, enabling additional clear recommendations for clinical questions currently unresolved by high-quality data.

Enhancement of peripheral seal of medical face masks using a 3-dimensional-printed custom frame.

BACKGROUND: During the COVID-19 pandemic, American Society for Testing and Materials level 3 and level 2 medical face masks (MFMs) have been used for most health care workers and even for the first responders owing to a shortage of N95 respirators. However, the MFMs lack effective peripheral seal, leading to concerns about their adequacy to block aerosol exposure for proper protection. The purpose of this study was to evaluate the peripheral seal of level 3 and level 2 MFMs with a 3-dimensional (3D-) printed custom frame. METHODS: Level 3 and level 2 MFMs were tested on 10 participants with and without a 3D-printed custom frame; the efficiency of mask peripheral seal was determined by means of quantitative fit testing using a PortaCount Fit Tester based on ambient aerosol condensation nuclei counter protocol. RESULTS: The 3D-printed custom frame significantly improved the peripheral seal of both level 3 and level 2 MFMs compared with the masks alone (P < .001). In addition, both level 3 and level 2 MFMs with the 3D-printed custom frame met the quantitative fit testing standard specified for N95 respirators. PRACTICAL IMPLICATIONS: The 3D-printed custom frame over level 3 and level 2 MFMs can offer enhanced peripheral reduction of aerosols when using collapsible masks. With the shortage of N95 respirators, using the 3D-printed custom frame over a level 3 or level 2 MFM is considered a practical alternative to dental professionals.

Characterizing the Symptoms of Patients with Persistent Post-Treatment Lyme Symptoms: A Survey of Patients at a Lyme Disease Clinic in Rhode Island.

BACKGROUND: 10-20% of individuals diagnosed with Lyme disease develop chronic symptoms after antibiotic treatment. METHODS: A convenience sample of adults with self- reported, persistent post-Lyme treatment symptoms seeking treatment at the Lifespan Lyme Disease Center in Rhode Island completed a demographic and medical survey, the Patient Reported Outcomes Measurement Information System (PROMIS)-29 v2.0, and other short-form PROMIS measures of cognitive function, sleep disturbance, and fatigue. RESULTS: Compared to average standardized scale scores (T=50; SD=10), participants had mild impairments in physical (T=41) and social (T=42) functioning, mild symptoms of depression (T=56), anxiety (T=60), and sleep disturbance (T=57), and moderate pain interference (T=62), and fatigue (T=65). Participants reported greater symptoms than some other clinical samples including those with cancer and chronic pain. Post-hoc analyses revealed that women reported higher levels of fatigue than men. CONCLUSIONS: People with persistent post-Lyme treatment symptoms report debilitating symptoms and functional impairments which must be considered in clinical care.

The Compounding Effect of Rurality on Health Disparities Among Black Patients with COVID-19.

Background: West Virginia had garnered national attention for its vaccination rollout against coronavirus 2019 (COVID-19). Outcomes of this mostly rural population, however, have been underreported. As the pandemic continues, identifying high risk populations remains important to further epidemiologic information and target vaccines. Purpose: The objective of this study is to examine the effects of COVID-19 and the influence of race and rurality on hospitalization and outcomes in Appalachians. Methods: In this retrospective study, data from patients who tested positive and were admitted for COVID-19 and seen within the state's largest health system (West Virginia University Health System) between March 18 and September 16, 2020 were analyzed. Cases were stratified into rural or urban based on rural urban continuum codes (RUCCs) and by race into 'white,' 'black,' or 'other.' Associations between rurality, rurality and race, and outcomes were assessed. Results: A total of 2011 adult West Virginians tested positive, of which 8.2% were hospitalized. Of the hospitalized patients, 33.5% were rural and 11.6% were black. Rural black patients were three times more likely (OR: 3.33; 95%CI:1.46-7.60) to be admitted. Rural blacks were also more likely to have a history of obstructive pulmonary disease (OR: 2.73; 1.24-6.01), hypertension (OR: 2.78; 1.38-5.57), and multiple chronic conditions (3.04; 1.48-6.22). Implications: Rural blacks were more likely to have risk factors for severe COVID-19 influencing their increased risk of hospitalization. These findings support that race as a risk factor for severe COVID-19 is compounded by rurality and identifies an important target group for vaccination.

Lessons Learned from a Rhode Island Academic Out-Patient Lyme and Tick-Borne Disease Clinic.

Although the prevalence of Lyme and tick-borne diseases (TBDs) continues to rise, there is conflicting information regarding the best approach to management. The Lifespan Lyme Disease Clinic (LDC) is an academic out- patient clinic for Lyme and other TBDs. A chart review of 218 new patients between March and November 2018 was conducted. Symptoms most commonly reported included fatigue (66.5%), joint pain (58.2%), cognitive difficulty (32.1%), and headaches (27.9%). Most (87.1%) patients had received TBD-directed antibiotic treatment prior to their first appointment. Of the 136 patients who had experienced more than 6 months of symptoms attributed to Lyme, 55.1% had positive two-tiered serologies. Many patients characterized themselves as having "chronic Lyme" or had a diagnosis of "post-treatment Lyme disease syndrome," a condition for which there is no clear consensus on pathophysiology or treatment. Outlined here are some lessons learned and practical approaches used by LDC physicians in caring for this patient population.

The Impact of Alcohol Hangover on Simulated Driving Performance During a 'Commute to Work'-Zero and Residual Alcohol Effects Compared.

Driving is increasing across the world and road traffic accidents are a major cause of serious injuries and fatalities. The link between alcohol consumption and impaired driving has long been established and has led to legislation in many countries, with enforcement of legal limits based on blood alcohol concentration levels. Alcohol hangover research is an emerging field with a range of laboratory and naturalistic studies now clearly demonstrating the significant impairments that can result from hangover, even when alcohol levels are measured at or close to zero the day following a social drinking occasion. Driving is a commonplace activity but requires competency with a range of complex and potentially demanding tasks. Driving impaired can have serious consequences, including death and serious injury. There have been only limited alcohol hangover driving studies. The studies presented examined the consequences of alcohol hangover with a driving simulator contrasting a group with zero residual alcohol (N = 26) next day and another with residual alcohol (N = 26) assessed with breathalyzer in the morning before undertaking a 20 min commute to work. All participants completed a morning drive after a night without alcohol consumption and another after a night of social drinking. The driving scenarios were relatively demanding including traffic and pedestrians, traffic lights and other potential hazards in a mixed rural and urban journey. Subjective hangover and workload were assessed in addition to a range of driving performance variables, including divided attention, steering control and driving violations. Analyses contrasted driving in the no alcohol condition with the residual alcohol condition. The combined groups data (N = 52) was contrasted with the zero and residual alcohol groups. Significant contrasts were found for a range of driving measures, including divided attention, vehicle control, and driving violations as well as perceived workload. The pattern of impairment was broadly similar across both groups, indicating that whether or not residual alcohol was present, consistent driving impairment was seen. The relatively high number of significant variables may reflect the increased cognitive demand of the 20 min commute drive including busy and complex urban environments. This was also reflected in the significant increase in perceived workload recorded across the 6 dimensions of the National Aeronautics and Space Administration Task Load Index (NASA-TLX). Associations between subjective measures and driving performance with hangover suggested a potential lack of awareness of impairment, though were limited in number. The overall findings indicate that the levels of impairment seen reflect those seen with alcohol impaired driving, even when breath alcohol is zero.

The Effects of Alcohol Hangover on Mood and Performance Assessed at Home.

The current study evaluated the next day consequences of a social night of drinking compared to a no alcohol night, with standardised mood and portable screen-based performance measures assessed in the morning at participants' homes, and a breathalyser screen for zero alcohol. A mixed sex group (n = 20) took part in the study. Participants reported consuming on average 16.9 units (135 g) alcohol, resulting in a hangover rating of 60 (out of 100) compared to 0.3 following the no alcohol night. Statistical significance comparisons contrasting the hangover with the no alcohol condition revealed an increase in negative mood and irritability during hangover and an (unexpected) increase in risk and thrill seeking. Performance scores showed an overall slowing of responses across measures, but with less impact on errors. The results support the description of hangover as a general state of cognitive impairment, reflected in slower responses and reduced accuracy across a variety of measures of cognitive function. This suggests a general level of impairment due to hangover, as well as increased negative mood. The use of a naturalistic design enabled the impact of more typical levels of alcohol associated with real life social consumption to be assessed, revealing wide ranging neurocognitive impairment with these higher doses. This study has successfully demonstrated the sensitivity of home-based assessment of the impact of alcohol hangover on a range of subjective and objective measures. The observed impairments, which may significantly impair daily activities such as driving a car or job performance, should be further investigated and taken into account by policy makers.

Assessing Reproductive Decision-making Among HIV-Positive Women in Kumasi, Ghana.

BACKGROUND OR OBJECTIVES: HIV-positive women have higher rates of unmet need for contraception and unintended pregnancy and face unique obstacles in accessing family planning services, such as healthcare-related stigma and disclosing HIV status to partners. This study characterizes factors that influence the reproductive decision-making of women living with HIV and identifies areas for improvement in reproductive counseling in Kumasi. METHODS: In this cross-sectional study, HIV-positive women, ages 18 to 45 years, presenting for care at Komfo Anokye Teaching Hospital between June and August 2017 were interviewed using structured surveys. Information gathered included demographics, method of contraceptive use, initiation of anti-retroviral therapy (ART), knowledge and use of contraception, and future reproductive plans. The primary outcome was current family planning use and future reproductive desire. Univariate analysis was used to characterize the demographics of the study group. Bivariate analysis including Chi-squared test was employed to assess the association between use of family planning between women with an HIV-positive and HIV-negative partner, with significance set at p < 0.05. RESULTS: A total of 88 women were interviewed. The unmet need for contraception was 10%. Among all sexually active women, 26% did not use contraception. Fewer women with HIV-negative or untested partners were using contraception (65% and 67%, respectively), compared to women with HIV-positive partners (93%). Partner preference was the most common reason cited for not using a method of contraceptive (46%). Similar trends were found in future reproductive desires based on age cohorts, partner status, and use of family planning. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: Significant barriers to family planning use among HIV-positive women remain, especially those with a serodiscordant partner. Most partners were aware of their partner's HIV status. This highlights an important opportunity to include partners in HIV and contraceptive counseling.

Adjunctive treatment of clinically severe babesiosis with red blood cell exchange: a case series of nineteen patients.

BACKGROUND: Infection with the protozoan parasite Babesia, the causative agent of babesiosis, can result in asymptomatic to life-threatening illness. Severe cases of babesiosis are characterized by high levels of parasitemia (>4%-10%) and commonly treated with adjunctive red blood cell exchange (RCE) in addition to antimicrobial therapy. The efficacy of RCE in this context is unknown. STUDY DESIGN AND METHODS: Blood bank records were examined for requests for RCE during a 10-year period from 2007 to 2017. Relevant clinical and laboratory variables were extracted from medical records from presentation to 35 days after RCE and analyzed in univariate and multivariate models. RESULTS: Nineteen cases of babesiosis were identified in which RCE was performed. The median age of patients was 77 years, 74% of whom were male. A total of 37% of patients were asplenic. RCE was performed on average 1.3 days after presentation, with procedural urgency driven mainly by the level of parasitemia. Mean pre- and post-RCE levels of parasitemia were 12.9 and 3.4%, respectively, resulting in a mean percent reduction in parasitemia of 75%. Preprocedural parasitemia (p = 0.047) and age (p = 0.028) were both significant predictors of postprocedural hospital length of stay (post-RCE LOS). Neither postprocedural parasitemia (p = 0.12) nor percent reduction in parasitemia (p = 0.72) correlated with post-RCE LOS. Four patients died, none of whom were asplenic. Mortality was not correlated with hematologic, parasitologic, or clinical variables analyzed. CONCLUSIONS: Reduction in the level of parasitemia is the only known benefit of RCE in severe babesiosis.

Babesiosis-associated Splenic Rupture: Case Series From a Hyperendemic Region.

BACKGROUND: Spontaneous splenic rupture is an increasingly reported complication of babesiosis and has been described as a severe complication. METHODS: We performed a retrospective chart review in a high-prevalence area to identify 7 cases of babesiosis-related splenic rupture between 2014 and 2016. RESULTS: Splenic rupture occurred in approximately 1% of babesiosis cases. Compared to cases without splenic rupture, these patients were younger (by >10 years), healthier (most with ≤1 comorbidity), had a lower degree of parasitemia (<10%), and were less likely to have end-organ dysfunction other than their splenic involvement. CONCLUSIONS: Younger, healthier patients may be more prone to develop splenic rupture, as splenic histiocytes engage in more robust erythrophagocytosis, leading to pathological mechanical strain and rupture.

Varicella in the prison setting: A report of three outbreaks in Rhode Island and a review of the literature.

BACKGROUND: The prison setting carries unique risks for varicella outbreaks and the disease in adults, particularly those who are immunocompromised, can be life-threatening. In 2016-17, there were three outbreaks of varicella at three different correctional facilities in Rhode Island. The Centers for Disease Control and Prevention (CDC) recommend post-exposure vaccination within three to five days for affected populations however the Federal Bureau of Prisons (BOP) notes the logistical challenges of vaccinating exposed incarcerated individuals. MATERIAL AND METHODS: A descriptive analysis was performed for each outbreak along with an overview of the response. Varicella serologies were obtained from the exposed population at each facility and the results compiled for comparative analysis. A literature review was then performed to identify and analyze other reported varicella outbreaks in incarcerated populations. RESULTS: In each outbreak, the sentinel event was an inmate with herpes zoster. In prison A, there were 432 inmates exposed to the virus leading to 5 cases of varicella, while the outbreak in Prison B exposed 46 inmates and led to 3 cases. In Prison C, there was one case of primary varicella and 97 inmates were exposed. DISCUSSION: It is remarkable that there were 3 unrelated outbreaks in a short time and, although corroborating data would be necessary to establish a trend, it may signal an increased risk of varicella transmission within this population. Correctional facilities should remain vigilant and have plans for managing the disease including isolation protocols, serology testing and post-exposure vaccination when indicated. While the BOP does not provide clear recommendations on the use of post-exposure prophylaxis during an outbreak response in this population, the experience in Rhode Island and the review of the literate demonstrate steps that can be taken to facilitate a response including post-exposure vaccination in line with CDC recommendations.