Type 2 Diabetes Status, Diabetes Complication Severity Index Scores, and Their Relationship With COVID-19 Severity: A Retrospective Cohort Study of Hospitalized Patients in a Southwest Virginia Health System.

Background Studies have shown that patients with type 2 diabetes mellitus (T2DM) tend to have poorer outcomes associated with COVID-19, including increased rates of hospitalization, ICU admission, need for ventilatory support, and mortality. Methods We performed a retrospective cohort study that included all non-pregnant adult patients who were hospitalized as a result of COVID-19 in a Southwest Virginia health system between March 18, 2020, and August 31, 2022. T2DM status was treated as a binary variable. T2DM severity was assessed using the Diabetes Complications Severity Index (DCSI). Multivariate logistic regression was used to assess the relationship between T2DM status and COVID-19 severity outcomes. Multivariate logistic regression was also used to assess the relationship between DCSI score and COVID-19 severity outcomes among patients with an established diagnosis of T2DM at the time of COVID-19 hospital admission. Results Patients with T2DM had 1.27 times the odds of experiencing a poor COVID-19 clinical outcome (95% CI: 1.13, 1.43) and 1.35 times the odds of in-hospital mortality (95% CI: 1.14, 1.59) compared to patients without diabetes. Among patients with T2DM, increasing DCSI score was significantly associated with increased odds of experiencing a poor COVID-19 clinical outcome and in-hospital mortality. Conclusions Diabetic patients in our sample were at increased odds of experiencing poor COVID-19 clinical outcomes and in-hospital mortality compared to individuals without diabetes. Amongst patients with T2DM, increasing DCSI score was associated with worse COVID-19 outcomes. Clinical decision support tools may be able to utilize DCSI scores as an indicator of COVID-19 severity risk to facilitate decisions regarding treatment aggressiveness and resource allocation.

Triple Threat: Triple-Valve Endocarditis Case Report and Literature Review.

Triple valve endocarditis (TVE) is a rare presentation of endocarditis often requiring multivalvular surgery. Here we report a case of S. aureus triple valve endocarditis in a patient with a history of intravenous drug use and provide a literature review of TVE identification, treatment, and prognosis.

When Should Healthcare Workers With Coronavirus Disease 2019 (COVID-19) Return to Work? An Analysis of Follow-up Antigen Test Results After a Positive COVID Test.

A high percentage of healthcare workers (HCWs) who had met the Centers for Disease Control and Prevention criteria for returning to work 5 days after symptom onset remained positive for their return-to-work COVID-19 antigen test, suggesting continued infectiousness. Boosted HCWs were more likely to be antigen positive on their return-to-work test compared to unvaccinated HCWs, which merits further research.

Deepening Our Understanding of COVID-19 Vaccine Decision-Making amongst Healthcare Workers in Southwest Virginia, USA Using Exploratory and Confirmatory Factor Analysis.

Vaccine hesitancy amongst healthcare workers (HCWs) has been a major challenge throughout the COVID-19 pandemic. While many studies have identified HCW characteristics and specific attitudes associated with COVID-19 vaccine hesitancy, researchers are still working towards developing a holistic understanding of the psychological constructs that influence COVID-19 vaccine decision-making in this population. Between 15 March and 29 March 2021, we distributed an online survey assessing individual characteristics and vaccine-related perceptions to employees of a not-for-profit healthcare system in Southwest Virginia (N = 2459). We then performed exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to describe patterns of vaccine-related thought amongst HCWs and identify latent psychometric constructs involved in vaccine decision-making. The goodness of model fit was assessed using the Tucker-Lewis Index (TLI), the Comparative Fit Index (CFI), and the Root Mean Square Error of Approximation (RMSEA). Internal consistency and reliability of each factor were assessed using Cronbach's alpha. EFA identified four latent psychometric constructs: Lack of trust in the COVID-19 vaccine; Anti-science sentiment; Adverse side-effects; and Situational risk assessment. The goodness of EFA model fit was adequate (TLI > 0.90, RMSEA ≤ 0.08) with acceptable internal consistency and reliability for three of four factors (Cronbach's alpha > 0.70). The CFA model also had adequate goodness of fit (CFI > 0.90, RMSEA ≤ 0.08). We believe the psychometric constructs identified in this study can provide a useful framework for interventions to improve vaccine uptake amongst this critical population.

Update in Human Immunodeficiency Virus and Aging.

Effective and consistent antiretroviral therapy has enabled people with human immunodeficiency virus (HIV) (PWH) to survive longer than previously encountered earlier in the epidemic. Consequently, PWH are subject to the struggles and clinical conditions typically associated with aging. However, the aging process in PWH is not the same as for those who do not have HIV. There is a complex interplay of molecular, microbiologic, and pharmacologic factors that leads to accelerated aging in PWH; this leads to increased risk for certain age-related comorbidities requiring greater vigilance and interventions in routine care.

Time to Reconsider Hepatitis A Vaccination in Food Handlers: Are We Seeing More Outbreaks and Severe Disease?

The risk for secondary infection from hepatitis A-infected food handlers to patrons is deemed as low. Thus, hepatitis A vaccination is not specifically recommended for persons who handle food in the absence of other risk factors in the United States. We describe an ongoing food handler-associated hepatitis A outbreak in southwest Virginia and recommend policy changes that will incentivize food industry employers to embrace broader food handler hepatitis A vaccination.

Examining drivers of coronavirus disease 2019 (COVID-19) vaccine hesitancy among healthcare workers.

OBJECTIVE: To assess characteristics and perceptions associated with vaccine hesitancy among healthcare workers to increase coronavirus disease 2019 (COVID-19) vaccine uptake in this population. DESIGN: Cross-sectional quantitative survey. SETTING: A not-for-profit healthcare system in southwestern Virginia. PARTICIPANTS: A convenience sample of 2,720 employees of a not-for-profit healthcare system. METHODS: Between March 15 and 29, 2021, we conducted an Internet-based survey. Our questionnaire assessed sociodemographic and work-related characteristics, vaccine experience and intentions, agreement with vaccine-related perceptions, the most important reasons for getting or not getting vaccinated, and trusted sources of information about COVID-19. We used χ2 analyses to assess the relationship between vaccine hesitancy and both HCW characteristics and vaccine-related perceptions. RESULTS: Overall, 18% of respondents were classified as vaccine hesitant. Characteristics significantly associated with hesitancy included Black race, younger age, not having a high-risk household member, and prior personal experience with COVID-19 illness. Vaccine hesitancy was also significantly associated with many vaccine-related perceptions, including concerns about short-term and long-term side effects and a belief that the vaccines are not effective. Among vaccine-acceptant participants, wanting to protect others and wanting to help end the pandemic were the most common reasons for getting vaccinated. Personal physicians were cited most frequently as trusted sources of information about COVID-19 among both vaccine-hesitant and vaccine-acceptant respondents. CONCLUSIONS: Educational interventions to decrease vaccine hesitancy among healthcare workers should focus on alleviating safety concerns, emphasizing vaccine efficacy, and appealing to a sense of duty. Such interventions should target younger adult audiences. Personal physicians may also be an effective avenue for reducing hesitancy among their patients through patient-centered discussions.

Diagnostic accuracy of a new COVID-19 antigen test obtained by mid-turbinate swab.

Context: At the mid-point of the COVID-19 pandemic, polymerase chain reaction (PCR) testing for SARS-CoV-2 was difficult to obtain and took several days to return a result. Our health system wished to explore the use of the Quidel Sofia™ antigen test to diagnose COVID-19 in our primary care clinics, but the test was approved for emergency use authorization by the US Food and Drug Administration with only 250 test subjects. In addition, because it was important to avoid aerosol generating procedures in primary care clinics, it was necessary to test the diagnostic performance of the antigen test using mid-turbinate (MT) swabs rather than the approved nasopharyngeal (NP) swab technique. Objective: To assess the diagnostic test characteristics of a SARS-CoV-2 antigen test performed using mid-turbinate nasal swabs compared with the presumed reference standard PCR test by NP swab. Study Design: Prospective cohort study. Setting or Dataset: Outpatient. Population studied: Adults with symptoms consistent with mild-moderate COVID-19. We attempted to recruit 800 subjects to provide statistical assurance that the test sensitivity was at least 90%. Intervention/Instrument: After informed consent, subjects underwent MT nasal swab for antigen testing followed by NP swabbing for PCR testing. Outcome Measures: Sensitivity, specificity, positive and negative predictive values, and likelihood ratios, all with associated 95% confidence intervals. Results: Due to recruitment difficulty (subject reluctance and staffing issues at the testing centers), we recruited only 117 subjects. Sensitivity was 0.750 (95% CI 0.566, 0.885), and specificity was 0.988 (95% CI 0.936, 1.000). Positive Predictive Value was 0.960 (95% CI 0.796, 0.999) and Negative Predictive Value was 0.913 (95% CI 0.836, 0.962). The likelihood ratio for a positive test was 63.75 (95% CI 8.99, 451.97) and the likelihood ratio for a negative test was 0.25 (95% CI 0.14, 0.46). Conclusions: This antigen test for SARS-CoV-2 was of reasonable clinical utility in a low prevalence environment but concerns about the actual prevalence of COVID-19 and the ramifications of false negatives limited its use. Difficulty recruiting subjects and the resultant delay in the results made it impossible to implement this antigen testing in primary care practices, but it is hoped that these data will contribute to the accumulation of evidence about diagnostic testing for COVID-19.

N95 reprocessing by low temperature sterilization with 59% vaporized hydrogen peroxide during the 2020 COVID-19 pandemic.

BACKGROUND: Response to the COVID-19 pandemic by hospital systems has been strained by severe shortages in personal protective equipment (PPE), particularly N95 respirators. Recently, the Centers for Disease Control and Prevention endorsed decontamination strategies to prolong the lifespan of single use respirators. Battelle and Duke University have validated hospital protocols to decontaminate respirators using vaporized hydrogen peroxide (VHP) at 30%-35% concentrations. To prolong our supply of respirators, we evaluated and implemented VHP decontamination at 59% hydrogen peroxide concentration while detailing the effects of this process on the filtration efficiency and quantitative fit of single-use respirators. This study may help other health systems develop local solutions to their N95 mask shortage during this COVID-19 pandemic. METHODS: N95 respirators (3M 8211 FF and 9210 FF) that were treated with 5 and 10 cycles of VHP by the V-PRO maX Low Temperature Sterilization System were evaluated quantitatively for filtration efficiency as well as with quantitative fit testing per Occupational Safety and Health Administration standards. A decontamination protocol was concurrently implemented at our institution. This process involved depositing used masks, reprocessing, and re-distributing treated masks efficiently back to frontline providers. Furthermore, we implemented patient safety officers on COVID-19/person under investigation units to ensure optimized donning/doffing of respirators through frontline provider education. RESULTS: There were no statistically significant changes in mean filtration efficiency between the control and VHP-treated respirators. Furthermore, both treated and untreated respirators demonstrated fit factors above the minimum pass requirement. CONCLUSIONS: We have successfully demonstrated that N95 respirator decontamination with VHP at 59% hydrogen peroxide can be safely utilized to decontaminate single-use N95 respirators without significant effects on filtration efficiency or quantitative fit testing. With the COVID-19 pandemic and N95 respirator shortage, health systems without access to commercial decontamination processes should investigate the viability of such a process in their facilities.

Drug-Susceptible and Multidrug-Resistant Mycobacterium tuberculosis in a Single Patient.

A patient who had initial infection with mixed strains of drug-susceptible and multidrug-resistant tuberculosis was presumed to have acquired drug resistance before confirmation that sequential strains were genotypically distinct. Transmitted infection with mixed strains is likely underappreciated; identifying these infections requires spoligotyping and whole-genome sequencing.

Braden score may be associated with time to onset of catheter-associated urinary tract infection in high-risk patients: Lessons learned from a root cause analysis tool.

Timely removal of the urinary catheter is an important strategy for decreasing catheter-associated urinary tract infections (CAUTIs). Data were aggregated from an electronic root cause analysis tool, which is used to collect and guide discussions on patient factors following a CAUTI event at our facility. This identified the Braden Scale score as a possible important predictor of early-onset CAUTI in high-risk patients and could potentially be leveraged for early action in urinary catheter removal.

Tuberculous Enteritis Presenting as Acute Appendicitis and Perirectal Abscess.

Mycobacterium tuberculosis has a wide variety of presentations. A rare occurrence is gastrointestinal tuberculosis. It may occur anywhere along the alimentary canal but usually occurs in the ileocecum with rare involvement of the appendix.

Tn2008-driven carbapenem resistance in Acinetobacter baumannii isolates from a period of increased incidence of infections in a Southwest Virginia hospital (USA).

OBJECTIVES: The objectives of this study were (i) to determine the genetic basis for carbapenem resistance in multidrug-resistant (MDR) Acinetobacter baumannii strains isolated from patients affected by a sudden increase in the incidence of infections by such organisms in a tertiary care hospital in Virginia, USA, in 2009-2010 and (ii) to examine whether such strains are commonly encountered in the hospital setting. METHODS: The whole genomes of one outbreak strain as well as one carbapenem-resistant and one carbapenem-sensitive strain from sporadic infections in 2010-2012 were sequenced and analysed. Then, 5 outbreak isolates and 57 sporadic isolates (of which 39 were carbapenem-resistant) were screened by PCR for relevant DNA elements identified in the genomics investigation. RESULTS: All three strains for which whole-genome sequences were obtained carried resistance genes linked to MDR phenotypes and a ca. 111-kbp plasmid (pCMCVTAb1) without drug resistance genes. Of these, the two carbapenem-resistant strains possessed a ca. 74-kbp plasmid (pCMCVTAb2) carrying a Tn2008 transposon that provides high-level carbapenem resistance. PCR analysis showed that all of the outbreak isolates carried both plasmids and Tn2008, and of the sporadic isolates 88% carried pCMCVTAb1, 25% contained pCMCVTAb2 and 50% of the latter group carried Tn2008. CONCLUSIONS: Carbapenem resistance in outbreak strains and 12% of sporadic isolates was due to the pCMCVTAb2-borne Tn2008. This is the first report of a Tn2008-driven outbreak of carbapenem-resistant A. baumannii infections in the Commonwealth of Virginia, which followed similar cases in Pennsylvania and Ohio.

Early clinical observations in prospectively followed patients with fungal meningitis related to contaminated epidural steroid injections.

UNLABELLED: Chinese translation BACKGROUND: Administration of epidural steroid injections (ESIs) with contaminated methylprednisolone resulted in an outbreak of fungal meningitis in many locations in the United States. OBJECTIVE: To characterize early clinical findings and initial response to treatment. DESIGN: Case series with standardized observation studied from 4 October to 31 October 2012. SETTING: An 800-bed hospital in Virginia. PATIENTS: 172 patients who presented to the hospital with exposure to contaminated ESI. INTERVENTION: Standardized approach to screening, case definition, treatment, and data collection. MEASUREMENTS: Clinical findings, cerebrospinal fluid (CSF) values, magnetic resonance imaging (MRI), serum and CSF voriconazole concentrations, and clinician assessment of response to therapy. RESULTS: Of 172 patients presenting to the hospital who had had ESI, 131 had lumbar puncture because of symptoms or signs consistent with central nervous system disease. Twenty-five (19%) had neutrophilic meningitis. All were started on voriconazole therapy alone. Three patients developed stroke during treatment. Ten patients had arachnoiditis, another had an epidural abscess, and 9 had urine retention. Fifteen continued to receive voriconazole, and 10 were switched to amphotericin B. Cerebrospinal fluid leukocyte counts began to decrease by day 13 of treatment. Findings on MRI included ventriculitis, leptomeningeal enhancement, infarction, hemorrhage, and arachnoiditis. Serum voriconazole levels varied, and CSF concentrations of voriconazole were approximately 50% those of serum. Exserohilum rostratum and Cladosporium species have been cultured. LIMITATIONS: This is an observational study of an evolving outbreak. Not all exposed patients presented for evaluation. Follow-up is too short to determine final outcomes. CONCLUSION: Meningitis after receipt of contaminated ESI has been diagnosed in many exposed patients presenting to 1 hospital. Most patients have improved on receipt of empirical voriconazole therapy. The full natural history and long-term sequelae of this infection are currently unknown. PRIMARY FUNDING SOURCE: None.