Fatal Primary Amebic Meningoencephalitis in Nebraska: Case Report and Environmental Investigation, August 2022.

Primary amebic meningoencephalitis (PAM) is a rare and lethal infection caused by Naegleria fowleri. We report an epidemiological and environmental investigation relating to a case of PAM in a previously healthy boy age 8 years. An interview of the patient's family was conducted to determine the likely exposure site and to assess risk factors. Data from the United States Geological Survey site at Waterloo, NE, on the Elkhorn River were used to estimate water temperature and streamflow at the time and site of exposure. Data from the National Weather Service were used to estimate precipitation and ambient air temperature at the time and site of exposure. Despite conventional treatment, the patient died 2 days after hospital admission. The patient participated in recreational water activities in the Elkhorn River in northeastern Nebraska 5 days before symptom onset. In the week before exposure, water and ambient air high temperatures reached annual highs, averaging 32.4°C and 35.8°C, respectively. The day before infection, 2.2 cm of precipitation was reported. Streamflow was low (407 ft3/s). Infections in several northern states, including Nebraska, suggest an expanding geographic range of N. fowleri transmission, which may lead to increased incidence of PAM in the United States. Similar environmental investigations at suspected exposure sites of future cases will allow data aggregation, enabling investigators to correlate environmental factors with infection risk accurately.

Risk for Infection in Humans after Exposure to Birds Infected with Highly Pathogenic Avian Influenza A(H5N1) Virus, United States, 2022.

During February 7─September 3, 2022, a total of 39 US states experienced outbreaks of highly pathogenic avian influenza A(H5N1) virus in birds from commercial poultry farms and backyard flocks. Among persons exposed to infected birds, highly pathogenic avian influenza A(H5) viral RNA was detected in 1 respiratory specimen from 1 person.

A poly(ethylene glycol) three-dimensional bone marrow hydrogel.

Three-dimensional (3D) hydrogels made from synthetic polymers have emerged as in vitro cell culture platforms capable of representing the extracellular geometry, modulus, and water content of tissues in a tunable fashion. Hydrogels made from these otherwise non-bioactive polymers can be decorated with short peptides derived from proteins naturally found in tissues to support cell viability and direct phenotype. We identified two key limitations that limit the ability of this class of materials to recapitulate real tissue. First, these environments typically display between 1 and 3 bioactive peptides, which vastly underrepresents the diversity of proteins found in the extracellular matrix (ECM) of real tissues. Second, peptides chosen are ubiquitous in ECM and not derived from proteins found in specific tissues, per se. To overcome this critical limitation in hydrogel design and functionality, we developed an approach to incorporate the complex and specific protein signature of bone marrow into a poly (ethylene glycol) (PEG) hydrogel. This bone marrow hydrogel mimics the elasticity of marrow and has 20 bone marrow-specific and cell-instructive peptides. We propose this tissue-centric approach as the next generation of 3D hydrogel design for applications in tissue engineering and beyond.

Investigation of a SARS-CoV-2 B.1.1.529 (Omicron) Variant Cluster - Nebraska, November-December 2021.

The B.1.1.529 (Omicron) variant of SARS-CoV-2 (the virus that causes COVID-19) was first detected in specimens collected on November 11, 2021, in Botswana and on November 14 in South Africa;* the first confirmed case of Omicron in the United States was identified in California on December 1, 2021 (1). On November 29, the Nebraska Department of Health and Human Services was notified of six probable cases† of COVID-19 in one household, including one case in a man aged 48 years (the index patient) who had recently returned from Nigeria. Given the patient's travel history, Omicron infection was suspected. Specimens from all six persons in the household tested positive for SARS-CoV-2 by reverse transcription-polymerase chain reaction (RT-PCR) testing on December 1, and the following day genomic sequencing by the Nebraska Public Health Laboratory identified an identical Omicron genotype from each specimen (Figure). Phylogenetic analysis was conducted to determine if this cluster represented an independent introduction of Omicron into the United States, and a detailed epidemiologic investigation was conducted. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§.

Continuing Education Module-The Childbirth Educator's Role in Teaching Post-Birth Warning Signs.

The U.S. maternal mortality rate has doubled in the past 25 years and has risen despite improvements in health care and an overwhelming global trend in the other direction. Forty-five countries have lower maternal mortality rates than the United States (CIA World Factbook, 2018). For a country that spends more than any other country on health care and more on childbirth-related care than any other area of hospitalization, this is a shockingly poor return on investment. After prolonged attention during pregnancy and birth, there is relatively little attention to the mother's health and well-being in the postpartum period. Yet more than half of childbirth-related deaths occur during this time (Muza, 2017). To minimize complications leading to maternal mortality, childbirth educators need to teach mother and families to identify and respond promptly to warning signs of postpartum complications.

Zwitterionic PEG-PC Hydrogels Modulate the Foreign Body Response in a Modulus-Dependent Manner.

Reducing the foreign body response (FBR) to implanted biomaterials will enhance their performance in tissue engineering. Poly(ethylene glycol) (PEG) hydrogels are increasingly popular for this application due to their low cost, ease of use, and the ability to tune their compliance via molecular weight and cross-linking densities. PEG hydrogels can elicit chronic inflammation in vivo, but recent evidence has suggested that extremely hydrophilic, zwitterionic materials and particles can evade the immune system. To combine the advantages of PEG-based hydrogels with the hydrophilicity of zwitterions, we synthesized hydrogels with comonomers PEG and the zwitterion phosphorylcholine (PC). Recent evidence suggests that stiff hydrogels elicit increased immune cell adhesion to hydrogels, which we attempted to reduce by increasing hydrogel hydrophilicity. Surprisingly, hydrogels with the highest amount of zwitterionic comonomer elicited the highest FBR. Lowering the hydrogel modulus (165 to 3 kPa), or PC content (20 to 0 wt %), mitigated this effect. A high density of macrophages was found at the surface of implants associated with a high FBR, and mass spectrometry analysis of the proteins adsorbed to these gels implicated extracellular matrix, immune response, and cell adhesion protein categories as drivers of macrophage recruitment. Overall, we show that modulus regulates macrophage adhesion to zwitterionic-PEG hydrogels, and demonstrate that chemical modifications to hydrogels should be studied in parallel with their physical properties to optimize implant design.

Control of thiol-maleimide reaction kinetics in PEG hydrogel networks.

Michael-type addition reactions are widely used to polymerize biocompatible hydrogels. The thiol-maleimide modality achieves the highest macromer coupling efficiency of the reported Michael-type pairs, but the resulting hydrogel networks are heterogeneous because polymerization is faster than the individual components can be manually mixed. The reactivity of the thiol dictates the overall reaction speed, which can be slowed in organic solvents and acidic buffers. Since these modifications also reduce the biocompatibility of resulting hydrogels, we investigated a series of biocompatible buffers and crosslinkers to decelerate gelation while maintaining high cell viability. We found that lowering the polymer weight percentage (wt%), buffer concentration, and pH slowed gelation kinetics, but crosslinking with an electronegative peptide was optimal for both kinetics and cell viability. Including a high glucose medium supplement in the polymer solvent buffer improved the viability of the cells being encapsulated without impacting gelation time. Slowing the speed of polymerization resulted in more uniform hydrogels, both in terms of visual inspection and the diffusion of small molecules through the network. However, reactions that were too slow resulted in non-uniform particle dispersion due to settling, thus there is a trade-off in hydrogel network uniformity versus cell distribution in the hydrogels when using these networks in cell applications. STATEMENT OF SIGNIFICANCE: The polymer network of thiol-maleimide hydrogels assembles faster than individual components can be uniformly mixed due to their fast gelation kinetics. The lack of homogeneity can result in variable cell-based assay results, resulting in batch-to-batch variability and limiting their use in predictive screening assays. Although these hydrogels are incredibly useful in tissue engineering, this network heterogeneity is a known problem in the field. We screened a variety of possible techniques to slow down the reaction speed and improve the homogeneity of these hydrogels, without sacrificing the viability and distribution of encapsulated cells. As others have reported, an electronegative crosslinker was the most effective technique to slow the reaction, but the chemical modification required is technically challenging. Of interest to a broad community, we screened buffer type, strength, and crosslinker electronegativity to find an optimal reaction speed that allows for high cell viability and small molecule diffusion, without allowing cells to settle during gelation, allowing application of these materials to the drug screening industry and tissue engineering community.

Complementary, Semiautomated Methods for Creating Multidimensional PEG-Based Biomaterials.

Tunable biomaterials that mimic selected features of the extracellular matrix (ECM) such as its stiffness, protein composition, and dimensionality are increasingly popular for studying how cells sense and respond to ECM cues. In the field, there exists a significant trade-off for how complex and how well these biomaterials represent the in vivo microenvironment versus how easy they are to make and how adaptable they are to automated fabrication techniques. To address this need to integrate more complex biomaterials design with high-throughput screening approaches, we present several methods to fabricate synthetic biomaterials in 96-well plates and demonstrate that they can be adapted to semiautomated liquid handling robotics. These platforms include (1) glass bottom plates with covalently attached ECM proteins and (2) hydrogels with tunable stiffness and protein composition with either cells seeded on the surface or (3) laden within the three-dimensional hydrogel matrix. This study includes proof-of-concept results demonstrating control over breast cancer cell line phenotypes via these ECM cues in a semiautomated fashion. We foresee the use of these methods as a mechanism to bridge the gap between high-throughput cell-matrix screening and engineered ECM-mimicking biomaterials.

Anomalously diffusing and persistently migrating cells in 2D and 3D culture environments.

Appropriately chosen descriptive models of cell migration in biomaterials will allow researchers to characterize and ultimately predict the movement of cells in engineered systems for a variety of applications in tissue engineering. The persistent random walk (PRW) model accurately describes cell migration on two-dimensional (2D) substrates. However, this model inherently cannot describe subdiffusive cell movement, i.e., migration paths in which the root mean square displacement increases more slowly than the square root of the time interval. Subdiffusivity is a common characteristic of cells moving in confined environments, such as three-dimensional (3D) porous scaffolds, hydrogel networks, and in vivo tissues. We demonstrate that a generalized anomalous diffusion (AD) model, which uses a simple power law to relate the mean square displacement to time, more accurately captures individual cell migration paths across a range of engineered 2D and 3D environments than does the more commonly used PRW model. We used the AD model parameters to distinguish cell movement profiles on substrates with different chemokinetic factors, geometries (2D vs 3D), substrate adhesivities, and compliances. Although the two models performed with equal precision for superdiffusive cells, we suggest a simple AD model, in lieu of PRW, to describe cell trajectories in populations with a significant subdiffusive fraction, such as cells in confined, 3D environments.

Furfural and 5-hydroxymethyl-furfural degradation using recombinant manganese peroxidase.

Biomass pretreatment-derived degradation compounds, such as furfural and 5-hydroxymethyl-furfural (HMF), inhibit the growth of fermentation microorganisms that utilize biomass to produce fuels and chemicals. Here we report that recombinant manganese peroxidase (rMnP) produced from the yeast Pichia pastoris can degrade furfural and HMF making them less toxic to microorganisms. Treatment with rMnP or manganese(III) acetate reduced furfural and HMF concentrations in a dose-dependent manner. Furfural disappearance was accompanied by malonate disappearance and accumulation of four distinct degradation products. Furfural was more readily degraded by rMnP and manganese(III) acetate than HMF. Growth assays using Saccharomyces cerevisiae indicated that rMnP treatment reduced the toxicity of furfural and HMF. This work provides an avenue to use rMnP to increase the growth of fermentation microorganisms that are inhibited by toxic compounds derived from pretreatment of biomass.

A biomaterial screening approach reveals microenvironmental mechanisms of drug resistance.

Traditional drug screening methods lack features of the tumor microenvironment that contribute to resistance. Most studies examine cell response in a single biomaterial platform in depth, leaving a gap in understanding how extracellular signals such as stiffness, dimensionality, and cell-cell contacts act independently or are integrated within a cell to affect either drug sensitivity or resistance. This is critically important, as adaptive resistance is mediated, at least in part, by the extracellular matrix (ECM) of the tumor microenvironment. We developed an approach to screen drug responses in cells cultured on 2D and in 3D biomaterial environments to explore how key features of ECM mediate drug response. This approach uncovered that cells on 2D hydrogels and spheroids encapsulated in 3D hydrogels were less responsive to receptor tyrosine kinase (RTK)-targeting drugs sorafenib and lapatinib, but not cytotoxic drugs, compared to single cells in hydrogels and cells on plastic. We found that transcriptomic differences between these in vitro models and tumor xenografts did not reveal mechanisms of ECM-mediated resistance to sorafenib. However, a systems biology analysis of phospho-kinome data uncovered that variation in MEK phosphorylation was associated with RTK-targeted drug resistance. Using sorafenib as a model drug, we found that co-administration with a MEK inhibitor decreased ECM-mediated resistance in vitro and reduced in vivo tumor burden compared to sorafenib alone. In sum, we provide a novel strategy for identifying and overcoming ECM-mediated resistance mechanisms by performing drug screening, phospho-kinome analysis, and systems biology across multiple biomaterial environments.

Perceived Benefits of Childbirth Education on Future Health-Care Decision Making.

The aim of this qualitative study was to explore the perception of women regarding long-term effects of childbirth education on future health-care decision making. This qualitative study used a purposive sample of 10 women who participated in facilitated focus groups. Analysis of focus group narratives provided themes in order of prevalence: (a) self-advocacy, (b) new skills, (c) anticipatory guidance, (d) control, (e) informed consent, and (f) trust. This small exploratory study does not answer the question of whether childbirth education influences future health-care decision making, but it demonstrates that the themes and issues from participants who delivered 15-30 years ago were comparable to current findings in the literature.

Mechanics of intact bone marrow.

The current knowledge of bone marrow mechanics is limited to its viscous properties, neglecting the elastic contribution of the extracellular matrix. To get a more complete view of the mechanics of marrow, we characterized intact yellow porcine bone marrow using three different, but complementary techniques: rheology, indentation, and cavitation. Our analysis shows that bone marrow is elastic, and has a large amount of intra- and inter-sample heterogeneity, with an effective Young׳s modulus ranging from 0.25 to 24.7 kPa at physiological temperature. Each testing method was consistent across matched tissue samples, and each provided unique benefits depending on user needs. We recommend bulk rheology to capture the effects of temperature on tissue elasticity and moduli, indentation for quantifying local tissue heterogeneity, and cavitation rheology for mitigating destructive sample preparation. We anticipate the knowledge of bone marrow elastic properties for building in vitro models will elucidate mechanisms involved in disease progression and regenerative medicine.

Smart device use and burnout among health science educators.

PURPOSE: This study examines the perceived level of stress and burnout among health science educators related to smart device use. METHODS: An interdisciplinary health science research team was created to perform a literature review and design a survey and assessment instrument to investigate the level of stress and burnout among health science educators as a result of excessive connectivity to the workplace through smart device use. A total of 977 assessments were completed through distribution by program directors in athletic training, nursing, radiologic sciences, and respiratory care. RESULTS: Participants in the study, who represented program directors and educators in the allied health sciences, reported 70% of their smart device use taking place between the hours of 6 am and 6 pm, followed by 30% between 6 pm and 12 am. Slightly more than 60% of participants reported feeling connected to the workplace at all hours of the day. Emotional exhaustion and personal accomplishment scores for participants were stronger than the norm as measured by the Maslach Burnout Inventory. DISCUSSION: There appears to be a strong feeling of connectedness to the workplace caused by the use of smart devices (60.7%). Some surveyed educators appear to manage their smart device use better than others because 55% of participants indicated they sometimes ignore work-related items after hours. Although several participants demonstrated physical signs of stress and burnout, a causal relationship between use of smart devices or work connectedness could not be established. CONCLUSION: Based on the findings of this study, the null hypothesis was rejected. Significant levels of emotional exhaustion were seen in a subset of study participants. Our findings indicate that emotional exhaustion occurs when healthy boundaries are not maintained for smart device use for work purposes after hours.

Childbirth education in rural haiti: reviving low-tech teaching strategies.

On a medical mission into rural mountainous regions of Haiti, the authors were charged with teaching safer childbirth practices to untrained, mostly illiterate traditional birth attendants (TBA) who spoke Haitian Creole. In this isolated region with no physician or accessible hospital, almost all births occur at home. With no electricity, safe water supply, or sanitation facilities, childbirth education was a challenge. Accustomed to electronic, high-tech teaching aids, these childbirth educators had to modify educational strategies for these extraordinary circumstances. A successful solution was to revive decades-old teaching techniques and visual aids once used in Lamaze classes. The purpose of this article is to describe the teaching environment, the target audience, and the low-tech approach to childbirth education in Haiti.

First do no harm: interventions during childbirth.

Although medical and technological advances in maternity care have drastically reduced maternal and infant mortality, these interventions have become commonplace if not routine. Used appropriately, they can be life-saving procedures. Routine use, without valid indications, can transform childbirth from a normal physiologic process and family life event into a medical or surgical procedure. Every intervention presents the possibility of untoward effects and additional risks that engender the need for more interventions with their own inherent risks. Unintended consequences to intrapartum interventions make it imperative that nurse educators work with other professionals to promote natural childbirth processes and advocate for policies that focus on ensuring informed consent and alternative choices. Interdisciplinary collaboration can ensure that intrapartum caregivers "first do no harm."