Hepatitis C Virus Elimination Programs in Louisiana and Washington: Importance of Screening and Surveillance Systems.

The US government has established a national goal of hepatitis C virus (HCV) elimination by 2030. To date, most HCV elimination planning and activity have been at the state level. Fifteen states presently have publicly available HCV elimination plans. In 2019, Louisiana and Washington were the first states to initiate 5-year funded HCV elimination programs. These states differ on motivation for pursuing HCV elimination and ranking on several indicators. Simultaneously, however, they have emphasized several similar elimination components including HCV screening promotion through public awareness, screening expansion, surveillance enhancement (including electronic reporting and task force development), and harm reduction. The 13 other states with published elimination plans have proposed the majority of the elements identified by Louisiana and Washington, but several have notable gaps. Louisiana's and Washington's comprehensive plans, funding approaches, and programs provide a useful framework that can move states and the nation toward HCV elimination.

Development of a competency model and tailored assessment method for high school science teachers utilizing a flipped learning approach.

Many professional development programs aim to improve student outcomes by enhancing teacher competencies. Effective evaluation of these programs requires a clear delineation of the competencies to be gained. A competency model was developed to evaluate the impact of a teacher professional program that aimed to improve teachers' ability to effectively implement technologically engaged modules in a flipped classroom setting. Competencies were identified via participatory evaluation techniques and assessments were aligned to the competencies. The competency of teachers in the knowledge, skills, and abilities needed for creation and delivery of effective flipped lessons can be tracked using a radar graph to guide tailored professional development.

Fibroblast growth factor receptor 1 amplification in laryngeal squamous cell carcinoma.

Fibroblast growth factor receptor 1 (FGFR1) has been noted to be amplified in a variety of squamous cell carcinomas (SCCa) of the head, neck, and lung and increased copy number (CN) is a predictor of poor outcomes. FGFR1 is a therapeutic target for lung SCCa and inhibition therapy is currently in clinical trials. Absolute quantification of FGFR1 from formalin fixed paraffin embedded (FFPE) tissue of laryngeal SCCa was examined in this retrospective study. A droplet digital polymerase chain reaction (ddPCR) was used for absolute quantitation of the FGFR1 gene CN. Of the 74 samples analyzed, FGFR1 CN analysis revealed 54% of samples had CN greater than 2 copies/cell (1.8-2.2 copies/cell), and 38% had CN values greater than 3. The mean and standard deviation FGFR1 CN was 4.17 ± 1.46 CN for African American patients (n = 41) and 3.78 ±1.85 CN for Caucasian patients (n = 31). Further, 60.9% of specimens from African Americans demonstrated increased FGFR1 CN compared to 48.4% of Caucasians. Two SCCA samples from Native American demonstrated increased FGFR1 CN (4.19 and 3.01 CN). The level of FGFR1 amplification did not correlate with tumor stage, lymph node staging, or metastasis. In this population, the proportion of patient samples with an FGFR1 amplification was three times higher than in reported for SCCA of the head and neck. Further, increased FGFR1 CN was observed in two racial groups not previously reported: African Americans and Native Americans. However, FGFR1 amplification is not prognostic in laryngeal squamous cell carcinomas.

Mechanisms of fosfomycin resistance in carbapenem-resistant Enterobacter sp.

We report on fosfomycin susceptibility and mechanisms of resistance in clinical strains of blaKPC-positive Enterobacter sp. (n = 19). A total of 14 strains (74%) were susceptible to fosfomycin; 8 strains (42%) were positive for fosA and no strains were positive for FosA3 or FosC2. FosA presence does not appear to correlate with susceptibility.

Decrease in Statewide Antipsychotic Prescribing after Implementation of Child and Adolescent Psychiatry Consultation Services.

OBJECTIVE: To learn if a quality of care Medicaid child psychiatric consultation service implemented in three different steps was linked to changes in statewide child antipsychotic utilization. DATA SOURCES/STUDY SETTING: Washington State child psychiatry consultation program primary data and Medicaid pharmacy division antipsychotic utilization secondary data from July 1, 2006, through December 31, 2013. STUDY DESIGN: Observational study in which consult program data were analyzed with a time series analysis of statewide antipsychotic utilization. DATA COLLECTION/EXTRACTION METHODS: All consultation program database information involving antipsychotics was compared to Medicaid pharmacy division database information involving antipsychotic utilization. PRINCIPAL FINDINGS: Washington State's total child Medicaid antipsychotic utilization fell from 0.51 to 0.25 percent. The monthly prevalence of use fell by a mean of 0.022 per thousand per month following the initiation of elective consults (p = .004), by 0.065 following the initiation of age/dose triggered mandatory reviews (p < .001), then by another 0.022 following the initiation of two or more concurrent antipsychotic mandatory reviews (p = .001). High-dose antipsychotic use fell by 57.8 percent in children 6- to 12-year old and fell by 52.1 percent in teens. CONCLUSIONS: Statewide antipsychotic prescribing for Medicaid clients fell significantly at different rates following each implementation step of a multilevel consultation and best-practice education service.

Can contaminated water be rendered safe for nasal saline irrigations?

OBJECTIVES/HYPOTHESIS: To compare sterile water to three methods of sterilization (carbon filtration, boiling, and ultraviolet [UV] light) for preparation of nasal saline irrigants free of bacterial and amebic contaminants. STUDY DESIGN: Bench-top translational research and cost comparison. METHODS: Sterile water was compared to common sterilization methods. Sterile water was contaminated with known concentrations of Staphylococcus aureus, Pseudomonas aeruginosa, Moraxella catarrhalis, Acinetobacter baumannii, Klebsiella pneumonia, Legionella pneumophila, and Naegleria fowleri. Test samples were subjected to boiling, carbon filtration, or ultraviolet light (UV) and then cultivated on appropriate media. Controls included samples of sterile water (negative control) and untreated test samples (positive control). RESULTS: Carbon filtration reduced but did not eliminate the number of organisms present in test samples. Boiling test samples for 5 minutes and UV light treatment resulted in sterilization of all organisms. Negative (sham contaminated) samples produced no growth, whereas positive (untreated) samples grew numerous organisms as expected. A cost comparison between bottled water and UV water sterilization (with SteriPEN Ultra) became equal in less than 2 years of consistent use. CONCLUSIONS: Carbon filtration reduces contamination but does not sterilize water and is thus unsafe for preparation of nasal saline irrigant. Boiling and UV treatment resulted in sterilization and are equivalent to purchased sterile water. Ultraviolet treatment was found to be safe, convenient, and a cost-effective alternative to purchased sterile water. LEVEL OF EVIDENCE: NA Laryngoscope, 127:1513-1519, 2017.

Multiclonal methicillin-resistant Staphylococcus aureus (MRSA) outbreak and its control after use of the Veterans Affairs (VA) MRSA bundle in a VA long-term care facility, 2004-2014.

A multiclonal methicillin-resistant Staphylococcus aureus (MRSA) outbreak with 91 infections occurred in our Veterans Affairs (VA) community living center over 46 months. Both similar and unique strains were shown by repetitive polymerase chain reaction to contribute to the outbreak, including 1 strain causing infections over a 33-month period. Most infections were soft tissue infections (67%). For 21 months after the initiation of the VA MRSA bundle, no infections were identified, and low rates of infection have been sustained an additional 4 years. The average annual rate of MRSA infection decreased by 62% (P < .001) from 0.6 per 1,000 resident days for 4 years prior to the bundle implementation to 0.09 per 1,000 resident days for 4 years after the bundle implementation.

Attitudes and perceptions of U.S. dental students and faculty regarding dental licensure.

The aim of this study was to assess the attitudes and perceptions of U.S. dental students and faculty members about National Board Dental Examination (NBDE) pass/fail reporting, an Integrated NBDE, clinical examinations, licensure process and strategies, and validity of licensure. A survey instrument consisting of ten statements with response options on a five-point Likert scale and a free-text comment section was developed and distributed through SurveyMonkey. A total of 411 students and 186 faculty members from ten U.S. dental schools participated, with an estimated response rate of 17%. Faculty and student responses were compared using the Mann-Whitney U test. These students' and faculty members' attitudes and perceptions were similar. Both groups showed mixed attitudes about NBDE scores as pass/fail, rather than numerical scores. The Integrated NBDE solicited mixed opinions and concerns that it would be complicated and stressful because students would be challenged to memorize information from earlier years. However, a single national clinical examination was highly preferred by both groups, preferably with simulated rather than real patients. Other strategies, such as background checks and continuing education requirements, were supported by both groups. Most of the licensure process strategies and policies were supported by both student and faculty respondents in the dental schools surveyed.

Contrasting Perspectives of Dental Faculty and Their Students Concerning Dental Academia.

Attitudes of dental students and faculty towards research, faculty recruitment, new school openings, and academic career rewards and disadvantages were evaluated. Both groups believe that research should be discretionary. Faculty had significantly higher support for supervising and encouraging students to conduct research. Students favored recruitment of better quality (not more) faculty, and some displayed concerns about a tuition increase if additional faculty members were recruited. Both groups said there is no significant need for new dental schools. Faculty displayed a more favorable view toward an academic career and a significantly more favorable view of faculty recruitment.

Perspectives of dental students and faculty about evidence-based dental practice.

OBJECTIVE: The study aimed at evaluating attitudes and perceptions of dental students and faculty toward evidence-based practice, integration of technology and social media, general practitioners' and specialists' scope of practice, and dental practice rewards and disadvantages. METHODS: A survey instrument was designed with 10 statements rated on a five-point Likert scale (strongly agree to strongly disagree) and an optional comment section. The survey instrument was delivered through SurveyMonkey, whereby 401 students and 182 faculty members from ten U.S. dental schools participated (16% estimated response rate). Null hypotheses regarding the equality between the responses of the two groups were statistically tested using Mann-Whitney U test. Statistical significance was set at .05. RESULTS: Evidence-based practice is positively perceived by both groups, but with significantly higher support by faculty than students (P = 0.002). Both groups agreed that technological advancements are advantageous (P = 0.95), but do not constitute good dentistry and cannot mask poor clinical skills. Students showed higher support for social media than faculty (P = 0.000). Both groups perceived group practices positively. Faculty members showed higher agreement than students toward limitation of dental specialists' practices to their specialties (P = 0.000). Both groups are aware of practice disadvantages, such as increased litigation, health risks, and detriment to the dentist's posture. However, they both perceive dental practice positively despite all these challenges. CONCLUSIONS: Students and faculty share generally comparable perspectives toward dental practice. They are both in agreement with evidence-based practice and adoption of technology. They both acknowledge practice limitations.

U.S. Dental students' and faculty members' attitudes about technology, instructional strategies, student diversity, and school duration: a comparative study.

In this study, attitudes and perceptions of U.S. dental students and faculty members were evaluated regarding four aspects of dental education: technology integration, instructional strategies, student diversity, and school duration. A survey instrument with eight statements using a five-point Likert scale and a free-text comment section was developed and distributed through Survey Monkey. A total of 426 students and 187 faculty members from ten U.S. dental schools participated, a response rate of 17 percent of those surveyed. Faculty and student responses were compared using the Mann-Whitney U test. The results of this analytic procedure revealed that the groups differed in their average responses for seven of the eight statements. Analysis of the faculty and student comments revealed similar themes between the two groups. Both dental students and dental faculty members stated that technology integration should be viewed as only a supplement to conventional instruction and showed mixed opinions about electronic textbooks. Further, both groups had positive views of the roles of problem-based learning, community service, and the integration of research practice into dental education. Both groups also valued diversity in the student body and supported the current four-year duration of dental school.

Cost-benefit and effectiveness analysis of rapid testing for MRSA carriage in a hospital setting.

A cost-effectiveness analysis was conducted comparing the polymerase chain reaction assay and traditional microbiological culture as screening tools for the identification of methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to the pediatric and surgical intensive care units (PICU and SICU) at a 722 bed academic medical center. In addition, the cost benefits of identification of colonized MRSA patients were determined. The cost-effectiveness analysis employed actual hospital and laboratory costs, not patient costs. The actual cost of the PCR assay was higher than the microbiological culture identification of MRSA ($602.95 versus $364.30 per positive carrier identified). However, this did not include the decreased turn-around time of PCR assays compared to traditional culture techniques. Patient costs were determined indirectly in the cost-benefit analysis of clinical outcome. There was a reduction in MRSA hospital-acquired infection (3.5 MRSA HAI/month without screening versus 0.6/month with screening by PCR). A cost-benefit analysis based on differences in length of stay suggests an associated savings in hospitalization costs: MRSA HAI with 29.5 day median LOS at $63,810 versus MRSA identified on admission with 6 day median LOS at $14,561, a difference of $49,249 per hospitalization. Although this pilot study was small and it is not possible to directly relate the cost-effectiveness and cost-benefit analysis due to confounding factors such as patient underlying morbidity and mortality, a reduction of 2.9 MRSA HAI/month associated with PCR screening suggests potential savings in hospitalization costs of $142,822 per month.

Detection of methicillin-resistant Staphylococcus aureus by a duplex droplet digital PCR assay.

Health care-associated infections with methicillin-resistant Staphylococcus aureus (MRSA) contribute to significant hospitalization costs. We report here a droplet digital PCR (ddPCR) assay, which is a next-generation emulsion-based endpoint PCR assay for high-precision MRSA analysis. Reference cultures of MRSA, methicillin-susceptible S. aureus (MSSA), and confounders were included as controls. Copan swabs were used to sample cultures and collect specimens for analysis from patients at a large teaching hospital. Swab extraction and cell lysis were accomplished using magnetic-driven agitation of silica beads. Quantitative PCR (qPCR) (Roche Light Cycler 480) and ddPCR (Bio-Rad QX100 droplet digital PCR system) assays were used to detect genes for the staphylococcal protein SA0140 (SA) and the methicillin resistance (mecA) gene employing standard TaqMan chemistries. Both qPCR and ddPCR assays correctly identified culture controls for MRSA (76), MSSA (12), and confounder organisms (36) with 100% sensitivity and specificity. Analysis of the clinical samples (211 negative and 186 positive) collected during a study of MRSA nasal carriage allowed direct comparison of the qPCR and ddPCR assays to the Cepheid MRSA GeneXpert assay. A total of 397 clinical samples were examined in this study. Cepheid MRSA GeneXpert values were used to define negative and positive samples. Both the qPCR and ddPCR assays were in good agreement with the reference assay. The sensitivities for the qPCR and ddPCR assays were 96.8% (95% confidence interval [CI], 93.1 to 98.5%) and 96.8% (95% CI, 93.1 to 98.5%), respectively. Both the qPCR and ddPCR assays had specificities of 91.9% (95% CI, 87.5 to 94.9%) for qPCR and 91.0% (95% CI, 86.4 to 94.2%) for ddPCR technology.

Healthcare utilization and costs of systemic lupus erythematosus in Medicaid.

Objective. Healthcare utilization and costs associated with systemic lupus erythematosus (SLE) in a US Medicaid population were examined. Methods. Patients ≥ 18 years old with SLE diagnosis (ICD-9-CM 710.0x) were extracted from a large Medicaid database 2002-2009. Index date was date of the first SLE diagnosis. Patients with and without SLE were matched. All patients had a variable length of followup with a minimum of 12 months. Annualized healthcare utilization and costs associated with SLE and costs of SLE flares were assessed during the followup period. Multivariate regressions were conducted to estimate incremental healthcare utilization and costs associated with SLE. Results. A total of 14,777 SLE patients met the study criteria, and 14,262 were matched to non-SLE patients. SLE patients had significantly higher healthcare utilization per year than their matched controls. The estimated incremental annual cost associated with SLE was $10,984, with the highest increase in inpatient costs (P < 0.001). Cost per flare was $11,716 for severe flares, $562 for moderate flares, and $129 for mild flares. Annual total costs for patients with severe flares were $49,754. Conclusions. SLE patients had significantly higher healthcare resource utilization and costs than non-SLE patients. Patients with severe flares had the highest costs.

Bacteria that masquerade as fungi: actinomycosis/nocardia.

The order Actinomycetales includes phylogenetically diverse but morphologically similar aerobic and anaerobic bacteria that exhibit filamentous branching structures which fragment into bacillary or coccoid forms. The aerobic actinomyces are a large, diverse group of gram-positive bacteria including Nocardia, Gordona, Tsukamurella, Streptomyces, Rhodococcus, Streptomycetes, Mycobacteria, and Corynebacteria. The anaerobic genera of medical importance include Actinomyces, Arachnia, Rothia, and Bifidobacterium. Both Actinomyces and Nocardia cause similar clinical syndromes involving the lung, bone and joint, soft tissue, and the central nervous system. The medically important Actinomyces organisms cause infections characterized by chronic progression, abscess formation with fistulous tracts and draining sinuses. Called "great masqueraders," diagnosis of actinomycosis and nocardiosis is often delayed. Once recognized, treatment of these infections requires long courses of parenteral and oral therapy. This review will compare and contrast infections due to Actinomyces and Nocardia.

Antibacterial activity of synthetic fire ant venom: the solenopsins and isosolenopsins.

BACKGROUND: We determined the in vitro activity of 9 synthetic fire ant venom alkaloids (+/-)-solenopsin A, (2R, 6R)-solenopsin A, (2S, 6S)-solenopsin B, (+/-)-isosolenopsin A, (2S, 6R)-isosolenopsin A,(2R, 6S)-isosolenopsin A, (+/-)-isosolenopsin B, (2S, 6R)-isosolenopsin B, and (2R, 6S)-isosolenopsin B against 6 species of bacteria (Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecalis, Escherichia coli, Stenotrophomonas maltophilia, and Pseudomonas aeruginosa). METHODS: The minimum inhibitory concentration and minimum bacteriocidal concentration were determined in accordance with the Clinical Laboratory Standards Institute guidelines. Time kill studies used American Type Culture Collection bacterial isolates tested at 5 times the minimum inhibitory concentration. RESULTS: None of the venom alkaloids inhibited E. coli or P. aeruginosa, whereas all the alkaloids inhibited S. pneumoniae. Only 4 alkaloids inhibited S. pneumoniae, S. aureus, and S. maltophilia. Time-kill kinetics indicates that all 4 active alkaloids had bactericidal activity. CONCLUSIONS: Specific isomers of synthetic fire ant venom alkaloids have antibacterial activity against human pathogens.

In search of the holy grail of antifungal therapy.

The ideal antifungal agent remains an elusive goal for treatment of life-threatening systemic fungal infections. Such an agent would have broad antifungal activity, low rates of resistance, flexible routes of administration, few associated adverse events, and limited drug-drug interactions. Only three of the seven classes of antifungal agents currently available are suitable for treatment of systemic infection: the polyenes, the azoles, and the echinocandins. None match all the characteristics of an ideal agent, the Holy Grail of antifungal therapy. Academia and industry need to collaborate in the search for new lead antifungal compounds using traditional screening methods as well as the new pharmacogenomics methods. Enhancing efficacy and reducing toxicity of the currently available therapeutic agents is also another important avenue of study. As an example, the Mycosis Research Center at the University of Mississippi Medical Center has identified pyogenic polyenes in commercial preparations of amphotericin B deoxycholate which correlate with infusion related toxicities. A highly purified formulation of amphotericin B appears promising, with a better therapeutic index compared to its parent compound as evidenced by results of in vitro and in vivo studies reviewed in this presentation.

Antibiotic surveillance of Streptococcus pneumoniae in Mississipi.

OBJECTIVE: A survey of antimicrobial resistance in S. pneumoniae isolates collected from representative geographic regions of Mississippi during two different respiratory seasons was conducted to determine rates and distribution of drug resistance. DESIGN: A total of 318 S. pneumoniae isolates was collected from July 1999 to March 2000, and 171 isolates were collected from July 2001 to March 2002. The minimum inhibitory concentration for 12 antibiotics was determined by the micro dilution method. SETTING: A total of 28 hospitals through out the state of Mississippi participated in the submission of S. pneumoniae isolates felt to be clinically relevant and reported to the attending physician. Specimens were transported to a central laboratory via state health department courier. PATIENT POPULATION: Isolates were obtained from hospital inpatients as well as outpatients seen in local clinics. MAIN OUTCOME MEASURES: Changes in the percentage of isolates resistant to the tested antibiotics and patient demographics were collected. RESULTS: Pediatric isolates accounted for 36% and 28%, respectively, in 2000 and 2002. The relative percentage of total respiratory isolates remained for each year. Resistance to penicillin increased in pediatric (58% vs. 71%) and adult (40% vs. 52%) as did resistance to ceftriaxone (pediatric 14% vs. 31%; adult 9% vs. 25%) from 2000 to 2002. The majority of isolates were resistant to multiple antibiotics in both years tested. CONCLUSION: The results of this study are comparable to those from other national studies of antimicrobial resistance in S. pneumoniae demonstrating increasing resistance to multiple classes of antibiotics quantitatively and qualitatively.

Vancomycin-tolerance among clinical isolates of Streptococcus pneumoniae in Mississippi during 1999-2001.

BACKGROUND: In recent years, infection with Streptococcus pneumoniae has been a serious worldwide health concern. Antimicrobial-resistant S pneumoniae is increasing in incidence worldwide, posing a potentially serious threat. Resistance to beta-lactams, macrolides, and trimethoprim-sulfamethoxazole represents a major problem in the treatment of pneumococcal infections METHODS: Our laboratory conducted a survey of local resistance patterns in S pneumoniae. Clinical isolates from two separate respiratory seasons were collected from representative geographic areas in Mississippi (totaling 28 hospitals) and were tested for antimicrobial resistance to penicillin, amoxicillin, ceftriaxone, cefuroxime, azithromycin, clindamycin, tetracycline, trimethoprim-sulfamethoxazole, levofloxacin, gatifloxacin, moxifloxacin, and vancomycin using reference methods. Vancomycin-tolerant strains of S pneumoniae were initially identified as those in which the vancomycin MIC was 0.5 microg/mL. Strain tolerance was confirmed by time kill studies RESULTS: For the 1999-2000 respiratory season, 318 isolates were available for testing; for 2001-2002, 166 isolates were available. Of the 484 total isolates tested, two isolates were identified as having increased tolerance to vancomycin. A greater than 2 log10 difference in viability between the tolerant isolates and the nontolerant isolates of S pneumoniae was observed in time kill studies CONCLUSIONS: Two vancomycin-tolerant isolates of S pneumoniae were identified and characterized. Antibiotic tolerance is defined as the ability of bacteria to survive but not proliferate in the presence of an antibacterial agent. Tolerance to vancomycin is particularly significant when the incidence of penicillin tolerance or resistance is high. In addition, tolerance to vancomycin is not detected by routine in vitro susceptibility testing.

The value of a gerontology certificate: a survey of Frank J Manning alumni, 1980-2001.

The Frank J. Manning Certificate Program in Gerontology at the University of Massachusetts Boston was established in 1979 as part of an Administration on Aging (AoA) grant to develop and expand services to the elderly citizens of the Commonwealth of Massachusetts. The program was designed to implement concepts associated with productive aging theory and traditionally has targeted learners age 60 and older. Alumni representing classes from 1980 to 2001 were surveyed by phone to learn if the original program objectives still have relevance today and to document how alumni have utilized knowledge and skills attained in the program. Almost 80% (364) of surviving alumni completed interviews. Specifically, alumni were asked about their volunteer experiences, employment, and advocacy efforts within the aging network of programs and services, as well as the impact of their training on their own aging. About 3/4 of the alumni had volunteered with elders since completing the program, while 1/4 worked in the aging network. Additional outcomes support the notion of life-long learning with many alumni continuing their education beyond the certificate program. In addition, many alumni reported utilizing knowledge and skills in caregiving for family members and friends. This study will help document the value of certificate-level training in Gerontology for its students and for the communities they serve.