Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients.

CONTEXT: Outcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree. OBJECTIVES: Determine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families. METHODS: This multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness. RESULTS: Our qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending. CONCLUSIONS: IA is a feasible and reasonable approach to CPR discussions in selected patient populations.

Experience and Attitudes Regarding Medical Aid in Dying, Act 39, among Vermont Specialty Practices.

Introduction: In 2013, the Vermont legislature passed Act 39: The Patient Choice and Control at End-of-Life Act, which legalized medical aid in dying (MAID) under specific circumstances for terminally ill Vermont residents. In the five years since the law was passed, 52 patients in Vermont have been prescribed medications to hasten death; however, important information regarding the experiences of the patient, caregiver, or physician involved in this process is lacking. Objective: To survey the subspecialty physicians with the greatest contact with these patient populations, to better understand the physicians' attitudes and experiences with Act 39, and to gather more data about the utilization of Act 39 in Vermont. Design: Physicians practicing Hematology/Oncology, Neurology, and/or Palliative Care at the University of Vermont Medical Group and affiliated hospitals in the state of Vermont were invited to participate. Participants were contacted via e-mail to complete blinded surveys, and responses were collected over several months in 2018. Results: The attitudes and practices related to Act 39 were collected from 37 subspecialty physicians in Vermont. Seventy-one percent of the participants supported MAID via Act 39; however, many felt that they could use more information and resources to counsel a patient (51.4%) and complete the paperwork and prescription for life-ending medication (37.4%). Conclusion: This is the first study to collect information regarding physicians' attitudes and experiences regarding Act 39 in Vermont. Most respondents supported Act 39, but there is a need and desire for more physician education and resources regarding patient counseling and paperwork.

Single tube identification and strain typing of Brucella melitensis by multiplex PCR.

We report the development of a single-tube, multi-locus variable number tandem repeat analysis (MLVA) assay for simultaneous speciation and strain typing of Brucella, the etiologic agent of brucellosis. Our MLVA assay consists of eight loci, two of which are species-specific markers that allow for definitive identification of Brucella melitensis, B. abortus, and Brucella species while ruling out related pathogenic bacterial genera. The remaining six loci are moderately variable loci capable of discriminating between Brucella strains originating within our study area. We applied the assay to a collection of 110 B. melitensis isolates of primarily Mexican origin and to smaller sample sizes of four other Brucella species for a total of 161 isolates. Simpson's index of diversity was 0.985 for B. melitensis and 0.938 for B. abortus. The assay accurately distinguished seven epidemiologically-linked clusters of B. melitensis infections and ascertained the source of infection in several laboratory-acquired cases. This assay is accessible to limited-resource settings due to its technological and economical feasibility. The timely and accurate information provided by this assay will potentially aid brucellosis control efforts, improve patient outcomes, and reduce the occurrence of laboratory-acquired infections.

Identification and evaluation of new target sequences for specific detection of Bordetella pertussis by real-time PCR.

A comparative analysis of the Bordetella pertussis, B. bronchiseptica, and B. parapertussis genome assemblies permitted the identification of regions with significant sequence divergence and the design of two new real-time PCR assays, BP283 and BP485, for the specific detection of B. pertussis. The performance characteristics of these two assays were evaluated and compared to those of culture and an existing real-time PCR assay targeting the repetitive element IS481. The testing of 324 nasopharyngeal specimens indicated that, compared to culture, the BP283 assay had a sensitivity and specificity of 100 and 96.8% and the BP485 assay had a sensitivity and specificity of 92.3 and 97.1%. Notably, B. holmesii was isolated from two specimens that were positive by the IS481 assay but negative by the BP283 and BP485 assays. These two assays represent an improvement in specificity over those of PCR assays targeting only IS481 and may be duplexed or used in conjunction with existing PCR assays to improve the molecular detection of B. pertussis.

Mycobacteria in nail salon whirlpool footbaths, California.

In 2000, an outbreak of Mycobacterium fortuitum furunculosis affected customers using whirlpool footbaths at a nail salon. We swabbed 30 footbaths in 18 nail salons from 5 California counties and found mycobacteria in 29 (97%); M. fortuitum was the most common. Mycobacteria may pose an infectious risk for pedicure customers.

Description of Campylobacter curvus and C. curvus-like strains associated with sporadic episodes of bloody gastroenteritis and Brainerd's diarrhea.

Campylobacter curvus is a rarely encountered Campylobacter species in human, animal, and environmental samples. During the course of two investigations, one involving a search for possible bacterial agents causing bloody gastroenteritis and a second concerning a small outbreak of Brainerd's diarrhea in northern California, 20 strains of C. curvus or C. curvus-like organisms were isolated by a microfiltration technique and prolonged incubation. The results suggest that C. curvus may be an underappreciated Campylobacter that may be involved in sporadic and outbreak cases of bloody or chronic diarrhea in humans.

Mycobacterium africanum cases, California.

Five Mycobacterium tuberculosis complex isolates in California were identified as M. africanum by spoligotyping, single nucleotide polymorphisms, a deletion mutation, and phenotypic traits, confirming it as a cause of tuberculosis in the United States. Three of the five patients from whom M. africanum was isolated had lived in Africa.

An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon.

BACKGROUND: In September 2000, a physician in northern California described four patients with persistent, culture-negative boils on the lower extremities. The patients had received pedicures at the same nail salon. We identified and investigated an outbreak of Mycobacterium fortuitum furunculosis among customers of this nail salon. METHODS: Patients were defined as salon customers with persistent skin infections below the knee. A case-control study was conducted that included the first 48 patients identified, and 56 unaffected friends and family members who had had a pedicure at the same salon served as controls. Selected M. fortuitum isolates, cultured from patients and the salon environment, were compared by pulsed-field gel electrophoresis. RESULTS: We identified 110 customers of the nail salon who had furunculosis. Cultures from 34 were positive for rapidly growing mycobacteria (32 M. fortuitum and 2 unidentified). Most of the affected patients had more than 1 boil (median, 2; range, 1 to 37). All patients and controls had had whirlpool footbaths. Shaving the legs with a razor before pedicure was a risk factor for infection (70 percent of patients vs. 31 percent of controls; adjusted odds ratio, 4.8; 95 percent confidence interval, 2.1 to 11.1). Cultures from all 10 footbaths at the salon yielded M. fortuitum. The M. fortuitum isolates from three footbaths and 14 patients were indistinguishable by electrophoresis. CONCLUSIONS: We identified a large outbreak of rapidly growing mycobacterial infections among persons who had had footbaths and pedicures at one nail salon. Physicians should suspect this cause in patients with persistent furunculosis after exposure to whirlpool footbaths.