Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can spread rapidly within skilled nursing facilities. After identification of a case of Covid-19 in a skilled nursing facility, we assessed transmission and evaluated the adequacy of symptom-based screening to identify infections in residents. METHODS: We conducted two serial point-prevalence surveys, 1 week apart, in which assenting residents of the facility underwent nasopharyngeal and oropharyngeal testing for SARS-CoV-2, including real-time reverse-transcriptase polymerase chain reaction (rRT-PCR), viral culture, and sequencing. Symptoms that had been present during the preceding 14 days were recorded. Asymptomatic residents who tested positive were reassessed 7 days later. Residents with SARS-CoV-2 infection were categorized as symptomatic with typical symptoms (fever, cough, or shortness of breath), symptomatic with only atypical symptoms, presymptomatic, or asymptomatic. RESULTS: Twenty-three days after the first positive test result in a resident at this skilled nursing facility, 57 of 89 residents (64%) tested positive for SARS-CoV-2. Among 76 residents who participated in point-prevalence surveys, 48 (63%) tested positive. Of these 48 residents, 27 (56%) were asymptomatic at the time of testing; 24 subsequently developed symptoms (median time to onset, 4 days). Samples from these 24 presymptomatic residents had a median rRT-PCR cycle threshold value of 23.1, and viable virus was recovered from 17 residents. As of April 3, of the 57 residents with SARS-CoV-2 infection, 11 had been hospitalized (3 in the intensive care unit) and 15 had died (mortality, 26%). Of the 34 residents whose specimens were sequenced, 27 (79%) had sequences that fit into two clusters with a difference of one nucleotide. CONCLUSIONS: Rapid and widespread transmission of SARS-CoV-2 was demonstrated in this skilled nursing facility. More than half of residents with positive test results were asymptomatic at the time of testing and most likely contributed to transmission. Infection-control strategies focused solely on symptomatic residents were not sufficient to prevent transmission after SARS-CoV-2 introduction into this facility.

Detection of SARS-CoV-2 Among Residents and Staff Members of an Independent and Assisted Living Community for Older Adults - Seattle, Washington, 2020.

In the Seattle, Washington metropolitan area, where the first case of novel coronavirus 2019 disease (COVID-19) in the United States was reported (1), a community-level outbreak is ongoing with evidence of rapid spread and high morbidity and mortality among older adults in long-term care skilled nursing facilities (SNFs) (2,3). However, COVID-19 morbidity among residents of senior independent and assisted living communities, in which residents do not live as closely together as do residents in SNFs and do not require skilled nursing services, has not been described. During March 5-9, 2020, two residents of a senior independent and assisted living community in Seattle (facility 1) were hospitalized with confirmed COVID-19 infection; on March 6, social distancing and other preventive measures were implemented in the community. UW Medicine (the health system linked to the University of Washington), Public Health - Seattle & King County, and CDC conducted an investigation at the facility. On March 10, all residents and staff members at facility 1 were tested for SARS-CoV-2, the virus that causes COVID-19, and asked to complete a questionnaire about their symptoms; all residents were tested again 7 days later. Among 142 residents and staff members tested during the initial phase, three of 80 residents (3.8%) and two of 62 staff members (3.2%) had positive test results. The three residents had no symptoms at the time of testing, although one reported an earlier cough that had resolved. A fourth resident, who had negative test results in the initial phase, had positive test results 7 days later. This resident was asymptomatic on both days. Possible explanations for so few cases of COVID-19 in this residential community compared with those in several Seattle SNFs with high morbidity and mortality include more social distancing among residents and less contact with health care providers. In addition, early implementation of stringent isolation and protective measures after identification of two COVID-19 cases might have been effective in minimizing spread of the virus in this type of setting. When investigating a potential outbreak of COVID-19 in senior independent and assisted living communities, symptom screening is unlikely to be sufficient to identify all persons infected with SARS-CoV-2. Adherence to CDC guidance to prevent COVID-19 transmission in senior independent and assisted living communities (4) could be instrumental in preventing a facility outbreak.

Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility - King County, Washington, March 2020.

Older adults are susceptible to severe coronavirus disease 2019 (COVID-19) outcomes as a consequence of their age and, in some cases, underlying health conditions (1). A COVID-19 outbreak in a long-term care skilled nursing facility (SNF) in King County, Washington that was first identified on February 28, 2020, highlighted the potential for rapid spread among residents of these types of facilities (2). On March 1, a health care provider at a second long-term care skilled nursing facility (facility A) in King County, Washington, had a positive test result for SARS-CoV-2, the novel coronavirus that causes COVID-19, after working while symptomatic on February 26 and 28. By March 6, seven residents of this second facility were symptomatic and had positive test results for SARS-CoV-2. On March 13, CDC performed symptom assessments and SARS-CoV-2 testing for 76 (93%) of the 82 facility A residents to evaluate the utility of symptom screening for identification of COVID-19 in SNF residents. Residents were categorized as asymptomatic or symptomatic at the time of testing, based on the absence or presence of fever, cough, shortness of breath, or other symptoms on the day of testing or during the preceding 14 days. Among 23 (30%) residents with positive test results, 10 (43%) had symptoms on the date of testing, and 13 (57%) were asymptomatic. Seven days after testing, 10 of these 13 previously asymptomatic residents had developed symptoms and were recategorized as presymptomatic at the time of testing. The reverse transcription-polymerase chain reaction (RT-PCR) testing cycle threshold (Ct) values indicated large quantities of viral RNA in asymptomatic, presymptomatic, and symptomatic residents, suggesting the potential for transmission regardless of symptoms. Symptom-based screening in SNFs could fail to identify approximately half of residents with COVID-19. Long-term care facilities should take proactive steps to prevent introduction of SARS-CoV-2 (3). Once a confirmed case is identified in an SNF, all residents should be placed on isolation precautions if possible (3), with considerations for extended use or reuse of personal protective equipment (PPE) as needed (4).

Automated System for Multiplexing Detection of COVID-19 and Other Respiratory Pathogens.

OBJECTIVE: Infectious diseases are global health challenge, impacted the communities worldwide particularly in the midst of COVID-19 pandemic. The need of rapid and accurate automated systems for detecting pathogens of concern has always been critical. Ideally, such systems shall detect a large panel of pathogens simultaneously regardless of well-equipped facilities and highly trained operators, thus realizing on-site diagnosis for frontline healthcare providers and in critical locations such as borders and airports. METHODS & RESULTS: Avalon Automated Multiplex System, AAMST, is developed to automate a series of biochemistry protocols to detect nucleic acid sequences from multiple pathogens in one test. Automated processes include isolation of nucleic acids from unprocessed samples, reverse transcription and two rounds of amplifications. All procedures are carried out in a microfluidic cartridge performed by a desktop analyzer. The system was validated with reference controls and showed good agreement with their laboratory counterparts. In total 63 clinical samples, 13 positives including those from COVID-19 patients and 50 negative cases were detected, consistent with clinical diagnosis using conventional laboratory methods. CONCLUSIONS: The proposed system has demonstrated promising utility. It would benefit the screening and diagnosis of COVID-19 and other infectious diseases in a simple, rapid and accurate fashion. Clinical and Translational Impact Statement- A rapid and multiplex diagnostic system proposed in this work can clinically help to control spread of COVID-19 and other infectious agents as it can provide timely diagnosis, isolation and treatment to patients. Using the system at remoted clinical sites can facilitate early clinical management and surveillance.

Improving adolescent human papillomavirus (HPV) immunization uptake in school-based health centers through awareness campaigns.

PURPOSE: The aim of this study was to measure the effect of a multicomponent human papillomavirus (HPV) vaccine promotion campaign on adolescent HPV vaccine uptake at school-based health centers (SBHCs) in Seattle, WA. METHODS: Youth-led HPV vaccine promotion campaigns were introduced in 2016 in 13 schools with SBHCs in Seattle. Five other schools with SBHCs served as controls. Vaccination records for students were obtained from the Washington Immunization Information System from September 2012 to August 2018. We compared increase in HPV vaccine uptake in SBHCs between 1) intervention and control schools, and 2) pre- and post-intervention periods in intervention schools using generalized estimating equations. RESULTS: HPV vaccine uptake was high at baseline among students that use SBHCs for vaccines and has steadily increased between 2012 and 2018. Implementing the promotion campaign resulted in 14% higher (95% Confidence Interval (CI): 1%, 30%) HPV vaccine uptake in intervention SBHCs compared to control SBHCs, adjusting for time and confounders. Comparing pre-and post-intervention periods in intervention SBHCs, HPV vaccine uptake was 14% higher (95% CI: -4%, 35%) in the post-intervention period. SBHCs that received more active intervention activities saw 9% higher (95% CI: 1%, 21%) vaccine uptake compared to those that received passive intervention. CONCLUSION: The vaccination promotion program implemented in a school-based setting resulted in higher HPV vaccine uptake in the post-intervention period compared to pre-intervention period, but this increase was not statistically significant. Even so, schools that received more intervention activities for longer periods of time had higher HPV vaccine uptake.

Undergraduate Students Experience of Nutrition Education Using the Flipped Classroom Approach: A Descriptive Cohort Study.

OBJECTIVE: To explore undergraduate students self-reported learning experience in a foundation nutrition education course/unit delivered using a flipped classroom approach (FCA), which requires students to complete independent learning before and after interactive in-class learning experiences. METHODS: A descriptive cohort study design used selected items from a self-report flipped classroom student engagement questionnaire to assess Australian undergraduate student (n = 105) engagement in the course/unit and compared with nonflipped courses, preference for FCA, academic achievement, learning behaviors for 3 FCA learning phases, and more or less engaging aspects of the course/unit. RESULTS: Most (66.5%) students were engaged or very engaged, with half (55%) more engaged in this course/unit compared with other nonflipped courses/units with a preference for the FCA (53%). Almost half of the students agreed the FCA improved their academic performance (grade) (45%) and other academic skills (ie, teamwork) (48.5%). Most student comments related to the value of participate phase activities. CONCLUSIONS AND IMPLICATIONS: The FCA engaged most students in learning and is an emerging learning and teaching approach appropriate for undergraduate nutrition dietetic education.

Accuracy of de novo assembly of DNA sequences from double-digest libraries varies substantially among software.

Advances in DNA sequencing have made it feasible to gather genomic data for non-model organisms and large sets of individuals, often using methods for sequencing subsets of the genome. Several of these methods sequence DNA associated with endonuclease restriction sites (various RAD and GBS methods). For use in taxa without a reference genome, these methods rely on de novo assembly of fragments in the sequencing library. Many of the software options available for this application were originally developed for other assembly types and we do not know their accuracy for reduced representation libraries. To address this important knowledge gap, we simulated data from the Arabidopsis thaliana and Homo sapiens genomes and compared de novo assemblies by six software programs that are commonly used or promising for this purpose (ABySS, CD-HIT, Stacks, Stacks2, Velvet and VSEARCH). We simulated different mutation rates and types of mutations, and then applied the six assemblers to the simulated data sets, varying assembly parameters. We found substantial variation in software performance across simulations and parameter settings. ABySS failed to recover any true genome fragments, and Velvet and VSEARCH performed poorly for most simulations. Stacks and Stacks2 produced accurate assemblies of simulations containing SNPs, but the addition of insertion and deletion mutations decreased their performance. CD-HIT was the only assembler that consistently recovered a high proportion of true genome fragments. Here, we demonstrate the substantial difference in the accuracy of assemblies from different software programs and the importance of comparing assemblies that result from different parameter settings.

Outbreak Investigation of COVID-19 Among Residents and Staff of an Independent and Assisted Living Community for Older Adults in Seattle, Washington.

IMPORTANCE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused epidemic spread of coronavirus disease 2019 (COVID-19) in the Seattle, Washington, metropolitan area, with morbidity and mortality concentrated among residents of skilled nursing facilities. The prevalence of COVID-19 among older adults in independent/assisted living is not understood. OBJECTIVES: To conduct surveillance for SARS-CoV-2 and describe symptoms of COVID-19 among residents and staff of an independent/assisted living community. DESIGN, SETTING, AND PARTICIPANTS: In March 2020, public health surveillance of staff and residents was conducted on site at an assisted and independent living residence for older adults in Seattle, Washington, after exposure to 2 residents who were hospitalized with COVID-19. EXPOSURES: Surveillance for SARS-CoV-2 infection in a congregate setting implementing social isolation and infection prevention protocols. MAIN OUTCOMES AND MEASURES: SARS-CoV-2 real-time polymerase chain reaction was performed on nasopharyngeal swabs from residents and staff; a symptom questionnaire was completed assessing fever, cough, and other symptoms for the preceding 14 days. Residents were retested for SARS-CoV-2 7 days after initial screening. RESULTS: Testing was performed on 80 residents; 62 were women (77%), with mean age of 86 (range, 69-102) years. SARS-CoV-2 was detected in 3 of 80 residents (3.8%); none felt ill, 1 male resident reported resolved cough and 1 loose stool during the preceding 14 days. Virus was also detected in 2 of 62 staff (3.2%); both were symptomatic. One week later, resident SARS-CoV-2 testing was repeated and 1 new infection detected (asymptomatic). All residents remained in isolation and were clinically stable 14 days after the second test. CONCLUSIONS AND RELEVANCE: Detection of SARS-CoV-2 in asymptomatic residents highlights challenges in protecting older adults living in congregate settings. In this study, symptom screening failed to identify residents with infections and all 4 residents with SARS-CoV-2 remained asymptomatic after 14 days. Although 1 asymptomatic infection was found on retesting, a widespread facility outbreak was avoided. Compared with skilled nursing settings, in assisted/independent living communities, early surveillance to identify asymptomatic persons among residents and staff, in combination with adherence to recommended preventive strategies, may reduce viral spread.

Evaluation of the impact of news coverage of an HIV multiclass drug-resistant cluster in Seattle, Washington.

OBJECTIVES: In February 2007, Public Health-Seattle and King County issued a press release describing a cluster of multiclass drug-resistant HIV cases among men who had sex with men (MSM). We evaluated the effect of the press release among MSM in the Seattle area. METHODS: We administered a rapid assessment survey at venues where MSM congregate. Eligible participants were men who had sex with men in the past year, were older than 18 years, and were residents of western Washington State. RESULTS: Among 325 participants, 57% heard or saw messages related to the press release. Of these, 87% remembered 1 or more key points, but only 5% remembered key prevention messages. Ninety-eight percent of participants thought it was important for the health department to get the message out about drug-resistant HIV. CONCLUSIONS: The press release was found to be a useful and well-received method to inform the public about an HIV drug-resistant cluster. Low retention and nonprominent coverage of key prevention messages suggests that health departments using press releases as a prevention tool need to carefully consider placement and emphasis of those messages in a press statement.

Access to regular HIV care and disease progression among black African immigrants.

OBJECTIVE: To describe the characteristics of human immunodeficiency virus (HIV)-infected black African immigrants living in King County, Washington, we evaluated delay in HIV diagnosis, access to HIV care, and risk of progression to AIDS or death. METHODS: We compared differences in the risk of progression to AIDS or death between HIV-positive African-born black individuals and 2 groups of HIV-positive US-born individuals. RESULTS: There were significant differences across the groups in residence at time of HIV diagnosis, gender, HIV transmission category, and initial CD4 count. Black Africans were more likely to present with an AIDS diagnosis (45%), compared to both US-born nonblacks (25%) and US-born blacks (35%). No significant independent associations were observed in rates of HIV disease progression when black African immigrants were compared to their US-born counterparts. CONCLUSIONS: Once having initiated HIV care, African-born blacks accessed HIV care and progressed to AIDS at similar rates compared to US-born individuals. However, African-born blacks initiated care with more advanced HIV disease. Results underscore the need for health interventions promoting HIV testing among black African immigrants and reducing barriers to HIV testing.

Completion of the Human Papillomavirus Vaccination Series Among Adolescent Users and Nonusers of School-Based Health Centers.

OBJECTIVES: Uptake and completion of the human papillomavirus (HPV) vaccine series among adolescents are suboptimal in the United States. We examined immunization registry data to determine completion of the 3-dose HPV vaccine series among adolescents in Seattle, Washington, born during 1995-2000 who received ≥1 dose of HPV vaccine. METHODS: Immunization data included the administrating facility, which identified adolescents who used school-based health centers (SBHCs) for any HPV vaccine dose. We calculated completion of the 3-dose series at any time and on time by the 13th birthday. We stratified analyses by sex and assessed differences in on-time and any-time completion between users and nonusers of SBHCs. RESULTS: Overall, 67.9% (8612 of 12 676) of females and 41.8% (3560 of 8521) of males with ≥1 dose of HPV vaccine completed the 3-dose series. Compared with female SBHC nonusers, female SBHC users had 37% higher odds of completing the series at any time (adjusted odds ratio [aOR] = 1.37; 95% CI, 1.19-1.58) and 33% higher odds of completing the series on time (aOR = 1.33; 95% CI, 1.08-1.64). Compared with male SBHC nonusers, male SBHC users had 45% higher odds of completing the series at any time (aOR = 1.45; 95% CI, 1.23-1.70) and 79% higher odds of completing the series on time (aOR = 1.79; 95% CI, 1.11-2.89). CONCLUSION: Adolescent SBHC users had higher odds of completing the HPV vaccine series than adolescents who received all doses in traditional health care settings. SBHCs should be leveraged to increase adolescent immunization rates.

Do people have insight into their face recognition abilities?

Diagnosis of developmental or congenital prosopagnosia (CP) involves self-report of everyday face recognition difficulties, which are corroborated with poor performance on behavioural tests. This approach requires accurate self-evaluation. We examine the extent to which typical adults have insight into their face recognition abilities across four experiments involving nearly 300 participants. The experiments used five tests of face recognition ability: two that tap into the ability to learn and recognize previously unfamiliar faces [the Cambridge Face Memory Test, CFMT; Duchaine, B., & Nakayama, K. (2006). The Cambridge Face Memory Test: Results for neurologically intact individuals and an investigation of its validity using inverted face stimuli and prosopagnosic participants. Neuropsychologia, 44(4), 576-585. doi:10.1016/j.neuropsychologia.2005.07.001; and a newly devised test based on the CFMT but where the study phases involve watching short movies rather than viewing static faces-the CFMT-Films] and three that tap face matching [Benton Facial Recognition Test, BFRT; Benton, A., Sivan, A., Hamsher, K., Varney, N., & Spreen, O. (1983). Contribution to neuropsychological assessment. New York: Oxford University Press; and two recently devised sequential face matching tests]. Self-reported ability was measured with the 15-item Kennerknecht et al. questionnaire [Kennerknecht, I., Ho, N. Y., & Wong, V. C. (2008). Prevalence of hereditary prosopagnosia (HPA) in Hong Kong Chinese population. American Journal of Medical Genetics Part A, 146A(22), 2863-2870. doi:10.1002/ajmg.a.32552]; two single-item questions assessing face recognition ability; and a new 77-item meta-cognition questionnaire. Overall, we find that adults with typical face recognition abilities have only modest insight into their ability to recognize faces on behavioural tests. In a fifth experiment, we assess self-reported face recognition ability in people with CP and find that some people who expect to perform poorly on behavioural tests of face recognition do indeed perform poorly. However, it is not yet clear whether individuals within this group of poor performers have greater levels of insight (i.e., into their degree of impairment) than those with more typical levels of performance.

Strategies for increasing adolescent immunizations in diverse ethnic communities.

PURPOSE: We sought to identify attitudes and knowledge of adolescent vaccination recommendations for tetanus, diphtheria, and acellular pertussis (Tdap); quadrivalent meningococcal conjugate (MCV4); and human papillomavirus (HPV) vaccines among Hispanic, Somali, and Ethiopian/Eritrean communities in King County, Washington. METHODS: In-person surveys of Hispanic, Somali, and Ethiopian/Eritrean adolescents (n = 45) and parents of adolescents (n = 157), and three focus groups with mothers of 11- to 18-year-olds were conducted to assess knowledge, attitudes, and barriers related to recommended adolescent vaccines. Bivariate analyses of parent survey responses were performed to evaluate possible differences between ethnic groups (chi-square test and Fisher exact test where possible). Findings were used to develop (1) culture-specific written brochures for community members, which addressed misperceptions about adolescent immunizations and related diseases, and (2) a presentation highlighting specific messages for health care providers (HCPs) in the target communities. HCPs were surveyed after delivery of the presentation (n = 20). RESULTS: We identified barriers to adolescent immunization including: parents' and adolescents' limited awareness of, and misperceptions regarding, recommended adolescent vaccines and vaccine preventable diseases; lack of HCP recommendations for vaccination; and inability to access health information in native languages. Awareness of tetanus, diphtheria, and acellular pertussis, quadrivalent meningococcal conjugate, and human papillomavirus vaccines varied by vaccine and ethnic group. Lack of knowledge of adolescent vaccination recommendations was the main reason given by parents that their adolescents had not been vaccinated. Most parents in the focus groups identified doctors as a trusted source of health information and reported that they would vaccinate their teens if their doctor recommended it. All the surveyed HCPs routinely recommend adolescent vaccines at well-child visits, 55% at acute visits, and 35% at injury visits. Eighty percent reported that they would be more likely to recommend HPV vaccine after our on-site presentation. CONCLUSIONS: A strong recommendation from the physician is a critical factor influencing parents' decision to vaccinate, even when hesitancy exists. Other factors (such as personal experiences with these diseases and religious and cultural beliefs) also influence parents' decisions regarding vaccination. Knowledge of beliefs, misperceptions, and concerns can help inform strategies to improve adolescent vaccine uptake among specific ethnic populations, including the availability of culturally tailored, translated information. Additionally, HCPs may benefit from guidance on communicating with ethnic populations to support meaningful dialogue with families about the risks and benefits of adolescent vaccines.

Colocalicostomy. A solution to an obliterated renal pelvis.

A thirty-nine-year-old paraplegic with an ileal conduit urinary diversion and long ureteral strictures bilaterally required urinary tract reconstruction to establish effective internal drainage. Reported techniques proved infeasible. Therefore, the right kidney with its small intrarenal pelvis was opened by anatrophic nephrotomy and anastomosed to a segment of transverse colon in two layers. The left kidney could not be anastomosed directly to the colon segment, so it was anastomosed end-to-side to an isolated jejunal segment. Colocalicostomy should be considered in the repair of an obliterated renal pelvis or an isolated, obstructed lower-pole calix.

Management of ureteroscopic ureteral injuries.

Ureteroscopy will continue to have a place in the management of renal stone disease and is invaluable to evaluate other types of ureteral lesions. Although ureteroscopy can be performed safely in most cases, it is invasive and there is a potential for ureteral injury. The well-trained urologic surgeon should be familiar with techniques to minimize the incidence of complications of ureteroscopy. However, faced with a ureteral complication, no matter the severity, the surgeon should have the ingenuity and expertise to restore anatomic integrity to the renal unit.

Molteno implant with mitomycin C: intermediate-term results.

PURPOSE: The authors examine the intermediate-term effects of adjunctive intraoperative mitomycin C (MMC) in a cohort of patients who received double-plate Molteno implants for complicated glaucomas. METHODS: A consecutive series of 21 patients who received MMC 0.5 mg/ml for 5 minutes as an adjunct to a double-plate Molteno implant was compared by life-table analysis to a historical control group of 18 patients who received either no adjunct or 5-fluorouracil (5-FU) but no MMC. RESULTS: At three years follow-up, 35% (95% confidence interval (CI), 15-57%) of patients who received MMC avoided failure criteria of intraocular pressure (IOP) less than 6 mm Hg or more than 21 mm Hg, addition of glaucoma medication, reoperation for glaucoma, or tube removal. Seventeen percent (95% CI, 4-37%) of patients in the control group at three years follow-up met similar criteria (p = 0.039). No late complications of tube erosion were seen in the MMC group. CONCLUSION: Intraoperative MMC offers an increased likelihood of a two- to three-year period of medication-free IOP control in patients undergoing double-plate Molteno implants, compared to similar patients receiving 5-FU or no adjunctive antimetabolite therapy.

Ophthalmologic findings in children with congenital cytomegalovirus infection.

BACKGROUND: Cytomegalovirus (CMV) infection is the most common congenital viral infection in the United States, affecting 0.5% to 2% of live births. Approximately 90% of infected infants are asymptomatic at birth. We undertook this study to determine the incidence and etiology of visual impairment and other ophthalmologic abnormalities in children with congenital CMV infection. METHODS: We prospectively evaluated 42 symptomatic and 83 asymptomatic children with congenital CMV infection, along with 21 control patients. One or more comprehensive ophthalmologic examinations were performed on each patient. The frequency and etiology of visual impairment and other ophthalmologic problems were tabulated for each patient. RESULTS: Nine of 42 (22%) patients in the symptomatic group had moderate to severe visual impairment in 16 eyes. Visual impairment was primarily due to optic atrophy in 6 of 16 (37%) eyes, macular scars in 2 of 16 (13%) eyes, and cortical visual impairment in 8 of 16 (50%) eyes. In comparison, none of 83 asymptomatic patients had severe visual impairment (P <.001). One asymptomatic patient had mild unilateral visual impairment caused by a macular scar. Strabismus developed in 12 of 42 (29%) symptomatic patients compared with 1 of 83 (1.2%) asymptomatic patients (P <.001). CONCLUSIONS: Visual impairment and strabismus are common in patients with symptomatic congenital CMV infection and rare in patients with asymptomatic congenital CMV infection. Visual impairment may be caused by cortical, optic nerve, and/or retinal abnormalities. Infants with symptomatic congenital CMV infection should undergo careful ophthalmologic screening and follow-up examinations.

Removal of a corneal foreign body through a lamellar corneal pocket.

A piece of glass was found in the posterior central cornea of a 43-year-old victim of a motor vehicle accident. The original entry of the foreign body had healed and epithelialized. This foreign body was removed through a peripheral corneal incision and corneal stromal pocket extended to the glass particle. This technique avoids creation of a corneal incision near the optical axis and prevents unwanted distortion of the corneal topography. The authors report this case to emphasize the importance of preserving corneal topography in corneal surgery.

Coping behaviour as an adaptation to stress: post-disturbance preening in colonial seabirds.

In humans, coping behaviour is an action taken to soothe oneself during or after a stressful or threatening situation. Some human behaviours with physiological functions also serve as coping behaviours, for example, comfort sucking in infants and comfort eating in adults. In birds, the behaviour of preening, which has important physiological functions, has been postulated to soothe individuals after stressful situations. We combine two existing modelling approaches - logistic regression and Darwinian dynamics - to explore theoretically how a behaviour with crucial physiological function might evolve into a coping behaviour. We apply the method to preening in colonial seabirds to investigate whether and how preening might be co-opted as a coping behaviour in the presence of predators. We conduct an in-depth study of the environmental correlates of preening in a large gull colony in Washington, USA, and we perform an independent field test for comfort preening by computing the change in frequency of preening in gulls that were alerted to a predator, but did not flee.