Antimicrobial resistance - moving forward?

BACKGROUND: When microorganisms (such as bacteria or viruses) are highly exposed to antimicrobial drugs, they can develop the capacity to defeat the drugs designed to eradicate them. Long-term accumulation of adaptations to survive drug exposure can lead to the development of antimicrobial resistance (AMR). The success of antibiotics has led to their widespread overuse and misuse in humans, animals and plants. MAIN TEXT: AMR is a global concern and solutions are not vertical actions in a single buy business model. Even if a transectoral approach is key, there is a lack of multi-disciplinary partnerships that allow for strategic cooperation between different sectors such as the pharmaceutical industry, agro-alimentary complex, patient care and education, NGOs and research and development. Global public health voices should lead this integration to align the progress of existing AMR successes. Maintaining the public's trust in preventive medicine, health systems and food production safety, together with public health driven, non-profit drug development, is a key factor. In its "Call for integrated action on AMR", signed by about 70 national and international organizations the World Federation of Public Health Associations (WFPHA) called "on all governments, the private sector, non-governmental organizations, health professionals, public and private research organizations, and all stakeholders to ensure that public health remains at the centre of all policy and scientific endeavours in the field of antimicrobial resistance". CONCLUSIONS: The "Global Charter for the Public's Health", developed by the WFPHA in association with WHO, is proposed in this article as a tool for implementation of complex public health actions such as AMR.

Estimated herd prevalence and sequence types of Coxiella burnetii in bulk tank milk samples from commercial dairies in Indiana.

BACKGROUND: Coxiella burnetii is the etiologic agent of Q fever, a zoonotic disease causing influenza-like illness, pregnancy loss, cardiovascular disease and chronic fatigue syndrome in people. C. burnetii is considered to be enzootic in ruminants, but clinical signs of infection do not always manifest. National studies have documented the presence of C. burnetii in dairy herds in Indiana. This represents an opportunity to better characterize the distribution and prevalence of C. burnetii infection at the state scale, allowing evaluation of the need for surveillance and response planning to occur at this level. A cross-sectional study was conducted to estimate the herd prevalence of C. burnetii in commercial cattle dairies in Indiana and characterize the strains of C. burnetii within these dairies. RESULTS: Bulk tank milk samples were collected between June and August of 2011 by the Indiana State Board of Animal Health (ISBOAH). A total of 316 of these samples were tested for the IS1111 transposon of C. burnetii using quantitative real time polymerase chain reaction (PCR). Single nucleotide polymorphism (SNP) genotyping was used to identify the multispacer sequence genotypes (ST) present in samples where the IS1111 transposon was identified. The geographic distribution of dairies testing positive for C. burnetii DNA and the identified STs were also evaluated. The estimated overall herd prevalence for C. burnetii DNA was 61.1 % (95 % CI 55.6-66.3 %). The highest estimated regional prevalence was 70.2 % in the Central region of Indiana. An ST was identifiable in 74 of the positive 178 samples (41.6 %) and none of the 10 negative samples tested. Of these samples, 71 (95.9 %) were identified as ST20, 2 (2.7 %) as ST8 and a combination of ST20 and ST8 was identified in a single sample. CONCLUSIONS: C. burnetii is present in dairy herds throughout Indiana. Indiana follows national trends with ST20 most commonly identified. The presence of multiple STs in a single bulk tank sample indicates that multiple strains of C. burnetii can circulate within a herd. This supports potential transmission of C. burnetii between goats and cattle, presenting the potential for a switch in the dominant genotype found in a given species.

African American Clergy and Depression: What they know; What they want to know.

UNLABELLED: Nearly 40% of African Americans use clergy as their primary source of help with depression. However, less than half of African American clergy are trained in counseling. OBJECTIVES: 1) to examine how African American cler recognize depression and 2) identify what they need to more effectively identify and address depression in their congregants. DESIGN: This was a descriptive, quantitative study using a Personal Profile Questionnaire and a Mental Health Counseling Survey. RESULTS: Sixty-five clergy completed the data collection tools; approximately 50% had some training in counseling. The majority could identify signs of depression. Eighty-one percent stated they needed additional education about depression and access to referral resources. CONCLUSIONS: If clergy take an active role in addressing the issue of depression and establishing liaisons with mental health professionals the stigma associated with depression could be greatly reduced, and individuals might enter into treatment earlier thus improving their quality of life.

Infant Appendicitis: A Case Presentation of Appendicitis in a Nine-Month-Old Infant With Respiratory Syncytial Virus (RSV) and Otitis Media and Review of Literature.

Appendicitis in children < 5 years old is uncommon and even less common in children < 1 year old. Symptoms of appendicitis can be non-specific and mimic other common pediatric diseases, causing delays in diagnosis. Without a timely diagnosis, young children with appendicitis are at risk of developing worsening disease, intra-abdominal abscess, perforation, and bacteremia.  We submit a case of a nine-month-old male infant presenting with fever, vomiting, and irritability seen the day prior and treated for otitis media, who was ultimately diagnosed with appendicitis with concomitant viral infection (respiratory syncytial virus and human rhinovirus/enterovirus) and treated with intravenous antibiotics and laparoscopic appendectomy.  This case illustrates how easy it is to misdiagnose infant appendicitis due to factors including normal developmental speech barriers, nonspecific presentations, and overlap of symptoms with many other common childhood illnesses, along with a challenging abdominal examination. Delay in diagnosis leads to increased rates of perforation and complications. Providers should trust abnormal physical examination findings, especially abdominal guarding against palpation, and keep a wide differential diagnosis in order to diagnose appendicitis in young children.

Risk of Aspiration Increased by Post-swallow Residue in Infant Fiberoptic Endoscopic Evaluation of Swallowing (FEES).

OBJECTIVE: To assess the risk of aspiration associated with post-swallow residue subsites in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in bottle-fed infants <1 year of age. METHODS: This is a retrospective matched-pairs cohort study at an academic tertiary children's hospital. FEES and Videofluoroscopic Swallowing Study (VFSS) trials performed within the same infant <5 days apart were paired by matching bolus consistency and bottle flow rate. Positive aspiration was defined by the "or rule" in which aspiration is positive when either FEES or VFSS within a matched pair is positive. RESULTS: Eighty-seven FEES-VFSS matched pairs from 29 patients (16 males; mean [SD] age, 2.9 [2.8] months) were included. The rate of positive aspiration, as defined by the "or rule", was 59% (51/87). In FEES, post-swallow pyriform sinus residue was present in 16% (14/87) and anterior commissure residue 27% (31/87). Risk of positive aspiration was increased by pyriform sinus residue (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.9-19.3, p < 0.01) and anterior commissure residue in FEES (OR 2.5, 95% CI 1.1-6.1, p = 0.03). In the neonate subgroup, <1 month of age, multivariate-adjusted analysis showed that anterior commissure residue had better diagnostic accuracy for aspiration than in older infants (overall 70% vs. 42%, p < 0.01; sensitivity 60% vs. 10%, p < 0.01), whereas pyriform sinus residue had worse accuracy (overall 41% vs. 70%, p = 0.02; sensitivity 13% vs. 43%, p = 0.02). CONCLUSION: This study demonstrates that pyriform sinus and anterior commissure residue during infant FEES were associated with fivefold and twofold increased risk of aspiration, respectively. LEVEL OF EVIDENCE: 3: Using a retrospective matched-pairs cohort, this study assesses the diagnostic accuracy of post-swallow residue in FEES for predicting aspiration. Laryngoscope, 134:1431-1436, 2024.

Feasibility of adolescent contraceptive care in the pediatric emergency department: A pilot randomized controlled trial.

BACKGROUND: This study assessed feasibility constructs of adolescent contraceptive care in the pediatric emergency department (PED), including contraception initiation. METHODS: We conducted a randomized trial in two PEDs with pregnancy-capable adolescents aged 15-18 years who were assigned to enhanced usual care (usual) or same-day initiation (same day). All received counseling and clinic referral, but same-day participants could also receive contraception in the PED. We trained PED clinicians in counseling and prescribing. Adolescents and clinicians rated feasibility using five Likert-type items (1 = strongly disagree to 5 = strongly agree) after the session. We assessed PED medication initiation and appropriateness via medical record review and contraception use and side effects at 30 days via adolescent survey. To further explore feasibility, we conducted clinician interviews at study completion; these were audio-recorded, transcribed, and analyzed. We hypothesized contraceptive care would be feasible (defined as average score ≥ 4 across five survey items). RESULTS: We enrolled 37 adolescents (12 in usual and 25 in same-day), mean age was 16.6 years, 73% were Black, and 19% were Hispanic. We trained 27 clinicians. Average feasibility scores were 4.6 ± 0.4 (adolescents) and 4.1 ± 0.8 (clinicians). Eleven (44%) same-day participants initiated contraception in the PED. One adolescent with migraines initially received estrogen-containing pills; this was corrected after discharge. At 30 days, same-day participants were more likely to report contraception use (78% vs. 13%; p = 0.007). One adolescent reported bloating as a side effect. Clinicians enjoyed delivering contraceptive care, found study resource materials useful, and identified staffing shortages as a barrier to care delivery. CONCLUSIONS: We are among the first to report on PED-based adolescent contraception initiation to prevent unintended pregnancy. Adolescents and clinicians reported that contraceptive care was feasible. Initiation was common and medications were largely appropriate and tolerated. Future efforts should explore integrating contraceptive care into routine PED care.

Safety and effectiveness of vocal fold injection laryngoplasty in infants less than one year of age.

INTRODUCTION: Injection laryngoplasty (IL) is commonly performed for unilateral vocal fold immobility (UVFI). However, the safety and efficacy in patients <1 year of age are not widely recognized. This study analyzes the safety and swallow outcomes in a cohort of patients <1 year who underwent IL. METHODS: This retrospective analysis evaluated patients at a tertiary children's institution between 2015 and 2022. Patients were eligible if they underwent IL for UVFI and were <1 year at time of injection. Baseline characteristics, perioperative data, oral diet tolerance, and preoperative and postoperative swallow data were collected. RESULTS: 49 patients were included, 12 (24%) of whom were premature. The average age at injection was 3.9 months (SD 3.8), time from UVFI onset to injection 1.3 months (2.0), and weight at injection 4.8 kg (2.1). The baseline American Association of Anesthesiologists physical status classification scores were 2 (14%), 3 (61%), and 4 (24%). 89% of patients had improvements in objective swallow function postoperatively. Of the 35 patients who were preoperatively enterally-dependent and did not have medical circumstances precluding advancement to oral feeds, 32 (n = 91%) tolerated an oral diet postoperatively. There were no long-term sequelae. Two patients had intraoperative laryngospasm, one intraoperative bronchospasm, and one with subglottic and posterior glottic stenosis was intubated for <12 h for increased work of breathing. CONCLUSIONS: IL is a safe and effective intervention that can reduce aspiration and improve diet in patients <1 year old. This procedure can be considered at institutions with the appropriate personnel, resources, and infrastructure.

Blastomycosis in man after kinkajou bite.

We report transmission of Blastomyces dermatitidis fungal infection from a pet kinkajou to a man. When treating a patient with a recalcitrant infection and a history of an animal bite, early and complete animal necropsy and consideration of nonbacterial etiologies are needed.

Low usage of government healthcare facilities for acute respiratory infections in guatemala: implications for influenza surveillance.

BACKGROUND: Sentinel surveillance for severe acute respiratory infections in hospitals and influenza-like illness in ambulatory clinics is recommended to assist in global pandemic influenza preparedness. Healthcare utilization patterns will affect the generalizability of data from sentinel sites and the potential to use them to estimate burden of disease. The objective of this study was to measure healthcare utilization patterns in Guatemala to inform the establishment of a sentinel surveillance system for influenza and other respiratory infections, and allow estimation of disease burden. METHODS: We used a stratified, two-stage cluster survey sample to select 1200 households from the Department of Santa Rosa. Trained interviewers screened household residents for self-reported pneumonia in the last year and influenza-like illness (ILI) in the last month and asked about healthcare utilization for each illness episode. RESULTS: We surveyed 1131 (94%) households and 5449 residents between October and December 2006 and identified 323 (6%) cases of pneumonia and 628 (13%) cases of ILI. Treatment for pneumonia outside the home was sought by 92% of the children <5 years old and 73% of the persons aged five years and older. For both children <5 years old (53%) and persons aged five years and older (31%) who reported pneumonia, private clinics were the most frequently reported source of care. For ILI, treatment was sought outside the home by 81% of children <5 years old and 65% of persons aged five years and older. Government ambulatory clinics were the most frequently sought source of care for ILI both for children <5 years old (41%) and persons aged five years and older (36%). CONCLUSIONS: Sentinel surveillance for influenza and other respiratory infections based in government health facilities in Guatemala will significantly underestimate the burden of disease. Adjustment for healthcare utilization practices will permit more accurate estimation of the incidence of influenza and other respiratory pathogens in the community.

Static endoscopic swallow evaluation in children.

OBJECTIVES: Static Endoscopic Evaluation of Swallowing (SEES) has been demonstrated to have a strong correlation with the Videofluoroscopic Swallow Study (VFSS) in adults. In children, Fiberoptic Endoscopic Evaluations of Swallow (FEES) are frequently performed to avoid repeated VFSS; however, a subset of the population does not tolerate FEES. The purpose of this study was to evaluate the utility of a modified SEES in children. METHODS: Charts of 50 consecutive patients who underwent FEES evaluations were reviewed. Patients age 3 months to 12 years undergoing SEES, FEES, and VFSS were extracted. We compared a binary assessment of outcome on SEES versus VFSS as the diagnostic standard to report characteristics, including sensitivity, specificity, and positive and negative predicted value. RESULTS: A total of 36 patients met all inclusion criteria (mean age 2.8 years). Using the VFSS as the diagnostic standard, residue seen on SEES had a sensitivity of 80.0%, specificity of 85.7%, a positive predictive value of 88.9%, and a negative predictive value of 75.0% for predicting deep penetration or aspiration. CONCLUSION: SEES may be helpful for developing an initial diagnostic impression and may serve as a platform for patient and caregiver counseling. In children who are unable to cooperate with FEES, SEES may provide clinical insight in predicting an abnormal swallow study; however, a normal SEES was less reliable in predicting a safe swallow on subsequent VFSS in this patient population. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1590-1594, 2020.

Consensus nested PCR amplification and sequencing of diverse reptilian, avian, and mammalian orthoreoviruses.

The orthoreoviruses are segmented RNA viruses that infect diverse vertebrate host species. While the most common human orthoreovirus, Mammalian Reovirus, is not typically associated with significant disease, the majority of Orthoreovirus species have been shown to cause significant and often fatal disease in reptiles, birds, and primates. There is significant potential for jumping species. A consensus nested-PCR method was designed for investigation of the RNA-dependent RNA polymerase gene of Orthoreovirus and Aquareovirus. This protocol was used to obtain sequencing template from reoviruses of three different vertebrate classes. Bayesian and maximum likelihood phylogenetic analysis found that all viruses analyzed clustered in the genus Orthoreovirus, that reptile reoviruses formed three distinct clusters, and that an African grey parrot reovirus clustered with Nelson Bay virus from bats. This PCR method may be useful for obtaining templates for initial sequencing of novel orthoreoviruses from diverse vertebrate hosts.

Injection Laryngoplasty for Children with Unilateral Vocal Fold Paralysis: Procedural Limitations and Swallow Outcomes.

OBJECTIVE: Vocal fold immobility with resultant dysphagia is a known cause of morbidity in the pediatric population. Herein we evaluate the efficacy and adverse events of injection laryngoplasty in children. STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic children's hospital. SUBJECTS AND METHODS: Patients <12 years of age with unilateral vocal fold immobility, dysphagia, and objective swallow study data were included. Primary outcome measures included perioperative adverse events and the ability to advance the diet, as defined by initiation of oral feeds or reduction in thickener following postoperative swallow study. RESULTS: The mean age of the cohort (N = 41) was 43.83 months (range, 0.5-144 months), and 46.3% of patients were <18 months old. Perioperative adverse events included increased oxygen requirement (n = 3), prolonged operating room time secondary to tenuous cardiopulmonary status (n = 2), and postoperative readmission within 30 days (n = 1). A total of 63.63% (n = 21 of 33) of patients safely advanced their diet following objective improvement on swallow study. Patients undergoing injection laryngoplasty ≤6 months of the onset of vocal fold immobility were more likely to advance their diet following surgery. CONCLUSION: Injection laryngoplasty has the potential to advance or initiate an oral diet for children with vocal fold immobility, including those in the first months of life. It is relatively free of adverse events, but certain limitations in the pediatric population must be considered. Preoperative characteristics, including timing of injection and premorbidity diet, may guide clinicians in predicting those patients most likely to advance their diet following injection laryngoplasty.

Household responses to school closure resulting from outbreak of influenza B, North Carolina.

School closure is a proposed strategy for reducing influenza transmission during a pandemic. Few studies have assessed how families respond to closures, or whether other interactions during closure could reduce this strategy's effect. Questionnaires were administered to 220 households (438 adults and 355 children) with school-age children in a North Carolina county during an influenza B virus outbreak that resulted in school closure. Closure was considered appropriate by 201 (91%) households. No adults missed work to solely provide childcare, and only 22 (10%) households required special childcare arrangements; 2 households incurred additional costs. Eighty-nine percent of children visited at least 1 public location during the closure despite county recommendations to avoid large gatherings. Although behavior and attitudes might differ during a pandemic, these results suggest short-term closure did not cause substantial hardship for parents. Pandemic planning guidance should address the potential for transmission in public areas during school closure.

Six novel gammaherpesviruses of Afrotheria provide insight into the early divergence of the Gammaherpesvirinae.

The Afrotheria represent an early branching of placental mammals. Only two herpesviruses from Afrotheria have been previously identified, and the genus Proboscivirus in the subfamily Betaherpesvirinae has been proposed for them. Six novel gammaherpesviruses were identified in four species in the superorder Afrotheria by detection and analysis of their DNA polymerase genes. Elephantid herpesvirus 3 (ElHV3) and Elephantid herpesvirus 4 (ElHV4) were identified from conjunctival swabs from Asian elephants (Elephas maximus). ElHV3 was also found in a vaginal swab from one elephant with vaginitis. Elephantid herpesvirus 5 (ElHV5) was identified from vaginal swabs of two Asian elephants with vaginal plaques. Elephantid herpesvirus 6 was discovered in a conjunctival swab from an African elephant (Loxodonta africana). Procavid herpesvirus 1 (PrHV1) was found in spleen and conjunctival swabs of rock hyrax (Procavia capensis). Trichechid herpesvirus 1 (TrHV1) was identified from skin and buffy coats of Florida manatees (Trichechus manatus latirostris). ElHV3 and ElHV4 form a distinct cluster, and ElHV5, ElHV6, TrHV1, and PrHV1 form a second cluster. These viruses may have codiverged with their host species. Phylogenetic analysis of these novel herpesviruses suggests that two separate groups of gammaherpesviruses may have codiverged with the Afrotheria.

Columbid herpesvirus-1 in two Cooper's hawks (Accipiter cooperii) with fatal inclusion body disease.

We report two separate naturally occurring cases of fatal herpesviral disease in Cooper's Hawks (Accipiter cooperii). Gross lesions included splenomegaly and hepatomegaly, with diffuse pale mottling or scattered small white foci. Histologic lesions included splenic and hepatic necrosis associated with eosinophilic intranuclear inclusion bodies characteristic of herpesvirus. In one case, necrosis and inclusions were also noted in bone marrow, thymus, bursa of Fabricius, thyroid gland, parathyroid gland, ceca, and the enteric system. Transmission electron microscopy demonstrated viral particles typical of herpesvirus within hepatocyte nuclei and budding from the nuclear membrane. Herpesviral DNA was amplified via polymerase chain reaction (PCR) of paraffin-embedded liver and spleen, and sequence data were consistent with columbid herpesvirus-1, an alphaherpesvirus of Rock Pigeons (Columba livia). PCR results provide evidence that this disease is transmitted to raptors via Rock Pigeons, most likely through ingestion of Rock Pigeons as prey.

Ranavirus infection of free-ranging and captive box turtles and tortoises in the United States.

Iridoviruses of the genus Ranavirus are well known for causing mass mortality events of fish and amphibians with sporadic reports of infection in reptiles. This article describes five instances of Ranavirus infection in chelonians between 2003 and 2005 in Georgia, Florida, New York, and Pennsylvania, USA. Affected species included captive Burmese star tortoises (Geochelone platynota), a free-ranging gopher tortoise (Gopherus polyphemus), free-ranging eastern box turtles (Terrapene carolina carolina), and a Florida box turtle (Terrepene carolina bauri). Evidence for Ranavirus infection was also found in archived material from previously unexplained mass mortality events of eastern box turtles from Georgia in 1991 and from Texas in 1998. Consistent lesions in affected animals included necrotizing stomatitis and/or esophagitis, fibrinous and necrotizing splenitis, and multicentric fibrinoid vasculitis. Intracytoplasmic inclusion bodies were rarely observed in affected tissues. A portion of the major capsid protein (MCP) gene was sequenced from each case in 2003-2005 and found to be identical to each other and to Frog virus 3 (FV3) across 420 base pairs. Ranavirus infections were also documented in sympatric species of amphibians at two locations with infected chelonians. The fragment profiles of HindIII-digested whole genomic DNA of Ranavirus, isolated from a dead Burmese star tortoise and a southern leopard frog (Rana utricularia) found nearby, were similar. The box turtle isolate had a low molecular weight fragment that was not seen in the digestion profiles for the other isolates. These results suggest that certain amphibians and chelonians are infected with a similar virus and that different viruses exist among different chelonians. Amphibians may serve as a reservoir host for susceptible chelonians. This report also demonstrated that significant disease associated with Ranavirus infections are likely more widespread in chelonians than previously suspected.

Association of West Nile virus with lymphohistiocytic proliferative cutaneous lesions in American alligators (Alligator mississippiensis) detected by RT-PCR.

West Nile virus (WNV) is known to affect captive populations of alligators and, in some instances, cause significant mortalities. Alligators have been shown to amplify the virus, serve as a reservoir host, and even represent a source of infection for humans. This study describes a cutaneous manifestation of WNV in captive-reared American alligators (Alligator mississippiensis), previously described as lymphohistiocytic proliferative syndrome of alligators (LPSA), based on the findings of gross examination, histopathologic evaluation, WNV antibody testing, and WNV reverse transcriptase polymerase chain reaction (RT-PCR). Forty alligators with LPSA and 41 controls were examined. There was a significant difference (P = 0.01(-21)) in the WNV serostatus between the treatment group (100%) and the control group (0%, 95% CI: 0-7.3%). In the treatment group, 97.5% (39/40) (95% CI: 92.7-102.3%) of the LPSA skin lesions were positive for WNV via RT-PCR. Of the skin sections within the treatment group that had no LPSA lesions, 7.5% (3/40) (95% CI: 0-15.7%) were positive for WNV. In the control group, all of the skin samples were negative for WNV (41/41) (0%; 95% CI: 0-7.3%). The LPSA skin lesions were significantly more likely to be WNV positive by RT-PCR when compared to control animals (P = 0.07(-20)) and normal skin sections from affected animals (P = 0.08(-16)). There was no significant difference in the WNV RT-PCR results between control animals and normal skin sections from affected animals (P = 0.24). These findings suggest that LPSA is a cutaneous manifestation of WNV in alligators.

Antemortem diagnosis and characterization of nasal intranuclear coccidiosis in Sulawesi tortoises (Indotestudo forsteni).

Intranuclear coccidia and Mycoplasma spp. were identified from the nasal cavity of 5 Sulawesi tortoises (Indotestudo forsteni) affected by chronic rhinosinusitis and oronasal fistulae. This study provides the first antemortem diagnosis of intranuclear coccidiosis in tortoises and the first cytomorphologic descriptions of this disease. Histopathologic and ultrastructural morphology of the intranuclear coccidia were identical to those previously described in tortoises. Nucleic acid sequence data of a 1715 base-pair fragment of the 18S small subunit rRNA gene identify this coccidian as a novel species.