E-cigarettes are battery-operated devices that heat a liquid and deliver an aerosolized product to the user. Pulmonary illnesses related to e-cigarette use have been reported, but no large series has ...been described. In July 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health received reports of lung injury associated with the use of e-cigarettes (also called vaping) and launched a coordinated public health investigation.
We defined case patients as persons who reported use of e-cigarette devices and related products in the 90 days before symptom onset and had pulmonary infiltrates on imaging and whose illnesses were not attributed to other causes. Medical record abstraction and case patient interviews were conducted with the use of standardized tools.
There were 98 case patients, 79% of whom were male; the median age of the patients was 21 years. The majority of patients presented with respiratory symptoms (97%), gastrointestinal symptoms (77%), and constitutional symptoms (100%). All case patients had bilateral infiltrates on chest imaging. A total of 95% of the patients were hospitalized, 26% underwent intubation and mechanical ventilation, and two deaths were reported. A total of 89% of the patients reported having used tetrahydrocannabinol products in e-cigarette devices, although a wide variety of products and devices was reported. Syndromic surveillance data from Illinois showed that the mean monthly rate of visits related to severe respiratory illness in June through August of 2019 was twice the rate that was observed in the same months in 2018.
Case patients presented with similar clinical characteristics. Although the definitive substance or substances contributing to injury have not been determined, this initial cluster of illnesses represents an emerging clinical syndrome or syndromes. Additional work is needed to characterize the pathophysiology and to identify the definitive causes.
To date, no report on coronavirus disease 2019 (COVID-19) pediatric patients in a large urban center with data on underlying comorbidities and coinfection for hospitalized cases has been published.
...This was a case series of Chicago COVID-19 patients aged 0-17 years reported to the Chicago Department of Public Health (CDPH) from March 5 to April 8, 2020. Enhanced case investigation was performed. χ 2 and Wilcoxon 2-sample tests were used to compare characteristics among hospitalized and nonhospitalized cases.
During March 5-April 8, 2020, 6369 laboratory-confirmed cases of COVID-19 were reported to CDPH; 64 (1.0%) were among children aged 0-17 years. Ten patients (16%) were hospitalized, and 7 (70%) required intensive care (median length of hospitalization, 4 days range, 1-14 days). Reported fever and dyspnea were significantly higher in hospitalized patients than in nonhospitalized patients (9/10 vs 28/54, P = .04 and 7/10 vs 10/54, P = .002, respectively). Hospitalized patients were significantly younger than nonhospitalized patients (median, 3.5 years vs 12 years; P = .03) and all either had an underlying comorbidity or coinfection. Among the 34 unique households with multiple laboratory-confirmed infections, the median number of laboratory-confirmed infections was 2 (range, 2-5), and 31 (91%) households had at least 1 COVID-19-infected adult. For 15 households with available data to assess transmission, 11 (73%) were adult-to-child, 2 (13%) child-to-child, and 2 (13%) child-to-adult.
Enhanced case investigation of hospitalized patients revealed that underlying comorbidities and coinfection might have contributed to severe disease. Given frequency of household transmission, healthcare providers should consider alternative dispositional planning for affected families of children living with comorbidities.
Opioid Prescribing Patterns Before Fatal Opioid Overdose Abbasi, Ali B.; Salisbury-Afshar, Elizabeth; Berberet, Craig E. ...
American journal of preventive medicine,
February 2020, 2020-02-00, 20200201, Volume:
58, Issue:
2
Journal Article
Peer reviewed
Open access
Although opioid prescribing has decreased since 2010, overdose deaths involving illicit opioids have continued to rise. This study explores prescribing patterns before fatal overdose of decedents who ...died of prescription and illicit opioid overdoses.
This retrospective cohort study was conducted in 2019 and included all 1,893 Illinois residents who died of an opioid-related overdose in 2016. Each decedent was linked to any existing Prescription Monitoring Program records, calculating weekly morphine milligram equivalents for 52 weeks before overdose.
Among the 1,893 fatal opioid overdoses, 309 involved any prescription opioid and 1,461 involved illicit opioids without the involvement of prescription opioids. The death rate because of illicit opioids was 23/100,000 among black residents versus 10.5/100,000 among whites. During the last year of life, 76% of prescription opioid decedents filled any opioid prescription totaling 10.7 prescriptions per decedent, compared with 36% of illicit opioid decedents totaling 2.6 prescriptions per decedent. During the last week of life, 33% of prescription opioid decedents filled an opioid prescription totaling 0.42 prescriptions per decedent, compared with 4% of illicit opioid decedents totaling 0.05 prescriptions per decedent.
Prescribing patterns alone may not be sufficient to identify patients who are at high risk for opioid overdose, especially for those using illicit opioids. Interventions aimed at reducing opioid overdoses should take into account different patterns of opioid prescribing associated with illicit and prescription opioid overdose deaths and be designed around the local characteristics of the opioid overdose epidemic.
Forecasts of life expectancy are an important component of public policy that influence age-based entitlement programs such as Social Security and Medicare. Although the Social Security ...Administration recently raised its estimates of how long Americans are going to live in the 21st century, current trends in obesity in the United States suggest that these estimates may not be accurate. From our analysis of the effect of obesity on longevity, we conclude that the steady rise in life expectancy during the past two centuries may soon come to an end.
Objectives
We sought to determine the impact of timing of appropriate antifungal therapy, as assessed by susceptibility results, on patient survival.
Methods
Patients ≥16 years of age with first ...episodes of candidaemia during 2001-09 were included. Clinical data were collected retrospectively, including time to appropriate antifungal therapy and patient survival.
Results
The study population included 446 patients 243 (54%) female, mean age 53 years with candidaemia, 380 (85%) of whom had antifungal susceptibility data. Candida albicans was the most common pathogen (221, 50%) followed by Candida glabrata (99, 22%), Candida parapsilosis (59, 13%), Candida tropicalis (48, 11%) and Candida krusei (6, 1%). Appropriate antifungal therapy consisted of fluconazole (177, 40%), an echinocandin (125, 28%), amphotericin B (41, 9%) and voriconazole (6, 1%); 97 (22%) failed to receive appropriate antifungal therapy. The 30 day mortality was 34% (151/446) and there was no clear relationship between time from positive culture to receipt of appropriate antifungal therapy and 30 day survival. On multivariable Cox regression, increased APACHE II score hazard ratio (HR) 1.11, 95% CI 1.09-1.13, P < 0.001, cirrhosis (HR 2.15, 95% CI 1.48-3.13, P < 0.001) and HIV infection (HR 2.03, 95% CI 1.11-3.72, P = 0.02) were independent predictors of mortality. A secondary analysis requiring patients in the early treatment group to have received ≥24 h of effective antifungal therapy did show a significant mortality benefit to receiving antifungal treatment within 72 h of a positive blood culture being drawn (30 day mortality for early treatment: 27% versus 40%, P = 0.004; HR for mortality with delayed treatment on multivariable analysis: 1.41, 95% CI 1.01-1.98, P = 0.045).
Conclusions
Candida bloodstream infection is associated with high mortality, despite timely receipt of appropriate antifungal therapy.
Background & Aims Patients with baseline hepatitis C virus-RNA levels (bHCV-RNA) > 6 log IU/mL or cirrhosis have a reduced probability of a sustained-virologic response (SVR). We examined the ...relation between bHCV-RNA, cirrhosis, and SVR with a mathematical model that includes the critical-drug efficacy (ϵc ; the efficacy required for a drug to clear HCV), the infection-rate constant (β), and the percentage of HCV-infected hepatocytes (π). Methods The relation between baseline factors and SVR was evaluated in 1000 in silico HCV-infected patients, generated by random assignment of realistic host and viral kinetic parameters. Model predictions were compared with clinical data from 170 noncirrhotic and 75 cirrhotic patients. Results The ranges chosen for β and the viral production rate ( p ) resulted in bHCV-RNA levels that were in agreement with the distribution observed in US patients. With these β and p values, higher bHCV-RNA levels led to higher ϵc , resulting in lower SVR rates. However, higher β values resulted in lower bHCV-RNA levels but higher π and ϵc , predicting lower rates of SVR. Cirrhotic patients had lower bHCV-RNA levels than noncirrhotic patients ( P = .013), and more had bHCV-RNA levels < 6 log IU/mL ( P < .001). Even cirrhotic patients with lower bHCV-RNA levels had lower SVR rates. An increase in β could explain the results observed in cirrhotic patients. Conclusions Our model predicts that higher bHCV-RNA levels lead to higher ϵc , reducing the chance of achieving SVR; cirrhotic patients have lower SVR rates because of large π values, caused by increased rates of hepatocyte infection.
Studies have suggested that African American patients infected with hepatitis C virus (HCV) do not respond as well to treatment with interferon (IFN) as white patients. Here we analyzed the ...difference in the viral kinetic response between genotype 1 HCV-infected African American patients (n = 19) and white patients (n = 16). Patients were treated with 10 mIU IFN-α2b daily with or without ribavirin for 1 month followed by 3 mIU IFN-α2b 3 times a week with ribavirin. The kinetic parameters (ϵ, treatment effectiveness at inhibiting virion production; δ, loss rate of virus-producing cells; c, clearance rate of free virions; τ, delay until viral decline starts) were estimated from the viral load decay profiles using a previously described mathematical model. Differences in early kinetic parameters and viral negativity frequencies at weeks 4, 12, and 48 were compared. Ribavirin did not appear to enhance any of the viral kinetic parameters, although this may have been due to the high dose of IFN used. African American patients exhibited significantly (
P = .005) lower drug effectiveness (88.6% vs. 98.2%) compared with white patients, accounting for a 0.8 log lower HCV RNA decrease in the first 24 hours of treatment. Significant differences (
P = .006) were also noted for δ. There was no correlation between any of the viral kinetic parameters and either age, body mass index (BMI), or genotype 1 subtype. No patient achieved viral negativity at weeks 4, 12, or 48 without an ϵ greater than 90%. The mean viral decline and viral negativity rates were statistically different between the two races; however, when controlling for treatment effectiveness, these differences were no longer apparent. In conclusion, the failure of IFN response in African American patients infected with genotype 1 HCV is in part due to an impaired ability to inhibit viral production. (H
epatology 2003;37:1343-1350.)
Contaminated water and other fluids are increasingly recognized to be associated with health care–associated infections. We investigated an outbreak of Gram-negative bloodstream infections at 3 ...outpatient hemodialysis facilities.
Matched case-control investigations.
Patients who received hemodialysis at Facility A, B, or C from July 2015 to November 2016.
Infection control practices, sources of water, dialyzer reuse, injection medication handling, dialysis circuit priming, water and dialysate test findings, environmental reservoirs such as wall boxes, vascular access care practices, pulsed-field gel electrophoresis, and whole-genome sequencing of bacterial isolates.
Cases were defined by a positive blood culture for any Gram-negative bacteria drawn July 1, 2015 to November 30, 2016 from a patient who had received hemodialysis at Facility A, B, or C.
Exposures in cases and controls were compared using matched univariate conditional logistic regression.
58 cases of Gram-negative bloodstream infection occurred; 48 (83%) required hospitalization. The predominant organisms were Serratia marcescens (n=21) and Pseudomonas aeruginosa (n=12). Compared with controls, cases had higher odds of using a central venous catheter for dialysis (matched odds ratio, 54.32; lower bound of the 95% CI, 12.19). Facility staff reported pooling and regurgitation of waste fluid at recessed wall boxes that house connections for dialysate components and the effluent drain within dialysis treatment stations. Environmental samples yielded S marcescens and P aeruginosa from wall boxes. S marcescens isolated from wall boxes and case-patients from the same facilities were closely related by pulsed-field gel electrophoresis and whole-genome sequencing. We identified opportunities for health care workers’ hands to contaminate central venous catheters with contaminated fluid from the wall boxes.
Limited patient isolates for testing, on-site investigation occurred after peak of infections.
This large outbreak was linked to wall boxes, a previously undescribed source of contaminated fluid and biofilms in the immediate patient care environment.
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