Using Wastewater Surveillance to Monitor Gastrointestinal Pathogen Infections in the State of Oklahoma

During the COVID-19 pandemic, wastewater surveillance was widely used to monitor temporal and geographical infection trends. Using this as a foundation, a statewide program for routine wastewater monitoring of gastrointestinal pathogens was established in Oklahoma. The results from 18 months of surveillance showed that wastewater concentrations of Salmonella, Campylobacter, and norovirus exhibit similar seasonal patterns to those observed in reported human cases (F = 4-29, p < 0.05) and that wastewater can serve as an early warning tool for increases in cases, offering between one- and two-weeks lead time. Approximately one third of outbreak alerts in wastewater correlated in time with confirmed outbreaks of Salmonella or Campylobacter and our results further indicated that several outbreaks are likely to go undetected through the traditional surveillance approach currently in place. Better understanding of the true distribution and burden of gastrointestinal infections ultimately facilitates better disease prevention and control and reduces the overall socioeconomic and healthcare related impact of these pathogens. In this respect, wastewater represents a unique opportunity for monitoring infections in real-time, without the need for individual human testing. With increasing demands for sustainable and low-cost disease surveillance, the usefulness of wastewater as a long-term method for tracking infectious disease transmission is likely to become even more pronounced.

Predicting COVID-19 cases in diverse population groups using SARS-CoV-2 wastewater monitoring across Oklahoma City

SARS-CoV-2 was discovered among humans in late 2019 and rapidly spread across the world. Although the virus is transmitted by respiratory droplets, most infected persons also excrete viral particles in their feces. This fact prompted a range of studies assessing the usefulness of wastewater surveillance to determine levels of infection and transmission and produce early warnings of outbreaks in local communities, independently of human testing. In this study, we collected samples of wastewater from 13 locations across Oklahoma City, representing different population types, twice per week from November 2020 to end of March 2021. Wastewater samples were collected and analyzed for the presence and concentration of SARS-CoV-2 RNA using RT-qPCR. The concentration of SARS-CoV-2 in the wastewater showed notable peaks, preceding the number of reported COVID-19 cases by an average of one week (ranging between 4 and 10 days). The early warning lead-time for an outbreak or increase in cases was significantly higher in areas with larger Hispanic populations and lower in areas with a higher household income or higher proportion of persons aged 65 years or older. Using this relationship, we predicted the number of cases with an accuracy of 81-92% compared to reported cases. These results confirm the validity and timeliness of using wastewater surveillance for monitoring local disease transmission and highlight the importance of differences in population structures when interpreting surveillance outputs and planning preventive action.

Diverse perspectives on death, disability, and quality of life: an exploratory study of racial differences in periviable decision-making

OBJECTIVE

To qualitatively explore perceptions of pain/suffering, disability, and coping by race among pregnant women facing the threat of a periviable delivery (22 0/7-24 6/7 weeks).

STUDY DESIGN

Interviews were conducted in-hospital prior to delivery. Transcripts were coded verbatim and responses were stratified by race (white vs non-white). Conventional content analysis was conducted using NVivo 12.

RESULTS

We recruited 30 women (50% white, 50% non-white). Most women expressed love and acceptance of their babies and described pain as a "means to an end." Non-white women focused almost exclusively on immediate survival and perseverance, while white women expressed concerns about quality of life beyond the NICU. The majority of non-white women were unable to recall any discussions with their doctors about their baby's comfort, pain, or suffering.

CONCLUSIONS

These findings may suggest that culturally tailored approaches to counseling and decision-support may be beneficial for patients from marginalized or minoritized groups.

Values clarification: Eliciting the values that inform and influence parents' treatment decisions for periviable birth

BACKGROUND

Values clarification can assist families facing the threat of periviable delivery in navigating the complexity of competing values related to death, disability, and quality of life (QOL).

OBJECTIVE

We piloted values clarification exercises to inform resuscitation decision making and qualitatively assess perceptions of QOL.

METHODS

We conducted a mixed-method study of women with threatened periviable delivery (22 0/7-24 6/7 weeks) and their important others (IOs). Participants engaged in three values clarification activities as part of a semi-structured interview-(a) Card sorting nine conditions as an acceptable/unacceptable QOL for a child; (b) Rating/ranking seven common concerns in periviable decision making (scale 0-10, not at all to extremely important); and (c) "Agreed/disagreed" with six statements regarding end-of-life treatment, disability, and QOL. Participants were also asked to define "QOL" and describe their perceptions of a good and poor QOL for their child. Analysis was conducted using SAS version 9.4 and NVivo 12.

RESULTS

All mild disabilities were an acceptable QOL, while two-thirds of participants considered long-term mechanical ventilation unacceptable. Although pregnant women rated "Impact on Your Physical/Mental Health" (average 5.6) and IOs rated "Financial Concerns" the highest (average 6.6), both groups ranked "Financial Concerns" as the most important concern (median 5.0 and 6.0, respectively). Most participants agreed that "Any amount of life is better than no life at all" (pregnant women 62.1%; IOs 75.0%) and disagreed that resuscitation would cause "Too much suffering" for their child (pregnant women 71.4%; IOs 80.0%). Half were familiar with the phrase "QOL". Although the majority described a good QOL in terms of emotional well-being (eg "loved", "happy", "supported"), a poor QOL was described in terms of functionality (eg "dependent" and "confined"). Additionally, financial stability emerged as a distinctive theme when IOs discussed poor QOL.

CONCLUSION

The study offers important insights on parental perspectives in periviable decision making and potential values clarification tools for decision support.

Creation of a Decision Support Tool for Expectant Parents Facing Threatened Periviable Delivery: Application of a User-Centered Design Approach

BACKGROUND

Shared decision-making (SDM) is optimal in the context of periviable delivery, where the decision to pursue life-support measures or palliation is both preference sensitive and value laden. We sought to develop a decision support tool (DST) prototype to facilitate SDM by utilizing a user-centered design research approach.

METHODS

We convened four patient and provider advisory boards with women and their partners who had experienced a surviving or non-surviving periviable delivery, pregnant women who had not experienced a prior preterm birth, and obstetric providers. Each 2-h session involved design research activities to generate ideas and facilitate sharing of values, goals, and attitudes. Participant feedback shaped the design of three prototypes (a tablet application, family story videos, and a virtual reality experience) to be tested in a final session.

RESULTS

Ninety-five individuals (48 mothers/partners; 47 providers) from two hospitals participated. Most participants agreed that the prototypes should include factual, unbiased outcomes and probabilities. Mothers and support partners also desired comprehensive explanations of delivery and care options, while providers wanted a tool to ease communication, help elicit values, and share patient experiences. Participants ultimately favored the tablet application and suggested that it include family testimonial videos.

CONCLUSION

Our results suggest that a DST that combines unbiased information and understandable outcomes with family testimonials would be meaningful for periviable SDM. User-centered design was found to be a useful method for creating a DST prototype that may lead to improved effectiveness, usability, uptake, and dissemination in the future, by leveraging the expertise of a wide range of stakeholders.

Examining the Impact of the Vaginal Birth After Cesarean Risk Calculator Estimation on Trial of Labor After Cesarean Counseling

Background. Because failed trial of labor after cesarean (TOLAC) is associated with greater morbidity than planned cesarean, it is important to distinguish women with a high likelihood of successful vaginal birth after cesarean (VBAC) from those likely to fail. The VBAC Calculator may help make this distinction but little is known about how often providers use it; nor whether use improves risk estimation and/or influences TOLAC counseling. Methods. In a cross-sectional survey, a convenience sample of obstetrical providers reported their likelihood (4-point Likert-type scale) to “Recommend,”“Offer,” or “Agree to” TOLAC for patients presented first through five clinical vignettes; then, in different order, by corresponding VBAC calculator estimates. Results. Of the 85 (of 101, 84% response rate) participants, 88% routinely performed TOLAC, but only 21% used the Calculator. The majority (67.1% to 89.3%) overestimated the likelihood of success for all but one vignette (which had the highest estimate of success). Most providers (42% to 89%) recommended TOLAC for all five vignettes. Given calculated estimates, the majority of providers (67% to 95%) recommended TOLAC for success estimates exceeding 40%. For estimates between 20% and 40%, most providers offered (58%) or agreed (68%) to TOLAC; and even below 20%, over half still agreed to TOLAC. The vignette with the lowest estimate of success (18.7%) had the weakest intraprovider agreement (kappa = 0.116; confidence interval [CI] = 0.045–0.187), whereas the strongest agreement was found in the two vignettes with highest success estimates: 77.9% (kappa = 0.549; CI = 0.382–0.716) and 96.6% (kappa = 0.527; CI = 0.284–0.770). Limitations. Survey responses may not reflect actual practice patterns. Conclusion. Providers are overly optimistic in their clinical estimation of VBAC success. Wider use of decision support could aid in risk stratification and TOLAC counseling to reduce patient morbidity.

Abstract P6-04-06: Stratification of Breast Cancers Based on Functional Phosphoprotein Signaling Profiles Elicited from Live Tumor Cells

Background: Abnormal signal transduction networks are frequent targets of existing and emerging molecularly targeted agents (MTAs). Unfortunately, most predictive biomarkers to guide therapeutic selection are based on indirect assessment of signal transduction through DNA mutations or transcriptional profiles rather than dynamic assessment of signal transduction proteins themselves. Classification of breast cancer based on functional signaling profiles derived from a set of signaling phosphoproteins induced upon growth factor stimulation of live breast cancer cells is likely to provide a more accurate system for MTA selection than indirect methods utilizing fixed or frozen tissue. Objective: This study aimed to demonstrate stratification of multiple breast cancer model systems based on functional signaling profiles elicited from live tumor cells in response to ex vivo stimuli. Methods: Breast cancer cell lines (MCF-7, HCC-1937, MDA-MB-231, BT474, and SKBR3) were exposed to either vehicle (control) or stimulated with 200 ng/ml epidermal growth factor (EGF) for 5 minutes then lysed and proteins extracted. Mean Fluorescence Intensity (MFI) levels of six phosphoproteins (pEGFR, pErk, pAkt, pP70S6K, pGSK3β, and pSTAT3) were determined in sextuplet using a multiplexed bead-immunoassay (BioPlex, BioRad) and a modulation score (MS), defined as the log 2 (MFI stimulated /MFI contrd), calculated for each. Scores were ranked by percentile relative to the median (0.66) and inter-quartile range (IQR) (154). Moderate responders were classified as those with MS between the 75th percentile (2.20) and the 75th percentile plus the IQR (3.74). High responders were those MS &gt; 3.74. Low responders were those MS falling between the IQR and 75th percentile (1.54-2.20) whereas non responders were classified as MS &lt; 1.54 Results: EGF stimulation resulted in high levels of EGFR-phosphorylation in all cells except BT474, which responded moderately (2.57). MS for pErk were high in MCF-7 cells (3.92), moderate in HCC -1937 (2.89) and none for the other lines tested. Moderate STAT-3 phosphorylation was observed in only MCF-7cells (2.34) whereas low pAkt MS were observed in only SKBR3 (1.78). All other markers across the five cell lines tested were non responders (&lt; 1.54), with pGSK3β and pP70S6K yielding MS &lt; 1.0 for all five cell lines. Interestingly, the relative MS rank order of all six proteins differed across each cell line suggesting further opportunity for stratification. Conclusions: Our data demonstrate that different breast cancer cell lines display unique functional phosphoprotein signaling profiles, thereby providing a mechanism for stratifying tumors based on individual signal transduction pathway activation. Further studies are underway to correlate the functional signaling profiles identified here to sensitivity and resistance to specific MTA treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-04-06.

Sharing good practice: developing network forums

In this report the authors describe how bringing together nurses from different specialties to share innovations and developments can enhance personal, professional and practice development on a much wider scale.

Home healthcare for patients receiving one-day mastectomy

The pressure to cut costs has resulted in outpatient to 1-day hospital stays for women who have a modified radical mastectomy. This article discusses the need for early identification of patients who require home healthcare immediately after surgery to decrease complications and reduce postoperative anxiety.

A service evaluation of stoma care nurses' practice

Stoma care nurses aim to meet the physical, psychological, social and spiritual needs of patients. Development of stoma care nursing services has varied, as it has been the responsibility of each nurse, resulting in differences in the mode of delivery. This qualitative and quantitative study involved stoma care nurses from six areas in Essex, to assess patient perception of the service they received. Overall, the satisfaction level was high despite differences in delivery of care especially timing and frequency of visits at home.

The Vancouver Lymphadenopathy-AIDS Study: 4. Effects of exposure factors, cofactors and HTLV-III seropositivity on number of helper T cells

Results of testing for antibody to human T-lymphotropic virus (HTLV-III) and absolute numbers of helper T cells in 219 participants in the Vancouver Lymphadenopathy-AIDS (acquired immune deficiency syndrome) Study were analysed. The mean absolute helper T-cell counts in the 141 HTLV-III seronegative and the 78 seropositive men were 897/mL and 659/mL respectively (p less than 0.001). Established AIDS risk factors such as elevated lifetime number of male sexual partners and frequent receptive anal intercourse did not appear to have any significant effect on number of helper T cells that was independent of HTLV-III antibody status. Seropositive men with less than 100, 100 to 500 or more than 500 male sexual partners in their lifetime had mean absolute helper T-cell counts of 667/mL, 651/mL and 662/mL respectively. Most other risk factors, as well, did not appear to exert any effect on absolute number of helper T cells that was independent of the effect of HTLV-III antibody status. However, independent effects of a history of mononucleosis or hepatitis and of cigarette smoking were noted. The data support the hypothesis that no immune dysfunction beyond that due to the initial infection alone arises from repeated exposure to HTLV-III. Most risk factors appear to act as exposure factors, exerting their effect on the immune system merely by increasing the probability of contact with the agent. The independent effects of a history of mononucleosis or hepatitis suggest that viral agents may be cofactors in the production of immune dysfunction.

Relation of HTLV-III seropositivity and lymphadenopathy

Testing for antibody to human T-lymphotropic retrovirus (HTLV-III) was carried out in five groups of homosexual men: 250 without lymphadenopathy (control group), 37 with slight or nonpersistent lymph node enlargement (intermediate group), 141 with persistent generalized lymphadenopathy, 32 with persistent generalized lymphadenopathy who underwent biopsy and 11 in whom acquired immune deficiency syndrome (AIDS) was diagnosed. The rates of HTLV-III seropositivity in the five groups were 18%, 32%, 61%, 94% and 91% respectively.

The Vancouver Lymphadenopathy-AIDS Study: 3. Relation of HTLV-III seropositivity, immune status and lymphadenopathy

In a study of 394 homosexual men recruited at the primary care level the prevalence of antibody to human T-lymphotropic retrovirus (HTLV-III) was higher among those with lymph node enlargement than among controls. The degree of abnormal immune function, as shown by abnormalities in immunoglobulin levels, immune complex activity and T-lymphocyte subsets, was correlated with the extent of lymphadenopathy. A similar pattern of immunologic abnormality was associated with seropositivity for HTLV-III antibody. However, HTLV-III seropositivity was the major determinant of immune function after adjustment for lymph node status. The results suggest that the immune dysfunction seen in patients with lymphadenopathy is due for the most part to the high prevalence of HTLV-III seropositivity in these populations. Lymphadenopathy, in many subjects, may in fact represent a physical sign of a stabilized compensated homeostatic host response. Factors responsible for severe immune decompensation associated with acquired immune deficiency syndrome (AIDS) may best be sought by prospective study of HTLV-III seropositive asymptomatic patients or those with stable persistent generalized lymphadenopathy and relatively normal immune function.

The Vancouver Lymphadenopathy-AIDS Study: 1. Persistent generalized lymphadenopathy

The Vancouver Lymphadenopathy-AIDS (acquired immune deficiency syndrome) Study is an ongoing prospective study of over 700 homosexual men attending six primary care practices in central Vancouver. A case-control study of risk factors for persistent generalized lymphadenopathy in homosexual men was conducted in five of the practices. The participants completed a questionnaire and underwent a complete physical examination at the time of enrollment and at a subsequent visit not less than 3 months later, and laboratory tests were performed after both visits. Persistent generalized lymphadenopathy was defined as the presence of lymph nodes greater than 1 cm in diameter at two or more extrainguinal sites for more than 3 months. Of the 519 patients who had completed both visits by February 1984, 126 (24%) were found to have the disease, and two controls without lymphadenopathy were frequency-matched on the basis of age and practice to each subject. More than 100 male sexual partners during one's lifetime, frequent receptive anal intercourse, a history of gonorrhea, use of illicit drugs and sexual contact in Los Angeles were identified as independent risk factors for persistent generalized lymphadenopathy. The similarity of these risk factors to those established for AIDS supports the hypothesis of a common etiology for the two diseases, and the high prevalence rate of persistent generalized lymphadenopathy further supports the hypothesis that AIDS is an uncommon response to a relatively common agent.

Cancer and aplastic anemia in British Columbia farmers

For evaluation of occupational mortality in agriculture, age-standardized proportional mortality ratios (PMR) were calculated for 28,032 male farmers with the use of British Columbia (B.C.) death registrations collected from 1950 to 1978. Farmers had significantly elevated risks of death from cancer of the lip (PMR = 191, P = .05), stomach (PMR = 119, P less than .0001), and prostate gland (PMR = 113, P less than .001). In addition, leukemia was higher than expected (PMR = 122, P less than .01), as was aplastic anemia (PMR = 174, P less than .01). The elevated risks were fairly consistent over the 29-year period for stomach, prostate gland, and lip cancer, as well as for leukemia. The PMR for aplastic anemia was highest for the years 1950-59 and declined over the next 19 years. Farmers also showed significant mortality deficits for several important cancer sites, including esophagus (PMR = 59, P less than .0001), colon (PMR = 84, P less than .001), larynx (PMR = 62, P less than .01), and lung (PMR = 66, P less than .0001) for the period 1950-78. More detailed studies in B.C. will be necessary to confirm and extend these cancer-agriculture associations.

Measurements of airway edema in allergic bronchoconstriction in the guinea pig

We tested the hypothesis that acute bronchoconstriction in the guinea pig was associated with airway edema by measuring extravascular water in the airways and lung parenchyma. Thirty guinea pigs were immunized with egg albumin and 30 nonimmunized guinea pigs served as controls. An aerosolized challenge with egg albumin produced acute respiratory distress in the immunized but not in the control animals. The animals were killed (6 per group) immediately and 1, 3, 6, and 24 h after the challenge, and the extravascular water content of the airways and parenchyma was measured. We found that airway extravascular water varied from 3.90 +/- 0.58 to 3.12 +/- 0.25 g/g dry tissue in the control group and from 3.61 +/- 0.41 to 3.79 +/- 0.33 g/g dry tissue in the experimental group. A two-way analysis of variance showed no difference between the groups. Similar results were found in parenchymal samples. We concluded that allergic bronchoconstriction in the guinea pig is not associated with airway edema.