181. Potential Benefit of Masking and other COVID-19 Infection Prevention Measures on Late-Onset Infections in the NICU

Background

Incidence of blood stream infections (BSI) among NICU admissions remains high, with associated mortality and morbidity. Due to COVID-19, there are increased infection prevention (IP) measures in NICUs including universal masking for all healthcare workers and families, social distancing, visitation restrictions, and increased attention to hand hygiene. These measures may also affect late-onset infection rates and offer understanding of novel interventions for prevention.

Methods

We examined infection rates during the 24 months prior to implementation of COVID-19 IP measures (PRE-period) compared to the months after implementation from April 2020 (POST-period). Late-onset infections were defined as culture-confirmed infection of the blood, urine, or identification of respiratory viral pathogens. An interrupted time series analysis of infection per 1000 patient days was performed based on a change-point Poisson regression with a lagged dependent variable and the number of patient days used as offsets. Each month was treated as independent with additional analysis using an observation-driven model to account for serial dependence.

Results

Multicenter analysis to date included all infants cared for at three centers (Level 3 and 4) from 2018-2020. Monthly BSI rates decreased in the POST-period at the three centers (Figure 1). At all centers actual BSI rate was lower than the expected rate in the POST-period (Figure 2). The combined BSI rate per 1000 patient days was 41% lower compared to the rate prior to implementation (95% CI, 0.42 to 0.84, P=0.004) (Table 1). In subgroup analysis by birthweight, infants< 1000g had a 39% reduction in BSI (P=0.023), for1000-1500g patients there was a 44% reduction (P=0.292) and in those > 1500g there was a 53% reduction (0.083).

Figure 1. PRE and POST MASKING and other COVID Infection Prevention Measures and Monthly BSI Rates.

Figure 2. PRE and POST MASKING and other COVID infection prevention measures and BSI Trends.

At all centers actual BSI rate was lower than the expected rate for that center in the POST period. UVA and Duke showed a baseline decrease and Pennsylvania Hospital showed a downward trend in infection rates. There was an approximate decrease in expected bloodstream infection events at Pennsylvania Hospital by 7 events, at UVA by 22 events and at Duke by 23 events. Overall, all three centers saw a decrease in their expected infections after COVID-19 infection prevention measures were implemented.

Table 1. Percent reduction in Bloodstream Infection at each center.

Conclusion

In this preliminary analysis, we found a reduction of BSI after the implementation of COVID-19 infection prevention measures. Additionally, there were fewer viral infections, though there were a limited number of episodes. Further analyses of multicenter data and a larger number of patients will elucidate the significance of these findings and the role some of these IP measures such as universal masking may have in infection prevention in the NICU.

Disclosures

All Authors: No reported disclosures

C-47 Associations of Executive Functioning with Neural Mechanisms of Reward Processing in Youth

Objective

Executive functioning (EF) deficits and difficulty adjusting to reward contingencies in youth are associated with concurrent and future psychopathology. Little is known about how EF relates to reward processing mechanisms. This study examines the associations of neural mechanisms of reward processing with cognitive flexibility and response inhibition, two subdomains of EF.

Method

dYouths (n = 22), ages 11-14, completed a youth-friendly monetary incentive delay task during multiband fMRI acquisition by hitting a piñata target via button press, to obtain a potential reward. The task included anticipation and feedback periods. On the same day, youths also completed two NIH Toolbox EF tasks on an iPad; the Dimensional Change Card Sort task and the Flanker task, measuring cognitive flexibility and response inhibition respectively. Whole-brain analyses evaluate brain activation associated with EF scores during anticipation and feedback periods.

Results

Cognitive flexibility was associated with left insula activation during feedback (xyz = -35,11,10, F(1,20) = 25.36, k = 30, p < .005, uncorrected), with lower scores predicting higher activation in left insula when participants failed to obtain a potential reward (r = -.52, p = 0.014). During reward anticipation, the Cognitive Flexibility x Reward Condition interaction predicted activation in the left fusiform (xyz = -45,-41,-16, F(1,20) = 23.94, k = 38) and left inferior frontal gyri (xyz = -39,33,10, F(1,20) = 16.86, k = 21; both p < .005, uncorrected), but post-hocs were non-significant. Response inhibition analyses are currently underway.

Conclusions

These preliminary results suggest that EF may moderate reward-related neural activation in brain areas related to stimulus-driven attentional networks. Subjects with lower cognitive flexibility may have difficulty reframing failure when a reward is missed. Findings may inform intervention efforts.

Evidence for causal top-down frontal contributions to predictive processes in speech perception

Perception relies on the integration of sensory information and prior expectations. Here we show that selective neurodegeneration of human frontal speech regions results in delayed reconciliation of predictions in temporal cortex. These temporal regions were not atrophic, displayed normal evoked magnetic and electrical power, and preserved neural sensitivity to manipulations of sensory detail. Frontal neurodegeneration does not prevent the perceptual effects of contextual information; instead, prior expectations are applied inflexibly. The precision of predictions correlates with beta power, in line with theoretical models of the neural instantiation of predictive coding. Fronto-temporal interactions are enhanced while participants reconcile prior predictions with degraded sensory signals. Excessively precise predictions can explain several challenging phenomena in frontal aphasias, including agrammatism and subjective difficulties with speech perception. This work demonstrates that higher-level frontal mechanisms for cognitive and behavioural flexibility make a causal functional contribution to the hierarchical generative models underlying speech perception.

Podocyte depletion and glomerulosclerosis have a direct relationship in the PAN-treated rat

BACKGROUND

Podocytes are highly differentiated glomerular epithelial cells with limited potential to divide. They are responsible for maintaining and supporting the glomerular basement membrane so as to facilitate efficient filtration. The hypothesis tested was whether the development of glomerulosclerosis in the puromycin aminonucleoside (PAN)-treated rat could be attributed to podocyte depletion.

METHODS

PAN was injected in Sprague-Dawley rats once, twice, or three times at 30-day intervals. Podocytes were counted in glomeruli using immunoperoxidase histochemistry and antibodies to both GLEPP1 (PTPRO) and WT-1. Podocytes were assayed in urine using reverse transcription-quantitative polymerase chain reaction (RT-QPCR). Glomerular areas were measured by computerized morphometry.

RESULTS

In a preliminary experiment, a single injection of PAN caused a reduction in the glomerular podocyte count by 25%. Additional independent confirmation that podocytes were lost from glomeruli after PAN injection was obtained identifying detached podocytes in Bowman's space, measurement of nephrin and GLEPP1 mRNAs in urine, ultrastructural analysis of glomeruli, and identification of TUNEL-positive apoptotic podocytes in glomeruli. In a second experiment, sequential podocyte depletion by 15, 31, and 53% was achieved by the administration of one, two, or three injections of PAN at 30-day intervals. The region of the glomerulus devoid of podocytes developed glomerulosclerosis, and this area progressively increased as podocytes were progressively depleted. The correlation coefficient (r(2)) value for the relationship between percent podocyte depletion and glomerulosclerotic area was 0.99. The Y intercept of this plot showed that glomerulosclerosis was initiated when only 10 to 20% of podocytes were lost.

CONCLUSION

This report supports the growing body of data linking glomerulosclerosis directly to a reduction in relative podocyte number [increased glomerular area per podocyte (GAPP)]. It raises important questions related to the mechanisms of podocyte loss, strategies for prevention of podocyte depletion, and the prevention of progression of glomerular diseases.

Provider resource planning. A study of methods in multispecialty groups and systems

This article profiles the state of the art in provider resource planning based on a sample of large multispeciality group practices. Senior administrative representatives from a geographically dispersed sample of 12 practices, each employing over 100 physicians, participated in telephone interviews to discuss their respective organization's provider resource planning practices. There was significant variation with regard to the structural and process components and evaluation criteria used to plan provider resources. Variability was most pronounced by the lack of consensus and experience within and across organizations regarding the number and type of criteria deemed useful in evaluating new position requests. This research suggests that there is an opportunity to develop more objective provider resource planning methods that recognize differences across organizations and their respective markets. The authors recommend a series of research steps to develop methods that would identify needs prospectively, minimize the complexities of provider resource planning and maximize the alignment of strategic plans and operations.

Utilization of advanced practice nurses in healthcare systems and multispecialty group practice

Cost-effective strategies for delivering primary care require the appropriate mix of healthcare providers. The authors define the scope of practice for the advanced practice nurse. Results of a nationwide survey of 26 large healthcare systems and multispecialty group practices are presented. Findings from these practice settings are contrasted with those previously reported in the literature. Implications for the future are discussed.

Familial cryptogenic fibrosing pleuritis with Fanconi's syndrome (renal tubular acidosis). A new syndrome

We describe two siblings with a progressive unrelenting and unique syndrome of bilateral fibrosing pleuritis of unknown cause occurring in association with Fanconi's syndrome (renal tubular acidosis). The parents of the siblings were second cousins. Both siblings had identical pleural histologic characteristics and identical urinary metabolic defects. This condition resulted in the development of severe respiratory failure in both patients and ultimately the death of the older sibling at the age of 21 years.

Variant angina in an adolescent

We describe a case of variant angina associated with acute myocardial ischemia in an adolescent presenting with severe chest pain and transient ST elevation. Subsequent cardiac catheterization revealed normal coronary anatomy, and the patient has been asymptomatic since discharge on calcium channel blockers. Variant angina is a rare cause of chest pain in adolescents.

Continuous veno-venous haemofiltration following cardio-pulmonary bypass. Indications and outcome in 35 patients

OBJECTIVE

To study the impact of continuous veno-venous haemofiltration on survival in patients with acute renal failure (ARF) following cardio-pulmonary bypass (CPB) surgery.

DESIGN

A retrospective study of all patients requiring haemofiltration after CPB over a 2 year period.

SETTING

A 20 bedded, adult cardothoracic intensive care unit in a postgraduate teaching hospital.

PATIENTS

35 patients (26 male, age range 24-74 years) required haemofiltration (2.7% of the total number of patients undergoing CPB).

MAIN RESULTS

Cardiovascular failure post CPB was the commonest causes of ARF (n = 16). Indications for haemofiltration were uremia (21), oligo-anuria (11), volume overload (2) and hyperkalaemia (1). Mean time from CPB to the initiation of haemofiltration was 8 days (range 0-15 days). Mean urea was 30 mmol/l and creatinine 362 mumol/l immediately prior to treatment. Urea was well-controlled in all patients, although 2 needed haemodiafiltration. Twenty-six patients died during their admission to the ICU (74% mortality). A further 3 patients died during their hospital admission, following discharge from ICU. Outcome was particularly poor in patients with cardiovascular failure following CPB (16 cases, 0 survivors). Survivors tended to commence filtration earlier (mean of 4 vs 7 days for non-survivors) and required treatment for a mean period of 8 days (range 1-26 days). Survival was determined by the number of failed organ systems at the start of haemofiltration. Thus, 100% of patients with single system failure survived, compared to only 10% with 3 or more system failure.

CONCLUSIONS

Despite the theoretical advantages of haemofiltration and the effective control of uraemia the mortality associated with ARF following CPB remains high and is probably determined by the number of failed organs systems.

Production, purification, and characterization of human recombinant IL-8 from the eucaryotic vector expression system baculovirus

The cDNA for the human chemotactic interleukin, IL-8, was subcloned from a bacterial source into the eucaryotic vector expression system baculovirus. Recombinant human IL-8 (rhIL-8) was synthesized and secreted from Sf9 cells derived from Spodoptera frugiperda following infection of a recombinant virus harboring the full-length IL-8 structural gene. Infected Sf9 cells produced rhIL-8 in a range from 0.5 to 2.0 mg of rhIL-8/liter of postinfection cell culture media. The recombinant interleukin was purified (greater than 600-fold) to homogeneity using preparative HPLC. rhIL-8 retained all of the physical, immunological, and biochemical properties observed for the natural product, monocyte-derived IL-8. rhIL-8 was assessed for biological efficacy by three criteria: (a) ability to induce chemotaxis in human neutrophils, (b) ability to induce oxygen burst metabolism, and (c) ability to be recognized by purified rabbit antibody generated against monocyte-derived IL-8. Antibody generated against monocyte-derived IL-8 recognized rhIL-8 isolated during all stages of the purification protocol. rhIL-8 was strongly chemotactic for human neutrophils and exhibited a chemotactic index comparable to that reported for other strong chemotactic peptides. rhIL-8 was identified following sodium dodecyl sulfate-polyacrylamide gel electrophoresis as a single silver-stained band having an estimated molecular weight of 9.2 kDa and displayed amino acid residue molar abundance homology predicted for the mature form of the interleukin. Baculovirus vector expression coupled to preparative HPLC proved to be a very efficient method for large-scale recombinant interleukin production.

Current management of pleural disease

The pleura may be affected by a variety of diseases. Radiological techniques are helpful in management but are rarely diagnostic. Diagnosis is usually made following careful assessment of aspirated fluid and pleural biopsy specimens. The management of pleural malignancy remains unsatisfactory.

A comparison of several agents with two delivery systems for the prevention of airway narrowing induced by nebulised pentamidine isethionate

Bronchial narrowing is the major side effect of inhaled nebulised pentamidine isethionate, used for the prophylaxis and treatment of Pneumocystis carinii pneumonia. Several agents and delivery systems were assessed for prophylaxis of bronchial narrowing in HIV-positive males receiving regular nebulised pentamidine isethionate. In a previous study we found the mean maximum fall in FEV1 with nebulised pentamidine alone to be 21%. FEV1 was measured before and after inhaling nebulised pentamidine, preceded by one of the following bronchodilator/immunoregulatory agents: Terbutaline metered dose inhaler (500 micrograms), nebulised salbutamol (5 mg), nebulised ipratropium bromide (500 micrograms), nebulised sodium cromoglycate (20 mg), and nedocromil sodium metered dose inhaler (4 mg). Each agent was administered once only to ten different subjects. Nebulised salbutamol gave most effective prophylaxis against bronchial narrowing induced by nebulised pentamidine (mean maximum fall in FEV1 = 5% vs. 21%, P less than 0.001). Terbutaline given by metered dose inhaler was significantly less effective than high dose terbutaline (10 mg) given by nebuliser, demonstrated in the previous study (mean maximum fall in FEV1 = 14% vs. 6%, P less than 0.05). Mean maximum falls in FEV1 for ipratropium bromide, sodium cromoglycate and nedocromil sodium were 16, 17 and 16%, respectively. High dose beta 2-agonists administered by nebuliser give more effective prophylaxis against nebulised pentamidine-induced bronchial narrowing than either lower doses given by metered dose inhaler, anticholinergics or immunoregulatory drugs.

Small bowel infarction mimicking Crohn's ileitis

A case of superior mesenteric arterial embolic occlusion with radiological features mimicking small bowel Crohn's disease is reported.

Novel compounds possessing potent cAMP and cGMP phosphodiesterase inhibitory activity. Synthesis and cardiovascular effects of a series of imidazo[1,2-a]quinoxalinones and imidazo[1,5-a]quinoxalinones and their aza analogues

A series of novel imidazoquinoxalinones and their aza analogues were prepared by the cyclization of o-amino(1H-imidazol-1-yl)aryls and heteroaryls with carbonyldiimidazole. The compounds were screened for inhibition of Type I and Type IV phosphodiesterases (PDE's) and evaluated for their vasorelaxant and positive inotropic activities in vitro. In general, compounds having potent PDE inhibitory activity also possessed good inotropic and vasodilator activity, although linear correlations between these activities could not be established.

Steroid trials in the assessment of reversibility of air flow limitation: a survey of current clinical practice of chest physicians

To evaluate how steroid trials are currently used in the assessment of reversibility of air flow limitation, a postal questionnaire was sent to 355 consultant members of the British Thoracic Society working in England and Wales; 253 questionnaires were returned (71% response rate). Two respondents did not undertake steroid trials; of the remaining 251, 75% prescribed 30-40 mg oral prednisolone, with the commonest treatment period being 2 weeks. A high dose steroid inhaler was sometimes used as an alternative by 31% of respondents. Although 71% of respondents made lung function measurements on several occasions before starting steroids and 76% made measurements during treatment, 78% assessed patients on only one occasion at the end of the trials to ascertain its outcome. Weight, blood pressure and glycosuria were measured less frequently after the steroid treatment compared to the pre-trial period. Blood glucose and serum electrolytes were infrequently measured both before and after treatment. Wide variations exist in steroid trial regimens and current practice may neither provide definitive evidence of treatment benefit nor an adequate safeguard for patients against potential side-effects.

Detection of bronchiectasis by high-resolution computed tomography in the yellow nail syndrome

High resolution computed tomography of the lungs was performed in three patients with the yellow nail syndrome to detect bronchiectasis. Standard CT was performed in a fourth patient. Evidence of bronchiectasis with bronchial wall thickening and bronchial dilatation was observed in all four patients. High resolution CT is a non-invasive method for detecting and assessing the extent of airway disease in the yellow nail syndrome.

On physicians and litigation

Because litigation involving physicians has come to influence the practice of medicine in several ways, we describe many of the legal processes involved. We also offer specific advice in regard to steps which can be effectively taken, and those which should be avoided. We close with a plea for active participation by physicians in the judicial process and in the promulgation of appropriate legislation.

Effect of terbutaline on bronchoconstriction induced by nebulised pentamidine

The severity, duration, and reversibility of pentamidine induced bronchial narrowing was studied with and without pretreatment with nebulised terbutaline 10 mg in an open study of 40 patients seropositive for the human immunodeficiency virus (HIV). All subjects received pentamidine 300 mg in 5 ml water via an Acorn System 22 jet nebuliser. The forced expiratory volume in one second (FEV1) fell in all 20 patients given pentamidine alone, the mean maximum fall being 20.6%. In the 20 patients given pentamidine preceded by nebulised terbutaline the mean maximum fall in FEV1 was 4%; three subjects had a fall in FEV1 of more than 10%.

Absence of interferon in sera of patients with Kawasaki syndrome

We measured serum interferon concentrations in 42 patients with Kawasaki syndrome. The children ranged in age from 7 months to 6 years. All acute sera were obtained within 12 days of the onset of fever. Convalescent sera (illness day 19 to 56) were available from 25 of 42 patients. Sera were also obtained from 40 controls ranging in age from 2 months to 12 years. Control sera included healthy children (n = 14), children with bacterial infection (n = 10) and children with viral infection (n = 16). Sera were coded and interferon concentrations were measured blindly using human diploid fibroblast cell monolayers challenged with 10(4) plaque-forming units of vesicular stomatitis virus. Specimens from 10 of 16 patients with viral infection were positive for interferon. Three of 10 patients with bacterial infection had detectable serum interferon. No interferon was detected in specimens from the 14 healthy control children or the 42 children with Kawasaki syndrome. Despite the use of a sensitive assay we were unable to detect interferon in the sera of patients with Kawasaki syndrome.

Combined cryptogenic fibrosing alveolitis and emphysema: the value of high resolution computed tomography in assessment

Simple tests of lung function may be misleading in the assessment of patients with interstitial lung disease. Eight patients are described with cryptogenic fibrosing alveolitis (histologically proven in four) with severe breathlessness and low gas transfer (median DLCO 32.4%, range 9.2 to 35.3%, % predicted) in whom lung volumes were preserved [median VC 98.7, range 67.5-131.1%; median TLC 92.5, range 88.1 to 121.2, (% predicted)], and in whom there was no evidence of airflow obstruction [median FEV1/FVC 84.6, range 68-116 (% predicted)]. All were current or ex-heavy smokers. Thoracic high resolution computed tomography revealed upper zone emphysema, the extent of which was not appreciated using conventional chest radiography. The atypical physiological and radiological features can be explained by coincidental cryptogenic fibrosing alveolitis and emphysema and high resolution computed tomography was valuable in the assessment of these patients.

Recurrent and fatal haemoptysis caused by an atheromatous abdominal aortic aneurysm

A 74 year old woman presented with a two month history of recurrent small hemoptyses and died after a subsequent massive haemoptysis. At postmortem examination the source of bleeding was found to be a leaking saccular, atheromatous abdominal aortic aneurysm, which had ruptured through the diaphragm into the lower lobe of the right lung.

Cardiotonic agents. 6. Histamine analogues as potential cardiovascular selective H2 agonists

Twenty-six alkyl and aralkyl histamine analogues were prepared as potential cardiotonic agents. Compounds were designed to allow interaction with a putative secondary aryl binding site at the H2 receptor, the presence of which was inferred from the structure of cyprohepatadine, which is known to have H2-antagonist properties. The compounds were examined for inotropic activity in ferret papillary muscle. Potent inotropic activity was generally found in N-alkyl- and N,N-dialkylimidazole-4-ethanamines, whereas N-(amidoalkyl)imidazole-4-ethanamines and N-alkylimidazole-4-propanamines were at best weakly active. Five compounds were examined in screens designed to assess hemodynamic effects and gastric acid secretion in vivo. Two of these compounds, alpha-(3-phenyl-2-transpropenyl)-1H-imidazole-4-ethanamine and N-heptyl-1H-imidazole-4-ethanamine, showed positive inotropic activity with minimal effects on heart rate and mean arterial pressure in vivo; however, both compounds were found to stimulate gastric acid secretion. These results demonstrate that selectivity between various H2-receptor-mediated activities can be obtained with substituted histamine analogues.

Effect of intravenous immune globulin on the coagulopathy of Kawasaki syndrome

We studied the effects of immune globulin and aspirin versus aspirin alone on platelet count, platelet activation, and factor-mediated coagulation in patients with Kawasaki syndrome. Coagulation tests were performed on the day of admission to the study and 4 to 6 days later. Twenty-three patients were enrolled; 12 received immune globulin intravenously plus aspirin, and 11 received aspirin alone. At initiation of the study the groups were comparable with regard to age, sex, race, and time from onset of illness to study entry. Coagulation values were similar at entry with the exception that the aspirin group had a geometric mean platelet count that was higher than the platelet count in the aspirin-immune globulin group (p = 0.02). Four days after entry there were no significant differences between the two groups in any coagulation studies. Although the immune globulin preparation used has been effective in reducing the prevalence of coronary artery aneurysms, it appears to have no early effect on reduction of platelet activation or other measures of coagulopathy. The mechanism of action of immune globulin in patients with Kawasaki syndrome remains to be elucidated.

Recent experience in the control and management of tuberculosis in a mental handicap hospital

Sixteen cases of tuberculosis (14 in inmates, only one of whom was female) occurred in a mental handicap hospital of some 400 inmates during the period 1973-85. This represents an annual incidence of 269 per 100,000, substantially higher than that in the surrounding community. In 1980, 29% of inmates had Grade 3 or 4 positive Heaf tests. Widespread chemoprophylaxis was successfully undertaken in 1980/81, the only problem encountered being interaction of isoniazid with carbamazepine. One Down's syndrome patient had recurrent disease, and a second developed disease despite chemoprophylaxis. Immunological investigation of a small number of Down's syndrome patients with tuberculosis showed no consistent defect.

Chronic necrotising pneumonia caused by Aspergillus niger

A woman with asthma developed chronic necrotising semi-invasive pneumonia due to mixed Aspergillus niger and Candida albicans infection; though not severely immunosuppressed, she may have been predisposed by long term oral corticosteroid and recurrent oral antibiotic treatment. The diagnosis should be considered in patients with chronic airflow limitation who develop cavitating pneumonia.

Alveolitis associated with sulphamethoxypyridazine

A woman developed alveolitis which appeared to be caused by sulphamethoxypyridazine and which resolved after withdrawal of the drug and six months' treatment with prednisolone.

Respiratory aspects of Shwachman's syndrome in adults

Shwachman's Syndrome is a rare disorder which causes considerable morbidity in childhood and can be confused with cystic fibrosis. Six patients (4 males; mean age 27 yrs) are described in order to illustrate the clinical picture of the syndrome in adults. Recognized features persisting in later life include pancreatic insufficiency and bone marrow dysfunction (all patients), short stature (5/6), advanced dental caries (4/6), and impaired glucose tolerance (2/6). Chest radiograph was normal in all patients whilst lung function tests showed mild restriction in three and obstruction in two. All patients were cyclically neutropenic (nadir count 2.1 x 10(9).l-1). Four of the six patients were thrombocytopenic and three had persistent immunoglobulin deficiencies. Neutrophil chemotaxis was abnormal in four patients and the nitro blue tetrazolium test was abnormal in a fifth. Two patients suffered from recurrent respiratory infections, one of whom died from bone marrow aplasia. Although Shwachman's Syndrome may be less troublesome in adults than in children, many of the abnormalities persist into adult life and may continue to cause diagnostic difficulty.