Multiple COVID-19 Clusters on a University Campus - North Carolina, August 2020

Preventing transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), in institutes of higher education presents a unique set of challenges because of the presence of congregate living settings and difficulty limiting socialization and group gatherings. Before August 2020, minimal data were available regarding COVID-19 outbreaks in these settings. On August 3, 2020, university A in North Carolina broadly opened campus for the first time since transitioning to primarily remote learning in March. Consistent with CDC guidance at that time (1,2), steps were taken to prevent the spread of SARS-CoV-2 on campus. During August 3-25, 670 laboratory-confirmed cases of COVID-19 were identified; 96% were among patients aged <22 years. Eighteen clusters of five or more epidemiologically linked cases within 14 days of one another were reported; 30% of cases were linked to a cluster. Student gatherings and congregate living settings, both on and off campus, likely contributed to the rapid spread of COVID-19 within the university community. On August 19, all university A classes transitioned to online, and additional mitigation efforts were implemented. At this point, 334 university A-associated COVID-19 cases had been reported to the local health department. The rapid increase in cases within 2 weeks of opening campus suggests that robust measures are needed to reduce transmission at institutes of higher education, including efforts to increase consistent use of masks, reduce the density of on-campus housing, increase testing for SARS-CoV-2, and discourage student gatherings.

Incident Type 2 Myocardial Infarction in a Cohort of Patients Undergoing Coronary or Peripheral Arterial Angiography

Background:

Despite growing recognition of type 2 myocardial infarction (T2MI; related to supply/demand mismatch), little is known about its risk factors or its association with outcome.

Methods:

A single-center cohort of patients undergoing coronary or peripheral angiography with or without intervention was prospectively enrolled and followed for incident type 1 and T2MI, and major adverse cardiovascular events (MACE, a composite of all-cause death, nonfatal myocardial infarction [MI], heart failure, stroke, transient ischemic attack, peripheral arterial complication, and cardiac arrhythmia), as well. T2MI was adjudicated using criteria from the Third Universal Definition of MI. Baseline characteristics, blood samples, and angiography information were obtained. Major end points subsequent to first MI were assessed using landmark analyses to compare the rates of first events only where everyone with a prior history of any MACE before MI were censored and adjusted for follow-up times. Cox proportional hazard models were used for time-to-event analyses with age and sex forced into all models and additional covariates evaluated by using the stepwise option for the selection.

Results:

One thousand two hundred fifty-one patients were enrolled and followed for a median of 3.4 years. Of these patients, 152 (12.2%) had T2MI during follow-up; T2MI was frequently recurrent. Multivariable predictors of T2MI were older age, lower systolic blood pressure, history of coronary artery disease, heart failure, chronic obstructive pulmonary disease, diabetes mellitus, nitrate use, and elevated concentrations of glucose, N-terminal pro-B type natriuretic peptide, and cystatin C. Patients with T2MI had higher rates of subsequent adverse events than those without T2MI (per 100 person-years: MACE, 53.7 versus 21.1, P <0.001; all-cause death, 23.3 versus 3.3, P <0.001; cardiovascular death, 17.5 versus 2.6, P <0.001; heart failure events, 22.4 versus 7.4, P <0.001); these rates are similar to those seen in patients with type 1 MI. Incident diagnosis of T2MI strongly predicted risk for subsequent MACE (adjusted hazard ratio, 1.90; 95% confidence interval, 1.46–2.48; P <0.001), all-cause death (adjusted hazard ratio, 2.96; 95% confidence interval, 2.01–4.36; P <0.001), and cardiovascular death (adjusted hazard ratio, 2.16; 95% confidence interval, 1.36–3.43; P =0.001).

Conclusions:

T2MI is common and associated with poor prognosis. Studies evaluating treatment strategies for management of T2MI are needed.

Clinical Trial Registration:

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00842868.

Clinical Interventions to Reduce Preventable Hospital Readmission After Percutaneous Coronary Intervention

Hospital readmissions are common and costly and, in some cases, may be related to problems with care processes. We sought to reduce readmissions after percutaneous coronary intervention (PCI) in a large tertiary care facility through programs to target vulnerabilities predischarge, after discharge, and during re-presentation to the emergency department. During initial hospitalization, we assessed patients’ readmission risk with a validated risk score and used a discharge checklist to ensure access to appropriate medications and close follow-up for high-risk patients. We also developed patient education videos about chest discomfort and heart failure. After discharge, we established a new follow-up clinic with cardiology fellows. A computerized system was developed to automatically notify cardiologists when patients presented to the emergency department within 30 days of PCI to enhance patient access to cardiology care in the emergency department. Early cardiologist assessment and assistance with triage was encouraged, and the emergency department used a risk stratification algorithm derived from a local database of patients to triage patients presenting with chest discomfort after PCI. We tracked the number of patients readmitted after PCI to our hospital. With our interventions, from 2011 to 2015, the index hospital readmission rate has declined from 9.6% to 5.3%. This program could provide tangible structural changes that can be implemented in other healthcare centers, both reducing the cost of care and improving the quality of care for patients with PCI.

Ocular infections caused by Candida species: Type of species, in vitro susceptibility and treatment outcome

PURPOSE

To report clinical and microbiological profile of patients with ocular candidiasis.

MATERIALS AND METHODS

Patients with ocular candidiasis were retrospectively identified from microbiology records. Significant isolates of Candida species were identified by Vitek 2 compact system. Minimum inhibitory concentration (MIC) of antifungal agents such as amphotericin B, itraconazole, voriconazole, fluconazole and caspofungin was determined by E test and of natamycin by microbroth dilution assay. Data on treatment and outcome were collected from medical records.

RESULTS

A total of 42 isolates of Candida were isolated from patients with keratitis-29, endophthalmitis-12 and orbital cellulitis-1. The most common species isolated was Candida albicans (12-keratitis, 4-endophthalmitis, 1-orbital cellulitis). All except one isolate were susceptible to amphotericin B. MIC of caspofungin was in the susceptible range in 28 (96.5%) corneal isolates while 12 out of 29 (41.3%) corneal isolates were sensitive to fluconazole. Resistance to voriconazole was seen in four corneal isolates. All isolates were susceptible to natamycin and all except two isolates were resistant or susceptible dose-dependent to itraconazole. Outcome of healed ulcer was achieved in 12/18 (66.6%) patients treated medically, while surgical intervention was required in 11 patients. Among the isolates from endophthalmitis patients, 11/12 were susceptible to amphotericin B, 6/12 to voriconazole and all to natamycin. Ten out of 11 patients (one patient required evisceration) with endophthalmitis were given intravitreal amphotericin B injection with variable outcome.

CONCLUSIONS

Ocular candidiasis needs early and specific treatment for optimal results. Candida species continue to be susceptible to most commonly available antifungals including amphotericin B, voriconazole and natamycin.

Chronic Recurrent Multifocal Osteomyelitis: A Diagnostic Dilemma: A Case Report and Review of the Literature

CASE

Chronic recurrent multifocal osteomyelitis, a misnomer in itself, is a rare disorder that presents infrequently to orthopaedic units. The differential diagnosis is wide, including neoplastic lesions and infection, which may lead to unnecessary interventional and surgical procedures. We present a case that exhibited the hallmark features of this condition-recurrent, multifocal, aseptic osteitis in a 9-year-old girl-and our rationalized management including imaging, nonsteroidal anti-inflammatory drugs, and bisphosphonates.

CONCLUSION

With increased awareness by orthopaedic surgeons, patients may be diagnosed and managed appropriately, enabling a benign course and limiting morbidity.

Biomarkers in acute heart failure

The care of patients with acutely decompensated heart failure is being reshaped by the availability and understanding of several novel and emerging heart failure biomarkers. The gold standard biomarkers in heart failure are B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide, which play an important role in the diagnosis, prognosis, and management of acute decompensated heart failure. Novel biomarkers that are increasingly involved in the processes of myocardial injury, neurohormonal activation, and ventricular remodeling are showing promise in improving diagnosis and prognosis among patients with acute decompensated heart failure. These include midregional proatrial natriuretic peptide, soluble ST2, galectin-3, highly-sensitive troponin, and midregional proadrenomedullin. There has also been an emergence of biomarkers for evaluation of acute decompensated heart failure that assist in the differential diagnosis of dyspnea, such as procalcitonin (for identification of acute pneumonia), as well as markers that predict complications of acute decompensated heart failure, such as renal injury markers. In this article, we will review the pathophysiology and usefulness of established and emerging biomarkers for the clinical diagnosis, prognosis, and management of acute decompensated heart failure.

In vitro and in vivo evaluation of 2-chloroethylnitrosourea derivatives as antitumor agents

AIM

To evaluate potential of Naphthal-NU, Napro-NU and 5-Nitro-naphthal-NU, 2-chloroethylnitrosourea compounds with substituted naphthalimide in the pre-clinical studies.

MATERIALS AND METHODS

In vitro cytotoxicity of three nitrosoureas was determined in human and mouse tumor cell lines by MTT assays. In vivo anti-tumor potential was evaluated in Sarcoma-180 (S-180) and Ehrlich's carcinoma (EC) solid tumors. Apoptosis in S-180 cells was analyzed by using Annexin V-Propidium Iodide (PI). Histological analysis of liver and kidney was performed at optimum dose (50 mg/kg). Expression status of CD4(+), CD8(+) and CD25(+) cells in treated mouse were also examined.

RESULTS

Significant tumor growth retardation by the compounds was noted in early and advanced disease groups, as the life span of drug treated mice increased considerably. Drug induced killing was observed by induction of apoptosis. Naphthal-NU and 5-Nitro-naphthal-NU were effective to normalize the tumor induced structural abnormalities of liver and kidney. The compounds have no immunotoxic effect on CD4(+) and CD8(+) T cells and down regulate CD4(+)CD25(+) regulatory T cells.

CONCLUSION

Overall data holds promise for the antitumor activity with lower toxicity of the compounds that can be utilized for the treatment of human malignant tumors.

Experiences of day care surgery in otolaryngology

Day care surgery in otolaryngology is gradually gaining popularity all around the world and the scope of day care surgery has improved significantly in recent years.380 patients underwent ear, nose and throat surgery during the period Sep 2002-Aug2004. All the cases were done under local anaesthesia. Strict criteria were adopted for admission and discharge of the patients.Most of the patients (90.6%) who underwent ENT day care surgery did not experience unusual peroperative or postoperative discomfort. There was no case requiring postoperative admission to a hospital. There was a high degree of patient preference and satisfaction to day care surgery.Following proper guide lines for day care surgery and strict admission and discharge criteria has gone a long way in making day care surgery a success. It can be concluded that high medical standards can be achieved with low expenditure with this form of management.

Ultrasound-guided infraclavicular axillary vein cannulation: a useful alternative to the internal jugular vein

BACKGROUND

Ultrasound (US) guidance reduces complications and increases accuracy during internal jugular vein (IJV) cannulation. The subclavian vein (SCV) is popular but is less amenable to US guidance. The axillary vein (AxV), a direct continuation of the SCV, is an alternative, but to date, experience with US is limited to small case series.

METHODS

Retrospective procedural data were collected on 2586 sequential patients referred for insertion of tunnelled central venous access at a UK tertiary centre from 2004 to 2011.

RESULTS

A total of 99.8% of patients tolerated the procedure with local anaesthesia ± sedation; six patients had general anaesthesia. Twenty-six (1%) patients had uncorrected coagulopathy or thrombocytopenia. A total of 2572 (99.5%) of patients were cannulated successfully: right AxV 1644 cases, left AxV 279, right IJV 547, left IJV 89, other techniques 13, and 14 (0.5%) cases failed. The initial site chosen was successful in 96%. In patients who previously underwent long-term cannulation, 93.3% of lines were sited easily. Forty-eight (1.9%) procedural complications occurred.

CONCLUSIONS

In this large analysis of US-guided central venous access in a complex patient group, the majority of patients were cannulated successfully and safely. The subset of patients undergoing AxV cannulation demonstrated a low rate of complications. The AxV route of access appears to be a safe and effective alternative to the IJV.

Chronic psychosocial stressors and salivary biomarkers in emerging adults

We investigated whole saliva as a source of biomarkers to distinguish individuals who have, and who have not, been chronically exposed to severe and threatening life difficulties. We evaluated RNA and DNA metrics, expression of 37 candidate genes, and cortisol release in response to the Trier Social Stress Test, as well as clinical characteristics, from 48 individuals stratified on chronic exposure to psychosocial stressors within the last year as measured by the Life Events and Difficulties Schedule. Candidate genes were selected based on their differential gene expression ratio in circulating monocytes from a published genome-wide analysis of adults experiencing different levels of exposure to a chronic stressor. In univariate analyses, we observed significantly decreased RNA integrity (RIN) score (P = 0.04), and reduced expression of glucocorticoid receptor-regulated genes (Ps < 0.05) in whole saliva RNA from individuals exposed to chronic stressors, as compared to those with no exposure. In those exposed, we observed significantly decreased BMI (P < 0.001), increased ever-smoking and increased lifetime alcohol abuse or dependence (P ≤ 0.03), and a reduction of cortisol release. In post hoc multivariate analyses including clinical and biospecimen-derived variables, we consistently observed significantly decreased expression of IL8 (Ps<0.05) in individuals exposed, with no significant association to RIN score. Alcohol use disorders, tobacco use, a reduced acute stress response and decreased salivary IL8 gene expression characterize emerging adults chronically exposed to severe and threatening psychosocial stressors.

ENT Disabilities in Candidates for Recruitment

BACKGROUND

Recruitment in the Army is subject to medical fitness as per laid down standards. A study of the frequency of referral and rejection gives us an understanding as to where to lay stress in the Ear Nose Throat Examination during recruitment medical.

METHOD

A three year analysis of candidates reporting for review of ENT disabilities was carried out from January 1999 to December 2001.

RESULTS

Of the 1156 candidates, 888(76.8%) were found to be fit. The commonest cause for rejection was Wax in ears in 496 cases (43%). 428(86.3%) were found to be fit on review. Chronic suppurative otitis media (21.9%) and tympanosclerosis (21.3%) were the other causes for rejection.

CONCLUSION

The desirable situation is wherein the evaluation by the specialist is in minimal variation with that of the initial recruitment medical examination. Awareness to have ears cleaned for wax before appearing for the examination, provision of better examination ambiance and equipment and a short training capsule will be beneficial to reduce the number of review cases to referral hospitals.

Reducing the economic impact of carpal tunnel surgery

A nurse-led carpal tunnel service was started in Leicester in 1999. Many developments in the service have been patient-driven. A large proportion of our patients are not salaried and many had expressed concerns about the amount of time taken off work after surgery. This therefore prompted us to encourage immediate hand function after surgery. Subsequently, in 494 patients studied prospectively, we have seen 93% of patients return to work by 2 weeks and 99% by 4 weeks. This has obvious benefits in terms of reducing loss of income. Furthermore there is potential for considerable economic savings.

Modified rush pin technique for two- or three-part proximal humeral fractures

PURPOSE

To report the outcomes of modified Rush pin fixation for proximal humeral fractures.

METHODS

42 men and 20 women aged 19 to 94 (mean, 64) years with 2- or 3-part proximal humeral fractures underwent reduction and fixation using the modified Rush pin technique. 11 patients died from reasons unrelated to the surgery.

RESULTS

Of 40 (out of 51) patients completing a subjective functional assessment using an Oxford Shoulder Questionnaire, 28 (70%) had 2-part and 10 (25%) had 3-part displaced fractures, and the remaining 2 (5%) had fracture-dislocations (one being 2-part and one 3-part). 25 (63%) patients were very satisfied (including one with a 3-part fracture after 6 months of rehabilitation), 7 (17%) were moderately satisfied, and 8 (20%) were not satisfied. There were 8 complications, including pin cut-out from the proximal fragment (n=2), proximal pin migration (n=2), distal pin migration (n=1), cortical perforation during surgery (n=1), mild ulnar nerve symptoms (n=1). No patients had non-union, myositis ossificans, avascular necrosis of the humeral head, or axillary nerve injury.

CONCLUSION

The modified Rush pin fixation minimises tissue dissection; the implants are cheap and readily available; and the technical expertise is easily learnt. This technique is a suitable alternative of fixing proximal humeral fractures, especially in the elderly.

Comparing the outcome of a carpal tunnel decompression at 2 weeks and 6 months

PURPOSE

The purpose of the study was to evaluate if 2-week Levine score can provide an adequately responsive outcome measure in carpal tunnel decompression by comparing it with 6-month score.

METHODS

The treatment outcome of 300 patients with carpal tunnel decompression was determined by using Levine score at 2 weeks and 6 months after surgery. The mean age of patients was 56 years, 71% (214) were women, and 55% (167) of operations were performed on the right hand. All patients were scored using the Levine questionnaire preoperatively and at 2 weeks and 6 months from date of surgery. The correlation between the scores was evaluated.

RESULTS

Although statistical significance was found between the preoperative score and the scores at both 2 weeks and 6 months, no statistical difference was found between the scores at 2 weeks and 6 months after surgery. Multiple regression analysis with the 2 week-6 month score difference as the dependent variable shows a predictable outcome at 2 weeks.

CONCLUSIONS

We conclude that the Levine score at 2 weeks is a reliable, responsive, and practical instrument for outcome measure in carpal tunnel surgery. It coincides with suture removal and provides a convenient and predictive assessment of the medium-term results in a high percentage of treated patients. We conclude that the 2 time points, 2 weeks and 6 months, are equivalent in outcome because a less than 10-point difference is not clinically meaningful.

Lidocaine is more efficient than the choice of propofol formulations to reduce incidence of pain on induction

BACKGROUND AND OBJECTIVE

Propofol is associated with pain on injection. It is common practice to premix lidocaine with propofol prior to injection. Lipuro propofol, a propofol emulsified in medium- and long-chain triglycerides, has been shown to reduce the intensity of injection pain compared to Diprivan, although a number of studies report no reduction in overall incidence of pain.

METHODS

We conducted this randomized double-blind trial to determine the extent of further pain reduction by adding lidocaine to Lipuro propofol. A total of 328 ASA I-III patients were randomized to one of four groups to receive Diprivan propofol (Group DP), Lipuro propofol (Group LP), Diprivan with lidocaine (Group DL) and Lipuro propofol with lidocaine (Group LL). The drug mixture was administered at a constant rate of 400 mL h(-1) via a 20-G cannula into a dorsal hand vein. Pain was assessed during induction and upon patient recovery, using a 10-point visual analogue scale.

RESULTS

Both the incidence and severity of pain were found to be significantly lower with addition of lidocaine to Lipuro propofol (P < 0.0002) compared to Lipuro alone, Diprivan with or without the addition of lidocaine.

CONCLUSION

Lidocaine added to Lipuro propofol makes induction of anaesthesia less painful compared to Lipuro propofol alone or Diprivan with lidocaine.

Extracorporeal carbon dioxide removal using the Novalung�in a patient with intracranial bleeding

A neurosurgical patient who required repeated surgery for intracranial haematoma developed acute respiratory distress syndrome. Raised intracranial pressure proved difficult to manage whilst attempting to maintain optimal gas exchange. The resultant arterial partial pressure of carbon dioxide remained unacceptably high, and treatment by extracorporeal carbon dioxide removal was started. A pumpless arteriovenous interventional lung assist device (Novalung) was connected from the right femoral artery to left femoral vein and reduced the arterial carbon dioxide, corrected the respiratory acidosis and enabled control of the intracranial pressure. Subsequently the requirements for both respiratory and cardiovascular support were reduced. The patient made a complete neurological recovery.

Bonfils semirigid endoscope for guidance during percutaneous tracheostomy

We report on the use of the Bonfils semirigid scope for endoscopic guidance during percutaneous dilational tracheostomy. Forty patients requiring percutaneous dilational tracheostomy on the General or Neurosurgical Intensive Care Unit were enrolled in this study. We used the '45 degree curved distal tip' scope in the first 15 patients, evaluating its ease of use, optical quality of focus and image resolution as well as light intensity on a 10-point scale. We evaluated straight and curved versions of it in another 15 and 10 patients, respectively. We examined the impact on ventilation and cardiovascular parameters. In all patients (n = 40) visualisation of the procedure was satisfactory. There were no clinically significant changes in ventilatory or cardiovascular parameters. The image quality for most patients received a score of 7-10. The Bonfils scope provides a practical alternative to flexible bronchoscopes in this setting.

Remifentanil patient-controlled analgesia following cardiac surgery

BACKGROUND

Remifentanil is increasingly used as a component of cardiac anaesthesia. Following cardiac surgery remifentanil is often substituted for alternative opioids on the intensive care unit. We were interested to evaluate postoperative continuation of remifentanil in the form of remifentanil patient control analgesia (RPCA) for those patients who received intraoperative remifentanil. The objectives of this study were to assess the safety, efficacy and feasibility of the RPCA.

METHODS

Ten patients who received an intravenous infusion of remifentanil perioperatively for coronary artery bypass graft surgery (CABG) had their remifentanil infusion converted to RPCA following extubation on the intensive care unit. Remifentanil patient control analgesia delivered an initial background infusion consistent with the infusion rate at extubation and with a bolus facility of 50 microg administered over 5 min followed by a 5-min lockout. Data collection included sedation and pain scores, respiratory rate, arterial blood gases, number of successful/unsuccessful attempts and the background infusion rate for each subject over a period of 12 h following extubation.

RESULTS

The data from nine male and one female patient were analyzed by using SPSS11 for Windows. During the study period the patients achieved adequate pain control and made more RPCA attempts at lower background infusion rates. No episodes of apnoea, SpO(2) less than 95% or a rise in PaCO(2) greater than 6.5 kPa were observed.

CONCLUSION

Remifentanil patient control analgesia with a background infusion was effective and safe for postoperative pain relief in this group of spontaneously breathing ICU patients following cardiac surgery.