Influenza Virus Genomic Surveillance, Arizona, USA, 2023-2024

Influenza viruses are constantly evolving and are therefore monitored worldwide in the hope to reduce the burden of disease by annual updates to vaccine recommendations. We conducted genomic sequencing of 110 influenza A and 30 influenza B viruses from specimens collected between October 2023 and February 2024 in Arizona, USA. We identified mutations in the hemagglutinin (HA) antigenic sites as well as the neuraminidase (NA) gene in our samples. We also found no unique HA and NA mutations in vaccinated yet influenza-infected individuals. Real-time genomic sequencing surveillance is important to ensure influenza vaccine effectiveness.

Telemedicine Reduces Missed Appointments but Disparities Persist

INTRODUCTION

Missed appointments also known as no-shows adversely affect clinical outcomes, clinic efficiency, and quality of care and have been attributed to barriers such as work schedule conflicts and lack of transportation. The widespread telemedicine implementation and adoption that has occurred as a consequence of the COVID-19 pandemic has the potential to address these barriers and improve missed appointment rates. This study aims to analyze the relationship between telemedicine and missed appointments.

METHODS

This retrospective cohort study used electronic health records data from a safety-net academic health center with federally qualified clinics (March 2020-December 2022). Bivariate and multivariable generalized estimating equations were used to analyze the relationship between no-show and appointment type (in-person versus telemedicine appointment). Stratified adjusted regression analyses were used to calculate the average change in the marginal effect of telemedicine appointments on no-shows across covariates. The data were analyzed from September 2023 to October 2023.

RESULTS

Hispanic patients accounted for 60% of the 474,212 appointments, followed by non-Hispanic White (22.5%), non-Hispanic Black (13.3%), Asian (2.7%), Native American (1%), and other race/ethnicity patients (0.6%). The no-show rate for telemedicine appointments was 12% compared with 25% for in-person appointments. Multivariable analysis showed that telemedicine appointment was associated with a decreased likelihood of no-show compared with in-person appointments (OR=0.40, 95% CI=0.40, 0.41). The average change in the marginal effect of telemedicine appointments on the reduction of no-shows across race/ethnicity was greatest for Native American and non-Hispanic Black patients.

CONCLUSIONS

Telemedicine appointments were associated with a decreased likelihood of no-shows, and the protective effect of telemedicine appointments on missed appointments was greatest for underserved groups. Strategies to increase telemedicine uptake, especially for underserved groups, are critical.

Genomic Sequencing Surveillance to Identify Respiratory Syncytial Virus Mutations, Arizona, USA

We conducted surveillance of respiratory syncytial virus (RSV) genomic sequences for 100 RSV-A and 27 RSV-B specimens collected during November 2022-April 2023 in Arizona, USA. We identified mutations within prefusion F-protein antigenic sites in both subtypes. Continued genomic surveillance will be critical to ensure RSV vaccine effectiveness.

Using source-associated mobile genetic elements to identify zoonotic extraintestinal E. coli infections

A one-health perspective may provide new and actionable information about Escherichia coli transmission. E. coli colonizes a broad range of vertebrates, including humans and food-production animals, and is a leading cause of bladder, kidney, and bloodstream infections in humans. Substantial evidence supports foodborne transmission of pathogenic E. coli strains from food animals to humans. However, the relative contribution of foodborne zoonotic E. coli (FZEC) to the human extraintestinal disease burden and the distinguishing characteristics of such strains remain undefined. Using a comparative genomic analysis of a large collection of contemporaneous, geographically-matched clinical and meat-source E. coli isolates (n = 3111), we identified 17 source-associated mobile genetic elements - predominantly plasmids and bacteriophages - and integrated them into a novel Bayesian latent class model to predict the origins of clinical E. coli isolates. We estimated that approximately 8 % of human extraintestinal E. coli infections (mostly urinary tract infections) in our study population were caused by FZEC. FZEC strains were equally likely to cause symptomatic disease as non-FZEC strains. Two FZEC lineages, ST131-H22 and ST58, appeared to have particularly high virulence potential. Our findings imply that FZEC strains collectively cause more urinary tract infections than does any single non-E. coli uropathogenic species (e.g., Klebsiella pneumoniae). Our novel approach can be applied in other settings to identify the highest-risk FZEC strains, determine their sources, and inform new one-health strategies to decrease the heavy public health burden imposed by extraintestinal E. coli infections.

Antibiotic-resistant Escherichia coli from retail poultry meat with different antibiotic use claims

Background

We sought to determine if the prevalence of antibiotic-resistant Escherichia coli differed across retail poultry products and among major production categories, including organic, “raised without antibiotics”, and conventional.

Results

We collected all available brands of retail chicken and turkey—including conventional, “raised without antibiotic”, and organic products—every two weeks from January to December 2012. In total, E. coli was recovered from 91% of 546 turkey products tested and 88% of 1367 chicken products tested. The proportion of samples contaminated with E. coli was similar across all three production categories. Resistance prevalence varied by meat type and was highest among E. coli isolates from turkey for the majority of antibiotics tested. In general, production category had little effect on resistance prevalence among E. coli isolates from chicken, although resistance to gentamicin and multidrug resistance did vary. In contrast, resistance prevalence was significantly higher for 6 of the antibiotics tested—and multidrug resistance—among isolates from conventional turkey products when compared to those labelled organic or “raised without antibiotics”. E. coli isolates from chicken varied strongly in resistance prevalence among different brands within each production category.

Conclusion

The high prevalence of resistance among E. coli isolates from conventionally-raised turkey meat suggests greater antimicrobial use in conventional turkey production as compared to “raised without antibiotics” and organic systems. However, among E. coli from chicken meat, resistance prevalence was more strongly linked to brand than to production category, which could be caused by brand-level differences during production and/or processing, including variations in antimicrobial use.

Electronic supplementary material

The online version of this article (10.1186/s12866-018-1322-5) contains supplementary material, which is available to authorized users.

Intermingled Klebsiella pneumoniae Populations Between Retail Meats and Human Urinary Tract Infections

BACKGROUND

Klebsiella pneumoniae is a common colonizer of the gastrointestinal tract of humans, companion animals, and livestock. To better understand potential contributions of foodborne K. pneumoniae to human clinical infections, we compared K. pneumoniae isolates from retail meat products and human clinical specimens to assess their similarity based on antibiotic resistance, genetic relatedness, and virulence.

METHODS

Klebsiella pneumoniae was isolated from retail meats from Flagstaff grocery stores in 2012 and from urine and blood specimens from Flagstaff Medical Center in 2011-2012. Isolates underwent antibiotic susceptibility testing and whole-genome sequencing. Genetic relatedness of the isolates was assessed using multilocus sequence typing and phylogenetic analyses. Extraintestinal virulence of several closely related meat-source and urine isolates was assessed using a murine sepsis model.

RESULTS

Meat-source isolates were significantly more likely to be multidrug resistant and resistant to tetracycline and gentamicin than clinical isolates. Four sequence types occurred among both meat-source and clinical isolates. Phylogenetic analyses confirmed close relationships among meat-source and clinical isolates. Isolates from both sources showed similar virulence in the mouse sepsis model.

CONCLUSIONS

Meat-source K. pneumoniae isolates were more likely than clinical isolates to be antibiotic resistant, which could reflect selective pressures from antibiotic use in food-animal production. The close genetic relatedness of meat-source and clinical isolates, coupled with similarities in virulence, suggest that the barriers to transmission between these 2 sources are low. Taken together, our results suggest that retail meat is a potential vehicle for transmitting virulent, antibiotic-resistant K. pneumoniae from food animals to humans.

Impact of saline irrigation and topical corticosteroids on the postsurgical sinonasal microbiota

BACKGROUND

Topical treatments with nasal saline irrigation, topical steroid sprays, or corticosteroid rinses can improve sinonasal symptoms in chronic rhinosinusitis (CRS). However, the impact of these therapies on commensals (Corynebacterium) and on biofilm pathogens associated with CRS (Staphylococcus aureus and Pseudomonas) is not well characterized.

METHODS

Paired nasal and sinus swabs were collected endoscopically from 28 controls and 14 CRS patients with nasal polyposis (CRSwNP) who had not received systemic antibiotics or corticosteroids in the previous 8 weeks. Total DNA from swab eluents were extracted and analyzed by 16S rRNA gene-based pyrosequencing. A total of 359,077 reads were obtained and classified taxonomically. The association of use of topical therapies with sinonasal microbiota composition was assessed by factor/vector-fitting. The proportional abundances of sinonasal bacteria between topical therapy users and nonusers were further compared by 2-tailed Kolmogorov-Smirnov test among controls and among CRSwNP participants.

RESULTS

Nasal saline irrigation, with or without added budesonide, was not associated with significantly distinct sinonasal microbiota composition or significantly decreased Pseudomonas or S. aureus abundances among either controls or CRSwNP participants. Corynebacterium was slightly lower in controls that reported using saline irrigation than those who did not. No significant association was found between nasal saline irrigation and the proportional abundances of Pseudomonas, S. aureus, and Corynebacterium in CRSwNP participants. However, male CRSwNP patients were noted to have significantly higher Corynebacterium proportional abundances than their female counterparts. The use of topical steroid sprays was associated with a distinct microbiota in control subjects, characterized by higher proportional abundances of Dolosigranulum and Simonsiella and a lower proportional abundance of Campylobacter.

CONCLUSION

Nasal saline irrigation is not associated with a distinct alteration in the proportional abundance of commensal bacteria or biofilm-forming pathogens in CRSwNP patients. However, use of topical intranasal corticosteroid sprays in control subjects is associated with a distinct sinonasal microbiota.

Selective serotonin reuptake inhibitor use during pregnancy increases the risk of postpartum hemorrhage and anemia: a hospital-based cohort study

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are known to increase the risk of gastrointestinal bleeding.

OBJECTIVE

Study the risk of bleeding-related complications in relation to SSRI in pregnancy.

PATIENTS/METHODS

This was a hospital-based cohort study. All women who gave birth at Karolinska University Hospital in Stockholm over a 5-year period (2007 to 2011) were included in the study. Those women who the electronic maternal health record indicated were using SSRI (n = 500) were considered exposed, and all other women formed a control population (n = 39,594). The main outcome measures were blood loss, postpartum hemorrhage (PPH), PP anemia and length of hospitalization.

RESULTS

The absolute risk of PPH and PP anemia for the 1.2% exposed to SSRI were 18.0% and 12.8%, respectively. Women with a vaginal non-surgical delivery who reported use of SSRI during pregnancy had approximately a 2-fold increased risk of both PPH (OR, 2.6; 95% CI, 2.0-3.5) and PP anemia (OR, 2.1; 95% CI, 1.5-2.9), as compared with controls. Blood loss and length of hospitalization were significantly higher among women using SSRI than non-users (arithmetic mean 484 mL vs. 398 mL, 3.8 days vs. 2.4 days, respectively).

CONCLUSION

The use of SSRI during pregnancy increases blood loss and doubles the risk of PPH and PP anemia in a setting where SSRI had not been considered a risk factor for increased blood loss. Because PPH is a leading cause of maternal mortality and morbidity, the awareness of bleeding-related complications is important, both in relation to pregnancy and to surgery in general.

The role of the human microbiome in otolaryngology-head and neck surgery: a contemporary review

OBJECTIVES/HYPOTHESIS

The human microbiome represents the collective genomes and gene products of microbes living within and on humans. The objective of this review is to provide a summary of the current microbiome literature pertaining to otolaryngology-head and neck surgery.

DATA SOURCE

Ovid MEDLINE.

METHODS

Scientific publications with clinical correlates.

RESULTS

Human microbiome studies have been facilitated by culture-independent, high-throughput sequencing methods. Data from the Human Microbiome Project has shown that the composition of the human microbiome is specific to each body site and that each individual has a unique microbiome. Alterations in the human microbiome are associated with some disease states; thus, novel therapeutic strategies are being developed based on concepts and findings stemming from microbiome research.

CONCLUSIONS

Although a growing body of research shows potential significance of the human microbiome for human health and disease, there is a paucity of microbiome studies in otolaryngology. More studies are required to increase our understanding of the indigenous microbiota and their effects on diseases of the head and neck.

Medical therapy reduces microbiota diversity and evenness in surgically recalcitrant chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a highly prevalent and heterogeneous condition frequently treated with antibiotics and corticosteroid therapy. However, the effect of medical therapy on sinus microbiota remains unknown.

METHODS

We enrolled CRS patients (n = 6) with patent maxillary antrostomies and active mucosal inflammation, who had not received antibiotics or corticosteroids in the previous 8 weeks. A pretreatment and posttreatment maxillary sinus swab was collected, from which DNA was extracted, pyrosequenced, and analyzed using a naïve Bayesian classifier and ecological analyses.

RESULTS

Four patients showed significant improvement in endoscopic appearance. The shifts in microbiota in response to therapy were highly individualized. There was no single common microbiota profile among patients with similar clinical outcomes, but overall there was significant decrease in microbiota diversity (t(5) = 2.05, p = 0.10) and evenness (t(5) = 2.28, p = 0.07) after treatment.

CONCLUSION

Our findings strongly correlate with earlier studies that examined the impact of antibiotics on human microbiota. We observed that posttreatment, patients frequently became colonized by taxa that are less susceptible to the prescribed antibiotics. Our findings highlight the challenge in seeking generalizable diagnostic and therapeutic options in CRS, particularly regarding microbiological response and outcomes.

Foodborne urinary tract infections: a new paradigm for antimicrobial-resistant foodborne illness

Urinary tract infections (UTIs) are among the most common bacterial infections worldwide. Disproportionately affecting women, UTIs exact a substantial public burden each year in terms of direct medical expenses, decreased quality of life, and lost productivity. Increasing antimicrobial resistance among strains of extraintestinal pathogenic Escherichia coli challenges successful treatment of UTIs. Community-acquired UTIs were long considered sporadic infections, typically caused by the patients' native gastrointestinal microbiota; however, the recent recognition of UTI outbreaks with probable foodborne origins has shifted our understanding of UTI epidemiology. Along with this paradigm shift come new opportunities to disrupt the infection process and possibly quell increasing resistance, including the elimination of non-therapeutic antimicrobial use in food-animal production.

Computational Studies of Novel Thermoelectric Materials

The thermoelectric properties of La-filled skutterudites and β-Zn4Sb3 are discussed from the point of view of their electronic structures. These are calculated from first principles within the local density approximation. The electronic structures are in turn used determine transport related quantities. β-Zn4Sb3 is found to be metallic with a complex Fermi surface topology, which yields a non-trivial dependence of the Hall concentration on the band filling. Calculations of the variation with band filling are used to extract the carrier concentration from the experimental Hall number. At this band filling, which corresponds to 0.1 electrons per 22 atom unit cell, we calculate a Seebeck coefficient and temperature dependence in good agreement with the experimental value. The high Seebeck coefficients in a metallic material are remarkable, and arise because of the strong energy dependence of the Fermiology near the experimental band filling. Virtual crystal calculations for La(Fe,Co)4Sb12 show that the system obeys almost perfect rigid band behavior with varying Co concentration, and has a substantial band gap at a position corresponding to the composition LaFe3CoSb12. The valence band maximum occurs at the Γ point and is due to a singly degenerate dispersive (Fe,Co)-Sb band, which by itself would not be favorable for TE. However, very flat transition metal derived bands occur in close proximity and become active as the doping level is increased, giving a non-trivial dependence of the properties on carrier concentration and explaining the favorable TE properties.

Prediction of time to spontaneous onset of labour with lactate concentration in vaginal fluid in women with suspected preterm prelabour rupture of the membranes

OBJECTIVE

To assess whether lactate determination in vaginal fluid is associated with and can predict onset of labour for women with suspected preterm prelabour rupture of membranes (PPROMs).

DESIGN

Prospective observational study.

SETTING

Labour ward at South General Hospital, Stockholm, Sweden. POPULATION/PARTICIPANTS: Women with suspected PPROMs at 20-36 completed weeks of gestation (n = 81).

METHODS

All women underwent a speculum examination and a test for determining lactate concentration in vaginal fluid. We used logistic regression to estimate the association between lactate concentration in vaginal fluid and time to onset of labour.

MAIN OUTCOME MEASURE

Time from examination to spontaneous onset of labour (cervix > or =4 cm).

RESULTS

The median time between examination and onset of labour was 13.6 hours for those with a high (> or =4.5 mmol/l) lactate concentration and 1152 hours (i.e. 48 days) for those with a low (<4.5 mmol/l) lactate concentration. For a lactate threshold of 4.5 mmol/l, the likelihood ratio for positive test (LR+) was 12.6, and LR- was 0.14 for the outcome of spontaneous onset of labour within 48 hours.

CONCLUSIONS

A high lactate concentration in vaginal fluid is strongly associated with whether a woman with suspected PPROM will commence onset of labour within 48 hours. If confirmed, use of lactate ('LAC test') as a predictive test for onset of preterm labour may be an attractive tool in bedside obstetrics.

Association between lactate in vaginal fluid and time to spontaneous onset of labour for women with suspected prelabour rupture of the membranes

OBJECTIVES

To assess whether lactate determination in vaginal fluid is associated with, and can predict, onset of labour for women with suspected prelabour rupture of the membranes (PROM).

DESIGN

Prospective observational study.

SETTING

Labour ward at Soder Hospital, Stockholm, Sweden.

POPULATION

Women with suspected PROM after 34 weeks of gestation, who later had spontaneous onset of labour (n = 179).

METHODS

All women underwent a speculum examination and a test for determining lactate concentration in vaginal fluid. We used logistic regression to estimate the association between lactate concentration in vaginal fluid and time to onset of labour.

MAIN OUTCOME MEASURES

Time from examination to onset of labour (cervix > or =4 cm), within 24 hours and 48 hours.

RESULTS

The median time interval between examination and spontaneous onset of labour was 8.4 hours for women with 'high' lactate (> or =4.5 mmol/l) and 54 hours for those with 'low' lactate concentrations (<4.5 mmol/l). Among 86 women with high lactate concentrations, 76 (88%) had started labour within 24 hours compared with 20 of 93 (22%) women with low lactate concentrations (OR 27.7, 95% CI 12.2-63.3). After checking for the effect of visible amniotic fluid, the corresponding odds were still substantially increased (OR 13.5, 95% CI 5.3-34.3).

CONCLUSIONS

High lactate concentration (> or =4.5 mmol/l) in vaginal fluid can be used to predict whether a woman with suspected PROM will commence spontaneous onset of labour within 24 or 48 hours.

Validation of a laboratory method of measuring postpartum blood loss

Laboratory methods give more accurate measurement of blood loss in the postpartum period than visual estimation. In order to evaluate a laboratory method used to quantify blood loss postpartum, blood lost at gynecological operations was collected in a measuring bottle. The measured amount of blood (50-1,000 ml) was then poured onto absorbent paper towels and sanitary pads, in order to mimic conditions when measuring blood loss in clinical trials in the postpartum period. The amount of blood absorbed onto the absorbent paper and sanitary pads was measured by a rapid method of automatic extraction and photometric measurement of alkaline hematin. The study shows that the method provides a reliable and accurate means of measuring blood loss. The error in each case was less than 10% with an intraclass correlation coefficient of almost 1.

The reliability of catheter-tip transducers for the measurement of intrauterine pressure in the third stage of labour

In order to assess the reliability of intrauterine pressure measurements in the third stage of labour, catheter-tip transducers were used in 20 women randomly allocated into two groups of 10. In each case in the first group two catheters were tied together and introduced transcervically into the uterine cavity after delivery of the placenta. In each case in the second group two catheters were inserted independently into the same uterine cavity. The active and cumulative active pressures recorded from the pairs of catheters within each uterine cavity were compared. Comparison of individual active pressure readings from separate transducers revealed good agreement whether the catheters were tied together or were separate. Cumulative active pressure was very similar when assessed by each catheter in the same uterus. Intrauterine catheter-tip transducers can be used reliably to measure uterine activity in the third stage of labour although there may be minor contraction by contraction differences in recordings of individual active pressures.

A 25-year experience with 519 anterior colporrhaphy procedures

A 25-year experience with 519 anterior colporrhaphies was reviewed to assess the results in treating genuine and mixed stress urinary incontinence, the incidence of new urinary incontinence following prolapse surgery, the incidence of new detrusor instability after incontinence and prolapse surgery, and the morbidity associated with anterior colporrhaphy. The cure rate in treating genuine stress incontinence in 194 patients was increased from 75 to 94% when a Kelly-Kennedy-type technique was modified to include a vaginal retropubic urethropexy. The surgical cure in treating mixed incontinence was unsatisfactory (64%) in unselected cases but good (84%) in selected cases. Previous incontinence surgery, especially more than one procedure, significantly reduced the cure rate for genuine stress incontinence. The incidence of new incontinence after prolapse surgery in one subgroup of patients was 11%, indicating the need for measures to minimize this possibility at prolapse surgery. The incidence of new detrusor instability after surgery was 6% (higher after incontinence surgery than after prolapse surgery). The incidence of significant morbidity, excluding incontinence, was minimal (1%) among the 519 anterior colporrhaphies.

The fascia lata sling procedure for treating recurrent genuine stress incontinence of urine

The fascia lata sling procedure has been used over the past 22 years in our unit for treating recurrent urinary stress incontinence when irreparably poor local support tissues were suspected. Sixty-nine patients had undergone one previous operation to correct urinary stress incontinence. One hundred one patients had two or more previous operations. The cure rate for the condition of genuine stress incontinence has been 100% in the last 148 cases and 98.2% overall. However, the cure rate for the symptom of urinary stress incontinence was 92.4%. There were only three sling failures in the entire series, occurring in the first 22 cases. Ten other patients had urinary incontinence with stress because of motor urge incontinence. The most troublesome postoperative problem has been delayed voiding.

Intraurethral-intravesical cough-pressure spike differences in 267 patients surgically cured of genuine stress incontinence of urine

Cough-pressure spike differences between the urethra and bladder were compared before and after surgery that cured genuine stress incontinence in 267 women. In 97.4% of 151 patients cured by a fascia lata sling procedure, the urethralvesical cough-pressure transmission ratio was greater than 100%, and in no case was it less than 100%. In 46.6% of 116 patients cured by anterior colporrhaphy, the cough-pressure transmission ratio was greater than 100%, and in 20.7% of the 116 patients, the transmission ratio was less than 100%. The 24 women in the latter group were cured by a sufficient increase in resting intraurethral pressure (to augment the maximal intraurethral closure pressure with stress) to maintain continence with increased intra-abdominal pressure. We believe that urethral kinking at the instant of increased intra-abdominal pressure with stress produced the greater than 100% cough-pressure transmission ratio seen in 201 (75.3%) of the 267 patients cured of genuine stress incontinence.

Chest pain as a predictor of coronary artery disease in patients with obstructive aortic valve disease

To clarify the association between chest pain and significant coronary artery disease in patients who have aortic valve disease, 76 consecutive candidates for aortic valve replacement were evaluated prospectively with use of a historical questionnaire and coronary arteriography. Of the 76 patients, 19 (25 percent) had no chest pain, 21 (28 percent) had chest pain that was not typical of angina pectoris and 36 (47 percent) had chest pain typical of anigina pectoris. In 18 of 19 patients the absence of chest pain correlated with the absence of coronary artery disease. The single patient without chest pain who had coronary artery disease had evidence of an inferior myocardial infarction in the electrocardiogram. Thus, absence of chest pain and the absence of electrocardiographic evidence of infarction predicted the absence of coronary disease in all cases. The presence of chest pain did not predict the presence of coronary artery disease, but the more typical the pain of angina pectoris the more likely were patients to have significant coronary artery disease. Of the 21 patients with atypical chest pain, 6 (29 percent) had coronary artery disease, but of the 36 patients with typical angina pectoris 23 (64 percent) had significant coronary artery disease. In addition, when patients with chest pain not typical of angina pectoris also had coronary artery disease, the diseased vessels usually supplied smaller areas of the left ventricle than when the pain was typical of angina pectoris. In 21 of 23 patients (91 percent) with typical angina pectoris and significant coronary artery disease, lesions were present in the left coronary artery. There was no systolic pressure gradient across the aortic valve that excluded the presence of coronary artery disease, although all patients with a calculated aortic valve area of less than 0.4 cm2 were free of coronary artery disease. Patients with severe left ventricular dysfunction were more likely to have normal coronary arteries.