Effects of inoculum and beta-lactamase activity in AmpC- and extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae clinical isolates tested by using NCCLS ESBL methodology

Escherichia coli and Klebsiella pneumoniae isolates with extended-spectrum beta-lactamases (ESBLs) or AmpC cephalosporinases generally respond as predicted to NCCLS tests for ESBL production. However, inoculum size may affect MICs. The effect of inoculum level in clinical isolates expressing beta-lactamases were studied at inocula within 0.5 log unit of the standard inoculum, using broth microdilution methodology with ceftazidime, cefotaxime, cefepime, cefpodoxime, and aztreonam. Strains with TEM-1 or no beta-lactamases gave consistent MIC results with inocula of 10(5) and 10(6) CFU/ml. When the bacteria were screened for ESBL production and the lower inoculum was used, several strains with ESBLs, including CTX-M-10, TEM-3, TEM-10, TEM-12, TEM-6, SHV-18, and K1, gave false-negative results for one or more antimicrobial agents (MICs below the NCCLS screening concentration for detecting suspected ESBLs). When the higher inoculum was used, MICs of at least one antimicrobial agent increased at least fourfold in strains producing TEM-3, TEM-10, TEM-28, TEM-43, SHV-5, SHV-18, and K1. All antimicrobial agents showed an inoculum effect with at least one ESBL producer. Confirmatory clavulanate effects were seen for both inocula for all ESBL-producing strains with all antimicrobial agents tested, except for the CTX-M-10-producing E. coli with ceftazidime and the SHV-18-producing K. pneumoniae with cefotaxime. In kinetic studies, cefpodoxime and cefepime were hydrolyzed by ESBLs in a manner similar to that of cefotaxime. When total beta-lactamase activity and hydrolysis parameters were evaluated, however, no single factor was predictive of inoculum effects. These results indicate that the NCCLS screening and confirmation tests are generally predictive of ESBL production, but false-negative results can arise when a lower inoculum is used in testing.     

Rapid,Full-Scale Change to Virtual PCIT During the COVID-19 Pandemic: Implementation and Clinical Implications

Health agencies call for the immediate mobilization of existing interventions in response to numerous child and family mental health concerns that have arisen as result of the COVID-19 pandemic. Answering this call, this pilot study describes the rapid, full-scale change from a primarily clinic-based Parent–Child Interaction Therapy (PCIT) model to a virtual service model (i.e., I-PCIT) in an academic and community-based program in Miami, Florida. First, we describe the virtual service training model our program developed and its implementation with 17 therapists (M_Age?=?32.35, 88.2% female, 47.1% Hispanic) to enable our clinic to shift from providing virtual services to a small portion of the families served (29.1%) to all of the families served. Second, we examine the effect of I-PCIT on child and caregiver outcomes during the 2-month stay-at-home period between March 16, 2020, and May 16, 2020, in 86 families (M_ChildAge?=?4.75, 71% Hispanic). Due to the rapid nature of the current study, all active participants were transferred to virtual services, and therefore there was no comparison or control group, and outcomes represent the most recently available scores and not treatment completion. Results reveal that I-PCIT reduced child externalizing and internalizing problems and caregiver stress, and increased parenting skills and child compliance with medium to large effects even in the midst of the COVID-19 pandemic. Finally, the study examined components of our virtual service training model associated with the greatest improvements in child and caregiver outcomes. Preliminary findings revealed that locally and collaboratively developed strategies (e.g., online communities of practice, training videos and guides) had the strongest association with child and caregiver outcomes. Implications for virtual service delivery, implementation, and practice in the midst of the COVID-19 pandemic are discussed.

     

Weekly carboplatin and paclitaxel followed by concomitant paclitaxel, fluorouracil, and hydroxyurea chemoradiotherapy: curative and organ-preserving therapy for advanced head and neck cancer.

PURPOSE: The paclitaxel, fluorouracil, and hydroxyurea regimen of paclitaxel, infusional fluorouracil, hydroxyurea, and twice-daily radiation therapy (TFHX) administered every other week has resulted in 3-year survival rates of 60% of stage IV patients. Locoregional and distant failure rates were 13% and 23%, respectively. To reduce distant failure rates, we added a brief course of induction chemotherapy to TFHX. PATIENTS AND METHODS: Sixty-nine patients received six weekly doses of carboplatin (AUC2) and paclitaxel (135 mg/m2) followed by five cycles of TFHX. RESULTS: Ninety-six percent had stage IV disease. Response to induction chemotherapy was partial response 52% and complete response (CR) 35%. Symptomatically, there was a significant reduction in mouth and throat pain. The most common grade 3 or 4 toxicity was neutropenia (36%). Best response following completion of TFHX was CR in 83%. Toxicities of TFHX consisted of grade 3 or 4 mucositis (74% and 2%) and dermatitis (47% and 14%). At a median follow-up of 28 months, locoregional or systemic disease progression were each noted in five patients. The overall 3-year progression-free survival was 80% (95% confidence interval [CI], 71% to 90%), and the 2- and 3-year overall survival rates were 77% (95% CI, 66% to 87%) and 70% (95% CI, 59% to 82%), respectively. At 12 months, five patients were completely feeding-tube dependent. CONCLUSION: Administration of carboplatin and paclitaxel before TFHX chemoradiotherapy results in high response activity and may decrease distant failure rates. Overall survival, progression, and organ preservation/functional outcome data support definitive evaluation of this approach.     

The Impact of Managed Care on the Practice of Occupational Therapy by Hand Therapists

Current Occupational Therapy (OT) literature on managed care is limited to opinion or anecdotal experience. Questionnaires were mailed to 214 OTs practicing as hand therapists nationwide to test the null hypothesis that there was no difference in reimbursement or barriers to practice for OT services between patients enrolled in managed care organizations and those enrolled in fee-for-service insurance plans. Statistically significant results were obtained indicating greater barriers to reimbursement for OT under managed care. The primary effect has been the increased administrative demands it places on both therapists and patients. [Article copies available for a fee from The Haworth Document Delivery Service: 1–800–342–9678. E-mail address: getinfo@haworth.com]     

Motivations,Barriers, and Outcomes of Patient-Reported Shared Decision Making in Eosinophilic Esophagitis

Digestive Diseases and Sciences - Little is known about patient choice in treatment of eosinophilic esophagitis (EoE). Determine motivators and barriers to using common EoE therapies and describe...     

Differential Willingness to Undergo Smallpox Vaccination Among African-American and White Individuals

OBJECTIVE:  To examine potential disparities in willingness to be vaccinated against smallpox among different U.S. racial/ethnic groups.
DESIGN:  Cross-sectional survey using an experimental design to assess willingness to be vaccinated among African Americans compared to whites according to 2 strategies: a post-exposure "ring vaccination" method and a pre-exposure national vaccination program.
SETTING:  Philadelphia County district courthouse.
PARTICIPANTS:  Individuals awaiting jury duty.
MEASUREMENTS:  We included 2 scenarios representing these strategies in 2 otherwise identical questionnaires and randomly assigned them to participants. We compared responses by African Americans and whites.
MAIN RESULTS:  In the pre-exposure scenario, 66% of 190 participants were willing to get vaccinated against smallpox. In contrast, 84% of 200 participants were willing to get vaccinated in the post-exposure scenario ( P  = .0001). African Americans were less willing than whites to get vaccinated in the pre-exposure scenario (54% vs 77%; P  = .004), but not in the post-exposure scenario (84% vs 88%; P  = .56). In multivariate analyses, overall willingness to undergo vaccination was associated with vaccination strategy (odds ratio, 3.29; 95% confidence interval, 1.8 to 6.1).
CONCLUSIONS:  Racial disparity in willingness to get vaccinated varies by the characteristics of the vaccination program. Overall willingness was highest in the context of a post-exposure scenario. These results highlight the importance of considering social issues when constructing bioterror attack response plans that adequately address the needs of all of society's members.