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To assess changes in SARS-CoV-2 spike binding antibody prevalence in the Dominican Republic and implications for immunologic protection against variants of concern, we prospectively enrolled 2,300 patients with undifferentiated febrile illnesses in a study during March 2021-August 2022. We tested serum samples for spike antibodies and tested nasopharyngeal samples for acute SARS-CoV-2 infection using a reverse transcription PCR nucleic acid amplification test. Geometric mean spike antibody titers increased from 6.6 (95% CI 5.1-8.7) binding antibody units (BAU)/mL during March-June 2021 to 1,332 (95% CI 1,055-1,682) BAU/mL during May-August 2022. Multivariable binomial odds ratios for acute infection were 0.55 (95% CI 0.40-0.74), 0.38 (95% CI 0.27-0.55), and 0.27 (95% CI 0.18-0.40) for the second, third, and fourth versus the first anti-spike quartile; findings were similar by viral strain. Combining serologic and virologic screening might enable monitoring of discrete population immunologic markers and their implications for emergent variant transmission.

Background: Population-level SARS-CoV-2 immunological protection is poorly understood but can guide vaccination and non-pharmaceutical intervention priorities. Our objective was to characterise cumulative infections and immunological protection in the Dominican Republic., Methods: Household members ≥5 years were enrolled in a three-stage national household cluster serosurvey in the Dominican Republic. We measured pan-immunoglobulin antibodies against the SARS-CoV-2 spike (anti-S) and nucleocapsid glycoproteins, and pseudovirus neutralising activity against the ancestral and B.1.617.2 (Delta) strains. Seroprevalence and cumulative prior infections were weighted and adjusted for assay performance and seroreversion. Binary classification machine learning methods and pseudovirus neutralising correlates of protection were used to estimate 50% and 80% protection against symptomatic infection., Findings: Between 30 Jun and 12 Oct 2021 we enrolled 6683 individuals from 3832 households. We estimate that 85.0% (CI 82.1-88.0) of the ≥5 years population had been immunologically exposed and 77.5% (CI 71.3-83) had been previously infected. Protective immunity sufficient to provide at least 50% protection against symptomatic SARS-CoV-2 infection was estimated in 78.1% (CI 74.3-82) and 66.3% (CI 62.8-70) of the population for the ancestral and Delta strains respectively. Younger (5-14 years, OR 0.47 [CI 0.36-0.61]) and older (≥75-years, 0.40 [CI 0.28-0.56]) age, working outdoors (0.53 [0.39-0.73]), smoking (0.66 [0.52-0.84]), urban setting (1.30 [1.14-1.49]), and three vs no vaccine doses (18.41 [10.69-35.04]) were associated with 50% protection against the ancestral strain., Interpretation: Cumulative infections substantially exceeded prior estimates and overall immunological exposure was high. After controlling for confounders, markedly lower immunological protection was observed to the ancestral and Delta strains across certain subgroups, findings that can guide public health interventions and may be generalisable to other settings and viral strains., Funding: This study was funded by the US CDC., Competing Interests: E.J.N. is the PI on a US CDC funded U01 award that funded the study, and C.L.L., A.K., D.D., M.d.S.A., A.C.R., H.M., S.G., M.C.E., W.D., N.I., G.A., B.H., K.D., M.B., E.F., and L.I. have received salaries, consultancy fees, or travel paid through this award. E.Z.G., B.L., and A.E.-B. are employees of the US CDC. B.H., C.T., L.C., F.P., and R.S.-R. are employees of the Ministry of Ministry of Health and Social Assistance, Dominican Republic, that was subcontracted with funds from the US CDC award. A.K. and E.F. are supported by the Welcome Trust, UK. D.B. had a patent for COVID-19 vaccine licensed to Janssen. We declare no other competing interests., (© 2022 The Author(s).)

Introduction: The novel coronavirus disease 2019 (COVID-19) has been a major health concern worldwide. This study aims to develop a Bayesian model to predict critical outcomes in patients with COVID-19., Methods: Sensitivity and specificity were obtained from previous meta-analysis studies. The complex vulnerability index (IVC-COV2 index for its abbreviation in Spanish) was used to set the pretest probability. Likelihood ratios were integrated into a Fagan nomogram for posttest probabilities, and IVC-COV2 + National Early Warning Score (NEWS) values and CURB-65 scores were generated. Absolute and relative diagnostic gains (RDGs) were calculated based on pretest and posttest differences., Results: The IVC-COV2 index was derived from a population of 1,055,746 individuals and was based on mortality in high-risk (71.97%), intermediate-risk (26.11%), and low-risk (1.91%) groups. The integration of models in which IVC-COV2 intermediate + NEWS ≥ 5 and CURB-65 > 2 led to a "number needed to (NNT) diagnose" that was slightly improved in the CURB-65 model (2 vs. 3). A comparison of diagnostic gains revealed that neither the positive likelihood ratio (P = 0.62) nor the negative likelihood ratio (P = 0.95) differed significantly between the IVC-COV2 NEWS model and the CURB-65 model., Conclusion: According to the proposed mathematical model, the combination of the IVC-COV2 intermediate score and NEWS or CURB-65 score yields superior results and a greater predictive value for the severity of illness. To the best of our knowledge, this is the first population-based/mathematical model developed for use in COVID-19 critical care decision-making., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Baez et al.)

Background: Dignitary medicine is an emerging field of training that involves the specialized care of diplomats, heads of state, and other high-ranking officials. In an effort to provide guidance on training in this nascent field, we convened a panel of experts in dignitary medicine and using the Delphi methodology, created a consensus curriculum for training in dignitary medicine., Methods: A three-round Delphi consensus process was performed with 42 experts in the field of dignitary medicine. Predetermined scores were required for an aspect of the curriculum to advance to the next round. The scores on the final round were used to determine the components of the curriculum. Scores below the threshold to advance were dropped in the subsequent round., Results: Our panel had a high degree of agreement on the required skills needed to practice dignitary medicine, with active practice in a provider's baseline specialty, current board certification, and skills in emergency care and resuscitation being the highest rated skills dignitary medicine physicians need. Skills related to vascular and emergency ultrasound and quality improvement were rated the lowest in the Delphi analysis. No skills were dropped from consideration., Conclusions: The results of our work can form the basis of formal fellowship training, continuing medical education, and publications in the field of dignitary medicine. It is clear that active medical practice and knowledge of resuscitation and emergency care are critical skills in this field, making emergency medicine physicians well suited to practicing dignitary medicine.

Background: Community-acquired pneumonia (CAP) is one of the leading causes of morbidity and mortality in the USA. Our objective was to assess the predictive value on critical illness and disposition of a sequential Bayesian Model that integrates Lactate and procalcitonin (PCT) for pneumonia., Methods: Sensitivity and specificity of lactate and PCT attained from pooled meta-analysis data. Likelihood ratios calculated and inserted in Bayesian/ Fagan nomogram to calculate posttest probabilities. Bayesian Diagnostic Gains (BDG) were analyzed comparing pre and post-test probability. To assess the value of integrating both PCT and Lactate in Severity of Illness Prediction we built a model that combined CURB65 with PCT as the Pre-Test markers and later integrated the Lactate Likelihood Ratio Values to generate a combined CURB 65 + Procalcitonin + Lactate Sequential value., Results: The BDG model integrated a CUBR65 Scores combined with Procalcitonin (LR+ and LR-) for Pre-Test Probability Intermediate and High with Lactate Positive Likelihood Ratios. This generated for the PCT LR+ Post-test Probability (POSITIVE TEST) Posterior probability: 93% (95% CI [91,96%]) and Post Test Probability (NEGATIVE TEST) of: 17% (95% CI [15-20%]) for the Intermediate subgroup and 97% for the high risk sub-group POSITIVE TEST: Post-Test probability:97% (95% CI [95,98%]) NEGATIVE TEST: Post-test probability: 33% (95% CI [31,36%]) . ANOVA analysis for CURB 65 (alone) vs CURB 65 and PCT (LR+) vs CURB 65 and PCT (LR+) and Lactate showed a statistically significant difference (P value = 0.013)., Conclusions: The sequential combination of CURB 65 plus PCT with Lactate yielded statistically significant results, demonstrating a greater predictive value for severity of illness thus ICU level care.

Background: Disasters burden on hospital emergency intensive care units (ICUs). This burden is increased in Latin America (LATAM) where hospital resources, intrahospital disaster simulations, and perceived level of preparedness vary greatly among different communities. The objective of the study was to assess LATAM ICU leaders' knowledge and attitudes regarding disaster preparedness., Methods: We developed a ten-item, web-based knowledge and attitude survey administered via LATAM ICU leaders online forums. Descriptive statistics were used. Epi Info™ software was used for analysis. Chi-square and Fisher's exact test with P < 0.05 were implemented for statistical significance, and odds ratio was used to measure the strength of association among variables., Results: There were 68 respondents in the survey. 13/68 respondents felt prepared for disasters. 16/68 worked at hospitals with 250+ beds and 52/68 represented hospitals with <250 beds. 23/68 participated in hospital committees for disaster, 24/68 participated in simulations or drills, and 22/68 participated in trainings or courses for disasters. Feeling prepared for disasters did not correlate with hospital size (odds ratio [OR] = 2.87 [95% confidence interval (CI): 0.83-9.92], P = 0.91), participation in hospital committees for disaster (OR = 3.10 [95% CI: 1.02-9.26], P = 0.08), and participation in simulations or drills (OR = 2.78 [95% CI: 0.93-8.29], P = 0.11), but participation in disaster trainings and courses appeared to directly correlate with the perception of being prepared (OR = 3.43 [95% CI: 1.13-10.41], P = 0.03)., Conclusion: Among the 68 centers represented, the majority did not feel their institution to be adequately prepared for disasters, but training appeared to change that perception. A small sample size represents the major limitation of this study., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 International Journal of Critical Illness and Injury Science.)

Objective: We sought out to determine the correlation between the injury severity score (ISS) and multiple organ dysfunction syndrome (MODS) between severely injured young adults (18-54 years) and elderly (>55 years) patients., Materials and Methods: This was a cross-sectional observational study. We included all adult cases (>18 years) diagnosed with trauma defined by the International Classification of Diseases, Ninth Revision. For significance testing, Chi-square test and odds ratio were used. Severe injuries were defined by an ISS >15. The presence of MODS was based on the definitions proposed by society for critical care medicine., Results: A total of 469 young and 173 elderly patients were included in the study. Among the 469 young adults, 193 had ISS >15, whereas out of the 173 elderly patients, 88 had an ISS >15. Severely injured young and elderly groups were more likely to develop MODS compared with those with an ISS <15 ( P < 0.001 and P < 0.001, respectively). The elderly had a higher likelihood of developing MODS ( P < 0.001; odds ratio: 5.17; 95% confidence interval: 2.74-9.80)., Conclusion: This study demonstrated a direct relationship between an ISS >15 and the development of MODS. We also observed a five-fold increase in the development of MODS among severely injured elderly patients., Competing Interests: There are no conflicts of interest.

Background: Bayes' theorem describes the probability of an event, based on conditions that might be related to the event.[1] We developed the Bayesian Diagnostic Gains (BDG) method as a simple tool for interpreting diagnostic impact.[234567]., Aim: We aimed to evaluate the clinical diagnostic impact of contrast-enhanced ultrasound (CEUS) compared to traditional abdominal computed tomography (CT) and standard ultrasound (US) in a Bayesian Clinical Decision Scheme., Materials and Methods: Our mathematical method uses Bayesian Diagnostic Gains (BDG) model. For the purposes of our model, the EMTRAS was used as pretest probability and stratified as low risk (0-3 points = 10%), moderate risk (4-6 points = 42%), and high risk (7-12 points = 80%) based on mortality risk. Sensitivity and specificity for US, CT, and CEUS were obtained from pooled data and used to calculate LR- and LR+. Bayesian/Fagan nomogram was used to attain posttest probabilities using baseline probability of an event on the first axis (PRE), with LR on the second axis, and read off the pos-test probability (POST) on the third axis. For the nomogram analysis, the pretest probability (Pre) scoring for the EMTRAS score was obtained using the original EMTRAS data. Posttest probabilities were obtained based on the Bayes/Fagan Nomgram. Relative diagnostic gain (RDG) and absolute diagnostic gain (ADG) were calculated based on the differences deducted from pre- and post-test probabilities. IBM® SPSS® Statistics 20 was used for analysis and modeling. ANOVA was used for association between EMTRAS, CT scan, and CEUS, where P value set at 0.05., Results: Pooled data for Sensitivity (Se), Specificity (Sp), LR+, and LR- were obtained for US (Se = 45.7%, Sp = 91.8%, LR+ = 5.57, and LR- = 0.59), CEUS (Se 91.4%, Sp 100%, LR+ 91, and LR-0.09), and CT (Se = 94.8%, SP = 98.7%, LR+ = 73, and LR- =0.05). ANOVA analysis for LR+ and LR- showed no significant difference ( P < 0.8745 and P < 0.9841). Comparison of CT and CEUS did not yield statistically significant differences for LR+ ( P < 0.1)., Conclusion: In this Bayesian model, the diagnostic performance of CEUS was found to be similar to traditional abdominal CT. The greatest diagnostic gain was observed in low pretest positive LR groups., Competing Interests: There are no conflicts of interest.

We aim in this study to provide levels of susceptibility of 162 bloodstream isolates of non-Candida albicans and non-C. tropicalis species from a sentinel program conducted in 11 hospitals in Brazil. Additionally, we compared the broth microdilution (BMD) method of the European Committee of Susceptibility Testing (EUCAST) with Clinical Laboratory Standards Institute (CLSI) BMD method for fluconazole, itraconazole, voriconazole, and amphotericin B. The study included 103 C. parapsilosis, 38 C. glabrata, 8 C. orthopsilosis, and 7 C. krusei isolates, and single isolates of Pichia anomala, C. famata, C. lusitaniae, C. kefyr, C. guilliermondii, and C. metapsilosis. Of note, we observed cross-resistance between fluconazole and voriconazole for two isolates being one C. parapsilosis and one C. glabrata. Good essential agreement (EA) was observed between the EUCAST and the CLSI results for C. parapsilosis and for fluconazole, itraconazole, voriconazole, and amphotericin B, respectively: 98%, 99%, 98%, and 97%. Otherwise, for C. glabrata, the EA for fluconazole was 84.2% and for voriconazole 89.4%. Because data from Brazil are scarce, our results contribute to the consolidation of the database of candidemia agents and monitoring of trends in the profile of drug resistance., (© 2012 Federation of European Microbiological Societies. Published by Blackwell Publishing Ltd. All rights reserved.)

This study was undertaken to determine factors that influence the access to trauma center care of pediatric and geriatric patients injured in motor vehicle collisions (MVC). Hospital discharge records for 1997 were obtained from the Pennsylvania Health Care Cost Containment Council and were analyzed. Of cases with an Injury Severity Score of > 15, 52.6% of elderly cases and 48.6% of pediatric cases were transported to and received their care in non-trauma center hospitals. These very high "mis-triage" rates could not be explained by differences in injury severity, body region or population density. In order to assess potential out-of-hospital factors, a file containing matched records from Emergency Medical Services (EMS) calls and hospital discharges from MVC cases across Pennsylvania for the year 1996 was constructed and analyzed. There were no significant vital signs differences between trauma center and non-trauma center cases, with the single exception of the Glasgow Coma Scale score, for both the pediatric and geriatric age groups. A reevaluation of out-of-hospital trauma triage is needed.