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Introduction: Advanced airway management and ventilation of trauma patients are often needed during acute stabilization and resuscitation and later, in those admitted. In addition to endotracheal intubation for advanced airway management, tracheostomy is commonly used in critically ill patients when prolonged mechanical ventilation is required. However, the outcomes associated with airway management approaches and the timing of a tracheostomy in critically ill patients are mixed. This protocol intended to compare the effect of tracheostomy in major trauma patients vs. management with non-invasive techniques and endotracheal intubation during admission, examine complications and outcomes associated with the three types of airway management approaches, and explore the association of clinical and social determinants of health variables with complications in patients requiring advanced airway management., Methods: A total of 911 adult trauma patients admitted to a Level 1 trauma center surgical intensive care unit (SICU) were included in this retrospective, single-center, quantitative study from 2019 to 2021. Descriptive and correlational analyses were used to examine outcomes of ventilator days, length of stay, pneumonia, readmission, mortality, and associations with the airway management approach. The outcomes of ventilator days and length of stay were compared between groups with a one-way ANOVA, and differences between groups on outcomes of pneumonia, readmission, and mortality were estimated using crosstabulations and chi-square (x²) statistics. Hypothesized relationships of clinical and social determinants of health variables associated with outcomes of ventilator days, hospital length of stay, pneumonia, readmission, and mortality in patients requiring advanced airway management ≥ four days were estimated., Results: There was no significant difference in outcomes of pneumonia and mortality between the advanced airway management groups (p=0.856 and p=0.167, respectively). There were significant differences in ventilator days, length of stay (LOS), and readmission. Between the groups: endotracheal intubation only, early (<10 days post-intubation) tracheostomy, and late (>10 days post-intubation) tracheostomy in SICU patients (p <0.001, p=0.028, and p=0.003, respectively). Specifically, patients in the early tracheostomy group had a higher readmission rate (33.3%) as compared to endotracheal tube patients (2.3%) and late tracheostomy patients (0.0%). Social determinants of health variables (smoking and functional dependence) were also significantly correlated with readmission in the early tracheostomy and endotracheal tube airway management groups (p=.047 and p=.022, respectively). Additionally, clinical variables of injury severity scores, ED arrival systolic blood pressure (SBP), and presence of pre-existing comorbidities were found to be significantly associated with complications of pneumonia, readmission, and mortality within the patients (n=229) requiring advanced airway approaches., Conclusion: Adult trauma patients with early tracheostomy airway management may experience a higher readmission rate related to the complexity of their injuries than patients managed with endotracheal intubation or late tracheostomy. Clinical and social determinants of health factors may be associated with complications. Further studies examining these associations in larger samples are needed to examine the validity of these findings., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. The Institutional Review Board (IRB) of the Good Samaritan University Hospital issued approval (IRB # 22-010). As this research included experimentation on human subjects' data, this study was approved by the institution’s ethics committee, the Good Samaritan University Hospital Institutional Review Board (IRB # 22-010), receiving an exempt category designation 45 CFR 46.104 Category 4(iii) (2018 Requirements) prior to conducting the research. This research was conducted according to established ethical guidelines, and informed consent was obtained from the participants according to the federal requirements described in 45 CFR 46.104. This research study complies with all regulations and informed consent was obtained as required by 45 CFR 46.104. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Cunningham et al.)

Background: Candida auris has become a growing concern worldwide because of increases in incidence of colonization and reports of invasive infections. There are limited data on clinical factors associated with poor outcomes in patients with C. auris bloodstream infection (BSI)., Methods: We assembled a multicenter retrospective cohort of patients with C. auris BSI from 2 geographics areas in US healthcare settings. We collected data on demographic, clinical, and microbiologic characteristics to describe the cohort and constructed multivariate logistic regression models to understand risk factors for 2 clinical outcomes, all-cause mortality during facility admission, and blood culture clearance., Results: Our cohort consisted of 187 patients with C. auris BSI (56.1% male, 55.6% age >65 years); 54.6% died by facility discharge and 66.9% (of 142 with available data) experienced blood culture clearance. Pitt bacteremia score at infection onset was associated with mortality (odds ratio [95% confidence interval]: 1.19 [1.01-1.40] per 1-point increase). Hemodialysis was associated with a reduced odds of microbiologic clearance (0.15 [0.05-0.43]) and with mortality (3.08 [1.27-7.50])., Conclusions: The Pitt bacteremia score at the onset of C. auris BSI may be a useful tool in identifying patients at risk for mortality. Targeted infection prevention practices in patients receiving hemodialysis may be useful to limit poor outcomes., Competing Interests: Potential conflicts of interest . For completion and integrity, L. M. A. reports as conflicts of interests not related to this study serving in the past 24 months in the advisory boards for: Shionogi, Pfizer, innovivia, Biomeriux, La joya, abbvie, and Ferring pharmaceutica. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Young adults with Cerebral Palsy (CP) have lower employment rates compared to young adults in general, as they may be confronted with physical, sensory, and cognitive impairments, coupled with personal and societal barriers as they mature. These challenges are clear, but the solutions are less so. Understanding the factors that impact employment is vital. This study aimed to identify and examine variables related to employment for this population through the lens of the International Classification of Functioning, Disability, and Health (ICF) model. The Rehabilitation Services Administration (RSA-911) federal dataset was used to examine the relationship between functioning and disability within the context of personal and environmental factors as predictors of employment among young adults with CP. Following a descriptive cross-sectional design using a secondary analysis of this national dataset, binomial logistic regression was used to predict employment outcomes. Data representing those with CP who participated in vocational rehabilitation (VR) services and were between 18 and 30 years of age at the time of exit were extracted from the 2019 RSA-911 dataset (n = 2465). Just under one-third (30.4 %, n = 750) emerged as employed, while 69.6 % (n = 1715) were unemployed at exit from their VR programs in 2019. Significant predictors for employment were participation in career and other support services, having basic skills and literacy, and being of non-Hispanic/Latino ethnicity. These findings concur with the persistent low employment rates for adults with CP and reinforce the need to understand the factors that increase employability. Healthcare professionals are urged to incorporate participation in self-management activities for all transition-aged youth that will not only improve health outcomes but promote future independence and increase awareness of vocational services for this population., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Introduction: Recent revisions of national field triage guidelines recommend the addition of age-specific systolic blood pressure (SBP) measurement for identifying the most severely injured children requiring transport to a trauma center. The purpose of this study was to determine the frequency in which blood pressures are documented by Emergency Medical Service (EMS) providers and the role this measurement has had, among other factors, in triage decisions., Methods: This is an exploratory descriptive study with a retrospective review from the trauma registry database of all pediatric trauma admissions that arrived by EMS at a level II pediatric trauma center from January 1, 2019 to December 31, 2022., Results: Two hundred ninety-eight patient records of patients aged 0 to 14 were included. EMS providers documented blood pressure in 70.1% of the total sample. A significant difference in the frequency of this documentation was seen between ages zero to nine and = > 10 years (χ 2 (1,298) = 28.98 p <0.001). No children ages zero to nine years had SBP of < 70 mmHg + (2x age in years) documented by EMS. There were two children aged = > 10 who had a documented SBP < 90 and 12 children with documented EMS heart rate > SBP., Conclusion: Many children transported by EMS in this hospital's catchment area did have a field blood pressure measurement documented, but the frequency was significantly less in younger-aged children. The blood pressure measurements of children determined to have severe injuries in the sample did not meet the inclusion criteria for high risk of serious injury by the newly established national guidelines. This suggests other prehospital criteria, such as mechanism of injury or visual cues, prompted EMS to transport these pediatric trauma patients to a regional trauma center for specialized care., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board of Good Samaritan University Hospital Office issued approval 2023.06.20.07.15. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Frederick et al.)

Introduction Falls during hospitalization are a leading cause of preventable trauma-related injuries. Factors associated with fall risk include an unfamiliar environment, changes in health status, and efficacy based on the home environment. Assessing fall efficacy with an individualized prevention plan can decrease falls. The primary aim of this study was to estimate the effect of implementing a fall efficacy screening and intervention on reducing patient falls. Methods The study utilized a quasi-experimental, cross-sectional design with a convenience sample of patients admitted to an in-patient adult medical unit within a community hospital over a twelve-month period. Sampling times included pre-implementation, immediately post-implementation, and a second post-implementation phase. The intervention consisted of an admission fall efficacy screening tool and an individualized educational initiative. Statistical analysis included descriptive statistics of central tendency and dispersion, along with inferential statistics using independent sample t-tests, chi-square tests, correlations, and binary logistic regression. Results Among the study participants (n=2,074), the total sample had an average age of 67.7 (+/- 17.4) years and had mean scores of 13.3 (6.9) on the Short Falls Efficacy Scale-International and 51.8 (20.3) on the Morse Fall Scale. Fifty-two percent of the study population were female; 16.2% of the patients were diagnosed with cerebrovascular accident (CVA) or CVA-like symptoms. Fall rates decreased with a rate of change of -4.15% after efficacy screening and intervention. Males demonstrated higher efficacy in avoiding falls compared to females (t(828) = 3.369, p <0.001). Patients with a CVA diagnosis demonstrated higher efficacy scores compared to non-CVA patients (t(2071) = -3.348, p <0.001). FES risk groups (OR of 5.632, 95% CI (2.171-7.892)) and age over 65 (OR 1.21, 95% CI (1.006-1.442)) were significant predictors of a fall when patients with a primary CVA diagnosis were omitted from the sample (p= 0.022 and 0.046 respectively). Conclusion The findings suggest that efficacy screening may be associated with decreased falls for acute care non-CVA inpatient populations over 65 years of age. Further research into the predictive utility of fall efficacy screening in acute care CVA and non-CVA hospitalized patient populations aged 65 years and above is recommended., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Good Samaritan University Hospital Office of the IRB issued approval IRB#: 2019.05.22.01. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ragione et al.)

Introduction: Although numerous risk factors and prediction models affecting morbidity and mortality in geriatric hip fracture patients have been previously identified, there are scant published data on predictors for perioperative Surgical Intensive Care Unit (SICU) admission in this patient population. Determining if a patient will need an SICU admission would not only allow for the appropriate allocation of resources and personnel but also permit targeted clinical management of these patients with the goal of improving morbidity and mortality outcomes. The purpose of this study was to identify specific risk factors predictive of SICU admission in a population of geriatric hip fracture patients. Unlike previous studies which have investigated predominantly demographic, comorbidity, and laboratory data, the present study also considered a frailty index and length of time from injury to presentation in the Emergency Department (ED)., Methods: A total of 501 geriatric hip fracture patients admitted to a Level 1 trauma center were included in this retrospective, single-center, quantitative study from January 1, 2019, to December 31, 2022. Using a logistical regression analysis, more than 25 different variables were included in the regression model to identify values predictive of SICU admission. Predictive models of planned versus unplanned SICU admissions were also estimated. The discriminative ability of variables in the final models to predict SICU admission was assessed with receiver operating characteristic curves' area under the curve estimates., Results:  Frailty, serum lactate > 2, and presentation to the ED > 12 hours after injury were significant predictors of SICU admission overall (P = 0.03, 0.038, and 0.05 respectively). Additionally, the predictive model for planned SICU admission had no common significant predictors with unplanned SICU admission. Planned SICU admission significant predictors included an Injury Severity Score (ISS) of 15 and greater, a higher total serum protein, serum sodium <135, systolic blood pressure (BP) under 100, increased heart rate on admission to ED, thrombocytopenia (<120), and higher Anesthesia Society Association physical status classification (ASA) score (P = 0.007, 0.04, 0.05, 0.002, 0.041, 0.05, and 0.005 respectively). Each SICU prediction model (overall, planned, and unplanned) demonstrated sufficient discriminative ability with the area under the curve (AUC) values of 0.869, 0.601, and 0.866 respectively. Finally, mean hospital Length of Stay (LOS) and mortality were increased in SICU admissions when compared to non-SICU admissions., Conclusion: Of the three risk factors predictive of SICU admission identified in this study, two have not been extensively studied previously in this patient population. Frailty has been associated with increased mortality and postoperative complications in hip fracture patients, but this is the first study to date to use a novel frailty index specifically designed and validated for use in hip fracture patients. The other risk factor, time from injury to presentation to the ED serves as an indicator for time a hip fracture patient spent without receiving medical attention. This risk factor has not been investigated heavily in the past as a predictor of SICU admissions in this patient population., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Trejo et al.)

Background: Although a rare complication, dislocation following hemiarthroplasty (HA) for a femoral neck hip fracture is associated with increased mortality, readmission, and possible revision surgery. To date many of the specific risk factors have been difficult to demonstrate. Patient factors, surgical factors, as well as morphological factors need to be assessed. Therefore, the purpose of this study was to elucidate the risk factors for dislocation of HA following femoral neck hip fractures in the geriatric population., Methods: This was a retrospective review of 270 patients who had hip fractures. Medical records between the years 2016 and 2022 informed binomial regression predictive models. The discriminative ability of variables in the final model and acetabular anteversion to predict dislocation was assessed with area under the curve (AUC) estimates., Results: Center edge angle (odds ratio 1.23), abduction angle (odds ratio 1.17), and depth width ratio (2.96 e-11 ) were significant predictors of dislocation (P = .003, .028, and <.001, respectively). Center edge angle and depth width ratio (<44.1 ° and .298), respectively, were cut scores for risk. Dementia had a high discriminative of ability, as did men (AUC = 0.617, 0.558, respectively). Acetabular anteversion was not predictive of dislocation (P = .259) and theorized anteversion safe zones had poor discriminative ability with AUCs of 0.510 and 0.503, respectively., Conclusions: Morphological factors related to hip dysplasia and a shallow acetabulum, which can be assessed with a radiograph alone, were found to be predictors of instability following HA in the elderly. Hemiarthroplasty implant design and manufacturer, and also acetabular version did not contribute to instability risk., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Half of all reported violent incidents in health care settings occur in the emergency department (ED) placing all staff members at risk. However, research typically does not include all ED work groups or validated measures beyond nurses and physicians., Objective: The aims of this study were to (a) validate an established instrument measuring perceptions of causes of violence and attitudes toward managing violence within an inclusive workforce sample; and (b) explore variation in perceptions, attitudes, and incidence of violence and safety to inform a violence prevention program., Methods: This is an investigator-initiated single-site cross-sectional survey design assessing the psychometric properties of the Management of Aggression and Violence Attitude Scale (MAVAS) within a convenience sample (n = 134). Construct validity was assessed using exploratory factor analysis and reliability was evaluated by the Cronbach's α estimation. Descriptive, correlational, and inferential estimates explored differences in perceptions, attitudes, and incidence of violence and safety., Results: Exploratory factor analysis indicated validity of the MAVAS with a seven-factor model. Its internal consistency was satisfactory overall (Cronbach's α= 0.87) and across all subscales (Cronbach's α values = 0.52-0.80). Significant variation in incidence of physical assault, perceptions of safety, and causes of violence was found between work groups., Conclusions: The MAVAS is a valid and reliable tool to measure ED staff members' perceptions of causes of violence and attitudes toward managing violence. In addition, it can inform training according to differences in work group learner needs., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Society of Trauma Nurses.)

Background: Men who have sex with men (MSM) and persons living with human immunodeficiency virus (PLWH) were disproportionately affected by global mpox outbreak in 2022. In this retrospective review, we describe epidemiology and clinical characteristics of mpox infection in South Florida with a focus on human immunodeficiency virus (HIV) status., Methods: This was a retrospective observational study of 198 adult patients with confirmed diagnosis of mpox between 01 January 2020, and 10 September 2022, in two large health systems in South Florida. A descriptive analysis was performed to summarize demographic, clinical and laboratory characteristics, and outcomes of the patients., Results: Young male patients and PLWH were disproportionately represented among patients with mpox. HIV positive patients were less likely to have adenopathy and myalgia and were more likely to have oral or facial lesions. 22.7% of studied patients were diagnosed with one or more concurrent STI at the time of mpox diagnosis., Conclusions: We suggest screening for sexually transmitted infections and HIV for patients diagnosed with mpox. We suggest prompt consultation or referral to infectious disease specialist if needed for the patients who are diagnosed with mpox especially in the severely immunocompromised host., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The COVID-19 Omicron variant has imposed a tremendous burden on healthcare services. We characterized the types of the Omicron variant-associated hospitalizations and their associations with clinical outcomes. Consecutive adults hospitalized with COVID-19 during the Omicron variant surge period of 1-14 January 2022, were classified into one of three groups based on their clinical presentations on admission: Group 1-primary COVID-19; Group 2-extrapulmonary manifestations of COVID-19; and Group 3-incidental COVID-19. Of the 500 patients who were hospitalized, 51.4% fell into Group 1, 16.4% into Group 2, and 32.2% into Group 3. The patients in Groups 1 and 2 were older, with higher proportions of comorbidities than patients in Group 3. The Group 1 patients had the highest mortality rate (15.6%), followed by Group 2 (8.5%), and Group 3 (0.6%), with adjusted odds ratios (OR) of 22.65 (95% confidence interval [CI], 2.75-239.46; p = 0.004) and 10.95 (95% CI, 1.02-117.28; p = 0.048), respectively, compared to Group 3. Those in Group 1 showed a greater utilization of intensive care services (15.9%), followed by Group 2 (10.9%), and Group 3 (2.5%), with adjusted ORs of 7.95 (95% CI, 2.52-25.08; p < 0.001) and 5.07 (95% CI, 1.34-19.15; p = 0.017), respectively, compared to Group 3. The patients in Groups 1 and 2 had longer hospitalization stays than the patients in Group 3 ( p < 0.001 and p = 0.002, respectively). Older age (≥65 years) was an independent factor associated with longer hospital stays (OR = 1.72, 95% CI, 1.07-2.77). These findings can help hospitals prioritize patient care and service planning for future SARS-CoV-2 variants.

Despite increasing rates of renal replacement therapy, data supporting the safe and effective use of HIV treatment guidelines preferred regimens in people on hemodialysis or peritoneal dialysis is limited. Bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) is a guideline recommended initial regimen for most people with HIV with FDA-approval for use in virologically suppressed people receiving chronic hemodialysis; however, the safety and efficacy of BIC/FTC/TAF remains unknown when used in patients on chronic ambulatory peritoneal dialysis (CAPD). We report the first case of BIC/FTC/TAF use in CAPD.

Background: The COVID-19 pandemic has posed a tremendous burden on healthcare services. We evaluated its impact on an emergency department (ED)-based opt-out Human immunodeficiency virus (HIV) testing in a public healthcare system., Methods: The programmatic data of ED-based HIV testing from July 2018 to March 2021 at the Memorial Regional Hospital, Hollywood, Florida was analyzed by interrupted time series analysis to evaluate the immediate and gradual effects of the COVID-19 pandemic on the number of monthly HIV tests, with an interruption point at March 2020., Results: The average number of monthly HIV tests were significantly lower during the pandemic than the pre-pandemic (791 ± 187 vs 1745 ± 266, P < .001). There was a slight decline trend in the number of monthly HIV tests before the pandemic (estimate -10.29, P = .541). HIV testing dramatically decreased during the initial 7 months of the pandemic, compared to the pre-pandemic period, with the largest decline in the number of HIV tests on March 2020 (estimate -678.48, P = .007). HIV testing slightly increased every month (estimate 4.84, P = .891) during the pandemic period, and the number of HIV tests per month rebounded to the pre-pandemic levels by October 2020., Conclusions: ED-based HIV testing significantly decreased during the initial 7 months of the pandemic in south Florida. Multiple strategies are necessary to maintain HIV testing during this pandemic era., (Copyright © 2022 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Abstract: BACKGROUND: In the last few decades, the revised diagnostic criteria for multiple sclerosis (MS) and the development of numerous new MS therapies have created the possibility of early diagnosis and opportune MS management. However, these changes, and the mounting emphasis on patient choice and shared decision making, have not been accompanied by improvements in information provided to patients with MS (PwMS). Information provision for PwMS increases disease-related knowledge that may assist them in decision making and quality of life. The purpose of this study was to validate the Multiple Sclerosis and Magnetic Resonance Imaging Knowledge Questionnaire (MSMRIKQ) to improve patients' shared decision-making capabilities. METHODS: In this methodological study, the instrument development process was completed in 4 stages using principles of measurement theory: (1) establishing a pool of items after patient and clinician panels' review, (2) evaluating the validity of the scale-both face and content validity, (3) pilot testing the scale, and (4) post-pilot testing statistical analysis of items and scale reliability and validity. RESULTS: The 20-item instrument was finalized based on a panel of MS experts' and patients' comments. The final version of the MSMRIKQ was pilot tested with a sample of 46 PwMS. Face validity was established on all MSMRIKQ items. Individual item-level and scale-level content validity indices for universal agreement estimates were acceptable at item-level content validity index = 1 and scale-level content validity index = 1 for the 20 items. The Kuder-Richardson 20 reliability estimate for the entire scale was 0.58; the Kuder-Richardson 20 estimates for the subscales of MS and magnetic resonance imaging knowledge were 0.35 and 0.51, respectively. The split-half reliability with Spearman-Brown correction for the total scale was 0.60. The Poisson regression model was significant for predicting MS knowledge within this population. CONCLUSION: The MSMRIKQ is a basic knowledge instrument for clinical and research use., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 American Association of Neuroscience Nurses.)

Objective: The aim of the study was to describe implementation of an outpatient antibiotic stewardship program at primary care practices in South Florida and the proportion of appropriate and inappropriate orders and reasons for inappropriateness during the intervention., Methods: An antibiotic stewardship committee at a large hospital system implemented aspects of The Core Elements of Outpatient Antibiotic Stewardship at outpatient facilities in 2018. Interventions included an education/awareness campaign directed at prescribers (audit and feedback, routine education at prescribers' meetings, availability of updated guidelines in a shared drive and antibiogram via intranet) and patients (posters, tear-off sheets on symptom relief for viral illness). Orders were evaluated using clinical documentation, current antibiogram, and Infectious Diseases Society of America guidelines. An appropriate order was defined as a correct antibiotic and dose/frequency and duration of therapy. An inappropriate antibiotic order was defined as not meeting 1 or more of the abovementioned conditions. Descriptive statistics assessed the data., Results: In this retrospective review of 2934 oral antibiotic orders from January 1 to December 31, 2018, 2565 (87.4%) were necessary while 369 (12.6%) were unnecessary. Of 2565 necessary orders, 1448 (56.5%) were appropriate while 1117 (43.5%) were inappropriate. Of 1117 inappropriate orders, 24.9% had all 3 conditions; 41.5% of inappropriate orders were solely due to wrong duration of therapy., Conclusions: Although our institution demonstrated commitment to optimizing antibiotic prescribing by providing resources to clinicians and patients about evidence-based antibiotic prescribing, inappropriate antibiotic prescribing was persistent. The interventions used must continue to evolve and include point-of-care access to guidelines and clinical decision support tools., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The mortality associated with Coronavirus Disease 2019 is greatly influenced by known risk factors such as elderly age, cardiovascular disease, hypertension, diabetes, and immunosuppression. As cytomegalovirus reactivation in critically ill patients has been linked with higher morbidity and mortality in intensive care settings, it has been suggested that cytomegalovirus reactivation might lead to worse clinical outcomes of patients with Coronavirus Disease 2019. Here we describe the clinical course of 11 patients with Coronavirus Disease 2019 and concomitant cytomegalovirus viremia. We conclude that further research is necessary to formulate guidelines on diagnosis and treatment of cytomegalovirus reactivation in Coronavirus Disease 2019 patients., (© 2022 The Authors.)

Background: First responders (FRs) may have a significant risk of coronavirus 19 (COVID-19) infection than the general population due to job-related exposures. We aimed to determine the prevalence and exposure patterns of COVID-19 among FRs., Methods: Between March and April 2020, FRs in Broward County, Florida, were screened for COVID-19 infection by real-time reverse transcription polymerase chain reaction assay using nasopharyngeal swabs. Demographics and COVID-19 positive rate of the FRs were summarized., Results: A total of 3375 FRs were screened for COVID-19 infection. The median age of FRs tested was 42 years (IQR 33-52 years), and 1464 (43.4%) were men. A total of 2902 (85.9%) were asymptomatic, and 473 (14.1%) reported symptoms associated with COVID-19. Overall, 289 (8.6%) were positive, with the highest rates among the age between 25 and 49 years. Of those testing positive, 235 (81.3%) were asymptomatic. Fourteen days after their first positive test, 81 (69.8%) of the 116 asymptomatically infected FRs were negative, and 35 (30.2%) remained positive and asymptomatic., Conclusions: The FRs in Broward County, FL, had an overall infection rate of 8.6% at the time of COVID-19 testing, and asymptomatic FRs accounted for 81.3% of infection. Active surveillance should be focused on the asymptomatic FRs with COVID-19., (© The Author(s) 2020. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Abstract: Peripheral neuropathy is one of the most frequent complaints in patients with HIV. Many complex syndromes exist, with the etiology being secondary to the disease process itself, antiretroviral medication, or immune reconstitution. However, isolated mononeuropathy is rare. In this case, we present a previously healthy man who complained of several months of worsening right foot drop that did not improve with physical therapy or lifestyle interventions. He had begun to use an solid ankle-foot orthotic on this right lower limb to minimize tripping and prevent falls. He had no other neuromuscular involvement or constitutional complaints. Nerve conduction study of the right lower limb showed decreased peak amplitude, prolonged distal latency, and decreased conduction velocity of the deep peroneal nerve. Electromyography revealed abnormal insertional activity and absent motor unit action potentials in both the right tibialis anterior and right extensor digitorum brevis muscles. Magnetic resonance imaging of the right lower limb was suggestive of acute/subacute denervation of the right tibialis anterior muscle. An extensive laboratory workup revealed active HIV infection with a significant viral load. Once the diagnosis was made, the patient was started on antiretroviral treatment. Six months later, his foot drop had entirely resolved, in association with significant improvements in viral load and CD4 count. He has since been ambulating without assistive devices and his HIV/AIDS disease process remains well controlled. This clinical vignette is the first, to our knowledge, to illustrate that an acute focal mononeuropathy causing foot drop and gait dysfunction in an otherwise healthy-appearing individual can be a heralding sign of HIV/AIDS. Furthermore, it also suggests that this functional deficit can be reversed with timely initiation of antiretroviral treatment. Early recognition, diagnosis, and treatment in this patient have not only led to an uncomplicated AIDS disease course but also restored his ability to ambulate with complete independence and improved his quality of life., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Coronavirus disease (COVID-19) is a worldwide pandemic causing multiple fatalities and morbidities worldwide. We report a case of severe pneumonia causing acute respiratory distress syndrome due to a coinfection with SARS-CoV-2 and Mycobacterium abscessus in an elderly patient with multiple myeloma in Florida, USA. Case Presentation . An 84-year-old male with a medical history significant for multiple myeloma not in remission was sent to the emergency department to rule out COVID-19 infection prior to continuing his chemotherapy sessions. At presentation, he had nonspecific mild symptoms and an unremarkable physical examination. He had significant blood test findings including serum lactate dehydrogenase 373 U/L, high sensitive C-reactive protein 17.40 mg/l, and ferritin 415 ng/ml. Xpert-SARS-CoV-2 was positive. Chest radiograph revealed patchy areas of interstitial infiltrates in mid to lower lung zones. During his hospitalization course, his oxygenation deteriorated, requiring mechanical intubation. Repeat chest radiograph showed worsening bilateral infiltrates. He was started on broad-spectrum antibiotics and eventually weaned off mechanical intubation and extubated. On the 11 th day of admission, he was found to be bradycardic and in shock, and he was reintubated. His labs showed worsening inflammatory markers along with kidney dysfunction to the point of requiring renal replacement therapy. He received both convalescent plasma and remdesivir for treatment of COVID-19 pneumonia. Eventually, repeat blood cultures came back positive for the growth of acid-fast beaded bacilli. While awaiting final culture and sensitivity reports, his antibiotics were upgraded to cover possible nocardia infection. Repeat blood and sputum cultures resulted in growth of AFB bacilli Mycobacterium abscessus 1 week after., Conclusions: This case report highlights the importance of keeping a broad differential and considering multiple coinfections, including atypical ones during this COVID-19 pandemic, such as the one that was discussed above, Mycobacterium abscessus , in order to provide goal-directed therapy., Competing Interests: All authors have no financial disclosure or conflicts of interest., (Copyright © 2021 Jose A. Rodriguez et al.)

Purpose: Ledipasvir/sofosbuvir is an oral combination therapy containing fixed doses of direct-acting antiviral agents indicated for the treatment of hepatitis C virus (HCV) infection. Currently there are limited data on the clinical efficacy of crushed ledipasvir/sofosbuvir administered via feeding tube., Summary: This case report discusses the successful treatment of chronic HCV genotype 1b infection with crushed ledipasvir/sofosbuvir administered through a percutaneous endoscopic gastrostomy (PEG) tube in a patient with human immunodeficiency virus (HIV) coinfection and high-grade sarcoma who had severe swallowing difficulties. The patient received crushed ledipasvir/sofosbuvir daily for a total of 12 weeks. At 12 weeks the patient had achieved a sustained virologic response., Conclusion: Currently, ledipasvir/sofosbuvir is available only as a tablet, with limited pharmacokinetic data available to guide clinicians on use of the fixed-dose combination medication in crushed form. This case report highlights our experience treating a patient with HCV/HIV coinfection through administration of crushed ledipasvir/sofosbuvir via PEG tube, which we found to be a safe and effective therapeutic option., (© American Society of Health-System Pharmacists 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Coronavirus 2 (SARS-CoV-2) is now considered a pandemic causing Coronavirus disease (COVID-19), multiple fatalities and morbidities which have been associated with it worldwide. We report a severe pneumonia causing acute respiratory distress syndrome due to a coinfection with SARS-COV-2 and Parainfluenza 4 virus in a Hispanic 21 year old male in Florida, USA. The case represents the importance of prompt diagnosis and awareness of the potential co-infection with other respiratory viruses and this novel deadly virus., Competing Interests: All authors have no financial disclosure or conflicts of interest. We acknowledge that the manuscript has not been previously published nor it is being, (© 2020 The Author(s).)

BACKGROUND Histoplasmosis results from the inhalation of spores from the fungus, Histoplasma capsulatum. A case is presented of pulmonary histoplasmosis associated with altered mental state and hypercalcemia following allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia (AML). CASE REPORT A 75-year-old man with a five-day history of AML treated with allogeneic hematopoietic stem cell transplantation, presented with weakness, fatigue, and slow mentation. Computed tomography (CT) of the brain was unremarkable. Laboratory investigations showed serum albumin of 2.9 g/dL, calcium of 11.6 mg/dL, ionized calcium of 1.55 mmol/L, parathyroid hormone (PTH) <6.3 pg/mL, and 25-hydroxy vitamin D of 14.4 ng/mL. Treatment began with intravenous cefepime 1 gm bid, normal saline, and the bisphosphonate, pamidronate, administered as a single dose. Three days later, his clinical status declined. He developed a dry productive cough, his oxygen saturation (O₂ Sat) was 90%, and his mental status worsened. Chest CT showed diffuse bilateral lung infiltrates with ground glass opacities. Bronchioalveolar lavage and transbronchial biopsy were negative for Pneumocystis jiroveci pneumonia (PJP). The CMV rival load was 195 IU/mL. Urinalysis for Histoplasma antigen and the Fungitell® assay were positive. Treatment commenced with intravenous voriconazole (250 mg, bid) and ganciclovir (5 mg/kg, bid). A left lower lobe transbronchial lung biopsy was positive for Histoplasma capsulatum and negative for CMV. CONCLUSIONS This case report has highlighted the need for awareness of the diagnosis of histoplasmosis in patients with allogeneic hematopoietic stem cell transplantation who present with an altered mental state in the setting of hypercalcemia.

Micrococcus species are typically considered contaminants from skin and mucous membranes. However, especially in severely immunocompromised patients, a blood culture with Micrococcus could be the cause of a significant infection. We report a 65-year-old female with non-Hodgkin's lymphoma who developed native valve infective endocarditis due to Micrococcus luteus . There is no defined therapeutic regimen for infective endocarditis due to Micrococcus luteus ; however, our patient was successfully treated for six weeks with vancomycin and rifampin. To our knowledge, there is only one other case report of native valve endocarditis due to Micrococcus luteus ., Competing Interests: The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2019 The Author(s).)

BACKGROUND Ecthyma gangrenosum is an uncommon cutaneous infection commonly caused by Pseudomonas aeruginosa affecting typically immunocompromised patients. The presence of ecthyma gangrenosum can be associated with severe systemic infection often with a fatal prognosis. Most cases of ecthyma gangrenosum occur around the axilla, buttocks, and limbs; the scrotum is rarely affected. CASE REPORT A 68-year-old male with previously diagnosed acute myeloid leukemia, presented with left scrotal pain, fever, and rigors. Physical examination showed 2 ulcerating lesions with central black eschars surrounded by erythematous halos on the superior aspect of the left scrotum. Diagnosis of ecthyma gangrenosum was confirmed as both blood and lesion cultures showed growth of P. aeruginosa. After early empiric antibiotic treatment, the lesions significantly improved, and no sign of recurrence or new lesions was noticed. CONCLUSIONS Ecthyma gangrenosum should be considered in the differential diagnosis of ulcerating lesions of the scrotum. An early diagnosis and aggressive antibiotic treatment are imperative for resolution of this infection.