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Two nonsynchronous events have affected the management of community-acquired pneumonia (CAP): spiraling empiricism for CAP and the "golden era" of clinical microbiology. The development of broad-spectrum antibiotics has led to widespread empiric use without ascertaining the etiology of the infecting microbe. Unfortunately, this approach clashes with the second event, which is the advent of molecular-based microbiology that can identify the causative pathogen rapidly at the point of care. The urinary antigen is a most effective rapid test that has allowed targeted therapy for Legionnaire disease at the point of care. The high specificity (> 90%) allows the clinician to administer appropriate anti-Legionella therapy based on a single rapid test; however, its low sensitivity (76%) means that a notable number of cases of Legionnaire disease will go undiagnosed if other tests, especially culture, are not performed. Further, culture for Legionella is not readily available. If a culture is not performed, epidemiologic identification of the source of the bacterium cannot be ascertained by molecular fingerprinting of the patient and the putative source strain. We recommend resurrection of the basic principles of infectious disease, which are to identify the microbial etiology of the infection and to use narrow, targeted antimicrobial therapy. To reduce antimicrobial overuse with subsequent antimicrobial resistance, these basic principles must be applied in concert with traditional and newer tests in the clinical microbiology laboratory. [ABSTRACT FROM AUTHOR]

Rationale: Isoniazid given daily for 9 months is the standard treatment for latent tuberculosis infection (LTBI), but its effectiveness is limited by poor completion rates. Shorter course regimens and regimens using directly observed therapy result in improved adherence but have higher upfront costs.Objectives: To evaluate the costs and cost-effectiveness of regimens for the treatment of LTBI.Methods: We used a computerized Markov model to estimate total societal costs and benefits associated with four regimens for the treatment of LTBI: self-administered isoniazid daily for 9 months, directly observed isoniazid twice-weekly for 9 months, directly observed isoniazid plus rifapentine once weekly for 3 months, and self-administered rifampin daily for 4 months. In the base-case analysis, subjects were assumed to have newly positive tuberculin skin tests after recent exposure to infectious tuberculosis.Measurements and Main Results: We determined the costs of treatment, quality-adjusted life-years gained, and cases of active tuberculosis prevented. In the base-case analysis, rifampin dominated (less costly with increased benefits) all other regimens except isoniazid plus rifapentine, which was more effective at a cost $48,997 per quality-adjusted life year gained. Isoniazid plus rifapentine dominated all regimens at a relative risk of disease 5.2 times the baseline estimate, or with completion rates less than 34% for isoniazid or 37% for rifampin. Rifampin could be 17% less efficacious than self-administered isoniazid and still be cost-saving compared with this regimen.Conclusions: In our model, rifampin is cost-saving compared with the standard therapy of self-administered isoniazid. Isoniazid plus rifapentine is cost-saving for extremely high-risk patients and is cost-effective for lower-risk patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: The Allegheny County Health Department (ACHD) in Pennsylvania distributed the first guidelines for prevention and control of health care-acquired Legionnaires' disease (LD) by 1995. The proactive approach advocated in the guidelines differed notably from that of the Centers for Disease Control and Prevention (CDC) by recommending routine environmental testing of the hospital water distribution system even when cases of health care-acquired Legionnaires' disease had never been identified. OBJECTIVES: Our purpose was to (1) evaluate the impact of the ACHD guidelines on the Legionella diagnostic and preventive practices of health care facilities in Allegheny and surrounding counties and (2) compare the incidence of health care-acquired LD before and after issuance of the ACHD guidelines. METHODS: CDC case reports of LD from 1991 to 2001 were tabulated and compiled by the ACHD Infectious Disease Unit and the Association for Professionals in Infection Control and Epidemiology, Inc, Three Rivers Chapter. A survey was distributed to 110 hospitals and long-term care facilities in the region. The results were analyzed as occurring either in the preguideline period (1991-1994) or postguideline period (1995-2001). RESULTS: A significant decrease in the number of health care-acquired cases was demonstrated between the preguideline (33%) and postguideline (9%) periods (P=.0001). In contrast, community-acquired cases increased from 67% pre guideline to 91% post guideline. A total of 71% of the facilities were colonized with Legionella. Disinfection of the water distribution system was initiated by 44% of facilities. Use of urinary antigen testing significantly increased from 40% pre guideline to 79% post guideline (P=.0001). CONCLUSIONS: Health care-acquired LD declined significantly after the issuance of guidelines for prevention and control of health care-acquired LD. The decline was associated with health care facilities performing routine environmental monitoring of their water distribution systems followed by the initiation of disinfection methods if indicated. Two unanticipated benefits were (1) cases of LD in the community and long-term care facilities were uncovered as a result of increased availability of Legionella tests and (2) litigation and unfavorable publicity involving ACHD hospitals ceased. [ABSTRACT FROM AUTHOR]

Background: Although fluoroquinolones possess excellent in vitro activity against Legionella, few large-scale clinical trials have examined their efficacy in the treatment of Legionnaires disease. Even fewer studies have applied rigorous criteria for diagnosis of community-acquired Legionnaires disease, including culture of respiratory secretions on selective media.Methods: Data from six clinical trials encompassing 1,997 total patients have been analyzed to determine the efficacy of levofloxacin (500 mg qd or 750 mg qd) in treating patients with community-acquired pneumonia (CAP) due to Legionella.Results: Of the 1,997 total patients with CAP from the clinical trials, 75 patients had infection with a Legionella species. Demographics showed a large portion of these patients were < 55 years of age and nonsmokers. More than 90% of mild-to-moderate and severe cases of Legionella infection resolved clinically at the posttherapy visit, 2 to 14 days after treatment termination. No deaths were reported for any patient with Legionnaires disease treated with levofloxacin during the studies.Conclusions: Levofloxacin was efficacious at both 500 mg for 7 to 14 days and 750 mg for 5 days. Legionnaires disease is not associated only with smokers, the elderly, and the immunosuppressed, but also has the potential to affect a broader demographic range of the general population than previously thought. [ABSTRACT FROM AUTHOR]

Two women in their late 20s present to you with histories of abdominal swelling, vomiting, and diarrhea. In both cases, CT scan reveals ascites. Is this ovarian cancer...or something else? You make the diagnosis. [ABSTRACT FROM AUTHOR]

Environmental monitoring and clinical surveillance for Legionella species were done for 12 months as recommended by the Allegheny County Health Department (Pittsburgh). The water system of a hospital was found to be colonized with Legionella pneumophila serogroup 5. Three patients with nosocomial L. pneumophila serogroup 5 disease were subsequently diagnosed after laboratory tests for legionellae were made available for all patients with nosocomial pneumonia. All serogroup 5 isolates from the hospital water matched the 3 patient isolates by pulsed-field gel electrophoresis (PFGE). Furthermore, isolates found in the water supply dating back 10 years showed the same PFGE pattern. In contrast, 12 L. pneumophila serogroup 5 isolates from eight other institutions had different PFGE patterns. Routine environmental cultures were important in stimulating the application of Legionella laboratory testing, which subsequently identified unsuspected patients with nosocomial legionnaires' disease. [ABSTRACT FROM AUTHOR]

We evaluated a human monocyte cell line (HL-60) as a model for testing the intracellular activity of anti-Legionella antibiotics; 1.5 x 10(6) HL-60 cells/well were differentiated into adherent cells and infected with 1.5 x 10(7) cfu of Legionella pneumophila. The most active agents against L. pneumophila as judged by broth dilution MICs were (in order of activity) azithromycin, clarithromycin, roxithromycin, quinupristin/dalfopristin, erythromycin and dirithromycin. The most active inhibitors of L. pneumophila intracellular multiplication were (in order of activity) azithromycin, erythromycin, quinupristin/dalfopristin, roxithromycin, dirithromycin and clarithromycin. All the agents were highly active against Legionella micdadei and Legionella bozemanii when compared with L. pneumophila. [ABSTRACT FROM AUTHOR]

Abstract Sport nutrition is a constantly evolving field with literally thousands of research papers published annually. For this reason, keeping up to date with the literature is often difficult. This paper presents a well-referenced overview of the current state of the science related to how to optimize training through nutrition. More specifically, this article discusses: 1.) how to evaluate the scientific merit of nutritional supplements; 2.) general nutritional strategies to optimize performance and enhance recovery; and, 3.) our current understanding of the available science behind weight gain, weight loss, and performance enhancement supplements. Our hope is that ISSN members find this review useful in their daily practice and consultation with their clients.

Abstract Position Statement: The International Society of Sports Nutrition (ISSN) bases the following position stand on a critical analysis of the literature on the use of beta-hydroxy-beta-methylbutyrate (HMB) as a nutritional supplement. The ISSN has concluded the following. 1. HMB can be used to enhance recovery by attenuating exercise induced skeletal muscle damage in trained and untrained populations. 2. If consuming HMB, an athlete will benefit from consuming the supplement in close proximity to their workout. 3. HMB appears to be most effective when consumed for 2 weeks prior to an exercise bout. 4. Thirty-eight mg·kg·BM-1 daily of HMB has been demonstrated to enhance skeletal muscle hypertrophy, strength, and power in untrained and trained populations when the appropriate exercise prescription is utilized. 5. Currently, two forms of HMB have been used: Calcium HMB (HMB-Ca) and a free acid form of HMB (HMB-FA). HMB-FA may increase plasma absorption and retention of HMB to a greater extent than HMB-CA. However, research with HMB-FA is in its infancy, and there is not enough research to support whether one form is superior. 6. HMB has been demonstrated to increase LBM and functionality in elderly, sedentary populations. 7. HMB ingestion in conjunction with a structured exercise program may result in greater declines in fat mass (FM). 8. HMB’s mechanisms of action include an inhibition and increase of proteolysis and protein synthesis, respectively. 9. Chronic consumption of HMB is safe in both young and old populations.

Abstract Position Statement: The International Society of Sports Nutrition (ISSN) bases the following position stand on a critical analysis of the literature on the safety and efficacy of the use of energy drinks (ED) or energy shots (ES). The ISSN has concluded the following. 1. Although ED and ES contain a number of nutrients that are purported to affect mental and/or physical performance, the primary ergogenic nutrients in most ED and ES appear to be carbohydrate and/or caffeine. 2. The ergogenic value of caffeine on mental and physical performance has been well-established but the potential additive benefits of other nutrients contained in ED and ES remains to be determined. 3. Consuming ED 10-60 minutes before exercise can improve mental focus, alertness, anaerobic performance, and/or endurance performance. 4. Many ED and ES contain numerous ingredients; these products in particular merit further study to demonstrate their safety and potential effects on physical and mental performance. 5. There is some limited evidence that consumption of low-calorie ED during training and/or weight loss trials may provide ergogenic benefit and/or promote a small amount of additional fat loss. However, ingestion of higher calorie ED may promote weight gain if the energy intake from consumption of ED is not carefully considered as part of the total daily energy intake. 6. Athletes should consider the impact of ingesting high glycemic load carbohydrates on metabolic health, blood glucose and insulin levels, as well as the effects of caffeine and other stimulants on motor skill performance. 7. Children and adolescents should only consider use of ED or ES with parental approval after consideration of the amount of carbohydrate, caffeine, and other nutrients contained in the ED or ES and a thorough understanding of the potential side effects. 8. Indiscriminant use of ED or ES, especially if more than one serving per day is consumed, may lead to adverse events and harmful side effects. 9. Diabetics and individuals with pre-existing cardiovascular, metabolic, hepatorenal, and neurologic disease who are taking medications that may be affected by high glycemic load foods, caffeine, and/or other stimulants should avoid use of ED and/or ES unless approved by their physician.

Abstract Background Phosphatidic acid (PA) has been reported to activate the mammalian target of rapamycin (mTOR) signaling pathway and is thought to enhance the anabolic effects of resistance training. The purpose of this pilot study was to examine if oral phosphatidic acid administration can enhance strength, muscle thickness and lean tissue accruement during an 8-week resistance training program. Methods Sixteen resistance-trained men were randomly assigned to a group that either consumed 750 mg of PA (n = 7, 23.1 ± 4.4 y; 176.7 ± 6.7 cm; 86.5 ± 21.2 kg) or a placebo (PL, n = 9, 22.5 ± 2.0 y; 179.8 ± 5.4 cm; 89.4 ± 13.6 kg) group. During each testing session subjects were assessed for strength (one repetition maximum [1-RM] bench press and squat) and body composition. Muscle thickness and pennation angle were also measured in the vastus lateralis of the subject’s dominant leg. Results Subjects ingesting PA demonstrated a 12.7% increase in squat strength and a 2.6% increase in LBM, while subjects consuming PL showed a 9.3% improvement in squat strength and a 0.1% change in LBM. Although parametric analysis was unable to demonstrate significant differences, magnitude based inferences indicated that the Δ change in 1-RM squat showed a likely benefit from PA on increasing lower body strength and a very likely benefit for increasing lean body mass (LBM). Conclusions Results of this study suggest that a combination of a daily 750 mg PA ingestion, combined with a 4-day per week resistance training program for 8-weeks appears to have a likely benefit on strength improvement, and a very likely benefit on lean tissue accruement in young, resistance trained individuals.

Abstract Background A dietary supplement containing a blend of 170 mg of N-oleyl-phosphatidylethanolamine (NOPE) and 100 mg of epigallocatechin-3-gallate (EGCG) has been shown to improve compliance to low caloric diets. Considering the cost of dietary ingredients, many manufacturers attempt to determine the lowest efficacious dose. Thus, the purpose of this study was to evaluate the efficacy of 8-weeks of supplementation with a daily intake of 120 mg of NOPE and 105 mg of EGCG in conjunction with a low caloric diet and regular, moderate exercise on dietary compliance in healthy, overweight adults. An additional purpose was to examine the effect of this supplement/diet/exercise paradigm on changes in body composition, sensation of appetite, mood and severity of binge eating. Methods Fifty healthy, overweight (BMI > 25 m·kg2) men (15) and women (35) (SUP; n = 25; 32.7 ± 13.75 y; BMI = 33.4 ± 6.2; PLA; n = 25, 34.3 ± 12.7 years; BMI = 33.2 ± 6.8) were recruited for a double-blind, placebo controlled study. Each volunteer was randomly assigned to either the supplement (SUP; n = 25) or placebo group (PLA; n = 25). Based upon a self-reported 3-day dietary recall all volunteers were recommended a 500 kcal or 30% (maximum of 1000 kcal) reduction in caloric intake. Volunteers were also encouraged to exercise 30 minutes per day, three times per week. Results Subjects in SUP were significantly more compliant (x2 = 3.86, p = 0.049) in maintaining a low caloric diet at week 4, but this was not able to be maintained through the 8-week study. In addition, a significant difference in mood, feelings of fatigue and confusion were noted between the groups at week 4, but again not maintained by week 8 where only feelings of tension were improved. No differences between groups (p > 0.05) were observed for body mass, body composition, feelings of hunger, and binge eating after eight weeks. Conclusion Supplementing with a combination of 120 mg of NOPE and 105 mg of EGCG does appear to enhance compliance to a low caloric diet and improve mood for 4 –weeks, but loses its effectiveness by week 8.

Abstract Purpose To determine the effects of 16 wk. of beta-hydroxy-beta-methylbutyrate (HMB) administration on age-related changes in functionality and diffusion tensor imaging (DTI) determined myofiber dimensions. Methods Twelve young (44 wk.), 6 middle-aged (60 wk.), 10 old (86 wk.), and 5 very old (102 wk.) male Fisher-344 rat's body composition and grip strength were assessed at baseline. Following, 6 young, 6 middle-aged, 5 old and 5 very old rats were sacrificed for baseline myofiber dimensions and gene transcript factor expression in the soleus (SOL) and gastrocnemius (GAS). The remaining 6 young and 5 old rats were given HMB for 16 wk. and then sacrificed. Results Fat mass increased in the middle-aged control condition (+49%) but not the middle-aged HMB condition. In addition, fat mass declined (-56%) in the old HMB condition but not the old control condition. Normalized strength declined and maintained respectively in the control and HMB conditions from 44 to 60 wk. and increased (+23%) (p < 0.05) from 86 to 102 wk. in only the HMB condition. Declines occurred in myofiber size in all muscles from 44 to 102 wk. in the control condition(-10 to -15%), but not HMB condition. Atrogin-1 mRNA expression in the SOL and GAS muscles was greater in the 102-wk control condition than all other conditions: SOL (+45%) and GAS (+100%). This elevation was blunted by HMB in the 102 wk. old SOL. There was a condition effect in the SOL for myogenin, which significantly increased (+40%) only in the 102-wk. HMB group relative to the 44-wk. group. Conclusions HMB may blunt age-related losses of strength and myofiber dimensions, possibly through attenuating the rise in protein breakdown.

Abstract Position Statement: Admittedly, research to date examining the physiological effects of meal frequency in humans is somewhat limited. More specifically, data that has specifically examined the impact of meal frequency on body composition, training adaptations, and performance in physically active individuals and athletes is scant. Until more research is available in the physically active and athletic populations, definitive conclusions cannot be made. However, within the confines of the current scientific literature, we assert that: 1. Increasing meal frequency does not appear to favorably change body composition in sedentary populations. 2. If protein levels are adequate, increasing meal frequency during periods of hypoenergetic dieting may preserve lean body mass in athletic populations. 3. Increased meal frequency appears to have a positive effect on various blood markers of health, particularly LDL cholesterol, total cholesterol, and insulin. 4. Increased meal frequency does not appear to significantly enhance diet induced thermogenesis, total energy expenditure or resting metabolic rate. 5. Increasing meal frequency appears to help decrease hunger and improve appetite control. The following literature review has been prepared by the authors in support of the aforementioned position statement.

Abstract Regardless of age or gender, resistance training or provision of adequate amounts of dietary protein (PRO) or essential amino acids (EAA) can increase muscle protein synthesis (MPS) in healthy adults. Combined PRO or EAA ingestion proximal to resistance training, however, can augment the post-exercise MPS response and has been shown to elicit a greater anabolic effect than exercise plus carbohydrate. Unfortunately, chronic/adaptive response data comparing the effects of different protein sources is limited. A growing body of evidence does, however, suggest that dairy PRO, and whey in particular may: 1) stimulate the greatest rise in MPS, 2) result in greater muscle cross-sectional area when combined with chronic resistance training, and 3) at least in younger individuals, enhance exercise recovery. Therefore, this review will focus on whey protein supplementation and its effects on skeletal muscle mass when combined with heavy resistance training.

Abstract Background A randomized, single-blinded, placebo-controlled, parallel design study was used to examine the effects of a pre-workout supplement combined with three weeks of high-intensity interval training (HIIT) on aerobic and anaerobic running performance, training volume, and body composition. Methods Twenty-four moderately-trained recreational athletes (mean ± SD age = 21.1 ± 1.9 yrs; stature = 172.2 ± 8.7 cm; body mass = 66.2 ± 11.8 kg, VO2max = 3.21 ± 0.85 l·min-1, percent body fat = 19.0 ± 7.1%) were assigned to either the active supplement (GT, n = 13) or placebo (PL, n = 11) group. The active supplement (Game Time®, Corr-Jensen Laboratories Inc., Aurora, CO) was 18 g of powder, 40 kcals, and consisted of a proprietary blend including whey protein, cordyceps sinensis, creatine, citrulline, ginseng, and caffeine. The PL was also 18 g of powder, 40 kcals, and consisted of only maltodextrin, natural and artificial flavors and colors. Thirty minutes prior to all testing and training sessions, participants consumed their respective supplements mixed with 8-10 oz of water. Both groups participated in a three-week HIIT program three days per week, and testing was conducted before and after the training. Cardiovascular fitness (VO2max) was assessed using open circuit spirometry (Parvo-Medics TrueOne® 2400 Metabolic Measurement System, Sandy, UT) during graded exercise tests on a treadmill (Woodway, Pro Series, Waukesha, WI). Also, four high-speed runs to exhaustion were conducted at 110, 105, 100, and 90% of the treadmill velocity recorded during VO2max, and the distances achieved were plotted over the times-to-exhaustion. Linear regression was used to determine the slopes (critical velocity, CV) and y-intercepts (anaerobic running capacity, ARC) of these relationships to assess aerobic and anaerobic performances, respectively. Training volumes were tracked by summing the distances achieved during each training session for each subject. Percent body fat (%BF) and lean body mass (LBM) were assessed with air-displacement plethysmography (BOD POD®, Life Measurement, Inc., Concord, CA). Results Both GT and PL groups demonstrated a significant (p = 0.028) increase in VO2max from pre- to post-training resulting in a 10.3% and 2.9% improvement, respectively. CV increased (p = 0.036) for the GT group by 2.9%, while the PL group did not change (p = 0.256; 1.7% increase). ARC increased for the PL group by 22.9% and for the GT group by 10.6%. Training volume was 11.6% higher for the GT versus PL group (p = 0.041). %BF decreased from 19.3% to 16.1% for the GT group and decreased from 18.0% to 16.8% in the PL group (p = 0.178). LBM increased from 54.2 kg to 55.4 kg (p = 0.035) for the GT group and decreased from 52.9 kg to 52.4 kg in the PL group (p = 0.694). Conclusion These results demonstrated improvements in VO2max, CV, and LBM when GT is combined with HIIT. Three weeks of HIIT alone also augmented anaerobic running performance, VO2max and body composition.

Abstract Position Statement: The position of The Society regarding caffeine supplementation and sport performance is summarized by the following seven points: 1.) Caffeine is effective for enhancing sport performance in trained athletes when consumed in low-to-moderate dosages (~3-6 mg/kg) and overall does not result in further enhancement in performance when consumed in higher dosages (≥ 9 mg/kg). 2.) Caffeine exerts a greater ergogenic effect when consumed in an anhydrous state as compared to coffee. 3.) It has been shown that caffeine can enhance vigilance during bouts of extended exhaustive exercise, as well as periods of sustained sleep deprivation. 4.) Caffeine is ergogenic for sustained maximal endurance exercise, and has been shown to be highly effective for time-trial performance. 5.) Caffeine supplementation is beneficial for high-intensity exercise, including team sports such as soccer and rugby, both of which are categorized by intermittent activity within a period of prolonged duration. 6.) The literature is equivocal when considering the effects of caffeine supplementation on strength-power performance, and additional research in this area is warranted. 7.) The scientific literature does not support caffeine-induced diuresis during exercise, or any harmful change in fluid balance that would negatively affect performance.

Abstract Background High-intensity interval training has been shown to be a time-efficient way to induce physiological adaptations similar to those of traditional endurance training. Creatine supplementation may enhance high-intensity interval training, leading to even greater physiological adaptations. The purpose of this study was to determine the effects of high-intensity interval training (HIIT) and creatine supplementation on cardiorespiratory fitness and endurance performance (maximal oxygen consumption (VO2PEAK), time-to-exhaustion (VO2PEAKTTE), ventilatory threshold (VT), and total work done (TWD)) in college-aged men. Methods Forty-three recreationally active men completed a graded exercise test to determine VO2PEAK, VO2PEAKTTE, and VT. In addition, participants completed a time to exhaustion (TTE) ride at 110% of the maximum workload reached during the graded exercise test to determine TWD (TTE (sec) × W = J). Following testing, participants were randomly assigned to one of three groups: creatine (creatine citrate) (Cr; n = 16), placebo (PL; n = 17), or control (n = 10) groups. The Cr and PL groups completed four weeks of HIIT prior to post-testing. Results Significant improvements in VO2PEAK and VO2PEAKTTE occurred in both training groups. Only the Cr group significantly improved VT (16% vs. 10% improvement in PL). No changes occurred in TWD in any group. Conclusion In conclusion, HIIT is an effective and time-efficient way to improve maximal endurance performance. The addition of Cr improved VT, but did not increase TWD. Therefore, 10 g of Cr per day for five days per week for four weeks does not seem to further augment maximal oxygen consumption, greater than HIIT alone; however, Cr supplementation may improve submaximal exercise performance.

Abstract Background The purpose of the present study was to examine the acute effects of a thermogenic nutritional supplement containing caffeine, capsaicin, bioperine, and niacin on muscular strength and endurance performance. Methods Twenty recreationally-active men (mean ± SD age = 21.5 ± 1.4 years; stature = 178.2 ± 6.3 cm; mass = 76.5 ± 9.9 kg; VO2 PEAK = 3.05 ± 0.59 L/min-1) volunteered to participate in this randomized, double-blinded, placebo-controlled, cross-over study. All testing took place over a three-week period, with each of the 3 laboratory visits separated by 7 days (± 2 hours). During the initial visit, a graded exercise test was performed on a Lode Corival cycle ergometer (Lode, Groningen, Netherlands) until exhaustion (increase of 25 W every 2 min) to determine the maximum power output (W) at the VO2 PEAK (Parvo Medics TrueOne® 2400 Metabolic Measurement System, Sandy, Utah). In addition, one-repetition maximum (1-RM) strength was assessed using the bench press (BP) and leg press (LP) exercises. During visits 2 and 3, the subjects were asked to consume a capsule containing either the active supplement (200 mg caffeine, 33.34 mg capsaicin, 5 mg bioperine, and 20 mg niacin) or the placebo (175 mg of calcium carbonate, 160 mg of microcrystalline cellulose, 5 mg of stearic acid, and 5 mg of magnesium stearate in an identical capsule) 30 min prior to the testing. Testing included a time-to-exhaustion (TTE) ride on a cycle ergometer at 80% of the previously-determined power output at VO2 PEAK followed by 1-RM LP and BP tests. Results There were no differences (p > 0.05) between the active and placebo trials for BP, LP, or TTE. However, for the BP and LP scores, the baseline values (visit 1) were less than the values recorded during visits 2 and 3 (p ≤ 0.05). Conclusion Our findings indicated that the active supplement containing caffeine, capsaicin, bioperine, and niacin did not alter muscular strength or cycling endurance when compared to a placebo trial. The lack of increases in BP and LP strength and cycle ergometry endurance elicited by this supplement may have been related to the relatively small dose of caffeine, the high intensity of exercise, the untrained status of the participants, and/or the potential for caffeine and capsaicin to increase carbohydrate oxidation.

Abstract Background Intermittent bouts of high-intensity exercise result in diminished stores of energy substrates, followed by an accumulation of metabolites, promoting chronic physiological adaptations. In addition, β-alanine has been accepted has an effective physiological hydrogen ion (H+) buffer. Concurrent high-intensity interval training (HIIT) and β-alanine supplementation may result in greater adaptations than HIIT alone. The purpose of the current study was to evaluate the effects of combining β-alanine supplementation with high-intensity interval training (HIIT) on endurance performance and aerobic metabolism in recreationally active college-aged men. Methods Forty-six men (Age: 22.2 ± 2.7 yrs; Ht: 178.1 ± 7.4 cm; Wt: 78.7 ± 11.9; VO2peak: 3.3 ± 0.59 l·min-1) were assessed for peak O2 utilization (VO2peak), time to fatigue (VO2TTE), ventilatory threshold (VT), and total work done at 110% of pre-training VO2peak (TWD). In a double-blind fashion, all subjects were randomly assigned into one either a placebo (PL – 16.5 g dextrose powder per packet; n = 18) or β-alanine (BA – 1.5 g β-alanine plus 15 g dextrose powder per packet; n = 18) group. All subjects supplemented four times per day (total of 6 g/day) for the first 21-days, followed by two times per day (3 g/day) for the subsequent 21 days, and engaged in a total of six weeks of HIIT training consisting of 5–6 bouts of a 2:1 minute cycling work to rest ratio. Results Significant improvements in VO2peak, VO2TTE, and TWD after three weeks of training were displayed (p < 0.05). Increases in VO2peak, VO2TTE, TWD and lean body mass were only significant for the BA group after the second three weeks of training. Conclusion The use of HIIT to induce significant aerobic improvements is effective and efficient. Chronic BA supplementation may further enhance HIIT, improving endurance performance and lean body mass.

Abstract Background Ageing is associated with a significant reduction in skeletal muscle carnosine which has been linked with a reduction in the buffering capacity of muscle and in theory, may increase the rate of fatigue during exercise. Supplementing beta-alanine has been shown to significantly increase skeletal muscle carnosine. The purpose of this study, therefore, was to examine the effects of ninety days of beta-alanine supplementation on the physical working capacity at the fatigue threshold (PWCFT) in elderly men and women. Methods Using a double-blind placebo controlled design, twenty-six men (n = 9) and women (n = 17) (age ± SD = 72.8 ± 11.1 yrs) were randomly assigned to either beta-alanine (BA: 800 mg × 3 per day; n = 12; CarnoSyn™) or Placebo (PL; n = 14) group. Before (pre) and after (post) the supplementation period, participants performed a discontinuous cycle ergometry test to determine the PWCFT. Results Significant increases in PWCFT (28.6%) from pre- to post-supplementation were found for the BA treatment group (p < 0.05), but no change was observed with PL treatment. These findings suggest that ninety days of BA supplementation may increase physical working capacity by delaying the onset of neuromuscular fatigue in elderly men and women. Conclusion We suggest that BA supplementation, by improving intracellular pH control, improves muscle endurance in the elderly. This, we believe, could have importance in the prevention of falls, and the maintenance of health and independent living in elderly men and women.

Abstract Background We have recently demonstrated that consuming a thermogenic drink (TD) acutely increases energy expenditure and serum markers of lipolysis in healthy, college-aged individuals. The purpose of this study was to determine if consuming TD over 28 days affects its acute thermogenic and lipolytic effects as well as body composition and clinical chemistry safety markers. Methods Sixty healthy, males (mean ± SE; 23 ± 1 years, 177 ± 2 cm, 81.7 ± 2.1 kg, 22.8 ± 1.4% body fat; n = 30) and females (23 ± 1 years, 166 ± 2 cm, 62.1 ± 1.8 kg, 28.3 ± 1.4% body fat; n = 30) reported to the laboratory on day 0 (T1) for determination of body composition, resting energy expenditure (REE) as well as glycerol and free fatty acid (FFA) levels before and after ingesting either 336 ml of TD or a non-caloric, non-caffeinated placebo (PLA) drink. Following day 0, participants supplemented daily with 336 ml·day-1 of either TD or PLA and repeated identical testing procedures on day 28 (T2). Day 28 area under the curve (AUC) values were calculated for REE, FFA, and glycerol. Day 28 acute data and prolonged AUC comparisons between groups were analyzed using ANOVAs with repeated measures. Results Percent body fat (p = 0.02) and fat mass (p = 0.01) decreased in the TD group compared to the PLA group after 28 days. Day 28 FFA AUC values (p = 0.048) were greater in the TD group compared to the PLA group. There was no significant difference in day 28 REE AUC values (p = 0.30) or glycerol AUC values (p = 0.21), although a significant increase in REE values in the PLA group may have confounded these findings. There were no differences between groups concerning blood and clinical safety markers. Conclusion Within-group elevations in FFA and REE values in the TD group were still evident following a 28-day supplementation period which may contribute to the observed decrements in %BF. Further, prolonged TD supplementation did not alter the assessed clinical safety markers. Future studies should examine the synergistic and independent effects of the active ingredients in addition to effects of longer ingestion periods of TD ingestion with or without exercise at promoting and sustaining changes in body composition.

Abstract Position Statement: The position of the Society regarding nutrient timing and the intake of carbohydrates, proteins, and fats in reference to healthy, exercising individuals is summarized by the following eight points: 1.) Maximal endogenous glycogen stores are best promoted by following a high-glycemic, high-carbohydrate (CHO) diet (600 – 1000 grams CHO or ~8 – 10 g CHO/kg/d), and ingestion of free amino acids and protein (PRO) alone or in combination with CHO before resistance exercise can maximally stimulate protein synthesis. 2.) During exercise, CHO should be consumed at a rate of 30 – 60 grams of CHO/hour in a 6 – 8% CHO solution (8 – 16 fluid ounces) every 10 – 15 minutes. Adding PRO to create a CHO:PRO ratio of 3 – 4:1 may increase endurance performance and maximally promotes glycogen re-synthesis during acute and subsequent bouts of endurance exercise. 3.) Ingesting CHO alone or in combination with PRO during resistance exercise increases muscle glycogen, offsets muscle damage, and facilitates greater training adaptations after either acute or prolonged periods of supplementation with resistance training. 4.) Post-exercise (within 30 minutes) consumption of CHO at high dosages (8 – 10 g CHO/kg/day) have been shown to stimulate muscle glycogen re-synthesis, while adding PRO (0.2 g – 0.5 g PRO/kg/day) to CHO at a ratio of 3 – 4:1 (CHO: PRO) may further enhance glycogen re-synthesis. 5.) Post-exercise ingestion (immediately to 3 h post) of amino acids, primarily essential amino acids, has been shown to stimulate robust increases in muscle protein synthesis, while the addition of CHO may stimulate even greater levels of protein synthesis. Additionally, pre-exercise consumption of a CHO + PRO supplement may result in peak levels of protein synthesis. 6.) During consistent, prolonged resistance training, post-exercise consumption of varying doses of CHO + PRO supplements in varying dosages have been shown to stimulate improvements in strength and body composition when compared to control or placebo conditions. 7.) The addition of creatine (Cr) (0.1 g Cr/kg/day) to a CHO + PRO supplement may facilitate even greater adaptations to resistance training. 8.) Nutrient timing incorporates the use of methodical planning and eating of whole foods, nutrients extracted from food, and other sources. The timing of the energy intake and the ratio of certain ingested macronutrients are likely the attributes which allow for enhanced recovery and tissue repair following high-volume exercise, augmented muscle protein synthesis, and improved mood states when compared with unplanned or traditional strategies of nutrient intake.

Abstract Background Exercise and high-protein/reduced-carbohydrate and -fat diets have each been shown separately, or in combination with an energy-restricted diet to improve body composition and health in sedentary, overweight (BMI > 25) adults. The current study, instead, examined the physiological response to 10 weeks of combined aerobic and resistance exercise (EX) versus exercise + minimal nutrition intervention designed to alter the macronutrient profile, in the absence of energy restriction, using a commercially available high-protein/low-carbohydrate and low-fat, nutrient-dense food supplement (EXFS); versus control (CON). Methods Thirty-eight previously sedentary, overweight subjects (female = 19; male = 19) were randomly assigned to either CON (n = 10), EX (n = 14) or EXFS (n = 14). EX and EXFS participated in supervised resistance and endurance training (2× and 3×/wk, respectively); EXFS consumed 1 shake/d (weeks 1 and 2) and 2 shakes/d (weeks 3–10). Results EXFS significantly decreased total energy, carbohydrate and fat intake (-14.4%, -27.2% and -26.7%, respectively; p < 0.017), and increased protein and fiber intake (+52.1% and +21.2%, respectively; p < 0.017). EX and EXFS significantly decreased fat mass (-4.6% and -9.3%, respectively; p < 0.017), with a greater (p < 0.05) decrease in EXFS than EX and CON. Muscle mass increase only reached significance in EXFS (+2.3%; p < 0.017), which was greater (p < 0.05) than CON but not EX (+1.1%). Relative VO2max improved in both exercise groups (EX = +5.0% and EXFS = +7.9%; p < 0.017); however, only EXFS significantly improved absolute VO2max (+6.2%; p = 0.001). Time-to-exhaustion during treadmill testing increased in EX (+9.8%) but was significantly less (p < 0.05) than in EXFS (+21.2%). Total cholesterol and LDL decreased only in the EXFS (-12.0% and -13.3%, respectively; p < 0.017). Total cholesterol-to-HDL ratio, however, decreased significantly (p < 0.017) in both exercise groups. Conclusion Absent energy restriction or other dietary controls, provision of a high-protein/low-carbohydrate and -fat, nutrient-dense food supplement significantly, 1) modified ad libitum macronutrient and energy intake (behavior effect), 2) improved physiological adaptations to exercise (metabolic advantage), and 3) reduced the variability of individual responses for fat mass, muscle mass and time-to-exhaustion – all three variables improving in 100% of EXFS subjects.

Abstract Background Total body water (TBW) estimations have been used to estimate body composition, particularly fat-free mass, to aid in nutritional interventions, and to monitor hydration status. In the past, bioimpedance spectroscopy (BIS) devices have been used to estimate TBW. Previous investigations have examined the validity of the XiTRON 4000B (XiTRON Technologies) BIS device for estimating TBW. Recently, a new BIS device (Imp™ SFB7) has become available, claiming greater precision when estimating TBW. The Imp™ SFB7 (SFB7) is based on similar BIS principles, while offering increased portability and a greater range of frequencies when compared to older devices, such as the XiTRON 4000B (4000B). The purpose of this study was to examine the validity of the SFB7 for estimating total body water in healthy college-age men and women compared to the 4000B and deuterium oxide (D2O). Methods Twenty-eight Caucasian men and women (14 men, 14 women; 24 ± 4 yrs; 174.6 ± 8.7 cm; 72.80 ± 17.58 kg) had their TBW estimated by the SFB7, the 4000B, and D2O. Results Both BIS devices produced similar standard error of estimate (SEE) and r values (SFB7, SEE = 2.12L, r = 0.98; 4000B, SEE = 2.99L, r = 0.96) when compared to D2O, though a significant constant error (CE) was detected for the 4000B (2.26L, p ≤ 0.025). The 4000B produced a larger total error (TE) and CE (TE = 3.81L, CE = 2.26L) when compared to the SFB7 (TE = 2.21L, CE = -0.09L). Additionally, the limits of agreement were larger for the 4000B (-3.88 to 8.39L) than the SFB7 (-4.50 to 4.31L). These results were consistent when sex was analyzed separately, though women produced lower SEE and TE values for both devices. Conclusion The 4000B and SFB7 are valid BIS devices when compared to D2O to estimate TBW in college-age Caucasian men and women. Furthermore, the new SFB7 device displayed greater precision in comparison to the 4000B, which may decrease the error when estimating TBW on an individual basis.

Abstract Background To determine the acute effects of ingesting a thermogenic drink (Celsius, Delray Beach, FL) (TD) on changes in metabolism and lipolysis. Methods Healthy college-aged male (23.2 ± 4.0 y, 177.2 ± 6.1 cm, 81.7 ± 11.3 kg, 22.8 ± 7.3 % fat; n = 30) and female (23.4 ± 3.1 y, 165.6 ± 8.7 cm, 62.1 ± 9.9 kg, 28.3 ± 7.4 % fat; n = 30) participants were matched according to height and weight to consume 336 ml of the TD or a non-caloric, non-caffeinated placebo (PLA). After a 12 h fast, participants reported for pre-consumption measures of height, weight, heart rate, blood pressure, resting energy expenditure (REE), respiratory exchange ratio (RER), glycerol and free-fatty acid (FFA) concentrations. REE and RER were determined at 60, 120, and 180 min post-consumption. Serum glycerol and FFA concentrations were determined at 30, 60, 120 and 180 min post-consumption. Results When compared to PLA, TD significantly increased REE at 60, 120 and 180 min (p < 0.05). FFA concentrations were significantly greater in TD compared to PLA at 30, 60, 120 and 180 min post-consumption (p < 0.05). No between-group differences were found in RER. Conclusion Acute TD ingestion significantly increased REE, FFA and glycerol appearance. If sustained, these changes may help to promote weight loss and improve body composition; however, these findings are currently unknown as are the general safety and efficacy of prolonged consumption.

Abstract Background The present study examined the acute effects of a nutritional supplement intended to improve adenosine triphosphate (ATP) concentrations on vertical jump height, isometric strength of the leg extensors, leg extension endurance, and forearm flexion endurance. Methods Twenty-four healthy men (mean age ± SD = 23 ± 4 yrs, stature = 181 ± 7 cm, and body mass = 82 ± 12 kg) volunteered to complete a familiarization trial plus 2 randomly-ordered experimental trials separated by a 7-day washout period. Participants received either 6 (body mass < 91 kg) or 8 (body mass ≥ 91 kg) tablets of the treatment (TR; 625 mg of adenylpyrophosphoric acid and calcium pyruvate, 350.8 mg of cordyceps sinensis extract and yohimbine hydrochloride) or placebo (PL; 980 mg of microcrystalline cellulose) 1 hour prior to the following tests: countermovement vertical jump (CVJ), forearm flexion repetitions to exhaustion, isometric maximal voluntary contractions (MVCs) of the leg extensors, and a 50-repetition maximal concentric isokinetic leg extension endurance test. Results There were no differences between the TR and PL trials for CVJ height (P > 0.05), isometric MVC peak torque (P > 0.05), maximal concentric isokinetic peak torque (P > 0.05), percent decline during the leg extension endurance tests (P > 0.05), or repetitions to exhaustion during the forearm flexion endurance tests (P > 0.05). Conclusion These findings indicated no improvements in the measured variables as a result of ingesting this nutritional supplement. Future studies should examine whether chronic supplementation or a loading period is necessary to observe any ergogenic effects of this supplement.

Abstract The purpose of this study was to examine the effects of 5 days of Creatine (Cr) loading on the electromyographic fatigue threshold (EMGFT) in college-aged women. Fifteen healthy college-aged women (mean ± SD = 22.3 ± 1.7 yrs) volunteered to participate in this double-blind, placebo-controlled study and were randomly placed into either placebo (PL – 10 g of flavored dextrose powder; n = 8) or creatine (Cr – 5 g di-creatine citrate plus 10 g of flavored dextrose powder; n = 7; Creatine Edge, FSI Nutrition) loading groups. Each group ingested one packet 4 times per day (total of 20 g/day) for 5 days. Prior to and following supplementation, each subject performed a discontinuous incremental cycle ergometer test to determine their EMGFT value, using bipolar surface electrodes placed on the longitudinal axis of the right vastus lateralis. Subjects completed a total of four, 60 second work bouts (ranging from 100–350 W). The EMG amplitude was averaged over 10 second intervals and plotted over the 60 second work bout. The resulting slopes from each successive work bouts were used to calculate EMGFT. A two-way ANOVA (group [Cr vs. PL] × time [pre vs. post]) resulted in a significant (p = 0.031) interaction. Furthermore, a dependent samples t-test showed a 14.5% ± 3.5% increase in EMGFT from pre- to post-supplementation with Cr (p = 0.009), but no change for the PL treatment (-2.2 ± 5.8%; p = 0.732). In addition, a significant increase (1.0 ± 0.34 kg; p = 0.049) in weight (kg) was observed in the Cr group but no change for PL (-0.2 kg ± 0.2 kg). These findings suggest that 5 days of Cr loading in women may be an effective strategy for delaying the onset of neuromuscular fatigue during cycle ergometry.

Abstract Background Methods used to estimate percent body fat can be classified as a laboratory or field technique. However, the validity of these methods compared to multiple-compartment models has not been fully established. This investigation sought to determine the validity of field and laboratory methods for estimating percent fat (%fat) in healthy college-age women compared to the Siri three-compartment model (3C). Methods Thirty Caucasian women (21.1 ± 1.5 yrs; 164.8 ± 4.7 cm; 61.2 ± 6.8 kg) had their %fat estimated by BIA using the BodyGram™ computer program (BIA-AK) and population-specific equation (BIA-Lohman), NIR (Futrex® 6100/XL), a quadratic (SF3JPW) and linear (SF3WB) skinfold equation, air-displacement plethysmography (BP), and hydrostatic weighing (HW). Results All methods produced acceptable total error (TE) values compared to the 3C model. Both laboratory methods produced similar TE values (HW, TE = 2.4%fat; BP, TE = 2.3%fat) when compared to the 3C model, though a significant constant error (CE) was detected for HW (1.5%fat, p ≤ 0.006). The field methods produced acceptable TE values ranging from 1.8 – 3.8 %fat. BIA-AK (TE = 1.8%fat) yielded the lowest TE among the field methods, while BIA-Lohman (TE = 2.1%fat) and NIR (TE = 2.7%fat) produced lower TE values than both skinfold equations (TE > 2.7%fat) compared to the 3C model. Additionally, the SF3JPW %fat estimation equation resulted in a significant CE (2.6%fat, p ≤ 0.007). Conclusion Data suggest that the BP and HW are valid laboratory methods when compared to the 3C model to estimate %fat in college-age Caucasian women. When the use of a laboratory method is not feasible, NIR, BIA-AK, BIA-Lohman, SF3JPW, and SF3WB are acceptable field methods to estimate %fat in this population.

Purpose: Report the clinical findings, risk factors, treatment, and visual outcomes associated with  Streptococcus  endophthalmitis in comparison to culture-positive endophthalmitis associated with non- Streptococcus  species., Methods: A retrospective chart review of adults between 18 and 89 years of age diagnosed with exogenous culture-positive endophthalmitis between January 1, 2009, and January 1, 2018, at the Duke Eye Center (Durham, North Carolina) with at least six months of follow-up from time of initial diagnosis was conducted. Clinical data including patient demographics, ocular history, baseline corrected visual acuity (VA) prior to presentation, time to presentation, presenting exam findings, VA at presentation, presumed etiology of endophthalmitis, medical and surgical management, and VA at the six-month follow-up was extracted and statistically analyzed., Results: Fifty-six eyes from 56 patients with culture-positive endophthalmitis were identified. Eyes with  Streptococcus  (n=18) had elevated intraocular pressure (IOP) at presentation (p=0.002), worse mean VA (Snellen) at presentation (20/14159 vs. 20/3098, p<0.001), and worse mean VA (Snellen) at six months (20/3475 vs. 20/235, p<0.001) compared to non- Streptococcus  cases (n=38). Time to presentation (days) (median, IQR) was longer in eyes that underwent glaucoma surgery for both Streptococcus (2241 (836, 3709) vs. 3 (2, 31), p=0.003) and non- Streptococcus  endophthalmitis (1236 (125, 3582) vs. 6 (4, 25), p<0.0001). There was no difference in VA at six months between  Streptococcus  and non- Streptococcus  eyes based on treatment.  Conclusions: Streptococci are rare but important causes of exogenous endophthalmitis, and in our study, they were associated with worse visual outcomes than non- Streptococci . A history of any glaucoma surgery, even procedures performed years earlier, should be elicited when evaluating patients with ocular symptoms., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Duke University Health System Institutional Review Board issued approval Pro00091062. Review charts and access patient data components were determined to be in compliance with all applicable Health Insurance Portability and Accountability Act (HIPAA) regulations. 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, Woodward et al.)

Background: Infectious diseases (ID) physicians are increasingly faced with the challenge of caring for patients with terminal illnesses or incurable infections., Methods: This was a retrospective cohort of all patients with an ID consult within an academic health system 1/1/2014 - 12/31/2023, including community, general, and transplant ID consult services., Results: There were 60,820 inpatient ID consults (17,235 community, 29,999 general, and 13,586 transplant) involving 37,848 unique patients. The number of consults increased by 94% and the rate rose from 5.0 to 9.9 consults per 100 inpatients (p<0.001). In total, 7.5% of patients receiving an ID consult died during admission, and 1,006 (2.6%) of patients were discharged to hospice. In-hospital mortality was 5.2% for community ID, 7.8% for general ID, and 10.7% for transplant ID patients (p<0.001). Six-month mortality was 9% for all non-obstetric admissions, , vs. 19% for community ID, 20.9% for general ID, and 22.3% for transplant ID.In total 2,866 (7.6%) of all patients receiving ID consultation also received palliative care consultation during the same hospitalization. The index ID consult preceded any palliative consult in the majority (69.5%) of cases. 16.3% of patients had a do-not-resuscitate order during the index hospitalization. 12.2% of all patients with a do-not-resuscitate order had this placed on the same day as the ID consult., Conclusions: Patients receiving ID consultation were increasingly complex and more likely to die soon after consultation. These results provide a framework for ID clinicians to consider their role in end-of-life care., (© 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.)

We identified 23 cases of Mycobacterium immunogenum respiratory acquisition linked to a colonized plumbing system at a new hospital addition. We conducted a genomic and epidemiologic investigation to assess for clonal acquisition of M. immunogenum from hospital water sources and improve understanding of genetic distances between M. immunogenum isolates. We performed whole-genome sequencing on 28 M . immunogenum isolates obtained from August 2013 to July 2021 from patients and water sources on four intensive care and intermediate units at an academic hospital. Study hospital isolates were recovered from 23 patients who experienced de novo respiratory isolation of M. immunogenum and from biofilms obtained from five tap water outlets. We also analyzed 10 M . immunogenum genomes from previously sequenced clinical ( n = 7) and environmental ( n = 3) external control isolates. The 38-isolate cohort clustered into three clades with pairwise single-nucleotide polymorphism (SNP) distances ranging from 0 to 106,697 SNPs. We identified two clusters of study hospital isolates in Clade 1 and one cluster in Clade 2 for which clinical and environmental isolates differed by fewer than 10 SNPs and had less than 0.5% accessory genome variation. A less restrictive combined threshold of 40 SNPs and 5% accessory genes reliably captured additional isolates that met clinical criteria for hospital acquisition, but 12 (4%) of 310 epidemiologically unrelated isolate pairs also met this threshold. Core and accessory genome analyses confirmed respiratory acquisition of multiple clones of M. immunogenum from hospital water sources to patients. When combined with epidemiologic investigation, genomic thresholds accurately distinguished hospital acquisition., Competing Interests: A.W.B. reports funding from Insmed for clinical trials (payments to the institution) and the Centers for Disease Control and Prevention (payments to the institution), outside of the submitted work. J.E.S. reports funding from AN2 Pharmaceuticals for clinical trials (payments to the institution), UpToDate, and the Academy for Continued Healthcare Learning, outside of the submitted work. A.M.G. reports participation on the Society for Healthcare Epidemiology of America Webinar Program Committee, outside of the submitted work. B.G.W. reports funding from the Centers for Disease Control and Prevention (contract paid to the institution) and participation on the Society for Healthcare Epidemiology of America Guidelines Committee, outside of the submitted work. M.J.L. reports equity in Resonantia Diagnostics and a pending patent pertaining to biofilm, outside of the submitted work. R.M.D. reports funding from the Cystic Fibrosis Foundation and the National Heart, Lung, and Blood Institute of the National Institutes of Health (grants paid to the institution), outside of the submitted work. D.J.A. reports funding from the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention (grants paid to the institution), as well as UpToDate and Infection Control Education for Major Sports, outside of the submitted work. All other authors have no potential conflicts of interest to declare.

Objective: Pandemic-associated stress may have exacerbated preexisting mental health and substance use disorders (MH/SUD) and caused new MH/SUD diagnoses which would be expected to lead to an increase in visits to emergency departments and hospital admissions for these conditions. This study assessed whether the proportion of hospital and emergency department encounters for MH/SUD diagnoses increased during the first year of the COVID-19 pandemic in the United States., Methods: We conducted a longitudinal (interrupted time series) analysis of 994,724 eligible encounters identified by electronic query between January 1, 2016 and March 31, 2021. Of these, 55,574 encounters involved MH/SUD diagnosis. The pre-pandemic period was defined as January 1, 2016 to March 31, 2020, and the pandemic period was defined as April 1, 2020 to March 31, 2021. All statistical analyses were performed with R., Results: No significant trend in MH/SUD encounters at baseline (rate ratio 1.00, 95% CI 0.99-1.01, p = 0.75) was observed. However, the onset of the pandemic was temporally associated with a significant level increase in the proportion of MH/SUD encounters relative to overall encounters (rate ratio 1.14, 95% CI 1.06-1.21, p<0.001) with no change in the overall trend (rate ratio 0.99, 95% CI 0.90-1.10, p = 0.89)., Conclusions: The significant pandemic-associated increase in the proportion of MH/SUD encounters relative to overall encounters was driven largely by sustained numbers of MH/ SUD encounters despite a decrease in total encounters. Increased support for mental health care is needed for these vulnerable patients during pandemics., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Der et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

A pseudo-outbreak of bronchoscopy-associated Mycobacterium chelonae and M. mucogenicum was traced to contaminated ice machine water and ice. A nonsterile ice bath was used to cool uncapped, sterile, saline syringes used to slow procedural bleeding. Joining the growing evidence of bronchoscopy pseudo-outbreaks, our investigation describes several lessons for future prevention.