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The duration of immunity after infection from SARS-CoV-2 conferring protection from subsequent COVID-19 episodes is not yet fully understood. We reviewed the literature for cases of documented reinfection.A comprehensive computerized search in PubMed, through 15 December 2020, using the following terms in combination:We identified 23 cases globally, for which viral genome analysis was performed in 10 cases and serology in 19 cases. The mean interval between the two episodes was 15 weeks. Mean age of cases was 44.5 years, and 10 (43.5%) were women. In 17/23 cases, no comorbidity was observed. In 10 cases, the first episode was more severe than the ensuing episode, whereas in seven cases the ensuing episode was more severe. In four cases, there was no difference in severity and in two cases both episodes were asymptomatic.From this sample of 23 cases, a clear pattern of the second episode being less or more severe did not emerge. A better understanding of immunity to SARS-CoV-2, necessary to assess the probability of a second infection and the durability of protection conferred by vaccination, is warranted.

To date the pathophysiology of COVID-19 remains unclear: this represents a factor determining the current lack of effective treatments. In this paper, we hypothesized a complex host response to SARS-CoV-2, with the Contact System (CS) playing a pivotal role in innate immune response. CS is linked with different proteolytic defense systems operating in human vasculature: the Kallikrein–Kinin (KKS), the Coagulation/Fibrinolysis and the Renin–Angiotensin (RAS) Systems. We investigated the role of the mediators involved. CS consists of Factor XII (FXII) and plasma prekallikrein (complexed to high-molecular-weight kininogen-HK). Autoactivation of FXII by contact with SARS-CoV-2 could lead to activation of intrinsic coagulation, with fibrin formation (microthrombosis), and fibrinolysis, resulting in increased D-dimer levels. Activation of kallikrein by activated FXII leads to production of bradykinin (BK) from HK. BK binds to B2-receptors, mediating vascular permeability, vasodilation and edema. B1-receptors, binding the metabolite [des-Arg9]-BK (DABK), are up-regulated during infections and mediate lung inflammatory responses. BK could play a relevant role in COVID-19 as already described for other viral models. Angiotensin-Converting-Enzyme (ACE) 2 displays lung protective effects: it inactivates DABK and converts Angiotensin II (Ang II) into Angiotensin-(1-7) and Angiotensin I into Angiotensin-(1-9). SARS-CoV-2 binds to ACE2 for cell entry, downregulating it: an impaired DABK inactivation could lead to an enhanced activity of B1-receptors, and the accumulation of Ang II, through a negative feedback loop, may result in decreased ACE activity, with consequent increase of BK. Therapies targeting the CS, the KKS and action of BK could be effective for the treatment of COVID-19.

The transformation of the Military Health System to the Defense Health Agency under the National Defense Authorization Act of 2017 is a change of historical proportion. Change can be seen as hard, yet change is always happening. What is actually hard is providing leadership to accomplish the mission and goals for ourselves and our organizations within constant change. Those of us selected for leadership positions often receive standardized preparation and experiences to help us with this challenge. The hard part, though, is not what we often think it is. Leadership is not hard because of the amount of change or the people we are leading. Leadership is hard because, as we increase our rank and responsibilities, there are more people we need to see as people, having an outward mindset toward them, to have a positive influence and impact. In this article, I share the challenge I experienced with an outward mindset in leading the transition of our military treatment facility under the transformation to Defense Health Agency.

Purpose. COVID-19 displays a variety of clinical manifestations; in pauci-symptomatic patients olfactory (OD) and gustatory dysfunctions (GD) may represent the first or only symptom. To date, literature addressing these disorders is scarce. Aim of this study is to investigate the timing of recovery from OD and GD in a real-life COVID-19 population.Methods. We followed up by a phone interview the first 100 patients discharged a month earlier from three Italian non-intensive care wards.Results. All patients were Caucasian, mean age was 65 years, 60% were males. OD and GD were early symptoms reported by 29% and 41% of patients, respectively. Among the 42 symptomatic patients, the male/female ratio was 2:1; 83% reported an almost resolved dysfunction at follow-up. The recovery rate was not significantly different between males and females. The mean duration of OD and GD was 18 and 16 days, respectively. The mean recovery time from OD or GD resulted significantly longer for females than for males (26 vs 14 days, p=0.009). Among the 42 symptomatic, the mean age of males was significantly higher than that of females (66 vs 57 years, p=0.04), while the opposite was observed in the 58 asymptomatic patients (60 vs 73 years, p=0.0018).Conclusions. Recovery from OD or GD was rapid, occurring within 4 weeks in most patients. Chemosensory dysfunctions in women was less frequent, but longer lasting. The value of our study is its focus on a significantly older population than those previously described, and to add further data on gender differences.

Purpose Infections caused by ESBL-producing Enterobacteriaceae (ESBL-EB) are a major health problem, but data regarding elderly patients is lacking. Methods We performed a retrospective observational study quantifying the effects of antimicrobial treatment and primary infection site on clinical outcomes in an historical case series of 42 patients aged 80.7 ± 10 years admitted to an Internal Medicine ward in Italy for ESBL-EB bloodstream infections (BSI). Results At multivariate risk analysis, we found that urinary tract as primary infection site (RR = 0.181 [0.037–0.886], p = 0.035) and definitive antibiotic therapy (RR = 0.517 [0.147–0.799], p = 0.038) decreased the relative risk of a negative clinical response, while the respiratory tract origin increased the relative risk (RR = 2.788 [1.407–9.228], p = 0.025). Also regarding 30 days mortality, multivariate risk analysis identified that urinary tract as primary infection site (RR = 0.098 [0.011–0.743], p = 0.025) and definitive antibiotic therapy (RR = 0.236 [0.058–0.961], p = 0.044) decreased the relative risk, while the respiratory origin increased the relative risk (RR = 4.241 [1.040–17.295], p = 0.014). We observed similar outcomes in patients definitively treated with carbapenems or with carbapenem-free treatments. Additionally, an initially inappropriate therapy did not correlate with worse outcomes if a switch to an effective definitive treatment was performed promptly. Conclusions Carbapenem-sparing regimens (e.g. piperacillin-tazobactam alone or with an aminoglycoside) could be empirically safely used in elderly patients at high risk of ESBL-EB BSI and for definitive treatment of ascertained cases if the primary site is the urinary tract, leaving early carbapenem use for cases at higher risk of death, such as those with pneumonia.

This paper describes the health profile of Brazilian mothers in Massachusetts according to data collected through Massachusetts Standard Certificate of Live Births (1989 revision) filed with the Massachusetts Registry of Vital Records and Statistics during 1999 and 2009. To our knowledge this is the first time that such information is reviewed with a focus on Brazilian immigrants. The findings of this article suggests that Brazilian mothers who gave birth in Massachusetts between 1999 and 2009 fared better than all mothers in Massachusetts in most obstetric health indicators considered.

Environmental Threats to Healthy Aging, with a Closer Look at Alzheimer's & Parkinson's Diseases, a report published by Greater Boston Physicians for Social Responsibility and the Science and Environmental Health Network (2008), explains emerging theories about contributors to and prevention of Alzheimer's and Parkinson's diseases. Replete with graphics, maps, and diagrams, the report links a surprising number and variety of toxic exposures early in life to these neurodegenerative diseases diagnosed later in life. It also describes their relationships in what is described as the “Western disease cluster.” Evidence that good nutrition, physical activity, comfortable socio-economic status, and social and intellectual engagement throughout life are associated with a sturdier cognitive status late in life is presented.

The importance of teaching students to make real art—art with meaning—can be introduced by the following story.An art dealer (this story is authentic) bought a canvas signed “Picasso” and traveled all the way to Cannes to discover whether it was genuine. Picasso was working in his studio. He cast a single look at the canvasand said: “It's a fake.” A few months later the dealer bought another canvas signed Picasso. Again he traveled to Cannes and again Picasso, after a single glance, grunted: “It's a fake.” “But cher maitre,” expostulated the dealer, “it so happens that I saw you working on this very picture several years ago.” Picasso shrugged: “I often paint fakes.” (Koestler, 1964, p.82).

Malnutrition can be defined as a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size, composition) body function and clinical outcome. Malnutrition is a highly prevalent condition in the acute hospital setting with studies reporting rates of approximately 40%. Malnutrition is associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, longer lengths of hospital stay and increased mortality. Unidentified malnutrition not only heightens the risk of adverse complications for patients but results in an increase in health care costs. This can be prevented if special attention is given to their nutritional care. For this reason, hospital and healthcare organizations should have a policy and a specific set of protocols for identifying patients at nutritional risk, leading to appropriate care plans. The objective of this monograph is to provide evidence-based recommendations for the proper management of malnutrition by multi-parametric analysis of the guidelines available to date.

Recruitment of the CD19/CD21 coreceptor is thought to lower the threshold for effective signaling through the B cell Ag receptor. We provide evidence supporting a second role for coreceptor recruitment, and that is to enhance the survival/proliferative potential of the responding B cells. We show that B cell Ag receptor signaling in the absence of coreceptor recruitment induces cellular accumulation of the anti-apoptotic protein Bcl-xL, whereas CD19-mediated signals are required for Bcl-2 accumulation. The expression of both anti-apoptotic proteins correlates with the enhanced responsiveness of both resting and cycling B cells to growth-promoting signals delivered through CD40. These results provide further evidence for the necessity of coreceptor recruitment during Ag-dependent B cell activation and indicate that Ags derived from inflammatory sites function as better thymus-dependent Ags than their counterparts not coated with complement fragments.

Community mental health centers have seldom been involved in marketing their services. Marketing is defined as responding sensitively to human needs, not hucksterism, and is an appropriate activity for centers. Centers are vulnerable because of declining federal funding and in order to serve the poor, must also service other populations with greater ability to pay for services or face retrenchment. Over the past twenty years, locally controlled centers have broadened their missions to serve many types of personal and family problems, not just the chronically ill. Centers should omit "mental health" for their names because of the stigma. Guidelines for creation of a positive image including name and logo selection, color, open houses, and ad campaigns are given using Madison Center (formerly the Mental Health Center of St. Joseph County) as a case study. Reactions of other providers, creative delivery of services through consultation and education, market segmentation and message levels of advertising are also discussed.

Little has been published regarding Community Mental Health Centers and the collection of fees from clients. As centers of the 1980s have faced a sudden decrease in government funding, an effective system of cash collections has become paramount. Many locally-controlled centers have changed their mission to serving a broad spectrum of people with personal problems as well as the chronically mentally ill. This paper documents a system used by a midwestern center resulting in a 230% increase in client fee collections over four years. An integrative model describes collections assessment, developing an accountability system, basic principles of collections, fee setting and client mix. The ability to serve the poor, chronically mentally ill in the future will depend on the ability to serve the broader population of a community.