System approaches in governmental public health: Findings from an analysis of the literature

The U.S. public health enterprise is a complex system of public and private partners, loosely coupled, which work together to improve the public's health. This scoping review utilized peer-reviewed and grey literature to understand systems approaches may be used in the design or enhancement of public health governance structures and service delivery mechanisms. Titles and s were screened against the research question and retained materials were reviewed in full. The final analytic sample included 34 articles from an initial pool of 1128 unique citations that collectively described 25 systems approaches. The findings indicate that few avenues may be present to guide design or enhancement of public health systems when needs arise, such as in response to the COVID-19 pandemic. Scarcity of literature on this topic presents a challenge, and further analytical studies are needed to inform evidence-based systems design strategies and applications. © 2021 John Wiley & Sons, Ltd.

Australian Public Universities: A crisis of governance*

In dialogue with other articles within this special issue, in this article we argue that the financial crisis triggered by the onset of COVID-19 is revealing a failed governance structure within Australian public universities that has ultimately enabled the conditions that led to the crisis currently before us. We suggest that the impact of COVID-19 has laid bare a series of problems that were in the process of unfolding years before the pandemic hit. Finally, we will examine this failure of leadership through the lens of the statutory nature and governance structures of Australian public universities, cast against the current rhetoric that metaphorically equates universities with commercial corporations, to determine the extent to which such a metaphor is accurate, and ultimately (we contend) detrimental to an effective and efficient university sector.

System approaches in governmental public health: Findings from an analysis of the literature

The U.S. public health enterprise is a complex system of public and private partners, loosely coupled, which work together to improve the public's health. This scoping review utilized peer-reviewed and grey literature to understand systems approaches may be used in the design or enhancement of public health governance structures and service delivery mechanisms. Titles and s were screened against the research question and retained materials were reviewed in full. The final analytic sample included 34 articles from an initial pool of 1128 unique citations that collectively described 25 systems approaches. The findings indicate that few avenues may be present to guide design or enhancement of public health systems when needs arise, such as in response to the COVID-19 pandemic. Scarcity of literature on this topic presents a challenge, and further analytical studies are needed to inform evidence-based systems design strategies and applications.

CONCOMITANT PULMONARY MUCORMYCOSIS AND PULMONARY ASPERGILLOSIS IN A YOUNG PATIENT WITH COVID-19

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary mucormycosis (PM) is a rare fungal infection with mortality up to 80% [1]. We describe a young patient with diabetes who developed acute respiratory distress syndrome (ARDS) due to COVID-19 complicated by both PM and pulmonary aspergillosis. CASE PRESENTATION: A 24-year-old woman with type 2 diabetes and obesity was hospitalized with COVID-19. She was treated with remdesivir, dexamethasone and vancomycin and cefepime for presumed superimposed bacterial pneumonia. She was intubated on hospital day (HD) 7 for hypoxemia and started on renal replacement therapy on HD 9. On HD 11-14 she was febrile;she had positive serum and bronchoalveolar lavage (BAL) galactomannan antigen (index 6.44), voriconazole and micafungin were started. Venous-venous extracorporeal membrane oxygenation (VV-ECMO) was started on HD 15 for refractory hypoxemia and CT chest revealed bilateral complete lung collapse and opacification with a few cavities within the right lung. CT chest on HD 19 showed bilateral lung cavities. Tracheal aspirate on HD 27 grew heavy Klebsiella aerogenes. On HD 30, fungal cultures obtained from the BAL sample on HD 13 and HD 16 speciated with Rhizomucor pusillus and amphotericin B was started. The patient had refractory shock and expired on HD 32. DISCUSSION: The positive serum and BAL Galactomannan antigens are indicative of invasive pulmonary aspergillosis and the fungal cultures speciated to Rhizomucor pusillus. COVID-19 associated pulmonary aspergillosis (CAPA) has been increasingly recognized but there have only been a handful of documented cases of COVID-19 associated PM [2]. Mucormycosis is an angio-invasive fungal infection, considered to be "opportunistic". Rhino-orbito-cerebral disease is the most common manifestation in diabetic patients, while PM is more commonly seen in hematologic malignancy and transplant patients. There are increasing reports of nosocomial mucormycosis [3]. Common clinical features of PM are fever, neutropenia, dyspnea, and cough [1]. Radiological features include peribronchial ground-glass opacities, consolidations, nodules or masses. PM can be difficult to diagnose as galactomannan and 1,3 beta-d glucan are not found in mucor;cultures and/or biopsy are needed thus a high index of suspicion is required for prompt diagnosis. Our patient was immunocompetent at baseline but did have diabetes (HbA1c 8.3%). Other contributing factors might include COVID-19 itself, ARDS biology, and steroid use. Treatment of PM includes liposomal amphotericin B, glycemic control, and surgical resection when possible. CONCLUSIONS: Our case represents a young diabetic patient with COVID-19 ARDS requiring VV-ECMO who developed both pulmonary aspergillosis and pulmonary mucormycosis. More research is needed to understand the degree of immune dysregulation from the viral COVID-19 pneumonia, ARDS, and glucocorticoids that contributed to these opportunistic infections. REFERENCE #1: Lin E, Moua T, Limper AH. Pulmonary mucormycosis: clinical features and outcomes. Infection. 2017 Aug;45(4):443-448. doi: 10.1007/s15010-017-0991-6. Epub 2017 Feb 20. PMID: 28220379. REFERENCE #2: Koehler P, Bassetti M, Chakrabarti A, Chen SCA, Colombo AL, Hoenigl M, Klimko N, Lass-Flörl C, Oladele RO, Vinh DC, Zhu LP, Böll B, Brüggemann R, Gangneux JP, Perfect JR, Patterson TF, Persigehl T, Meis JF, Ostrosky-Zeichner L, White PL, Verweij PE, Cornely OA;European Confederation of Medical Mycology;International Society for Human Animal Mycology;Asia Fungal Working Group;INFOCUS LATAM/ISHAM Working Group;ISHAM Pan Africa Mycology Working Group;European Society for Clinical Microbiology;Infectious Diseases Fungal Infection Study Group;ESCMID Study Group for Infections in Critically Ill Patients;Interregional Association of Clinical Microbiology and Antimicrobial Chemotherapy;Medical Mycology Society of Nigeria;Medical Mycology Society of China Medicine Education Association;Infectious Diseases Working Party of the German Society for H ematology and Medical Oncology;Association of Medical Microbiology;Infectious Disease Canada. Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. Lancet Infect Dis. 2020 Dec 14:S1473-3099(20)30847-1. doi: 10.1016/S1473-3099(20)30847-1. Epub ahead of print. PMID: 33333012;PMCID: PMC7833078. REFERENCE #3: Rammaert B, Lanternier F, Zahar JR, Dannaoui E, Bougnoux ME, Lecuit M, Lortholary O. Healthcare-associated mucormycosis. Clin Infect Dis. 2012 Feb;54 Suppl 1:S44-54. doi: 10.1093/cid/cir867. PMID: 22247444. DISCLOSURES: No relevant relationships by Erica Feldman, source=Web Response no disclosure on file for Jeremy Orr;