Community-Acquired Pseudomonas aeruginosa Meningitis in a Pediatric Patient.

This case report presents a rare and significant case of community-acquired Pseudomonas aeruginosa meningitis in a healthy 13-month-old male patient in rural Liberia. Pseudomonas aeruginosa meningitis, particularly in the absence of predisposing factors, is a rare occurrence with a high mortality rate. The challenges in diagnosing this condition, especially in resource-limited settings, are highlighted. The patient initially presented with fever, seizures, and altered consciousness, and lumbar puncture revealed turbid cerebrospinal fluid (CSF) with elevated white blood cell count. Subsequent CSF culture confirmed Pseudomonas aeruginosa infection. Prompt initiation of appropriate antibiotic therapy, including a push dose of meropenem, resulted in clinical improvement. However, the patient exhibited post-meningitis sequelae, including hearing and visual impairments. Comprehensive follow-up care and rehabilitation services are crucial for managing these long-term complications. By sharing this case, we aim to increase awareness and facilitate early recognition of Pseudomonas aeruginosa meningitis, leading to improved patient care and outcomes in similar clinical scenarios.

Optic Disc Elevation Secondary to Cerebral Malaria Resolves Completely With Mannitol Administration and Corresponds to Clinical Improvement.

This case report describes a 14-year-old boy presenting with cerebral malaria in a resource-limited setting. The patient exhibited optic disc elevation, indicating increased intracranial pressure (ICP). Due to the unavailability of advanced neuroimaging, point-of-care ultrasound (POCUS) was employed to assess the optic disc. After administration of a weight-based dose of mannitol, optic disc elevation resolved completely, accompanied by clinical improvement. This case highlights the potential of POCUS as a valuable tool for the assessment and management of cerebral malaria in resource-limited settings.

Achieving Health Equity for LGBTQ+ Adolescents.

The lesbian, gay, bisexual, transgender, and queer (LGBTQ+) adolescent population experiences health disparities due to barriers to care, including lack of access to culturally competent health care providers. The purpose of this quality improvement project was to increase access to culturally competent care through continuing education, a physical makeover of clinic space, and a social marketing campaign. The impact of the project on the number of LGBTQ+ adolescent patients at the clinic and the rate of documentation of sexual orientation and gender identity data was evaluated via a chart audit. Changes in nurses' and health care providers' knowledge as a result of the continuing education were evaluated with a pretest and a posttest. The number of LGBTQ+ patients and provider knowledge increased following the continuing education. Sexual orientation and gender identity data were documented during 87.5% of visits. The participants' knowledge increased by 4.7% following the continuing education. Further, five physical changes to the clinic were completed and a social marketing campaign was launched. This quality improvement project demonstrates that continuing education can be an effective way to increase cultural competence for the care of LGBTQ+ individuals. [J Contin Educ Nurs. 2022;53(8):348-354.].

Hematologic and plasma biochemical prognostic indicators for stranded free-ranging phocids presented for rehabilitation.

This retrospective study used data obtained from medical records of 530 stranded free-ranging harbor (Phoca vitulina), grey (Halichoerus grypus), harp (Pagophilus groenlandicus), and hooded seals (Cystophora cristata) presented to the Marine Mammal Stranding Center in Brigantine, New Jersey from January 1998 through December 2016. The objective was to identify hematological and plasma biochemical parameters of seals at time of presentation that were associated with successful rehabilitation and with duration of hospitalization using univariate and multivariate logistic regressions. At presentation, animals that subsequently survived rehabilitation had greater alkaline phosphatase activity and absolute lymphocyte and total calcium concentrations and lower blood urea nitrogen, sodium, chloride, phosphorus, and total bilirubin concentrations and lower aspartate aminotransferase and alanine aminotransferase activities than animals that eventually died or were euthanized while under care. Results suggest that young, actively growing animals are more likely to survive rehabilitation and that bloodwork consistent with dehydration, systemic disease, and exhaustion are negative prognostic indicators. These results provide prognostic indicators that may aid clinical decision-making for seals presented for rehabilitation.

Supporting free clinic patients' social needs with MSW interns: A pilot study.

Social needs, which are social risk factors including lack of access to stable housing, healthy food, or reliable transportation, are recognized as integral to health. Free clinics tend to serve patients with social needs, yet, few are screened or receive assistance. Lack of personnel, resources, and procedures to identify and assist patients are reasons few free clinics consider social needs. To address this service gap, a midwestern free clinic and neighboring Masters of Social Work (MSW) program established a partnership. A social needs screen was developed and integrated into health care practice. An MSW intern was also embedded as a member of the health care team to provide social needs assistance. A 6-month pilot study was conducted to assess the value of the screen and use of MSW assistance services. Of the 223 patients screened, 66.4% (n = 146) scored positive for social needs. Only four percent (n = 6) of the patients used MSW services. Chi-square analyses reveal significant differences in social needs by age, gender, race, education, and primary language. The findings suggest that the screening and MSW intern services are valuable; however, they further suggest that screening alone may be insufficient to encourage utilization of MSW services.

Care coordination to target patient complexity and reduce disparities in primary care.

OBJECTIVE: The purpose of this study was to describe our Activation and Coordination Team (ACT) model for interprofessional care coordination in primary care and examine feasibility of using ACT medical and social complexity criteria to categorize patients into Quadrants that determine resource utilization. Research questions were: (a) Are there significant differences in demographic, medical, and social characteristics by Quadrant; (b) Do patients with combined high medical and social complexity differ from those with either high medical or social complexity; and (c) Is there an association between initial screening risk level and ACT Complexity Quadrant placement? DESIGN: Cross-sectional, descriptive. SAMPLE: Patients (N = 167) aged 18-65 enrolled in an urban Medicaid managed care network. MEASUREMENTS: Screening and comprehensive health risk assessment questionnaires and clinical data collection from electronic health records. RESULTS: Patient characteristics differed significantly by Quadrant. Combined medical and social complexity produced greater impact than additive effects. Patients who initially screened low risk nevertheless met ACT criteria for medical and/or social complexity. CONCLUSIONS: Greater effects for individuals with medical and social issues are due to interactions among factors. Traditional screening may miss patients with complex needs who need care coordination. Care coordination skills should be incorporated into population health curricula.

Identifying and managing depression through collaborative care: expanding social work's impact.

While behavioral health symptoms commonly present in primary care, most primary care providers lack the time, resources, and expertise to identify and treat them on their own. To address this need, many quality improvement efforts are underway to expand teams and integrate behavioral health assessments and interventions into primary care. Due to their expertise in behavioral health, community supports, and behavioral activation, social workers are natural leaders in integrating care. This paper describes one urban academic medical center's efforts to ensure adolescent and adult patients with depressive symptoms are connected to adequate care and support. A case study is included to demonstrate the Collaborative Care Team model as described, including details regarding the role social workers play. Key quality improvement and policy considerations for scaling up and sustaining collaborative initiative are included.

The role of social workers in addressing nonmedical needs in primary health care.

Nonmedical needs are intricately linked to health. Unaddressed nonmedical needs often result in poorer health and increased healthcare costs. Although social workers are well positioned to address nonmedical needs, their role in healthcare environments to address nonmedical needs is limited. The limited role relates to a lack of reimbursement streams, which stems from poor articulation about their unique contributions. An analysis of a case study in which a social worker using AIMS, a protocolized care coordination model, was undertaken to highlight specific activities performed by social workers. Implications for patient health outcomes and healthcare costs are discussed.

Managing Depression among Diverse Older Adults in Primary Care: The BRIGHTEN Program.

OBJECTIVES: A variety of specific cultural adaptations have been proposed for older adult and minority mental health interventions. The objective of this study was to determine whether the BRIGHTEN Program, an individually tailored, interdisciplinary "virtual" team intervention, would equally meet the needs of a highly diverse sample of older adults with depression. METHODS: Older adults who screened positive for depression were recruited from primary and specialty care settings to participate in the BRIGHTEN program. A secondary data analysis of 131 older adults (37.4% African-American, 29.0% Hispanic, 29.8% Non-Hispanic White) was conducted to explore the effects of demographic variables (race/ethnicity, income and education) on treatment outcome. RESULTS: Compared to baseline, participants demonstrated significant improvements on the SF-12 Mental Health Composite and depression (GDS-15) scores at 6-month follow-up. There were no differences on outcome measures based on race/ethnicity, income or education with one exception-a difference between 12th grade and graduate degree education on SF-12 Mental Health Composite scores. CONCLUSIONS: While not explicitly tailored for specific ethnic groups, the BRIGHTEN program may be equally effective in reducing depression symptoms and improving mental health functioning in a highly socioeconomically and ethnically diverse, community-dwelling older adult population. CLINICAL IMPLICATIONS: Implications for behavioral health integration in primary care are discussed.

Soluble T cell immunoglobulin mucin domain 3 is shed from CD8+ T cells by the sheddase ADAM10, is increased in plasma during untreated HIV infection, and correlates with HIV disease progression.

UNLABELLED: Chronic HIV infection results in a loss of HIV-specific CD8(+) T cell effector function, termed "exhaustion," which is mediated, in part, by the membrane coinhibitory receptor T cell immunoglobulin mucin domain-3 (Tim-3). Like many other receptors, a soluble form of this protein has been described in human blood plasma. However, soluble Tim-3 (sTim-3) is poorly characterized, and its role in HIV disease is unknown. Here, we show that Tim-3 is shed from the surface of responding CD8(+) T cells by the matrix metalloproteinase ADAM10, producing a soluble form of the coinhibitory receptor. Despite previous reports in the mouse model, no alternatively spliced, soluble form of Tim-3 was observed in humans. Shed sTim-3 was found in human plasma and was significantly elevated during early and chronic untreated HIV infection, but it was not found differentially modulated in highly active antiretroviral therapy (HAART)-treated HIV-infected subjects or in elite controllers compared to HIV-uninfected subjects. Plasma sTim-3 levels were positively correlated with HIV load and negatively correlated with CD4 counts. Thus, plasma sTim-3 shedding correlated with HIV disease progression. Despite these correlations, we found that shedding Tim-3 did not improve the function of CD8(+) T cells in terms of gamma interferon production or prevent their apoptosis through galectin-9. Further characterization studies of sTim-3 function are needed to understand the contribution of sTim-3 in HIV disease pathogenesis, with implications for novel therapeutic interventions. IMPORTANCE: Despite the overall success of HAART in slowing the progression to AIDS in HIV-infected subjects, chronic immune activation and T cell exhaustion contribute to the eventual deterioration of the immune system. Understanding these processes will aid in the development of interventions and therapeutics to be used in combination with HAART to slow or reverse this deterioration. Here, we show that a soluble form of T cell exhaustion associated coinhibitory molecule 3, sTim-3, is shed from the surface of T cells. Furthermore, sTim-3 is elevated in the plasma of treatment-naive subjects with acute or chronic HIV infection and is associated with markers of disease progression. This is the first study to characterize sTim-3 in human plasma, its source, and mechanism of production. While it is still unclear whether sTim-3 contributes to HIV pathogenesis, sTim-3 may represent a new correlate of HIV disease progression.

T cell Ig and mucin domain-containing protein 3 is recruited to the immune synapse, disrupts stable synapse formation, and associates with receptor phosphatases.

CD8(+) CTLs are adept at killing virally infected cells and cancer cells and releasing cytokines (e.g., IFN-γ) to aid this response. However, during cancer and chronic viral infections, such as with HIV, this CTL response is progressively impaired due to a process called T cell exhaustion. Previous work has shown that the glycoprotein T cell Ig and mucin domain-containing protein 3 (Tim-3) plays a functional role in establishing T cell exhaustion. Tim-3 is highly upregulated on virus and tumor Ag-specific CD8(+) T cells, and antagonizing Tim-3 helps restore function of CD8(+) T cells. However, very little is known of how Tim-3 signals in CTLs. In this study, we assessed the role of Tim-3 at the immunological synapse as well as its interaction with proximal TCR signaling molecules in primary human CD8(+) T cells. Tim-3 was found within CD8(+) T cell lipid rafts at the immunological synapse. Blocking Tim-3 resulted in a significantly greater number of stable synapses being formed between Tim-3(hi)CD8(+) T cells and target cells, suggesting that Tim-3 plays a functional role in synapse formation. Further, we confirmed that Tim-3 interacts with Lck, but not the phospho-active form of Lck. Finally, Tim-3 colocalizes with receptor phosphatases CD45 and CD148, an interaction that is enhanced in the presence of the Tim-3 ligand, galectin-9. Thus, Tim-3 interacts with multiple signaling molecules at the immunological synapse, and characterizing these interactions could aid in the development of therapeutics to restore Tim-3-mediated immune dysfunction.