Delayed Tracheostomy in a Patient With Prolonged Invasive Mechanical Ventilation due to COVID-19.

Coronavirus disease 2019 (COVID-19) can cause acute respiratory distress syndrome (ARDS) that is associated with high mortality among patients requiring invasive mechanical ventilation. We present a case of a 56-year-old male with hypertension and obesity who presented with chest pain from COVID-19. The patient required endotracheal intubation due to worsening hypoxia and remained intubated for 33 days. Tracheostomy placement was delayed in part due to persistent COVID-19 positive testing until hospital day 37. The patient required a total of 52 days in the ICU prior to discharge to a rehabilitation facility. This case highlights the extensive resources needed for critically ill patients with COVID-19 and the long duration that patients may test positive for the virus after onset of symptoms. It also raises questions about the timing and safety of tracheostomy placement among those patients requiring mechanical ventilation from COVID-19.

Prevalence and Severity of Artifacts in Optical Coherence Tomographic Angiograms.

Importance: Artifacts can affect optical coherence tomographic angiography (OCTA) images and may be associated with misinterpretation of OCT scans in both clinical trials and clinical settings. Objectives: To identify the prevalence and type of artifacts in OCTA images associated with quantitative output and to analyze the role of proprietary quality indices in establishing image reliability. Design, Setting, and Participants: This cross-sectional study evaluated baseline OCTA images acquired in multicenter clinical trials and submitted to the Fundus Photograph Reading Center in Madison, Wisconsin, between January 1, 2016, and December 31, 2018. Images were captured using the 3 mm × 3 mm and/or 6 mm × 6 mm scan protocol with commercially available OCTA systems. Artifacts, including decentration, segmentation error, movement, blink, refraction shift, defocus, shadow, Z offset, tilt, and projection, were given a severity grade based on involvement of cross-sectional OCT and area of OCT grid affected. Main Outcomes and Measures: Prevalence and severity of OCTA artifacts and area under the receiver operating characteristic curve (AUC) of quality indices with image reliability. Results: A total of 406 OCTA images from 234 eyes were included in this study, of which 221 (54.4%) were 6 mm × 6 mm scans and 185 (45.6%) were 3 mm × 3 mm scans. At least 1 artifact was documented in 395 images (97.3%). Severe artifacts associated with the reliability of quantitative outputs were found in 217 images (53.5%). Shadow (26.9% [109 images]), defocus (20.9% [85 images]), and movement (16.0% [65 images]) were the 3 most prevalent artifacts. Prevalence of artifacts did not vary with the imaging system used or with the scan protocol; however, the type of artifacts varied. Commercially recommended quality index thresholds had an AUC of 0.80 to 0.83, sensitivity of 97% to 99%, and specificity of 37% to 41% for reliable images. Conclusions and Relevance: Findings from this study suggest that artifacts associated with quantitative outputs on commercially available OCTA devices are highly prevalent and that identifying common artifacts may require correlation with the angiogram and cross-sectional OCT scans. Knowledge of these artifacts and their implications for OCTA indices appears to be warranted for more accurate interpretation of OCTA images.

Precursors and Development of Geographic Atrophy with Autofluorescence Imaging: Age-Related Eye Disease Study 2 Report Number 18.

PURPOSE: To describe the sequence of events leading to development of geographic atrophy (GA) in age-related macular degeneration with fundus autofluorescence (FAF) imaging. DESIGN: Post hoc analysis of FAF images from the Age-Related Eye Disease Study 2. PARTICIPANTS: Fundus autofluorescence images of 120 eyes (109 patients) with incident GA and at least 2 years of preceding FAF images. METHODS: Images of incident GA were stacked and aligned over FAF images of preceding annual visits. The regions of retina where incident GA developed were assessed on prior years' FAF images. These regions, defined as precursor lesions, were classified into minimal change autofluorescence, predominant hypoautofluorescence (decreased autofluorescence), predominant hyperautofluorescence (increased autofluorescence), and mixed autofluorescence. The natural progression in precursor lesions leading to GA formation and their associations with incident GA size and GA enlargement rate were evaluated. MAIN OUTCOME MEASURES: Incident GA area and enlargement rate and precursor pattern frequency. RESULTS: Incident GA had a mean area of 1.00 mm2 (range, 0.15-8.22 mm2) and an enlargement rate of 0.97 mm2/year (standard deviation, 1.66 mm2/year). Predominant hypoautofluorescence was the most common precursor lesion, increasing from 42% to 81% over 3 years before onset of GA. Almost 30% of eyes showed minimal change autofluorescence 3 years before GA. Among the other precursors, 70% progressed to predominant hypoautofluorescence before GA developed. The type of precursor lesions was not associated with incident GA area. Geographic atrophy evolving from minimal change autofluorescence precursor lesions was associated with faster GA enlargement rates compared with other precursor lesion classes. CONCLUSIONS: Using image registration, we identified changes in autofluorescence images before the onset of GA. Decreased autofluorescence was the most common change, although minimal changes also were seen in one third of the images. Incident GA that arises from predominantly normal autofluorescence is associated with faster enlargement rates compared with GA arising from abnormal autofluorescence. Faster GA enlargement rates also were associated with incident GA size, area of surround abnormal autofluorescence, and presence of reticular pseudodrusen.

Challenges to sustainability of hand hygiene at a rural hospital in Rwanda.

BACKGROUND: Many hand hygiene (HH) programs have been implemented across Sub-Saharan Africa (SSA); however, most of these have been in large, referral hospitals. Our objective was to assess the impact of HH programs aimed at improving compliance at a rural hospital, and to identify unique challenges to HH sustainability. METHODS: Interventions to improve HH through providing handwashing stations, health care worker (HCW) training, and alcohol handrub were completed in 2014 and 2015. HH infrastructure, compliance, and glove use were assessed among HCWs after the intervention in 2015 and 2016. HCWs were interviewed about challenges to sustainability of HH compliance. RESULTS: Total HH compliance decreased 32.1% between 2015 and 2016 (P < .001). HH for patient protection was completed significantly less than HH for HCW protection in 2016, and HCWs appeared to substitute HH for patient protection with glove use. A high rate of physician turnover was associated with a larger decrease in HH compliance compared with nurses, and interviews suggested recruiting and retention of key personnel might play a role in HH sustainability. Availability of alcohol-based handrub in patient rooms decreased from 100% in 2015 to 79.5% in 2016 (P < .01). CONCLUSIONS: Many challenges exist to sustaining HH compliance in SSA. In rural settings, difficulty recruiting and retaining trained personnel, inconsistent availability in HH infrastructure, and variability in HCW HH training may be contributing factors.

Improving Hand Hygiene Practices in a Rural Hospital in Sub-Saharan Africa.

OBJECTIVE To improve hand hygiene (HH) compliance among physicians and nurses in a rural hospital in sub-Saharan Africa (SSA) using the World Health Organization's (WHO's) Guidelines on Hand Hygiene in Health Care. DESIGN This study was a quasi-experimental design divided into 4 phases: (1) preparation of materials and acquisition of the hospital administration's support, (2) baseline evaluation, (3) intervention, and (4) follow-up evaluation. SETTING A 160-bed, non-referral hospital in Gitwe, Rwanda PARTICIPANTS A total of 12 physicians and 54 nurses participated in this study. METHODS The intervention consisted of introducing locally produced alcohol-based hand rub (ABHR); educating healthcare workers (HCWs) on proper HH practice; providing pocket-sized ABHR bottles for HCWs; placing HH reminders in the workplace; and surveying HCWs at surrounding health centers regarding HH compliance barriers. Hand hygiene infrastructure, compliance, and knowledge were assessed among physicians and nurses using baseline observations and a follow-up evaluation survey. RESULTS Overall, HH compliance improved from 34.1% at baseline to 68.9% post intervention (P.05). CONCLUSION Hand hygiene campaigns using WHO methods in SSA have been implemented exclusively in large, referral hospitals. This study shows that an HH program using the WHO tools successfully improved HH in a low-income, rural hospital in SSA. Infect Control Hosp Epidemiol 2016;37:834-839.

Calsyntenin-1 regulates axon branching and endosomal trafficking during sensory neuron development in vivo.

Precise regulation of axon branching is crucial for neuronal circuit formation, yet the mechanisms that control branch formation are not well understood. Moreover, the highly complex morphology of neurons makes them critically dependent on protein/membrane trafficking and transport systems, although the functions for membrane trafficking in neuronal morphogenesis are largely undefined. Here we identify a kinesin adaptor, Calsyntenin-1 (Clstn-1), as an essential regulator of axon branching and neuronal compartmentalization in vivo. We use morpholino knockdown and a Clstn-1 mutant to show that Clstn-1 is required for formation of peripheral but not central sensory axons, and for peripheral axon branching in zebrafish. We used live imaging of endosomal trafficking in vivo to show that Clstn-1 regulates transport of Rab5-containing endosomes from the cell body to specific locations of developing axons. Our results suggest a model in which Clstn-1 patterns separate axonal compartments and define their ability to branch by directing trafficking of specific endosomes.