Beau Bruce

Background Nontyphoidal Salmonella causes an estimated 1.35 million US infections annually. Antimicrobial-resistant strains are a serious public health threat. We examined the association between resistance and the clinical outcomes of hospitalization, length-of-stay ≥3 days, and death. Methods We linked epidemiologic data from the Foodborne Diseases Active Surveillance Network with antimicrobial resistance data from the National Antimicrobial Resistance Monitoring System (NARMS) for nontyphoidal Salmonella infections from 2004 to 2018. We defined any resistance as resistance to ≥1 antimicrobial and clinical resistance as resistance to ampicillin, azithromycin, ceftriaxone, ciprofloxacin, or trimethoprim-sulfamethoxazole (for the subset of isolates tested for all 5 agents). We compared outcomes before and after adjusting for age, state, race/ethnicity, international …

Background Culture-independent diagnostic testing (CIDT) provides rapid results to clinicians and is quickly displacing traditional detection methods. Increased CIDT use and sensitivity likely result in higher case detection but might also obscure infection trends. Severe illness outcomes, such as hospitalization and death, are likely less affected by changes in testing practices and can be used as indicators of the expected case incidence trend had testing methods not changed. Methods Using US Foodborne Diseases Active Surveillance Network data during 1996–2019 and mixed effects quasi-Poisson regression, we estimated the expected yearly incidence for nine enteric pathogens. Results Removing the effect of CIDT use, CIDT panel testing and culture-confirmation of CIDT testing, the modelled incidence in all but three pathogens (Salmonella, Shigella …

Background/objectivesTo report a series of patients with glaucoma and optic nerve abnormalities on magnetic resonance imaging (MRI) in at least one-eye, and to determine whether these findings correlate with the severity of glaucoma.Patients and methodsRetrospective study of all patients who underwent a brain/orbits MRI without and with contrast at our institution between 07/1/2019-6/30/2022. Patients with optic nerve T2-hyperintensity and/or MRI optic nerve atrophy in at least one-eye and a diagnosis of isolated glaucoma in at least one-eye were included. Demographic information, glaucoma clinical characteristics, glaucoma severity parameters, and MRI indication were collected.ResultsFifty-six patients (112 eyes) (age 65 years-old [range 26–88]; 70% male) had isolated bilateral glaucoma with at least one-eye MRI optic nerve abnormality. The indication for MRI was atypical/asymmetric glaucoma in 91 …

Peripheral blood gene expression profiles can distinguish ischemic stroke from intracerebral hemorrhage and controls. However, it can be difficult to clinically distinguish “mimics” of transient ischemic attacks (TIA) and minor strokes from true TIAs and minor strokes. Even with imaging this can be a challenging differential diagnosis in the ED and other acute settings. Hence, there is a need for defining a molecular profile from blood that could guide triage of TIA mimics to reduce ED burden. This multi-site project collected peripheral blood from the participants and generated gene-level data from RNA sequencing. The cohort was composed of patients with a) TIA mimic presentation (n= 142 TIA mimics: an acute onset of neurological symptoms lasting <24h, that can be explained by some identifiable process other than cerebral ischemia including migraine, seizure, peripheral vestibular disease, brain tumors, syncope …

We fit a power law distribution to US foodborne disease outbreaks to assess underdetection and underreporting. We predicted that 788 fewer than expected small outbreaks were identified annually during 1998–2017 and 365 fewer during 2018–2019, after whole-genome sequencing was implemented. Power law can help assess effectiveness of public health interventions.

PurposeThe Fundus photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) studies showed that ED providers poorly recognized funduscopic findings in patients in the ED. We tested a modified version of the Brain and Optic Nerve Study Artificial Intelligence (BONSAI) deep learning system on nonmydriatic fundus photographs from the FOTO-ED studies to determine if the deep learning system could have improved the detection of papilledema had it been available to ED providers as a real-time diagnostic aid.DesignRetrospective secondary analysis of a cohort of patients included in the FOTO-ED studies.MethodsThe testing data set included 1608 photographs obtained from 828 patients in the FOTO-ED studies. Photographs were reclassified according to the optic disc classification system used by the deep learning system (“normal optic discs,” “papilledema,” and “other optic …

Information on the causative agent in an enteric disease outbreak can be used to generate hypotheses about the route of transmission and possible vehicles, to guide environmental assessments, and to target outbreak control measures. However, only about 40% of outbreaks reported in the United States include a confirmed etiology. The goal of this project was to identify clinical and demographic characteristics that can be used to predict the causative agent in an enteric disease outbreak and to use these data to develop an online tool for investigators to use during an outbreak when hypothesizing about the causative agent. Using data on enteric disease outbreaks from all transmission routes (animal contact, environmental contamination, foodborne, person-to-person, waterborne, unknown) reported to the U.S. Centers for Disease Control and Prevention, we developed random forest models to predict the …

Background In the United States, Yersinia enterocolitica causes a diarrheal disease historically associated with winter months and understood to predominantly occur among Black or African American infants and Asian children. Clinical laboratory adoption of culture-independent diagnostic tests (CIDTs), in place of culture methods has led to marked increases in diagnoses. Methods We describe laboratory-diagnosed infections caused by Y. enterocolitica in 10 state health departments of the Foodborne Diseases Active Surveillance Network. A counterfactual random forest model was used to identify individual, and community-level social determinants of health associated with the type of test used to detect Y. enterocolitica. Results Annual reported incidence of Y. enterocolitica infection increased from 0.3 per 100,000 in 2010 to 1.3 per 100,000 in 2021. The …

We agree with Appleton et al. that there is no easy solution for improving the use and accuracy of the ocular fundus examination by physicians. Unfortunately, ensuring that patients are examined by direct ophthalmoscopy (DO) does little to ensure accurate examination which, like consistent use, has been very difficult to improve in a sustained fashion even with extensive training efforts.[1] Furthermore, many findings in our study were subtle (eg, a single retinal hemorrhage) and difficult to detect with DO, even for skilled examiners.[2] We believe that education of non-ophthalmologists in ocular fundus assessment will prove more useful if directed at interpretation of fundus photography rather than at learning DO techniques. Evaluating the cost-effectiveness of non-mydriatic ocular fundus photography in the emergency department (ED) is difficult because of the heterogeneity of underlying conditions that present with …

Background:Radiologic findings of intracranial hypertension (RAD-IH) are common in idiopathic intracranial hypertension (IIH) patients. Paralleling the increasing rates of obesity, the burden of IIH is growing. Urgent neuro-ophthalmology consultations for possible IIH in patients with incidentally detected RAD-IH are increasing, with many patients receiving unnecessary lumbar punctures (LPs) and treatments. This retrospective observational study aimed to determine the prevalence of neuro-ophthalmology consultations for RAD-IH, rate of funduscopic examination by referring providers, prevalence of papilledema, outcomes after neuro-ophthalmic evaluation, and rates of misdiagnosis.Methods:Records of 1,262 consecutive new patients seen in one neuro-ophthalmology clinic from January 2019 to January 2020 were reviewed. We identified patients who were: 1) referred with concern for IIH because of findings of …

Background Campylobacter is the most common cause of bacterial diarrhea in the United States; resistance to macrolides and fluoroquinolones limits treatment options. We examined the epidemiology of US Campylobacter infections and changes in resistance over time. Methods The Foodborne Diseases Active Surveillance Network receives information on laboratory-confirmed Campylobacter cases from 10 US sites, and the National Antimicrobial Resistance Monitoring System receives a subset of isolates from these cases for antimicrobial susceptibility testing. We estimated trends in incidence of Campylobacter infection, adjusting for sex, age, and surveillance changes attributable to culture-independent diagnostic tests. We compared percentages of isolates resistant to erythromycin or ciprofloxacin during 2005–2016 with 2017–2018 and used multivariable logistic …

We thank Dr. Shubhakaran for his comments on our article 1 and for sharing his views about the importance of fundus examination. We agree that non-ophthalmologist physicians doing general and neurologic examinations perform ophthalmoscopy infrequently, and often poorly, even when clearly indicated. 2 Dr. Subhakaran touches on many important advantages of nonmydriatic fundus camera over direct ophthalmoscopy, including better diagnostic accuracy, lower risk of medico-legal liability, objective recording for future comparison, and possibility of telemedicine. We showed that non-mydriatic fundus photographs has a role in the acute evaluation of neurologic conditions 1, but its use may be extended to many other medical settings, such pediatric ophthalmology 3 or even infectious diseases in endemic areas as described by Dr. Subhakaran. We believe that nonmydriatic fundus photographs have …

We appreciate Drs. Bono and Quattrone's contributions to this area of research and thank them for highlighting their work in support of our conclusions. We have also found that bilateral transverse sinus stenosis (TSS) can occur rarely in patients with normal CSF opening pressure.[1] Concerning idiopathic intracranial hypertension (IIH), clinical management in our practice is guided by visual function and symptom severity; we usually obtain lumbar puncture only at the time of diagnosis unless there is diagnostic uncertainty or evidence of worsening. Therefore, it is likely that our results will be useful to others who practice in a similar fashion, even though we did not demonstrate normalization of the CSF opening pressure. In addition, as we reported,[2] there was a trend toward higher initial CSF opening pressure predicting both a poor clinical course and greater visual field loss, even though there was no association …

Listeria monocytogenes can cause severe foodborne illness, including miscarriage during pregnancy or death in newborn infants. When outbreaks of L. monocytogenes illness occur, it may be possible to determine the food source of the outbreak. However, most reported L. monocytogenes illnesses do not occur as part of a recognized outbreak and most of the time the food source of sporadic L. monocytogenes illness in people cannot be determined. In the United States, L. monocytogenes isolates from patients, foods, and environments are routinely sequenced and analyzed by whole genome multilocus sequence typing (wgMLST) for outbreak detection by PulseNet, the national molecular surveillance system for foodborne illnesses. We investigated whether machine learning approaches applied to wgMLST allele call data could assist in attribution analysis of food source of L. monocytogenes isolates. We …

Shiga toxin–producing Escherichia coli (STEC) causes acute diarrheal illness. To determine risk factors for non-O157 STEC infection, we enrolled 939 patients and 2,464 healthy controls in a case–control study conducted in 10 US sites. The highest population-attributable fractions for domestically acquired infections were for eating lettuce (39%), tomatoes (21%), or at a fast-food restaurant (23%). Exposures with 10%–19% population attributable fractions included eating at a table service restaurant, eating watermelon, eating chicken, pork, beef, or iceberg lettuce prepared in a restaurant, eating exotic fruit, taking acid-reducing medication, and living or working on or visiting a farm. Significant exposures with high individual-level risk (odds ratio> 10) among those> 1 year of age who did not travel internationally were all from farm animal environments. To markedly decrease the number of STEC-related illnesses …

PurposePrompt neuro-ophthalmology consultation prevents diagnostic errors and improves patient outcomes. The scarcity of neuro-ophthalmologists means that the increasing outpatient demand cannot be met, prompting many emergency department (ED) referrals by non–neuro-ophthalmologists. We describe our quaternary care institution’s ED and inpatient neuro-ophthalmology consultation patterns and patient outcomes.DesignProspective observational study.ParticipantsConsecutive neuro-ophthalmology ED and inpatient consultation requests over 1 year.MethodsWe collected patient demographics, distance traveled, insurance status, referring provider details, consultation question, final diagnosis, complexity of consultation, time of consultation, and need for outpatient follow-up.Main Outcome MeasuresConsultation patterns and diagnoses, complexity, and follow-up.ResultsOf 494 consecutive adult ED and …

We were pleased to see the Practice Parameter addressing the fall risk among neurological patients.[1] We believe that these guidelines will help improve the safety and quality of life of patients. We would like to emphasize the role of visual field deficits as an important neurologic cause of fall related morbidity.Neurologic disorders frequently cause visual loss, especially visual field defects, and visual loss is common in the elderly. Loss of visual acuity or visual field has been associated with an increased risk of falls.[5, 6] A recent, prospective population cohort study of 2520 older adults found that visual field loss was the most important component of vision related to increased fall risk.[6] In this study, there was 8% higher odds of falling for each 10% loss in binocular visual field the patient experienced. This risk remained after adjustment for other factors, including several neurologic conditions including poor balance …

CDC and health departments investigate foodborne disease outbreaks to identify a source. To generate and test hypotheses about vehicles, investigators typically compare exposure prevalence among case-patients with the general population using a one-sample binomial test. We propose a Bayesian alternative that also accounts for uncertainty in the estimate of exposure prevalence in the reference population. We compared exposure prevalence in a 2020 outbreak of Escherichia coli O157:H7 illnesses linked to leafy greens with 2018–2019 FoodNet Population Survey estimates. We ran prospective simulations using our Bayesian approach at three time points during the investigation. The posterior probability that leafy green consumption prevalence was higher than the general population prevalence increased as additional case-patients were interviewed. Probabilities were >0.70 for multiple leafy green items …

We appreciate Dr. Shubhakaran et al.'s comments on our article.[1] We agree that the funduscopic examination is a very important part of the overall physical examination and that direct ophthalmoscopy is not performed as often or as accurately as it should be.[2] We have shown that nonmydriatic fundus photography is a relatively fast, clinically feasible alternative to direct ophthalmoscopy even in a busy emergency department setting.[3] We also found that emergency physicians themselves--without specific training in reading fundus photographs--had substantially better sensitivity for abnormalities when reading fundus photographs than when using the direct ophthalmoscope (46% of abnormalities identified with fundus photographs vs. 0% with direct ophthalmoscopy) and that photographs were often useful even when normal.[4] Combining digital photographs with mobile technologies, such as smartphones, has …

Consumption of unpasteurised milk in the United States has presented a public health challenge for decades because of the increased risk of pathogen transmission causing illness outbreaks. We analysed Foodborne Disease Outbreak Surveillance System data to characterise unpasteurised milk outbreaks. Using Poisson and negative binomial regression, we compared the number of outbreaks and outbreak-associated illnesses between jurisdictions grouped by legal status of unpasteurised milk sale based on a May 2019 survey of state laws. During 2013–2018, 75 outbreaks with 675 illnesses occurred that were linked to unpasteurised milk; of these, 325 illnesses (48%) were among people aged 0–19 years. Of 74 single-state outbreaks, 58 (78%) occurred in states where the sale of unpasteurised milk was expressly allowed. Compared with jurisdictions where retail sales were prohibited (n = 24), those where …