Infectious Disease Testing Research Articles

Advancements in Rapid and Affordable Diagnostic Testing for Respiratory Infectious Diseases: Evaluation of Aptamer Beacon Technology for Rapid and Sensitive Detection of SAR-CoV-2 in Breath Condensate.

The demand for rapid and efficient diagnostic point-of-care tests for respiratory infectious diseases has become increasingly critical in the current landscape. The emphasis on accessibility has been underscored over the past year, making it crucial to have biological components that exhibit fast and accurate kinetics. The foundation for precise, swift, and effective testing relies on the availability of highly responsive biological agents. Two published aptamer DNA sequences designated Song and MSA52 and their truncated internal stem-loop structures were studied for their potential to serve as aptamer beacons for rapid COVID detection. The candidate beacons were covalently labeled with Atto 633 dye attached to their 5' ends and Iowa Black quencher attached to their 3' ends. The whole aptamer structures exhibited the greatest fluorescence signal intensities and higher fluorescence background than their truncated internal stem-loop beacon structures suggesting that the distance between fluorophores and quenchers was greater for the whole aptamer beacon candidates versus the isolated stem-loop structures. Beacon candidates were tested against two heat- or gamma radiation-killed SARS-CoV-2 Washington 1/2020 virus samples and three different COVID spike (S) proteins to test their effectiveness. Despite the higher background fluorescence, the whole aptamer beacons showed better signal-to-noise ratios and were selected for further investigation. Limit of detection (LOD) studies revealed that both the whole Song and whole MSA52 aptamer beacon candidates had a LOD of 9.61 × 103 genome equivalents in phosphate-buffered saline using the red channel of a Promega Quantus™ fluorometer which correlated well with confirmatory spectrofluorometry. Cross-reactivity studies using numerous COVID variants, related coronaviruses, and other common respiratory pathogens suggested greater COVID selectivity for the whole MSA52 versus the whole Song aptamer beacon candidate, indicating promise for specific COVID detection. Importantly, both whole aptamer beacon candidates exhibited very rapid "bind and detect" fluorescence increases within the first 1-2min of mixing the beacons with killed SARS-CoV-2 viruses in 100µl samples. Overall, this work illustrates the strong potential for aptamer beacons for rapid, on-site detection and presumptive diagnosis of COVID in breath condensates or other small liquid samples. This research highlights the strong potential of aptamer beacons for addressing the need for fast and convenient diagnostic tools in global health contexts, especially in resource-limited settings.

Experiences of Pain Management Nurses during the COVID-19 Pandemic: A Qualitative Study

BackgroundThe knowledge and skills of pain management nurses positions them well to manage people's pain and provide critical services to patients with COVID-19. AimTo understand the personal and professional experiences and the support pain management nurses received during the COVID-19 pandemic. MethodsBetween July 2020 and 2021, data were collected through semi-structured telephone interviews from members of the American Society for Pain Management Nursing. Content analysis was used. ResultsEighteen pain management nurses who worked during the early stages of the pandemic were interviewed. Three main categories were identified: experiencing stress and burden, pain management strategies changed, learning to cope with support. Pain management nurses reported fear of exposure, difficulties with staff shortages, the complex social milieu, and how pain management took a backseat to other symptoms of COVID-19. They coped through support from their colleagues, organizational leaders, and community members. Pain management nurses provided recommendations for future care of patients’ pain during a pandemic. ConclusionsPain management nurses shared their professional and personal experiences and the support they received while managing patients’ pain during the COVID-19 pandemic. Their experiences provided findings on the importance of pain management and to support nurses during personal and professional vulnerabilities during crises. Key recommendations on the care of patients’ pain in future pandemics included developing expertise in pain management and health-related emergencies; engaging nurses in supportive mental health services, infectious disease testing, and vaccine efforts; and planning for surge capacity to reach out to underserved people living with pain.

A-269 Post-pandemic Opportunities for Commercial Laboratories in Infectious Disease Diagnostics and Public Health

Abstract Background Aegis launched COVID-19 testing with a daily capacity of 3000 tests and scaled to over 100 000 tests/day in one year. The lab has performed over 14.2M COVID-19 tests to date, servicing a broad network of physicians, urgent care centers, nursing homes, public schools, departments of health, and retail pharmacies across the United States. As SARS-CoV-2 infections reach an equilibrium, Aegis recognized the opportunity to address broader public health needs and leveraged the partnerships, technologies, and infrastructure developed to build the Infectious Disease Testing (IDT) menu aimed at limiting the spread of health risks within the community. Methods Real-time polymerase chain reaction (RT-PCR) tests for common and rare bacterial, viral, and parasitic pathogens associated with genital health (GH) and sexually transmitted infections (STI), as well as infections of the urinary (UTI), gastrointestinal (GI), and respiratory tracts (RTI) were validated. These tests are performed in 384-well custom PCR plates, pre-spotted with primers and probes capable of detecting the presence of DNA or RNA (LOD = 10 copies/µL) from 30 different organisms in up to 12 patient samples simultaneously. Syndromic panels were developed for ordering based on similar intended use, and providers have the option to order panels or stand-alone tests based on medical necessity. Following receipt into the lab, the total nucleic acid is extracted from the primary specimen and pipetted into the PCR assay plate with Taq DNA polymerase master mix, and analysis and reporting of ordered targets are complete within nine hours, on average. Results and de-identified demographic data are parsed from the laboratory information management system (LIMS) to Microsoft PowerBI software to internally track testing trends, positivity rates, and outbreaks of infectious diseases. Results Historical data including ordered profiles, matrices, and pathogens detected combined with de-identified demographic data such as patient age, gender, race, residing state, and collection month were imported into PowerBI and used to create interactive visuals for a dashboard to monitor trends and predict future testing patterns. The IDT panels ordered most frequently include STI (27.1%), upper RTI (23.6%), bacterial vaginosis (21.0%), GI bacterial (15.1%), candidiasis (13.7%), and GI viral (13.0%). The majority (74%) of GH/STI tests were ordered for patients between the ages of 15 to 34 years, and the most prevalent infections detected were bacterial vaginosis (35%), mycoplasma hominis (22%), and chlamydia trachomatis (4%). Sixty-one percent (61%) of upper RTI tests were ordered for patients between the ages of 0 to 14 years, and fluctuations in positivity rates followed seasonal trends for pathogens such as rhinovirus, influenza, adenovirus, RSV, and enterovirus D68. GI profiles were predominantly ordered for the younger (0–14 years, 35%) and the older (>65 years, 18%) population with e. coli O157 (11%), norovirus (9%), sapovirus (6%), and astrovirus (4%) infections detected at the highest rates. Conclusion The COVID-19 pandemic underscored the importance of molecular diagnostics for SARS-CoV-2 infection and surveillance. Experience gained during the COVID-19 response allowed Aegis to repurpose the resources, capacity, and infrastructure to create business development opportunities aimed at laboratory growth in infectious diseases and public health.

A-361 Implementation of a Fit-for-purpose Point of Care Quality Assurance Program

Abstract Background All individuals should have equitable access to accurate and timely testing for infectious diseases. Point of care testing (PoCT) has been developed to support populations having limited access to laboratory-based testing. Unlike laboratory-based testing, PoCT is often performed by non-laboratory staff and outside the jurisdiction of regulatory frameworks. Under these conditions, quality assurance (QA) of PoCT is often lacking; inaccurate testing can go undetected, leading to poor patient outcomes. A fit-for-purpose QA program was developed to monitor the quality of PoCT for infectious disease testing, particularly in low-middle income countries and in testing outside the laboratory regulatory environment. Methods In collaboration with the World Health Organization (WHO), the National Serology Reference Laboratory (NRL) reviewed the barriers to participation in QA programs experienced by PoCT sites. Using this information, NRL developed a QA model specifically designed for PoCT for infectious disease. In collaboration with Foundation for Innovative and New Diagnostics (FIND, Geneva, Switzerland), Kirby Institute (Sydney, Australia) and Flinders University (Adelaide, Australia), NRL implemented the PoCT QA model across Africa, Asia, and remote regional Australia. The model consists of competency panels (CP - one positive and one negative sample) and external quality assessment (EQA) panels. The EQA panels contain five samples. Whereas the test site knows the reactivity of the CP samples, the EQA samples are tested blinded. Both panels use inactivated samples that are stable at ambient temperature. The model uses streamlined logistics channels, with data collection and analysis using smartphone technology and QR codes. NRL designed a method for randomizing the identity of EQA sample vials so test sites can test QA panels ad hoc, and not be limited to specific test event dates. A range of support material such as pictorial instructions for use, virtual training events and on-line videos were produced to support test sites. Results More than 100 test sites from 14 countries have participated in the NRL PoCT QA programs. The model is designed so data is collected by test sites scanning QR codes and entering results directly into a data entry screen. The NRL PoCT QA program removed barriers to participation by offering sample types that are inactivated and stable at ambient temperature for extended periods of time, removing the need for dry ice shipping. The program is cost effective making it accessible to low- and middle-income countries. Data is collected using novel smartphone technology, facilitating results to be entered into a central database for immediate analysis. Testing of the QA samples can be done at any time, avoiding set test events. Conclusion Implementation of a fit-for-purpose PoCT QA for infectious disease testing removes the barriers to participation and facilitates the monitoring of testing over time. Any deficiencies in testing can be detected and addressed rapidly, ensuring that accurate test results are reported, and the population protected.

Sub-5-Minute Ultrafast PCR using Digital Microfluidics

The development of a rapid and reliable polymerase chain reaction (PCR) method for point-of-care (POC) diagnosis is crucial for the timely identification of pathogens. Microfluidics, which involves the manipulation of small volumes of fluidic samples, has been shown to be an ideal approach for POC analysis. Among the various microfluidic platforms available, digital microfluidics (DMF) offers high degree of configurability in manipulating μL/nL-scale liquid and achieving automation. However, the successful implementation of ultrafast PCR on DMF platforms presents challenges due to inherent system instability. In this study, we developed a robust and ultrafast PCR in 3.7–5 min with a detection sensitivity comparable to conventional PCR. Specifically, the implementation of the pincer heating scheme homogenises the temperature within a drop. The utilization of a μm-scale porous hydrophobic membrane suppresses the formation of bubbles under high temperatures. The design of a groove around the high-temperature zone effectively mitigates the temperature interference. The integration of a soluble sensor into the droplets provides an accurate and instant in-drop temperature sensing. We envision that the fast, robust, sensitive, and automatic DMF system will empower the POC testing for infectious diseases.

Single-molecule RNA capture-assisted droplet digital loop-mediated isothermal amplification for ultrasensitive and rapid detection of infectious pathogens

To minimize and control the transmission of infectious diseases, a sensitive, accurate, rapid, and robust assay strategy for application on-site screening is critical. Here, we report single-molecule RNA capture-assisted digital RT-LAMP (SCADL) for point-of-care testing of infectious diseases. Target RNA was captured and enriched by specific capture probes and oligonucleotide probes conjugated to magnetic beads, replacing laborious RNA extraction. Droplet generation, amplification, and the recording of results are all integrated on a microfluidic chip. In assaying commercial standard samples, quantitative results precisely corresponded to the actual concentration of samples. This method provides a limit of detection of 10 copies mL−1 for the N gene within 1 h, greatly reducing the need for skilled personnel and precision instruments. The ultrasensitivity, specificity, portability, rapidity and user-friendliness make SCADL a competitive candidate for the on-site screening of infectious diseases.

Diagnostic yield of workups ordered by pediatric ophthalmologists for bilateral pediatric cataracts at a tertiary pediatric hospital in the United States

Children with unexplained bilateral cataracts routinely undergo testing for genetic, infectious, and metabolic etiologies. We evaluated the diagnostic yield of various tests ordered by pediatric ophthalmologists to evaluate bilateral cataracts in children at a single institution. We retrospectively identified all children with bilateral unexplained cataracts who underwent cataract surgery by a pediatric ophthalmologist at Children's Hospital Colorado from 2006 to 2022. We reviewed the results of genetic, infectious, and metabolic testing ordered by pediatric ophthalmologists to evaluate the cataracts in these children. A total of 43 children met inclusion criteria. Of these, 34 (79%) had genetic testing, 34 (79%) had infectious disease testing, 33 (77%) had galactosemia testing, and 17 (40%) had urine-reducing substances testing performed during their cataract evaluation. Of the genetic tests ordered, 17 (50%) revealed a pathogenic mutation associated with cataracts. Twenty-three (68%) patients were IgG-positive for a TORCH infection, but no child was found to be positive on confirmatory testing. Of the galactosemia and URS tests ordered, 3 tests (9%) and 1 (6%) test were initially found to be abnormal, respectively, but confirmatory testing and clinical judgment ruled out metabolic disease in each case. Genetic testing should be strongly considered in all cases of unexplained bilateral pediatric cataracts. Metabolic and infectious testing is best considered only after consultation with the child's pediatrician, guided by the patient's clinical context and the availability of genetic testing.

Ependymal cyst in the caudal cranial fossa of a young Belgian Malinois dog with abnormal cerebrospinal fluid findings

Abstract Fluid-filled cavities within the brain are well-recognized in human and veterinary medicine. Congenital or acquired brain cystic lesions could be isolated or associated with other diseases. Clinical signs related to cysts depend on their size and the mass effect they exert on surrounding neuroanatomical structures. We present a case of a 5-month-old Belgian Malinois dog with cervical pain and right head tilt. The dog had a normal haematochemical profile and negative infectious disease tests. A contrast enhancement Computed Tomography scan revealed the presence of a thin-walled cystic lesion in the caudal cranial fossa at the level of the right pontine-cerebellar junction. A cerebrospinal fluid tap was performed by lumbar puncture, revealing a monocytic pleocytosis. After initial improvement following corticosteroid and antibiotic therapy, clinical signs worsened, and the dog underwent a second clinical evaluation and magnetic resonance imaging examination. After euthanasia a complete postmortem examination was performed. Histological and immunohistochemical findings were suggestive of an ependymal cyst.

Survey of blood collection and transfusion practices among institutions in Africa.

Dramatic improvements in blood transfusion have occurred during the last two decades. Transfusion medicine services and practices in Africa remain underexplored. A survey of blood bank/transfusion medicine (BBTM) practices, available blood products, blood product source(s), pre-transfusion testing, and blood donor infectious disease testing methodologies across Africa was performed using the American Society for Clinical Pathology (ASCP) listserv. Survey recipients included hospital-based laboratories/blood banks, national transfusion medicine services, and free-standing laboratories (collectively referred to as institutions). Responses from a total of 81 institutions across 22 countries were analyzed. All 81 institutions provide at least one type of blood product-whole blood, red blood cells (RBCs), platelets, plasma, and cryoprecipitate, with whole blood (90.1%, 73 of 81) and RBCs (79.0%, 64 of 81) most common, while cryoprecipitate is least common (12.4%, 10 of 81). Only five countries had a responding institution that provides all types of products. Among institutions that collect blood onsite, the most common sources of blood products are patients' family members (94.1%, 48 of 51) and pre-screened on-demand volunteer donors (82.4%, 42 of 51). The most commonly screened infectious agents are HIV and hepatitis B virus (both 81.5%), while 70.4% (57 of 81) test for hepatitis C virus (HCV) and Treponema pallidum. This study highlights significant variability and restrictions in blood product availability, pre-transfusion testing, and blood donor infectious disease testing across Africa. Further studies are needed to ascertain barriers to improving blood donor availability, blood product safety, and infectious disease testing.

Determining the rate of infectious disease testing through contagion potential.

The emergence of new strains, varying in transmissibility, virulence, and presentation, makes the existing epidemiological statistics an inadequate representation of COVID-19 contagion. Asymptomatic individuals continue to act as carriers for the elderly and immunocompromised, making the timing and extent of vaccination and testing extremely critical in curbing contagion. In our earlier work, we proposed contagion potential (CP) as a measure of the infectivity of an individual in terms of their contact with other infectious individuals. Here we extend the idea of CP at the level of a geographical region (termed a zone). We estimate CP in a spatiotemporal model based on infection spread through social mixing as well as SIR epidemic model optimization, under varying conditions of virus strains, reinfection, and superspreader events. We perform experiments on the real daily infection dataset at the country level (Italy and Germany) and state level (New York City, USA). Our analysis shows that CP can effectively assess the number of untested (and asymptomatic) infected and inform the necessary testing rates. Finally, we show through simulations that CP can trace the evolution of the infectivity profiles of zones due to the combination of inter-zonal mobility, vaccination policy, and testing rates in real-world scenarios.

Development of non-electrically controlled SalivaDirect LAMP (NEC-SD-LAMP), a new nonelectrical infectious disease testing method

In this study, non-electrically controlled SalivaDirect loop-mediated isothermal amplification (NEC-SD-LAMP), which can detect infections by amplifying viral DNA expression in saliva without using electrical control systems, was developed. By this method, only by adding water to the device, viral DNA was extracted from saliva using SalivaDirect, the extracted DNA was amplified via loop-mediated isothermal amplification (LAMP), and the results were visually confirmed. Melting palmitic acid maintained the optimal temperature for the LAMP reaction, as the temperature of palmitic acid is maintained at 62.9 °C, its melting point. By exploiting the proximity of the melting point to the optimal temperature for LAMP, LAMP can be performed without electricity. We detected several viruses in the saliva using this method. NEC-SD-LAMP could clearly distinguish 3 types of viral DNA, indicating the high specificity of this reaction. Furthermore, the viral concentration detection limit of the device was 2 copies per µL, indicating that it is possible to detect DNA viral infections in saliva even before the onset of viral infection.

Building School-Academic Partnerships to Implement COVID-19 Testing in Underserved Populations.

In April 2021, the US government made substantial investments in students' safe return to school by providing resources for school-based coronavirus disease 2019 (COVID-19) mitigation strategies, including COVID-19 diagnostic testing. However, testing uptake and access among vulnerable children and children with medical complexities remained unclear. The Rapid Acceleration of Diagnostics Underserved Populations program was established by the National Institutes of Health to implement and evaluate COVID-19 testing programs in underserved populations. Researchers partnered with schools to implement COVID-19 testing programs. The authors of this study evaluated COVID-19 testing program implementation and enrollment and sought to determine key implementation strategies. A modified Nominal Group Technique was used to survey program leads to identify and rank testing strategies to provide a consensus of high-priority strategies for infectious disease testing in schools for vulnerable children and children with medical complexities. Among the 11 programs responding to the survey, 4 (36%) included prekindergarten and early care education, 8 (73%) worked with socioeconomically disadvantaged populations, and 4 focused on children with developmental disabilities. A total of 81 916 COVID-19 tests were performed. "Adapting testing strategies to meet the needs, preferences, and changing guidelines," "holding regular meetings with school leadership and staff," and "assessing and responding to community needs" were identified as key implementation strategies by program leads. School-academic partnerships helped provide COVID-19 testing in vulnerable children and children with medical complexities using approaches that met the needs of these populations. Additional work is needed to develop best practices for in-school infectious disease testing in all children.

Disposable Device for Bacterial Vaginosis Detection.

Due to the increasing demand for clinical testing of infectious diseases at the point-of-care, the global market claims alternatives for rapid diagnosis tools such as disposable biosensors, avoiding the need for specialized laboratories and skilled personnel. Bacterial vaginosis (BV) is an infectious disease that commonly affects reproductive-age women and predisposes the infection of sexually transmitted diseases. Especially in asymptomatic cases, BV can lead to pelvic inflammatory conditions, postpartum endometritis, and preterm labor. Conventionally, BV diagnosis involves the microscopic analysis of vaginal swab samples; it thus requires highly trained personnel. In response, we report a novel microfluidic paper-based analytical device for BV diagnosis. Sialidase, a biomarker overexpressed in BV, was detected by exploiting an immunosensing mechanism previously discovered by our team. This technology employs a graphene oxide-coated surface as a quencher of fluorescence; the fluorescence of the immunoprobes that do not experiment immunoreactions (antibody-antigen) are deactivated by graphene oxide via non-radiative energy transfer, whereas those immunoprobes undergoing immunoreactions preserve their photoluminescence due to the distance and the low affinity between the immunocomplex and the graphene oxide-coated surface. Our paper-based test was typically carried out within 20 min, and the sample volume was 6 μL. Besides, it was tested with 14 vaginal swabs specimens to discriminate clinical samples of women with normal microbiota from those with BV. Our disposable device represents a new tool to prevent the consequences of BV.

The Current Policy Debate around the Regulation of LDTs: What It Means for Infectious Disease Testing and Where It May Be Headed

The debate over federal regulation of diagnostic tests is not new, but scientific advances, societal developments, and global events over the past decade have accelerated efforts by the Food and Drug Administration (FDA) and members of Congress to revise the regulatory oversight of these devices, including laboratory-developed tests (LDTs). Despite years of congressional hearings and public meetings, legislation in the House and Senate, draft guidance from the FDA, and debate in the stakeholder community, LDT regulation remains unchanged, and the path forward remains unclear. LDTs play an essential role in infectious disease (ID) management and treatment, and changes in their regulation will have far-reaching implications for diagnostic laboratories. LDTs are widely used by clinical microbiology laboratories for the diagnosis and monitoring of a myriad infectious diseases, and until three years ago, such testing was conducted largely out of the spotlight. The COVID-19 pandemic changed this by bringing ID tests into the forefront. As the 118th Congress gets under way, the regulation and oversight of diagnostic tests, including LDTs, remains at the forefront of health care policy discussions on Capitol Hill and with the FDA. Change is coming, and it is important that clinical microbiologists, ID physicians, and other laboratorians have a seat at the table when such changes are being discussed.

Fighting against COVID‐19: Innovations and applications

Fighting against <scp>COVID</scp>‐19: Innovations and applications

Advances in paper based isothermal nucleic acid amplification tests for water-related infectious diseases

Water-associated or water-related infectious disease outbreaks are caused by pathogens such as bacteria, viruses, and protozoa, which can be transmitted through contaminated water sources, poor sanitation practices, or insect vectors. Low- and middle-income countries bear the major burden of these infections due to inadequate hygiene and subpar laboratory facilities, making it challenging to monitor and detect infections in a timely manner. However, even developed countries are not immune to these diseases, as inadequate wastewater management and contaminated drinking water supplies can also contribute to disease outbreaks. Nucleic acid amplification tests have proven to be effective for early disease intervention and surveillance of both new and existing diseases. In recent years, paper-based diagnostic devices have made significant progress and become an essential tool in detecting and managing water-associated infectious diseases. In this review, we have highlighted the importance of paper and its variants as a diagnostic tool and discussed the properties, designs, modifications, and various paper-based device formats developed and used for detecting water-associated pathogens.

Investigating Viral Involvement in Immunocompromised Patients Using Comprehensive Infectious Disease Testing Including FilmArray Respiratory Panel 2.1 on Bronchoscopy: A Retrospective Study.

Introduction Reports are rare on the usefulness of the FilmArray Respiratory Panel 2.1 (FARP) using lower respiratory tract specimens. This retrospective study assessed its use, as part of a comprehensive infectious disease panel, to detect the viral causes of pneumonia using bronchoalveolar lavage samples from immunosuppressed patients. Methods This study included immunocompromised patients who underwent bronchoalveolar lavage or bronchial washing by bronchoscopy between April 1, 2021, and April 30, 2022. The collected samples were submitted for comprehensive testing, including FARP test; reverse transcription polymerase chain reaction (RT-PCR) for cytomegalovirus, varicella-zoster virus DNA, and herpes simplex virus; PCR for Pneumocystis jirovecii DNA; antigen testing for Aspergillus and Cryptococcus neoformans; and loop-mediated isothermal amplification method for Legionella. Results Out of 23 patients, 16 (70%) showed bilateral infiltrative shadows on computed tomography and three (13%) were intubated. The most common causes of immunosuppression were anticancer drug use (n=12, 52%) and hematologic tumors (n=11, 48%). Only two (9%) patients tested positive for severe acute respiratory syndrome coronavirus 2 and adenovirus by FARP. Four patients (17%) tested positive for cytomegalovirus by RT-PCR, but no inclusion bodies were identified cytologically. Nine (39%) patients tested positive for Pneumocystis jirovecii by PCR, but cytology confirmed the organism in only one case. Conclusions Comprehensive infectious disease testing, performed using bronchoalveolar lavage samples collected from lung lesions in immunosuppressed patients, showed low positive detection by FARP. The viruses currently detectable by FARP may be less involved in viral pneumonia diagnosed in immunocompromised patients.

Role of Recent PCR Tests for Infectious Ocular Diseases: From Laboratory-Based Studies to the Clinic.

Infectious uveitis is a vision-threatening condition that requires prompt clinical diagnosis and proper treatment. However, rapid and proper diagnosis in infectious uveitis remains challenging. Several examination tests, including polymerase chain reaction (PCR) tests, are transitioning from laboratory-based basic research-level tests to bedside clinical tests, and recently tests have changed to where they can be performed right next to clinicians. In this review, we introduce an updated overview of recent studies that are representative of the current trends in clinical microbiological techniques including PCR tests for infectious uveitis.

Pain or Weakness? An Immunocompromised Patient Presenting with Inability to Walk

IntroductionErythema nodosum (EN) appears as tender erythematous nodules, mainly on the pretibial areas. The causes are varied including medication side effects, infections, autoimmune conditions, malignancy, and is idiopathic in 50% of cases. The pathophysiology is not completely understood but may involve an immunologic response or hypersensitivity reaction to various stimuli, leading to immune complex deposition in the venules of septae in subcutaneous fat. Case Presentation17-year-old male with right mandible ameloblastoma (positive for BRAF V600E mutation), who was diagnosed in May 2022, and has been semi-compliant with dabrafenib, BRAF V600E mutation kinase inhibitor, for the previous 6 months and was off for about 1 week when he presented with fever, followed by painful rash of extremities, including soles and palms, and ascending weakness with inability to walk, concerning for neurological insult. The rash was confluent, macular patches, non-pruritic, blanching with a needle-like tenderness. We questioned whether the inability to walk was neurological or related to pain. Brain Magnetic Resonance Imaging (MRI) was unremarkable. Extensive infectious disease testing yielded rhinovirus/enterovirus positive Polymerase Chain Reaction (PCR) but was negative for all other pathogens, including Streptococcus A infection. Rheumatologic workup was negative. He was treated with Non-Steroidal Anti-Inflammatory Drugs and triamcinolone cream which provided improvement of rash and presenting symptoms. Skin biopsy showed granulomatous panniculitis compatible with EN. Dabrafenib was discontinued. DiscussionPatient’s initial presentation was concerning for acute onset of ascending weakness in an immunocompromised patient, suggestive of Guillain-Barré syndrome. Muscular strength was difficult to examine upon initial physical exam likely due to patient effort versus experienced symptoms and patient’s need for assistance to ambulate. However, detailed neurological examination and having normal brain MRI led to the conclusion that the acute change was EN-related pain, rather than weakness. After extensive infectious and rheumatological work up, we concluded that the patient’s EN was likely secondary to Dabrafenib use even if adherence was suboptimal. Clinicians should be aware that EN is an adverse reaction which has been reported in relation to Dabrafenib, as evidenced by a retrospective chart review and case report.

"To Be Honest, You Probably Would Have to Read It 50 Times": Stakeholders Views on Using the Opt-Out Approach for Vaccination in Jails.

Despite national guidelines on infectious disease testing and vaccination in prisons, there is heterogeneity on the implementation of these practices in jails. We sought to better understand perspectives on the implementation of opt-out vaccination for infectious diseases in jails by interviewing a broad group of stakeholders involved in infectious diseases vaccination, testing, and treatment in Massachusetts jails. The research team conducted semistructured interviews with people incarcerated in Hampden County Jail (Ludlow, Massachusetts), clinicians working in jail and community settings, corrections administrators, and representatives from public health, government, and industry between July 2021 and March 2022. Forty-eight people were interviewed, including 13 people incarcerated at the time of interview. Themes that emerged included the following: misunderstandings of what opt-out means, indifference to the way vaccines are offered, belief that using the opt-out approach will increase the number of individuals who receive vaccination, and that opt-out provides an easy way for vaccine rejection and reluctance to accept vaccination. There was a clear divide in stakeholders' support of the opt-out approach, which was more universally supported by those who work outside of jails compared to those who work within or are incarcerated in jails. Compiling the perspectives of stakeholders inside and outside of jail settings on the opt-out approach to vaccination is the first step to develop feasible and effective strategies for implementing new health policies in jail settings.