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Liver transplant (LT) for undocumented immigrants presents numerous challenges. Although the United Network for Organ Sharing has implemented multiple policy changes to lessen the disparities in LT throughout the years, undocumented immigrants remain especially marginalized and disadvantaged when compared with other populations. Since 2013, the Mount Sinai Hospital’s Recanati Miller Transplant Institute has transplanted 16 undocumented immigrants with successful outcomes. Here, we will share our experience of evaluating, caring for, and transplanting these patients and also highlight our team’s mission to ensure that this population has equitable access to lifesaving medical treatment.

Early liver transplantation (LT) for alcohol-associated hepatitis (AH) is the fastest growing indication for LT, but prediction of harmful alcohol use post-LT remains limited. Among 10 ACCELERATE-AH centers, we examined psychosocial evaluations from consecutive LT recipients for AH from 2006 to 2017. A multidisciplinary panel used content analysis to develop a maximal list of psychosocial variables. We developed an artificial intelligence model to predict post-LT harmful alcohol use. The cohort included training (N= 91 among 8 centers) and external validation (N= 25 among 2 centers) sets, with median follow-up of 4.4 (IQR 3.0–6.0) years post-LT. In the training set, AUC was 0.930 (95%CI 0.862–0.998) with positive predictive value of 0.891 (95%CI 0.620–1.000), internally validated through fivefold cross-validation. In the external validation set, AUC was 0.692 (95%CI 0.666–0.718) with positive predictive value of 0.82 (95%CI 0.625–1.000). The model identified specific variables related to social support and substance use as highly important to predict post-LT harmful alcohol use. We retrospectively developed and validated a model that identified psychosocial profiles at LT predicting harmful alcohol use post-LT for AH. This preliminary model may inform selection and post-LT management for AH and warrants prospective evaluation in larger studies among all alcohol-associated liver disease being considered for early LT.

Among children at a community testing site, a widely available SARS-CoV-2 antigen test was highly specific. Although it had lower sensitivity relative to real-time reverse transcription-polymerase chain reaction, antigen testing identified children with live SARS-CoV-2 virus.

Gastroenteritis caused from infections with Salmonella enterica(salmonellosis) causes significant morbidity in Australia. In addition to acute gastroenteritis, approximately 8.8% of people develop irritable bowel syndrome (IBS) and 8.5% of people develop reactive arthritis (ReA). We estimated the economic cost of salmonellosis and associated sequel illnesses in Australia in a typical year circa 2015. We estimated incidence, hospitalizations, other health care usage, absenteeism, and premature mortality for four age groups using a variety of complementary data sets. We calculated direct costs (health care) and indirect costs (lost productivity and premature mortality) by using Monte Carlo simulation to estimate 90% credible intervals (CrI) around our point estimates. We estimated that 90,833 cases, 4,312 hospitalizations, and 19 deaths occurred from salmonellosis in Australia circa 2015 at a direct cost of AUD 23.8 million (90% CrI, 19.3 to 28.9 million) and a total cost of AUD 124.4 million (90% CrI, 107.4 to 143.1 million). When IBS and ReA were included, the estimated direct cost was 35.7 million (90% CrI, 29.9 to 42.7 million) and the total cost was AUD 146.8 million (90% CrI, 127.8 to 167.9 million). Foodborne infections were responsible for AUD 88.9 million (90% CrI, 63.9 to 112.4 million) from acute salmonellosis and AUD 104.8 million (90% CrI, 75.5 to 132.3 million) when IBS and ReA were included. Targeted interventions to prevent illness could considerably reduce costs and societal impact from Salmonellainfections and sequel illnesses in Australia.

AbstractSalmonellaTyphimurium is a common cause of foodborne illness in Australia. We report on seven outbreaks of SalmonellaTyphimurium multilocus variable-number tandem-repeat analysis (MLVA) 03-26-13-08-523 (European convention 2-24-12-7-0212) in three Australian states and territories investigated between November 2015 and March 2016. We identified a common egg grading facility in five of the outbreaks. While no SalmonellaTyphimurium was detected at the grading facility and eggs could not be traced back to a particular farm, whole genome sequencing (WGS) of isolates from cases from all seven outbreaks indicated a common source. WGS was able to provide higher discriminatory power than MLVA and will likely link more SalmonellaTyphimurium cases between states and territories in the future. National harmonization of Salmonellasurveillance is important for effective implementation of WGS for Salmonellaoutbreak investigations.

AbstractIn Australia, the incidence of SalmonellaTyphimurium has increased dramatically over the past decade. Whole-genome sequencing (WGS) is transforming public health microbiology, but poses challenges for surveillance. To compare WGS-based approaches with conventional typing for Salmonellasurveillance, we performed concurrent WGS and multilocus variable-number tandem-repeat analysis (MLVA) of SalmonellaTyphimurium isolates from the Australian Capital Territory (ACT) for a period of 5 months. We exchanged data via a central shared virtual machine and performed comparative genomic analyses. Epidemiological evidence was integrated with WGS-derived data to identify related isolates and sources of infection, and we compared WGS data for surveillance with findings from MLVA typing. We found that WGS data combined with epidemiological data linked an additional 9% of isolates to at least one other isolate in the study in contrast to MLVA and epidemiological data, and 19% more isolates than epidemiological data alone. Analysis of risk factors showed that in one WGS-defined cluster, human cases had higher odds of purchasing a single egg brand. While WGS was more sensitive and specific than conventional typing methods, we identified barriers to uptake of genomic surveillance around complexity of reporting of WGS results, timeliness, acceptability, and stability. In conclusion, WGS offers higher resolution of SalmonellaTyphimurium laboratory surveillance than existing methods and can provide further evidence on sources of infection in case and outbreak investigations for public health action. However, there are several challenges that need to be addressed for effective implementation of genomic surveillance in Australia.

AbstractFoodborne disease surveillance aims to reduce the burden of illness due to contaminated food. There are several different types of surveillance systems, including event-based surveillance, indicator-based surveillance, and integrated food chain surveillance. These approaches are not mutually exclusive, have overlapping data sources, require distinct capacities and resources, and can be considered a hierarchy, with each level being more complex and resulting in a greater ability to detect and control foodborne disease. Event-based surveillance is generally the least resource-intensive system and makes use of informal data sources. Indicator-based surveillance is seen as traditional notifiable disease surveillance and consists of routinely collected data. Integrated food chain surveillance is viewed as the optimal practice for conducting continuous risk analysis for foodborne diseases, but also requires significant ongoing resources and greater multisectoral collaboration compared to the other systems. Each country must determine the most appropriate structure for their surveillance system for foodborne diseases based on their available resources. This review explores the evidence on the principles, minimum capabilities, and minimum requirements of each type of surveillance and discusses examples from a range of countries. This review forms the evidence base for the Strengthening the Surveillance and Response for Foodborne Diseases: A Practical Manual.

The article offers news briefs and insights on contemporary art. Topics examined by the authors include the book "Contemporary Art: 1989-Present," by Suzanne Hudson and Alexander Dumbadze, the high prices fetched by artworks sold at auction in the 21st-century and the opening of the Broad Art Museum in Los Angeles, California.

AbstractBackground:Estimates of the incidence of foodborne illness are increasingly used at national and international levels to quantify the burden of disease and advocate for improvements in food safety. The calculation of such estimates involves multiple datasets and several disease multipliers, applied to dozens of pathogens. Unsurprisingly, this process often produces wide interval estimates.Materials and Methods:Using a model of foodborne gastroenteritis in Australia, we calculate the contribution of both data and multipliers to the width of the interval. We then compare pathogen-specific estimates of the proportion of gastroenteritis that is foodborne from national-level studies conducted in Canada, Greece, France, the Netherlands, New Zealand, the United Kingdom, and the United States.Results:Overall, we estimate that 74% (range 63–92%) of the interval width for foodborne gastroenteritis in Australia is a result of uncertainty in the proportion of gastroenteritis that is due to contaminated food. Across national studies, we find considerable variability in point estimates and the width of interval estimates for the foodborne proportion for relatively common pathogens such as Salmonellaspp., Campylobacterspp., and norovirus.Conclusions:While some uncertainty in estimates of gastroenteritis incidence is inevitable, an understanding of the drivers of this uncertainty can help to focus further research. In particular, this work highlights the value of studies quantifying the routes of transmission for common pathogens.

AbstractBackground:Estimates of the burden of illness acquired from food inform public health policy and prioritize interventions. A key component of such estimates is the proportion of illnesses that are acquired by foodborne transmission. In view of the shortage of requisite data, these proportions are commonly obtained through a process known as expert elicitation. We report findings from an elicitation process used to assess the importance of the foodborne transmission route for nine pathogens in Australia, circa 2010.Materials and Methods:Eleven experts were asked to estimate the proportion of illness acquired by five transmission routes: food, environmental, water, person, and zoonotic, together with a 90% certainty interval for foodborne transmission. Foodborne estimates and intervals from each expert were combined using both modified triangular and Program Evaluation and Review Technique (PERT) distributions, in @Risk version 6, to generate final distributions from which median estimates and 95% Credible Intervals (CrI) were calculated.Results:Shiga toxin–producing Escherichia coli(STEC) was the only pathogen believed to have an important zoonotic transmission route, while norovirus, hepatitis A virus, non-STEC pathogenic E. coli, and Shigellaspp. were all thought to be primarily spread from person to person. Foodborne transmission was the main route for Clostridium perfringens(98%, CrI: 84–100), Listeria monocytogenes(98%, CrI: 86–100), nontyphoidal Salmonellaspp. (72%, CrI: 50–87), and Campylobacterspp. (77%, CrI: 60–90). Foodborne estimates using the modified triangular distribution had wider CrI than these calculated using the PERT distribution.Conclusions:Foodborne proportions for most pathogens in this study were the same or lower than those estimated circa 2000 in Australia, with the greatest decline for non-STEC pathogenic E. coli. Inclusion of certainty intervals from experts helps to quantify the precision of foodborne proportions. A decline in estimates of the foodborne proportion for common pathogens will influence final estimates of the burden of illness acquired from food.

This research identified competencies required to command a brigade. Interviews and surveys of military personnel provided a multisource perspective of brigade command competencies, including the proficiency level needed for each competency. Thirty-nine competencies were identified and categorized into 4 training-oriented clusters: leadership skills, operational skills, personal capabilities, and knowledge base. Participants reported their preferred methods to develop the competencies within each cluster. The competencies can be used to assess training effectiveness and to identify potential training gaps. Additionally, the model has utility outside of the military, as it describes a framework for leaders who must bridge the gap between organizational and strategic leadership.

Autologous ex vivohematopoietic stem cell gene therapy is particularly relevant in lysosomal storage diseases (LSD) as it offers the prospect of both a safe transplant, as observed in immune deficiency and hematologic illness, and an effective transplant, since it delivers greater enzyme levels to host tissues than is possible in allogeneic transplant. We report early data from such an approach in an allogeneic transplant refractory LSD, Mucopolysaccharidosis type IIIA (MPSIIIA, Sanfilippo syndrome).

Mouse innate-like B cells are a heterogeneous collection of multifunctional cells that control infection, play housekeeping roles, contribute to adaptive immunity, and suppress inflammation. We show that, among leukocytes, chemokine internalization by the D6 receptor is a unique and universal feature of all known innate-like B-cell populations and, to our knowledge, the most effective unifying marker of these cells. Moreover, we identify novel D6activeB1-cell subsets, including those we term B1d, which lack CD5 and CD11b but exhibit typical B1-cell properties, including spontaneous ex vivo production of IgM, IL-10, and anti-phosphorylcholine antibody. The unprecedented opportunity to examine D6 on primary cells has allowed us to clarify its ligand specificity and show that, consistent with a scavenging role, D6 internalizes chemokines but cannot induce Ca2+fluxes or chemotaxis. Unexpectedly, however, D6 can also suppress the function of CXCR5, a critical chemokine receptor in innate-like B-cell biology. This is associated with a reduction in B1 cells and circulating class-switched anti-phosphorylcholine antibody in D6-deficient mice. Therefore, in the present study, we identify a unifying marker of innate-like B cells, describe novel B1-cell subsets, reveal a dual role for D6, and provide the first evidence of defects in resting D6-deficient mice.

To define the role of the α2β1 integrin in pathologic angiogenesis, we investigated tumor-associated growth and angiogenesis in wild-type and α2-null mice. Our findings reveal that the α2β1 integrin plays an important role in angiogenesis via regulation of VEGFR1 expression. When challenged with B16F10 melanoma cells, mice lacking α2β1 integrin ex-pression exhibit increased tumor angiogenesis associated with up-regulated VEGFR1 expression. In contrast, there was no α2β1 integrin-dependent difference in the angiogenic response to Lewis lung carcinoma (LLC) cells. Interestingly, whereas B16F10 cells secrete high levels of placental growth factor (PLGF), LLC cells produce high levels of VEGF, but low levels of PLGF. The α2β1 integrin-dependent difference in angiogenesis was restored to LLC cells by expression of PLGF, strongly suggesting that the angiogenic phenotype and tumor growth in the α2-null host is dependent on specific interactions between the tumor cell and the genetically defined integrin repertoire of the host microenvironment. Thus integrin α2-null mice represent an example of genetic alterations of “the soil” determining response to the “seed.”

Analysis of cardiac troponin T and I have been shown to be effective in detecting minor myocardial injury in cardiac patients who present with acute coronary syndromes (ACS). Determination of minor myocardial injury is significant, as these patients have a higher short-term morbidity and mortality than other unstable angina patients with normal concentrations for these markers. In this report, two theories are given as to why cardiac troponin is superior to other markers such as CK-MB for risk stratification. The ‘low cut-off concentration model’ is based on the fact that troponin is not increased in patients with skeletal muscle disease or injury, resulting in low baseline concentrations of the cardiac isoforms in the absence of active cardiac disease. This enables the use of low decision limits. Troponin also has a higher myocardial tissue content relative to CK-MB, thereby also increasing its clinical sensitivity to irreversible injury. In the ‘reversible ischemia model’, cytoplasmic free troponin T and I leak across the membrane of myocytes as the result of reduced coronary blood flow. Jeopardized myocardial tissue can recover with acute recanalization. Support for this model comes from clinical observations and animal studies.