Clinical outcomes of immunomodulation therapy in immunocompromised patients with severe Covid-19 and high oxygen requirement.

Covid-19 disease is implicated in increased mortality among immunocompromised patients. The JAK inhibitor, baricitinib (bar), or the IL-6 inhibitor, tocilizumab (toc), demonstrated a survival benefit in patients with severe disease.However, evidence supporting their use in immunocompromised patients with severe Covid-19 is scarce.We aimed to assess clinical outcomes of bar/toc treatment in immunocompromised patients. A multi-center registry of consecutive immunocompromised patients hospitalized due to severe Covid-19 during the Omicron variant dominance period. After excluding patients who did not require high oxygen supply, patients treated with bar/toc were compared to patients treated by standard of care (SOC). Primary outcome was in hospital mortality. Secondary outcomes were 30 and 60 day mortality, super-infection and thromboembolic events. Among an overall 228 immunocompromised patients hospitalized in six Israeli hospitals with severe Covid-19, 112 patients required high oxygen support, of whom 48 (43%) were treated with bar/toc. In-hospital mortality rates were exceptionally high and did not significantly differ between bar/toc and SOC treated patients (62.5% vs. 64.1%, p = 1.0). A logistic regression analysis revealed that advanced age and incomplete vaccination were predictors of in-hospital mortality. Patients treated with bar/toc had no excess of suspected super-infection (62.8% vs. 60.7%, p = 0.84) or thromboembolic events (8.3% vs 3.1%, p = 0.39). In immunocompromised patients with severe Covid-19 and a high oxygen demand, bar/toc therapy was not associated with reduced mortality or with a higher rate of associated complications, compared to SOC. Larger prospective studies should better address efficacy and safety.

Diagnosis and Risk Factors of Prediabetes and Diabetes in People Living With Human Immunodeficiency Virus: Evaluation of Clinical and Microbiome Parameters.

Diabetes mellitus (DM) is more common among people living with human immunodeficiency virus (PLWH) compared with healthy individuals. In a prospective multicenter study (N = 248), we identified normoglycemic (48.7%), prediabetic (44.4%), and diabetic (6.9%) PLWH. Glycosylated hemoglobin (HbA1c) and fasting blood glucose (FBG) sensitivity in defining dysglycemia was 96.8%, while addition of oral glucose tolerance test led to reclassification of only 4 patients. Inclusion of 93 additional PLWH with known DM enabled identification of multiple independent predictors of dysglycemia or diabetes: older age, higher body mass index, Ethiopian origin, HIV duration, lower integrase inhibitor exposure, and advanced disease at diagnosis. Shotgun metagenomic microbiome analysis revealed 4 species that were significantly expanded with hyperglycemia/hyperinsulinemia, and 2 species that were differentially more prevalent in prediabetic/diabetic PLWH. Collectively, we uncover multiple potential host and microbiome predictors of altered glycemic status in PLWH, while demonstrating that FBG and HbA1c likely suffice for diabetes screening. These potential diabetic predictors merit future prospective validation.

The use of a kaolin-based hemostatic dressing to attenuate bleeding in dogs: A series of 4 cases.

OBJECTIVE: To describe the use of a synthetic hemostatic dressing, QuikClot Combat Gauze (QCG), in dogs with bleeding wounds. CASE SERIES SUMMARY: Two dogs presented with bleeding traumatic wounds, and QCG was used to achieve hemostasis during stabilization of these dogs. In the other 2 dogs, QCG was used to help attenuate bleeding associated with a surgical procedure. NEW OR UNIQUE INFORMATION PROVIDED: While hemostatic dressings have been widely studied and used in human medicine, there is minimal information on the use and efficacy of these hemostatic dressings in veterinary medicine. This case series describes the use of QCG in dogs with hemorrhaging wounds. QCG could be a valuable resource in veterinary emergency and critical care settings.

Risk factors and outcomes of COVID-19 in adult patients with hematological malignancies: A single-center study showing lower than expected rates of hospitalization and mortality.

BACKGROUND: Studies addressing coronavirus disease 2019 (COVID-19) in patients with hematological malignancies have reported mortality rates of up to 40%; however, included predominantly hospitalized patients. METHODS: During the first year of the pandemic, we followed adult patients with hematological malignancies treated at a tertiary center in Jerusalem, Israel, who contracted COVID-19, with the aim of studying risk factors for adverse COVID-19-related outcomes. We used remote communication to track patients managed at home-isolation, and patient questioning to assess the source of COVID-19 infection, community versus nosocomial. RESULTS: Our series included 183 patients, median age was 62.5 years, 72% had at least one comorbidity and 39% were receiving active antineoplastic treatment. Hospitalization, critical COVID-19, and mortality rates were 32%, 12.6%, and 9.8%, respectively, remarkably lower than previously reported. Age, multiple comorbidities, and active antineoplastic treatment were significantly associated with hospitalization due to COVID-19. Treatment with monoclonal antibodies was strongly associated with both hospitalization and critical COVID-19. In older (≥60) patients not receiving active antineoplastic treatment, mortality, and severe COVID-19 rates were comparable to those of the general Israeli population. We did not detect patients that contracted COVID-19 within the Hematology Division. CONCLUSION: These findings are relevant for the future management of patients with hematological malignancies in COVID-19-affected regions.

Evaluation of a stepped, fixed-height magnification marker stand for use with a 100-mm marker in implant sizing prediction in 52 total hip replacement procedures in dogs.

OBJECTIVE: To describe the use of a 100-millimeter marker placed on a stepped, fixed-height magnification marker stand to measure radiographic magnification on accuracy of implant size prediction when used for canine total hip replacement (THR) implant size selection. STUDY DESIGN: Retrospective study. ANIMALS: Fifty-two hips in 45 dogs. METHODS: This study evaluated 52 consecutive canine total hip replacement surgery pre-planning procedures involving 45 dogs with 7 undergoing staged bilateral THRs. Data collected included demographic information, measured radiographic magnification for magnification recalibration, implant size prediction of the cups (52) and the stems (52) based on digital templates superimposed on digital radiographs, and the actual implant sizes used during surgery. RESULTS: Use of the magnification marker stand (MMS) and template application system resulted in an accurate prediction of implant size of 98/104 implants (94.2%) implants. CONCLUSION: A 100-mm marker placed on a magnification marker stand was a viable method to measure and recalibrate for magnification on digital radiographs during the template process to predict the THR implant sizes that should be available when the surgery begins. CLINICAL SIGNIFICANCE: This stepped calibration marker stand is helpful in determination of an accurate preoperative THR implant size prediction, lowering implant stock thresholds, operating time, and associated complications. Additionally, the radiographic documentation of the marker's step height allows for indefinite confirmation of the magnification marker height used and for accurate repeatability for all follow-up imaging examinations and contralateral procedure planning.

Preclosure povidone-iodine lavage in total hip replacement surgery: Infection outcomes and cost-benefit analysis.

OBJECTIVE: To report the outcomes and cost-benefit analysis of preclosure povidone-iodine lavage (PrePIL) used to reduce the risk of infection following total hip replacement (THR) surgery. STUDY DESIGN: Retrospective study. ANIMALS: One thousand six hundred ninety-nine dogs, 17 cats. METHODS: The medical records of 2213 consecutive THR cases were reviewed to determine the incidence of infection. The last 102 were treated with PrePIL using a commercially sourced 0.035% povidone-iodine solution. Postoperative infection rates were compared. A cost-benefit analysis was used to calculate if a PrePIL protocol is economically feasible. RESULTS: Twenty-one THRs out of 2111 (0.99%) that did not have PrePIL developed infection. Infection occurred in none of the 102 PrePIL cases. Cost analysis revealed a PrePIL break-even cost at $49.74 and a break-even infection rate of 0.949%. No complications were identified related to the use of PrePIL. CONCLUSION: Preclosure povidone-iodine lavage appeared to be efficacious in lowering THR infection rates, and it appeared to be safe for this use based on our 102 consecutive cases. The cost of the PrePIL was minimal compared to the overall cost to resolve THR infection and the potential effect on hip function prognosis. The math formulas developed can be used by surgeons to calculate cost effectiveness and break-even cost based on their THR infection rate, and to compare to the cost of a THR revision and infection resolution. CLINICAL SIGNIFICANCE: At current costs, PrePIL can be used in 2415 THR cases at a similar cost of a single revision surgery and resolution of a periprosthetic infection.

Outcome of canine cementless collared stem total hip replacement with proximal femoral periprosthetic cerclage application: 184 consecutive cases.

OBJECTIVE: To report outcomes of cementless collared stem total hip replacement (THR) with proximal femoral periprosthetic cerclage application in dogs. STUDY DESIGN: Retrospective case series. ANIMALS: Client-owned dogs (n = 150) with THR (n = 184). METHODS: Serial postoperative radiographs and medical records of dogs that underwent consecutive index cementless THR, with a single full cerclage wire placed distal to the femoral neck osteotomy line and proximal to the lesser trochanter, were reviewed for intraoperative and postoperative complications. RESULTS: No proximal femoral fractures occurred. No complications associated with the use of the cerclage wire were encountered. A fissure (n = 1) or fractures (n = 2) occurred near the tip of the femoral stem in three cases postoperatively. All three cases required plate and screw fixation. All dogs returned to subjectively normal function at home and all owners were satisfied with the outcome. CONCLUSION: A single full cerclage wire may minimize the risk of a proximal femur fracture following cementless collared stem total hip replacement in dogs. No complications were encountered with the cerclage wire. CLINICAL SIGNIFICANCE: Application of a cerclage wire is a simple and economically feasible procedure that requires minimal additional instrumentation, takes little time, and may decrease the risk of proximal femur fractures after cementless press-fit THR.

Erratum: Corridengum to: Self-Rated Smell Ability Enables Highly Specific Predictors of COVID-19 Status: A Case-Control Study in Israel.

[This corrects the article DOI: 10.1093/ofid/ofaa589.].

Gastrointestinal manifestations of synthetic cannabinoids: a retrospective cohort study.

BACKGROUND: Synthetic cannabinoids (SC) are chemical substances which activate cannabinoid receptors similarly to tetrahydrocannabinol, but with a higher efficacy. These substances are used as illicit recreational drugs, often smoked as herbal mixtures. The continuing availability and rapid evolution of SC is an ongoing health risk. The adverse effects of SC are wide ranging, and span from mild behavioral changes to death. Knowledge regarding gastrointestinal (GI) manifestations of SC use is sparse. METHODS: Single tertiary-care referral medical center retrospective study. RESULTS: The medical records of patients presented to hospital emergency care due to SC use between January 2014 and February 2018 were retrieved from Hadassah Mount Scopus Hospital's computerized database. The records were reviewed for clinical outcomes and laboratory tests. Fifty-five (55) patients were identified with a hospital presentation due to SC use. Twenty-one (21) out of 55 patients (38%) reported gastrointestinal complaints. The most common complaints were abdominal pain and vomiting. Of those, 28% had recurrent emergency department presentations due to abdominal pain and 66% presented with leukocytosis. Serum lactate was elevated in 66% of patients with GI manifestations. One patient had an abnormal computerized tomography (CT) abdominal angiography scan, which was compatible with intestinal ischemia. CONCLUSIONS: The clinical spectrum of gastrointestinal manifestations in SC intoxication ranges from mild symptoms, such as abdominal pain and vomiting, to even more severe symptoms suggestive of intestinal ischemia. Clinicians should be aware that abdominal pain and other gastrointestinal complaints can be associated with SC use.

Comparison of magnetic resonance imaging findings in relation to body weight in dogs with thoracolumbar disease.

OBJECTIVE: To compare the incidence of MRI lesions between dogs weighing < 15 kg (33 lb) and dogs weighing ≥ 15 kg. ANIMALS: 494 dogs with clinical signs of thoracolumbar disease. PROCEDURES: Electronic medical records of affected dogs that underwent MRI of the thoracolumbar vertebral column between January 2016 and July 2018 were reviewed. Data extracted included age, body weight, breed, sex, MRI findings, and lesion location. Data were compared between dogs weighing < 15 kg and dogs weighing ≥ 15 kg. RESULTS: Of dogs weighing < 15 kg, 94.4% (371/393) were chondrodystrophic breeds. Only 24.8% (25/101) of dogs weighing ≥ 15 kg were chondrodystrophic breeds. Lesions consistent with intervertebral disk disease (IVDD) had an overall incidence of 87.2% (431/494). In dogs weighing < 15 kg, the incidence of IVDD was 94.7% (372/393), compared with 58.4% (59/101) in dogs weighing ≥ 15 kg. Dogs weighing < 15 kg had a significantly higher incidence of IVDD lesions in the T12-13 segment, compared with dogs weighing ≥ 15 kg. Dogs weighing ≥ 15 kg were 11.9 times (95% CI, 5.1 to 27.9) and 7.4 times (95% CI, 2.3 to 23) as likely to have a neoplastic lesion and fibrocartilaginous embolic myelopathy, respectively, compared with dogs weighing < 15 kg. CONCLUSIONS AND CLINICAL RELEVANCE: IVDD was the most common MRI finding in the study population. Dogs weighing ≥ 15 kg had a higher incidence of nonintervertebral disk lesions, compared with dogs weighing < 15 kg.

Direct Fluconazole Disk Susceptibility Testing for Candida glabrata-Positive Blood Cultures.

Direct susceptibility testing from blood cultures has been reported to reduce the time interval between a positive blood culture to preliminary reporting of susceptibility and can underpin timely appropriate treatment of candidemia. The aim of this study was to evaluate direct susceptibility testing of Candida glabrata to fluconazole using disk diffusion compared to the Sensititre YeastOne broth microdilution-based method. We tested 83 isolates recovered from 93 spiked and prospective blood culture bottles. Comparison of the two methods showed excellent agreement, with no very major errors and only two major errors (2.4%). The accuracy of the fluconazole disk method was 97.6% (95% confidence interval [CI], 91.6 to 99.7), with a sensitivity of 100% (95% CI, 82.3 to 100) and a specificity of 96.9% (95% CI, 89.2 to 99.6). Direct antifungal disk susceptibility testing from blood cultures is a rapid and easy-to-perform method to determine fluconazole susceptibility of C. glabrata isolates and can be used safely to reduce susceptibility report time and improve clinical decision making regarding appropriate treatment.

Reversible Taste Loss in a COVID-19 Patient With Preexisting Chronic Smell Impairment.

Smell loss is important for coronavirus disease-2019 (COVID-19) screening and diagnosis. Particular attention should be paid to individuals with pre-COVID-19 chronic hyposmia or anosmia. We report a case of reversible taste impairment in a COVID-19 patient with chronically impaired sense of smell. This case emphasizes the importance of COVID-19-related taste assessment.

Self-Rated Smell Ability Enables Highly Specific Predictors of COVID-19 Status: A Case-Control Study in Israel.

BACKGROUND: Clinical diagnosis of coronavirus disease 2019 (COVID-19) is essential to the detection and prevention of COVID-19. Sudden onset of loss of taste and smell is a hallmark of COVID-19, and optimal ways for including these symptoms in the screening of patients and distinguishing COVID-19 from other acute viral diseases should be established. METHODS: We performed a case-control study of patients who were polymerase chain reaction-tested for COVID-19 (112 positive and 112 negative participants), recruited during the first wave (March 2020-May 2020) of the COVID-19 pandemic in Israel. Patients reported their symptoms and medical history by phone and rated their olfactory and gustatory abilities before and during their illness on a 1-10 scale. RESULTS: Changes in smell and taste occurred in 68% (95% CI, 60%-76%) and 72% (95% CI, 64%-80%) of positive patients, with odds ratios of 24 (range, 11-53) and 12 (range, 6-23), respectively. The ability to smell was decreased by 0.5 ± 1.5 in negatives and by 4.5 ± 3.6 in positives. A penalized logistic regression classifier based on 5 symptoms had 66% sensitivity, 97% specificity, and an area under the receiver operating characteristics curve (AUC) of 0.83 on a holdout set. A classifier based on degree of smell change was almost as good, with 66% sensitivity, 97% specificity, and 0.81 AUC. The predictive positive value of this classifier was 0.68, and the negative predictive value was 0.97. CONCLUSIONS: Self-reported quantitative olfactory changes, either alone or combined with other symptoms, provide a specific tool for clinical diagnosis of COVID-19. A simple calculator for prioritizing COVID-19 laboratory testing is presented here.

Onset, duration and unresolved symptoms, including smell and taste changes, in mild COVID-19 infection: a cohort study in Israeli patients.

OBJECTIVES: To characterize longitudinal symptoms of mild coronavirus disease 2019 (COVID-19) patients for a period of 6 months, to potentially aid in disease management. METHODS: Phone interviews were conducted with 103 patients with mild COVID-19 in Israel over a 6-month period (April 2020 to October 2020). Patients were recruited via social media and word to mouth and were interviewed up to 4 times, depending on reports of their unresolved symptoms. Inclusion criteria required participants to be residents of Israel aged 18 years or older, with positive COVID-19 real-time PCR results and nonsevere symptoms. The onset, duration, severity and resolution of symptoms were analysed. RESULTS: A total of 44% (45/103), 41% (42/103), 39% (40/103) and 38% (39/103) of patients experienced headache, fever, muscle ache and dry cough as the first symptom respectively. Smell and taste changes were experienced at 3.9 ± 5.4 and 4.6 ± 5.7 days (mean ± standard deviation (SD)) after disease onset respectively. Among prevalent symptoms, fever had the shortest duration (5.8 ± 8.6 days), and taste and smell changes were the longest-lasting symptoms (17.2 ± 17.6 and 18.9 ± 19.7 days; durations censored at 60 days). Longer recovery of the sense of smell correlated with the extent of smell change. At the 6-month follow-up, 46% (47/103) of the patients had at least one unresolved symptom, most commonly fatigue (22%, 23/103), smell and taste changes (15%, 15/103 and 8%, 8/103 respectively) and breathing difficulties (8%, 8/103). CONCLUSIONS: Long-lasting effects of mild COVID-19 manifested in almost half of the participants reporting at least one unresolved symptom after 6 months.

Total hip replacement in dogs with contralateral pelvic limb amputation: A retrospective evaluation of 13 cases.

OBJECTIVE: To report the clinical characteristics, surgical management, and medium-term outcomes of total hip replacement (THR) performed in dogs with previous contralateral pelvic limb amputation. ANIMALS: Thirteen client-owned dogs. STUDY DESIGN: Multi-institutional retrospective clinical study. METHODS: Data recorded from medical records included signalment, indication for amputation and THR, and surgical complications. Implant positioning and complications were assessed on radiographs. Clinical outcomes were evaluated during follow-up examinations by one of the authors and through a mobility- and lifestyle-based questionnaire completed by owners. RESULTS: All 13 dogs had satisfactory clinical results at follow-up a median of 3 months (range, 2-36) after THR. No postoperative luxation was recorded. Four dogs had minor complications that did not require additional treatment. The only major complication was one failure of osseointegration of a cementless acetabular cup, and it was successfully revised. CONCLUSION: Total hip replacement resulted in satisfactory clinical results and acceptable morbidity in this population. CLINICAL SIGNIFICANCE: Total hip replacement should be considered in dogs with severe coxofemoral joint disease and contralateral pelvic limb amputation.

Case Report of Increased Exposure to Antiretrovirals following Sleeve Gastrectomy.

Bariatric surgery is increasingly performed in morbidly obese HIV patients. Limited data exist regarding antiretroviral drug exposure after bariatric surgery. We report a case of a morbidly obese HIV patient who underwent sleeve gastrectomy. Abacavir, lamivudine, and dolutegravir therapeutic drug monitoring was performed at several time points pre- and postsurgery. Significantly increased levels were measured, particularly for abacavir, whose levels increased ∼12-fold. Several mechanistic explanations for these findings are discussed.

Blood cultures of adult patients discharged from the emergency department-is the safety net reliable?

We investigated the clinical implications of the practice in our emergency department (ED) of discharging patients with pending blood cultures. We reviewed the medical records of adults discharged with positive blood cultures from the ED of a 330-bed university hospital during a five-year period. Clinical characteristics, laboratory data, and antibiotic treatment prescribed in the ED and at discharge were accessed. Antimicrobial susceptibility profiles were used to determine whether antibiotic treatment was adequate. The outcomes assessed for 90 days following discharge were return to the ED, hospitalization, modified diagnosis, and death. Of 220,681 visits to the ED, 1362 showed positive blood cultures; of these, 307 (22.5%) were from discharged patients. More than half the isolates (56.3%) were considered contaminants. Of 124 visits with true bacteremia, Enterobacteriaceae were the most common pathogens (67.0%). This is concordant with urinary tract infection (UTI) being the most common diagnosis (52.4%). With antibiotic treatment, 69.4% had been discharged with antibiotic treatment, which was adequate in two-thirds of them. Among the 77 who returned to the ED, 27.5% had persistent bacteremia. The diagnosis was changed in 44.2% of them, mostly with brucellosis or bone and joint infections, and 84.4% were subsequently hospitalized. Within three months, 5.6% of bacteremic patients died, all after hospitalization. Bacteremia in discharged patients occurred mainly in association with UTI. Outcomes were generally favorable, although only about half received appropriate antibiotic treatment. Diagnoses were changed in a relatively high proportion of patients following culture results.

The Epidemiology and Susceptibility of Candidemia in Jerusalem, Israel.

Objectives: Invasive Candida infections pose a major public health problem worldwide and is a major cause of nosocomial bloodstream infection. Our aim was to assess dynamics in incidence, species distribution and antifungal susceptibility of candidemia episodes in Jerusalem, to better understand the epidemiology of invasive isolates and to better direct therapy. Methods: We analyzed the incidence dynamics, species distribution and susceptibility pattern of 899 candidemia episodes during 2005-2016 in Jerusalem. Results: The overall incidence of candidemia was relatively low of 0.62 per 1,000 admissions. Candida albicans was the leading pathogen (39.4%); however, there was a shift toward non-albicans species, with Candida glabrata predominating among them (40%). As expected, more than one-third of candidemias occurred in intensive care units. However, the distribution between species varied and Candida tropicalis was the leading pathogen in hematology-oncology patients. The susceptibility of isolates to antifungals remained stable throughout the years. Only a minority of Candida albicans isolates were non-susceptible to fluconazole (3.3%), however, an unexpectedly high resistance rate (37.8%) was observed in Candida parapsilosis isolates. We found an alarming rate of caspofungin resistance in Candida glabrata (33.6%) and Candida krusei (67%); this may reflect misclassification of resistance by the E-test method. Conclusions: This is the first comprehensive candidemia analysis in the Jerusalem area that should serve as a basis for decision-making regarding appropriate antifungal treatment in the hospital setting. The exceptional high resistance rate amongst Candida parapsilosis emphasizes the importance of antifungal susceptibility monitoring in medical centers serving large urban areas to better direct appropriate treatment.