Antiretroviral Stewardship: Top 10 Questions Encountered by Stewardship Teams and Solutions to Optimize Therapy.

PURPOSE: Infectious disease pharmacists and physicians overseeing antimicrobial stewardship programs possess expertise and often advanced certification in management of antiretrovirals to treat HIV. Stewardship programs are responsible for managing facility formularies and must stay up to date with the latest antiretrovirals, including once daily formulations and depot injectables. Furthermore, stewardship program members need to understand drug-interactions, short-, and long-term toxicities of these regimens, including dyslipidemia and cardiovascular effects. Patients receiving chronic antiretroviral therapy may present to the acute care, ambulatory care, and long-term care settings. Like other antimicrobials, audit-and-feedback, drug monitoring, and dose-optimization are often required to prevent antiretroviral associated medication errors and minimize resistance. METHODS: A narrative review was conducted on antiretroviral stewardship, addressing common clinical questions encountered by stewardship teams and best practices to optimize antiretroviral therapy and reduce the risk for treatment interruptions, resistance, drug interactions, long term toxicities, and other adverse effects. FINDINGS: People living with HIV are often hospitalized and treated by medical teams without formal HIV training. For this reason, these patients are at greater risk for medication errors during hospitalization and between transitions of care. Many opportunities are present for antiretroviral stewardship to mitigate these errors. Frequent updates to simplify HIV regimen, maintain select patients on fixed-dose combination tablets, and strategies to minimize drug interactions make it difficult for even the seasoned clinician to keep up regularly. IMPLICATIONS: Despite the availability of free online HIV resources and progress made in HIV management, significant opportunities for antiretroviral stewardship remain. Implementing electronic order entry updates, formulary upgrades, and formal pharmacy renal dose adjustments to optimize antiretroviral therapy will help clinicians harness these opportunities. Dedicated time and expertise for antiretroviral stewardship as part of local antimicrobial stewardship programs are needed.

Clinical Characteristics and Outcomes of Patients With Mpox Who Received Tecovirimat in a New York City Health System.

Background: The 2022 global mpox outbreak was notable for transmission between persons outside of travel and zoonotic exposures and primarily through intimate contact. An understanding of the presentation of mpox in people with human immunodeficiency virus (HIV) and other immunocompromising conditions and knowledge of the efficacy of tecovirimat continue to evolve. Methods: This retrospective study describes clinical features and outcomes of persons with mpox who received tecovirimat. Data were obtained via medical record review of patients prescribed tecovirimat in a health system in New York City during the height of the outbreak in 2022. Results: One hundred thirty people received tecovirimat between 1 July and 1 October 2022. People with HIV (n = 80) experienced similar rates of recovery, bacterial superinfections, and hospitalization compared to patients without immunocompromising conditions. Individuals determined to be severely immunocompromised (n = 14) had a higher risk of hospitalization than those without severe immunocompromise (cohort inclusive of those with well-controlled HIV, excluding those without virologic suppression, n = 101): 50% versus 9% (P < .001). Hospitalized patients (n = 18 [13% of total]) were primarily admitted for bacterial superinfections (44.4%), with a median hospital stay of 4 days. Of those who completed follow-up (n = 85 [66%]), 97% had recovery of lesions at time of posttreatment assessment. Tecovirimat was well tolerated; there were no reported severe adverse events attributed to therapy. Conclusions: There were no significant differences in outcomes between people with HIV when evaluated as a whole and patients without immunocompromising conditions. However, mpox infection was associated with higher rates of hospitalization in those with severe immunocompromise, including patients with HIV/AIDS. Treatment with tecovirimat was well tolerated.Key Points: In our mpox cohort, people with HIV had similar rates of recovery and complications as those without HIV or other immunocompromising conditions. Severe immunocompromise was associated with a higher hospitalization rate. Tecovirimat was well tolerated, with minimal side effects.

Fulminant myocarditis secondary to murine typhus mimicking acute coronary syndrome.

Myocarditis is a disease with variable clinical presentation, ranging from an uncomplicated febrile illness to cardiogenic shock. Herein, we report a case of fulminant myocarditis secondary to murine typhus in a 52-year-old male that initially mimicked an acute coronary syndrome. Emergent coronary angiography showed angiographically normal coronary arteries. Left ventriculography showed global hypokinesis with an ejection fraction of 10%. The patient required mechanical support with an intra-aortic balloon pump and fully recovered. .

Decreased transfusion requirements with use of acute normovolemic hemodilution in open aortic aneurysm repair.

OBJECTIVE: Acute normovolemic hemodilution (ANH) is an operative blood conservation technique involving the removal and storage of patient blood after the induction of anesthesia, with maintenance of normovolemia by crystalloid and/or colloid replacement. Developed and used predominately in cardiac surgery, ANH has been applied to the vascular surgery population. However, data regarding the effects on transfusion requirements in this population are limited. The objective of the present study was to compare the transfusion requirements and coagulopathy for patients who had undergone open abdominal aortic aneurysm repair (oAAAR) using ANH to those for patients who had received only product replacements, as clinically indicated. METHODS: We performed a retrospective review of patients who had undergone elective oAAAR at a quaternary aortic referral center from 2017 to 2019. Those eligible for ANH, with no active cardiac ischemia, no valvular disease, normal left ventricular and right ventricular function, chronic kidney disease stage <3, hematocrit >38%, and a normal coagulation profile were included in the present study. Patient demographics and characteristics and operative variables, including aneurysm extent, clamp site, visceral and renal ischemia time, operative time, and transfusion requirements, were collected. Postoperative morbidity, mortality, and length of stay were analyzed. The patients with and without ANH were matched and compared. Continuous measures were analyzed using Wilcoxon rank sum tests and t tests. RESULTS: During the study period, 209 oAAARs had been performed. Of the 209 patients, 76 had met the inclusion criteria. Of these 76 patients, 27 had undergone ANH and 49 had not. The patients with ANH had required fewer PRBC transfusions intraoperatively (median, 0 U; interquartile range [IQR], 0-1 U; median, 1 U; IQR, 0-2 U; P = .02), at 24 hours (median, 0 U; IQR, 0-1 U; vs median, 1 U; IQR, 0-2 U; P = .008), at 48 hours (median, 0 U; IQR, 0-1 U; vs median, 1 U; IQR, 0-2; P = .007), and throughout the admission (median, 0 U; IQR, 0-1 U; vs median, 2 U; IQR, 0-2 U; P = .011). No difference was found in the number of intraoperative platelet or cryoprecipitate transfusions. At 48 hours, the ANH group had had significantly greater platelet counts (142 ± 35.8 × 103/µL vs 124 ± 37.6 × 103/µL; P = .044), lower partial thromboplastin time, and lower international normalized ratio. No difference in myocardial infarction, return to the operating room, or mortality (one death overall). The ANH patients had a shorter length of stay (7.0 ± 2.7 vs 8.8 ± 4.8 days; P = .041). CONCLUSIONS: The use of ANH during oAAAR resulted in fewer intraoperative and postoperative PRBC transfusions with improved coagulation parameters and a shorter hospital length of stay.

Reducing Catheter-associated Urinary Tract Infections via Cost-saving Diagnostic Stewardship.

We conducted a quality improvement project at our large, public, tertiary-care, academic hospital to reduce the standardized infection ratio (SIR) of hospital-acquired catheter-associated urinary tract infections (CAUTIs). Our diagnostic stewardship program, based on education and audit and feedback, significantly reduced inpatient urine culture orders and CAUTI SIR.

A machine-compiled database of genome-wide association studies.

Tens of thousands of genotype-phenotype associations have been discovered to date, yet not all of them are easily accessible to scientists. Here, we describe GWASkb, a machine-compiled knowledge base of genetic associations collected from the scientific literature using automated information extraction algorithms. Our information extraction system helps curators by automatically collecting over 6,000 associations from open-access publications with an estimated recall of 60-80% and with an estimated precision of 78-94% (measured relative to existing manually curated knowledge bases). This system represents a fully automated GWAS curation effort and is made possible by a paradigm for constructing machine learning systems called data programming. Our work represents a step towards making the curation of scientific literature more efficient using automated systems.

Electroencephalography Measures are Useful for Identifying Large Acute Ischemic Stroke in the Emergency Department.

BACKGROUND: Early diagnosis of stroke optimizes reperfusion therapies, but behavioral measures have incomplete accuracy. Electroencephalogram (EEG) has high sensitivity for immediately detecting brain ischemia. This pilot study aimed to evaluate feasibility and utility of EEG for identifying patients with a large acute ischemic stroke during Emergency Department (ED) evaluation, as these data might be useful in the prehospital setting. METHODS: A 3-minute resting EEG was recorded using a dense-array (256-lead) system in patients with suspected acute stroke arriving at the ED of a US Comprehensive Stroke Center. RESULTS: An EEG was recorded in 24 subjects, 14 with acute cerebral ischemia (including 5 with large acute ischemic stroke) and 10 without acute cerebral ischemia. Median time from stroke onset to EEG was 6.6 hours; and from ED arrival to EEG, 1.9 hours. Delta band power (P = .004) and the alpha/delta frequency band ratio (P = .0006) each significantly distinguished patients with large acute ischemic stroke (n = 5) from all other patients with suspected stroke (n = 19), with the best diagnostic utility coming from contralesional hemisphere signals. Larger infarct volume correlated with higher EEG power in the alpha/delta frequency band ratio within both the ipsilesional (r = -0.64, P = .013) and the contralesional (r = -0.78, P = .001) hemispheres. CONCLUSIONS: Within hours of stroke onset, EEG measures (1) identify patients with large acute ischemic stroke and (2) correlate with infarct volume. These results suggest that EEG measures of brain function may be useful to improve diagnosis of large acute ischemic stroke in the ED, findings that might be useful to pre-hospital applications.

The Role of Implant-Tooth Distance on Marginal Bone Levels and Esthetics.

PURPOSE: The peri-implant bone and mucosa architecture contribute to the health and esthetics of single-tooth dental implants. The implant-tooth distance (ITD) has been regarded as a key determinant of their outcomes. This study was conducted to determine the relationship between ITD and peri-implant bone, mucosa, and pink esthetic scores (PES) for anterior single-tooth implants. MATERIALS AND METHODS: For 44 dental implants with a microthread conical abutment interface design placed in 38 participants, periapical radiographs and photographs were evaluated at 1 and 4 years to assess interproximal bone levels and PES. RESULTS: Mean mesial and distal marginal bone level change over 4 years was 0.20 ± 1.00 mm and 0.20 ± 0.74 mm, respectively. In this cohort there was no relationship between ITD and interproximal bone changes or papilla fill at 4 years; however, marginal bone changes influenced PES score-the smaller the ITD, the lower the PES (P < .001). Alone, ITD did not influence marginal bone levels or papilla in this cohort. CONCLUSION: These results imply a complex relationship between ITD, marginal bone levels, and PES scores for single-tooth implants.

Engineered Stochastic Adhesion Between Microbes as a Protection Mechanism Against Environmental Stress.

INTRODUCTION: Microbes aggregate when they display adhesive proteins on their outer membrane surfaces, which then form bridges between microbes. Aggregation protects the inner microbes from harsh environmental conditions such as high concentrations of antibiotics, high salt conditions, and fluctuations in pH. The protective effects of microbial aggregation make it an attractive target for improving the ability of probiotic strains to persist in the gut environment. However, it remains challenging to achieve synthetic microbial aggregation using natural adhesive proteins because these proteins frequently mediate microbial virulence. OBJECTIVES: Construction of synthetic proteins that mediate aggregation between microbes to enhance the survival of cells delivered to stressful environments. METHODS: We construct synthetic adhesins by fusing adhesive protein domains to surface display peptides. The resulting aggregated populations of bacteria are characterized using immunofluorescence, microscopy, flow cytometry, and quantification of colony forming units. RESULTS: We assemble a series of synthetic adhesins, demonstrate their display on the outer membrane of Escherichia coli, and show that they mediate bacterial aggregation. Further engineering of the size and motif composition of the adhesive domain shows that principles from natural adhesins can be applied to our synthetic adhesins. Finally, we show that aggregation allows E. coli cells to resist treatment with antimicrobial peptides and survive inside the gut of Caenorhabditis elegans. CONCLUSIONS: Our results demonstrate that synthetic aggregation can allow bacteria to resist biocidal environmental conditions. Synthetic adhesins may be used to facilitate microbial colonization of previously inaccessible environmental niches, either in remote natural environments or inside living organisms.

Weaponizing human EGF-containing fibulin-like extracellular matrix protein 1 (EFEMP1) for 21st century cancer therapeutics.

De-regulated EFEMP1 gene expression in solid tumors has been widely reported with conflicting roles. We dissected EFEMP1 to identify domains responsible for its cell context-dependent dual functions, with the goal being to construct an EFEMP1-derived tumor-suppressor protein (ETSP) that lacked tumor-promoting function. Exon/intron boundaries of EFEMP1 were used as boundaries of functional modules in constructing EFEMP1 variants, with removal of various module(s), and/or mutating an amino acid residue to convert a weak integrin binding-site into a strong one. A series of in vitro assays on cancerous features, and subcutaneous and intracranial xenograft-formation assays, were carried out for effects from overexpression of wild-type and variant forms of EFEMP1 in two glioma subpopulations characterized as tumor mass-forming cells (TMCs) or stem-like tumor initiating cells (STICs), where EFEMP1 showed cellcontext- dependent dual functions. One of the EFEMP1 variants was identified as the sought-after ETSP, which had a stronger tumor-suppression function in TMCs by targeting EGFR and angiogenesis, and a new tumor-suppression function in STICs by targeting NOTCH signaling and MMP2-mediated cell invasion. Therefore, ETSP may form the basis for further important research to develop a novel cancer therapy to treat many types of cancer by its tumor suppressor effect in the extracellular matrix compartment.

Anti-EGFR function of EFEMP1 in glioma cells and patient prognosis.

EGFR is one of the key oncogenes subjected to targeted therapy for several cancers, as it is known to be amplified and/or mutated in up to 40% of malignant gliomas. EFEMP1, a fibulin-like extracellular protein, exerts both tumor suppressive and oncogenic effects in various cancers and glioma cell models. Although EFEMP1's anti-cancer activity has most commonly been attributed to its anti-angiogenic effects, we showed for gliomas that EFEMP1's binding to EGFR accounts for its suppression of the intracranial tumorigenicity of glioma cells expressing high levels of EGFR. In gliomas where EFEMP1 expression, and thus the anti-EGFR effect of EFEMP1, was suppressed, heightened levels of EGFR expression were associated with unfavorable patient outcomes in prognostic models. Results from the current study clearly demonstrate the impact that the anti-EGFR function of EFEMP1 has on the expression of EGFR and patient prognosis. A glioma prognostic model also suggests EFEMP1's context-dependent oncogenic function in gliomas expressing low levels of EGFR. Hence the level of EFEMP1 expression may have a predictive value for choosing patients for anti-EGFR therapy.

Multireference configuration interaction studies on the ground and excited states of N2O2: the potential energy curves of N2O2 along N-N distance.

In this paper, the ground and excited states of N2O2 were studied at the multireference configuration interaction (MRCI) level of theory with Dunning's [J. Chem. Phys. 90, 1007 (1985); 96, 6796 (1992)] correlation consistent basis sets augo-cc-pVDZ and aug-cc-pVTZ. The geometry optimizations were performed for the ground state of N2O2. The vertical excitation energies and transition moments were calculated for the low-lying singlet states of N2O2 including the lowest three 1A1 states, two 1B1 states, one 1B2 state, and two 1A2 states at the MRCI level of theory with Dunning's correlation consistent basis sets aug-cc-pVDZ, aug-cc-pVTZ, and aug-cc-pVQZ. Furthermore, for the first time, the potential energy curves were calculated at the complete active space self-consistent-field and MRCI levels of theory for as many as 12 N2O2 singlet electronic states along the N-N distance. The dissociation asymptotes of these 12 N2O2 singlet electronic states were discussed.

Computational studies on the ground and excited states of BrOOBr.

In this work, theoretical computations for the ground and excited states of BrOOBr have been performed at high-level ab initio molecular orbital theories. The ground-state geometries of BrOOBr in different forms (trans, cis, and twist form) have been optimized at the couple-cluster CCSD(T) level of theory with cc-pVTZ and aug-cc-pVTZ basis sets, which indicates that at CCSD(T)/cc-pVTZ level of theory, the twist form is 4.96 kcal/mol more stable than the trans form and 10.67 kcal/mol more stable than the cis form; at the CCSD(T)/aug-cc-pVTZ basis set the twist form is 4.33 kcal/mol more stable than the trans form and 9.54 kcal/mol more stable than the cis form. The vertical excitation energies and potential-energy curves for the singlet and triplet low-lying excited states of BrOOBr were calculated at both the complete active space self-consistent-field (CASSCF) level of theory and the multireference internally contracted configuration interaction (MRCI) level of theory. The differences of potential-energy curves at CASSCF and MRCI levels of theory are found for the BrOOBr excited states. At CASSCF level of theory, none of the BrOOBr excited states are bound. However, at MRCI level of theory, all the BrOOBr states studied in this work are bound or slightly bound at the Frank-Condon region. In addition, the scalar relativistic effect and the spin-orbital coupling effect on the vertical excitation energies of the electronic states of BrOOBr were estimated.