Autochthonous Chagas Disease - Missouri, 2018.

On December 13, 2017, the Missouri Department of Health and Senior Services (MDHSS) was notified of a suspected case of Chagas disease in a Missouri woman. The patient had donated blood, and laboratory screening revealed antibodies to Trypanosoma cruzi, the parasite that causes Chagas disease. Evaluation by physicians found no clinical symptoms consistent with Chagas disease. The patient had no travel history that would have suggested a significant risk for Chagas disease risk and had no occupational exposure to the disease agent. She had never received a blood transfusion or organ transplant. Confirmatory testing of the patient's serum at CDC for T. cruzi antibody was consistent with infection. These findings raise the possibility that the exposure to T. cruzi occurred locally (autochthonously) in Missouri. Although the insect vector for the parasite T. cruzi, triatomines (commonly known as "kissing bugs"), has been identified previously in Missouri, no locally acquired human cases of Chagas disease have been identified in the state. Health care providers and public health professionals should be aware of the possibility of locally acquired Chagas disease in the southern United States.

Approach to Positive Blood Cultures in the Hospitalized Patient: A Review.

The use of blood cultures as a diagnostic tool has increased over the years along with improvements in techniques and results. The diagnostic dilemma arises when blood cultures are positive and there is possibility of contamination. Hence obtaining blood cultures in the appropriate setting and the interpretation of blood cultures by the hospitalist is imperative to the management of the hospitalized patient.

A Quality Improvement Initiative: Developing a Multi-Disciplinary Team for Infective Endocarditis.

BACKGROUND: As guidelines do not describe how to develop a multi-disciplinary team(MDT), we provide a model using quality improvement tools to design a MDT for infective endocarditis (IE). METHODS: Primary service, specialty teams and whether they had surgery or not (indications, reasons, outcomes and complications) were recorded for IE patients for January-December 2016. Criteria: age >18years and definite IE per modified Duke criteria. RESULTS: Of all cases, 29/82 met criteria. Primary service: internal medicine 18(62.1%), medical intensive care and cardiology 4(13.8%) each, family medicine 2(7.9%) and pediatrics 1(3.4%). Surgery was indicated in 21(72.4%), 9 (42.9%) underwent surgery, 12 (57.1%) did not [6/9(66.67%) left side IE died, all right side IE (3,25%) survived] and 2 (22.2%) had missed opportunities and this was chosen as the leverage point. MDT was developed to reduce the number of left sided IE patients not undergoing surgery despite indications. CONCLUSIONS: Quality improvement and team development tools help in developing MDT for IE.

Trends in Infective Endocarditis Mortality in the United States: 1999 to 2020: A Cause for Alarm.

BACKGROUND: Data on national trends in mortality due to infective endocarditis (IE) in the United States are limited. METHODS AND RESULTS: Utilizing the multiple causes of death data from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2020, IE and substance use were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. Between 1999 and 2020, the IE-related age-adjusted mortality rates declined. IE-related crude mortality accelerated significantly in the age groups 25-34 years (average annual percentage change, 5.4 [95% CI, 3.1-7.7]; P<0.001) and 35-44 years (average annual percentage change, 2.3 [95% CI, 1.3-3.3]; P<0.001), but remained stagnant in those aged 45-54 years (average annual percentage change, 0.5 [95% CI, -1.9 to 3]; P=0.684), and showed a significant decline in those aged ≥55 years. A concomitant substance use disorder as multiple causes of death in those with IE increased drastically in the 25-44 years age group (P<0.001). The states of Kentucky, Tennessee, and West Virginia showed an acceleration in age-adjusted mortality rates in contrast to other states, where there was predominantly a decline or static trend for IE. CONCLUSIONS: Age-adjusted mortality rates due to IE in the overall population have declined. The marked acceleration in mortality in the 25- to 44-year age group is a cause for alarm. Regional differences with acceleration in IE mortality rates were noted in Kentucky, Tennessee, and West Virginia. We speculate that this acceleration was likely due mainly to the opioid crisis that has engulfed several states and involved principally younger adults.

Contemporary Trends and Outcomes of Prosthetic Valve Infective Endocarditis in the United States: Insights from the Nationwide Inpatient Sample.

BACKGROUND: Prosthetic valve endocarditis (PVE) carries high mortality and morbidity as compared to native valve endocarditis (NVE). Contemporary data on PVE are lacking, we aimed to study contemporary trends, outcomes, and burden of PVE using nationally representative data. METHODS: We used the National Inpatient Sample from 2000 to 2017 to identify patients admitted with PVE using ICD-9-CM and ICD-10 codes. Risk-adjusted rates were calculated using an Analysis of Covariance (ANCOVA) with the Generalized Linear Model (GLM). Trends were assessed with linear regression and Pearson's Chi-square when appropriate. Binomial logistic regression was used to assess predictors of in-hospital mortality. RESULTS: We identified 43,602 hospitalizations for PVE. PVE hospitalizations increased from 1803 in 2000 to 3450 in 2017. Risk-adjusted mortality decreased from 10.7% in 2002 to 7.3% in 2017 (P<0.01). Logistic regression analysis on mortality showed increase association with age (OR, 1.021, 95%CI [1.017-1.024], p<0.01), Hispanics (OR, 1.493, 95%CI [1.296-1.719], p<0.01) and patients with drug abuse (OR, 1.233, 95%CI [1.05-1.449], p=0.01). Co-morbid conditions like congestive heart failure (OR, 1.511, 95%CI [1.366-1.673], p<0.01), renal failure (OR, 1.572, 95%CI [1.427-1.732], p<0.01) and weight loss (OR, 1.425, 95%CI [1.093-1.419], p<0.01) were also associated with higher mortality. CONCLUSIONS: Over the years the adjusted in-hospital mortality in PVE has trended down but the average cost of stay has increased despite decrease in length of stay.

Acute retinal necrosis secondary to Varicella Zoster Virus.

A 54 year old female presented to the ophthalmology clinic with pain and decreased vision in her left eye. No past medical history other than primary varicella zoster infection, in her childhood. The eye exam revealed a macular region with scattered areas of retinal opacity along with patches of necrosis on the periphery. She was started on valganciclovir and referred to the infectious disease clinic. Cell Count, blood chemistry and HIV were negative. Serum was sent for polymerase chain reaction (PCR) for Varicella Zoster Virus (VZV), Herpes Simplex Virus (HSV) and Cytomegalovirus (CMV). The VZV PCR was positive. She had decreased vision on the right eye two days later, and exam revealed peripheral retinal whitening. She was admitted and started on intravenous acyclovir. VZV is one of the most common causes of ARN and has been described in both immunocompetent and immunocompromised persons. Visual changes are usually noted weeks to months after the antecedent herpes zoster. Retinal involvement is bilateral in over half of cases, suggesting that VZV reaches the central nervous system hematogenously. The retinal exam reveals multifocal necrotizing lesions, often initially involving the peripheral retina. Therapy includes intravenous acyclovir with consideration of intravitreal foscarnet and other antivirals for progressing disease.

Tailoring of recommendations to reduce serious cutaneous adverse drug reactions: a pharmacogenomics approach.

The Health Sciences Authority launched a pharmacogenetics initiative in 2008 to facilitate evaluation of pharmacogenetics associations pertinent for Chinese, Malays and Indians in Singapore. The aim was to reduce the incidence and unpredictability of serious adverse drug reactions, with a focus on serious skin adverse drug reactions. This paper describes the gathering of evidence and weighing of factors that led to different genotyping recommendations for HLA-B*15:02 with carbamazepine and HLA-B*58:01 with allopurinol, despite both having strong genetic associations. Translation of pharmacogenomics at a national level requires careful deliberation of the prevalence of at-risk allele, strength of genetic associations, positive predictive value, cost-effectiveness and availability of alternative therapies. Our experience provides a perspective on translating genomic discoveries in advancing drug safety.

Singapore Chapter of Rheumatologists Consensus Statement on the Eligibility for Government Subsidy of Biologic Disease Modifying Antirheumatic Agents for Treatment of Rheumatoid Arthritis (RA).

INTRODUCTION: Up to 30% of patients with rheumatoid arthritis (RA) respond inadequately to conventional non-biologic disease modifying antirheumatic drugs (nbDMARDs), and may benefit from therapy with biologic DMARDs (bDMARDs). However, the high cost of bDMARDs limits their widespread use. The Chapter of Rheumatologists, College of Physicians, Academy of Medicine, Singapore aims to define clinical eligibility for government-assisted funding of bDMARDs for local RA patients. MATERIALS AND METHODS: Evidence synthesis was performed by reviewing 7 published guidelines on use of biologics for RA. Using the modified RAND/UCLA Appropriateness Method (RAM), rheumatologists rated indications for therapies for different clinical scenarios. Points reflecting the output from the formal group consensus were used to formulate the practice recommendations. RESULTS: Ten recommendations including diagnosis of RA, choice of disease activity measure, initiation and continuation of bDMARD and option of first and second-line therapies were formulated. The panellists agreed that a bDMARD is indicated if a patient has (1) active RA with a Disease Activity Score in 28 joints (DAS28) score of ≥3.2, (2) a minimum of 6 swollen and tender joints, and (3) has failed a minimum of 2 nbDMARD combinations of adequate dose regimen for at least 3 months each. To qualify for continued biologic therapy, a patient must have (1) documentation of DAS28 every 3 months and (2) at least a European League Against Rheumatism (EULAR) moderate response by 6 months after commencement of therapy. CONCLUSION: The recommendations developed by a formal group consensus method may be useful for clinical practice and guiding funding decisions by relevant authorities in making bDMARDs usage accessible and equitable to eligible patients in Singapore.

Changing worldwide epidemiology of systemic lupus erythematosus.

Developed countries have better systemic lupus erythematosus survival rates than developing countries, or countries with lower economic performance. This is in part because of a higher human development index, defined by standard of living (a marker for gross domestic product), literacy rates, and life expectancy, with contribution from ethnic variations within individual countries, and unique environmental factors.