Medical Student Patient Outreach to Ensure Continuity of Care During the COVID-19 Pandemic.

Background: In response to the COVID-19 pandemic, the Yale New Haven Health System began rescheduling nonurgent outpatient appointments as virtual visits in March 2020. While Yale New Haven Health expanded its telemedicine infrastructure to accommodate this shift, many appointments were delayed and patients faced considerable uncertainty. Objective: Medical students created the Medical Student Task Force (MSTF) to help ensure continuity of care by calling patients whose appointments were delayed during this transition to telemedicine. Methods: Eighty-five student volunteers called 3765 internal medicine patients with canceled appointments, completing screening for 2197 patients. Volunteers screened for health care needs, assessed preferences for future appointments, and offered emotional support and information about COVID-19. Urgent or emergent patient concerns were triaged and escalated to providers. In this analysis, we used a mixed-methods approach: call information and provider responses were analyzed quantitatively, and patient feedback was analyzed qualitatively via thematic analysis. Results: Ninety-one percent of patients screened found the MSTF calls helpful. Twenty-one percent of patients reported health concerns, with 1% reporting urgent concerns escalated to and addressed by providers. Themes of patient comments included gratitude for outreach and social contact, utility of calls, and well-wishes for health care workers. Conclusions: By calling patients whose appointments had been canceled during a rapid transition to telemedicine, the MSTF helped bridge a potential gap in care by offering patients communication with their care teams, information, and support. We propose that this model could be used in other care systems urgently transitioning to outpatient telemedicine, whether during ongoing outbreaks of COVID-19 or other public health emergencies.

Persistent and relapsing babesiosis in immunocompromised patients.

BACKGROUND: Human babesiosis is a tickborne malaria-like illness that generally resolves without complication after administration of atovaquone and azithromycin or clindamycin and quinine. Although patients experiencing babesiosis that is unresponsive to standard antimicrobial therapy have been described, the pathogenesis, clinical course, and optimal treatment regimen of such cases remain uncertain. METHODS: We compared the immunologic status, clinical course, and treatment of 14 case patients who experienced morbidity or death after persistence of Babesia microti infection, despite repeated courses of antibabesial treatment, with those of 46 control subjects whose infection resolved after a single course of standard therapy. This retrospective case-control study was performed in southern New England, New York, and Wisconsin. RESULTS: All case patients were immunosuppressed at the time of acute babesiosis, compared with <10% of the control subjects. Most case patients experienced B cell lymphoma and were asplenic or had received rituximab before babesial illness. The case patients were more likely than control subjects to experience complications, and 3 died. Resolution of persistent infection occurred in 11 patients after 2-10 courses of therapy, including administration of a final antimicrobial regimen for at least 2 weeks after babesia were no longer seen on blood smear. CONCLUSIONS: Immunocompromised people who are infected by B. microti are at risk of persistent relapsing illness. Such patients generally require antibabesial treatment for >or=6 weeks to achieve cure, including 2 weeks after parasites are no longer detected on blood smear.

Tablet-based Hearing Screening in Children Aged 5 to 17 in Rural Dominican Republic.

OBJECTIVE: The principal aim of this study was to examine the feasibility of hearing screening using tablet audiometry among a cohort of school-aged children in rural Dominican Republic. The authors hypothesized that the tablet audiometer would serve as an expeditious means for hearing loss screening in various remote locations. STUDY DESIGN: Cross-sectional. SETTING: Twenty-three remote locations in and around the city of La Romana, Dominican Republic. The quietest location available in each site was used for testing. PATIENTS: Inclusion criteria comprised children aged 5 to 17 currently residing in the testing location. Children aged <5 years or >18 years were excluded. INTERVENTION: Screening. MAIN OUTCOME MEASURES: For each subject, air conduction thresholds were obtained bilaterally at 500, 1000, 2000, and 4000 Hz; testing duration was also measured. Hearing loss was suspected if any threshold measured ≥30 dB. RESULTS: In this cohort of 423 subjects, 44 (10.4%) failed the screening protocol. The mean thresholds for 500, 1000, 2000, and 4000 Hz frequencies were 26.05, 22.73, 17.57, and 17.15 dB, respectively. Of the 658 thresholds obtained at ≥30 dB, the majority were at 500 or 1000 Hz. The mean testing duration was 494 seconds. CONCLUSIONS: These results suggest that children living in remote communities can be screened quickly for hearing loss using a tablet audiometer. However, significant background noise during testing negatively impacted the low-frequency measurements, thus compromising test reliability. Despite extending the reach of existing audiological services, the value of tablet audiometry is not entirely clear in rural environments with uncontrollable background noise.

Use of real-time polymerase chain reaction for identification of methicillin-resistant Staphylococcus aureus directly from positive blood culture bottles.

The utility of real-time polymerase chain reaction (RT-PCR) testing for detection of methicillin-resistant Staphylococcus aureus (MRSA) directly from positive blood culture bottles was evaluated. One hundred forty-two blood cultures showing Gram-positive cocci in clusters were detected. Each blood culture sample was tested for the presence of MRSA by PCR analysis (SmartCycler) via detection of the mecA and orfX genes. In parallel, they were plated on standard media for identification and characterization. PCR analysis directly from the blood culture bottle required a total time of 120 min (45 min for preparation and 75 min for the reaction). By comparison, conventional laboratory procedures required between 48 and 72 h. The overall test accuracy was 97% with a high positive likelihood ratio and a low negative likelihood ratio.

Necrotizing nocardial scleritis after combined penetrating keratoplasty and phacoemulsification with intraocular lens implantation: a case report and review of the literature.

We report the history and clinical presentation of an 88-year-old female with Fuchs dystrophy who developed an acute anterior necrotizing scleritis in her left eye 23 months after an uncomplicated combined penetrating keratoplasty and phacoemulsification with intraocular lens implantation which progressed to slceral perforation with uveal prolapses. The patient underwent a complete systemic work-up for both autoimmune and infectious causes of scleritis. Surgical specimens of the area of scleral perforation were sent for histology and microbiologic studies. Analysis of surgical specimens revealed the presence of culture-proven Nocardia asteroides as a causative agent for the patient's scleral perforation. Results of her systemic autoimmune work-up were not conclusive. Successful treatment with tectonic scleral reinforcement with donor corneal tissue and preserved pericardium, oral and topical trimethoprim-sulfamethoxazole and topical amikacin salvaged the globe and increased vision. The patient's final best-corrected visual acuity sixteen months after her last operation remains 20/70. Prompt surgical intervention with submission of appropriate specimens for pathological diagnosis and microbiology, along with consultation with rheumatologic and infectious disease specialists, are mandatory to minimize visual loss in cases of suspected infectious necrotizing scleritis.

Bacillus megaterium delayed onset lamellar keratitis after LASIK.

PURPOSE: To report the history and clinical presentation of a 23-year-old man who developed delayed onset lamellar keratitis in his right eye 2 weeks after uneventful LASIK for correction of myopia. METHODS: Initial clinical presentation suggested an infectious etiology, which led to therapeutic elevation of the LASIK flap and further microbiologic investigation with bacterial cultures. RESULTS: Bacterial cultures revealed Bacillus megaterium, which was sensitive to all antibiotics against which it was tested. Twenty-four hours after initiating aggressive topical and oral antibiotic therapy, symptomatic relief occurred in the affected eye. The patient's uncorrected final visual acuity at 1-year follow-up was 20/15 in the right eye, and the stromal bed developed a faint peripheral non-visually significant scar. CONCLUSIONS: This case is an unusual presentation and course for microbial keratitis following LASIK, which occurred despite aseptic technique and fluoroquinolone antibiotic prophylaxis. Following refractive surgery one should be prepared to culture the lamellar interface in cases of suspected microbial keratitis and begin aggressive antibiotic therapy.

Mycobacterium chelonae-Mycobacterium abscessus complex clear corneal wound infection with recurrent hypopyon and perforation after phacoemulsification and intraocular lens implantation.

We report a clear corneal wound infection occurring in a 74-year-old man caused by a member of the Mycobacterium chelonae-Mycobacterium abscessus complex, presenting as crystalline keratopathy with recurrent hypopyon. This led to perforation after phacoemulsification with posterior chamber intraocular lens implantation. Only after corneal biopsy of the incision was the causative organism isolated and found to be sensitive to clarithromycin and ciprofloxacin. Despite aggressive therapy, a full-thickness corneal perforation developed, requiring emergent cyanoacrylate glue to preserve ocular integrity. Both the difficulty and delays in obtaining a correct diagnosis led to severe ocular morbidity. Infectious lamellar keratitis limited to the clear cornea phacoemulsification incision is rare, but some unusual organisms such as atypical mycobacteria may be encountered.

Patterns of infection in patients maintained on long-term peritoneal dialysis therapy with multiple episodes of peritonitis.

The causes of peritonitis in patients with end-stage renal disease maintained on long-term peritoneal dialysis (PD) are unclear. One possible explanation for peritonitis, particularly in patients with multiple episodes of infection, is the release of planktonic bacteria from biofilm on the walls of catheters. Bacteria form biofilm on the walls of catheters within 48 hours of their placement. If this explanation were correct, one would expect there to be reappearance of organisms causing infection in patients with multiple episodes of peritonitis. The charts of all patients starting long-term PD at New Haven CAPD from January 1, 1990, through July 31, 2000, were reviewed. Patients were included in the study if they had experienced more than one episode of culture-positive peritonitis and complete data were available concerning cultured organisms and antibiotic sensitivity patterns. Episodes of infection, organisms, and sensitivities and catheter changes were reviewed. Of 630 patients, 198 were identified as meeting these criteria. There were 114 men; 104 patients were white. Of 198 patients, 157 (80%) had at least one repeat infection with the same organism. In 124 (79%) patients, more than 50% of the peritonitis episodes were caused by the same organism. Of 90 patients who had more than four episodes of infection in their history, 59 (65%) had at least half or more of their episodes caused by the same organism. Sequential analyses for independence revealed that for Staphylococcus epidermidis and for Staphylococcus aureus, there was a significantly increased likelihood for these organisms to follow themselves as causative organisms of peritonitis. When the data were analyzed using the Spearman correlation test, the results indicated that the likelihood of repeat infections occurring was significantly greater than by chance alone. Of 67 patients with catheter changes and subsequent peritonitis, only 10 (15%) developed repeat infections with the same organism after the catheter change. Eight of these were due to yeast. These data support the hypothesis that bacterial biofilm on the walls of peritoneal catheters may be associated with peritonitis in patients maintained on long-term PD and may contribute to at least some of these episodes of infection.

Nontuberculous mycobacterial peritonitis in peritoneal dialysis patients.

While nontuberculous mycobacterial peritonitis is uncommon among peritoneal dialysis (PD) patients, these infections have serious consequences. They present a significant diagnostic and therapeutic challenge for clinicians. Diagnosis can be delayed due to the slow growth rate of some mycobacterial species. These organisms can also be overlooked when adequate culture media are not used in the microbiological evaluation process. The choice of antimicrobial therapy depends upon isolation and speciation of the infecting Mycobacterium species, and prompt catheter removal is essential. Because serious intra-abdominal complications may follow infection, identifying patient risk factors for nontuberculous mycobacterial peritonitis and initiating prompt diagnosis and treatment are essential. We report three cases of peritonitis associated with Mycobacterium chelonae and Mycobacterium gordonae, each with a unique presentation, and discuss the appropriate diagnosis and treatment strategies for the management of PD-associated mycobacterial infections.

Severe Legionella pneumophila pneumonia in a patient with iron overload.

Iron plays a crucial role in the energy metabolism of microorganisms. Humans have developed iron-withholding mechanisms as a form of non-specific immunity. We describe a patient with iron overload and severe Legionella pneumophila pneumonia. This report emphasizes the importance of early consideration of and appropriate therapy against Legionella for patients with iron overload who present with community-acquired pneumonia.

Necrotizing nocardial scleritis after combined penetrating keratoplasty and phacoemulsification with intraocular lens implantation: a case report and review of the literature

We report the history and clinical presentation of an 88-year-old female with Fuchs dystrophy who developed an acute anterior necrotizing scleritis in her left eye 23 months after an uncomplicated combined penetrating keratoplasty and phacoemulsification with intraocular lens implantation which progressed to slceral perforation with uveal prolapses. The patient underwent a complete systemic work-up for both autoimmune and infectious causes of scleritis. Surgical specimens of the area of scleral perforation were sent for histology and microbiologic studies. Analysis of surgical specimens revealed the presence of culture-proven Nocardia asteroides as a causative agent for the patient's scleral perforation. Results of her systemic autoimmune work-up were not conclusive. Successful treatment with tectonic scleral reinforcement with donor corneal tissue and preserved pericardium, oral and topical trimethoprim-sulfamethoxazole and topical amikacin salvaged the globe and increased vision. The patient's final best-corrected visual acuity sixteen months after her last operation remains 20/70. Prompt surgical intervention with submission of appropriate specimens for pathological diagnosis and microbiology, along with consultation with rheumatologic and infectious disease specialists, are mandatory to minimize visual loss in cases of suspected infectious necrotizing scleritis.

Relato de caso de esclerite necrosante aguda, evoluindo para perfuração escleral com prolapso uveal, 23 meses após procedimento de ceratoplastia penetrante e facoemulsificação com implante de lente intra-ocular no olho esquerdo sem intercorrências.A paciente foi submetida à avaliação completa auto-imune para esclerite. Biópsia da área de perfuração escleral foi encaminhada para avaliação patológica e microbiológica. Análise de material cirúrgico revelou presença de cultura proveniente de Nocardia asteroides como agente causal da perfuração escleral. Resultados de exames do sistema auto-imune não foram conclusivos. Tratamento foi um sucesso com reforço escleral tectônico do tecido corneano doador, utilização de pericárdio preservado, associado ao uso sistêmico e tópico de sulfametoxazol-trimetropina e amicacina colírio. Apresentou melhora visual após o tratamento e a melhor correção visual final, 16 meses após o último procedimento cirúrgico foi de 20/70. Intervenção cirúrgica precoce, análise patológica e microbiológica do material, associados a consulta a especialistas na área de doenças infecciosas e reumatologia, são primordiais para minimizar perda visual em casos de suspeitas de esclerite infecciosa necrosante.