Lung Ultrasound for Pleural Line Abnormalities, Confluent B-Lines, and Consolidation: Expert Reproducibility and a Method of Standardization.

OBJECTIVES: Discrete B-lines have clear definitions, but confluent B-lines, consolidations, and pleural line abnormalities are less well defined. We proposed definitions for these and determined their reproducibility using COVID-19 patient images obtained with phased array probes. METHODS: Two raters collaborated to refine definitions, analyzing disagreements on 107 derivation scans from 10 patients. Refined definitions were used by those raters and an independent rater on 1260 validation scans from 105 patients. Reliability was evaluated using intraclass correlation coefficients (ICC) or Cohen's kappa. RESULTS: The agreement was excellent between collaborating raters for B-line abnormalities, ICC = 0.97 (95% confidence interval [CI] 0.97-0.98) and pleural line to consolidation abnormalities, ICC = 0.90 (95% CI 0.87-0.92). The independent rater's agreement for B-line abnormalities was excellent, ICC = 0.97 (95% CI 0.96-0.97) and for pleural line to consolidation was good, ICC = 0.88 (95% CI 0.84-0.91). Agreement just on pleural line abnormalities was weak (collaborators, κ = 0.54, 95% CI 0.48-0.60; independent, κ = 0.54, 95% CI 0.49-0.59). CONCLUSION: With proposed definitions or via collaboration, overall agreement on confluent B-lines and pleural line to consolidation abnormalities was robust. Pleural line abnormality agreement itself was persistently weak and caution should be used interpreting pleural line abnormalities with only a phased array probe.

Point-of-Care Lung Ultrasound for COVID-19: Findings and Prognostic Implications From 105 Consecutive Patients.

BACKGROUND: The prognostic value of point-of-care lung ultrasound has not been evaluated in a large cohort of patients with COVID-19 admitted to general medicine ward in the United States. The aim of this study was to describe lung ultrasound findings and their prognostic value in patients with COVID-19 admitted to internal medicine ward. METHOD: This prospective observational study consecutively enrolled 105 hospitalized participants with COVID-19 at 2 tertiary care centers. Ultrasound was performed in 12 lung zones within 24 hours of admission. Findings were assessed relative to 4 outcomes: intensive care unit (ICU) need, need for intensive respiratory support, length of stay, and death. RESULTS: We detected abnormalities in 92% (97/105) of participants. The common findings were confluent B-lines (92%), non-homogenous pleural lines (78%), and consolidations (54%). Large confluent B-lines, consolidations, bilateral involvement, and any abnormality in ≥ 6 areas were associated with a longer hospitalization and need for intensive respiratory support. Large confluent B-lines and bilateral involvement were also associated with ICU stay. A total lung ultrasound score <5 had a negative predictive value of 100% for the need of intensive respiratory support. A higher total lung ultrasound score was associated with ICU need (median total 18 in the ICU group vs. 11 non-ICU, p = 0.004), a hospitalization ≥ 9d (15 vs 10, p = 0.016) and need for intensive respiratory support (18 vs. 8.5, P < 0.001). CONCLUSIONS: Most patients hospitalized with COVID-19 had lung ultrasound abnormalities on admission and a higher lung ultrasound score was associated with worse clinical outcomes except death. A low total lung ultrasound score (<5) had a negative predictive value of 100% for the need of intensive respiratory support. Point-of-care ultrasound can aid in the risk stratification for patients with COVID-19 admitted to general wards.

Single Dose Versus 3 Doses of Intramuscular Benzathine Penicillin for Early Syphilis in HIV: A Randomized Clinical Trial.

Background: Patients coinfected with syphilis and human immunodeficiency virus (HIV) may have a slower decrease in rapid plasma reagin (RPR) titers. Currently a single dose of 2.4 million units of intramuscular benzathine penicillin G (BPG) is recommended for the treatment of early syphilis. Some observational studies have suggested that this regimen may lead to high failure rates in coinfected patients. Methods: We conducted an open-label randomized clinical trial to compare the efficacy of single-dose and 3-dose regimens of BPG for the treatment of early syphilis in HIV-infected individuals. RPR titers were monitored every 3 months. Treatment success was defined as a decrease in RPR titers of ≥2 dilutions (4-fold) during a 12-month follow-up period. Results: Sixty-four patients were included. In the intention-to-treat analysis, treatment success rates were 80% (28 of 35 subjects) and 93% (27 of 29 subjects) in the single-dose and 3-dose regimens, respectively (absolute difference, 13% [95% confidence interval {CI}, -5% to 30%; P = .17). In the per-protocol analysis, success rates were 93% (27 of 29) and 100% in the single-dose and 3-dose regimens, respectively (absolute difference, 7% [95% CI, -7% to 22%]; P = .49). CD4 T-cell count, RPR titer and syphilis stage did not affect treatment results. Conclusions: When compared with a single dose of BPG, a 3-dose regimen did not improve syphilis serological outcomes. Our results support the Centers for Disease Control and Prevention recommendation of a single dose of BPG in HIV-infected patients with early syphilis. Clinical Trials Registration: NCT02611765.

The perception and experience of gender-based discrimination related to professional advancement among Japanese physicians.

Previous studies from the US have found that female physicians often experience gender-based discrimination related to professional advancement. In Japan, female physicians are underrepresented in leadership positions but little is known about the prevalence of gender discrimination. We investigated the perception and prevalence of gender-based career obstacles and discrimination among Japanese physicians. The study was based on surveys of alumnae from 13 medical schools and alumni from 3 medical schools. In total, 1,684 female and 808 male physicians completed a self-administered questionnaire (response rate 83% and 58%). More women than men had the perception of gender-based career obstacles for women (77% vs. 55%; p < 0.0001). Women with part-time positions were more likely to have the perception of gender-based career obstacles than women working full-time (OR 1.32, 95% CI: 1.01-1.73). More women than men reported experience of gender discrimination related to professional advancement (21% vs. 3%; p < 0.0001). Factors associated with experience of gender discrimination included age (p < 0.0001), marital status (p < 0.0001), academic positions (p < 0.0001), subspecialty board certification (p = 0.0011), and PhD status (p < 0.0001). Women older than 40 years were more likely to experience gender discrimination compared with younger women (OR 5.77, 95% CI: 1.83-18.24 for women above 50, and OR 3.2, 95% CI: 1.48-7.28 for women between 40 and 49) and women with PhD were more likely to experience gender discrimination (OR 4.23, 95% CI: 1.81-9.89). Our study demonstrated that a significant proportion of Japanese women experienced gender-based discrimination and perceived gender-based career obstacles compared with male physicians.

Aerococcal infection at three US Tertiary Care Hospitals.

OBJECTIVES: The aim of the present study was to determine clinical features of Aerococcus infections and the significance of the Aerococcus species isolated from any clinical samples. METHODS: Electronic records of all cultures yielding Aerococcus species from 2002 to 2012 were obtained from three tertiary care hospitals. We performed an in-depth review of medical records. RESULTS: Aerococcus was isolated from ≥ 1 site in 93 patients. Blood cultures were positive in 64 patients; 15 with definite bacteremia, including 3 with endocarditis, 7 with urinary tract infections, 13 with probable bacteremia, and 36 in which Aerococcus was judged to be a possible contaminant. Of 19 urine isolates, 10 were from patients with symptomatic urinary tract infections and 7 were from patients with asymptomatic bacteriuria; in 2 cases, urine isolates were regarded as possible contaminants. Most patients with urinary isolates had underlying urological abnormalities. Other sources for Aerococcus included synovial fluid, bile, bone, intraabdominal abscess, and ovarian abscess. All of the isolates tested with ampicillin, cefazolin, clindamycin, and vancomycin were susceptible. A total of two patients with definite Aerococcus infection died, but all of the others responded to antibiotic therapy. CONCLUSIONS: Aerococcus often is considered a contaminant; however, in our case series, 35% of cases in which Aerococcus was isolated from any site indicated a definite infection. In patients with positive blood cultures for Aerococcus, at least 23% were associated with infection. Appropriate attention needs to be directed to Aerococcus when it is isolated from a normally sterile site.

Point-of-Care Lung Ultrasound Findings in Patients with COVID-19 Pneumonia.

Patients with novel coronavirus disease (COVID-19) typically present with bilateral multilobar ground-glass opacification with a peripheral distribution. The utility of point-of-care ultrasound has been suggested, but detailed descriptions of lung ultrasound findings are not available. We evaluated lung ultrasound findings in 10 patients admitted to the internal medicine ward with COVID-19. All of the patients had characteristic glass rockets with or without the Birolleau variant (white lung). Thick irregular pleural lines and confluent B lines were also present in all of the patients. Five of the 10 patients had small subpleural consolidations. Point-of-care lung ultrasound has multiple advantages, including lack of radiation exposure and repeatability. Also, lung ultrasound has been shown to be more sensitive than a chest radiograph in detecting alveolar-interstitial syndrome. The utilization of lung ultrasound may also reduce exposure of healthcare workers to severe acute respiratory syndrome-coronavirus-2 and may mitigate the shortage of personal protective equipment. Further studies are needed to evaluate the utility of lung ultrasound in the diagnosis and management of COVID-19.

Trypanosoma cruzi meningoencephalitis in a patient with acquired immunodeficiency syndrome.

As a result of global migration, a significant number of people with Trypanosoma cruzi infection now live in the United States, Canada, many countries in Europe, and other non-endemic countries. Trypanosoma cruzi meningoencephalitis is a rare cause of ring-enhancing lesions in patients with acquired immunodeficiency syndrome (AIDS) that can closely mimic central nervous system (CNS) toxoplasmosis. We report a case of CNS Chagas reactivation in an AIDS patient successfully treated with benznidazole and antiretroviral therapy in the United States.

Cost-effective diagnostic checklists for meningitis in resource-limited settings.

BACKGROUND: Checklists can standardize patient care, reduce errors, and improve health outcomes. For meningitis in resource-limited settings, with high patient loads and limited financial resources, central nervous system diagnostic algorithms may be useful to guide diagnosis and treatment. However, the cost effectiveness of such algorithms is unknown. METHODS: We used decision analysis methodology to evaluate the costs, diagnostic yield, and cost effectiveness of diagnostic strategies for adults with suspected meningitis in resource-limited settings with moderate/high HIV prevalence. We considered 3 strategies: (1) comprehensive "shotgun" approach of utilizing all routine tests; (2) "stepwise" strategy with tests performed in a specific order with additional tuberculosis (TB) diagnostics; (3) "minimalist" strategy of sequential ordering of high-yield tests only. Each strategy resulted in 1 of 4 meningitis diagnoses: bacterial (4%), cryptococcal (59%), TB (8%), or other (aseptic) meningitis (29%). In model development, we utilized prevalence data from 2 Ugandan sites and published data on test performance. We validated the strategies with data from Malawi, South Africa, and Zimbabwe. RESULTS: The current comprehensive testing strategy resulted in 93.3% correct meningitis diagnoses costing $32.00 per patient. A stepwise strategy had 93.8% correct diagnoses costing an average of $9.72 per patient, and a minimalist strategy had 91.1% correct diagnoses costing an average of $6.17 per patient. The incremental cost-effectiveness ratio was $133 per additional correct diagnosis for the stepwise over minimalist strategy. CONCLUSIONS: Through strategically choosing the order and type of testing coupled with disease prevalence rates, algorithms can deliver more care more efficiently. The algorithms presented herein are generalizable to East Africa and Southern Africa.