Predicting Hospital Resource Use During COVID-19 Surges: A Simple but Flexible Discretely Integrated Condition Event Simulation of Individual Patient-Hospital Trajectories.

OBJECTIVES: To assist with planning hospital resources, including critical care (CC) beds, for managing patients with COVID-19. METHODS: An individual simulation was implemented in Microsoft Excel using a discretely integrated condition event simulation. Expected daily cases presented to the emergency department were modeled in terms of transitions to and from ward and CC and to discharge or death. The duration of stay in each location was selected from trajectory-specific distributions. Daily ward and CC bed occupancy and the number of discharges according to care needs were forecast for the period of interest. Face validity was ascertained by local experts and, for the case study, by comparing forecasts with actual data. RESULTS: To illustrate the use of the model, a case study was developed for Guy's and St Thomas' Trust. They provided inputs for January 2020 to early April 2020, and local observed case numbers were fit to provide estimates of emergency department arrivals. A peak demand of 467 ward and 135 CC beds was forecast, with diminishing numbers through July. The model tended to predict higher occupancy in Level 1 than what was eventually observed, but the timing of peaks was quite close, especially for CC, where the model predicted at least 120 beds would be occupied from April 9, 2020, to April 17, 2020, compared with April 7, 2020, to April 19, 2020, in reality. The care needs on discharge varied greatly from day to day. CONCLUSIONS: The DICE simulation of hospital trajectories of patients with COVID-19 provides forecasts of resources needed with only a few local inputs. This should help planners understand their expected resource needs.

Blastomycosis in solid organ transplant recipients-A retrospective series from southeastern Wisconsin.

Blastomycosis is a fungal infection caused primarily by Blastomyces dermatitis. The fungus is endemic to the Ohio, Mississippi, and St. Lawrence River areas of the United States. Organ transplant recipients are at risk of blastomycosis due to pharmacologic immunosuppression. Over a 20-year period, 30 cases of blastomycosis post-solid organ transplantation were identified at our center. The cumulative incidence of blastomycosis among SOT recipients was 0.99%. There was a male predominance (70% male) and a median age of 59 at the time of diagnosis. Regarding transplant type, 23 patients received kidney transplants, 4 received liver transplants, 2 received pancreas transplants and 1 received a heart transplant. Median time to blastomycosis identification post-transplant was 67.8 months (range: 1-188 months). Amphotericin B was used as initiation therapy in most cases, followed by itraconazole, voriconazole, or in select cases fluconazole or posaconazole maintenance therapy. Regarding comorbid conditions, 87% of patients had diabetes, 50% had congestive heart failure, and 20% had chronic pulmonary disease. Nine patients (30%) developed blastomycosis-related acute respiratory distress syndrome, 33% of these died with a median time to death of 22 days (range 20 days to 2 months); these were the only deaths attributable to blastomycosis.

HIV-associated neurocognitive disorders (HAND).

Neurocognitive impairment still occurs in the era of HAART, though its onset appears to be delayed and its severity reduced, while HIV-infected individuals live longer with the infection. HAND defines three categories of disorders according to standardized measures of dysfunction: asymptomatic neurocognitive impairment (ANI), mild neurocognitive disorder (MND), and HIV-associated dementia (HAD). The pathogenic mechanisms underlying HAND involve host and virus characterizations and interactions and seem to depend heavily on the overall condition of the immune system. Since there are insufficient data at this point to determine the best therapeutic approach, and since HAART apparently is not sufficient to prevent or reverse HAND, therapy with a combination of drugs with high CPE should be considered while adjunctive and alternative therapies are being explored.

Long Segment Colon Degloving From Blunt Abdominal Trauma.

It is extremely rare for blunt abdominal trauma to result in serious injuries to hollow organs. Degloving injuries of the colon are one of the rarest injuries following blunt abdominal trauma. Intestinal degloving is often seen following rapid deceleration, changes in velocity, crushes and motor vehicle collisions (MVCs). Victims with intestinal degloving injuries can experience vague symptoms despite the severity of the lesion. We present the case of a 21-year-old male with insulin-dependent type 1 diabetes who was involved in a high-speed MVC. He sustained second- and third-degree burns to the extremities, right carotid artery dissection, and multiple fractures to the mandible, pelvis and forearm. Free fluid was also noted in the pelvis prompting an emergent exploratory laparotomy. In the operating room, he was found to have a cecal serosal injury involving more than 50% of the circumference and a sigmoid and descending colon degloving injury of 50 cm. The injured segments were resected, and primary anastomoses were created. Degloving of the colon is extremely rare and the sigmoid is one of the more frequently documented locations of injury. Our case contributes to the limited literature available pertaining to the treatment of evolution of these severe colon injuries.

Conservative Treatment of Empyema Formation Following Intrathoracic Rib Fixation With Antibiotics and Tissue Plasminogen Activator/Dornase.

Rib plating is a recommended intervention for patients with multiple rib fractures or flail chest to improve shortness of breath, significantly reduce pain, and shorten the length of hospital stay. Here, we report a unique and extremely rare finding in a patient with empyema following intrathoracic rib fixation. A 32-year-old male with a history of alcohol use disorder presented to the emergency department trauma bay after a motor vehicle accident. Computed tomography (CT) showed right hemopneumothorax and fourth to ninth rib fractures with displacement. The right fifth and sixth ribs were then plated using a titanium RibFix bridge, implanted intrathoracically along the posterior surface of the ribs. On postoperative day 11, the patient developed an empyema and a CT-guided drainage catheter was placed into the collection. The patient was given a 3-day course of tissue plasminogen activator (tPA) and DNase for the treatment of his empyema. On postoperative day 15, a repeat CT scan demonstrated significant improvement in the empyema with evidence of abscess resolution. Antibiotics were discontinued after a total of 7 days and the patient was discharged on postoperative day 20. This case report contributes information to the management of complications in intrathoracic rib fixation.

Performance of the Cue COVID-19 point-of-care molecular test: insights from a multi-site clinic service model.

The COVID-19 pandemic highlighted the critical need for rapid and accurate molecular diagnostic testing. The Cue COVID-19 Point-of-Care Test (Cue POCT) is a nucleic acid amplification test (NAAT), authorized by Health Canada and FDA as a POCT for SARS-CoV-2 detection. Cue POCT was deployed at a network of clinics in Ontario, Canada with n = 13,848 patrons tested between 17 July 2021 and 31 January 2022. The clinical performance and operational experience with Cue POCT were examined for this testing population composed mostly of asymptomatic individuals (93.7%). A head-to-head prospective clinical verification was performed between 17 July and 4 October for all POCT service clients (n = 3,037) with paired COVID-19 testing by Cue and RT-PCR. Prospective verification demonstrated a clinical sensitivity of 100% and clinical specificity of 99.4% for Cue COVID-19 POCT. The lack of false negatives and low false positive rate (0.64%), underscores the high accuracy (99.4%) of Cue POCT to provide rapid PCR quality results. Low error rates (cancellation rate of 0% and invalid rate of 0.63%) with the current software version were additionally noted. Taken together, these findings highlight the value of accurate molecular COVID-19 POCT in a distributed service delivery model to rapidly detect cases in the community with the potential to curb transmission in high-exposure settings (i.e., in-flight, congregate workplace, and social events). The insights gleaned from this operational implementation are readily transferable to future POCT diagnostic services. IMPORTANCE This manuscript reports on the findings of a large asymptomatic population who underwent surveillance COVID testing on the Cue COVID-19 Point-of-Care Test (POCT). Review of test performance of this rapid molecular POCT, as compared to gold standard RT-PCR, is valuable to many audiences, including public health, emergency testing services, employers, and the general population of consumers who are seeking a user-friendly, accurate, cost-effective, and sustainable testing model for COVID screening. The findings from this operational experience also inform future models of POCT services beyond COVID.

Functional Outcome Based on Mechanical Axis Alignment Following Total Knee Arthroplasty.

Background Total knee arthroplasty (TKA) is the most commonly performed and highly successful surgical intervention for end-stage osteoarthritis of the knee, and it offers patients pain relief, functional recovery, and improved quality of life. The success of knee arthroplasty depends on various factors such as precise surgical technique, alignment of the limb and components, patient selection, and compliance with rehabilitation. Mechanical alignment of the lower limb has been considered an important factor in planning and assessing the success of TKA. Optimal alignment remains a matter of controversy; hence, it is paramount to assess the alignment and functional outcomes. Aim and objective This study aimed to evaluate the reliability of conventional instrumentation in imparting the intended femoral and tibial coronal alignment, as well as study the functional outcome among the neutrally aligned outliers with respect to the mechanical axis of the lower limb using standing long-leg radiographs. Methodology This is a prospective, hospital-based, observational study that was conducted on 60 knees in 42 patients with primary osteoarthritis of the knee joint in the department of orthopedics, Satguru Partap Singh (SPS) Hospitals, Ludhiana. Patients undergoing total knee arthroplasty who fulfilled the inclusion criteria were included in our study and evaluated using Knee Society Score and knee flexion range at periodic follow-up till six months. Preoperative and postoperative standing long-leg radiographs were done for all the patients, and their functional outcome was compared among inliers and outliers. Results Out of these 60 total knee arthroplasties, 18 patients were operated on both knees, and 24 patients were operated on a single knee. There were 25 female patients and 17 male patients. The mean for pre-operative mechanical axis alignment angle was 11.88° ± 5.63° with a range from -3° to 27°, which changed to 2.90° ± 1.59° with a range from 0° to 8° at six months follow-up. It was observed that 42 of the knees were in the inliers, and the remaining 18 knees were in the outliers group. On comparison among inliers and outliers, we found that the mean range of motion was 108.29° ± 4.82° for the inliers group and 106.11° ± 4.04° for the outliers group (p = 0.091), depicting non-significant statistical comparison. Mean Knee Society Score values in inliers and outliers group were 152.45 ± 5.33 and 151.61 ± 3.55, respectively (p = 0.740), showing no statistical significance. Conclusion At six months follow-up, there is no difference in the knee range of motion and Knee Society Scores between mechanical axis inliers and outliers. Thus, we conclude that although every knee arthroplasty is intended to have neutral mechanical alignment, there is no effect of mild mechanical axis malalignment on functional outcome following total knee arthroplasty in the short term.

Bronchopulmonary Fistula Development in an Elderly Male With COVID-19 Infection.

COVID-19 pneumonia can cause a wide range of complications including pneumothorax and empyema. However, in severe cases, it can lead to bronchopulmonary fistula (BPF) formation and a persistent air leak due to a connection between the pleural space and the bronchial tree. We report the case of a 77-year-old man with a history of hypertension, who presented to the emergency department for evaluation of dyspnea. Admission labs were significant for a positive rapid antigen SARS-Cov-2 test and elevated troponin I. A chest x-ray demonstrated patchy interstitial opacification and ground glass appearance bilaterally. Within the first 24 hours of presentation, the patient developed a right-sided spontaneous pneumothorax and had a 14 French pigtail catheter placed. The patient subsequently developed a persistent air leak after chest tube placement and required video-assisted thoracoscopic surgery (VATS) with talc pleurodesis and a 32 French chest tube placement. In this unique case, we describe an elderly patient's experience of bronchopulmonary fistula formation as a complication of COVID-19 pneumonia and the successful management of this complication with VATS.

Clostridioides difficile Pyogenic Liver Abscess With an Empyema.

INTRODUCTION: Reports of extraintestinal manifestations of Clostridioides difficile (C difficile) infections are rare. The frequency of these infections comprises approximately 0.17% to 0.6% of all C difficile infections. While they are becoming more frequent worldwide, the precise trend is unclear. CASE PRESENTATION: An 83-year-old female patient presented with pleuritic chest pain 2 to 3 months after a needle biopsy of her liver abscess confirmed C difficile. She was found to have extension of the liver abscess into the chest cavity, leading to empyema, and was treated with intravenous antimicrobials. DISCUSSION: This is the fifth known reported case of C difficile leading to a pyogenic liver abscess and the first case where the C difficile liver abscess was associated with an empyema. While long-term metronidazole is considered effective for managing extra intestinal C difficile infection, our patient was treated with vancomycin and meropenem. CONCLUSION: To determine epidemiology and a proper treatment regimen for extraintestinal C difficile infection, a greater accumulation of cases is necessary.

Benefits of Early Thoracic Surgery in the Elderly During the COVID-19 Pandemic: Lessons Learned From Performing a Video-Assisted Thoracotomy.

Elderly patients are often considered poor surgical candidates for intra-thoracic operations due to the number of comorbidities, increased risks associated with general anesthesia, decreased cardiopulmonary reserve, and overall increased frailty. In addition, coronavirus disease 2019 (COVID-19) is a critical psychosocial factor that, through secondary effects, can prevent patients from receiving optimal care. Patients are reduced to having limited contact with family, often a vital support system, which can contribute to feelings of hopelessness, loneliness, and depression. We report the case of a 95-year-old female who presented to the emergency department with increasing supplemental oxygen requirements two weeks after a ground-level fall. She was found to have multiple rib fractures and a left-sided hemothorax. Initial management included aggressive respiratory therapy, multiple pigtail chest tubes, and thrombolytics; however, these measures failed to drain the intrathoracic hematoma. Her care was complicated by the psychosocial and isolation factors of COVID-19 which led to the patient exhibiting symptoms of hopelessness, grief, lack of appetite, and loneliness. As conservative management did not improve her clinical care the patient required a video-assisted thoracoscopic surgery (VATS) to manage the retained hemothorax and facilitate re-expansion of her atelectatic lung. Once the patient was removed from COVID-19 precautions, she was taken to surgery and postoperatively the patient reported minimal pain, participated more in physical therapy, and increased her oral intake. In this unique case, a 95-year-old patient with a hemothorax that was successfully treated with a VATS had her clinical care complicated by the psychosocial implications of COVID-19.

Acute Pericarditis Due to SARS-COV-2 in a Kidney Transplant Recipient.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is highly contagious and typically presents with respiratory complications. Non-respiratory etiology has been increasingly identified in the literature, including cardiac manifestations. Here, we discuss an atypical case recently treated for SARS-CoV-2 presenting with acute pericarditis. Our patient's medical history of autoimmune disease and renal transplant further complicated her care. There is currently no standard of therapy for SARS-CoV-2-related pericarditis. We would like to highlight increased awareness of this rare complication as well as successful treatment regimens for acute management of the disease.

Cocaine and Levamisole Induced Vasculitis.

Levamisole adulterated cocaine is a rare cause of anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis. It is increasingly diagnosed because of raised awareness; however, it is still underdiagnosed in part because of its rarity and patients not reporting cocaine use. Here we report a case of levamisole-induced vasculitis. We present a 48-year-old non-Hispanic white male with a past medical history significant for Crohn's Disease and pneumonia who presented with acute bilateral ear pain and rash. His urinary drug screen was positive, which prompted suspicion of contamination and potential levamisole adulterated cocaine-associated vasculitis. A punch biopsy showed evidence of leukocytoclastic vasculitis and multiple fibrin thrombi further supporting contamination with levamisole. We believe this case highlights the importance of using patient history in guiding diagnostic testing in the setting of acute vasculitis. Once the history of illicit substance use was confirmed, our differential diagnosis and considerations for treatment significantly changed.

Urine My Heart: A Case of Aerococcal Endocarditis.

An elderly woman with previously known valvular disease presented to the emergency department due to altered mental status. In addition to obtaining an infectious work-up, a bedside echocardiogram was performed and revealed right heart strain prompting a formal echocardiogram evaluation and treatment for a possible pulmonary embolism. Initial laboratory work returned with blood and urine cultures positive for Aerococcus urinae. A transthoracic echocardiogram further revealed new aortic regurgitation. Given this, a transesophageal echocardiogram was completed, confirming new aortic insufficiency as well as findings of infective endocarditis. She did not undergo surgical intervention; however, she was discharged with a plan to continue intravenous antibiotics for six weeks. Although typically seen in genitourinary infections, A. urinae is a rare cause of infective endocarditis and is increasingly identified due to improved speciation techniques. We describe a unique presentation of invasive A. urinae infection to increase awareness and further research on a less commonly encountered bacteria that may present as a urinary tract infection and has the potential to cause invasive disease.

Retrohepatic Mass: A Case of Human Herpesvirus-8 Negative Multicentric Castleman's Disease.

Multicentric Castleman's disease (MCD) is a rare lymphoproliferative disorder with aggressive systemic presentation and poor prognosis. Here, we present a case of MCD in a 37-year-old Asian American woman with a past medical history of the polycystic ovarian syndrome (PCOS), human papilloma virus (HPV), herpes simplex virus-1 (HSV-1), iron deficiency, and vitamin B12 deficiency-related anemia. The patient underwent surgical resection with good recovery. Hemoglobin and erythrocyte sedimentation rate (ESR) normalized after surgical resection. Although the influence of risk factors such as human immunodeficiency virus (HIV) or human herpesvirus-8 (HHV-8) infections on MCD relapse are not well understood, patient education on MCD risk factors is important, as they may place the patient at greater risk for recurrence. MCD should be considered in patients with chronic inflammation and a mass on imaging.

Atypical Blue Rubber Bleb Nevus in an African-American Male.

Blue Rubber Bleb Nevus Syndrome (BRBNS), also known as Bean Syndrome, is a rare condition characterized by vascular ectasias that typically present systemically. Most diagnoses are made in early childhood due to cutaneous lesions in Caucasians with familial inheritance. Treatment is usually patient centered due to the wide variance in clinical presentation of the disease. Here, we present a case of BRBNS in a 65-year-old African-American patient with episodic gastrointestinal (GI) bleeding with no previous history. This case emphasizes the need for a higher clinical suspicion of the disease in patients with recurrent GI bleeding.

healthcareCOVID: a national cross-sectional observational study identifying risk factors for developing suspected or confirmed COVID-19 in UK healthcare workers.

OBJECTIVE: To establish the prevalence, risk factors and implications of suspected or confirmed coronavirus disease 2019 (COVID-19) infection among healthcare workers in the United Kingdom (UK). DESIGN: Cross-sectional observational study. SETTING: UK-based primary and secondary care. PARTICIPANTS: Healthcare workers aged ≥18 years working between 1 February and 25 May 2020. MAIN OUTCOME MEASURES: A composite endpoint of laboratory-confirmed diagnosis of SARS-CoV-2, or self-isolation or hospitalisation due to suspected or confirmed COVID-19. RESULTS: Of 6,152 eligible responses, the composite endpoint was present in 1,806 (29.4%) healthcare workers, of whom 49 (0.8%) were hospitalised, 459 (7.5%) tested positive for SARS-CoV-2, and 1,776 (28.9%) reported self-isolation. Overall, between 11,870 and 21,158 days of self-isolation were required by the cohort, equalling approximately 71 to 127 working days lost per 1,000 working days. The strongest risk factor associated with the presence of the primary composite endpoint was increasing frequency of contact with suspected or confirmed COVID-19 cases without adequate personal protective equipment (PPE): 'Never' (reference), 'Rarely' (adjusted odds ratio 1.06, (95% confidence interval: [0.87-1.29])), 'Sometimes' (1.7 [1.37-2.10]), 'Often' (1.84 [1.28-2.63]), 'Always' (2.93, [1.75-5.06]). Additionally, several comorbidities (cancer, respiratory disease, and obesity); working in a 'doctors' role; using public transportation for work; regular contact with suspected or confirmed COVID-19 patients; and lack of PPE were also associated with the presence of the primary endpoint. A total of 1,382 (22.5%) healthcare workers reported lacking access to PPE items while having clinical contact with suspected or confirmed COVID-19 cases. CONCLUSIONS: Suspected or confirmed COVID-19 was more common in healthcare workers than in the general population and is associated with significant workforce implications. Risk factors included inadequate PPE, which was reported by nearly a quarter of healthcare workers. Governments and policymakers must ensure adequate PPE is available as well as developing strategies to mitigate risk for high-risk healthcare workers during future COVID-19 waves.

Acquired Factor V Inhibitor After Antibiotic Therapy: A Clinical Case Report and Review of the Literature.

Acquired factor V inhibitor (aFVi) is an exceptionally rare hematologic condition that can range from incidental laboratory abnormalities to life-threatening hemorrhage. Bovine thrombin was formerly the most common cause of this condition; however, the decreased use of bovine thrombin in surgical procedures has led to a shift in the cause of aFVi toward antibiotic use and malignancies. Here we present a case of an 80-year-old Caucasian female on long-term warfarin therapy who presented with epistaxis and an elevated international normalized ratio, and a history of cephalosporin antibiotic use. We review the published literature beginning in 2016 to identify the evolving causes of aFVi. Additionally, we propose that stress-mediated immune regulation may contribute to antibody formation, preventing the interaction between factor V and the damaged phospholipid membranes. This case highlights the evolving causes of aFVi and should prompt physicians to consider this diagnosis in coagulopathies that do not correct with traditional therapies.

A Challenging Case of Lemierre's Syndrome With Central Nervous System Involvement and a Comprehensive Review.

Lemierre's syndrome (LS) is a complex medical condition that is characterized by an acute oropharyngeal infection leading to thrombophlebitis of the internal jugular vein and an eventual metastatic spread to distant vital organs. This metastatic spread is from septic emboli and is most frequently seen in the lungs, kidneys, and large joints. Central nervous system (CNS) involvement in LS is extremely rare, and only a few cases of CNS involvement have been reported in the literature. For all cases of LS, early diagnosis and treatment are crucial, yet due to the rarity of CNS complications in LS, diagnostic patterns and treatment algorithms are not fully understood for this subset of presentations. In this report, we present a case of 19-year-old immune-competent female who presented with a Fusobacterium oropharyngeal infection that was complicated by suppurative sinusitis, cavernous sinus thrombosis, meningitis, and an abducens nerve palsy. Our patient was treated with broad-spectrum antibiotics, anticoagulation, and multiple surgical interventions. This case highlights the importance of an early diagnosis and a multidisciplinary approach in managing LS to minimize the mortality and long-term morbidity of this relatively rare and complicated multisystem disease.

Design and Usability of an Electronic Health Record-Integrated, Point-of-Care, Clinical Decision Support Tool for Modeling and Simulation of Antihemophilic Factors.

BACKGROUND: With the consequences of inadequate dosing ranging from increased bleeding risk to excessive drug costs and undesirable administration regimens, the antihemophilic factors are uniquely suited to dose individualization. However, existing options for individualization are limited and exist outside the flow of care. We developed clinical decision support (CDS) software that is integrated with our electronic health record (EHR) and designed to streamline the process for our hematology providers. OBJECTIVES: The aim of this study is to develop and examine the usability of a CDS tool for antihemophilic factor dose individualization. METHODS: Our development strategy was based on the features associated with successful CDS tools and driven by a formal requirements analysis. The back-end code was based on algorithms developed for manual individualization and unit tested with 23,000 simulated patient profiles created from the range of patient-derived pharmacokinetic parameter estimates defined in children and adults. A 296-item heuristic checklist was used to guide design of the front-end user interface. Content experts and end-users were recruited to participate in traditional usability testing under an institutional review board approved protocol. RESULTS: CDS software was developed to systematically walk the point-of-care clinician through dose individualization after seamlessly importing the requisite patient data from the EHR. Classical and population pharmacokinetic approaches were incorporated with clearly displayed estimates of reliability and uncertainty. Users can perform simulations for prophylaxis and acute bleeds by providing two of four therapeutic targets. Testers were highly satisfied with our CDS and quickly became proficient with the tool. CONCLUSION: With early and broad stakeholder engagement, we developed a CDS tool for hematology provider that affords seamless transition from patient assessment, to pharmacokinetic modeling and simulation, and subsequent dose selection.

Disseminated M. bovis Infection and Vertebral Osteomyelitis following Immunotherapy for Bladder Cancer.

The use of BCG in immunotherapy for bladder cancer has been in practice for over 40 years. However, uncommon, serious complications can occur with the therapy. Here, we present a case of vertebral osteomyelitis secondary to dissemination of BCG following immunotherapy, an exceedingly rare presentation of an already rare complication.