Case Report: COVID Associated Pancytopenia Unmasking Previously Undiagnosed Pernicious Anemia.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated pancytopenia is a known but rare complication of COVID-19 syndrome that is not well described in literature. Severe acute respiratory syndrome coronavirus 2 has shown the potential to affect any organ including the bone marrow, which then results in a decrease in all three blood cell lines. These cases usually resolve with the passage of time and treatment of underlying risk factors. As COVID pneumonia rates continue to increase worldwide, it is crucial to be able to recognize this complication. Additionally, deeper investigation into patient's response to COVID infection can be complicated by unexpected underlying disease. We report a case of a symptomatic 24-year-old active duty male in Hawaii with post-COVID pancytopenia that was found to have previously undiagnosed pernicious anemia and his response to standard treatment.

Persons tested for SAR-CoV-2 at a military treatment facility in Hawaii.

Health inequalities based on race are well-documented, and the COVID-19 pandemic is no exception. Despite the advances in modern medicine, access to health care remains a primary determinant of health outcomes, especially for communities of color. African-Americans and other minorities are disproportionately at risk for infection with COVID-19, but this problem extends beyond access alone. This study sought to identify trends in race-based disparities in COVID-19 in the setting of universal access to care. Tripler Army Medical Center (TAMC) is a Department of Defense Military Treatment Facility (DoD-MTF) that provides full access to healthcare to active duty military members, beneficiaries, and veterans. We evaluated the characteristics of individuals diagnosed with SARS-CoV-2 infection at TAMC in a retrospective, case-controlled (1:1) study. Most patients (69%) had received a COVID-19 test within 3 days of symptom onset. Multivariable logistic regression analyses were used to identify factors associated with testing positive and to estimate adjusted odds ratios. African-American patients and patients who identified as "Other" ethnicities were two times more likely to test positive for SARS-CoV-2 relative to Caucasian patients. Other factors associated with testing positive include: younger age, male gender, previous positive test, presenting with >3 symptoms, close contact with a COVID-19 positive patient, and being a member of the US Navy. African-Americans and patients who identify as "Other" ethnicities had disproportionately higher rates of positivity of COVID-19. Although other factors contribute to increased test positivity across all patient populations, access to care does not appear to itself explain this discrepancy with COVID-19.

Does prior dengue virus exposure worsen clinical outcomes of Zika virus infection? A systematic review, pooled analysis and lessons learned.

Zika virus (ZIKV) recently caused a pandemic complicated by Guillain-Barre syndrome (GBS) and birth defects. ZIKV is structurally similar to the dengue viruses (DENV) and in vitro studies suggest antibody dependent enhancement occurs in ZIKV infections preceded by DENV; however, the clinical significance of this remains unclear. We undertook a PRISMA-adherent systematic review of all current human and non-human primate (NHP) data to determine if prior infection with DENV, compared to DENV-naïve hosts, is associated with a greater risk of ZIKV clinical complications or greater ZIKV peak viremia in vivo. We identified 1146 studies in MEDLINE, EMBASE and the grey literature, of which five studies were eligible. One human study indicated no increase in the risk of GBS in ZIKV infections with prior DENV exposure. Two additional human studies showed a small increase in ZIKV viremia in those with prior DENV exposure; however, this was not statistically significant nor was it associated with an increase in clinical severity or adverse pregnancy outcomes. While no meta-analysis was possible using human data, a pooled analysis of the two NHP studies leveraging extended data provided only weak evidence of a 0.39 log10 GE/mL rise in ZIKV viremia in DENV experienced rhesus macaques compared to those with no DENV exposure (p = 0.22). Using a customized quality grading criteria, we further show that no existing published human studies have offered high quality measurement of both acute ZIKV and antecedent DENV infections. In conclusion, limited human and NHP studies indicate a small and non-statistically significant increase in ZIKV viremia in DENV-experienced versus DENV-naïve hosts; however, there is no evidence that even a possible small increase in ZIKV viremia would correlate with a change in ZIKV clinical phenotype. More data derived from larger sample sizes and improved sero-assays are needed to resolve this question, which has major relevance for clinical prognosis and vaccine design.

Contextual factors and clinical reasoning: differences in diagnostic and therapeutic reasoning in board certified versus resident physicians.

BACKGROUND: The impact of context on the complex process of clinical reasoning is not well understood. Using situated cognition as the theoretical framework and videos to provide the same contextual "stimulus" to all participants, we examined the relationship between specific contextual factors on diagnostic and therapeutic reasoning accuracy in board certified internists versus resident physicians. METHODS: Each participant viewed three videotaped clinical encounters portraying common diagnoses in internal medicine. We explicitly modified the context to assess its impact on performance (patient and physician contextual factors). Patient contextual factors, including English as a second language and emotional volatility, were portrayed in the videos. Physician participant contextual factors were self-rated sleepiness and burnout.. The accuracy of diagnostic and therapeutic reasoning was compared with covariates using Fisher Exact, Mann-Whitney U tests and Spearman Rho's correlations as appropriate. RESULTS: Fifteen board certified internists and 10 resident physicians participated from 2013 to 2014. Accuracy of diagnostic and therapeutic reasoning did not differ between groups despite residents reporting significantly higher rates of sleepiness (mean rank 20.45 vs 8.03, U = 0.5, p < .001) and burnout (mean rank 20.50 vs 8.00, U = 0.0, p < .001). Accuracy of diagnosis and treatment were uncorrelated (r = 0.17, p = .65). In both groups, the proportion scoring correct responses for treatment was higher than the proportion scoring correct responses for diagnosis. CONCLUSIONS: This study underscores that specific contextual factors appear to impact clinical reasoning performance. Further, the processes of diagnostic and therapeutic reasoning, although related, may not be interchangeable. This raises important questions about the impact that contextual factors have on clinical reasoning and provides insight into how clinical reasoning processes in more authentic settings may be explained by situated cognition theory.

Guidelines for the prevention of travel-associated illness in older adults.

International travel to the developing world is becoming more common in elderly patients (defined here as individuals greater than 65 years old). When providing pre-travel counseling, providers must appreciate the changing physiology, comorbidities, immunity and pharmacokinetics associated with the aging process to prepare elderly patients for the stressors of international travel. These guidelines present an evidence-based approach to pre-travel counseling, immunization, and pharmacology concerns unique to elderly patients seeking care in a travel clinic setting.

The Association between Sexually Transmitted Infections, Length of Service and Other Demographic Factors in the U.S. Military.

BACKGROUND: Numerous studies have found higher rates of sexually transmitted infections (STIs) among military personnel than the general population, but the cumulative risk of acquiring STIs throughout an individual's military career has not been described. METHODS: Using ICD-9 diagnosis codes, we analyzed the medical records of 100,005 individuals from all service branches, divided in equal cohorts (n = 6,667) between 1997 and 2011. As women receive frequent STI screening compared to men, these groups were analyzed separately. Incidence rates were calculated for pathogen-specific STIs along with syndromic diagnoses. Descriptive statistics were used to characterize the individuals within each accession year cohort; repeat infections were censored. RESULTS: The total sample included 29,010 females and 70,995 males. The STI incidence rates (per 100 person-years) for women and men, respectively, were as follows: chlamydia (3.5 and 0.7), gonorrhea (1.1 and 0.4), HIV (0.04 and 0.07) and syphilis (0.14 and 0.15). During the study period, 22% of women and 3.3% of men received a pathogen-specific STI diagnosis; inclusion of syndromic diagnoses increased STI prevalence to 41% and 5.5%, respectively. In multivariate analyses, factors associated with etiologic and syndromic STIs among women included African American race, younger age and fewer years of education. In the overall sample, increasing number of years of service was associated with an increased likelihood of an STI diagnosis (p<0.001 for trend). CONCLUSION: In this survey of military personnel, we found very high rates of STI acquisition throughout military service, especially among women, demonstrating that STI-related risk is significant and ongoing throughout military service. Lower STI incidence rates among men may represent under-diagnosis and demonstrate a need for enhancing male-directed screening and diagnostic interventions.

Clinical Reasoning Tasks and Resident Physicians: What Do They Reason About?

PURPOSE: A framework of clinical reasoning tasks thought to occur in a clinical encounter was recently developed. It proposes that diagnostic and therapeutic reasoning comprise 24 tasks. The authors of this current study used this framework to investigate what internal medicine residents reason about when they approach straightforward clinical cases. METHOD: Participants viewed three video-recorded clinical encounters portraying common diagnoses. After each video, participants completed a post encounter form and think-aloud protocol. Two authors analyzed transcripts from the think-aloud protocols using a constant comparative approach. They conducted iterative coding of the utterances, classifying each according to the framework of clinical reasoning tasks. They evaluated the type, number, and sequence of tasks the residents used. RESULTS: Ten residents participated in the study in 2013-2014. Across all three cases, the residents employed 14 clinical reasoning tasks. Nearly all coded tasks were associated with framing the encounter or diagnosis. The order in which residents used specific tasks varied. The average number of tasks used per case was as follows: Case 1, 4.4 (range 1-10); Case 2, 4.6 (range 1-6); and Case 3, 4.7 (range 1-7). The residents used some tasks repeatedly; the average number of task utterances was 11.6, 13.2, and 14.7 for, respectively, Case 1, 2, and 3. CONCLUSIONS: Results suggest that the use of clinical reasoning tasks occurs in a varied, not sequential, process. The authors provide suggestions for strengthening the framework to more fully encompass the spectrum of reasoning tasks that occur in residents' clinical encounters.

Seroprevalence and seroincidence of herpes simplex virus (2006-2010), syphilis (2006-2010), and vaccine-preventable human papillomavirus subtypes (2000-2010) among US military personnel.

BACKGROUND: Sexually transmitted infections have historically been burdensome in military populations. We describe the seroprevalence and seroincidence of vaccine-preventable human papillomavirus (VP-HPV) subtypes in a sample of 200 servicemen, along with the seroprevalence and seroincidence of herpes simplex virus (HSV-1/2) and syphilis in a sample of 200 men and 200 women. METHODS: Sera from 200 men, along with associated demographic data, were obtained and tested for HPV serotypes at service entry and 10 years later. Similarly, 200 active-duty men and 200 active-duty women were tested for HSV-1/2 at entry to service and 4 years later. RESULTS: The baseline prevalence of VP-HPV subtypes was 14.5%, and cumulative seroincidence of new infection was 34% over a 10-year period (n = 68). Of these, 63% (n = 43) represented HPV-6, HPV-11, or both; 18% of new infections were either HPV-16 or HPV-18, and 19% (n = 13) were a mixture of all 4 strains. At entry to military service, 33.5% of men were seropositive for HSV-1 and 1.5% were positive for HSV-2; seroincidence was 3.4 and 1.1 per 100 person-years, respectively. Among women, 39% were seropositive for HSV-1 and 4.0% for HSV-2; seroincidence was 5.5 and 3.3 per 100 person-years, respectively. There were 2 prevalent and 3 incident cases of syphilis. CONCLUSIONS: Sexually transmitted infections in military populations are highly prevalent, incident, and epidemiologically distinct. Our data show the rates of HPV and HSV-1/2 acquisition that are higher than those seen in the general public, again highlighting the need for continued preventive efforts. Consideration of universal HPV vaccination among men is warranted.

Consequences of contextual factors on clinical reasoning in resident physicians.

Context specificity and the impact that contextual factors have on the complex process of clinical reasoning is poorly understood. Using situated cognition as the theoretical framework, our aim was to evaluate the verbalized clinical reasoning processes of resident physicians in order to describe what impact the presence of contextual factors have on their clinical reasoning. Participants viewed three video recorded clinical encounters portraying straightforward diagnoses in internal medicine with select patient contextual factors modified. After watching each video recording, participants completed a think-aloud protocol. Transcripts from the think-aloud protocols were analyzed using a constant comparative approach. After iterative coding, utterances were analyzed for emergent themes with utterances grouped into categories, themes and subthemes. Ten residents participated in the study with saturation reached during analysis. Participants universally acknowledged the presence of contextual factors in the video recordings. Four categories emerged as a consequence of the contextual factors: (1) emotional reactions (2) behavioral inferences (3) optimizing the doctor patient relationship and (4) difficulty with closure of the clinical encounter. The presence of contextual factors may impact clinical reasoning performance in resident physicians. When confronted with the presence of contextual factors in a clinical scenario, residents experienced difficulty with closure of the encounter, exhibited as diagnostic uncertainty. This finding raises important questions about the relationship between contextual factors and clinical reasoning activities and how this relationship might influence the cost effectiveness of care. This study also provides insight into how the phenomena of context specificity may be explained using situated cognition theory.

Campylobacter fetus bacteremia in an immunocompetent traveler.

Campylobacter fetus bacteremia is a rare human infection that occurs almost exclusively in the setting of advanced age, immunosuppression, human immunodeficiency virus infection, alcoholism, or recent gastrointestinal surgery. This report of C. fetus bacteremia in a 39-year-old immunocompetent traveler who ate raw beef identifies C. fetus as a potential emerging pathogen in normal hosts.