Lymphocytic Choriomeningitis Virus in Person Living with HIV, Connecticut, USA, 2021.

Lymphocytic choriomeningitis virus is an underreported cause of miscarriage and neurologic disease. Surveillance remains challenging because of nonspecific symptomatology, inconsistent case reporting, and difficulties with diagnostic testing. We describe a case of acute lymphocytic choriomeningitis virus disease in a person living with HIV in Connecticut, USA, identified by using quantitative reverse transcription PCR.

Provider Satisfaction With Infectious Diseases Telemedicine Consults for Hospitalized Patients During the Coronavirus Disease 2019 (COVID-19) Pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic, our institution transitioned infectious diseases (ID) consultations on hospitalized patients to telemedicine. We evaluated satisfaction with telemedicine among referring providers and ID consultants. Respondents were satisfied with telemedicine consults for hospitalized patients, although there were significant differences in perceptions of quality and timeliness between consultants and referring providers.

Nocardia thailandica Pulmonary Nocardiosis in a Post-Solid Organ Transplant Patient.

Nocardia thailandica is a rare pathogen related to Nocardia asteroides, Nocardia neocaledoniensis, and Nocardia caishijiensis that, since its original description in 2004, has only been reported to cause wound and ocular infections in humans. We report a case of pulmonary nocardiosis caused by Nocardia thailandica in a 66-year-old solid organ transplant patient from Connecticut, which was identified at the molecular taxonomic level by secA1 analysis, 16S rRNA gene sequencing, and matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). To our knowledge, this is the first reported case of N. thailandica in the United States and the first report of pulmonary infection by this pathogen in the literature.

Creation and Validation of an Automated Registry for Outpatient Parenteral Antibiotics.

Existing outpatient parenteral antibiotic therapy (OPAT) registries are resource intensive, and OPAT programs struggle to produce objective data to show the value of their work. We describe the building and validation of an automated OPAT registry within our electronic medical record and provide objective data on the value of the program. Variables and outcomes include age, sex, race, ethnicity, primary insurance payor, antibiotic names, infection syndromes treated, discharge disposition, 30-day all-cause readmission and death rates, complications, and an estimate of the hospital days saved. Records for 146 OPAT episodes were reviewed manually to validate the registry. Data were displayed in a dashboard within the electronic medical record. Over the 4-year time frame, our registry collected 3956 unique patients who completed 4710 episodes (approximately 1200 episodes per year). A total of 400 complications during OPAT were identified. All variables had an accuracy of >90% on validation. The OPAT program resulted in a reduction in hospital length of stay by 88 820 days, or roughly 22 000 days per year. We intend our registry to serve as a blueprint for similar OPAT programs with limited administrative resources. Wider application of our system would allow for easier aggregation and comparisons of OPAT practice and address the lack interinstitutional standardization of OPAT data and outcomes.

A transgenic mouse model expressing exclusively human hemoglobin E: indications of a mild oxidative stress.

Hemoglobin (Hb) E (ß26 Glu→Lys) is the most common abnormal hemoglobin (Hb) variant in the world. Homozygotes for HbE are mildly thalassemic as a result of the alternate splice mutation and present with a benign clinical picture (microcytic and mildly anemic) with rare clinical symptoms. Given that the human red blood cell (RBC) contains both HbE and excess α-chains along with minor hemoglobins, the consequence of HbE alone on RBC pathophysiology has not been elucidated. This becomes critical for the highly morbid ß(E)-thalassemia disease. We have generated transgenic mice exclusively expressing human HbE (HbEKO) that exhibit the known aberrant splicing of ß(E) globin mRNA, but are essentially non-thalassemic as demonstrated by RBC α/ß (human) globin chain synthesis. These mice exhibit hematological characteristics similar to presentations in human EE individuals: microcytic RBC with low MCV and MCH but normal MCHC; target RBC; mild anemia with low Hb, HCT and mildly elevated reticulocyte levels and decreased osmotic fragility, indicating altered RBC surface area to volume ratio. These alterations are correlated with a mild RBC oxidative stress indicated by enhanced membrane lipid peroxidation, elevated zinc protoporphyrin levels, and by small but significant changes in cardiac function. The C57 (background) mouse and full KO mouse models expressing HbE with the presence of HbS or HbA are used as controls. In select cases, the HbA full KO mouse model is compared but found to be limited due to its RBC thalassemic characteristics. Since the HbEKO mouse RBC lacks an abundance of excess α-chains that would approximate a mouse thalassemia (or a human thalassemia), the results indicate that the observed in vivo RBC mild oxidative stress arises, at least in part, from the molecular consequences of the HbE mutation.

A Colocalized Hepatitis C Virus Clinic in a Primary Care Practice Improves Linkage to Care in a High Prevalence Population.

BACKGROUND: There is an urgent need to increase patient access to treatment of chronic hepatitis C virus (HCV) infection. We developed a colocalized HCV clinic integrated within a primary care practice. We report the prevalence of HCV and evaluate the impact of the integrated clinic on the HCV cascade of care. METHODS: We performed a retrospective study of patients with chronic HCV infection from 2 clinic practices, an integrated clinic practice and a similar nonintegrated clinic practice, between July 2015 and July 2016. Demographic, clinical, and HCV testing data were reviewed to estimate the prevalence of chronic HCV and to construct a cascade of care. RESULTS: A total of 8405 primary care patients were included; 4796 (57.1%) received an HCV antibody test and 390 (8.1%) were positive. A total of 310 patients with chronic HCV were included in the analysis. There were 119 patients eligible for linkage to care in the nonintegrated clinic, of which 80 (67.2%) were referred, 38 (31.9%) were linked, and 18 (15.1%) initiated treatment during the study period. Among the 70 patients eligible for linkage to care in the integrated clinic practice, 51 (72.9%) were referred, 38 (54.3%) were linked, and 16 (22.9%) initiated treatment. In a multivariable analysis, patients in the integrated clinic practice had significantly higher odds of being linked to care than patients in the nonintegrated clinic practice (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] = 1.3-4.8). CONCLUSIONS: We found a high seroprevalence of chronic HCV within our clinic population and demonstrate that a HCV clinic integrated into a primary care center increases linkage to care for patients with chronic HCV.

Adverse Events and Healthcare Utilization Associated With Outpatient Parenteral Antimicrobial Therapy Among Older Versus Younger Adults.

Among older (n = 204) versus younger (n = 253) adults, there was no difference in adverse events (adjusted odds ratio [aOR] = 0.98; 95% confidence interval [CI] = 0.6-1.6) or healthcare utilization (incidence rate ratio = 1.09; 95% CI = 0.9-1.3) within 30 days after discontinuing outpatient parenteral antimicrobial therapy. Vancomycin (aOR = 1.92) and oxacillin (aOR = 3.12) were independently associated with adverse events.

Training to Cure-Implementing a Hepatitis C Clinic Curriculum in Primary Care Residency Training.

BACKGROUND: Residents lack exposure to chronic hepatitis C (HCV) infection management, limiting the pipeline of providers able to alleviate the treatment bottleneck. ACTIVITY: We surveyed 34 residents rotating through a new HCV curriculum comprised of a clinic primer, didactics, and supervised patient care. Outcome measures were knowledge and self-efficacy regarding HCV management. RESULTS: HCV knowledge scores improved significantly from 58% pre-clinic to 76% immediately post (p < 0.001)- and 66% 3-month post-clinic (p = 0.006). Residents felt more confident managing HCV after the clinic rotation. DISCUSSION: Our clinic curriculum is feasible, improves knowledge regarding HCV, and is a unique approach to preparing physicians to cure HCV.

Phase separation and crystallization of hemoglobin C in transgenic mouse and human erythrocytes.

Individuals expressing hemoglobin C (beta6 Glu-->Lys) present red blood cells (RBC) with intraerythrocytic crystals that form when hemoglobin (Hb) is oxygenated. Our earlier in vitro liquid-liquid (L-L) phase separation studies demonstrated that liganded HbC exhibits a stronger net intermolecular attraction with a longer range than liganded HbS or HbA, and that L-L phase separation preceded and enhanced crystallization. We now present evidence for the role of phase separation in HbC crystallization in the RBC, and the role of the RBC membrane as a nucleation center. RBC obtained from both human homozygous HbC patients and transgenic mice expressing only human HbC were studied by bright-field and differential interference contrast video-enhanced microscopy. RBC were exposed to hypertonic NaCl solution (1.5-3%) to induce crystallization within an appropriate experimental time frame. L-L phase separation occurred inside the RBC, which in turn enhanced the formation of intraerythrocytic crystals. RBC L-L phase separation and crystallization comply with the thermodynamic and kinetics laws established through in vitro studies of phase transformations. This is the first report, to the best of our knowledge, to capture a temporal view of intraerythrocytic HbC phase separation, crystal formation, and dissolution.

Screening for postpartum depression with the Edinburgh Postnatal Depression Scale in an indigent population: does a directed interview improve detection rates compared with the standard self-completed questionnaire?

BACKGROUND: The Edinburgh Postnatal Depression Scale (EPDS) is a well-validated screening tool for the detection of patients at risk for postpartum depression. It was postulated that screening utilizing the EPDS in a directed interview would increase the detection rate compared with a self-completed EPDS in an indigent population. OBJECTIVE: To compare the results of a self-completed EPDS with those of a directed interview utilizing the EPDS in the identification of patients at increased risk for postpartum depression. METHODS: All patients undergoing a 6-week postpartum evaluation in the obstetric clinic at a community teaching hospital between November 1, 2003 and March 31, 2004 were screened for postpartum depression using the self-completed EPDS. This was followed by a directed interview, which consisted of a verbally administered EPDS by a social worker blinded to the results of the self-completed EPDS. A positive screen was defined as an EPDS score of > or =12 by either method. The number of patients with a positive screen to either the self-completed EPDS, the directed interview EPDS, or both were recorded. The two techniques were compared by the McNemar Chi-square test. The self-completed and directed interview EPDS scores were compared by Pearson's correlation coefficient to examine differences in screening techniques. Demographic data and characteristics in each group were examined. RESULTS: Among the 134 patients evaluated, 24 (17.9%) screened positively for being at an increased risk of having postpartum depression. The self-completed EPDS and the directed interview EPDS screening detection rates were not different, identifying 23 (17.2%) and 22 (16.4%) patients, respectively (p = 1.0). The use of the self-completed EPDS and the directed interview EPDS in parallel detected one additional subject (0.7%; p = 0.99). The self-completed EPDS and directed interview EPDS scores correlated significantly (r = 0.94; p = 0.01). The demographics and characteristics of patients with a positive screen were not different from those with a negative screen. CONCLUSIONS: The self-completed EPDS and directed interview EPDS are equivalent screening techniques for postpartum depression. There is no evidence to suggest that parallel screening improves detection. Either technique should be incorporated into the postpartum visit to screen for postpartum depression.

Trauma in pregnancy.

Trauma is the leading nonobstetric cause of maternal mortality. The basic tenets of trauma evaluation and resuscitation should be applied in maternal trauma. Aggressive resuscitation of the mother is the best management for the fetus. Care must be taken to keep the patient in the left lateral decubitus position to avoid compression of the inferior vena cava and resultant hypotension. Radiographic studies should be used with care. Noninvasive diagnostics should be used when available. Cardiotocographic monitoring of a viable gestation should be initiated as soon as possible in the emergency department to evaluate fetal well-being. Urgent cesarean section should be considered if fetal distress is present or if the presence of the fetus is contributing to maternal instability.

Cytomegalovirus appendicitis in an immunocompetent host.

Cytomegalovirus (CMV) is a common viral pathogen. Asymptomatic infection or a mononucleosis syndrome are the most common manifestations in otherwise healthy individuals. End-organ disease is rare in immunocompetent individuals. Here, we describe a case of CMV appendicitis in a patient without an immune-compromising condition.

Risk factors for perinatal mortality in patients admitted to the hospital with the diagnosis of placental abruption.

OBJECTIVE: Placental abruption is a clinical term used when premature separation of the placenta from the uterine wall occurs prior to delivery of the fetus. Hypertension, substance abuse, smoking, intrauterine infection and recent trauma are risk factors for placental abruption. In this study, we sought for clinical factors that increase the risk for perinatal mortality in patients admitted to the hospital with the clinical diagnosis of placental abruption. MATERIALS AND METHODS: We identified all placental abruption cases managed over the past 6 years at our Center. Those with singleton pregnancies and a diagnosis of abruption based on strict clinical criteria were selected. Eleven clinical variables that had potential for increasing the risk for perinatal mortality were selected, logistic regression analysis was used to identify variables associated with perinatal death. RESULTS: Sixty-one patients were included in the study with 16 ending in perinatal death (26.2%). Ethnicity, maternal age, gravidity, parity, use of tobacco, use of cocaine, hypertension, asthma, diabetes, hepatitis C, sickle cell disease and abnormalities of amniotic fluid volume were not the main factors for perinatal mortality. Gestational age at delivery, birthweight and history of recent trauma were significantly associated with perinatal mortality. The perinatal mortality rate was 42% in patients who delivered prior to 30 weeks of gestation compared to 15% in patients who delivered after 30 weeks of gestation (p < 0.05). A three-fold increase in severe trauma was reported in the group of patients with perinatal mortality than in the group with perinatal survivors (25% versus 7%, respectively, p < 0.05). CONCLUSIONS: In patients admitted to hospital for placental abruption delivery prior to 30 weeks of gestation and a history of abdominal trauma are independent risk factors for perinatal death.

Birth defects surveillance.

Birth defects are identified at the time of delivery in approximately one out of thirty-three babies. Birth defect surveillance has become a very important public health tool for tracking rates and trends in the prevalence of these abnormalities and is useful in establishing risk factors and potential etiologies.

Foreign body aspiration in pregnancy.

A 24-year-old morbidly obese African American gravida 1, with a history of severe asthma complicated by multiple inpatient admissions, presents at 30 weeks gestation with a foreign body in her left main stem bronchus. After a failed bronchoscopy postpartum, the patient slipped into respiratory failure and was subsequently intubated, spending two weeks in the intensive care unit. After two more attempts of trying to retrieve the foreign object from her lung via bronchoscopy, she eventually contracted a postobstructive pneumonia and underwent a left lower lung lobectomy for curative treatment.

Paternal age and risk for cesarean delivery.

OBJECTIVE: To determine whether advanced paternal age is associated with increased risk for cesarean delivery. STUDY DESIGN: We used the 1990-2002 US linked live birth and infant death data files restricted to primiparous Caucasian and African-American women that delivered a singleton birth at ≥20 week's gestation (12.5 million). We examined temporal trends and risk ratios of cesarean birth in relation to paternal age before and after adjustments for known confounders. RESULTS: Among Caucasians, the cesarean delivery rates were 21.1%, 26.7% and 31.8% in fathers aged 20-29, 30-39 and ≥40 years, respectively. Among African-Americans, the corresponding rates were 24.1%, 33.2%, and 38.1%, respectively. These increased cesarean delivery rates persisted in analyses stratified by maternal age before and after adjustment for a variety of confounders. CONCLUSIONS: These findings suggest that increasing paternal age may be associated with an increased risk for cesarean delivery in primiparous women.