Hepatitis C Treatment in Persons Who Inject Drugs in a Medication Assisted Treatment Program: A Retrospective Review of an Integrated Model.

BACKGROUND: Hepatitis C virus (HCV) infection is common among persons who inject drugs (PWID), mostly due to needle sharing. The number of new cases in PWID are steadily increasing despite the availability of effective treatments. The objective of this model is to increase uptake and compliance with HCV treatment. We developed a model to treat HCV and opioid use disorder simultaneously in a methadone maintenance program. METHODS: Patients were screened on site for HCV at admission and then annually. Once HCV was positive, the genotypes and fibrosis scores were identified. Patients were enrolled into the treatment program after obtaining written consent. Patients either self-administered the medications at home or utilized a directly observed treatment (DOT). The sustained virologic response (SVR) was tested at 12 weeks posttreatment. We conducted a retrospective review of patients who received treatment and reviewed the demographic data, co-infections, medication administration, and SVR results at the end of study period. RESULTS: One hundred ninety patients were identified as Hepatitis C positive. 88.9% (169 patients) received HCV treatment during the study period. 62.7% (106 patients) were male and 37.3% were female (63 patients). 62.7% of them (106 patients) completed HCV treatment by the end of study period. Out of them, 96.2% (102 patients) achieved SVR. 68.9% (73 patients) utilized DOT for medication administration. CONCLUSIONS: Our model successfully treated HCV in our patient population, who are otherwise deprived of resources and access to health care. Replicating this model is a potential strategy to reduce the disease burden and break the transmission cycle of HCV.

Review of COVID-19 Variants and COVID-19 Vaccine Efficacy: What the Clinician Should Know?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a beta coronavirus that belongs to the Coronaviridae family. SARS-CoV-2 is an enveloped spherical-shaped virus. The ribonucleic acid (RNA) is oriented in a 5'-3'direction which makes it a positive sense RNA virus, and the RNA can be read directly as a messenger RNA. The nonstructural protein 14 (nsp14) has proofreading activity which allows the rate of mutations to stay low. A change in the genetic sequence is called a mutation. Genomes that differ from each other in genetic sequence are called variants. Variants are the result of mutations but differ from each other by one or more mutations. When a phenotypic difference is demonstrated among the variants, they are called strains. Viruses constantly change in two different ways, antigenic drift and antigenic shift. SARS-CoV-2 genome is also prone to various mutations that led to antigenic drift resulting in escape from immune recognition. The Center of Disease Control and Prevention (CDC) updates the variant strains in the different classes. The classes are variant of interest, variant of concern and variant of high consequence. The current variants included in the variant of interest by the USA are: B.1.526, B.1.525, and P.2; and those included in the variant of concern by the USA are B.1.1.7, P.1, B.1.351, B.1.427, and B.1.429. The double and triple mutant variants first reported in India have resulted in a massive increase in the number of cases. Emerging variants not only result in increased transmissibility, morbidity and mortality, but also have the ability to evade detection by existing or currently available diagnostic tests, which can potentially delay the diagnosis and treatment, exhibit decreased susceptibility to treatment including antivirals, monoclonal antibodies and convalescent plasma, possess the ability to cause reinfection in previously infected and recovered individuals, and vaccine breakthrough cases in fully vaccinated individuals. Hence, continuation of precautionary measures, genomic surveillance and vaccination plays an important role in the prevention of spread, early identification of variants, prevention of mutations and viral replication, respectively.

Review of COVID-19 Vaccines Approved in the United States of America for Emergency Use.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus causing a global pandemic. Coronaviruses are a large family of single-stranded ribonucleic acid (RNA) viruses. The virus has four essential structural proteins which include the spike (S) glycoprotein, matrix (M) protein, nucleocapsid (N) protein and small envelope (E) protein. Different technologies are being used for vaccine development to battle the pandemic. There are messenger ribonucleic acid (mRNA)-based vaccines, deoxyribonucleic acid (DNA) vaccines, inactivated viral vaccines, live attenuated vaccines, protein subunit-based vaccines, viral vector-based vaccines and virus-like particle-based vaccines. Vaccine development has five stages. In the clinical developmental stage, vaccine development can be sped up by combining phase 1 and 2. The vaccines can also be approved more swiftly on an emergent basis and released sooner for usage. The United States Food and Drug Administration (USFDA) has approved Pfizer-BioNTech, Moderna and Janssen coronavirus disease 2019 (COVID-19) vaccines for emergency use. There are other vaccines that have been approved around the world. The mRNA vaccines have been created using a novel technology and they contain a synthetically created RNA sequence of virus fragments encoding the S-protein which is injected. These vaccines have a relatively low cost of production and faster manufacturing time but can have comparatively lower immunogenicity and more than one dose of vaccine may be required. In the case of viral vector-based vaccines, genes encoding the SARS-CoV-2 S protein are isolated and following gene sequencings are introduced into the adenovirus vector. These vaccines have a relatively fast manufacturing time but the efficacy of the vaccine is variable based on the host's immune response to the viral vector. At the time of this paper, there were 81 vaccines in clinical development stage and 182 vaccines in preclinical development stage. Vaccines are an essential tool in our battle against COVID-19. Some of the COVID-19 vaccines have completed their phase III trials while many other potential vaccines are still in developmental stages. It used to take close to a decade for a vaccine to be developed and undergo rigorous testing until its production and availability to the public, but over the past year, we have seen multiple vaccines in different phases of testing against SARS-CoV-2 virus.

A case series of vestibular symptoms in positive or suspected COVID-19 patients.

Respiratory symptoms are the most common presentation of an acute COVID-19 infection, but thromboembolic phenomena, encephalopathy and other neurological symptoms have been reported. With these case series, we present multiple presentations of COVID-19 induced vestibular symptoms namely dizziness, vertigo and nystagmus. The patients reported in this case series are from different parts of the world, belong to different age groups and had manifested these symptoms in different periods of the pandemic. The pathophysiology of vestibular neuritis induced by COVID-19 is similar to any other viral infection. Whether in the inpatient or outpatient settings, COVID-19 should be considered in the differential diagnosis for patients presenting with these symptoms, irrespective of the presence of respiratory symptoms or hypoxia.

Primary Care Shortage in Medically Underserved and Health Provider Shortage Areas: Lessons from Delaware, USA.

OBJECTIVE: To examine the reasons contributing to the physician shortage in the country's medically underserved areas using the state of Delaware as a focus state. METHOD: A literature review regarding the shortage of physicians with data compilation from Delaware Department of Public Health (DPH) and Delaware Health and Social services (DHSS) was performed. A review of the "Conrad 30 J1 VISA waiver program," the most important and primary supplier of physicians to underserved areas of the state was performed. A survey interviewing the physicians recruited through this program to identify any challenges faced by them was designed and conducted. RESULTS: The number of primary care physicians providing direct patient care in Delaware in 2018 had declined about 6% from 2013. The average wait time to see a PCP was 8.2 days in 1998 as compared to 23.5 days in 2018. Forty-six percent of physicians serving in HPSAs in Delaware are IMGs recruited through the J1 VISA waiver program. Eighty percent of these IMGs are actively considering leaving the United States due to anxieties around physician immigration policies, mainly "Immigration backlog." CONCLUSION: The existing programs to recruit physicians to underserved areas seem to be inadequate. The state and the hospital systems should be able to utilize the J1 program to its full potential and focus on retaining these physicians after their assigned services. As the challenges of IMGs continue to worsen every day; the medical societies, hospitals, the state and federal government should advocate for policies that resolve these challenges.

Pediatric Care Struggles of US Trained International Medical Graduate Pediatricians in COVID-19 Pandemic.

BACKGROUND: Pediatrician shortage and healthcare access has been a serious issue especially in medically underserved and rural areas aplenty in the USA and has further worsened during the coronavirus disease 2019 (COVID-19) pandemic. Many US trained international medical graduates (IMGs) on a visa status serve these areas to fill in the physician gap. These physicians are usually on a visa and the majority of them have approved immigration petitions. During this pandemic, the sudden changes in immigration policies in addition to the longstanding administrative backlog and processing times had posed new challenges to the pediatricians and the communities served by them. The objective of this study was to determine the demographics, level of training and practice, immigration status, the clinical role they played in the communities they served and the various professional and personal setbacks they faced during the pandemic. METHODS: A survey was created and data were collected using data collection platform "Survey Monkey". Screening questions were designed to include only IMG pediatricians on a visa status. RESULTS: A total of 267 IMG pediatricians qualified for the survey on a nationwide basis. Of the physicians that participated in the survey, 58.4% were working in either medically underserved or physician shortage areas, 36% of the total physicians were working in a rural setting, 10.6% of the pediatricians had to be quarantined due to exposure to COVID-19, 0.8% were infected with COVID-19 themselves, and 81.3% of the pediatricians had faced hindrance in being able to work at a COVID-19 hotspot due to work site restrictions because of their visa status. CONCLUSION: IMG pediatricians play a valuable role in taking care of the children in medically underserved areas. The challenges surrounding the immigration backlog are contributing to significant hardships for these pediatricians and their families and are causing a hindrance to healthcare access to the children in medically underserved communities during the pandemic especially limiting the pediatricians' scope and geographic radius of the practice, thus not allowing them to practice to the full extent of their license.

Prevalence of US-trained International Medical Graduates (IMG) physicians awaiting permanent residency: a quantitative analysis.

BACKGROUND: International Medical Graduates (IMGs) contribute to about 23% of the physician workforce in the USA. Certain US-trained IMGs face long wait times for transitioning to a permanent resident status, which limits their ability to work to fullest capacity, especially during a public health emergency. OBJECTIVES: To estimate the number of US-trained IMGs awaiting permanent residency. STUDY DESIGN: Data were obtained from National Residency Matching Program (NRMP) to quantify the number of IMGs who secured residency training in the US from 2004 to 2020. Estimates of physician demographics were based on NRMP/ECFMG 2014 match data and Federation of State Medical Boards (FSMB) physician census data. RESULTS: Between 2004 and 2020, a total of 57,160 non-US IMGs who were not US citizens successfully matched to residency training programs. Applicants from India and China were noted to be impacted by delays in adjustment to permanent resident status. Per our estimate, there are between 1,460 and 1,959 US-trained physicians from China currently awaiting permanent residency, with applicants waiting since October 2015, and between 13,250 and 14,230 US-trained physicians from India currently awaiting permanent residency, with applicants waiting since June 2009. CONCLUSIONS: The total number of US-trained immigrant physicians in active practice awaiting permanent residency to the USA is estimated to be ranging between 14,710 and 16,189.

A Comparative Analysis of Cardiovascular Risk in Human Immunodeficiency Virus-Seropositive and -Seronegative Pre-Menopausal Women.

BACKGROUND: Human immunodeficiency virus (HIV) has been associated with an increased risk of coronary artery disease (CAD) in women. HIV-positive pre-menopausal women lose the cardio-protective effect of estrogen and are at a higher risk for developing CAD. Our study intended to assess the cardiovascular risk in HIV-positive pre-menopausal women. METHODS: This is a cross-sectional study using National Health and Nutrition Examination Survey (NHANES) datasets. The 10-year Framingham risk score for developing CAD was calculated for HIV-positive and HIV-negative women. The individual risk factors contributing to CAD were compared. The populations' intent to reduce their risk and their doctor's advice to reduce the risk were analyzed. A P-value < 0.05 was considered significant. RESULTS: Out of the available sample of 82,091 people, 9,635 women (11.7%) met the inclusion criteria of the study. Among them, 25 women were HIV-seropositive (0.25%). Though there was no significant difference in blood pressure, hemoglobin A1c, C-reactive protein, high-density lipoprotein or total cholesterol (P > 0.05), the mean Framingham risk score in pre-menopausal HIV-positive women (mean (M) = 2.12, standard deviation (SD) = 2.73) was significantly higher than the HIV-negative women (M = 0.95, SD = 1.94) (P < 0.01). Neither did majority of the HIV-positive women intend to decrease their cardiovascular risk nor did their healthcare providers advise them to do so. CONCLUSIONS: The risk of developing CAD in pre-menopausal women is higher from traditional risk factors itself. While HIV is now proven to be an independent risk factor for developing CAD in women, focus should be on reducing the risk from traditional methods.

Gender-Based Differences in Abdominal Aortic Aneurysm Rupture: A Retrospective Study.

BACKGROUND: Annually, 5% of sudden deaths are due to abdominal aortic aneurysm (AAA) rupture. There is evidence suggesting that AAA ruptures have worse outcomes in females than males and the aneurysms rupture at a smaller size in females than in males. The United States Preventive Services Task Force (USPSTF) recommends a one-time ultrasound screening for males aged 65 - 75 years who ever smoked. There is insufficient evidence to screen females aged 65 - 75 years who ever smoked though there is evidence suggesting that AAAs rupture at a smaller size and have worse outcomes in females. The objective of this study is to compare the characteristics, mortality and morbidity of ruptured AAAs in females and males. METHODS: This is a retrospective review of 117 patients from two teaching institutions over a period of 6 years. A total of 39 parameters were compared between males and females including demographic variables, comorbidities like hypertension, dyslipidemia, cardiovascular diseases; previous history of AAA; medications, characteristics of aneurysm, type of surgery and its outcome; postoperative complications and long-term survival. RESULTS: The overall incidence of AAA rupture was higher in males (68%) than in females (32%). Females die from AAA rupture at a later age. There was a significant difference in the size of AAA rupture between females (mean = 7.4 cm, standard deviation (SD) = 2.0) and males (mean = 8.2 cm, SD = 1.8; P = 0.04). The probability to undergo surgery for ruptured AAA was significantly lower for females as compared to males (P = 0.03). Females had higher overall mortality (P = 0.001), postoperative mortality (P = 0.02), higher length of intensive care unit (ICU) stay, incidence of postoperative complications, use of vasopressors and use of ventilator. CONCLUSIONS: Using a similar threshold of size of AAA for elective surgery for both males and females might not be appropriate. Further population-based studies are needed to warrant AAA screening for high-risk females owing to the higher morbidity and mortality.

Compliance with USPSTF recommendations on aspirin for prevention of cardiovascular disease in men.

OBJECTIVE: In 2009, United States Preventive Services Taskforce (USPSTF) recommends aspirin (ASA) for men aged 45-79 years when the benefit of coronary artery disease (CAD) risk reduction outweighs the harm of gastrointestinal haemorrhage. Our objective is to evaluate compliance with this USPSTF recommendation. METHODS: This study is a cross-sectional study and 2011-2012 National Health and Nutrition Examination Survey (NHANES) dataset was used for this study. Out of the available sample, 1155 (11.8%) had the inclusion criteria (men aged 45-79 years, no prior history of CAD). The participants' 10-year Framingham risk score for developing CAD was calculated to identify the people who meet criteria to take aspirin. The population characteristics that influence the physicians' decision to prescribe aspirin and the characteristics those influence the participants' compliance with doctor's advice to take aspirin were identified. RESULTS: Almost 91.5% qualified for aspirin intake. About 65% (595/916) of them were not advised by their providers to take aspirin. Among the 321 who were prescribed aspirin, 30% (96/321) were non-compliant and 1.2% (4/321) discontinued aspirin because of side effects. In the group that did not qualify for aspirin, 37.6% (32/85) were inappropriately prescribed aspirin out of which 78.1% (25/32) were actually taking it. Younger age and lesser comorbidities were significantly associated with under prescription by physicians (P < .001) and lower compliance by participants (P < .001). CONCLUSIONS: In April 2016, USPSTF updated the recommendations regarding benefits of aspirin. Our study evaluates the factors that influenced the compliance with the 2009 recommendations. This study highlights the challenges that the 2016 guidelines might have to face.

Health behavior and perceptions among African American women with metabolic syndrome.

BACKGROUND: Metabolic syndrome is a cluster of different risk factors (abdominal obesity, insulin resistance, high blood pressure, and high cholesterol) that predispose to the development of cardiovascular diseases. African American women (AAW) are easily predisposed to metabolic syndrome due to higher levels of insulin resistance. Various sociodemographic factors further contribute to higher prevalence. AIM: This study evaluates the current prevalence of metabolic syndrome in AAW and identifies the related sociodemographic risk factors. METHODS: The study utilized 2007-11 National Health and Nutrition Examination Survey (NHANES) data sets from the Centers for Disease Control (CDC). The sample was divided into two groups: AAW with and without metabolic syndrome. Sociodemographic, physical examination, laboratory parameters, and health perceptions were compared between the two groups. RESULTS: Out of the available sample of 30,442 individuals, 1918 (6.4%) met the inclusion criteria (AAW, age>20, non-pregnant women). The prevalence of metabolic syndrome was 47%. Older age, lower education level, low socioeconomic status, unmarried status, low physical activity level, and smoking were associated with higher prevalence of metabolic syndrome (p<0.001). The prevalence of borderline hypertension, hypertension, diabetes, stroke, and cardiovascular diseases was significantly higher in AAW with metabolic syndrome (p<0.001). CONCLUSION: In spite of the focus on prevention of cardiovascular risk factors and elimination of ethnic and gender disparities, metabolic syndrome is still widely prevalent in AAW and poses a threat to the goals of Healthy People 2020.