Nutritional needs, resources, and barriers among unhoused adults cared for by a street medicine organization in Chicago, Illinois: a cross-sectional study.

BACKGROUND: Those experiencing houselessness rely on obtaining food from community organizers and donations. Simultaneously, the houseless face disproportionally high rates of medical conditions that may be affected by diet including diabetes, hypertension, and hyperlipidemia. There is limited literature on the resources and barriers of the houseless community regarding optimal nutrition from an actionable perspective. Further, less data is available on how street medicine organizations may best impact the nutrition of the unhoused they serve. Elucidating this information will inform how organizational efforts may best support the nutrition of the houseless community. METHODS: In partnership with the medical student-run organization, Chicago Street Medicine, at Northwestern University Feinberg School of Medicine, twenty adults experiencing houselessness in Chicago, Illinois participated in the cross-sectional study. A 10-item survey was verbally administered to characterize the participants' daily food intake, food sources, barriers, resources, and nutritional preferences and needs. All data was directly transcribed into REDCap. Descriptive statistics were generated. RESULTS: Individuals consumed a median of 2 snacks and meals per day (IQR: 1-3). No participant consumed adequate servings of every food group, with only one participant meeting the dietary intake requirements for one food group. Participants most often received their food from donations (n = 15), purchasing themselves (n = 11), food pantries (n = 4), and shelters (n = 3). Eleven of nineteen participants endorsed dental concerns as a major barrier to consuming certain foods. Twelve participants had access to a can opener and twelve could heat their meals on a stove or microwave. Seven had access to kitchen facilities where they may prepare a meal. Approximately half of participants had been counseled by a physician to maintain a particular diet, with most related to reducing sugar intake. CONCLUSION: Most houseless participants were unable to acquire a balanced diet and often relied on organizational efforts to eat. Organizations should consider the chronic health conditions, dentition needs, and physical resources and barriers to optimal nutrition when obtaining food to distribute to the unhoused.

Multidrug resistant Aeromonas infection following medical leech therapy: A case report and development of a joint antimicrobial stewardship and infection prevention protocol.

OBJECTIVE: Aeromonas sp. infections are a recognized complication of medical leech therapy (MLT). In patients requiring MLT, ciprofloxacin or trimethoprim-sulphamethoxazole are commonly used to prevent such nosocomial infections. After a patient at our institution developed a MLT-associated multi-drug resistant (MDR) Aeromonas infection, we developed and evaluated a joint antimicrobial stewardship and infection prevention protocol for MLT at our institution. METHODS: We describe a case of a surgical site infection with MDR Aeromonas following MLT that was resistant to typically prescribed prophylactic antimicrobials, and development of a new leech culture protocol to proactively monitor for antimicrobial resistance among our institution's leech supply. We also report the rates of MLT-associated infections prior to and following implementation of this protocol and the antimicrobial susceptibility profiles detected in leech culture at our institution. RESULTS: Between October 2014 and February 2018, 46 patients received MLT at our institution. Other than the case described in this report, no other instances of MLT-related infections were noted during this time period. Culture results from 22 leeches in six batches since February 2018 showed that all were susceptible to ciprofloxacin, TMP-SMX, and ceftriaxone. Since initiation of a leech culture protocol, no further cases of MLT-associated infections have been reported at our institution. CONCLUSIONS: In light of increasing antimicrobial resistance and the potentially devastating consequences of MLT-associated infections, institutions offering MLT should be aware of these risks and ensure that protocols are in place to minimize infection risks for patients.

Case Report: Incidentally Discovered Strongyloides stercoralis Infection after Urinary Diversion.

Strongyloidiasis is a disease caused by the parasite Strongyloides stercoralis in humans. We present a case of incidentally discovered Strongyloides urinary tract infection in a patient in whom there was a urologic surgery consisting of urinary diversion created by self-bowel transplantation and conduit creation. Historical review demonstrated eosinophilia before surgery and detection of the parasite. Social review demonstrated endemic exposure. Our patient's case was differentiated from hyperinfection by the presence of rhabditiform larvae, and not filariform larvae, in the urine, suggesting localized small bowel infection was transferred to the urinary tract secondary to the creation of the ileal loop conduit. This patient's clinical course improved with antibiotic treatment of the bacterial infectious complications of surgery and resolution of Strongyloides infection with ivermectin. To our knowledge, this is the first case of Strongyloides infection of the urinary tract secondary to ileal loop conduit creation and not as a result of hyperinfection.

Cutaneous manifestations of Campylobacter jejuni infection: A case report and review of the literature.

A 51 year old man with active follicular lymphoma presented with several days of erythematous skin nodules on all extremities two weeks after a self-limited diarrheal illness. All serum immunoglobulin levels were found to be low. Blood cultures grew Campylobacter jejuni. The patient was given one week of azithromycin with complete resolution of his skin nodules. The literature of skin manifestations seen in active Campylobacter jejuni infection are reviewed. The majority of cases occur in immunocompromised hosts, many with low or no serum immunoglobulin levels. Postulated mechanisms include a lack of secretory IgA in intestinal mucosa predisposing susceptible patients to translocated enteric pathogens however the precise pathogenesis underlying cutaneous manifestations are unknown.

Emphysematous Cystitis.

Emphysematous cystitis is a relatively rare and potentially life-threatening condition characterized by the collection of gas in the bladder wall and lumen due to infection caused by gas-forming organisms. Imaging studies are necessary to detect emphysematous cystitis. The management consists of broad-spectrum antibiotics, strict glycemic control, and bladder drainage. Complications may arise in some cases, requiring surgical treatment. We present a case of extended spectrum beta-lactamase producing Escherichia coli and Klebsiella pneumoniae emphysematous cystitis in a known diabetic.

Diskitis, Osteomyelitis, Spinal Epidural Abscess, Meningitis, and Endocarditis Following Sacroiliac Joint Injection for the Treatment of Low-Back Pain in a Patient on Therapy for Hepatitis C Virus.

OBJECTIVE: Sacroiliac joint injections are frequently performed procedures in the management of acute and chronic low-back pain, including patients with various immunocompromised states. Infectious complications following these procedures along with other spinal injections are rarely reported, but the true incidence is unknown. The purpose of this report is to highlight the devastating neurologic sequela that can occur, and to discuss potential future management strategies. CASE REPORT: We present a patient who developed diskitis, osteomyelitis, spinal epidural abscess, meningitis, and endocarditis from Staphylococcus aureus, all of which developed shortly after a sacroiliac joint injection. The patient was on treatment for hepatitis C virus, and the resulting immunocompromised state likely contributed to the outcome. CONCLUSIONS: Immunocompromised patients should be identified prior to treatment, and the small possibility of devastating complications should be thoughtfully weighed against the potential benefit of the procedure. Conservative management should be maximized initially, and if a procedure is done, strict asepsis must be maintained. Prophylaxis for S. aureus should be considered for immunocompromised patients undergoing interventional spine procedures.

Adult immunization and its impact on children.

The prevention of illness through vaccination is one of the most essential services pediatricians provide to their patients. However, the importance of adult vaccination and its impact on the health of children are often overlooked. There remains a large portion of adults in the United States who are not compliant with the Advisory Committee on Immunization Practices immunization schedule. These people provide a potential reservoir for the spread of vaccine-preventable illness to children and adolescents. There are numerous contributing factors to the lack of immunization. Pediatricians, along with adult health care providers, can serve an important role by educating parents, guardians, and adult contacts of children on the importance of receiving the recommended adult vaccinations and the role of vaccines in preventing the spread of disease to the pediatric population.

Native valve endocarditis due to a novel strain of Legionella.

Legionellae are Gram-negative bacteria which are capable of causing disease, most commonly in the form of pneumonia. We describe a case of native valve endocarditis caused by a Legionella strain which by genotypic (16S rRNA and mip gene sequencing) and phenotypic analyses is unlike previously described strains of Legionella.

Molecular characterization of an allelic series of mutations in the mouse Nox3 gene.

The inner ear consists of the cochlea (the organ of hearing) and the vestibular system (the organs of balance). Within the vestibular system, linear acceleration and gravity are detected by the saccule and utricle. Resting above the neurosensory epithelia of these organs are otoconia, minute proteinaceous and crystalline (calcite) inertial masses that shift under the physical forces imparted by linear movements and gravity. It is the transduction and sensation of these movements and their integration with vision and proprioceptive inputs that contribute to the sensation of balance. It has been proposed that a reactive oxygen species- (ROS-) generating NADPH oxidase comprising the gene products of the Nox3, Noxo1, and Cyba genes plays a critical and constructive role in the process of inner-ear development, specifically, the deposition of otoconia. Inactivation in mouse of any of the NADPH oxidase components encoded by the Nox3, Noxo1, or Cyba gene results in the complete congenital absence of otoconia and profound vestibular dysfunction. Here we describe our use of PCR, reverse transcription-PCR (RT-PCR), and rapid amplification of cDNA ends (RACE) with traditional and high-throughput (HTP) sequencing technologies to extend and complete the molecular characterization of an allelic series of seven mutations in the Nox3 gene. Collectively, the mutation spectrum includes an endogenous retrovirus insertion, two missense mutations, a splice donor mutation, a splice acceptor mutation, premature translational termination, and a small duplication. Together, these alleles provide tools to investigate the mechanisms of otoconial deposition over development, throughout aging, and in various disease states.

Suboptimal nevirapine steady-state pharmacokinetics during intrapartum compared with postpartum in HIV-1-seropositive Ugandan women.

BACKGROUND: Conflicting data exist regarding the effect of pregnancy on steady-state nevirapine pharmacokinetics (PK), although steady-state nevirapine concentrations during pregnancy have never been characterized in sub-Saharan Africa. METHODS: This was a longitudinal intensive PK study in Ugandan pregnant women receiving nevirapine-based antiretroviral therapy. Participants underwent intensive 12-hour PK sampling during the second trimester (T2; n = 4), third trimester (T3; n = 15) and 6 weeks postpartum (PP; n = 15). HIV-1 RNA was performed within 2 weeks of each visit. Nevirapine C12 above 3000 ng/mL was classified as optimal based on the suggested value for therapeutic drug monitoring. RESULTS: The pharmacokinetics of nevirapine were influenced by pregnancy, demonstrated by a 20% reduction in the maximum concentration, minimum concentration (C12), and area under the curve between T3 and PP visits (P = 0.001, P = 0.011 and P = 0.005, respectively). Ten subjects (66.7%) had C12 values <3000 ng/mL during T3. Of these participants, 7 partcipant's C12 concentrations increased to >3000 ng/mL during the PP visit. HIV-1 RNA were <1000 copies per milliliter at T3 and <400 copies per milliliter at PP in all patients. CONCLUSIONS: Nevirapine exposure was reduced in Ugandan women during their third trimester compared with the same women PP, however, HIV RNA remained <1000 copies per milliliter. The long-term impact of intermittent suboptimal nevirapine concentrations during pregnancy is unknown.

Generation of a conditional null allele of NADPH oxidase activator 1 (NOXA1).

NADPH oxidase complexes are multiprotein assemblies that generate reactive oxygen species in a variety of mammalian tissues. The canonical phagocytic oxidase consists of a heterodimeric, enzymatic core comprised of the transmembrane proteins, CYBB andCYBA and is regulated, in part, by an "organizing" function of NCF1 and an "activating" activity of NCF2. In contexts outside of the phagocyte, these regulatory functions may be encoded not only by NCF1 and NCF2, but also alternatively by their respective paralogues, NOXO1 and NOXA1. To allow tissue-specific dissection of Noxa1 function in mouse, we have generated an allele of Noxa1 suitable for conditional inactivation. Moreover, by crossing Noxa1 conditional allele carriers to B6.129S4-Meox2(tm1(Cre)Sor)/J mice, we have generated first, Noxa1-null heterozygotes, and ultimately, Noxa1-null homozygotes. Through the thoughtful use of tissue-specific, Cre-expressing mouse strains, the Noxa1 conditional allele will offer insight into the roles of NOXA1 in the variety of tissues in which it is expressed.

Multiple brain abscesses due to Actinomyces species.

We report a case of multiple brain abscesses due to Actinomyces species in a 35-year-old immunocompetent man who presented with a 2-month history of headache, diplopia, fever, and weight loss. Despite receipt of broad-spectrum antibiotics for over a month, he continued to have headaches and diplopia. He subsequently underwent right anterior temporal lobectomy and evacuation of abscesses. The diagnosis was aided by identification of sulfur granule on histopathological examination of cerebral cavitary lesion and Gram-positive filamentous rods seen on tissue-Gram stain.

Breakthrough Candida infections in patients receiving voriconazole.

OBJECTIVE: To describe 2 instances of breakthrough Candida infection in 2 patients on treatment doses of voriconazole. CASE SUMMARIES: A 27-year-old woman with systemic lupus erythematosus was receiving high-dose voriconazole (400 mg twice daily) for central nervous system lesions of unknown origin and developed oral thrush. The patient was receiving concomitant therapy with phenytoin 400 mg/day. The voriconazole dose was increased to 400 mg 3 times daily, and the thrush resolved. A 50-year-old man with HIV infection was receiving enfuvirtide, lamivudine, tenofovir, and efavirenz 600 mg/day, as well as prophylactic trimethoprim/sulfamethoxazole and azithromycin. He was started on voriconazole 200 mg twice daily for pulmonary aspergillosis and developed esophageal candidiasis. The voriconazole dose was increased to 350 mg twice daily, and the thrush eventually resolved. DISCUSSION: Both reactions were probable according to the Naranjo probability scale. Significant drug interactions may have played a role in the development of breakthrough infections in these patients, specifically with phenytoin and efavirenz. Voriconazole is metabolized primarily by CYP2C19, as well as CYP2C9 and CYP3A4. Voriconazole is also known to inhibit these enzymes, and the manufacturer reports an extensive list of drugs that interact with voriconazole. CONCLUSIONS: Although requiring systematic evaluation, there may be a role for voriconazole serum concentration monitoring to ensure therapeutic efficacy when significant drug interactions are suspected.

Erythema nodosum associated with reactivation tuberculous lymphadenitis (scrofula).

A 73-year-old African American female presented to our clinic with painful lower extremity lesions of 2 weeks duration. She was in her usual state of health until 3 months prior to presentation when she reported symptoms of fatigue and weakness. She also noticed an enlarging mass on the left side of her neck. She denied fevers, chills, night sweats or cough. Her symptoms were unresponsive to a course of oral dicloxacillin. The neck mass enlarged over 8 weeks and she was referred to our institution for evaluation. CT scan of the neck showed an enlarged lymph node. Ten days prior to her presentation in dermatology, a fine needle aspirate of the enlarging lymph node revealed necrotizing granulomas. Tissue was sent for routine mycobacterial and fungal cultures. Routine blood work, chest radiograph, and a tuberculin skin test were also performed. At the time of her dermatology visit she described the development of multiple new painful, non-pruritic lesions, bilaterally on the lower extremities. She also reported a red crusted area that appeared at the site of her tuberculin test that was placed subsequent to the development of her lower extremity lesions. Her past medical history was significant for Parkinson's disease, hypothyroidism and hypertension. Her current medications included l-thyroxine, estrogen and diltiazem. Her travel history was only remarkable for a trip to Jamaica the previous spring. She was born and raised in Haiti. She reported a history of a positive tuberculin skin test 20 years ago, but received no therapy. Physical examination revealed a 2 x 3 centimeter firm, nontender left lateral neck mass (Fig. 1). Her right forearm revealed an erythematous, ulcerated, indurated plaque 1.5 cm in diameter (Fig. 2.). Her lower extremities revealed tender 0.5 to 1 cm erythematous nodules below the knees bilaterally (Fig. 3). A punch biopsy of a lower extremity nodule revealed a mild pervisacular dermal infiltrate. Within the subcutaneous tissue there was septal widening. There was also a lymphohistiocytic infiltrate with a slight admixture of neutrophils within the septa of the fat lobules. There was no evidence of necrotizing vasculitis or collagen necrosis. An acid-fast stain was not performed. The histologic findings were consistent with a diagnosis of erythema nodosum. Her laboratory evaluation including CBC, electrolytes, thyroid studies, angiotensin converting enzyme level and chest radiograph were normal. Approximately 1 week after her dermatological evaluation, the fine-needle aspirate culture grew Mycobacterium tuberculosis. A diagnosis of tuberculous lymphadenitis associated with erythema nodosum was confirmed. The patient was started on quadruple therapy of isoniazid, rifampin, ethambutol and pyrazinamide. Her lower limb skins lesions rapidly resolved over the subsequent month and her neck mass also diminished in size. She completed 6 months of antituberculous therapy with complete resolution of her lymphadenopathy.