Distinct Inflammatory Phenotypes are associated with subclinical and clinical Cardiovascular disease in People living with HIV

Despite inflammation being implicated in cardiovascular disease (CVD) in people with HIV (PWH), considerable heterogeneity within populations of PWH exists. Stratifying CVD risk based on inflammatory phenotype could play an important role. Using principal component analyses and unsupervised hierarchical clustering, we examined 38 biomarkers to identify inflammatory phenotypes in two independent cohorts of PWH. We identified three distinct inflammatory clusters present in both cohorts that associated with altered risk of both subclinical CVD (cohort 1) and prevalent clinical CVD (cohort 2) after adjusting for CVD risk factors. These data support precision medicine approaches to enhance CVD risk assessment in PWH.

Identification of Distinct Long COVID Clinical Phenotypes Through Cluster Analysis of Self-Reported Symptoms

Background

We aimed to describe the clinical presentation of individuals presenting with prolonged recovery from coronavirus disease 2019 (COVID-19), known as long COVID.

Methods

This was an analysis within a multicenter, prospective cohort study of individuals with a confirmed diagnosis of COVID-19 and persistent symptoms >4 weeks from onset of acute symptoms. We performed a multiple correspondence analysis (MCA) on the most common self-reported symptoms and hierarchical clustering on the results of the MCA to identify symptom clusters.

Results

Two hundred thirty-three individuals were included in the analysis; the median age of the cohort was 43 (interquartile range [IQR], 36–54) years, 74% were women, and 77.3% reported a mild initial illness. MCA and hierarchical clustering revealed 3 clusters. Cluster 1 had predominantly pain symptoms with a higher proportion of joint pain, myalgia, and headache; cluster 2 had a preponderance of cardiovascular symptoms with prominent chest pain, shortness of breath, and palpitations; and cluster 3 had significantly fewer symptoms than the other clusters (2 [IQR, 2–3] symptoms per individual in cluster 3 vs 6 [IQR, 5–7] and 4 [IQR, 3–5] in clusters 1 and 2, respectively; P < .001). Clusters 1 and 2 had greater functional impairment, demonstrated by significantly longer work absence, higher dyspnea scores, and lower scores in SF-36 domains of general health, physical functioning, and role limitation due to physical functioning and social functioning.

Conclusions

Clusters of symptoms are evident in long COVID patients that are associated with functional impairments and may point to distinct underlying pathophysiologic mechanisms of disease.

484 CHANGING PRACTICES OF DECISION MAKING REGARDING DO-NOT-ATTEMPT-CARDIOPULMONARY-RESUSCITATION ORDERS AMID THE COVID-19 PANDEMIC

Introduction

The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation into focus. This study aims to analyse Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic.

Methods

This was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1st to May 31 s t 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period. Pre-COVID-19 pandemic DNACPR documentation rates were also examined. Factors associated with DNACPR order instatement during the first wave of the COVID-19 pandemic were identified.

Results

Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. 50% of DNAR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of 131 patients aged 65 years or over within the cohort admitted with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 patients ≥65 without COVID-19 (p &lt; 0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (p &lt; 0.0001). Independent associations with DNACPR order documentation included increasing age (Odds Ratio [O.R.] 1.12; 95% CI 1.05-1.21); nursing home resident status (O.R. 3.57; 95% CI 1.02-12.50); frailty (O.R. 3.34; 95% CI 1.16-9.61) and chronic renal impairment (O.R. 5.49; 1.34-22.47). The case-fatality-rate of older patients with COVID-19 was 29.8% versus 5.4% without COVID-19. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived.

Conclusion

The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain clinical practice despite the pandemic.

Effectiveness of interferon-free therapy for the treatment of HCV-patients with compensated cirrhosis treated through the Irish early access program

BACKGROUND

We investigated the real-world effectiveness of interferon-free regimens for the treatment of patients with compensated cirrhosis infected with hepatitis C virus (HCV).

METHOD

Using the Irish national HCV treatment registry, the effectiveness and safety of interferon-free regimens for HCV-infected patients treated between April 2015 and August 2016, was determined.

RESULTS

A SVR12 was achieved in 86% of subjects treated with sofosbuvir/ledipasvir ± ribavirin (SOF/LDV±RBV), 93% treated with paritaprevir, ombitasvir and ritonavir combined with dasabuvir ± ribavirin (3D±RBV) and 89% treated with sofosbuvir/daclatasvir ± ribavirin (SOF/DCV±RBV). The discontinuation rate was 5% and the on-treatment mortality rate was 1%.

CONCLUSION

The availability of interferon-free regimens represents a significant breakthrough for the treatment of HCV infection. Treatments options, with high SVR12 rates, are now available for patients with compensated cirrhosis who were unsuitable for treatment with interferon-based regimens. Data obtained from studies conducted in real world practice provide robust information fundamental for input into future economic evaluations for agents used for the treatment of HCV infection.

The HIV Care Cascade and sub-analysis of those linked to but not retained in care: the experience from a tertiary HIV referral service in Dublin Ireland

BACKGROUND

The HIV Care Cascade model can be used to measure how clinical services align with United Nations' (UN) HIV treatment targets. Previous models have highlighted sequential losses at each step of the Cascade with a significant proportion being not retained in care (NRIC).

OBJECTIVE

We aimed to assess the feasibility of meeting the UN targets and assess factors associated with, and calculate the true proportion of those, NRIC.

METHODS

All people living with HIV who were linked to our service, one of three specialist HIV care providers in Dublin Ireland, from its establishment in 1993 to 1 December 2014, were included in the cohort and were categorized as linked to care, retained in care (RIC), on antiretroviral therapy (on ART), virally suppressed (HIV RNA <40copies/ml), and NRIC. An analysis of those NRIC was performed to categorize their current status through direct/indirect contact.

RESULTS

Of 1000 patients linked to care, 78.7% (n = 787) were RIC, of whom 91.5% (n = 720) were on ART, with 89.9% (n = 644) virally suppressed. Those RIC were more likely older (p = 0.006) and non-IVDU (p < 0.001). Of 213 (21.3%) NRIC, 56 (26.3%) emigrated, 27 (12.7%) transferred care, 15 (7.0%) stopped attending but were contactable, 38 (17.8%) died, and 77 (36.1%) were lost to follow-up. After revision, 10.5% of the cohort was confirmed as NRIC, with 6 of 15 defined as "stopped attending" re-linked to care following direct contact.

CONCLUSIONS

Our HIV Care Cascade model demonstrates that the true numbers of patients NRIC may be significantly lower than previously estimated and once RIC, treatment goals approaching the United Nations Programme on HIV and AIDS targets are possible with 91.5% on treatment and almost 90% of those on treatment virally suppressed. That 40% reengaged following direct contact suggests benefit through regular monitoring and direct contact based on the HIV Care Cascade model.

The effect of initiation of antiretroviral therapy on monocyte, endothelial and platelet function in HIV-1 infection

OBJECTIVES

Monocyte activation, endothelial dysfunction and platelet activation all potentially contribute to the increased risk of cardiovascular disease (CVD) reported in those with HIV-1 infection. To date, no study has examined how initiation of antiretroviral therapy (ART) affects markers of all three processes. We aimed to compare markers of monocyte, endothelial and platelet function between untreated HIV-positive subjects and HIV-negative controls and to examine the early effects of ART initiation on these markers.

METHODS

We measured monocyte [soluble CD14 (sCD14) and sCD163], endothelial [von Willebrand factor (vWF), intercellular adhesion molecule-1 (ICAM-1) and vascular adhesion molecule-1 (VCAM-1)] and platelet [soluble P-selectin (sP-selectin), soluble CD40 ligand (sCD40L) and soluble glycoprotein VI (sGPVI)] biomarkers before and at weeks 4 and 12 post ART initiation in HIV-positive and well-matched HIV-negative controls.

RESULTS

We examined 40 subjects, 25 HIV-positive subjects and 15 controls, with a median age of 34 years [interquartile range (IQR) 31, 40 years], of whom 60% were male and 47.5% Caucasian. Pre-ART, all biomarkers (monocyte, endothelial and platelet) were significantly higher in HIV-positive patients versus controls (all P < 0.05) and decreased with ART initiation, except for sCD14, which remained unchanged [median 1680 (IQR 1489, 1946) ng/mL at week 12 versus 1570 (IQR 1287, 2102) ng/mL at week 0; P = 0.7]. Although platelet activation markers reduced to levels comparable to those in controls, endothelial dysfunction markers remained elevated, as did sCD163 [at week 12, median 1005 (IQR 791, 1577) ng/mL in HIV-positive patients versus 621 (IQR 406, 700) ng/mL in controls; P < 0.0001].

CONCLUSIONS

ART initiation resulted in reductions in levels of CVD-associated biomarkers; however, although they improved, markers of endothelial dysfunction and monocyte activation remained elevated. How these persistent abnormalities affect CVD risk in HIV infection remains to be determined.

Isolation rooms for highly infectious diseases: an inventory of capabilities in European countries

Isolation of patients with highly infectious diseases (HIDs) in hospital rooms with adequate technical facilities is essential to reduce the risk of spreading disease. The European Network for Infectious Diseases (EUNID), a project co-funded by European Commission and involving 16 European Union member states, performed an inventory of high level isolation rooms (HIRs, hospital rooms with negative pressure and anteroom). In participating countries, HIRs are available in at least 211 hospitals, with at least 1789 hospital beds. The adequacy of this number is not known and will depend on prevailing circumstances. Sporadic HID cases can be managed in the available HIRs. HIRs could also have a role in the initial phases of an influenza pandemic. However, large outbreaks due to natural or to bioterrorist events will need management strategies involving healthcare facilities other than HIRs.

Calciphylaxis in a patient with normal renal function: response to treatment with sodium thiosulfate

Calciphylaxis is a rare, life-threatening cause of skin necrosis. The condition is primarily reported in patients with end-stage renal disease, and is associated with significant morbidity and mortality. Treatment has mainly been empirical. We report a case of calciphylaxis in a patient with normal renal function and hypoparathyroidism, who responded to treatment with sodium thiosulfate. To our knowledge, this is the first reported case of the use of sodium thiosulfate to treat calciphylaxis in a patient with normal renal function.

Maternal hepatotoxicity with nevirapine as part of combination antiretroviral therapy in pregnancy

OBJECTIVES

To describe the maternal tolerability of nevirapine as part of combination antiretroviral therapy in pregnancy at three HIV centres in Dublin, Ireland and to determine risk factors for development of significant hepatotoxicity.

METHODS

A retrospective study was carried out of all women prescribed nevirapine as part of combination antiretroviral therapy in pregnancy at three HIV centres in Dublin, Ireland (October 2000 to February 2003). Toxicities experienced were graded according to the Division of AIDS toxicity guidelines for adults. Statistical analysis was performed to determine whether there were differences between those that did and those that did not experience significant hepatotoxicity.

RESULTS

A total of 123 women initiated nevirapine as part of combination antiretroviral therapy in the study period. Eight women developed significant hepatotoxicity, including two women who died from fulminant hepatitis. Women who experienced more severe hepatotoxicity had higher pretreatment CD4 counts (P=0.01).

CONCLUSIONS

In this cohort, women who experienced more severe hepatotoxicity had higher pretreatment CD4 counts, lending additional weight to the need for caution in using nevirapine as part of combination antiretroviral therapy in women not requiring antiretroviral therapy for their own health.

An evaluation of extubation failure predictors in mechanically ventilated infants and children

OBJECTIVE

To assess the accuracy of traditional weaning indices in predicting extubation failure, and to compare their accuracy when indices are measured at the onset of a breathing trial (SBT) and at the end of the SBT before extubation.

DESIGN

Prospective study.

SETTING

Medical-surgical intensive care unit at a tertiary care hospital.

PATIENTS

Four hundred eighteen consecutive infants and children who received mechanical ventilation for at least 48 h and were deemed ready to undergo a SBT by their primary physician.

INTERVENTIONS

Respiratory frequency (RR), tidal volume (V(T)), maximal inspiratory pressure (P(imax)) and frequency-to-tidal volume ratio (f/V(T)) were obtained within the first 5 min of breathing through a T-piece. The primary physicians were unaware of those measurements and the decision to extubate a patient was made by them. RR, V(T), f/V(T) were remeasured before extubation by the respiratory therapists. Extubation failure was defined as needing re intubation within 48 h after extubation. The area under the receiver operating characteristic (ROC) curve was calculated for each index as a measure of the accuracy in predicting extubation outcome.

MEASUREMENTS AND MAIN RESULTS

Three hundred twenty-three patients successfully underwent the SBT and were extubated, but 48 of them (14%) required re-intubation. The ROC curve for V(T), RR, P(imax) and f/V(T) measured within the first 5 min of breathing were 0.54, 0.56, 0.57 and 0.57, respectively. The ROC curve did not increase significantly when the above indices were remeasured before extubation.

CONCLUSIONS

In a population which had passed SBT, the ability of the traditional weaning indices to discriminate between children successfully extubated and children re-intubated is very poor.

National guidelines for the active management of HIV in pregnancy

The number of HIV positive women becoming pregnant in Ireland is increasing, with many pregnancies occurring in women from countries of high HIV prevalence. The management of such patients offers the challenge of reducing the risk of maternal-fetal transmission of HIV infection, avoiding fetal-infant toxicities, and maintaining future maternal antiretroviral options. Guidelines for the optimal management of HIV disease in pregnancy have been produced by a subgroup of the Irish Infection Society consisting of GenitoUrinary Medicine and Infectious Diseases Consultants. They are based on currently available international data and guidelines. The national guidelines offer a broad management outline for HIV positive pregnant patients. Ultimately, each patient is assessed individually by a multidisciplinary team, and a careful plan for antenatal, intrapartum, and postpartum care is determined.

An early settler in sickness and in health

OBJECTIVE

This paper is an examination of an early Australian settler's states of mind in episodes of psychosis and some issues from her life which may have contributed to the psychoses.

METHOD

Hospital records of her psychoses and her diary entries in the months surrounding the onset of illness were investigated from a psychoanalytic perspective, and inferences about her underlying personality are drawn from a recent publication about her diaries.

RESULTS

An historical interpretation of her life and states of mind based on the documents is presented.

CONCLUSIONS

Failure to resolve psychic conflict led to restrictions in how she and her family lived, and left her susceptible to decompensation.

Molecular bases of C7 deficiency: three different defects

The molecular basis of C7 deficiency has been investigated in two Irish families and a number of Israeli families of Moroccan Sephardic Jewish origin. Exon PCR and sequencing revealed a heterozygous point mutation at the 3' splice acceptor site of intron 1 in one Irish family. In the other Irish family, exons 7 and 8 failed to amplify and they were shown to be deleted. Marker haplotype studies of the C6 and C7 gene region and Southern blots show that the Irish family with the splice defect also segregate for the deletion, which is not easily detected in heterozygotes. The Israeli C7-deficient cases all share a C7 haplotype and are homozygous for a mis-sense mutation in exon 9. However, one individual is heterozygous for markers at adjacent C6 loci, showing that there has been an intergenic recombination and suggesting that the deficiency mutation is of appreciable antiquity.

Molecular bases of C7 deficiency: three different defects

The molecular basis of C7 deficiency has been investigated in two Irish families and a number of Israeli families of Moroccan Sephardic Jewish origin. Exon PCR and sequencing revealed a heterozygous point mutation at the 3' splice acceptor site of intron 1 in one Irish family. In the other Irish family, exons 7 and 8 failed to amplify and they were shown to be deleted. Marker haplotype studies of the C6 and C7 gene region and Southern blots show that the Irish family with the splice defect also segregate for the deletion, which is not easily detected in heterozygotes. The Israeli C7-deficient cases all share a C7 haplotype and are homozygous for a mis-sense mutation in exon 9. However, one individual is heterozygous for markers at adjacent C6 loci, showing that there has been an intergenic recombination and suggesting that the deficiency mutation is of appreciable antiquity.

Human immunodeficiency virus and hepatitis--implications for operating room personnel

Human Immunodeficiency Virus, Hepatitis B and C are important blood borne viruses and pose occupational risks for operating room personnel. Increasing numbers of patients with these infections are appearing in Irish hospitals. In this review we describe in detail the occupational risks of these blood borne viruses for operating room personnel and how best to minimise them.

Intraabdominal infection: a review

Significant advances in our understanding of the pathogenesis and microbiology of intraabdominal sepsis have been made over the past 15 years. There has also been progress in various aspects of diagnosis and treatment of these infections. Computed tomography and ultrasonography have simplified the diagnosis of an intraabdominal abscess, and percutaneous drainage of abscesses has become an acceptable alternative to surgery. Novel surgical approaches have been tried, but their true role is not yet defined. A broader selection of less-toxic antimicrobial agents is now available as treatment for intraabdominal infection. The role of superinfecting pathogens is more clearly defined. Patients who would have died of this infection in a previous era now survive because of an array of supportive therapies.

Colonoscopy-associated listeriosis: report of a case

We report a case of meningitis due to Listeria monocytogenes that occurred following colonoscopy. The patient had cirrhosis, a portosystemic shunt, and diarrhea for which she was being evaluated. Only one previous report has linked colonoscopy to listeriosis. We review the pathogenesis of listeriosis and, in particular, the evidence that prior fecal colonization is followed by bacteremia in a susceptible host. The findings in this case are consistent with this pathogenetic sequence.

Cerebral phaeohyphomycosis caused by Xylohypha bantiana, with a review of the literature

A 76-year-old male with chief complaints of back and right leg sciatica was hospitalized. His abdominal CT scan revealed lumber spondylitic stenosis. A laminectomy was performed. Postoperatively, he became febrile, aphasic and had grand mal seizure. A left craniotomy of the front abscess, seen in the CT scan, was performed. H and E stained smears of drainage revealed dematiaceous, septate hyphae. Cultures of the abscess drainage grew an olivaceous-grey fungus. Based on macro- and micro-morphological characters, growth at 42 degrees C, and exoantigenic analysis, the patient's fungus was identified as Xylohypha bantiana. Treatment with amphotericin B and 5-fluorocytosine was initiated. Despite surgical procedures and antifungal therapy, the patient's condition deteriorated and he died a few weeks later due to cerebral edema. The case reported here is the first microscopically, culturally, histopathologically and exoantigenically proven case of phaeohyphomycosis caused by X. bantiana in the province of Alberta and from Canada. A review of the literature on cases of X. bantiana infections has also been presented.

A phenomenology of scut

OBJECTIVE

To identify, describe, and quantify the night-call duties that residents in internal medicine call "scutwork" and to compare faculty and residents' perceptions of scutwork.

DESIGN

Prospective, cross-sectional study.

SETTING

General internal medicine training program at a university-affiliated tertiary care hospital.

PARTICIPANTS

Forty-eight residents who spent 3 months or more on an internal medicine teaching unit during the previous year and 41 faculty members who spent 2 months or more on one of these units.

INTERVENTIONS

Postcall surveys and night-call diaries were used to analyze residents' activities, to derive a definition of scutwork, and to estimate its prevalence. Residents and faculty then completed a detailed questionnaire that included ratings of the educational value, "scut content," and residents' responsibility for 20 specific tasks.

MAIN RESULTS

Eighty-three percent of residents found scutwork and education to be mutually exclusive for the 20 tasks, although 20% indicated that scutwork was an appropriate task for residents. Residents' ratings of tasks as scut varied according to the context of the task. For example, obtaining routine consent from someone else's patient was considered scutwork by 98% of residents, whereas obtaining such consent from the residents's own patient was rated as scutwork by only 52% (P less than 0.01). Similarly, performing intravenous cannulation at the request of ward staff was rated as scut by 94% of residents, whereas performing cannulation at another resident's request was rated as scut by 56% (P less than 0.01). Night-time admission of a patient for an elective procedure was rated as scut by 75% of residents, whereas admission of such a patient after discussion with a faculty member was labeled scut by only 44% (P less than 0.01). Faculty ratings of such admissions did not show the same variation (24% for both). Faculty were more likely than residents to assess tasks as educational (50% compared with 26%, P less than 0.01) but were less likely to consider tasks as scutwork (47% compared with 62%, P = 0.12) or as work that should be done by nonresidents (35% compared with 46%, P greater than 0.2).

CONCLUSIONS

Our results suggest that the characteristics of scutwork can be identified, that the perception of scut varies between faculty and residents, and that the context of a task often determines whether residents perceive it as scut.

Antimicrobial prophylaxis for open heart operations

Between 1986 and 1988, 450 adults undergoing coronary artery bypass, cardiac valve replacement, or both were enrolled into a prospective, randomized, comparative trial of cephalothin versus cefamandole as perioperative prophylaxis. They were assessed during their hospitalization and at 6 weeks and 6 months after discharge for postoperative infectious complications. Eleven patients had major postoperative infections including 5 with sternal wound infections (three bacteremic), 6 with bacteremia, 1 with prosthetic valve endocarditis, and 3 with severe venous donor graft site infections. Eight major infections occurred in patients receiving cephalothin prophylaxis and three in patients receiving cefamandole, with all five sternal wound infections occurring in the cephalothin group. Postoperative pathogens responsible for the major infections included gram-negative aerobes in 5 patients, Staphylococcus aureus in 4, and Staphylococcus epidermidis in 2. Preoperative colonizing staphylococcal isolates were not predictive of postoperative staphylococcal pathogens. Although there was no statistically significant difference in rate of major postoperative infectious complications using either cephalothin or cefamandole prophylaxis, there was a trend in favor of cefamandole. Gram-negative aerobes are becoming increasingly important pathogens in this setting.