N THE PREANTIBIOTIC ERA, NATIVE valve endocarditis was virtually always fatal. Since the advent of antibiotic therapy, mortality decreased to 24% to 60% in published case series, with heart failure representing the leading cause of death. [1][2][3][4] During the past 3 decades, studies have suggested that valve surgery should be considered for patients with native valve endocarditis associated with complications that adversely affect prognosis: heart failure, 5-10 new valvular regurgitation, [11][12][13] refractory infection (ie, persistent fever or bacteremia, fungemia, or paravalvular abscess), 14,15 systemic embolization to vital organs, 16,17 and the presence of a vegetation on echocardiography as this represents a plausible risk for embolization. [18][19][20] However, methodological limitations of existing studies, the absence of randomized controlled trials, and the lack of a validated method to classify prognostic severity make management decisions problematic.Accurate prognostic classification may help facilitate individual treatment decisions and interpretation of therapeutic interventions in clinical trials. In this study, we derived and externally validated a prognostic classification system in 2 contemporaneous cohorts of adults with complicated leftsided native valve endocarditis. METHODS PatientsResearch patients were identified through systematic medical record review at the 7 Connecticut hospitals where valve surgery was performed. To create and test a prognostic classification system, we divided patients into derivation and validation cohorts (FIGURE). The derivation cohort (n = 259) was assembled from adults (Ͼ16 years) in whom complicated leftsided native valve endocarditis was di-
Background: COVID-19 is caused by the severe acute respiratory syndrome virus SARS-CoV-2. It is widely recognized as a respiratory pathogen, but neurologic complications can be the presenting manifestation in a subset of infected patients. Case presentation: We describe a 78-year old immunocompromised woman who presented with altered mental status after witnessed seizure-like activity at home. She was found to have SARS-CoV-2 infection and associated neuroinflammation. In this case, we undertake the first detailed analysis of cerebrospinal fluid (CSF) cytokines during COVID-19 infection and find a unique pattern of inflammation in CSF, but no evidence of viral neuroinvasion. Conclusion: Our findings suggest that neurologic symptoms such as encephalopathy and seizures may be the initial presentation of COVID-19. Central nervous system inflammation may associate with neurologic manifestations of disease.
We describe the 11th case of bioterrorism-related inhalational anthrax reported in the United States. The presenting clinical features of this 94-year-old woman were subtle and nondistinctive. The diagnosis was recognized because blood cultures were obtained prior to administration of antibiotics, emphasizing the importance of this diagnostic test in evaluating ill patients who have been exposed to Bacillus anthracis. The patient's clinical course was characterized by progression of respiratory insufficiency, pleural effusions and pulmonary edema, and, ultimately, death. Although her B anthracis bacteremia was rapidly sterilized after initiation of antibiotic therapy, viable B anthracis was present in postmortem mediastinal lymph node specimens. The source of exposure to B anthracis in this patient is not known. Exposure to mail that was cross-contaminated as it passed through postal facilities contaminated with B anthracis spores is one hypothesis under investigation.
Background Among the 1.2 million people with human immunodeficiency virus (HIV) in the United States, 25% are coinfected with hepatitis C virus (HCV). The availability of effective direct acting antivirals (DAAs) makes the goal of HCV elimination feasible, but implementation requires improvements to the HCV treatment cascade, especially linkage to and initiation of treatment in underserved populations. Methods In this retrospective review, a cohort of patients receiving care at a hospital-based HIV clinic in New Haven, Connecticut (January 1, 2014–March 31, 2017) with chronic HCV infection not previously treated with DAAs were followed longitudinally. Patients were referred to a colocated multidisciplinary team. Standardized referral and treatment algorithms and electronic medical record templates were developed, monthly meetings were held, and a registry was created to review progress. Results Of 173 patients, 140 (80.9%) were 50–70 years old, 115 (66.5%) were male, 99 (57.2%) were African American, 43 (24.9%) were white, and 23 (13.3%) were Hispanic. Comorbidities included the following: cirrhosis (25.4%), kidney disease (17.3%), mental health issues (60.7%), alcohol abuse (30.6%), and active drug use (54.3%). Overall, 161 (93.1%) were referred, 147 (85%) were linked, 122 (70.5%) were prescribed DAAs, and 97 (56.1%) had sustained viral response at 12 weeks posttreatment or cure (SVR12). Comparison between those with SVR12 and those unsuccessfully referred, linked, or treated, showed that among those not engaged in HCV care, there was a higher proportion of younger (mean age 54.2 vs 57 years old, P = .022), female patients (P = .001) and a higher frequency of missed appointments. Conclusions Establishing a colocated HCV clinic within an HIV clinic resulted in treatment initiation in 70.5% of patients and SVR12 in 56.1%. This success in a hard-to-treat population is a model for achieving microelimination goals set by the World Health Organization.
Objectives Effective and safe COVID‐19 vaccines have been developed and have resulted in decreased incidence and severity of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection and can decrease secondary transmission. However, there are concerns about dampened immune responses to COVID‐19 vaccination among immunocompromised patients, including people living with HIV (PLWH), which may blunt the vaccine's efficacy and durability of protection. This study aimed to assess the qualitative SARS‐CoV‐2 vaccine immunogenicity among PLWH after vaccination. Methods We conducted targeted COVID‐19 vaccination (all received BNT162b2 vaccine) of PLWH (aged ≥ 55 years per state guidelines) at Yale New Haven Health System and established a longitudinal survey to assess their qualitative antibody responses at 3 weeks after the first vaccination (and prior to receipt of the second dose of the COVID‐19 vaccine) (visit 1) and at 2–3 weeks after the second vaccination (visit 2) but excluded patients with prior COVID‐19 infection. Our goal was to assess vaccine‐induced immunity in the population we studied. Qualitative immunogenicity testing was performed using Healgen COVID‐19 anti‐Spike IgG/IgM rapid testing. Poisson regression with robust standard errors was used to determine factors associated with a positive IgG response. Results At visit 1, 45 of 78 subjects (57.7%) tested positive for SARS‐CoV‐2 anti‐Spike IgG after the first dose of COVID‐19 vaccine. Thirty‐nine subjects returned for visit 2. Of these, 38 had positive IgG (97.5%), including 20 of 21 subjects (95.2%) with an initial negative anti‐Spike IgG. Our bivariate analysis suggested that participants on an antiretroviral regimen containing integrase strand transfer inhibitors [relative risk (RR) = 1.81, 95% confidence interval (CI): 0.92–3.56, p = 0.085] were more likely to seroconvert after the first dose of the COVID‐19 vaccine, while those with a CD4 count < 500 cells/μL (RR = 0.59, 95% CI: 0.33–1.05, p = 0.071), and those diagnosed with cancer or another immunosuppressive condition (RR = 0.49, 95% CI: 0.18–1.28, p = 0.15) may have been less likely to seroconvert after the first dose of the COVID‐19 vaccine. The direction of these associations was similar in the multivariate model, although none of these findings reached statistical significance (RR integrase inhibitor = 1.71, 95% CI: 0.90–3.25, p = 0.10; RR CD4 count = 0.68, 95% CI: 0.39–1.19, p = 0.18; RR cancer or another immunosuppressive condition = 0.50, 95% CI: 0.19–1.33, p = 0.16). With regard to immunogenicity, we were able to record very high rates of new seroconversion following the second dose of the COVID‐19 vaccine. Conclusions ...
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