Recurrence of symptoms following cryptococcal meningitis - characterizing a diagnostic conundrum with multiple etiologies

alexandrossfakianakis shared this article with you from Inoreader Recurrence of symptoms following cryptococcal meningitis - characterizing a diagnostic conundrum with multiple etiologies via Clinical Infectious Diseases Advance Access Abstract Background Cryptococcal meningitis is a common cause of AIDS-related mortality. Although symptom recurrence after initial treatment is common, the etiology is often difficult to decipher. We sought to summarize characteristics, etiologies and outcomes among persons with second-episode symptomatic recurrence. Methods We prospectively enrolled Ugandans with cryptococcal meningitis and obtained patient characteristics, ART and cryptococcosis histories, clinical outcomes, and CSF analysis results. We independently adjudicated cases of second-episode meningitis to categorize patients as 1: microbiological relapse, 2: paradoxical Immune Reconstitution Inflammatory Syndrome (IRIS), 3: persistent elevated intracranial pressure (ICP) only, or 4: persistent symptoms only; along with controls of primary cryptococcal meningitis. We compared groups with chi-square or Kruskal Wallis tests as appropriate. Results 724 participants wer e included (n = 607 primary episode, n = 81 relapse, n = 28 paradoxical IRIS, n = 2 persistently elevated ICP, n = 6 persistent symptoms). Participants with culture-positive relapse had lower CD4 (25 cells/mcL, IQR 9-76) and lower CSF WBC (4 cells/mcL, IQR 4-85) counts than paradoxical IRIS (CD4 78 cells/mcL, IQR 47-142 and WBC 45 cells/mcL, IQR 8-128). Among those with CSF WBC <5 cells/mcL, 86% (43/50) had relapse. Among those with CD4 counts < 50 cells/mcL, 91% (39/43) had relapse. 18-week mortality (from current symptom onset) was 47% among first episodes of cryptococcal meningitis, 31% in culture-positive relapses, and 14% in paradoxical IRIS. Conclusions Poor immune reconstitution was noted more often in relapse compared to IRIS as evidenced by lower CSF WBC counts and blood CD4 counts. These easily obtained lab values should prompt initiation of antifungal treatment while awaiting culture results. View on Web

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Higher levels of cerebrospinal fluid and plasma neurofilament light in human immunodeficiency virus-associated distal sensory polyneuropathy

alexandrossfakianakis shared this article with you from Inoreader Higher levels of cerebrospinal fluid and plasma neurofilament light in human immunodeficiency virus-associated distal sensory polyneuropathy via Clinical Infectious Diseases Advance Access Abstract Background Neurofilament light chain (NFL) concentrations, reflecting axonal damage, are seen in several polyneuropathies, but have not been studied in HIV distal sensory polyneuropathy (DSP). We evaluated NFL in CSF and plasma in relation to DSP in people with HIV (PWH) from two independent cohorts, and in people without HIV (PWoH). Methods Cohort 1 consisted of PWH from the CHARTER Study. Cohort 2 consisted of PWH and PWoH from the HIV Neurobehavioral Research Center (HNRC). We evaluated DSP signs and symptoms in both cohorts. Immunoassays measured NFL in CSF for all and for plasma as well in Cohort 2. Results Cohort 1 consisted of 111 PWH, mean ± SD age 56.8 ± 8.32 years, 15.3% female, 38.7% black, 49.6% white, current CD4+ T-cells (median, IQR) 532/µL (295, 785), 83.5% with plasma HIV RNA ≤ 50 copies/mL. Cohort 2 consisted of 233 PWH of similar demographics to PWH in Cohort 1, but also 51 PWoH, t ogether age 58.4 ± 6.68 years, 41.2% female, 18.0% black, Hispanic, non-Hispanic white 52.0%, 6.00% white. In both cohorts of PWH, CSF and plasma NFL were significantly higher in both PWH with DSP signs. Findings were similar, albeit not significant, for PWoH. The observed relationships were not explained by confounds. Conclusions Both plasma and CSF NFL were elevated in PWH and PWoH with DSP. The convergence of our findings with others demonstrates that NFL is a reliable biomarker reflecting peripheral nerve injury. Biomarkers such as NFL might provide, validate, and optimize clinical trials of neuroregenerative strategies in HIV DSP. View on Web

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Acute hepatitis associated with an echovirus 9 infection in a heart transplant recipient

alexandrossfakianakis shared this article with you from Inoreader Acute hepatitis associated with an echovirus 9 infection in a heart transplant recipient via Journal of Medical Virology Abstract We report a case of severe acute hepatitis due to echovirus 9 in a heart transplant patient treated with conventional immunosuppressive therapy. This case supports the importance of testing for enteroviruses in any type of infectious presentation in immunocompromised populations. This article is protected by copyright. All rights reserved. View on Web

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Post‐COVID‐19 vaccination arm pain diagnosed as complex regional pain syndrome: a case report

alexandrossfakianakis shared this article with you from Inoreader Post‐COVID‐19 vaccination arm pain diagnosed as complex regional pain syndrome: a case report via Pain Practice Abstract As the vaccination efforts against the coronavirus disease-2019 (COVID-19) continue, more patients are likely to present with complications related to COVID-19 vaccination. We describe the first reported case of complex regional pain syndrome (CRPS), involving the upper extremities, that occurred after COVID-19 vaccination. The patient presented with acute-onset severe arm pain and swelling following vaccine administration. Based on the clinical, electrodiagnostic, and radionuclide three-phase bone scan findings, the patient was diagnosed with postvaccination CRPS. The COVID-19 vaccine possibly elicited an immune-mediated inflammatory response to the injected antigen in the patient, who was predisposed to CRPS due to inflammatory immunity. The COVID-19 vaccine elicited an immune-mediated inflammatory response to the injected antigen, resulting in CRPS following COVID-19 vaccination. View on Web

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Total calcium, dairy foods and risk of colorectal cancer: a prospective cohort study of younger US women

alexandrossfakianakis shared this article with you from Inoreader Total calcium, dairy foods and risk of colorectal cancer: a prospective cohort study of younger US women via International Journal of Epidemiology - Advance Access Abstract Background Although colorectal cancer (CRC) incidence is declining among adults aged ≥65 years, CRC incidence in younger adults has been rising. The protective role of calcium in colorectal carcinogenesis has been well established, but evidence is lacking on whether the association varies by age at diagnosis. We investigated the association between total calcium intake and risk of overall CRC and CRC before age 55 years. Methods In the Nurses' Health Study II (1991–2015), 94 205 women aged 25–42 years at baseline were included in the analysis. Diet was assessed every 4 years through validated food frequency questionnaires. Multivariable-adjusted hazard ratios (HRs) and 95% CIs for CRC were estimated using the Cox proportional hazards model. Results We documented 349 incident CRC cases during 2 202 604 person-years of follow-up. Higher total calcium intake was associated with a reduced risk of CRC. Compared with those with <750 mg/day of total calcium intake, the HR of CRC was 0.61 (95% CI, 0.38–0.97) for those who consumed ≥1500 mg/day (P for trend = 0.01). The HR per 300 mg/day increase was 0.85 (95% CI, 0.76–0.95). There was a suggestive inverse association between total calcium intake and CRC before age 55 years (HR per 300 mg/day increase, 0.87; 95% CI, 0.75–1.00), suggesting the importance of calcium intake in the younger population. Conclusions In a cohort of younger women, which reflects the birth cohorts, time periods and age ranges paralleling the recent rise in CRC, higher calcium intake was associated with a decreased risk of CRC. View on Web

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Diagnostic efficacy of positron emission computerized tomography scans in suspicious laryngeal findings postorgan preservation treatment

alexandrossfakianakis shared this article with you from Inoreader Diagnostic efficacy of positron emission computerized tomography scans in suspicious laryngeal findings postorgan preservation treatment via Head & Neck Abstract Background Larynx preservation protocols (LPP) for glottic primary squamous cell carcinoma has gained popularity worldwide. Direct laryngoscopy (DL) with biopsy is mandated when recurrence is suspected. The efficacy of 18Fluoro-deoxy-glucose positron emission computerized tomography (PET-CT) as alternative first-line diagnostic investigation in suspected recurrence was evaluated. Methods A retrospective study of patients with suspicious fiber-optic findings at more than 12 weeks after LPP. Sensitivity, specificity, and the negative predictive value (NPV) of DL and PET-CT were compared. Results Seventy-two patients presenting 105 cases of suspicious events were included in this study. Fifty-two events were initially investigated by DL and 53 events by PET-CT. The sensitivity of DL and PET-CT was 56.25% and 100%, respectively. The NPV was 84% for DL and 100% for PET-CT (p = 0.015). Conclusion Negative PET scans after LPP are highly accurate in ruling out recurrent/persistent disease and may spare the patient from negative biopsies. View on Web

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Comparative analysis and trends in liver transplant hospitalizations with clostridium difficile infections: A 10‐year national cross‐sectional study

alexandrossfakianakis shared this article with you from Inoreader Comparative analysis and trends in liver transplant hospitalizations with clostridium difficile infections: A 10‐year national cross‐sectional study via Transplant Infectious Disease ABSTRACT Goals and Background Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea in the United States. We aimed to determine comparative trends in inpatient outcomes of liver transplant (LT) patients based on CDI during hospitalizations. Methods The national inpatient sample (NIS) database was used to conduct the present retrospective study regarding CDI among the LT hospitalizations from 2009, to 2019. Primary outcomes included ten-year comparative trends of the length of stay (LOS) and mean inpatient charges (MIC). Secondary outcomes included comparative mortality and LT rejection trends. Results There was a 14.05% decrease in CDI in LT hospitalizations over the study period (P = 0.05). The trend in LOS did not significantly vary (P = 0.9). MIC increased significantly over last decade in LT hospitalizations with CDI (P < 0.001). LT hospitalizations of autoimmune etiology compared against non-autoimmune did not increase association with CDI, adjusted odds ratio (aOR) 0.97 [95% confidence interval (CI) 0.75-1.26, P = 0.87]. CDI was associated with increased mortality in LT hospitalizations, aOR 1.84 [95% confidence interval (CI) 1.52-2.24, P < 0.001].  In-hospital mortality for LT hospitalizations with CDI decreased by 7.75% over the study period (P = 0.3). CDI increased transplant rejections, aOR 1.3 [95% CI 1.08-1.65, P < 0.001]. There was a declining trend in transplant rejection for LT hospitalization with CDI from 5% to 3% over the study period (P = 0.0048). Conclusion CDI prevalence doesnot increase based on autoimmune LT etiology. It increases mortality in LT hospitalizations; however, trend for mortality and transplant rejections has been declining over the last decade. This article is protected by copyright. All rights reserved View on Web

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Cidofovir‐induced anterior uveitis in an allogeneic stem cell transplant recipient

alexandrossfakianakis shared this article with you from Inoreader Cidofovir‐induced anterior uveitis in an allogeneic stem cell transplant recipient via Transplant Infectious Disease Abstract Anterior uveitis is a reported complication of intravenous cidofovir, almost exclusively described in human immunodeficiency virus (HIV) infected patients treated for cytomegalovirus retinitis. In this study, we report the case of an allogeneic stem cell transplant recipient with significant visual impairment and hypotony following administration of high-dose intravenous cidofovir for hemorrhagic cystitis due to BK virus. View on Web

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The Use of Dissemination and Implementation to Improve Multimodal Analgesia in Head and Neck Surgery

alexandrossfakianakis shared this article with you from Inoreader The Use of Dissemination and Implementation to Improve Multimodal Analgesia in Head and Neck Surgery via The Laryngoscope The use of a multimodal analgesia approach in a Randomized Clinical Trial including acetaminophen, ketorolac, gabapentin, and a neurogenic extremity block in patients undergoing major head and neck ablative and reconstructive surgery significantly reduced the need for opioids in the immediate postoperative period of a seven-day hospital stay. Coordination of care and reducing variability in pain medication administration were highly dependent on dissemination and implementation processes put in place for perioperative phases of care. Objectives To optimize the delivery of multimodal analgesia to patients undergoing major head and neck oncologic surgeries. Methods Pilot study included patients enrolled to receive either scheduled acetaminophen and as-needed opioids (control group) or scheduled acetaminophen, gabapentin, ketorolac, and as-needed opioids (experimental group). RCT, a hybrid type 1 effectiveness-implementation pragmatic trial, was designed to test the effectiveness of the intervention. Arm A received scheduled acetaminophen and as-needed opioids. Arm B received scheduled gabapentin, ketorolac, a regional nerve block at the free tissue donor site, scheduled acetaminophen and as-needed opioids. Results Pilot: Thirty-one patients undergoing major head and neck surgery were enrolled. Mean MMEs administered in control group (n = 15) was 251.60 mg (SD = 224.57 mg); mean MMEs in Experimental group (n = 16) was 195.78 mg (SD = 131.08 mg), p = 0.401. LOS was 8.0 days in control versus 7.0 days in experimental group (p = 0.054). RCT: Interim analysis for safety and futility was planned during trial's design after 30 patients (n = 14 Arm A, and n = 16 Arm B). Mean MMEs administered were 135.1 mg in Arm A, (SD = 86.0 mg) versus mean MME of 51.3 mg in Arm B (SD = 43.3 mg, (p < 0.05)). Given clear superiority results, the trial was prematurely terminated. Functional pain scores, LOS, and complications were similar between the arms (p > 0.05). Variability of mean MME was compared before and after implementation of the management protocols: SD in RCT#1 was 181.46 mg versus 124.6 mg in RCT#2. Conclusion Multimodal analgesia significantly reduced the need for opioids in patients undergoing major head and neck surgery. Level of Evidence 1, Randomized Clinical Trial Laryngoscope, 2022 View on Web

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The evolution of fertility preservation care models in a large pediatric cancer and blood disorders center

alexandrossfakianakis shared this article with you from Inoreader The evolution of fertility preservation care models in a large pediatric cancer and blood disorders center via Pediatric Blood & Cancer Abstract Background Children and adolescents who receive gonadotoxic treatments are at risk for future infertility. While there is a growing focus on integrating fertility preservation (FP) within pediatric cancer and blood disorder centers, wide variations in care models and methods exist across institutions. The purpose of this work is to describe the evolution of FP care models within a large pediatric hematology/oncology center. Methods Models of care and associated timeframes are described, including a pre-FP program model, establishment of a formal FP program, integration of nurse navigators, and the addition of FP consult stratification based on urgency (urgent/nonurgent). The number of patient consults within each model, patient sex, diagnosis (oncologic/hematologic), and consult timing (pre-gonadotoxic treatment/posttreatment completion) were abstracted from the clinical database. Results The number of annual consults increased from 24 during the pre-FP program model (2015) to 181 during the current care model (2020). Over time, the proportion of consults for females and patients with nonmalignant hematologic disorders increased. Patient stratification reduced the proportion of consults needing to be completed urgently from 75% at the advent of the FP program to 49% in the current model. Conclusions The evolution of care models within our FP program allowed for growth in the number of consults completed, expansion of services to more patients with nonmalignant hematologic disorders, and more consults for female patients. Nurse navigators play a critical role in care facilitating referrals, coordination, and patient education. Urgency stratification has allowed FP team members to manage increasing FP-related encounters. View on Web

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