Increased Myocardial Infarction Risk Following Herpes Zoster Infection

Background

Myocardial infarction (MI) has been reported as a postinfection sequela of herpes zoster, but with limited data on incidence after zoster and protective effect of the zoster vaccine. This study investigates the risk of developing an MI 30 days postzoster, determines patient-specific risk factors, and investigates the impact of herpes zoster vaccination.

Methods

This retrospective cohort study included patients who received care at a Veterans Affairs facility between 2015 and 2020. Time to MI was determined from either 30 days post-zoster infection (zoster cohort) or a primary care appointment (control cohort).

Results

This study assessed a total of 2 165 584 patients. MI within 30 days occurred in 0.34% (n = 244) of the zoster cohort and 0.28% (n = 5782) of the control cohort (P = .0016). Patients with a documented herpes zoster infection during the study period were 1.35 times more likely to develop an MI within the first 30 days postinfection compared to the control cohort. Patients who received the recombinant zoster vaccine were less likely to have an MI postinfection (odds ratio, 0.82 [95% confidence interval, .74-.92]; P = .0003).

Conclusions

Herpes zoster infection was associated with an increased risk of MI within the first 30 days postinfection. History of prior MI, male sex, age ≥50 years, history of heart failure, peripheral vascular disease, human immunodeficiency virus, prior cerebrovascular accident, and renal disease increased odds of MI 30 days postinfection with herpes zoster. Herpes zoster vaccination decreased the odds of developing an MI in patients aged ≥50 years.

Increased Stroke Risk Following Herpes Zoster Infection and Protection With Zoster Vaccine

BACKGROUND

Studies evaluating stroke following varicella zoster virus (VZV) infection are limited, and the utility of zoster vaccination against this phenomenon is unclear. This study aimed to determine the risk of stroke 30 days following zoster infection and to evaluate the impact of zoster vaccinations on the risk of stroke in VZV-infected patients.

METHODS

This retrospective case-control study was conducted from January 2010 to January 2020 utilizing nationwide patient data retrieved from the Veterans Affairs' Corporate Data Warehouse.

RESULTS

A total of 2 165 505 patients ≥18 years of age who received care at a Veterans Affairs facility were included in the study, of whom 71 911 had a history of zoster infection. Zoster patients were found to have 1.9 times increased likelihood of developing a stroke within 30 days following infection (odds ratio [OR], 1.93 [95% confidence interval {CI}, 1.57-2.4]; P < .0001). A decreased risk of stroke was seen in patients who received the recombinant zoster vaccine (OR, 0.57 [95% CI, .46-.72]; P < .0001) or the live zoster vaccine (OR, 0.77 [95% CI, .65-.91]; P = .002).

CONCLUSIONS

Patients had a significantly higher risk of stroke within the first month following recent herpes zoster infection. Receipt of at least 1 zoster vaccination was found to mitigate this increased risk. Vaccination may therefore be viewed as a protective tool against the risk of neurologic postinfection sequelae.

Risk Factors Associated with Mortality in Hospitalized Patients with Laboratory Confirmed SARS-CoV-2 Infection During the Period of Omicron (B.1.1.529) Variant Predominance

Background

SARS-CoV-2 Omicron variant has a high transmission rate. In December 2021, Omicron became the dominant variant and quickly accounted for majority of infections in the United States. Drug shortages have led to prioritization of patients for COVID-19 treatment based on risk factors for severe disease.

Methods

A retrospective analysis of hospitalized patients with COVID-19 infection at Veteran Affairs Healthcare System across the United States. The primary outcome was 14-day all-cause mortality after the first documented positive SARS-CoV-2 laboratory test. Odds ratios were generated from a multivariate logistic regression of significant factors.

Results

This study included 12,936 COVID-19 inpatients during a period of Omicron predominance. Age ≥ 65 years is a predictor of 14-day mortality among the vaccinated and unvaccinated population (OR 4.05, CI 3.06-5.45, P ≤ .0001). Triple vaccinated patients demonstrated a 52% decreased risk of death with COVID-19 infection (OR 0.48, CI 0.37-0.61, P ≤ .0001). Patients who were double vaccinated had a 39% decreased risk of death with COVID-19 infection (OR 0.61, CI 0.46-0.80, P = .003).

Conclusion

Advanced age ≥ 65 is the greatest risk factor for mortality in hospitalized COVID-19 patients. COVID-19 vaccination, especially booster doses, was associated with a decreased risk of 14-day mortality compared to double vaccinated or non-vaccinated patients. Results of this study suggest that advanced age should be considered first for prioritization of COVID-19 treatments for Omicron.

Outcomes of multiple sclerosis patients admitted with COVID-19 in a large veteran cohort

Background

Given concerns over immune function, the decision whether to continue disease modifying therapy (DMT) in multiple sclerosis (MS) patients during the COVID-19 pandemic has been challenging, complicated by the risk of MS disease progression in the absence of treatment.

Methods

This retrospective analysis of patients treated for COVID-19 infection at veteran affairs healthcare systems across the United States, investigated 30-day all-cause mortality after first positive COVID-19 in patients with and without MS. We examined mortality risk impact of disease modifying therapy for MS, accounting for other relevant factors known to be associated with COVID-19 mortality. Patients were propensity score matched in a 1:20 fashion based on MS diagnosis.

Results

49,737 COVID-19 inpatient cases were identified, of which 258 were diagnosed with MS. In the propensity score matched cohort, MS patients taking DMT (excluding those receiving anti-CD20 antibodies) had a lower odds of 30 day mortality (OR: 0.18 [95%CI: 0.00988-0.94] p=0.041). Similarly, in the unmatched cohort, patients on DMT had a lower risk of death (OR: 0.16 [95%CI: 0.01-0.82] p=0.023). There was no statistically significant difference in mortality between those with and without MS. In the propensity matched cohort, age over 65, heart failure, chronic kidney disease (CKD), and diabetes increased the risk of mortality while vaccination reduced the risk of mortality.

Conclusion

Veteran patients with MS hospitalized for COVID-19 were less likely to die when taking DMTs (excluding those receiving anti-CD20 antibodies), accounting for other relevant factors. Results suggest that, in relation to the COVID-19 pandemic, not only is it safe to continue most DMTs in people with MS, but it may be beneficial given the decreased risk of COVID-19 mortality and decreased risk of MS disease progression.

Admissions and Mortality Related to Urinary Tract Infections in Male Veterans with Dementia

Objective To examine mortality and hospital readmission rates in male veterans with dementia diagnosed with urinary tract infection (UTI) compared with patients without dementia. Design Retrospective cohort study. Setting Veterans Healthcare Systems (VA). Participants Male inpatients with a diagnosis of UTI who were treated at any VA Healthcare Center from January 1, 2009, to December 31, 2018. Interventions None. Main Outcome Measures Mortality and hospital readmission for patients with and without dementia at 30, 60, and 90 days from UTI diagnosis. Results 262,515 veterans admitted with UTI were analyzed, and 58,940 (22.5%) had dementia. The mean age for veterans with dementia was 80.0 +/- 9.7 years. Veterans with dementia experienced less mortality than patients without dementia at 30 days (8.3% vs 8.5%; P < 0.001), but more mortality at 60-day (4.9% vs 4.7%; P < 0.001) and 90-day (3.6% vs 3.3%; P < 0.001) intervals. Death was 20% less likely at 30 days in patients with dementia. Veterans with dementia were readmitted more than those without dementia at 30-day (18.4% vs 16.0%), 60-day (4.5% vs 2.8%), and 90-day (3.4% vs 2.5%) intervals; P < 0.0001. Conclusion Though patients with dementia are at an increased risk for death long-term, risk of death is less than those without dementia shortly following UTI diagnosis. This highlights the possibility that veterans with dementia may be hospitalized and diagnosed with UTIs when in actuality they have asymptomatic bacteriuria. Patients with dementia and UTI therefore represent an important group of geriatric patients that could benefit from the oversight of a senior care pharmacist to help prevent unnecessary treatment of asymptomatic bacteriuria.

Smoking status related to Covid-19 mortality and disease severity in a veteran population

INTRODUCTION

Cigarette smoking is associated with development of significant comorbidities. Patients with underlying comorbidities have been found to have worse outcomes associated with Coronavirus Disease 2019 (Covid-19). This study evaluated 30-day mortality in Covid-19 positive patients based on smoking status.

METHODS

This retrospective study of veterans nationwide examined Covid-19 positive inpatients between March 2020 and January 2021. Bivariate analysis compared patients based on smoking history. Propensity score matching adjusted for age, gender, race, ethnicity, Charlson comorbidity index (0-5 and 6-19) and dexamethasone use was performed. A multivariable logistic regression with backwards elimination and Cox Proportional Hazards Ratio was utilized to determine odds of 30-day mortality.

RESULTS

The study cohort consisted of 25,958 unique Covid-19 positive inpatients. There was a total of 2,995 current smokers, 12,169 former smokers, and 8,392 non-smokers. Death was experienced by 13.5% (n = 3503) of the cohort within 30 days. Former smokers (OR 1.15; 95% CI, 1.05-1.27) (HR 1.13; 95% CI, 1.03-1.23) had higher risk of 30-day mortality compared with non-smokers. Former smokers had a higher risk of death compared to current smokers (HR 1.16 95% CI 1.02-1.33). The odds of death for current vs. non-smokers did not significantly differ.

CONCLUSION

Compared to veteran non-smokers with Covid-19, former, but not current smokers with Covid-19 had a significantly higher risk of 30-day mortality.

Sputum susceptibilities in a nationwide veteran cohort

BACKGROUND

Respiratory infections are one of the most common causes of morbidity and mortality. This study examined antimicrobial susceptibility of common respiratory isolates from veterans.

METHODS

Sputum culture data from the Veteran Health Administration were obtained retrospectively between January 2009 and 2019. Cumulative antibiograms were constructed for bacterial isolate susceptibility.

RESULTS

Sputum and bronchial cultures from approximately 10,345 veterans were included each year. Haemophilus influenzae has maintained high levels of susceptibility to third generation cephalosporins from 2009 (99.7%) to 2018 (97.2%). Third generation cephalosporin susceptibilities amongst Klebsiella pneumoniae have trended upward from 2009 to 2018 as well (79.1% vs 86.4%). In Pseudomonas aeruginosa isolates, there has been an increase in susceptibility rates to cefepime from 2009 to 2018 (79.6%, to 86.6%), gentamicin (81.5% to 89.1%), and piperacillin/tazobactam (86.5% to 90%). Fluoroquinolone susceptibilities amongst Escherichia coli have remained low but stable between 2009 and 2018. Third generation cephalosporin susceptibilities for S. pneumoniae improved slightly from 92.2% to 95% between 2009 and 2018 while susceptibility to azithromycin trended down slightly from 56.8% in 2009 to 51.7% in 2018 for S. pneumoniae.

DISCUSSION

The antibiogram of sputum isolates from the VA Healthcare System were examined to determine changes in patterns of resistance over a decade of use.

CONCLUSIONS

This large-scale study investigated nationwide sputum culture susceptibility trends. Avoidance of macrolides for empiric treatment of community acquired pneumonia and avoidance of fluoroquinolones for empiric treatment of hospital acquired or ventilator associated pneumonia may be warranted based on susceptibility trends.

Societal factors contributing to infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae in a veteran population

BACKGROUND

Veterans have a higher incidence of sexually transmitted infections (STIs) compared to the general population. The objective of this study is to evaluate the association of societal factors on the risk of chlamydia or gonorrhea.

METHODS

This retrospective cohort study evaluated data from Veteran Health Administration. Patients tested for chlamydia or gonorrhea between January 2009 and January 2019 were included. Descriptive statistics and regression were used to evaluate societal factors.

RESULTS

A total of 1,232,173 tests for chlamydia or gonorrhea were performed. There were 51,987 (4.2%) positive cases with 74.18% for chlamydia and 24.96% for gonorrhea. In 13.6% of veterans with reported military sexual trauma, there was no difference in risk of positivity (p = 0.39). Veterans with a history of combat had lower odds of testing positive (OR, 0.94; 95% CI, 0.91-0.97). Tests in veterans who were married had a 24% less chance of positivity (OR, 0.76; 95% CI, 0.74-0.79) compared to tests in divorced veterans. Positive number of cases increased each year.

CONCLUSION

Sexually transmitted infections are a growing concern. Gender, age, ethnicity, marital status, and race are societal identifiers which influence likelihood of STI acquisition.

Antimicrobial susceptibility trends for urinary isolates in the veteran population

BACKGROUND

Guidance on empiric treatment for urinary tract infections (UTIs) is lacking for the male population which comprises much of the Veteran population in the United States. This study evaluated susceptibility trends in antimicrobials used for treatment of UTIs in the inpatient and outpatient Veteran population nationwide.

METHODS

Urine culture data was retrospectively obtained from Corporate Data Warehouse. All urine cultures from Veteran Health Administration patients 18 years of age or older who were treated at any VA health care center in the years 2009 and 2018 were eligible. Antibiograms were constructed for bacterial isolate susceptibility.

RESULTS

In 2009 and 2018 isolates from 54,788 and 58,983 Veterans were analyzed, respectively. Escherichia coli was the most common bacteria isolated. For ceftriaxone, E coli susceptibilities were relatively high but trended downward from 2009 to 2018. Common urinary pathogen susceptibilities remained low for fluoroquinolones and trimethoprim-sulfamethoxazole.

DISCUSSION

Empiric therapy for Veterans with UTIs should be based on local susceptibility patterns as previously recommended first-line agents have fallen out of favor due to increasing resistance rates.

CONCLUSIONS

Both inpatient and outpatient stewardship is needed to ensure appropriate treatment, as viable treatment options for UTIs are becoming increasingly limited.

An Evaluation of Antimicrobial Prophylaxis for Dental Procedures at a Veterans Healthcare System; A Role for Senior Care Pharmacists?

OBJECTIVE: The primary objective of this study was to determine the prevalence of appropriate use of antibiotics before a dental procedure.<br/> DESIGN: Retrospective cohort study.<br/> SETTING: Veterans Healthcare Systems.<br/> PARTICIPANTS: Veterans who filled outpatient prescriptions for antimicrobial dental prophylaxis at the Veterans Administration Western New York Healthcare System from December 1, 2017, through October 1, 2019.<br/> INTERVENTIONS: None.<br/> MAIN OUTCOME MEASURES: Use of antibiotic dental prophylaxis was deemed appropriate if in accordance with guideline recommendations. Descriptive statistics were used to summarize data.<br/> RESULTS: A total of 130 veterans receiving antibiotics for dental prophylaxis were included in this evaluation. Of those who were included, only 16.9% received appropriate antibiotic dental prophylaxis. Patients with a prosthetic joint were significantly more likely to be inappropriately prescribed antibiotics for dental prophylaxis. Approximately 87% of patients who were inappropriately prescribed antibiotic prophylaxis had prosthetic joints (P < .0001).<br/> CONCLUSION: Most antibiotics for dental prophylaxis are prescribed inappropriately. The large amount of inappropriately used antibiotics in this study highlights the need for dental stewardship in our veteran population. Antibiotics for dental prophylaxis therefore represent an important stewardship target in the outpatient setting. This may be an ideal opportunity for senior care pharmacists to intervene upon.

1422. Evaluation of Diabetic Foot Infections and Osteomyelitis in a Veteran Population: Targets for Improved Outcomes

Background

Diabetic foot infections (DFI) complicated with osteomyelitis are a difficult infection to treat often resulting in poor outcomes. DFIs often require amputations, including serial amputations due to inadequate initial intervention and infection progression. This study examines various diagnostic and treatment strategies aimed to improve outcomes.

Methods

This retrospective cohort study included patients greater than or equal to 18 years of age with a DFI as identified via ICD 9 and ICD 10 codes from January 2005 to December 2018. Outcomes were analyzed to measure the impact of baseline characteristics on outcomes. The severity of infection was defined by PEDIS score (perfusion, extent, depth, infection, and sensation). Descriptive statistics were used to report differences.

Results

One hundred and thirty patients were included, 72% with osteomyelitis. The median PEDIS score was 3 (interquartile range 2–3). Magnetic resonance imaging was used to evaluate 38% of the population. Osteomyelitis patients who had an MRI performed were noted to have a higher rate of appropriate treatment and cure (56%) when compared with a similar group of patients who did not receive an MRI (25%) (P = 0.005). Comparing prolonged (> 4 weeks) therapy to short therapy, there was a significantly higher proportion of cures noted (62.71% vs. 36.62%, P < 0.0001). Failure was associated with less than 4 weeks of therapy (66.7%, P = 0.03) and presence of residual inflammation/infection after amputation (58.3%, P < 0.0001). Route of antibiotic had no impact on failure rates. However, patients with an initial drug-bug mismatch were more likely to fail. Sixty-six percent of patients with decreased ankle brachial index failed (P = 0.02).

Conclusion

Diabetic foot infections have serious consequences. Over a third of patients required further amputation or additional antibiotic therapy. Risk of failure was associated with short durations of therapy, poor perfusion, and residual inflammation after amputation. However, a higher rate of cures was noted with use of an MRI and prolonged therapy in patients. Stewardship initiatives may wish to focus on ensuring prolonged treatment courses and appropriate surgical intervention rather than on route of antibiotic therapy as there was no difference in failure rates.

Disclosures

All authors: No reported disclosures.

Autism spectrum disorder in the genetics clinic: a review

Autism spectrum disorders (ASDs) are a heterogeneous group of neurodevelopmental disorders affecting social communication, language and behavior. The underlying cause(s) in a given individual is often elusive, with the exception of clinically recognizable genetic syndromes with readily available molecular diagnosis, such as fragile X syndrome. Clinical geneticists approach patients with ASDs by ruling out known genetic and genomic syndromes, leaving more than 80% of families without a definitive diagnosis and an uncertain risk of recurrence. Advances in microarray technology and next-generation sequencing are revealing rare variants in genes with important roles in synapse formation, function and maintenance. This review will focus on the clinical approach to ASDs, given the current state of knowledge about their complex genetic architecture.

Hemizygous deletions on chromosome 1p21.3 involving the DPYD gene in individuals with autism spectrum disorder

We describe the identification and clinical presentation of four individuals from three unrelated families with hemizygous deletions involving the DPYD gene at chromosome 1p21.3. DPYD encodes dihydropyrimidine dehydrogenase, which is the initial and rate-limiting enzyme in the catabolism of pyrimidine bases. All four individuals described met diagnostic criteria for autism spectrum disorder with severe speech delay. Patient 1's deletion was originally reported in 2008, and more detailed clinical information is provided. Subsequently, this male individual was found to have a missense mutation in the X-linked PTCHD1 autism susceptibility gene, which may also contribute to the phenotype. Patients 2 and 3 are siblings with a novel deletion encompassing the DPYD gene. In their mother, the genomic region deleted from chromosome 1p21.3 was inserted into chromosome 10. A fourth proband had a novel 10-kb intragenic deletion of exon 6 of the DPYD gene detected on a higher resolution microarray. Our study suggests that hemizygous deletions involving the DPYD locus present with variable phenotypes which can include speech delay and autistic features, and may also be influenced by additional mutations in other genes, issues which need to be considered in genetic counseling.

Conservation of RET proto-oncogene splicing variants and implications for RET isoform function

The RET proto-oncogene encodes a receptor tyrosine kinase required for development of the kidney and neural crest-derived cell types. Alternative splicing of the 3' exons of human RET results in three protein isoforms with distinct C-termini: RET9, RET51, and RET43. These RET isoforms show differential binding to downstream adapter molecules, suggesting they may have distinct signaling functions. We have characterized Ret 3' sequences in mouse and investigated alternative splicing of this region. We found that the organization of Ret 3' sequences is very similar to human RET. The mouse locus also has alternatively spliced C-terminal coding regions, and the sequences corresponding to RET9 and RET51 are highly conserved in both position and sequence with the human locus. Further, we compared the predicted C-terminal amino acids of RET9 and RET51 in seven vertebrate species, and found that they are well conserved. We have identified sequence encoding a putative ret43 isoform in mouse, however the predicted amino acid sequence showed low homology to human RET43. Our data suggest that RET isoforms are evolutionarily highly conserved over a broad range of species, which may indicate that each isoform has a distinct role in normal RET function.

Dielectric properties of a binary cryoelectrochemical solvent according to a solvatochromic probe

The application of a solvatochromic dye to determination of the dielectric properties of organic solvent mixtures is described. The dye 2,6-diphenyl-4-(2,4,6-triphenylpyridino)phenolate (Reichardt's dye) features an intramolecular charge transfer band in its visible spectrum with a large associated change in dipole moment between the ground and excited states. The position of the charge transfer band is sensitive to local dielectric environment and so is an indicator of solvation of the dye. Room-temperature spectra of Reichardt's dye in the cryoelectrochemical solvent system 2:1 (v/v) ethyl chloride/butyronitrile and in the neat components are reported and related to the dielectric properties of the mixture. The effective dielectric properties of the mixture scale with the value of the Pekar factor, 1/ε(OP) - 1/ε(S), that is predicted from the mole fraction-weighted (or volume fraction-weighted) sum of the dielectric constants for the pure components, suggesting that strongly selective solvation of the dye by one component of the solvent mixture does not occur. The results are pertinent to a recent study of electrode kinetics in the solvent mixture.

Electrochemical investigations of the interaction of metal chelates with DNA. 3. Electrogenerated chemiluminescent investigation of the interaction of tris(1,10-phenanthroline)ruthenium(II) with DNA

The electrogenerated chemiluminescence (ECL) that results from the oxidation of tris(1,10-phenanthroline)ruthenium(II), at a gold electrode in the presence of oxalate, was used to investigate the interaction of the Ru(II) chelate with calf thymus DNA. The decrease in ECL emission from the excited state, Ru(phen)3(2+*), in the presence of DNA, is ascribed to binding to binding of the chelate to the DNA strand. An ECL titration of the metal complex with DNA allowed determination of the equilibrium constant (K) and binding-site size (s) for association of Ru(phen)3(2+), under the assumption that only the free metal complex contributes to the observed emission. In 25 mM Na2C2O4, 2 mM phosphate buffer, pH 5, 0.05% Tween-20, 0.05% Triton X-100, regression based on the McGhee/von Hippel model, which accounts for free base pair gaps between binding sites, yielded K = 8.1 (+/- 0.2) x 10(3) M-1 and s = 4 bp.